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Growth on neck
The FP recognized the lesion as a linear epidermal nevus.
Epidermal nevi (EN) are congenital hamartomas of ectodermal origin that are uncommon (occurring in < 1% of newborns and children), sporadic, and usually present at birth, although they can appear in early childhood. EN are associated with disorders of the eye, nervous system, and musculoskeletal system in 10% to 30% of patients.
EN are linear, round or oblong, well circumscribed, elevated, and flat topped. EN are often yellow-tan to dark brown in color, with a surface that is uniformly velvety or warty. They most commonly occur on the head and neck, although they can occur on the trunk and proximal extremities.
The FP determined that the patient had no neurological, musculoskeletal, or vision problems that could be associated with a linear epidermal nevus syndrome and reassured the patient and his mother that the nevus was not dangerous and did not need to be removed.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M. Epidermal nevus and nevus sebaceous. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine, 2nd ed. New York, NY: McGraw-Hill; 2013:958-962.
To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.
You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.
The FP recognized the lesion as a linear epidermal nevus.
Epidermal nevi (EN) are congenital hamartomas of ectodermal origin that are uncommon (occurring in < 1% of newborns and children), sporadic, and usually present at birth, although they can appear in early childhood. EN are associated with disorders of the eye, nervous system, and musculoskeletal system in 10% to 30% of patients.
EN are linear, round or oblong, well circumscribed, elevated, and flat topped. EN are often yellow-tan to dark brown in color, with a surface that is uniformly velvety or warty. They most commonly occur on the head and neck, although they can occur on the trunk and proximal extremities.
The FP determined that the patient had no neurological, musculoskeletal, or vision problems that could be associated with a linear epidermal nevus syndrome and reassured the patient and his mother that the nevus was not dangerous and did not need to be removed.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M. Epidermal nevus and nevus sebaceous. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine, 2nd ed. New York, NY: McGraw-Hill; 2013:958-962.
To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.
You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.
The FP recognized the lesion as a linear epidermal nevus.
Epidermal nevi (EN) are congenital hamartomas of ectodermal origin that are uncommon (occurring in < 1% of newborns and children), sporadic, and usually present at birth, although they can appear in early childhood. EN are associated with disorders of the eye, nervous system, and musculoskeletal system in 10% to 30% of patients.
EN are linear, round or oblong, well circumscribed, elevated, and flat topped. EN are often yellow-tan to dark brown in color, with a surface that is uniformly velvety or warty. They most commonly occur on the head and neck, although they can occur on the trunk and proximal extremities.
The FP determined that the patient had no neurological, musculoskeletal, or vision problems that could be associated with a linear epidermal nevus syndrome and reassured the patient and his mother that the nevus was not dangerous and did not need to be removed.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M. Epidermal nevus and nevus sebaceous. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine, 2nd ed. New York, NY: McGraw-Hill; 2013:958-962.
To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.
You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.
Red-Brown Plaque on the Leg
The Diagnosis: Wells Syndrome
A punch biopsy taken from the perimeter of the lesion demonstrated mild spongiosis overlying a dense nodular to diffuse infiltrate of lymphocytes, neutrophils, and numerous eosinophils, some involving underlying fat lobules (Figure, A and B). In some areas, eosinophilic degeneration of collagen bundles surrounded by a rim of histiocytes, "flame features," were observed (Figure C). The clinical and histological features were consistent with Wells syndrome (WS), also known as eosinophilic cellulitis. Given the localized mild nature of the disease, the patient was started on a midpotency topical corticosteroid.
Wells syndrome is a rare inflammatory condition characterized by clinical polymorphism, suggestive histologic findings, and a recurrent course.1,2 This condition is especially rare in children.3,4 Caputo et al1 described 7 variants in their case series of 19 patients: classic plaque-type variant (the most common clinical presentation in children); annular granuloma-like (the most common clinical presentation in adults); urticarialike; bullous; papulonodular; papulovesicular; and fixed drug eruption-like. Wells syndrome is thought to result from excess production of IL-5 in response to a hypersensitivity reaction to an exogenous or endogenous circulating antigen.3,4 Increased levels of IL-5 enhance eosinophil accumulation in the skin, degranulation, and subsequent tissue destruction.3,4 Reported triggers include insect bites, viral and bacterial infections, drug eruptions, recent vaccination, and paraphenylenediamine in henna tattoos.3-7 Additionally, WS has been reported in the setting of gastrointestinal pathologies, such as celiac disease and ulcerative colitis, and with asthma exacerbations.8,9 However, in half of pediatric cases, no trigger can be identified.7
Clinically, WS presents with pruritic, mildly tender plaques.7 Lesions may be localized or diffuse and range from mild annular or circinate plaques with infiltrated borders to cellulitic-appearing lesions that are occasionally associated with bullae.5,6 Patients often report prodromal symptoms of burning and pruritus.5,6 Lesions rapidly progress over 2 to 3 days, pass through a blue grayish discoloration phase, and gradually resolve over 2 to 8 weeks.5,6,10 Although patients generally heal without scarring, WS lesions have been described to resolve with atrophy and hyperpigmentation resembling morphea.5-7 Additionally, patients typically experience a relapsing remitting course over months to years with eventual spontaneous resolution.1,5 Patients also may experience systemic symptoms including fever, lymphadenopathy, and arthralgia, though they do not develop more widespread systemic manifestations.2,3,7
Diagnosis of WS is based on clinicopathologic correlation. Histopathology of WS lesions demonstrates 3 phases. The acute phase demonstrates edema of the superficial and mid dermis with a dense dermal eosinophilic infiltrate.1,6,10 The subacute granulomatous phase demonstrates flame figures in the dermis.1,2,6,7,10 Flame figures consist of palisading groups of eosinophils and histiocytes around a core of degenerating basophilic collagen bundles associated with major basic protein.1,2,6,7,10 Finally, in the resolution phase, eosinophils gradually disappear while histiocytes and giant cells persist, forming microgranulomas.1,2,10 Notably, no vasculitis is observed and direct immunofluorescence is negative.3,7 Although flame figures are suggestive of WS, they are not pathognomonic and are observed in other conditions including Churg-Strauss syndrome, parasitic and fungal infections, herpes gestationis, bullous pemphigoid, and follicular mucinosis.2,5
Wells syndrome is a self-resolving and benign condition.1,10 Physicians are recommended to gather a complete history including review of medications and vaccinations; a history of insect bites, infections, and asthma; laboratory workup consisting of a complete blood cell count with differential and stool samples for ova and parasites; and a skin biopsy if the diagnosis is unclear.7 Identification and treatment of underlying causes often results in resolution.6 Systemic corticosteroids frequently are used in both adult and pediatric patients, though practitioners should consider alternative treatments when recurrences occur to avoid steroid side effects.3,6 Midpotency topical corticosteroids present a safe alternative to systemic corticosteroids in the pediatric population, especially in cases of localized WS without systemic symptoms.3 Other medications reported in the literature include cyclosporine, dapsone, antimalarial medications, and azathioprine.6 Despite appropriate therapy, patients and physicians should anticipate recurrence over months to years.1,6
- Caputo R, Marzano AV, Vezzoli P, et al. Wells syndrome in adults and children: a report of 19 cases. Arch Dermatol. 2006;142:1157-1161.
- Smith SM, Kiracofe EA, Clark LN, et al. Idiopathic hypereosinophilic syndrome with cutaneous manifestations and flame figures: a spectrum of eosinophilic dermatoses whose features overlap with Wells' syndrome. Am J Dermatopathol. 2015;37:910-914.
- Gilliam AE, Bruckner AL, Howard RM, et al. Bullous "cellulitis" with eosinophilia: case report and review of Wells' syndrome in childhood. Pediatrics. 2005;116:E149-E155.
- Nacaroglu HT, Celegen M, Karkıner CS, et al. Eosinophilic cellulitis (Wells' syndrome) caused by a temporary henna tattoo. Postepy Dermatol Alergol. 2014;31:322-324.
- Heelan K, Ryan JF, Shear NH, et al. Wells syndrome (eosinophilic cellulitis): proposed diagnostic criteria and a literature review of the drug-induced variant. J Dermatol Case Rep. 2013;7:113-120.
- Sinno H, Lacroix JP, Lee J, et al. Diagnosis and management of eosinophilic cellulitis (Wells' syndrome): a case series and literature review. Can J Plast Surg. 2012;20:91-97.
- Cherng E, McClung AA, Rosenthal HM, et al. Wells' syndrome associated with parvovirus in a 5-year-old boy. Pediatr Dermatol. 2012;29:762-764.
- Eren M, Açikalin M. A case report of Wells' syndrome in a celiac patient. Turk J Gastroenterol. 2010;21:172-174.
- Cruz MJ, Mota A, Baudrier T, et al. Recurrent Wells' syndrome associated with allergic asthma exacerbation. Cutan Ocul Toxicol. 2012;31:154-156.
- Van der Straaten S, Wojciechowski M, Salgado R, et al. Eosinophilic cellulitis or Wells' syndrome in a 6-year-old child. Eur J Pediatr. 2006;165:197-198.
The Diagnosis: Wells Syndrome
A punch biopsy taken from the perimeter of the lesion demonstrated mild spongiosis overlying a dense nodular to diffuse infiltrate of lymphocytes, neutrophils, and numerous eosinophils, some involving underlying fat lobules (Figure, A and B). In some areas, eosinophilic degeneration of collagen bundles surrounded by a rim of histiocytes, "flame features," were observed (Figure C). The clinical and histological features were consistent with Wells syndrome (WS), also known as eosinophilic cellulitis. Given the localized mild nature of the disease, the patient was started on a midpotency topical corticosteroid.
Wells syndrome is a rare inflammatory condition characterized by clinical polymorphism, suggestive histologic findings, and a recurrent course.1,2 This condition is especially rare in children.3,4 Caputo et al1 described 7 variants in their case series of 19 patients: classic plaque-type variant (the most common clinical presentation in children); annular granuloma-like (the most common clinical presentation in adults); urticarialike; bullous; papulonodular; papulovesicular; and fixed drug eruption-like. Wells syndrome is thought to result from excess production of IL-5 in response to a hypersensitivity reaction to an exogenous or endogenous circulating antigen.3,4 Increased levels of IL-5 enhance eosinophil accumulation in the skin, degranulation, and subsequent tissue destruction.3,4 Reported triggers include insect bites, viral and bacterial infections, drug eruptions, recent vaccination, and paraphenylenediamine in henna tattoos.3-7 Additionally, WS has been reported in the setting of gastrointestinal pathologies, such as celiac disease and ulcerative colitis, and with asthma exacerbations.8,9 However, in half of pediatric cases, no trigger can be identified.7
Clinically, WS presents with pruritic, mildly tender plaques.7 Lesions may be localized or diffuse and range from mild annular or circinate plaques with infiltrated borders to cellulitic-appearing lesions that are occasionally associated with bullae.5,6 Patients often report prodromal symptoms of burning and pruritus.5,6 Lesions rapidly progress over 2 to 3 days, pass through a blue grayish discoloration phase, and gradually resolve over 2 to 8 weeks.5,6,10 Although patients generally heal without scarring, WS lesions have been described to resolve with atrophy and hyperpigmentation resembling morphea.5-7 Additionally, patients typically experience a relapsing remitting course over months to years with eventual spontaneous resolution.1,5 Patients also may experience systemic symptoms including fever, lymphadenopathy, and arthralgia, though they do not develop more widespread systemic manifestations.2,3,7
Diagnosis of WS is based on clinicopathologic correlation. Histopathology of WS lesions demonstrates 3 phases. The acute phase demonstrates edema of the superficial and mid dermis with a dense dermal eosinophilic infiltrate.1,6,10 The subacute granulomatous phase demonstrates flame figures in the dermis.1,2,6,7,10 Flame figures consist of palisading groups of eosinophils and histiocytes around a core of degenerating basophilic collagen bundles associated with major basic protein.1,2,6,7,10 Finally, in the resolution phase, eosinophils gradually disappear while histiocytes and giant cells persist, forming microgranulomas.1,2,10 Notably, no vasculitis is observed and direct immunofluorescence is negative.3,7 Although flame figures are suggestive of WS, they are not pathognomonic and are observed in other conditions including Churg-Strauss syndrome, parasitic and fungal infections, herpes gestationis, bullous pemphigoid, and follicular mucinosis.2,5
Wells syndrome is a self-resolving and benign condition.1,10 Physicians are recommended to gather a complete history including review of medications and vaccinations; a history of insect bites, infections, and asthma; laboratory workup consisting of a complete blood cell count with differential and stool samples for ova and parasites; and a skin biopsy if the diagnosis is unclear.7 Identification and treatment of underlying causes often results in resolution.6 Systemic corticosteroids frequently are used in both adult and pediatric patients, though practitioners should consider alternative treatments when recurrences occur to avoid steroid side effects.3,6 Midpotency topical corticosteroids present a safe alternative to systemic corticosteroids in the pediatric population, especially in cases of localized WS without systemic symptoms.3 Other medications reported in the literature include cyclosporine, dapsone, antimalarial medications, and azathioprine.6 Despite appropriate therapy, patients and physicians should anticipate recurrence over months to years.1,6
The Diagnosis: Wells Syndrome
A punch biopsy taken from the perimeter of the lesion demonstrated mild spongiosis overlying a dense nodular to diffuse infiltrate of lymphocytes, neutrophils, and numerous eosinophils, some involving underlying fat lobules (Figure, A and B). In some areas, eosinophilic degeneration of collagen bundles surrounded by a rim of histiocytes, "flame features," were observed (Figure C). The clinical and histological features were consistent with Wells syndrome (WS), also known as eosinophilic cellulitis. Given the localized mild nature of the disease, the patient was started on a midpotency topical corticosteroid.
Wells syndrome is a rare inflammatory condition characterized by clinical polymorphism, suggestive histologic findings, and a recurrent course.1,2 This condition is especially rare in children.3,4 Caputo et al1 described 7 variants in their case series of 19 patients: classic plaque-type variant (the most common clinical presentation in children); annular granuloma-like (the most common clinical presentation in adults); urticarialike; bullous; papulonodular; papulovesicular; and fixed drug eruption-like. Wells syndrome is thought to result from excess production of IL-5 in response to a hypersensitivity reaction to an exogenous or endogenous circulating antigen.3,4 Increased levels of IL-5 enhance eosinophil accumulation in the skin, degranulation, and subsequent tissue destruction.3,4 Reported triggers include insect bites, viral and bacterial infections, drug eruptions, recent vaccination, and paraphenylenediamine in henna tattoos.3-7 Additionally, WS has been reported in the setting of gastrointestinal pathologies, such as celiac disease and ulcerative colitis, and with asthma exacerbations.8,9 However, in half of pediatric cases, no trigger can be identified.7
Clinically, WS presents with pruritic, mildly tender plaques.7 Lesions may be localized or diffuse and range from mild annular or circinate plaques with infiltrated borders to cellulitic-appearing lesions that are occasionally associated with bullae.5,6 Patients often report prodromal symptoms of burning and pruritus.5,6 Lesions rapidly progress over 2 to 3 days, pass through a blue grayish discoloration phase, and gradually resolve over 2 to 8 weeks.5,6,10 Although patients generally heal without scarring, WS lesions have been described to resolve with atrophy and hyperpigmentation resembling morphea.5-7 Additionally, patients typically experience a relapsing remitting course over months to years with eventual spontaneous resolution.1,5 Patients also may experience systemic symptoms including fever, lymphadenopathy, and arthralgia, though they do not develop more widespread systemic manifestations.2,3,7
Diagnosis of WS is based on clinicopathologic correlation. Histopathology of WS lesions demonstrates 3 phases. The acute phase demonstrates edema of the superficial and mid dermis with a dense dermal eosinophilic infiltrate.1,6,10 The subacute granulomatous phase demonstrates flame figures in the dermis.1,2,6,7,10 Flame figures consist of palisading groups of eosinophils and histiocytes around a core of degenerating basophilic collagen bundles associated with major basic protein.1,2,6,7,10 Finally, in the resolution phase, eosinophils gradually disappear while histiocytes and giant cells persist, forming microgranulomas.1,2,10 Notably, no vasculitis is observed and direct immunofluorescence is negative.3,7 Although flame figures are suggestive of WS, they are not pathognomonic and are observed in other conditions including Churg-Strauss syndrome, parasitic and fungal infections, herpes gestationis, bullous pemphigoid, and follicular mucinosis.2,5
Wells syndrome is a self-resolving and benign condition.1,10 Physicians are recommended to gather a complete history including review of medications and vaccinations; a history of insect bites, infections, and asthma; laboratory workup consisting of a complete blood cell count with differential and stool samples for ova and parasites; and a skin biopsy if the diagnosis is unclear.7 Identification and treatment of underlying causes often results in resolution.6 Systemic corticosteroids frequently are used in both adult and pediatric patients, though practitioners should consider alternative treatments when recurrences occur to avoid steroid side effects.3,6 Midpotency topical corticosteroids present a safe alternative to systemic corticosteroids in the pediatric population, especially in cases of localized WS without systemic symptoms.3 Other medications reported in the literature include cyclosporine, dapsone, antimalarial medications, and azathioprine.6 Despite appropriate therapy, patients and physicians should anticipate recurrence over months to years.1,6
- Caputo R, Marzano AV, Vezzoli P, et al. Wells syndrome in adults and children: a report of 19 cases. Arch Dermatol. 2006;142:1157-1161.
- Smith SM, Kiracofe EA, Clark LN, et al. Idiopathic hypereosinophilic syndrome with cutaneous manifestations and flame figures: a spectrum of eosinophilic dermatoses whose features overlap with Wells' syndrome. Am J Dermatopathol. 2015;37:910-914.
- Gilliam AE, Bruckner AL, Howard RM, et al. Bullous "cellulitis" with eosinophilia: case report and review of Wells' syndrome in childhood. Pediatrics. 2005;116:E149-E155.
- Nacaroglu HT, Celegen M, Karkıner CS, et al. Eosinophilic cellulitis (Wells' syndrome) caused by a temporary henna tattoo. Postepy Dermatol Alergol. 2014;31:322-324.
- Heelan K, Ryan JF, Shear NH, et al. Wells syndrome (eosinophilic cellulitis): proposed diagnostic criteria and a literature review of the drug-induced variant. J Dermatol Case Rep. 2013;7:113-120.
- Sinno H, Lacroix JP, Lee J, et al. Diagnosis and management of eosinophilic cellulitis (Wells' syndrome): a case series and literature review. Can J Plast Surg. 2012;20:91-97.
- Cherng E, McClung AA, Rosenthal HM, et al. Wells' syndrome associated with parvovirus in a 5-year-old boy. Pediatr Dermatol. 2012;29:762-764.
- Eren M, Açikalin M. A case report of Wells' syndrome in a celiac patient. Turk J Gastroenterol. 2010;21:172-174.
- Cruz MJ, Mota A, Baudrier T, et al. Recurrent Wells' syndrome associated with allergic asthma exacerbation. Cutan Ocul Toxicol. 2012;31:154-156.
- Van der Straaten S, Wojciechowski M, Salgado R, et al. Eosinophilic cellulitis or Wells' syndrome in a 6-year-old child. Eur J Pediatr. 2006;165:197-198.
- Caputo R, Marzano AV, Vezzoli P, et al. Wells syndrome in adults and children: a report of 19 cases. Arch Dermatol. 2006;142:1157-1161.
- Smith SM, Kiracofe EA, Clark LN, et al. Idiopathic hypereosinophilic syndrome with cutaneous manifestations and flame figures: a spectrum of eosinophilic dermatoses whose features overlap with Wells' syndrome. Am J Dermatopathol. 2015;37:910-914.
- Gilliam AE, Bruckner AL, Howard RM, et al. Bullous "cellulitis" with eosinophilia: case report and review of Wells' syndrome in childhood. Pediatrics. 2005;116:E149-E155.
- Nacaroglu HT, Celegen M, Karkıner CS, et al. Eosinophilic cellulitis (Wells' syndrome) caused by a temporary henna tattoo. Postepy Dermatol Alergol. 2014;31:322-324.
- Heelan K, Ryan JF, Shear NH, et al. Wells syndrome (eosinophilic cellulitis): proposed diagnostic criteria and a literature review of the drug-induced variant. J Dermatol Case Rep. 2013;7:113-120.
- Sinno H, Lacroix JP, Lee J, et al. Diagnosis and management of eosinophilic cellulitis (Wells' syndrome): a case series and literature review. Can J Plast Surg. 2012;20:91-97.
- Cherng E, McClung AA, Rosenthal HM, et al. Wells' syndrome associated with parvovirus in a 5-year-old boy. Pediatr Dermatol. 2012;29:762-764.
- Eren M, Açikalin M. A case report of Wells' syndrome in a celiac patient. Turk J Gastroenterol. 2010;21:172-174.
- Cruz MJ, Mota A, Baudrier T, et al. Recurrent Wells' syndrome associated with allergic asthma exacerbation. Cutan Ocul Toxicol. 2012;31:154-156.
- Van der Straaten S, Wojciechowski M, Salgado R, et al. Eosinophilic cellulitis or Wells' syndrome in a 6-year-old child. Eur J Pediatr. 2006;165:197-198.
A healthy 7-year-old boy presented with an enlarging hyperpigmented plaque on the anterior aspect of the lower left leg of 2 months' duration. His mother reported onset following a mosquito bite. Clotrimazole was used without improvement. His mother denied recent travel, similar lesions in close contacts, fever, asthma, and arthralgia. Physical examination revealed a 5.2 ×3-cm nonscaly, red-brown, ovoid, thin plaque with a slightly raised border.
Antidepressants and children
A clinical pathway to standardize use of maintenance IV fluids
Clinical question
Can an evidence-based clinical pathway improve adherence to recent recommendations to use isotonic solutions for maintenance intravenous fluids in hospitalized children?
Background
The traditional teaching regarding composition of maintenance intravenous fluids (IVF) in children has been based on the Holliday-Segar method.1 Since its publication in Pediatrics in 1957, concerns have been raised regarding the risk of iatrogenic hyponatremia caused by giving hypotonic fluids determined by this method,2 especially in patients with an elevated risk of increased antidiuretic hormone (ADH) secretion.3 Multiple recent systematic reviews and meta-analyses have confirmed that isotonic IVF reduces the risk of hyponatremia in hospitalized children.4
Study design
Interrupted time series analysis before and after pathway implementation.
Setting
370-bed tertiary care free-standing children’s hospital.
Synopsis
A multidisciplinary team was assembled, comprising physicians and nurses in hospital medicine, general pediatrics, emergency medicine, and nephrology. After a systematic review of the recent literature, a clinical algorithm and web-based training module were developed. Faculty in general pediatrics, hospital medicine, and emergency medicine were required to complete the module, while medical and surgical residents were encouraged but not required to complete the module. A maintenance IVF order set was created and embedded into all order sets previously containing IVF orders and was also available in stand-alone form.
Inclusion criteria (“pathway eligible”) included being euvolemic and requiring IVF. Exclusion criteria included fluid status derangements, critical illness, severe serum sodium abnormalities (serum sodium ≥150 mEq/L or ≤130 mEq/L) use of TPN or ketogenic diet. In the order set, IVF composition was determined based on risk factors for increased ADH secretion. Inclusion of potassium in IVF was also determined by the pathway.
Over the 1-year study period, 11,602 pathway-eligible encounters in 10,287 patients were reviewed. Use of isotonic maintenance IVF increased significantly from 9.3% to 50.6%, while use of hypotonic fluids decreased from 94.2% to 56.6%. Use of potassium-containing IVF increased from 52.9% to 75.3%. Dysnatremia continued to occur due to hypotonic IVF use.
Bottom line
A combined clinical pathway and training module to standardize the composition of IVF is feasible, and results in increased use of isotonic and potassium-containing fluids.
Citation
Rooholamini S, Clifton H, Haaland W, et al. Outcomes of a clinical pathway to standardize use of maintenance intravenous fluids. Hosp Pediatr. 2017 Dec;7(12):703-9.
Dr. Chang is a pediatric hospitalist at Baystate Children’s Hospital in Springfield, Mass., and is the pediatric editor of The Hospitalist.
References
1. Holliday MA et al. The maintenance need for water in parenteral fluid therapy. Pediatrics 1957;19:823-32.
2. Friedman JN et al. Comparison of isotonic and hypotonic intravenous maintenance fluids: a randomized clinical trial. JAMA Pediatr. 2015;169:445-51.
3. Fuchs J et al. Current Issues in Intravenous Fluid Use in Hospitalized Children. Rev Recent Clin Trials. 2017;12:284-9.
4. McNab S et al. Isotonic versus hypotonic solutions for maintenance intravenous fluid administration in children. Cochrane Database. Syst Rev 2014:CD009457.
Clinical question
Can an evidence-based clinical pathway improve adherence to recent recommendations to use isotonic solutions for maintenance intravenous fluids in hospitalized children?
Background
The traditional teaching regarding composition of maintenance intravenous fluids (IVF) in children has been based on the Holliday-Segar method.1 Since its publication in Pediatrics in 1957, concerns have been raised regarding the risk of iatrogenic hyponatremia caused by giving hypotonic fluids determined by this method,2 especially in patients with an elevated risk of increased antidiuretic hormone (ADH) secretion.3 Multiple recent systematic reviews and meta-analyses have confirmed that isotonic IVF reduces the risk of hyponatremia in hospitalized children.4
Study design
Interrupted time series analysis before and after pathway implementation.
Setting
370-bed tertiary care free-standing children’s hospital.
Synopsis
A multidisciplinary team was assembled, comprising physicians and nurses in hospital medicine, general pediatrics, emergency medicine, and nephrology. After a systematic review of the recent literature, a clinical algorithm and web-based training module were developed. Faculty in general pediatrics, hospital medicine, and emergency medicine were required to complete the module, while medical and surgical residents were encouraged but not required to complete the module. A maintenance IVF order set was created and embedded into all order sets previously containing IVF orders and was also available in stand-alone form.
Inclusion criteria (“pathway eligible”) included being euvolemic and requiring IVF. Exclusion criteria included fluid status derangements, critical illness, severe serum sodium abnormalities (serum sodium ≥150 mEq/L or ≤130 mEq/L) use of TPN or ketogenic diet. In the order set, IVF composition was determined based on risk factors for increased ADH secretion. Inclusion of potassium in IVF was also determined by the pathway.
Over the 1-year study period, 11,602 pathway-eligible encounters in 10,287 patients were reviewed. Use of isotonic maintenance IVF increased significantly from 9.3% to 50.6%, while use of hypotonic fluids decreased from 94.2% to 56.6%. Use of potassium-containing IVF increased from 52.9% to 75.3%. Dysnatremia continued to occur due to hypotonic IVF use.
Bottom line
A combined clinical pathway and training module to standardize the composition of IVF is feasible, and results in increased use of isotonic and potassium-containing fluids.
Citation
Rooholamini S, Clifton H, Haaland W, et al. Outcomes of a clinical pathway to standardize use of maintenance intravenous fluids. Hosp Pediatr. 2017 Dec;7(12):703-9.
Dr. Chang is a pediatric hospitalist at Baystate Children’s Hospital in Springfield, Mass., and is the pediatric editor of The Hospitalist.
References
1. Holliday MA et al. The maintenance need for water in parenteral fluid therapy. Pediatrics 1957;19:823-32.
2. Friedman JN et al. Comparison of isotonic and hypotonic intravenous maintenance fluids: a randomized clinical trial. JAMA Pediatr. 2015;169:445-51.
3. Fuchs J et al. Current Issues in Intravenous Fluid Use in Hospitalized Children. Rev Recent Clin Trials. 2017;12:284-9.
4. McNab S et al. Isotonic versus hypotonic solutions for maintenance intravenous fluid administration in children. Cochrane Database. Syst Rev 2014:CD009457.
Clinical question
Can an evidence-based clinical pathway improve adherence to recent recommendations to use isotonic solutions for maintenance intravenous fluids in hospitalized children?
Background
The traditional teaching regarding composition of maintenance intravenous fluids (IVF) in children has been based on the Holliday-Segar method.1 Since its publication in Pediatrics in 1957, concerns have been raised regarding the risk of iatrogenic hyponatremia caused by giving hypotonic fluids determined by this method,2 especially in patients with an elevated risk of increased antidiuretic hormone (ADH) secretion.3 Multiple recent systematic reviews and meta-analyses have confirmed that isotonic IVF reduces the risk of hyponatremia in hospitalized children.4
Study design
Interrupted time series analysis before and after pathway implementation.
Setting
370-bed tertiary care free-standing children’s hospital.
Synopsis
A multidisciplinary team was assembled, comprising physicians and nurses in hospital medicine, general pediatrics, emergency medicine, and nephrology. After a systematic review of the recent literature, a clinical algorithm and web-based training module were developed. Faculty in general pediatrics, hospital medicine, and emergency medicine were required to complete the module, while medical and surgical residents were encouraged but not required to complete the module. A maintenance IVF order set was created and embedded into all order sets previously containing IVF orders and was also available in stand-alone form.
Inclusion criteria (“pathway eligible”) included being euvolemic and requiring IVF. Exclusion criteria included fluid status derangements, critical illness, severe serum sodium abnormalities (serum sodium ≥150 mEq/L or ≤130 mEq/L) use of TPN or ketogenic diet. In the order set, IVF composition was determined based on risk factors for increased ADH secretion. Inclusion of potassium in IVF was also determined by the pathway.
Over the 1-year study period, 11,602 pathway-eligible encounters in 10,287 patients were reviewed. Use of isotonic maintenance IVF increased significantly from 9.3% to 50.6%, while use of hypotonic fluids decreased from 94.2% to 56.6%. Use of potassium-containing IVF increased from 52.9% to 75.3%. Dysnatremia continued to occur due to hypotonic IVF use.
Bottom line
A combined clinical pathway and training module to standardize the composition of IVF is feasible, and results in increased use of isotonic and potassium-containing fluids.
Citation
Rooholamini S, Clifton H, Haaland W, et al. Outcomes of a clinical pathway to standardize use of maintenance intravenous fluids. Hosp Pediatr. 2017 Dec;7(12):703-9.
Dr. Chang is a pediatric hospitalist at Baystate Children’s Hospital in Springfield, Mass., and is the pediatric editor of The Hospitalist.
References
1. Holliday MA et al. The maintenance need for water in parenteral fluid therapy. Pediatrics 1957;19:823-32.
2. Friedman JN et al. Comparison of isotonic and hypotonic intravenous maintenance fluids: a randomized clinical trial. JAMA Pediatr. 2015;169:445-51.
3. Fuchs J et al. Current Issues in Intravenous Fluid Use in Hospitalized Children. Rev Recent Clin Trials. 2017;12:284-9.
4. McNab S et al. Isotonic versus hypotonic solutions for maintenance intravenous fluid administration in children. Cochrane Database. Syst Rev 2014:CD009457.
Can Exercise Improve Vision in Children With MS?
A positive association was observed between moderate-to-vigorous physical activity and retinal nerve fiber layer thickness in pediatric patients.
NASHVILLE—Moderate-to-vigorous physical activity is positively associated with retinal nerve fiber layer thickness in children with multiple sclerosis (MS), according to research presented at the 2018 CMSC Annual Meeting. This finding may help to support an intervention targeting moderate-to-vigorous physical activity to improve anterior visual pathway integrity in children with MS.
More than one-third of pediatric patients with MS experience optic neuritis, and most experience visual pathway abnormalities, including reductions in the retinal nerve fiber layer and ganglion cell inner-plexiform layer. Previous studies in
To investigate the associations between mild-to-vigorous physical activity, the retinal nerve fiber layer, and the ganglion cell inner-plexiform layer in pediatric patients with MS, Alexander L. Pearson, a medical student at the University of Ottawa in Ontario, and colleagues conducted a cross-sectional study.
The researchers recruited participants from the Pediatric MS and Demyelinating Disorders Center at the Hospital for Sick Children in Toronto. Eligible participants had a diagnosis of MS (according to the International Pediatric MS Study Group consensus definitions) and were younger than 18. Patients with neuroinflammatory abnormalities associated with underlying systemic or neurologic disorders, recurrent neuroinflammatory disorders other than MS, coexisting ocular pathologies, visual acuity ±6 diopters or worse, were excluded.
Participants received standardized visual evaluations, including ocular coherence tomography. Investigators performed evaluations more than 90 days after an optic neuritis episode using a spectral-domain ocular coherence tomography Cirrus scanner. Participants also completed the Godin Leisure-Time Exercise Questionnaire (GLTEQ) more than 30 days after a relapse. This questionnaire was used to calculate the health contribution score.
Generalized linear models were used to assess the associations between moderate-to-vigorous physical activity, the retinal nerve fiber layer, and the ganglion cell inner-plexiform layer when controlling for sex, number of optic neuritis episodes, disease duration at time of ocular coherence tomography, and within-subject correlation between eyes. Bonferroni correction was used to adjust for multiple comparisons.
Thirty patients participated in this study; 23 were female. Ocular coherence tomography was performed at a mean age of 15.7 (range, 10.6–18.0) and a median of 1.9 years from disease onset. The median retinal nerve fiber layer was 90 μm, and the median ganglion cell inner-plexiform layer was 73.5 μm. The median amount of moderate-to-vigorous physical activity was 26.5 metabolic equivalents per week.
The research team found that moderate-to-vigorous physical activity was positively associated with retinal nerve fiber layer thickness. Although the retinal nerve fiber layer and ganglion cell inner-plexiform layer were moderately correlated, moderate-to-vigorous physical activity was not associated with the ganglion cell inner-plexiform layer, said the authors.
“Next steps include a trial using mild-to-vigorous physical activity to improve anterior visual pathway integrity in children with MS,” the researchers concluded.
A positive association was observed between moderate-to-vigorous physical activity and retinal nerve fiber layer thickness in pediatric patients.
A positive association was observed between moderate-to-vigorous physical activity and retinal nerve fiber layer thickness in pediatric patients.
NASHVILLE—Moderate-to-vigorous physical activity is positively associated with retinal nerve fiber layer thickness in children with multiple sclerosis (MS), according to research presented at the 2018 CMSC Annual Meeting. This finding may help to support an intervention targeting moderate-to-vigorous physical activity to improve anterior visual pathway integrity in children with MS.
More than one-third of pediatric patients with MS experience optic neuritis, and most experience visual pathway abnormalities, including reductions in the retinal nerve fiber layer and ganglion cell inner-plexiform layer. Previous studies in
To investigate the associations between mild-to-vigorous physical activity, the retinal nerve fiber layer, and the ganglion cell inner-plexiform layer in pediatric patients with MS, Alexander L. Pearson, a medical student at the University of Ottawa in Ontario, and colleagues conducted a cross-sectional study.
The researchers recruited participants from the Pediatric MS and Demyelinating Disorders Center at the Hospital for Sick Children in Toronto. Eligible participants had a diagnosis of MS (according to the International Pediatric MS Study Group consensus definitions) and were younger than 18. Patients with neuroinflammatory abnormalities associated with underlying systemic or neurologic disorders, recurrent neuroinflammatory disorders other than MS, coexisting ocular pathologies, visual acuity ±6 diopters or worse, were excluded.
Participants received standardized visual evaluations, including ocular coherence tomography. Investigators performed evaluations more than 90 days after an optic neuritis episode using a spectral-domain ocular coherence tomography Cirrus scanner. Participants also completed the Godin Leisure-Time Exercise Questionnaire (GLTEQ) more than 30 days after a relapse. This questionnaire was used to calculate the health contribution score.
Generalized linear models were used to assess the associations between moderate-to-vigorous physical activity, the retinal nerve fiber layer, and the ganglion cell inner-plexiform layer when controlling for sex, number of optic neuritis episodes, disease duration at time of ocular coherence tomography, and within-subject correlation between eyes. Bonferroni correction was used to adjust for multiple comparisons.
Thirty patients participated in this study; 23 were female. Ocular coherence tomography was performed at a mean age of 15.7 (range, 10.6–18.0) and a median of 1.9 years from disease onset. The median retinal nerve fiber layer was 90 μm, and the median ganglion cell inner-plexiform layer was 73.5 μm. The median amount of moderate-to-vigorous physical activity was 26.5 metabolic equivalents per week.
The research team found that moderate-to-vigorous physical activity was positively associated with retinal nerve fiber layer thickness. Although the retinal nerve fiber layer and ganglion cell inner-plexiform layer were moderately correlated, moderate-to-vigorous physical activity was not associated with the ganglion cell inner-plexiform layer, said the authors.
“Next steps include a trial using mild-to-vigorous physical activity to improve anterior visual pathway integrity in children with MS,” the researchers concluded.
NASHVILLE—Moderate-to-vigorous physical activity is positively associated with retinal nerve fiber layer thickness in children with multiple sclerosis (MS), according to research presented at the 2018 CMSC Annual Meeting. This finding may help to support an intervention targeting moderate-to-vigorous physical activity to improve anterior visual pathway integrity in children with MS.
More than one-third of pediatric patients with MS experience optic neuritis, and most experience visual pathway abnormalities, including reductions in the retinal nerve fiber layer and ganglion cell inner-plexiform layer. Previous studies in
To investigate the associations between mild-to-vigorous physical activity, the retinal nerve fiber layer, and the ganglion cell inner-plexiform layer in pediatric patients with MS, Alexander L. Pearson, a medical student at the University of Ottawa in Ontario, and colleagues conducted a cross-sectional study.
The researchers recruited participants from the Pediatric MS and Demyelinating Disorders Center at the Hospital for Sick Children in Toronto. Eligible participants had a diagnosis of MS (according to the International Pediatric MS Study Group consensus definitions) and were younger than 18. Patients with neuroinflammatory abnormalities associated with underlying systemic or neurologic disorders, recurrent neuroinflammatory disorders other than MS, coexisting ocular pathologies, visual acuity ±6 diopters or worse, were excluded.
Participants received standardized visual evaluations, including ocular coherence tomography. Investigators performed evaluations more than 90 days after an optic neuritis episode using a spectral-domain ocular coherence tomography Cirrus scanner. Participants also completed the Godin Leisure-Time Exercise Questionnaire (GLTEQ) more than 30 days after a relapse. This questionnaire was used to calculate the health contribution score.
Generalized linear models were used to assess the associations between moderate-to-vigorous physical activity, the retinal nerve fiber layer, and the ganglion cell inner-plexiform layer when controlling for sex, number of optic neuritis episodes, disease duration at time of ocular coherence tomography, and within-subject correlation between eyes. Bonferroni correction was used to adjust for multiple comparisons.
Thirty patients participated in this study; 23 were female. Ocular coherence tomography was performed at a mean age of 15.7 (range, 10.6–18.0) and a median of 1.9 years from disease onset. The median retinal nerve fiber layer was 90 μm, and the median ganglion cell inner-plexiform layer was 73.5 μm. The median amount of moderate-to-vigorous physical activity was 26.5 metabolic equivalents per week.
The research team found that moderate-to-vigorous physical activity was positively associated with retinal nerve fiber layer thickness. Although the retinal nerve fiber layer and ganglion cell inner-plexiform layer were moderately correlated, moderate-to-vigorous physical activity was not associated with the ganglion cell inner-plexiform layer, said the authors.
“Next steps include a trial using mild-to-vigorous physical activity to improve anterior visual pathway integrity in children with MS,” the researchers concluded.
Vaccine-related febrile seizures have zero developmental impact
MALMO, SWEDEN – Children who experience a febrile seizure in conjunction with a vaccination have developmental outcomes comparable with those of children who have non–vaccine-related febrile seizures and healthy controls who’ve never had a febrile seizure, according to the first prospective case-control cohort study to examine the issue.
This finding has important implications for clinical practice, Lucy Deng, MD, observed at the annual meeting of the European Society for Paediatric Infectious Diseases.
“Febrile seizures associated with a vaccine can decrease parent and provider confidence in vaccine safety,” the pediatrician noted. Based upon her study results, however, physicians now can offer a truly evidence-based message of reassurance.
“If you have a child with a vaccine-related febrile seizure, you can give the same advice to those parents as for anyone else who’s had a febrile seizure, in that there is no difference in the clinical outcomes of vaccine-proximate and non–vaccine-proximate febrile seizures. Vaccine-proximate febrile seizures are usually brief, they don’t require any antiepileptic drugs, their length of stay is usually less than a day, and developmentally at 12-24 months post initial febrile seizure, they’re exactly the same as children who’ve never had a seizure before or who’ve had a non-vaccine-related febrile seizure,” said Dr. Deng of the National Centre for Immunisation Research and Surveillance in Sydney.
The impetus for her study was straightforward: “We all know that most children with a history of febrile seizures have normal behavior, intelligence, and academic achievement and do not later develop epilepsy. What we didn’t know before is if all of these facts apply to vaccine-proximate febrile seizures,” she explained.
The clinical severity analysis portion of this prospective case-control cohort study included 1,085 children with febrile seizures seen at five Australian children’s hospitals. Sixty-eight of them had vaccine-proximate febrile seizures, for a 6.6% rate. The febrile seizures in the other 1,027 children didn’t occur within 2 weeks following a vaccination.
Measles vaccine was implicated in 56 of the 68 children with vaccine-proximate febrile seizures, or 82%. Because Australian children receive their first measles-containing vaccine at age 12 months, the average age of the cohort with vaccine-proximate febrile seizures was 13 months, significantly younger than the 20-month average for children with non–vaccine-related febrile seizures.
In a multivariate analysis adjusted for patient age, gender, and history of prior afebrile seizures, the groups with vaccine-proximate and vaccine-unrelated febrile seizures didn’t differ significantly in terms of the proportion with a hospital length of stay greater than 1 day (20% vs. 15%), ICU admission (1.5% vs. 2.3%), seizure duration of more than 15 minutes (16% vs. 12%), repeat seizures within 24 hours (9% vs. 10%), or discharge on antiepileptic medication (4.4% vs. 4.3%).
In the developmental outcomes analysis, 62 of the children with vaccine-proximate febrile seizures, 70 with vaccine-unrelated febrile seizures, and 85 healthy controls with no seizure history underwent formal assessment using the third edition of the Bayley Scales of Infant and Toddler Development 12-24 months after their initial febrile seizure. Scores adjusted for years of maternal education were closely similar in all three groups across all five test domains: cognitive, language, motor, social-emotional, and general-adaptive.
Dr. Deng reported having no financial conflicts of interest regarding the study, which was partially funded by the Australian National Centre for Immunisation Research and Surveillance.
MALMO, SWEDEN – Children who experience a febrile seizure in conjunction with a vaccination have developmental outcomes comparable with those of children who have non–vaccine-related febrile seizures and healthy controls who’ve never had a febrile seizure, according to the first prospective case-control cohort study to examine the issue.
This finding has important implications for clinical practice, Lucy Deng, MD, observed at the annual meeting of the European Society for Paediatric Infectious Diseases.
“Febrile seizures associated with a vaccine can decrease parent and provider confidence in vaccine safety,” the pediatrician noted. Based upon her study results, however, physicians now can offer a truly evidence-based message of reassurance.
“If you have a child with a vaccine-related febrile seizure, you can give the same advice to those parents as for anyone else who’s had a febrile seizure, in that there is no difference in the clinical outcomes of vaccine-proximate and non–vaccine-proximate febrile seizures. Vaccine-proximate febrile seizures are usually brief, they don’t require any antiepileptic drugs, their length of stay is usually less than a day, and developmentally at 12-24 months post initial febrile seizure, they’re exactly the same as children who’ve never had a seizure before or who’ve had a non-vaccine-related febrile seizure,” said Dr. Deng of the National Centre for Immunisation Research and Surveillance in Sydney.
The impetus for her study was straightforward: “We all know that most children with a history of febrile seizures have normal behavior, intelligence, and academic achievement and do not later develop epilepsy. What we didn’t know before is if all of these facts apply to vaccine-proximate febrile seizures,” she explained.
The clinical severity analysis portion of this prospective case-control cohort study included 1,085 children with febrile seizures seen at five Australian children’s hospitals. Sixty-eight of them had vaccine-proximate febrile seizures, for a 6.6% rate. The febrile seizures in the other 1,027 children didn’t occur within 2 weeks following a vaccination.
Measles vaccine was implicated in 56 of the 68 children with vaccine-proximate febrile seizures, or 82%. Because Australian children receive their first measles-containing vaccine at age 12 months, the average age of the cohort with vaccine-proximate febrile seizures was 13 months, significantly younger than the 20-month average for children with non–vaccine-related febrile seizures.
In a multivariate analysis adjusted for patient age, gender, and history of prior afebrile seizures, the groups with vaccine-proximate and vaccine-unrelated febrile seizures didn’t differ significantly in terms of the proportion with a hospital length of stay greater than 1 day (20% vs. 15%), ICU admission (1.5% vs. 2.3%), seizure duration of more than 15 minutes (16% vs. 12%), repeat seizures within 24 hours (9% vs. 10%), or discharge on antiepileptic medication (4.4% vs. 4.3%).
In the developmental outcomes analysis, 62 of the children with vaccine-proximate febrile seizures, 70 with vaccine-unrelated febrile seizures, and 85 healthy controls with no seizure history underwent formal assessment using the third edition of the Bayley Scales of Infant and Toddler Development 12-24 months after their initial febrile seizure. Scores adjusted for years of maternal education were closely similar in all three groups across all five test domains: cognitive, language, motor, social-emotional, and general-adaptive.
Dr. Deng reported having no financial conflicts of interest regarding the study, which was partially funded by the Australian National Centre for Immunisation Research and Surveillance.
MALMO, SWEDEN – Children who experience a febrile seizure in conjunction with a vaccination have developmental outcomes comparable with those of children who have non–vaccine-related febrile seizures and healthy controls who’ve never had a febrile seizure, according to the first prospective case-control cohort study to examine the issue.
This finding has important implications for clinical practice, Lucy Deng, MD, observed at the annual meeting of the European Society for Paediatric Infectious Diseases.
“Febrile seizures associated with a vaccine can decrease parent and provider confidence in vaccine safety,” the pediatrician noted. Based upon her study results, however, physicians now can offer a truly evidence-based message of reassurance.
“If you have a child with a vaccine-related febrile seizure, you can give the same advice to those parents as for anyone else who’s had a febrile seizure, in that there is no difference in the clinical outcomes of vaccine-proximate and non–vaccine-proximate febrile seizures. Vaccine-proximate febrile seizures are usually brief, they don’t require any antiepileptic drugs, their length of stay is usually less than a day, and developmentally at 12-24 months post initial febrile seizure, they’re exactly the same as children who’ve never had a seizure before or who’ve had a non-vaccine-related febrile seizure,” said Dr. Deng of the National Centre for Immunisation Research and Surveillance in Sydney.
The impetus for her study was straightforward: “We all know that most children with a history of febrile seizures have normal behavior, intelligence, and academic achievement and do not later develop epilepsy. What we didn’t know before is if all of these facts apply to vaccine-proximate febrile seizures,” she explained.
The clinical severity analysis portion of this prospective case-control cohort study included 1,085 children with febrile seizures seen at five Australian children’s hospitals. Sixty-eight of them had vaccine-proximate febrile seizures, for a 6.6% rate. The febrile seizures in the other 1,027 children didn’t occur within 2 weeks following a vaccination.
Measles vaccine was implicated in 56 of the 68 children with vaccine-proximate febrile seizures, or 82%. Because Australian children receive their first measles-containing vaccine at age 12 months, the average age of the cohort with vaccine-proximate febrile seizures was 13 months, significantly younger than the 20-month average for children with non–vaccine-related febrile seizures.
In a multivariate analysis adjusted for patient age, gender, and history of prior afebrile seizures, the groups with vaccine-proximate and vaccine-unrelated febrile seizures didn’t differ significantly in terms of the proportion with a hospital length of stay greater than 1 day (20% vs. 15%), ICU admission (1.5% vs. 2.3%), seizure duration of more than 15 minutes (16% vs. 12%), repeat seizures within 24 hours (9% vs. 10%), or discharge on antiepileptic medication (4.4% vs. 4.3%).
In the developmental outcomes analysis, 62 of the children with vaccine-proximate febrile seizures, 70 with vaccine-unrelated febrile seizures, and 85 healthy controls with no seizure history underwent formal assessment using the third edition of the Bayley Scales of Infant and Toddler Development 12-24 months after their initial febrile seizure. Scores adjusted for years of maternal education were closely similar in all three groups across all five test domains: cognitive, language, motor, social-emotional, and general-adaptive.
Dr. Deng reported having no financial conflicts of interest regarding the study, which was partially funded by the Australian National Centre for Immunisation Research and Surveillance.
REPORTING FROM ESPID 2018
Key clinical point: Parents now can confidently be reassured that vaccine-proximate febrile seizures have no long-term consequences.
Major finding: as in controls with no seizure history.
Study details: This prospective case-control study comprised 1,180 children at five Australian children’s hospitals.
Disclosures: The study was partially funded by the Australian National Centre for Immunisation Research and Surveillance. The presenter reported having no financial conflicts.
Trio of blood biomarkers elevated in children with LRTIs
TORONTO – While C-reactive protein, procalcitonin, and proadrenomedullin are associated with development of severe clinical outcomes in children with lower respiratory tract infections, proadrenomedullin is most strongly associated with disease severity, preliminary results from a prospective cohort study showed.
“Despite the fact that pneumonia guidelines call the site of care decision the most important decision in the management of pediatric pneumonia, no validated risk stratification tools exist for pediatric lower respiratory tract infections (LRTI),” lead study author Todd A. Florin, MD, said at the annual Pediatric Academic Societies meeting. “Biomarkers offer an objective means of classifying disease severity and clinical outcomes.”
PCT is a precursor of calcitonin secreted by the thyroid, lung, and intestine in response to bacterial infections. It also has been shown to be associated with adverse outcomes and mortality in adults, with results generally suggesting that it is a stronger predictor of severity than CRP. “There is limited data on the association of CRP or PCT with severe outcomes in children with LRTIs,” Dr. Florin noted. “One recent U.S. study of 532 children did demonstrate an association of elevated PCT with ICU admission, chest drainage, and hospital length of stay in children with [community-acquired pneumonia] CAP.”
ProADM, meanwhile, is a vasodilatory peptide with antimicrobial and anti-inflammatory functions synthesized during severe infections. It has a half-life of several hours and has been shown to be associated with disease severity in adults with LRTI. Recent studies have shown that it has improved prognostication over WBC, CRP, and PCT. “In two small studies of children with pneumonia, proADM levels were significantly elevated in children with complicated pneumonia, compared to those with uncomplicated pneumonia,” Dr. Florin said. “Although all three of these markers demonstrate promise in predicting severe outcomes in adults with LRTIs, very few studies have examined their association with disease severity in pediatric disease. Therefore, the aim of the current analysis was to determine the association between blood biomarkers and disease severity in children who present to the ED with lower respiratory tract infections.”
In a study known as Catalyzing Ambulatory Research in Pneumonia Etiology and Diagnostic Innovations in Emergency Medicine (CARPE DIEM), he and his associates performed a prospective cohort analysis of children with suspected CAP who were admitted to the Cincinnati Children’s Hospital ED between July 2012 and December 2017. They limited the analysis to children aged 3 months to 18 years with signs and symptoms of an LRTI, and all eligible patients were required to have a chest radiograph ordered for suspicion of CAP. They excluded children hospitalized within 14 days prior to the index ED visit, immunodeficient or immunosuppressed children, those with a history of aspiration or aspiration pneumonia, and those who weighed less than 5 kg because of blood drawing maximums. Biomarkers were measured only in children with focal findings on chest x-ray in the ED. The primary outcome was disease severity: mild (defined as discharged home), moderate (defined as hospitalized, but not severe) and severe (defined as having an ICU length of stay of greater than 48 hours, chest drainage, severe sepsis, noninvasive positive pressure ventilation, intubation, vasoactive infusions, or death). Biomarkers were obtained at the time of presentation to the ED, prior to the occurrence of clinical outcomes.
Over a period of 4.5 years, the researchers enrolled 1,142 patients. Of these, 478 had focal findings on chest x-ray and blood obtained. The median age of these 478 children was 4.4 years, 52% were male, and 82% had all three biomarkers performed. Specifically, 456 had CRP and PCT performed, while 358 had proADM performed. “Not every child had every marker performed due to challenges in obtaining sufficient blood for all three biomarkers in some children,” Dr. Florin explained.
Preliminary data that Dr. Florin presented at PAS found that the median CRP, PCT, and proADM did not differ by gender, race, ethnicity, or insurance status. “In addition, there were not significant differences in the distribution of disease severity by biomarker performed, with approximately 27% of patients being classified as mild, 66% as moderate, and 7% as severe,” he said.
The median CRP was 2.4 ng/mL in those with mild disease, 2.5 ng/mL in those with moderate disease, and 6.25 ng/mL in those with severe disease, with the difference between the two subclasses of nonsevere disease and moderate disease and severe disease reaching statistical significance (P = .002). The median PCT was 0.16 ng/mL in those with mild disease, 0.26 ng/mL in those with moderate disease, and 0.49 ng/mL in those with severe disease, with the difference between the two subclasses of nonsevere disease and moderate disease and severe disease reaching statistical significance (P = .047). Meanwhile, the median proADM was 0.53 ng/mL in those with mild disease, 0.59 ng/mL in those with moderate disease, and 0.81 ng/mL in those with severe disease, with the difference between the two subclasses of nonsevere disease and moderate disease and severe disease also reaching statistical significance (P less than .0001).
Next, the researchers performed logistic regression of each biomarker individually and in combination. They found that and had the best ability to discriminate those developing severe vs. nonsevere disease (area under the receiving operating curve of 0.72, vs. 0.67 and 0.60, respectively). When CRP and PCT markers were combined with proADM, they were no longer associated with severe disease, while a strong association with proADM remained significant.
Dr. Florin acknowledged certain limitations of the study, including the fact that requiring collection of blood samples may have resulted in an enrollment bias toward patients receiving phlebotomy or IV line placement in the ED. “In addition, the children in the moderate-severity group are likely more heterogeneous than the other two severity groups,” he said. “Finally, given that this is a single-center study, we had a relatively small number of outcomes for some of the individual severity measures, which may have limited power and precision.”
He concluded his presentation by saying that he is “cautiously optimistic” about the study results. “As is the case in many biomarker studies, I do not anticipate that any single biomarker will be the magic bullet for predicting disease severity in pediatric CAP,” Dr. Florin said. “It will likely be a combination of clinical factors and several biomarkers that will achieve optimal prognostic ability. That said, our results suggest that similar to adult studies, proADM appears to have the strongest association with severe disease, compared with CRP and PCT. Combinations of biomarkers did not perform better than proADM alone. With the advent of rapid point-of-care diagnostics, these markers may have a role in management and site-of-care decisions for children with LRTI.”
The study received funding support from the Gerber Foundation, the National Institute of Allergy and Infectious Diseases, and Cincinnati Children’s Hospital Medical Center. Dr. Florin reported having no financial disclosures.
TORONTO – While C-reactive protein, procalcitonin, and proadrenomedullin are associated with development of severe clinical outcomes in children with lower respiratory tract infections, proadrenomedullin is most strongly associated with disease severity, preliminary results from a prospective cohort study showed.
“Despite the fact that pneumonia guidelines call the site of care decision the most important decision in the management of pediatric pneumonia, no validated risk stratification tools exist for pediatric lower respiratory tract infections (LRTI),” lead study author Todd A. Florin, MD, said at the annual Pediatric Academic Societies meeting. “Biomarkers offer an objective means of classifying disease severity and clinical outcomes.”
PCT is a precursor of calcitonin secreted by the thyroid, lung, and intestine in response to bacterial infections. It also has been shown to be associated with adverse outcomes and mortality in adults, with results generally suggesting that it is a stronger predictor of severity than CRP. “There is limited data on the association of CRP or PCT with severe outcomes in children with LRTIs,” Dr. Florin noted. “One recent U.S. study of 532 children did demonstrate an association of elevated PCT with ICU admission, chest drainage, and hospital length of stay in children with [community-acquired pneumonia] CAP.”
ProADM, meanwhile, is a vasodilatory peptide with antimicrobial and anti-inflammatory functions synthesized during severe infections. It has a half-life of several hours and has been shown to be associated with disease severity in adults with LRTI. Recent studies have shown that it has improved prognostication over WBC, CRP, and PCT. “In two small studies of children with pneumonia, proADM levels were significantly elevated in children with complicated pneumonia, compared to those with uncomplicated pneumonia,” Dr. Florin said. “Although all three of these markers demonstrate promise in predicting severe outcomes in adults with LRTIs, very few studies have examined their association with disease severity in pediatric disease. Therefore, the aim of the current analysis was to determine the association between blood biomarkers and disease severity in children who present to the ED with lower respiratory tract infections.”
In a study known as Catalyzing Ambulatory Research in Pneumonia Etiology and Diagnostic Innovations in Emergency Medicine (CARPE DIEM), he and his associates performed a prospective cohort analysis of children with suspected CAP who were admitted to the Cincinnati Children’s Hospital ED between July 2012 and December 2017. They limited the analysis to children aged 3 months to 18 years with signs and symptoms of an LRTI, and all eligible patients were required to have a chest radiograph ordered for suspicion of CAP. They excluded children hospitalized within 14 days prior to the index ED visit, immunodeficient or immunosuppressed children, those with a history of aspiration or aspiration pneumonia, and those who weighed less than 5 kg because of blood drawing maximums. Biomarkers were measured only in children with focal findings on chest x-ray in the ED. The primary outcome was disease severity: mild (defined as discharged home), moderate (defined as hospitalized, but not severe) and severe (defined as having an ICU length of stay of greater than 48 hours, chest drainage, severe sepsis, noninvasive positive pressure ventilation, intubation, vasoactive infusions, or death). Biomarkers were obtained at the time of presentation to the ED, prior to the occurrence of clinical outcomes.
Over a period of 4.5 years, the researchers enrolled 1,142 patients. Of these, 478 had focal findings on chest x-ray and blood obtained. The median age of these 478 children was 4.4 years, 52% were male, and 82% had all three biomarkers performed. Specifically, 456 had CRP and PCT performed, while 358 had proADM performed. “Not every child had every marker performed due to challenges in obtaining sufficient blood for all three biomarkers in some children,” Dr. Florin explained.
Preliminary data that Dr. Florin presented at PAS found that the median CRP, PCT, and proADM did not differ by gender, race, ethnicity, or insurance status. “In addition, there were not significant differences in the distribution of disease severity by biomarker performed, with approximately 27% of patients being classified as mild, 66% as moderate, and 7% as severe,” he said.
The median CRP was 2.4 ng/mL in those with mild disease, 2.5 ng/mL in those with moderate disease, and 6.25 ng/mL in those with severe disease, with the difference between the two subclasses of nonsevere disease and moderate disease and severe disease reaching statistical significance (P = .002). The median PCT was 0.16 ng/mL in those with mild disease, 0.26 ng/mL in those with moderate disease, and 0.49 ng/mL in those with severe disease, with the difference between the two subclasses of nonsevere disease and moderate disease and severe disease reaching statistical significance (P = .047). Meanwhile, the median proADM was 0.53 ng/mL in those with mild disease, 0.59 ng/mL in those with moderate disease, and 0.81 ng/mL in those with severe disease, with the difference between the two subclasses of nonsevere disease and moderate disease and severe disease also reaching statistical significance (P less than .0001).
Next, the researchers performed logistic regression of each biomarker individually and in combination. They found that and had the best ability to discriminate those developing severe vs. nonsevere disease (area under the receiving operating curve of 0.72, vs. 0.67 and 0.60, respectively). When CRP and PCT markers were combined with proADM, they were no longer associated with severe disease, while a strong association with proADM remained significant.
Dr. Florin acknowledged certain limitations of the study, including the fact that requiring collection of blood samples may have resulted in an enrollment bias toward patients receiving phlebotomy or IV line placement in the ED. “In addition, the children in the moderate-severity group are likely more heterogeneous than the other two severity groups,” he said. “Finally, given that this is a single-center study, we had a relatively small number of outcomes for some of the individual severity measures, which may have limited power and precision.”
He concluded his presentation by saying that he is “cautiously optimistic” about the study results. “As is the case in many biomarker studies, I do not anticipate that any single biomarker will be the magic bullet for predicting disease severity in pediatric CAP,” Dr. Florin said. “It will likely be a combination of clinical factors and several biomarkers that will achieve optimal prognostic ability. That said, our results suggest that similar to adult studies, proADM appears to have the strongest association with severe disease, compared with CRP and PCT. Combinations of biomarkers did not perform better than proADM alone. With the advent of rapid point-of-care diagnostics, these markers may have a role in management and site-of-care decisions for children with LRTI.”
The study received funding support from the Gerber Foundation, the National Institute of Allergy and Infectious Diseases, and Cincinnati Children’s Hospital Medical Center. Dr. Florin reported having no financial disclosures.
TORONTO – While C-reactive protein, procalcitonin, and proadrenomedullin are associated with development of severe clinical outcomes in children with lower respiratory tract infections, proadrenomedullin is most strongly associated with disease severity, preliminary results from a prospective cohort study showed.
“Despite the fact that pneumonia guidelines call the site of care decision the most important decision in the management of pediatric pneumonia, no validated risk stratification tools exist for pediatric lower respiratory tract infections (LRTI),” lead study author Todd A. Florin, MD, said at the annual Pediatric Academic Societies meeting. “Biomarkers offer an objective means of classifying disease severity and clinical outcomes.”
PCT is a precursor of calcitonin secreted by the thyroid, lung, and intestine in response to bacterial infections. It also has been shown to be associated with adverse outcomes and mortality in adults, with results generally suggesting that it is a stronger predictor of severity than CRP. “There is limited data on the association of CRP or PCT with severe outcomes in children with LRTIs,” Dr. Florin noted. “One recent U.S. study of 532 children did demonstrate an association of elevated PCT with ICU admission, chest drainage, and hospital length of stay in children with [community-acquired pneumonia] CAP.”
ProADM, meanwhile, is a vasodilatory peptide with antimicrobial and anti-inflammatory functions synthesized during severe infections. It has a half-life of several hours and has been shown to be associated with disease severity in adults with LRTI. Recent studies have shown that it has improved prognostication over WBC, CRP, and PCT. “In two small studies of children with pneumonia, proADM levels were significantly elevated in children with complicated pneumonia, compared to those with uncomplicated pneumonia,” Dr. Florin said. “Although all three of these markers demonstrate promise in predicting severe outcomes in adults with LRTIs, very few studies have examined their association with disease severity in pediatric disease. Therefore, the aim of the current analysis was to determine the association between blood biomarkers and disease severity in children who present to the ED with lower respiratory tract infections.”
In a study known as Catalyzing Ambulatory Research in Pneumonia Etiology and Diagnostic Innovations in Emergency Medicine (CARPE DIEM), he and his associates performed a prospective cohort analysis of children with suspected CAP who were admitted to the Cincinnati Children’s Hospital ED between July 2012 and December 2017. They limited the analysis to children aged 3 months to 18 years with signs and symptoms of an LRTI, and all eligible patients were required to have a chest radiograph ordered for suspicion of CAP. They excluded children hospitalized within 14 days prior to the index ED visit, immunodeficient or immunosuppressed children, those with a history of aspiration or aspiration pneumonia, and those who weighed less than 5 kg because of blood drawing maximums. Biomarkers were measured only in children with focal findings on chest x-ray in the ED. The primary outcome was disease severity: mild (defined as discharged home), moderate (defined as hospitalized, but not severe) and severe (defined as having an ICU length of stay of greater than 48 hours, chest drainage, severe sepsis, noninvasive positive pressure ventilation, intubation, vasoactive infusions, or death). Biomarkers were obtained at the time of presentation to the ED, prior to the occurrence of clinical outcomes.
Over a period of 4.5 years, the researchers enrolled 1,142 patients. Of these, 478 had focal findings on chest x-ray and blood obtained. The median age of these 478 children was 4.4 years, 52% were male, and 82% had all three biomarkers performed. Specifically, 456 had CRP and PCT performed, while 358 had proADM performed. “Not every child had every marker performed due to challenges in obtaining sufficient blood for all three biomarkers in some children,” Dr. Florin explained.
Preliminary data that Dr. Florin presented at PAS found that the median CRP, PCT, and proADM did not differ by gender, race, ethnicity, or insurance status. “In addition, there were not significant differences in the distribution of disease severity by biomarker performed, with approximately 27% of patients being classified as mild, 66% as moderate, and 7% as severe,” he said.
The median CRP was 2.4 ng/mL in those with mild disease, 2.5 ng/mL in those with moderate disease, and 6.25 ng/mL in those with severe disease, with the difference between the two subclasses of nonsevere disease and moderate disease and severe disease reaching statistical significance (P = .002). The median PCT was 0.16 ng/mL in those with mild disease, 0.26 ng/mL in those with moderate disease, and 0.49 ng/mL in those with severe disease, with the difference between the two subclasses of nonsevere disease and moderate disease and severe disease reaching statistical significance (P = .047). Meanwhile, the median proADM was 0.53 ng/mL in those with mild disease, 0.59 ng/mL in those with moderate disease, and 0.81 ng/mL in those with severe disease, with the difference between the two subclasses of nonsevere disease and moderate disease and severe disease also reaching statistical significance (P less than .0001).
Next, the researchers performed logistic regression of each biomarker individually and in combination. They found that and had the best ability to discriminate those developing severe vs. nonsevere disease (area under the receiving operating curve of 0.72, vs. 0.67 and 0.60, respectively). When CRP and PCT markers were combined with proADM, they were no longer associated with severe disease, while a strong association with proADM remained significant.
Dr. Florin acknowledged certain limitations of the study, including the fact that requiring collection of blood samples may have resulted in an enrollment bias toward patients receiving phlebotomy or IV line placement in the ED. “In addition, the children in the moderate-severity group are likely more heterogeneous than the other two severity groups,” he said. “Finally, given that this is a single-center study, we had a relatively small number of outcomes for some of the individual severity measures, which may have limited power and precision.”
He concluded his presentation by saying that he is “cautiously optimistic” about the study results. “As is the case in many biomarker studies, I do not anticipate that any single biomarker will be the magic bullet for predicting disease severity in pediatric CAP,” Dr. Florin said. “It will likely be a combination of clinical factors and several biomarkers that will achieve optimal prognostic ability. That said, our results suggest that similar to adult studies, proADM appears to have the strongest association with severe disease, compared with CRP and PCT. Combinations of biomarkers did not perform better than proADM alone. With the advent of rapid point-of-care diagnostics, these markers may have a role in management and site-of-care decisions for children with LRTI.”
The study received funding support from the Gerber Foundation, the National Institute of Allergy and Infectious Diseases, and Cincinnati Children’s Hospital Medical Center. Dr. Florin reported having no financial disclosures.
AT PAS 18
Key clinical point: Blood biomarkers such as C-reactive protein (CRP), procalcitonin (PCT), and proadrenomedullin (proADM) may have a role in management and site-of-care decisions for children with LRTIs.
Major finding: The proADM alone was associated with the largest odds for severe disease (OR 13.1), compared with CRP alone (OR 1.6) and PCT alone (OR 1.4).
Study details: Preliminary results from prospective cohort analysis of 478 children with suspected community-acquired pneumonia who were admitted to the Cincinnati Children’s Hospital ED.
Disclosures: The study received funding support from the Gerber Foundation, the National Institute of Allergy and Infectious Diseases, and Cincinnati Children’s Hospital Medical Center. Dr. Florin reported having no financial disclosures.
Maintenance chemo boosts survival for youth with high-risk rhabdomyosarcoma
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
CHICAGO – Maintenance chemotherapy is life-prolonging for youth with high-risk rhabdomyosarcoma, finds a trial of 371 patients aged 0 to 21 years who had completed standard intensive therapy.
The 5-year rate of overall survival was 86.5% for those who received maintenance therapy with the combination of low-dose intravenous vinorelbine and oral cyclophosphamide, compared with 73.7% for those who did not, translating to a near halving of the risk of death (hazard ratio, 0.52; P = .0111). The regimen was well tolerated.
In an interview at the annual meeting of the American Society of Clinical Oncology, lead study author Gianni Bisogno, MD, PhD, discussed the risk-benefit profile of maintenance chemotherapy and the practice-changing nature of the new data. Dr. Bisogno, a professor at the University Hospital of Padova in Italy and chair of the European Paediatric Soft tissue Sarcoma Study Group, also described plans for a new trial that will explore alternate maintenance schedules and collaboration with colleagues in North America to further improve pediatric rhabdomyosarcoma outcomes.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
CHICAGO – Maintenance chemotherapy is life-prolonging for youth with high-risk rhabdomyosarcoma, finds a trial of 371 patients aged 0 to 21 years who had completed standard intensive therapy.
The 5-year rate of overall survival was 86.5% for those who received maintenance therapy with the combination of low-dose intravenous vinorelbine and oral cyclophosphamide, compared with 73.7% for those who did not, translating to a near halving of the risk of death (hazard ratio, 0.52; P = .0111). The regimen was well tolerated.
In an interview at the annual meeting of the American Society of Clinical Oncology, lead study author Gianni Bisogno, MD, PhD, discussed the risk-benefit profile of maintenance chemotherapy and the practice-changing nature of the new data. Dr. Bisogno, a professor at the University Hospital of Padova in Italy and chair of the European Paediatric Soft tissue Sarcoma Study Group, also described plans for a new trial that will explore alternate maintenance schedules and collaboration with colleagues in North America to further improve pediatric rhabdomyosarcoma outcomes.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
CHICAGO – Maintenance chemotherapy is life-prolonging for youth with high-risk rhabdomyosarcoma, finds a trial of 371 patients aged 0 to 21 years who had completed standard intensive therapy.
The 5-year rate of overall survival was 86.5% for those who received maintenance therapy with the combination of low-dose intravenous vinorelbine and oral cyclophosphamide, compared with 73.7% for those who did not, translating to a near halving of the risk of death (hazard ratio, 0.52; P = .0111). The regimen was well tolerated.
In an interview at the annual meeting of the American Society of Clinical Oncology, lead study author Gianni Bisogno, MD, PhD, discussed the risk-benefit profile of maintenance chemotherapy and the practice-changing nature of the new data. Dr. Bisogno, a professor at the University Hospital of Padova in Italy and chair of the European Paediatric Soft tissue Sarcoma Study Group, also described plans for a new trial that will explore alternate maintenance schedules and collaboration with colleagues in North America to further improve pediatric rhabdomyosarcoma outcomes.
REPORTING FROM ASCO 2018
It’s not about time
Like most couples of retirement age, rituals dominate our breakfasts. I eat eggs. Marilyn leans toward baked goods. We each have a bowl of fruit and finish by working the New York Times mini-crossword on our electronic devices. Solving it usually takes somewhere between 40 seconds and 4 minutes. The challenge lies in how fast one can complete the puzzle. And, being who we are, Marilyn and I have ritualized this into a serious competition. She usually takes the first turn and then tries to psyche me out by announcing, “I did it in 2:34, but you should be able to solve it in less than 2 minutes.” This bit of gamesmanship often means that I am going to start the day with thin layer of nervous perspiration.
The claimed disabilities range from an anxiety disorder and ADHD to a problem with reading comprehension. The number of students requesting a test environment modification at Pomona College, Claremont, Calif., is 22% up from 5% in 2014. At Marlboro College in Vermont, one in three students asks for more time or a less distracting setting.
This phenomenon raises two obvious questions. First, what has happened to the bell-shaped curve? Was it too boring hanging out with all those people under the bell? Do folks feel safer and more secure in the tails? I guess we have to be happy that young people are less afraid to admit they are different. But it does make one wonder how we should go about defining a disability.
The second question is whether timed tests deserve a place in our educational toolbox? How often is processing speed important? I would like the woman piloting my flight to San Francisco to be quick-witted. But what about the research chemist working on a more durable tire compound? Is it a problem that it took him 30% longer than his classmates to successfully finish his college statistics final exam?
What about the lawyer who bills you $500 per hour to review the contract with your employer? It might have been helpful to know before you hired him that he routinely requested an extra hour and a half to complete his exams in law school. But I suspect that for the most part timed tests probably don’t produce better graduates. In the past they may have been used to thin oversubscribed disciplines, and certainly time limits have been the norm at every level of education I encountered. However, the best taught courses had exams with an abundance of time. Either you knew the information or you didn’t. An extra 2 hours wasn’t going to make a difference.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.
Like most couples of retirement age, rituals dominate our breakfasts. I eat eggs. Marilyn leans toward baked goods. We each have a bowl of fruit and finish by working the New York Times mini-crossword on our electronic devices. Solving it usually takes somewhere between 40 seconds and 4 minutes. The challenge lies in how fast one can complete the puzzle. And, being who we are, Marilyn and I have ritualized this into a serious competition. She usually takes the first turn and then tries to psyche me out by announcing, “I did it in 2:34, but you should be able to solve it in less than 2 minutes.” This bit of gamesmanship often means that I am going to start the day with thin layer of nervous perspiration.
The claimed disabilities range from an anxiety disorder and ADHD to a problem with reading comprehension. The number of students requesting a test environment modification at Pomona College, Claremont, Calif., is 22% up from 5% in 2014. At Marlboro College in Vermont, one in three students asks for more time or a less distracting setting.
This phenomenon raises two obvious questions. First, what has happened to the bell-shaped curve? Was it too boring hanging out with all those people under the bell? Do folks feel safer and more secure in the tails? I guess we have to be happy that young people are less afraid to admit they are different. But it does make one wonder how we should go about defining a disability.
The second question is whether timed tests deserve a place in our educational toolbox? How often is processing speed important? I would like the woman piloting my flight to San Francisco to be quick-witted. But what about the research chemist working on a more durable tire compound? Is it a problem that it took him 30% longer than his classmates to successfully finish his college statistics final exam?
What about the lawyer who bills you $500 per hour to review the contract with your employer? It might have been helpful to know before you hired him that he routinely requested an extra hour and a half to complete his exams in law school. But I suspect that for the most part timed tests probably don’t produce better graduates. In the past they may have been used to thin oversubscribed disciplines, and certainly time limits have been the norm at every level of education I encountered. However, the best taught courses had exams with an abundance of time. Either you knew the information or you didn’t. An extra 2 hours wasn’t going to make a difference.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.
Like most couples of retirement age, rituals dominate our breakfasts. I eat eggs. Marilyn leans toward baked goods. We each have a bowl of fruit and finish by working the New York Times mini-crossword on our electronic devices. Solving it usually takes somewhere between 40 seconds and 4 minutes. The challenge lies in how fast one can complete the puzzle. And, being who we are, Marilyn and I have ritualized this into a serious competition. She usually takes the first turn and then tries to psyche me out by announcing, “I did it in 2:34, but you should be able to solve it in less than 2 minutes.” This bit of gamesmanship often means that I am going to start the day with thin layer of nervous perspiration.
The claimed disabilities range from an anxiety disorder and ADHD to a problem with reading comprehension. The number of students requesting a test environment modification at Pomona College, Claremont, Calif., is 22% up from 5% in 2014. At Marlboro College in Vermont, one in three students asks for more time or a less distracting setting.
This phenomenon raises two obvious questions. First, what has happened to the bell-shaped curve? Was it too boring hanging out with all those people under the bell? Do folks feel safer and more secure in the tails? I guess we have to be happy that young people are less afraid to admit they are different. But it does make one wonder how we should go about defining a disability.
The second question is whether timed tests deserve a place in our educational toolbox? How often is processing speed important? I would like the woman piloting my flight to San Francisco to be quick-witted. But what about the research chemist working on a more durable tire compound? Is it a problem that it took him 30% longer than his classmates to successfully finish his college statistics final exam?
What about the lawyer who bills you $500 per hour to review the contract with your employer? It might have been helpful to know before you hired him that he routinely requested an extra hour and a half to complete his exams in law school. But I suspect that for the most part timed tests probably don’t produce better graduates. In the past they may have been used to thin oversubscribed disciplines, and certainly time limits have been the norm at every level of education I encountered. However, the best taught courses had exams with an abundance of time. Either you knew the information or you didn’t. An extra 2 hours wasn’t going to make a difference.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.
Pediatric Dermatology Consult - June 2018
The patient was diagnosed with granuloma annulare on the basis of history and clinical exam. A potassium hydroxide prep of skin scrapings was performed to rule out tinea corporis, and did not show evidence of fungal elements. The patient was treated with topical betamethasone with partial improvement.
First described as a “ringed eruption of the fingers” by Thomas Colcott Fox in 1895, granuloma annulare (GA) is a relatively common, benign, and self-limited condition whose precise etiology remains unclear. It is characterized commonly by pink to violaceous aciform or annular plaques on clinical examination. In some cases of GA, annular lesions are not present, or may be formed of grouped papules.
GA is characterized histologically by patchy interstitial lymphocytes and histiocytes palisading around mucin. Deep GA, an unusual subtype observed only in children, features a fibrin rather than a mucin core. This granulomatous picture is consistent with a Th1-mediated inflammatory process, and indeed, macrophage tumor necrosis factor production, as well as interleukin-2 and interferon-gamma production have been observed in GA. The reason for this exaggerated Th1 response is unknown, although in susceptible individuals trauma3 (an example of the Koebner phenomenon), arthropod assault,4 and herpes simplex infection5 (an example of Wolf isotopic response) all have been observed to trigger localized and/or generalized GA. Generalized GA has been associated with hyperlipidemia and the human leukocyte antigen–BW35 allele. GA has been described as a paraneoplastic eruption; atypical features such as associated pain or appearance in an uncharacteristic location often are present in such cases.6,7
Diagnosis of typical GA is clinical. If unusual features make you suspect tinea, leprosy, mycosis fungoides, or other annular lesions, then biopsy showing features typical of GA can reveal the correct diagnosis. Biopsy also can help to distinguish papular GA from warts or molluscum contagiosum. If extensive GA are present, then serum lipid testing for hypercholesterolemia or hypertriglyceridemia should be considered.
Other annular and raised lesions are on the differential for GA, but careful attention to the patient’s history and examination can clarify the diagnosis. Urticaria multiforme, a variant of annular urticaria, presents with numerous annular and polycyclic wheals, sometimes with central darkening that may be mistaken for necrosis. This patient did not present with polycyclic wheals. Furthermore, the lesions in urticaria multiforme are typically transient, with individual lesions lasting less than 24 hours, which was not the case with this patient. Wells syndrome, also known as eosinophilic cellulitis, is a condition marked by recurrent episodes of pruritus followed by appearance of edematous, painful, indurated, or edematous papules or plaques, although bullae and vesicles also may be present. The face and extremities are frequently involved and spontaneous resolution typically occurs in 2 months. Annular lesions are possible but papules, plaques, and nodules are more common in Wells syndrome. Annular elastolytic giant cell granuloma (AEGCG), also known as actinic granuloma and Miescher granuloma of the face, is an entity characterized clinically by chronic, persistent, sun-distributed, annular plaques typically seen in older women with significant sun damage. AEGCG is considered by some to be a variant of GA, but if this is the case, it is a distinct subtype with different epidemiologic, clinical, and histopathologic characteristics from GA. Interstitial granulomatous dermatitis is histologically and clinically distinct from GA, presenting as subtly erythematous cords or extensive annular or serpiginous plaques in the axilla, groin, buttocks, or chest, typically in adult patients with rheumatoid arthritis, reactive arthritis, psoriatic arthritis, or ankylosing spondylitis. Tinea corporis, the clinical manifestation of cutaneous dermatophyte infection, may be mistaken for granuloma annulare. However, tinea corporis lesions are scaly, whereas GA does not scale. Histologic examination of tinea corporis reveals hyphae, which are not present in GA.
GA is a relatively common, idiopathic, benign skin disease with numerous annular and papular mimics. Absence of scale, pain, and significant pruritus are important clues to the diagnosis, and biopsy can be helpful when the diagnosis is unclear. Treatment, although not necessary, may be offered using any of a number of modalities. The most consistent and effective healer of GA, however, is time.
References
1. J Am Acad Dermatol. 1980 Sep;3(3):217-30.
2. J Am Acad Dermatol. 2016 Sep;75(3):457-65.
3. Dermatol Online J. 2013 Dec 16;19(12):20719.
4. Acta Derm Venereol. 2008;88(5):519-20.
5. J Cutan Med Surg. 2014 Nov;18(6):413-9.
6. South Med J. 1997 Oct;90(10):1056-9.
7. Am J Dermatopathol. 2003 Apr;25(2):113-6.
8. Am J Clin Dermatol. 2013 Aug;14(4):279-90.
9. Br J Dermatol. 1994 Apr;130(4):494-7.
The patient was diagnosed with granuloma annulare on the basis of history and clinical exam. A potassium hydroxide prep of skin scrapings was performed to rule out tinea corporis, and did not show evidence of fungal elements. The patient was treated with topical betamethasone with partial improvement.
First described as a “ringed eruption of the fingers” by Thomas Colcott Fox in 1895, granuloma annulare (GA) is a relatively common, benign, and self-limited condition whose precise etiology remains unclear. It is characterized commonly by pink to violaceous aciform or annular plaques on clinical examination. In some cases of GA, annular lesions are not present, or may be formed of grouped papules.
GA is characterized histologically by patchy interstitial lymphocytes and histiocytes palisading around mucin. Deep GA, an unusual subtype observed only in children, features a fibrin rather than a mucin core. This granulomatous picture is consistent with a Th1-mediated inflammatory process, and indeed, macrophage tumor necrosis factor production, as well as interleukin-2 and interferon-gamma production have been observed in GA. The reason for this exaggerated Th1 response is unknown, although in susceptible individuals trauma3 (an example of the Koebner phenomenon), arthropod assault,4 and herpes simplex infection5 (an example of Wolf isotopic response) all have been observed to trigger localized and/or generalized GA. Generalized GA has been associated with hyperlipidemia and the human leukocyte antigen–BW35 allele. GA has been described as a paraneoplastic eruption; atypical features such as associated pain or appearance in an uncharacteristic location often are present in such cases.6,7
Diagnosis of typical GA is clinical. If unusual features make you suspect tinea, leprosy, mycosis fungoides, or other annular lesions, then biopsy showing features typical of GA can reveal the correct diagnosis. Biopsy also can help to distinguish papular GA from warts or molluscum contagiosum. If extensive GA are present, then serum lipid testing for hypercholesterolemia or hypertriglyceridemia should be considered.
Other annular and raised lesions are on the differential for GA, but careful attention to the patient’s history and examination can clarify the diagnosis. Urticaria multiforme, a variant of annular urticaria, presents with numerous annular and polycyclic wheals, sometimes with central darkening that may be mistaken for necrosis. This patient did not present with polycyclic wheals. Furthermore, the lesions in urticaria multiforme are typically transient, with individual lesions lasting less than 24 hours, which was not the case with this patient. Wells syndrome, also known as eosinophilic cellulitis, is a condition marked by recurrent episodes of pruritus followed by appearance of edematous, painful, indurated, or edematous papules or plaques, although bullae and vesicles also may be present. The face and extremities are frequently involved and spontaneous resolution typically occurs in 2 months. Annular lesions are possible but papules, plaques, and nodules are more common in Wells syndrome. Annular elastolytic giant cell granuloma (AEGCG), also known as actinic granuloma and Miescher granuloma of the face, is an entity characterized clinically by chronic, persistent, sun-distributed, annular plaques typically seen in older women with significant sun damage. AEGCG is considered by some to be a variant of GA, but if this is the case, it is a distinct subtype with different epidemiologic, clinical, and histopathologic characteristics from GA. Interstitial granulomatous dermatitis is histologically and clinically distinct from GA, presenting as subtly erythematous cords or extensive annular or serpiginous plaques in the axilla, groin, buttocks, or chest, typically in adult patients with rheumatoid arthritis, reactive arthritis, psoriatic arthritis, or ankylosing spondylitis. Tinea corporis, the clinical manifestation of cutaneous dermatophyte infection, may be mistaken for granuloma annulare. However, tinea corporis lesions are scaly, whereas GA does not scale. Histologic examination of tinea corporis reveals hyphae, which are not present in GA.
GA is a relatively common, idiopathic, benign skin disease with numerous annular and papular mimics. Absence of scale, pain, and significant pruritus are important clues to the diagnosis, and biopsy can be helpful when the diagnosis is unclear. Treatment, although not necessary, may be offered using any of a number of modalities. The most consistent and effective healer of GA, however, is time.
References
1. J Am Acad Dermatol. 1980 Sep;3(3):217-30.
2. J Am Acad Dermatol. 2016 Sep;75(3):457-65.
3. Dermatol Online J. 2013 Dec 16;19(12):20719.
4. Acta Derm Venereol. 2008;88(5):519-20.
5. J Cutan Med Surg. 2014 Nov;18(6):413-9.
6. South Med J. 1997 Oct;90(10):1056-9.
7. Am J Dermatopathol. 2003 Apr;25(2):113-6.
8. Am J Clin Dermatol. 2013 Aug;14(4):279-90.
9. Br J Dermatol. 1994 Apr;130(4):494-7.
The patient was diagnosed with granuloma annulare on the basis of history and clinical exam. A potassium hydroxide prep of skin scrapings was performed to rule out tinea corporis, and did not show evidence of fungal elements. The patient was treated with topical betamethasone with partial improvement.
First described as a “ringed eruption of the fingers” by Thomas Colcott Fox in 1895, granuloma annulare (GA) is a relatively common, benign, and self-limited condition whose precise etiology remains unclear. It is characterized commonly by pink to violaceous aciform or annular plaques on clinical examination. In some cases of GA, annular lesions are not present, or may be formed of grouped papules.
GA is characterized histologically by patchy interstitial lymphocytes and histiocytes palisading around mucin. Deep GA, an unusual subtype observed only in children, features a fibrin rather than a mucin core. This granulomatous picture is consistent with a Th1-mediated inflammatory process, and indeed, macrophage tumor necrosis factor production, as well as interleukin-2 and interferon-gamma production have been observed in GA. The reason for this exaggerated Th1 response is unknown, although in susceptible individuals trauma3 (an example of the Koebner phenomenon), arthropod assault,4 and herpes simplex infection5 (an example of Wolf isotopic response) all have been observed to trigger localized and/or generalized GA. Generalized GA has been associated with hyperlipidemia and the human leukocyte antigen–BW35 allele. GA has been described as a paraneoplastic eruption; atypical features such as associated pain or appearance in an uncharacteristic location often are present in such cases.6,7
Diagnosis of typical GA is clinical. If unusual features make you suspect tinea, leprosy, mycosis fungoides, or other annular lesions, then biopsy showing features typical of GA can reveal the correct diagnosis. Biopsy also can help to distinguish papular GA from warts or molluscum contagiosum. If extensive GA are present, then serum lipid testing for hypercholesterolemia or hypertriglyceridemia should be considered.
Other annular and raised lesions are on the differential for GA, but careful attention to the patient’s history and examination can clarify the diagnosis. Urticaria multiforme, a variant of annular urticaria, presents with numerous annular and polycyclic wheals, sometimes with central darkening that may be mistaken for necrosis. This patient did not present with polycyclic wheals. Furthermore, the lesions in urticaria multiforme are typically transient, with individual lesions lasting less than 24 hours, which was not the case with this patient. Wells syndrome, also known as eosinophilic cellulitis, is a condition marked by recurrent episodes of pruritus followed by appearance of edematous, painful, indurated, or edematous papules or plaques, although bullae and vesicles also may be present. The face and extremities are frequently involved and spontaneous resolution typically occurs in 2 months. Annular lesions are possible but papules, plaques, and nodules are more common in Wells syndrome. Annular elastolytic giant cell granuloma (AEGCG), also known as actinic granuloma and Miescher granuloma of the face, is an entity characterized clinically by chronic, persistent, sun-distributed, annular plaques typically seen in older women with significant sun damage. AEGCG is considered by some to be a variant of GA, but if this is the case, it is a distinct subtype with different epidemiologic, clinical, and histopathologic characteristics from GA. Interstitial granulomatous dermatitis is histologically and clinically distinct from GA, presenting as subtly erythematous cords or extensive annular or serpiginous plaques in the axilla, groin, buttocks, or chest, typically in adult patients with rheumatoid arthritis, reactive arthritis, psoriatic arthritis, or ankylosing spondylitis. Tinea corporis, the clinical manifestation of cutaneous dermatophyte infection, may be mistaken for granuloma annulare. However, tinea corporis lesions are scaly, whereas GA does not scale. Histologic examination of tinea corporis reveals hyphae, which are not present in GA.
GA is a relatively common, idiopathic, benign skin disease with numerous annular and papular mimics. Absence of scale, pain, and significant pruritus are important clues to the diagnosis, and biopsy can be helpful when the diagnosis is unclear. Treatment, although not necessary, may be offered using any of a number of modalities. The most consistent and effective healer of GA, however, is time.
References
1. J Am Acad Dermatol. 1980 Sep;3(3):217-30.
2. J Am Acad Dermatol. 2016 Sep;75(3):457-65.
3. Dermatol Online J. 2013 Dec 16;19(12):20719.
4. Acta Derm Venereol. 2008;88(5):519-20.
5. J Cutan Med Surg. 2014 Nov;18(6):413-9.
6. South Med J. 1997 Oct;90(10):1056-9.
7. Am J Dermatopathol. 2003 Apr;25(2):113-6.
8. Am J Clin Dermatol. 2013 Aug;14(4):279-90.
9. Br J Dermatol. 1994 Apr;130(4):494-7.
A 9-year-old girl presented to the dermatology clinic, referred by her pediatrician, for evaluation of asymptomatic lesions on her shins and feet for 2 months. She started developing one lesion over her right shin with other lesions appearing on the opposite leg a few weeks after, and treated the areas initially with an over-the-counter antifungal cream without improvement. She has been healthy and denied any recent fevers or upper respiratory infections, and said she had not taken any medications or vitamin supplements. She reported camping with her father occasionally but denied any bug or tick bites. No other family members were affected. There was no personal or family history of diabetes mellitus or high cholesterol, and there are no pets at home.