Tuesday, May 26, 2015

What's In a Name? Neurobehavioral Disorder with Prenatal Alcohol Exposure (ND-PAE)

This is the second of the 2 articles on fetal alcohol syndrome (aka ND-PAE) in the June AAP Grand Rounds. Maybe I'm testy and in need of a vacation, but I found this article to be unnecessarily difficult to unravel and find a real take-home message.

Source: Chasnoff IJ, Wells AM, King L. Misdiagnosis and missed diagnosis in foster and adopted children with prenatal alcohol exposure. Pediatrics. 2015;135(2):264-270; doi:10.1542/peds.2014-2171. See AAP Grand Rounds commentary by Dr. Emily Todd (subscription required).

PICO Question: Among foster or adopted children referred for mental health evaluation, what is the frequency of missed diagnosis and misdiagnosis of fetal alcohol spectrum disorders?
Question type: Diagnosis
Study design: Retrospective chart review

Tuesday, May 19, 2015

Can Pregnant Women Safely Drink Alcohol Now?

Is there any amount of alcohol consumption in pregnancy that can be deemed safe for the fetus? Well, possibly, but we still don't know what that amount should be. This study advances our knowledge, and is interesting in that it is a prospective study with some of the perils of retrospective data collection.

Source: Lundsberg LS, Illuzzi JL, Belanger K, et al. Low-to-moderate alcohol consumption and the risk of selected birth outcomes: a prospective cohort study. Ann Epidemiol. 2015;25(1):46-52; doi:10.1016/j.annepidem.2014.10.011. See AAP Grand Rounds commentary by Dr. Ronald Holmes (subscription required). 

PICO Question: Among pregnant women with a singleton gestation resulting in a live birth, is low to moderate prenatal alcohol exposure associated with selected adverse birth outcomes compared to women who did not drink alcohol during pregnancy?
Question type: Harm/Causation
Study design: Prospective cohort

Tuesday, May 12, 2015

What's the Best Hospital for My Child's Heart Surgery?

I can certainly imagine parents of a child with complex congenital heart disease asking such a question. Wouldn't it be nice to be able to give them an answer? Well, this study provides some guidelines, but a straight answer actually runs a very crooked path.

Source: Chan T, Kim J, Minich L, et al. Surgical volume, hospital quality, and hospitalization cost in congenital heart surgery in the United States. PediatrCardiol. 2015;36(1):205-213; doi:10.1007/s00246-014-0987-2. See AAP Grand Rounds commentary by Dr. Jeffrey Anderson (subscription required).

PICO Question: Among hospitals where surgery for congenital heart disease is performed, what is the relationship between surgical volume and hospitalization costs?
Question type: Descriptive
Study design: Retrospective cross-sectional

Tuesday, May 5, 2015

Playing the CONSORT Game: Issues with Randomization and Bias in Clinical Trials

I used this article as an example several weeks ago for a discussion with pediatric residents and medical students on interpreting clinical studies of treatments. It had just the right amount of concerns - not too flagrant, but enough to give caution in using the results. Maybe next time the authors will pay more attention to CONSORT.

Source: Gupta SK, Vitanza JM, and Collins MH. Efficacy and safety of oral budesonide suspension in pediatric patients with eosinophilic esophagitis. Clin Gastroenterol Hepatol. 2015;13(1):66-76.e3; doi:10.1016/j.cgh.2014.05.021. See AAP Grand Rounds commentary by Drs. Michael Herzlinger and Albert Ross (subscription required).

PICO Question: Among children with eosinophilic esophagitis, is oral budesonide suspension an effective therapy compared to placebo, and what dose is most effective?
Question type: Intervention
Study design: Randomized controlled trial

Friday, May 1, 2015

May Day in Evidence-Land

Colleagues and trainees at my institution sometimes are surprised that I use Wikipedia for some information sources, but in fact it's not bad in terms of providing evidence-based information for many topics, as long as they are accessed reasonably frequently (and thus errors and pranks are corrected sooner) and they have adequate reference information (beware the topics that Wikipedia editors have labelled as needing better documentation). So, it shouldn't be surprising that I turned to Wikipedia to look up some May Day "evidence." Sadly, it has a nice example of the "needs additional citations" comment. Still, I was interested to learn that the concept started in ancient Rome and that, among other features, it was commonly celebrated at women's colleges and other academic institutions about a hundred years ago.

Starting on May Day 2015, the fortunate subscribers among you will be able to access this month's complete AAP Grand Rounds commentaries, that include articles on live versus killed influenza vaccine (BTW, recommendations have changed with live vaccine no longer preferred for the 2-8 year olds), fathers' roles in breastfeeding, and emergency department visits for cancer patients, among others.

In the upcoming Tuesdays this month I'll be commenting on 2 separate articles related to fetal alcohol syndrome, treatment for eosinophilic esophagitis (is this a new fad diagnosis?), and links between surgical volume and costs/outcomes for complicated cardiac surgery.

Also, I know you're waiting with bated breath as am I, this month we'll see the 2015 edition of the Red Book!

Tuesday, April 28, 2015

Breastfeeding and Obesity - More Controversy!

From an evidence perspective, I think the whole "breast is best" dictum intrigues me more than any other topic. I think the statement, on the surface, is likely to be true; I've certainly seen nothing to contradict that. However, and what an evidence-based approach provides, we don't really have a great understanding of the magnitude of the benefits of breastfeeding. Such an understanding would add much to our discussions with young mothers and mothers-to-be about breastfeeding. The study reviewed here is another good step towards developing that knowledge base.

Source: Carling SJ, Demment MM, Kjolhede CL, et al. Breastfeeding duration and weight
gain trajectory in infancy. Pediatrics. 2015;135(1):111-119; doi:10.1542/peds.2014-1392. See AAP Grand Rounds commentary by Dr. Lawrence Noble (subscription required). 

PICO Question: Among infants at higher risk for obesity, how does duration of breastfeeding affect the rate of weight gain?
Question type: Causation
Study design: Prospective cohort

Tuesday, April 21, 2015

Pelvic Fractures: Know Your Test Limitations

This study, one of the many gushing from the Pediatric Emergency Care Applied Research Network (PECARN), gives us a chance to review issues with prospective observational studies as well as what makes a good screening test.

Source: Kwok MY, Yen K, Atabaki S, et al. Sensitivity of plain pelvis radiography in children with blunt torso trauma. Ann Emerg Med. 2015;63(1):63-71; doi:10.1016/j.annemergmed.2014.06.017. See AAP Grand Rounds commentary by Dr. Pamela Okada (subscription required). 

PICO Question: Among children with blunt torso trauma, what is the sensitivity of plain anteroposterior radiographs for identifying pelvic fractures or dislocations?
Question type: Diagnosis
Study design: Prospective cohort

Tuesday, April 14, 2015

Strict Rest After Concussion: Is This Study a Game Changer?

For several years, I directed a general pediatric board exam review course, and I recall struggling to help determine how to present proper management of children with concussion. We wanted to present information that was both useful in practice but also likely to help attendees answer multiple choice questions on the board examination. Although some recommendations existed for management of concussion, they were based largely on anecdote rather than evidence, and we concluded that there was no "correct" answer for management of post-concussive symptoms. When I saw this article, I had hopes that we now had a better answer.

Source: Thomas DG, Apps JN, Hoffmann RG, et al. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics. 2015;135(2):213-223; doi:10.1542/peds.2014-0966. See AAP Grand Rounds commentary by Dr. Cynthia LaBella (subscription required). 

PICO Question: Among patients seen in an emergency department for an acute concussion, does 5 days of strict rest result in faster symptom resolution compared to 1-2 days of rest followed by stepwise return to activity?
Question type: Prognosis
Study design: Randomized controlled trial

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