Tuesday, September 9, 2014

Balancing Radiation Risk and Accuracy in Cranial Imaging

The authors of this study chose what I think is an unusual study design: a non-inferiority analysis of a retrospective patient group. It seems like a recipe for biased results, but let's dig a little deeper.

Source: Boyle TP, Paldino M, Amir A, et al. Comparison of rapid cranial MRI to CT for ventricular shunt malfunction. Pediatrics. 2014;134(1):e47-e54; doi:10.1542/peds.2013-3739. See AAP Grand Rounds commentary by Dr. Harris Cohen (subscription required).

PICO Question: Among children evaluated for possible ventricular shunt malfunction, is rapid cranial MRI as accurate as CT?
Question type: Diagnosis
Study design: Retrospective cohort

Tuesday, September 2, 2014

More on Infection Risk in International Adoption

My July 15 commentary focused on prevalence of acute hepatitis A in international adoptees in Minnesota. This week's article is a similar study, but is centered in France. The results are a little different, stressing the importance of always being aware of how a research study's patient population might differ from your own.

Source: Sciauvaud J, Rigel E, Pascal J, et al. Transmission of infectious diseases from internationally adopted children to their adoptive families. Clin Microbiol Infect. 2014; 20:746-751. See AAP Grand Rounds commentary by Dr. Deena Sutter (subscription required).

PICO Question: Among internationally adopted children, what are the rates and types of infectious diseases and how often are these diseases transmitted to adoptive families?
Question type: Descriptive
Study design: Retrospective cohort

Monday, September 1, 2014

See You in September

Not to get too nostalgic here, but the 1966 version of this song, recorded by the Happenings, was a big hit at my summer band camp. I looked up the lyrics, there is absolutely no medical allusion there, so 'nuff said.

However, the September issue of AAP Grand Rounds has plenty of great pediatric commentary, including association of psychopathology with sleep disorders, physical fitness and academic success, mental health and foster care, and an update on fluoride use in young children. Tune into Evidence eMended for commentary on cranial imaging in VP shunt malfunction, steroids following operative procedures for biliary atresia, infection risk in international adoptions (again!), and association of influenza infection with pneumococcal carriage, not to mention another infamous "5th Tuesday" wild-card commentary.

See you!

Tuesday, August 26, 2014

Asthma - Why Can't We Use the Best Treatments?

This study is interested on 2 fronts: First, it's an example of a big gap in EBM: how does one translate effective clinical management strategies into real-world practice? A second lesson for us lies in the pitfalls of survey research and sampling bias.

Source: Okelo SO, Siberry GK, Solomon BS, et al. Asthma treatment decisions by pediatric residents do not consistently conform to guidelines or improve with level of training. Acad Pediatr.2014;14(3):287-293; doi:10.1016/j.acap.2013.12.008. See AAP Grand Rounds commentary by Dr. Shelley Springer (subscription required).

PICO Question: Among pediatric residents, how do treatment decisions for asthma compare to asthma treatment guidelines, and does conformation with guidelines improve with increased level of training?
Question type: Occurrence
Study design: Cross-sectional web-based survey

Tuesday, August 19, 2014

Intractable Seizure Management - Does Lorazepam Flunk the Test?

This multicenter randomized controlled trial is interesting on a couple of levels. First, it likely will reverse a 2008 Cochrane review's conclusions stating that lorazepam may be preferred over diazepam for status epilepticus in children. It also is a great example of an exception to using informed consent, to accommodate emergency situations.

Source: Chamberlain JM, Okada P, Holsti M, et al. Lorazepam vs diazepam for pediatric status epilepticus. A randomized clinical trial. JAMA. 2014;311(16):1652-1660; doi:10.1001/jama.2014.2625. See AAP Grand Rounds Commentary by Dr. Gordon Millichap (subscription required).

PICO Question: Among emergency department patients aged 3 months to 17 years with convulsive status epilepticus, is treatment with lorazepam more effective and safer than treatment with diazepam?
Question type: Intervention
Study design: Double-blind randomized trial

Tuesday, August 12, 2014

Testicular Torsion - Is Pulse Oximetry Good Enough for Screening?

It isn't often a brief research letter makes it to the pages of AAP Grand Rounds. No one should change clinical practice based on these very preliminary findings, but the results are pretty eye catching.

Source: Chen HW, Weng LC, Want TM, et al. Potential use of pulse oximetry for the diagnosis of testicular torsion Research Letter. JAMA Pediatr. 2014;168(6):578-579; doi:10.1001/jamapediatrics.2014.86. See AAP Grand Rounds commentary by Dr. Shelley Springer (subscription required). 

PICO Question: Among children with scrotal pain, can pulse oximetry differentiate between testicular torsion and a non-torsed testicle?
Question type: Diagnosis
Study design: Prospective case series

Tuesday, August 5, 2014

Cry Me a RIVUR - When the "Perfect" Study Doesn't Give Us the Answers

My curmudgeonly self intrudes whenever I see a catchy acronym employed to designate what should otherwise be a serious scientific study. So, the Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) trial falls in that category. The investigators were forced to leave out a "C" for Children to make it sound cute. Nonetheless, I want to convey the importance of this study, particularly for the knowledge gaps it reveals which are likely to remain unresolved for a long time.

Source: The RIVUR Trial Investigators, Hoberman A, Greenfield SP, et al. Antibiotic prophylaxis for children with vesicoureteral reflux. N Eng J Med 2014; 370:2367-2376. doi:10.1056/NEJMoa1401811. See AAP Grand Rounds commentary by Dr. Christine Sethna (subscription required).

PICO Question: Among children aged 2 to 71 months with grade I to IV vesicoureteral reflux, is antibiotic prophylaxis more effective than placebo in preventing recurrent urinary tract infection?
Question type: Intervention
Study type: Randomized controlled trial

Friday, August 1, 2014

It's August at AAP Grand Rounds and Evidence eMended

Washington, DC, is unusually cool for this time of year, but I can still tell it's August because the traffic is lighter! Nice for those of us who don't retreat to the beach for the late summer.

Speaking of the beach, I've always felt that AAP Grand Rounds makes for great beach reading. Check out this month's commentaries on UTI in young infants, imaging for appendicitis, use of sports screening guidelines, and much more. My weekly blogs this month will cover the big randomized controlled trial on prophylaxis for UTI (next Tuesday!), pulse oximetry to diagnose testicular torsion, use of antiepileptic drugs in the emergency room, and slow uptake on use of asthma guidelines.

Have a great summer!

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