Tuesday, September 1, 2015

Early Intervention in Autism - Hopeful Results

We spent the entire month of August on randomized controlled trials, but I had to sneak in at least 1 more for September. This study is a good illustration of a well-done study that still leaves us with more questions than answers; it provides a glimmer of hope, but a mountain of questions that need answers before full implementation.

Source: Estes A, Munson J, Rogers SJ, et al. Long-term outcomes of early intervention in 6-year-old children with autism spectrum disorder. J Am Acad Chil Adolesc Psychiatry. 2015; 54(7): 580-587. doi:10.1016/j.jaac.2015.04.005. See AAP Grand Rounds commentary by Dr. Shelley Springer (subscription required). 

PICO Question: Among children with autism who begin intensive early behavioral interventions at 18-30 months, do benefits persist at age 6 years?
Question type: Intervention

Study design: Randomized controlled trial

Welcome to September!

I hope the primary care providers out there can rest a bit after the wave of camp and school physicals and settle in to see how the winter viral season unfolds. In the meantime, take a look at this month’s AAP Grand Rounds issue, with some highly intriguing reviews of articles on suicide in young black children, breastfeeding effects on hospitalization, and financial costs of abusive head trauma, among others.

In this month’s blog, I’ll be posting weekly on topics including monitor alarm fatigue in a children’s hospital, benefits of early intervention in autism, telemedicine for children with special healthcare needs, and a possible link between elevated blood pressure and periodontal disease in obese teenagers. Stay tuned!

Tuesday, August 25, 2015

Brain Protection With Hypothermia - Does It Work?

In our final of 4 commentaries on randomized controlled trials (RCTs), we finally come across one relatively free of flaws. It's a good comparison to the preceding RCTs from weeks 1 - 3.

Source: Moler FW, Silverstein FS, Holubkow R, et al for the THAPCA Trial Investigators. Therapeutic hypothermia after out-of-hospital cardiac arrest in childrenNew Engl J Med.2015;372(20):1898-1908; doi:10.1056/NEJMoa1411480. See AAP Grand Rounds Commentary by Dr. Susan Bratton (subscription required). 

PICO Question: Among children aged 2 days-18 years who are resuscitated but remain comatose following an out-of-hospital cardiac arrest, do those treated for 2 days with therapeutic hypothermia have greater survival with acceptable cognitive function compared to those whose temperature is maintained in a normal range?
Question type: Prognosis
Study design: Randomized controlled 

Tuesday, August 18, 2015

School Lunch - What Can We Learn From Randomizing School Cafeteria Services?

Source: Cohen JFW, Richardson SA, Cluggish SA, et al. Effects of choice architecture and chef-enhanced meals on the selection and consumption of healthier school foods: a randomized clinical trial. JAMA Pediatr. 2015;169(5):431-437; doi:10.1001/jamapediatrics.2014.3805. See AAP Grand Rounds Commentary by Dr. Justin Schreiber (subscription required). 

PICO Question: Among elementary and middle school students, do chef-enhanced meals and/or choice architecture influence food selection and consumption?
Question type: Intervention
Design: Randomized controlled 

Tuesday, August 11, 2015

Is Surgery Best for Spasticity in Cerebral Palsy? Surgeons Say Yes

Last week I totally trashed a randomized controlled trial, the beginning of a month's focus on this study design. This week, we have a pretty well-designed trial, but with some concerns. Nonetheless, the surgeons performing the trial pronounced it a game-changer; they are altering their practice based on the results. Are they correct? Read on.

Source: Van Heest A, Bagley A, Molitor F, et al. Tendon transfer surgery in upper-extremity cerebral palsy is more effective than botulinum toxin injections or regular, ongoing therapy. J Bone Joint Surg.2015;97(7):529-536; doi:10.2106/JBJS.M.01577. See AAP Grand Rounds commentary by Dr. William Hennrikus (subscription required). 

PICO Question: Among children with upper-extremity cerebral palsy, does greater functional improvement result from tendon transfer surgery, botulinum toxin injections, or ongoing physical therapy?
Question type: Intervention
Study design: Prospective randomized and observational

Tuesday, August 4, 2015

Urinary Tract Prophylaxis: An Underpowered Trial with No Conclusions

Randomized trials are great, provided they are well designed. Some flaws in this study pretty much guaranteed we wouldn't learn much from it.

Source: Lee SJ, Lee JW. Probiotics prophylaxis in infants with primary vesicoureteral reflux. Pediatr Nephrol. 2015;30(4):609-613; doi:10.1007/s00467-014-2988-z. See AAP Grand Rounds commentary by Dr. Pamela Singer (subscription required). 

PICO Question: Among children aged 1 week to 12 months with primary vesicoureteral reflux, what is the incidence of recurrent urinary tract infection with probiotic prophylaxis compared to antibiotic prophylaxis?
Question type: Intervention
Study type: Randomized trial

Saturday, August 1, 2015

It's Heating Up for August's AAP Grand Rounds

We are nearing the end of summer, and the AAP Grand Rounds August edition is out with some hot topics, including a look at changes in pneumococcal disease after the 13-valent vaccine came into use, maternal smoking and heart defects, childhood pneumonia links to lung function in adults, and much more.

This month's issue provided me with an opportunity to look at 4 randomized controlled trials (RCTs), covering hypothermia for cardiac arrest, school lunches, tendon transfer procedures, and probiotics as UTI prophylaxis. Join me each week, and you'll see that not all RCTs are created equal.

Tuesday, July 28, 2015

Jousting Guidelines for Teenage Statin Use: Which is Correct?

I love a good controversy, and pharmacologic treatment of elevated low-density lipoprotein cholesterol (LDL-C) definitely qualifies as one. The long-term health of billions of individuals world-wide is at stake, not to mention the billions of dollars pouring into the pharmaceutical industry.

Source: Gooding HC, Rodday AM, Wong JB, et al. Application of pediatric and adult guidelines for treatment of lipid levels among US adolescents transitioning to young adulthood. JAMA Pediatrics 2015; 169(6):569-74. doi:10.1001/jamapediatrics.2015.0168. See AAP Grand Rounds commentary by Dr. Charlene Wong (subscription required).

PICO Question: Among adolescents and young adults 17-21 years old, what proportion meet criteria for pharmacologic treatment of elevated low-density lipoprotein cholesterol under pediatric versus adult dyslipidemia guidelines?
Question type: Descriptive
Study design: Cross-sectional survey

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