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

Tuesday, April 7, 2015

What Do Pertussis Vaccination and the Masters Golf Tournament Have in Common?

Well, actually not much, unless a child with pertussis is in the gallery and has onset of a paroxysmal coughing spell during tournament favorite Rory McIlroy's backswing. The odds of that happening, even in an era of pertussis resurgence in the United States, are pretty low, but it's an excuse to discuss what to do with odds and odds ratios in medical research.

Source: Martin SW, Pawloski L, Williams M, et al. Pertactin-negative Bordetella pertussis strains: evidence for a possible selective advantage. Clin Infect Dis. 2015;60(2):223-227; doi:10.1093/cid/ciu788. See AAP Grand Rounds commentary by Dr. Rebecca Brady (subscription required). 

PICO Question: Among individuals with pertussis, are those who have received at least 1 dose of pertussis vaccine more likely to have infection due to Bordetella pertussis strains that are pertactin-deficient compared to those who are unvaccinated?
Question type: Descriptive
Study design: Retrospective cohort

Wednesday, April 1, 2015

Just Foolin' Around

Hot off the presses - a new antibiotic, gorillacillin, treats all known bacterial pathogens without development of resistant strains!!!

Or not.... In medicine, we know never to say never or always, but that doesn't stop me from a little wishful thinking for April Fool's Day. 

April's AAP Grand Rounds doesn't cover anything like an earth-shattering new antibiotic, but there's still some great topics in there. The issue explores some controversy in universal drug testing in pregnant women, as well as some new help in assessing bruising in young children, an assessment of "informal kinship care," and growth rate associations with wheezing illness. Over the next 4 Tuesdays, I'll be discussing some changes in pertussis strains that might relate to new vaccine concerns, rest protocols for children with concussion, xray reliability in pelvic fractures, and more breastfeeding/obesity controversy. Take time during some of our April showers to take a look.

Tuesday, March 31, 2015

Hospitalists versus PCPs: "What we've got here is failure to communicate."

A recent article about miscommunication between hospitalists and primary care providers caught my eye, and I thought it would be a good conversation starter for a "Fifth Tuesday" posting, where I stray from the confines of AAP Grand Rounds and talk about whatever I want. I'm just disappointed the authors never mentioned the movie they quasi-plagiarized, "Cool Hand Luke."

Jones CD, et al. A failure to communicate: A qualitative exploration of care coordination between hospitalists and primary care providers around patient hospitalizations. J Gen Intern Med 2015; 30(4):417-24. doi 10.1007/s11606-014-3056-x.

Tuesday, March 24, 2015

40 Years in the Desert of Osteomyelitis

When I began my pediatric infectious diseases fellowship over 30 years ago, it was already well-established that a short course of IV therapy, followed by a more extended regimen of high-dose oral antibiotic therapy, was effective treatment for uncomplicated acute hematogenous osteomyelitis. Why are we still discussing this 40 years after landmark studies supported this approach?

Source: Keren R, Shah SS, Srivastava R, et al. Comparative effectiveness of intravenous vs oral antibiotics for postdischarge treatment of acute osteomyelitis in children. JAMA Pediatr. 2015; 169(2):120-128. doi:10.1001/jamapediatrics.2014.2822. See AAP Grand Rounds commentary by Dr. Matthew Garber (subscription required). 

PICO Question: Among children hospitalized with acute hematogenous osteomyelitis, how does postdischarge treatment with intravenous antibiotics compare to treatment with oral antibiotics?
Question type: Intervention
Study design: Retrospective cohort

Tuesday, March 17, 2015

Handoffs as Tradeoffs - Have Trainee Duty Hour Restrictions Decreased Medical Errors?

Welcome to the morass that is 21st century medicine: a multitude of available tests and treatments, improved survival accompanied by increased complexity in patient care, the (usually dysfunctional) electronic health record, and Big Data. Plop the Accreditation Council for Graduate Medical Education's duty hour restrictions into this, and you have a recipe for disaster. Is there anyone left who actually knows the patient? Here's a little progress to stem the tide.

Source: Starmer AJ, Spector ND, Srivastava R, et al. Changes in medical errors after implementation of a handoff program. N Engl J Med.2014;371(19):1803-1812; doi:10.1056/NEJMsa1405556. See AAP Grand Rounds commentary by Dr. Justin Schreiber (subscription required). 

PICO Question: Among pediatric residents, does use of a standardized handoff improvement program decrease preventable adverse events and medical errors?
Question type: Prevention
Study design: Prospective intervention

Tuesday, March 10, 2015

A "Cheap" Study of Colds and Flu

We have several classic household studies of respiratory illness epidemiology from the 1960s and 1970s, but not much recently. It's pretty expensive to do household surveillance studies, but this group of investigators tried to get by save a few dollars and still provide us with some more current information.

Source: Monto AS, Malosh RE, Petrie JG, et al. Frequency of acute respiratory illnesses and circulation of respiratory viruses in households with children over 3 surveillance seasons. J Infect Dis. 2014;210(11):1792-1799; doi:10.1093/infdis/jiu327. See AAP Grand Rounds commentary by Dr. Rebecca Brady (subscription required).

PICO Question: Among households with children, what are the frequencies and causative agents of acute respiratory illnesses?
Question type: Descriptive
Study design: Longitudinal prospective cohort

Tuesday, March 3, 2015

Home Births and Congenital Heart Disease Screening: An Oxymoron?

I guess this study was mostly a proof of concept attempt, showing that children born at home still could be screened for cyanotic congenital heart disease. However, it made me wonder more about how this proposal fit into the concept of home births in general.

Source: Lhohst J, Goetz E, Belling J, et al. Pulse oximetry screening for critical congenital heart disease in planned out-of-hospital births. J Pediatr. 2014;165(3):485-509; doi:10.1016/j.jpeds.2014.05.011. See AAP Grand Rounds commentary by Dr. Jeffrey Anderson (subscription required). 

PICO Question: Among infants with planned out-of-hospital births, is routine pulse oximetry feasible in identifying critical congenital heart disease?
Question type: Diagnosis
Study design: Prospective cohort

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