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Adding Fever to WHO Criteria for Diagnosing Pneumonia Enhances the Ability to Identify Pneumonia Cases Among Wheezing Children
608
Abstracts
There are numerous methodological issues that make the find ings nearly uninterpretable. However, it does seem that in a real world setting with providers of various levels of training performing FAST examinations, the utility of a negative exam ination in the setting of blunt trauma remains high. Nonetheless, it is important to interpret the findings of the examination in the context of the clinical picture of the patient over time. The con clusions of the authors that the FAST has no utility in the stable patient is not borne out by their own results, nor does it take into account the benefit of enhancing provider experience in seeing different types of negative examinations. , ADDING FEVER TO WHO CRITERIA FOR DIAGNOSING PNEUMONIA ENHANCES THE ABILITY TO IDENTIFY PNEUMONIA CASES AMONG WHEEZING CHILDREN. Cardoso MA, Nascimento Carvalho CM, Ferraro F, Alves FM, Cousens SN. Arch Dis Child 2011;96:58 61. This prospective study evaluated the World Health Organiza tion (WHO) criteria for diagnosing pneumonia both before and after the addition of fever as a criterion. Based on the concern that children with non severe pneumonia were receiving antibi otics unnecessarily, the WHO sought to modify its guidelines. The guidelines rely on simple clinical signs including tachypnea or lower chest retractions, and aid in the identification and treatment of pneumonia in developing countries. In this study, researchers from the University of Sao Paolo examined a total of 410 patients with diagnoses of acute bronchitis, acute bronchiolitis, wheezing, recurrent wheezing, and pneumonia. A chest X ray study was considered the gold standard for confirmation of pneumonia. The study concluded that the WHO criteria can predict pneumonia with high sensitivity (84% with 95% confidence interval [CI] 83% 99%), particularly in children < 24 months of age (94% with 95% CI 83 99%). Adding fever to the diagnostic criteria improved the specificity of the diagnosis (46% compared to 19%), without a decrease in sensitivity (81% with 95% CI 70 90%). [Erin Drasler, MD Denver Health Medical Center, Denver, CO] Comment: The study was limited by the fact that not all pa tients had X ray studies performed, leading to a potential false negative rate that cannot be quantified and that could be impor tant. In addition, although the WHO criteria were not designed for use in urban EDs, the question of which patients should have X ray study performed is relevant. Thus, although the criteria may bias toward over diagnosis and over treatment, the addition of fever may help to limit this over treatment and prove to be useful in certain ED situations to guide when an X ray study may be needed. , PREDICTIVE VALUE OF A FLAT INFERIOR VENA CAVA ON INITIAL COMPUTED TOMOGRAPHY FOR HEMODYNAMIC DETERIORATION IN PATIENTS WITH BLUNT TORSO TRAUMA. Matsumoto S, Sekine K, Yamazaki M, et al. J Trauma 2010;69:1398 402. Patients who exhibit post traumatic hypovolemic shock are more likely to require surgical intervention and have higher
mortality rates. Earlier indications of hypovolemia could aid in initiating prompt management of the critically ill trauma pa tient. This study investigated the utility in measuring the diam eter of the inferior vena cava (IVC) from computed tomography (CT) of the abdomen and pelvis among patients with blunt torso trauma. This study was performed in Japan in a medical system where prehospital intravenous fluid administration is not yet ap proved. Subjects studied were patients with blunt abdominal trauma who obtained CT scans within 30 min of arrival to the hospital. Anteroposterior and maximal transverse diameters of the IVC at the level of the renal vein were measured. A flat vena cava (FVC) was defined as a transverse to anteroposterior diameter of < 4:1. The hemodynamic status of the patients was divided into three categories: patients who deteriorated after CT scan (D), patients who were stable on arrival and after CT scan (S), and patients who arrived with signs of shock but responded to fluid boluses before CT and remained stable after CT (R). Trauma patients who deteriorated after CT scan had a signifi cantly smaller IVC than those who remained stable. All of the patients with an FVC were in group D and had hemodynamic compromise after CT scan. On multivariate analysis including hemoglobin, heart rate, Glasgow Coma Scale, injury severity score, and base excess, the only two variables predictive of hemodynamic deterioration were FVC and blood pressure. [Jodi Thomson, MD, PHD Denver Health Medical Center, Denver, CO] Comment: Although the results of this study are interesting, they are limited by the fact that CT scan can be used only in the stable trauma patient. Because bedside ultrasound can provide similar data on IVC diameter and can be performed at the bedside in all patients regardless of hemodynamic stability, the utilization of CT for this determination, although apparently accurate, seems unnecessary. , DURATION OF RED CELL STORAGE INFLUENCES MORTALITY AFTER TRAUMA. Weinberg JA, McGwin G, Vandromme MJ, et al. J Trauma 2010;69:1427 32. This retrospective analysis of trauma patients admitted to a level I trauma center between January 2000 and May 2009 iden tified 1647 patients who received red blood cell (RBC) transfusion within the first 24 h of admission and examined their overall mor tality. Patients were categorized according to RBC storage age (‘‘fresh’’ if < 14 days old vs. ‘‘old’’ if 14 or more days old) and number of units transfused (1 2 vs. 3 or more units). Patients who received both fresh and old blood were excluded. No signif icant difference was found in overall in hospital mortality be tween patients; however, a trend toward lower mortality was noted in patients who received more than 3 units of fresh blood in comparison to old blood (p = 0.08). When adjusted for con founders, the adjusted relative risk (RR) of mortality was statisti cally significant for the receipt of old blood (RR 1.57; 95% confidence interval 1.14 2.15, p = 0.006). Of note, in regards to demographics, the fresh blood group had significantly higher mean patient age (44 vs. 40 years, p < 0.03) and higher prevalence of head injury (32% vs. 24%, p < 0.03), whereas the old blood group received higher volume of fresh frozen plasma (3.47 vs. 2.76 units, p < 0.03). The authors concluded that, despite
Abstracts
There are numerous methodological issues that make the find ings nearly uninterpretable. However, it does seem that in a real world setting with providers of various levels of training performing FAST examinations, the utility of a negative exam ination in the setting of blunt trauma remains high. Nonetheless, it is important to interpret the findings of the examination in the context of the clinical picture of the patient over time. The con clusions of the authors that the FAST has no utility in the stable patient is not borne out by their own results, nor does it take into account the benefit of enhancing provider experience in seeing different types of negative examinations. , ADDING FEVER TO WHO CRITERIA FOR DIAGNOSING PNEUMONIA ENHANCES THE ABILITY TO IDENTIFY PNEUMONIA CASES AMONG WHEEZING CHILDREN. Cardoso MA, Nascimento Carvalho CM, Ferraro F, Alves FM, Cousens SN. Arch Dis Child 2011;96:58 61. This prospective study evaluated the World Health Organiza tion (WHO) criteria for diagnosing pneumonia both before and after the addition of fever as a criterion. Based on the concern that children with non severe pneumonia were receiving antibi otics unnecessarily, the WHO sought to modify its guidelines. The guidelines rely on simple clinical signs including tachypnea or lower chest retractions, and aid in the identification and treatment of pneumonia in developing countries. In this study, researchers from the University of Sao Paolo examined a total of 410 patients with diagnoses of acute bronchitis, acute bronchiolitis, wheezing, recurrent wheezing, and pneumonia. A chest X ray study was considered the gold standard for confirmation of pneumonia. The study concluded that the WHO criteria can predict pneumonia with high sensitivity (84% with 95% confidence interval [CI] 83% 99%), particularly in children < 24 months of age (94% with 95% CI 83 99%). Adding fever to the diagnostic criteria improved the specificity of the diagnosis (46% compared to 19%), without a decrease in sensitivity (81% with 95% CI 70 90%). [Erin Drasler, MD Denver Health Medical Center, Denver, CO] Comment: The study was limited by the fact that not all pa tients had X ray studies performed, leading to a potential false negative rate that cannot be quantified and that could be impor tant. In addition, although the WHO criteria were not designed for use in urban EDs, the question of which patients should have X ray study performed is relevant. Thus, although the criteria may bias toward over diagnosis and over treatment, the addition of fever may help to limit this over treatment and prove to be useful in certain ED situations to guide when an X ray study may be needed. , PREDICTIVE VALUE OF A FLAT INFERIOR VENA CAVA ON INITIAL COMPUTED TOMOGRAPHY FOR HEMODYNAMIC DETERIORATION IN PATIENTS WITH BLUNT TORSO TRAUMA. Matsumoto S, Sekine K, Yamazaki M, et al. J Trauma 2010;69:1398 402. Patients who exhibit post traumatic hypovolemic shock are more likely to require surgical intervention and have higher
mortality rates. Earlier indications of hypovolemia could aid in initiating prompt management of the critically ill trauma pa tient. This study investigated the utility in measuring the diam eter of the inferior vena cava (IVC) from computed tomography (CT) of the abdomen and pelvis among patients with blunt torso trauma. This study was performed in Japan in a medical system where prehospital intravenous fluid administration is not yet ap proved. Subjects studied were patients with blunt abdominal trauma who obtained CT scans within 30 min of arrival to the hospital. Anteroposterior and maximal transverse diameters of the IVC at the level of the renal vein were measured. A flat vena cava (FVC) was defined as a transverse to anteroposterior diameter of < 4:1. The hemodynamic status of the patients was divided into three categories: patients who deteriorated after CT scan (D), patients who were stable on arrival and after CT scan (S), and patients who arrived with signs of shock but responded to fluid boluses before CT and remained stable after CT (R). Trauma patients who deteriorated after CT scan had a signifi cantly smaller IVC than those who remained stable. All of the patients with an FVC were in group D and had hemodynamic compromise after CT scan. On multivariate analysis including hemoglobin, heart rate, Glasgow Coma Scale, injury severity score, and base excess, the only two variables predictive of hemodynamic deterioration were FVC and blood pressure. [Jodi Thomson, MD, PHD Denver Health Medical Center, Denver, CO] Comment: Although the results of this study are interesting, they are limited by the fact that CT scan can be used only in the stable trauma patient. Because bedside ultrasound can provide similar data on IVC diameter and can be performed at the bedside in all patients regardless of hemodynamic stability, the utilization of CT for this determination, although apparently accurate, seems unnecessary. , DURATION OF RED CELL STORAGE INFLUENCES MORTALITY AFTER TRAUMA. Weinberg JA, McGwin G, Vandromme MJ, et al. J Trauma 2010;69:1427 32. This retrospective analysis of trauma patients admitted to a level I trauma center between January 2000 and May 2009 iden tified 1647 patients who received red blood cell (RBC) transfusion within the first 24 h of admission and examined their overall mor tality. Patients were categorized according to RBC storage age (‘‘fresh’’ if < 14 days old vs. ‘‘old’’ if 14 or more days old) and number of units transfused (1 2 vs. 3 or more units). Patients who received both fresh and old blood were excluded. No signif icant difference was found in overall in hospital mortality be tween patients; however, a trend toward lower mortality was noted in patients who received more than 3 units of fresh blood in comparison to old blood (p = 0.08). When adjusted for con founders, the adjusted relative risk (RR) of mortality was statisti cally significant for the receipt of old blood (RR 1.57; 95% confidence interval 1.14 2.15, p = 0.006). Of note, in regards to demographics, the fresh blood group had significantly higher mean patient age (44 vs. 40 years, p < 0.03) and higher prevalence of head injury (32% vs. 24%, p < 0.03), whereas the old blood group received higher volume of fresh frozen plasma (3.47 vs. 2.76 units, p < 0.03). The authors concluded that, despite