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Fibromyalgia therapy
September 2015 Volume 167 Number 3
Concussion coming soon to a clinic near you — Paul G. Fisher, MD
“Personalized” intervention — James F. Padbury, MD
Copyright ª 2015 by Elsevier Inc.
O
ver the last decade, there has been a sharp increase in the diagnosis of concussion, owing to broader definitions and increased public and physician awareness of brain injury. A growing body of research, published in The Journal and elsewhere, has highlighted suboptimal clinical awareness, diagnosis, and management, with the investigators often hailing from emergency departments throughout North America. Is concussion a diagnosis handled mostly in the emergency department? In this issue, Taylor et al characterize trends in health care utilization and costs for children diagnosed with concussion or minor head injury within a large regional pediatric network from 2007 to 2013. During that time period, the rate of concussion more than doubled. The proportion of head injuries diagnosed as concussion rose from 42% to 72%. In 2007, more than one-half of new concussion diagnoses were seen in emergency departments; by 2013 less than 30% were evaluated in emergency departments and just over one-half of new diagnoses were seen by a primary care provider. Meanwhile, the mean overall cost per unique patient diagnosed with concussion declined from 2007 to 2013. Wherever you practice, concussion will be coming soon to a clinic near you. Given the observed lower cost per patient in this study, we can speculate that milder cases of concussion are increasingly being diagnosed. There is growing vigilance about concussion. All these trends merit close attention now and in the future. With an explosion of new pediatric sports medicine facilities and concussion clinics staffed by pediatricians, neurosurgeons, neurologists, orthopedists, emergency medicine and sports medicine physicians, and others, we will need to strike a balance between under- and over-diagnosis of concussion. We will need to be mindful of economic forces driving the creation of concussion centers and insure that we serve patients with concussions, without debilitating well children or children minimally affected by any head contact. Article page 738< n this issue of The Journal, Bravo et al report on a study of individualized evaluation and interventions for cardiovascular support of low birth weight infants. The children were monitored by echocardiography for low superior vena cava flow (SVC). Among the 127 infants evaluated over the first 4 days of life, 22% developed low SVC flow. These infants were randomized to intervention with dopamine or dobutamine and followed with a large number of evaluations including near-infrared spectroscopy, cranial ultrasounds, tissue oxygenation status, neonatal morbidities, and neurodevelopmental outcome. It is, perhaps, the thorough and careful design of the study (more than the results) that deserves a review. Infants in the dobutamine group showed better improvements in base excess than those in the placebo group. Low SVC flow significantly increased the risk of death and severe ischemic events, but these were largely attributable to the association of low SVC flow with gestational age. The authors contend that the results provide the basis for a large intervention trial that will include other interventions like volume expansion in the study design. We have very limited techniques for monitoring cardiovascular function in low birth weight infants. The approach in this study serves to illustrate ways in which we may “personalize” our care and, thus, improve outcomes. Article page 572<
I
503
Research in practice furthers our understanding of group A streptococcal perineal infection — Sarah S. Long, MD
Diuretics for diabetes insipidus — Thomas R. Welch, MD
Provider education for evaluating children with suspected constipation — Sarah S. Long, MD
504
T
he curiosity to ask and answer a clinical question, the high standard of care and record keeping in practice, and the diligence to acquire collaborators in order to see a study through to publication make us academics want to join the practice of Clegg et al! Their work furthers our understanding substantially of the epidemiology, management, and expected outcome of perineal group A streptococcal (GAS) infection. Occurrence is not as skewed toward boys as reported by others, which likely reflected less knowledge or examination of the preferred perivaginal site of infection in girls, compared with more of the obvious perianal site in boys. Nearly 80% of perineal GAS infection in the current study occurred in children under 7 years of age. “Season” of diagnosis mirrored that of GAS pharyngitis. In fact, when sought, almost all patients with perineal GAS infection had colonization of the pharynx (although a minority had associated symptoms). Amoxicillin was highly effective, and only 12% had recurrence. Recurrence was significantly associated with having symptoms for longer than 1 week prior to treatment and having a sibling diagnosed with perineal GAS infection before or after the patient’s initial episode. Article page 687<
T
he concept of using diuretics for a patient with diabetes insipidus (DI) seems counterintuitive. However, thiazides have been very useful in the management of children with nephrogenic DI for quite some time. In that condition, their effect is somewhat unclear, but by inducing mild volume contraction, they may reduce distal nephron delivery of salt and water, leading to a decrease in urine output. Although the underlying defect in central DI is obviously very different from that of nephrogenic DI, the clinical presentation and electrolyte physiology is similar. In older children and adults, the use of vasopressin analogues (such as desmopressin [DDAVP]) is the standard therapy for central DI. This approach is fraught with difficulty in infants, however. Given that most of their intake is liquid, symptomatic hyponatremia is a frequent complication when infants with central DI are treated with DDAVP. In light of the efficacy of thiazides in nephrogenic DI, many have employed them for infants with central DI, in place of DDAVP. There is, however, very little published information on this approach. The current issue of The Journal includes a single-center report of 13 children with central DI treated with thiazides from the Mayo Clinic. In general, this approach worked very well in these children. In particular, complications requiring hospital admission were very rare. The article provides quite a bit of detail to guide clinicians wanting to use this approach. Article page 658<
n this issue of The Journal, Kurowski et al at the Ann & Robert H. Lurie Children’s Hospital of Chicago show how an educational module pays dividends both for the patient and the healthcare system. They evaluated a 2-month baseline frequency of recording in the medical record whether a digital rectal examination was performed or abdominal radiographs were obtained in patients 4-18 years of age who, after visiting their Emergency Department (ED) with the complaint of abdominal pain, were discharged with the diagnosis of constipation. They devised oral and Powerpoint presentations to educate care providers in the ED on the Rome III criteria for diagnosis of constipation, which include historical features of bowel habits and finding a large fecal mass on digital rectal examination, but do not include recommendation for abdominal radiographs because of their unlikely value in the diagnostic algorithm. After approximately 1 year’s time and completion of the module by at least 75% of the targeted care providers, they repeated a 2-month assessment of performance of the digital rectal examination and abdominal radiographs. Findings were straightforward. In this patient population, performance of digital rectal examination rose from approximately one-quarter to one-half of patients, and abdominal radiographs fell
I
Vol. 167, No. 3
from almost three-quarters to one-quarter of patients. This change in practice saved time, money, and radiation. A longer-term goal might be to use anticipatory guidance to decrease the prevalence of constipation in children or to decrease visits to the ED for children with constipation. Meanwhile, knowledge of the Rome criteria, >90% performance of digital rectal examination when constipation is the suspected diagnosis, and avoidance of abdominal radiographs, as well as appropriate referrals to gastroenterology subspecialists, are triple bonuses. Article page 706<
Moving on from natural disaster — Paul G. Fisher, MD
Fibromyalgia therapy — Thomas R. Welch, MD
September 2015
W
e remember with sadness the Great East Japan Earthquake and ensuing tsunamis that occurred off the coast of Japan near Sendai on March 11, 2011. The damage created by those forces, along with the subsequent failure of the Fukishima nuclear plant, will have a toll on the children of Japan for many years to come. An estimated 20 000 or more people died, and tens of thousands of children were displaced. In the midst of this tragedy, Tatsuta et al were already conducting a prospective birth cohort study of 749 mother-child dyads in the affected Sanriku coastal area in order to better understand the effect of fish consumption and other neurotoxins on child development. The quake struck around the 7-year age assessments, and compulsorily divided their residual sample into 123 children assessed before the disaster and 289 afterwards. Although the latter subsample was delayed many months in its assessment, these children were found to have significantly lower IQs and accompanying information, arithmetic, and vocabulary subscores. Performance and full-scale IQ were not affected. Whether the forced prolonged closure of schools or posttraumatic stress contributed the most to this difference is unclear, but will require further determination over time. The authors should be congratulated for their perseverance in continuing their research in light of such tragedy and also for their commitment to advancing the well being of children subjected to disaster. Article page 745<
A
lthough we do not often consider chronic amplified pain syndromes as important in children, the incidence of these is surprisingly high. As many as 2%-6% of children, for example, may meet the criteria for fibromyalgia. Despite this, there are very few guidelines on the management of fibromyalgia in children. This is unfortunate in that some children may be very seriously involved and compromised by the condition. There is little evidence that medications play a useful role in the management of childhood fibromyalgia. A group in Philadelphia has developed an intense program of physical and occupational therapy for children with another pain syndrome, complex regional pain syndrome. In this issue of The Journal, Sherry et al from this program describe a similar approach in 64 children with fibromyalgia. The report is particularly useful, as it presents 1-year follow-up data in this chronic condition. The data in this report are optimistic. Children generally showed improvement in several objective measures, including pain, function, and quality of life. These improvements occurred in the context of no medications. The program is very resource-intense, involving up to 8 hours of therapy daily. It will be very interesting to see the degree to which this experience can be replicated in other centers. In any case, it is most encouraging to see these results in such a disabling condition. Article page 731<
505
Concussion coming soon to a clinic near you — Paul G. Fisher, MD
“Personalized” intervention — James F. Padbury, MD
Copyright ª 2015 by Elsevier Inc.
O
ver the last decade, there has been a sharp increase in the diagnosis of concussion, owing to broader definitions and increased public and physician awareness of brain injury. A growing body of research, published in The Journal and elsewhere, has highlighted suboptimal clinical awareness, diagnosis, and management, with the investigators often hailing from emergency departments throughout North America. Is concussion a diagnosis handled mostly in the emergency department? In this issue, Taylor et al characterize trends in health care utilization and costs for children diagnosed with concussion or minor head injury within a large regional pediatric network from 2007 to 2013. During that time period, the rate of concussion more than doubled. The proportion of head injuries diagnosed as concussion rose from 42% to 72%. In 2007, more than one-half of new concussion diagnoses were seen in emergency departments; by 2013 less than 30% were evaluated in emergency departments and just over one-half of new diagnoses were seen by a primary care provider. Meanwhile, the mean overall cost per unique patient diagnosed with concussion declined from 2007 to 2013. Wherever you practice, concussion will be coming soon to a clinic near you. Given the observed lower cost per patient in this study, we can speculate that milder cases of concussion are increasingly being diagnosed. There is growing vigilance about concussion. All these trends merit close attention now and in the future. With an explosion of new pediatric sports medicine facilities and concussion clinics staffed by pediatricians, neurosurgeons, neurologists, orthopedists, emergency medicine and sports medicine physicians, and others, we will need to strike a balance between under- and over-diagnosis of concussion. We will need to be mindful of economic forces driving the creation of concussion centers and insure that we serve patients with concussions, without debilitating well children or children minimally affected by any head contact. Article page 738< n this issue of The Journal, Bravo et al report on a study of individualized evaluation and interventions for cardiovascular support of low birth weight infants. The children were monitored by echocardiography for low superior vena cava flow (SVC). Among the 127 infants evaluated over the first 4 days of life, 22% developed low SVC flow. These infants were randomized to intervention with dopamine or dobutamine and followed with a large number of evaluations including near-infrared spectroscopy, cranial ultrasounds, tissue oxygenation status, neonatal morbidities, and neurodevelopmental outcome. It is, perhaps, the thorough and careful design of the study (more than the results) that deserves a review. Infants in the dobutamine group showed better improvements in base excess than those in the placebo group. Low SVC flow significantly increased the risk of death and severe ischemic events, but these were largely attributable to the association of low SVC flow with gestational age. The authors contend that the results provide the basis for a large intervention trial that will include other interventions like volume expansion in the study design. We have very limited techniques for monitoring cardiovascular function in low birth weight infants. The approach in this study serves to illustrate ways in which we may “personalize” our care and, thus, improve outcomes. Article page 572<
I
503
Research in practice furthers our understanding of group A streptococcal perineal infection — Sarah S. Long, MD
Diuretics for diabetes insipidus — Thomas R. Welch, MD
Provider education for evaluating children with suspected constipation — Sarah S. Long, MD
504
T
he curiosity to ask and answer a clinical question, the high standard of care and record keeping in practice, and the diligence to acquire collaborators in order to see a study through to publication make us academics want to join the practice of Clegg et al! Their work furthers our understanding substantially of the epidemiology, management, and expected outcome of perineal group A streptococcal (GAS) infection. Occurrence is not as skewed toward boys as reported by others, which likely reflected less knowledge or examination of the preferred perivaginal site of infection in girls, compared with more of the obvious perianal site in boys. Nearly 80% of perineal GAS infection in the current study occurred in children under 7 years of age. “Season” of diagnosis mirrored that of GAS pharyngitis. In fact, when sought, almost all patients with perineal GAS infection had colonization of the pharynx (although a minority had associated symptoms). Amoxicillin was highly effective, and only 12% had recurrence. Recurrence was significantly associated with having symptoms for longer than 1 week prior to treatment and having a sibling diagnosed with perineal GAS infection before or after the patient’s initial episode. Article page 687<
T
he concept of using diuretics for a patient with diabetes insipidus (DI) seems counterintuitive. However, thiazides have been very useful in the management of children with nephrogenic DI for quite some time. In that condition, their effect is somewhat unclear, but by inducing mild volume contraction, they may reduce distal nephron delivery of salt and water, leading to a decrease in urine output. Although the underlying defect in central DI is obviously very different from that of nephrogenic DI, the clinical presentation and electrolyte physiology is similar. In older children and adults, the use of vasopressin analogues (such as desmopressin [DDAVP]) is the standard therapy for central DI. This approach is fraught with difficulty in infants, however. Given that most of their intake is liquid, symptomatic hyponatremia is a frequent complication when infants with central DI are treated with DDAVP. In light of the efficacy of thiazides in nephrogenic DI, many have employed them for infants with central DI, in place of DDAVP. There is, however, very little published information on this approach. The current issue of The Journal includes a single-center report of 13 children with central DI treated with thiazides from the Mayo Clinic. In general, this approach worked very well in these children. In particular, complications requiring hospital admission were very rare. The article provides quite a bit of detail to guide clinicians wanting to use this approach. Article page 658<
n this issue of The Journal, Kurowski et al at the Ann & Robert H. Lurie Children’s Hospital of Chicago show how an educational module pays dividends both for the patient and the healthcare system. They evaluated a 2-month baseline frequency of recording in the medical record whether a digital rectal examination was performed or abdominal radiographs were obtained in patients 4-18 years of age who, after visiting their Emergency Department (ED) with the complaint of abdominal pain, were discharged with the diagnosis of constipation. They devised oral and Powerpoint presentations to educate care providers in the ED on the Rome III criteria for diagnosis of constipation, which include historical features of bowel habits and finding a large fecal mass on digital rectal examination, but do not include recommendation for abdominal radiographs because of their unlikely value in the diagnostic algorithm. After approximately 1 year’s time and completion of the module by at least 75% of the targeted care providers, they repeated a 2-month assessment of performance of the digital rectal examination and abdominal radiographs. Findings were straightforward. In this patient population, performance of digital rectal examination rose from approximately one-quarter to one-half of patients, and abdominal radiographs fell
I
Vol. 167, No. 3
from almost three-quarters to one-quarter of patients. This change in practice saved time, money, and radiation. A longer-term goal might be to use anticipatory guidance to decrease the prevalence of constipation in children or to decrease visits to the ED for children with constipation. Meanwhile, knowledge of the Rome criteria, >90% performance of digital rectal examination when constipation is the suspected diagnosis, and avoidance of abdominal radiographs, as well as appropriate referrals to gastroenterology subspecialists, are triple bonuses. Article page 706<
Moving on from natural disaster — Paul G. Fisher, MD
Fibromyalgia therapy — Thomas R. Welch, MD
September 2015
W
e remember with sadness the Great East Japan Earthquake and ensuing tsunamis that occurred off the coast of Japan near Sendai on March 11, 2011. The damage created by those forces, along with the subsequent failure of the Fukishima nuclear plant, will have a toll on the children of Japan for many years to come. An estimated 20 000 or more people died, and tens of thousands of children were displaced. In the midst of this tragedy, Tatsuta et al were already conducting a prospective birth cohort study of 749 mother-child dyads in the affected Sanriku coastal area in order to better understand the effect of fish consumption and other neurotoxins on child development. The quake struck around the 7-year age assessments, and compulsorily divided their residual sample into 123 children assessed before the disaster and 289 afterwards. Although the latter subsample was delayed many months in its assessment, these children were found to have significantly lower IQs and accompanying information, arithmetic, and vocabulary subscores. Performance and full-scale IQ were not affected. Whether the forced prolonged closure of schools or posttraumatic stress contributed the most to this difference is unclear, but will require further determination over time. The authors should be congratulated for their perseverance in continuing their research in light of such tragedy and also for their commitment to advancing the well being of children subjected to disaster. Article page 745<
A
lthough we do not often consider chronic amplified pain syndromes as important in children, the incidence of these is surprisingly high. As many as 2%-6% of children, for example, may meet the criteria for fibromyalgia. Despite this, there are very few guidelines on the management of fibromyalgia in children. This is unfortunate in that some children may be very seriously involved and compromised by the condition. There is little evidence that medications play a useful role in the management of childhood fibromyalgia. A group in Philadelphia has developed an intense program of physical and occupational therapy for children with another pain syndrome, complex regional pain syndrome. In this issue of The Journal, Sherry et al from this program describe a similar approach in 64 children with fibromyalgia. The report is particularly useful, as it presents 1-year follow-up data in this chronic condition. The data in this report are optimistic. Children generally showed improvement in several objective measures, including pain, function, and quality of life. These improvements occurred in the context of no medications. The program is very resource-intense, involving up to 8 hours of therapy daily. It will be very interesting to see the degree to which this experience can be replicated in other centers. In any case, it is most encouraging to see these results in such a disabling condition. Article page 731<
505