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Journal Club: October 2016

Should we believe the Urinalysis?

Shabnam Jain, MD, MPH

In the post-HIB, post-pneumococcal immunization era, urinary tract infections (UTIs) are the most common serious bacterial infection (SBI) in infants and young children. The diagnosis of UTI is challenging in this population and has received much attention, including a 2011 AAP clinical practice guideline on diagnosis and management of UTI in febrile infants and young children. [1] In a recent article in Pediatrics on the association between uropathogens and pyuria, Shaikh et al found that 13% of symptomatic children whose urine was positive for a known uropathogen had absence of pyuria. [2] These authors and the accompanying commentary by Aaron Friedman support the importance of a urine culture even in the presence of a negative urinalysis (UA). [2,3] On the other hand, Schroeder et al in 2015 reported that in infants < 3 months with a bacteremic UTI, urinalysis has a very high sensitivity of 96-97% for UTI, higher than previously reported. They suggest that the UA is reliable even in young infants. [4] These two studies contradict the utility of a urinalysis as a screening test for UTI.

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Journal Club: September 2016

Rosenberg T, et al. Outcome of Benign Acute Childhood Myositis: The Experience of 2 Large Tertiary Care Pediatric Hospitals. Pediatr Emerg Care. 2016 Aug 20. [Epub ahead of print]

  • Retrospective Review of 54 patients with benign acute childhood myositis.
  • CPK at least 3 times normal with median of 1800 and peak of 8500.
  • 75% males, all children under 16 years of age.
  • 40 of the 54 were admitted for IV hydration; but no details relative to what drove the admission or mean CPK levels on admission.
  • None of the 54 patients encountered renal failure.
  • Take-home points:
    • 1) good history: Patients unable to walk or walk on tiptoes with foot plantar flexion and some knee flexion so as not to stretch calf muscles
    • 2) good exam: bilateral tenderness to calf palpation, moderate pain to calf when foot is dorsiflexed, patient walks on tip toes with knees slightly flexed
    • 3) minimal labs: Renal function test, CPK, and urinalysis
      • Urinalysis: if hemoglobin positive but without red blood cells, likely represents myoglobinuria
      • BUN and creatinine- if evidence of acute renal failure, probable admission for IV hydration. If only some dehydration, can be discharged home.
      • CPK–levels less than 3000 can be discharged home. Levels more than 16,000 have been associated with renal injury (but this data was extrapolated from other clinical situations with increased CPK)
  • Final take-home: Minimal labs needed, minimal intervention required other than hydration and/or pain management, admission may depend on size of patient and ability to get around at home.

Reviewed by Sam Spizman MD

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Blog = Journal Club

Esteemed Emory PEM division and other followers of this blog:

Apologies for the disruption in the blog. Apparently, having a single editor is NOT a good idea! We have a few important updates to the blog and its format moving forward, as well as other projects in the works for the blog.

  • A new blog administrator – Please welcome Lekha Shah, who will be assisting in administering the blog. She is an important part of the lead time, which also includes our fabulous CHOA librarian, Emily Lawson.
  • Only journal club postings – The primary purpose of this blog has always been to serve as an online venue for our fellows’/division’s journal club (JC). Under the guidance of Nick Jones and Brian Costello, the JC has been modified. Thus the blog should follow suit. Every presentation at JC will be posted on the blog as well. Because our fabulous urgent care physicians and fellows are excluded from this rotation, they will also be doing JC postings. JC postings will:
    • discuss a recent publication in the literature or
    • feature an article that answers a recent clinical question the doctor had
    • NOT repeat prior articles covered in the blog.
  • FOAM Party – We will still be doing periodic postings of FOAM party to encourage the division to dive into the fabulous world of FOAM.
  • Bonus Posts – We’ll have plenty of these as well. We will feature accomplishments from our division on the blog for all to read, celebrate, and recognize how awesome our division is!

Moving forward, the blog will become a hub of medical education within our division. Blackboard is disappearing, the teaching council has been working hard on developing objectives related to learners who rotate in our pediatric emergency departments, and our former online handbook has gone defunct. So in the future (some sooner, some later), you can expect to see on the blog:

  • rotation objectives for all learners rotating in the PED
  • educational material focused on each rotation objectives – this will include handouts, links to pre-existing resources, mini-digital lessons, and more
  • other material useful to the entire division as it relates to teaching
  • material generated by learners doing an elective with the PED (procedure & urgent care)
  • cool case corner – at this point, we are unable to present cases due to legal, but we are working on gaining approval
  • Twitter – eventually we hope to push info to our Twitter account as well as share pearls from our fellows’ conference

As always, if you want to write something for the blog, please let us know. We welcome all relevant  material.

If you have ideas, let us know! We want the blog to represent our division’s accomplishments, our pride in medical education, and our wonderful, loving, ED family.



Maneesha Agarwal, Lead Blog Administrator


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PEM Relevant Articles: March 2016

Koelink E, et al. Primary Care Physician Follow-up of Distal Radius Buckle Fractures. Pediatrics. 2016 Jan;137(1).

This article followed a group of children aged 2-17 with distal radial buckle fracture to see what proportion would get PCP only follow-up. At 28 days they noted that 87% had gotten PCP follow-up only with the next largest group (6.1%) being those who did not seek any follow-up. Only 2.8% were brought back to the ED and 3.9% were referred to a specialist by their PCP. Of note, 98.8% returned to their usual activities in 4 weeks. The study did point out that only 47% of patient got specific guidance about the injury by their PCP. While the number of patients enrolled (200) was fairly modest, the results show that it is safe and effective to have these patients see their PCP rather than a specialist with the caveat that we should be giving better guidance on the treatment course at discharge as the PCP might not give it. [NJ] Continue reading

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Article of the Month: March 2016

Tsze DS, Mallory MD, Cravero JP. Practice Patterns and Adverse Events of Nitrous Oxide Sedation and Analgesia: A Report from the Pediatric Sedation Research Consortium. J Pediatr. 2016 Feb;169: 260-5.e2.

Main Points
  • Review of 1634 N2O administrations on pediatric patients in 40 children’s & community hospitals (1/2 by Adv Practice nurses or PAs in ED or sedation units) showed 5.3% prevalence of ADEs (adverse drug events).
  • Most common ADE: vomiting (2.4%); increased risk associated with
    • opioid use (OR 2.89)
    • NPO < 2 hrs (OR 4.16)
  • Serious ADE cases: 3 (0.2%);
    • 2 airway obstruction (both had IV morphine, neither desaturated),
    • 1 transient desaturation (9 m/o ASA 3 due to neurologic, CV and genetic conditions);
  • no cases aspiration
  • Complications not associated with highest concentration
  • Vast majority of cases with opioids and benzodiazepines occurred without apparent ADE
  • Unsuccessful sedation: 1.2%
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Landmark Article: Management of Skin and Soft Tissue Infections in Afebrile Neonates.

Montague EC, Hilinski J, Andresen D, Cooley A. Evaluation and treatment of mastitis in infants. Pediatr Infect Dis J. 2013 Nov;32(11):1295-6.

Kharazmi SA, Hirsh DA, Simon HK, Jain S. Management of afebrile neonates with skin and soft tissue infections in the pediatric emergency department. Pediatr Emerg Care. 2012 Oct;28(10):1013-6.

Neonates are our most vulnerable population; with little immune defenses of their own we care for them in the most careful and calculated manner.  We are all aware that their signs of infection can be subtle and often find ourselves wondering: Does this patient need a full septic work up? In febrile neonates with a rectal temperature greater than or equal to 38 degrees Celsius the answer remains yes.  However, what about the afebrile neonates that come with a localized skin or soft tissue infection?  Do they too need a full septic work up, IV antimicrobials, and do they warrant an admission? These two articles discuss the utility of doing blood, urine, and CSF studies on afebrile neonates with skin and soft tissue infections (SSTI). Both retrospective studies involve patients seen in our very own tertiary care pediatric hospitals a population where community acquired MRSA is prevalent.  The first article specifically discusses afebrile neonates with SSTI while the second looks at all infants less than 120 days of age with mastitis. The bottom line for both being that not one afebrile neonate in their cohort, including those with a positive wound culture, had positive blood, urine, or CSF cultures!

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Bonus: Experiencing International Conference of Emergency Medicine in Cape Town, South Africa

Sawubona (Hello in Zulu)!

If you have never been to an international medical conference, please consider attending at least one in your medical career.  The benefits are numerous.  For one, you learn that we are all very interconnected and that people in South Africa, Tanzania, Australia and the United Kingdom are all grappling with similar healthcare management, infrastructure and utilization concerns.  Whether it be the patient or parent with child who showed up in the ED with concerns regarding a fever of a few hours versus the football (either American Football or the game of football where you actually use your feet in other words – Soccer) player who suffered blunt trauma to the brain who could have a concussion versus a clinically important traumatic brain injury.

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