When to Consider the Use of Antibiotics in the Treatment of 2009 H1N1 Influenza-Associated Pneumonia
A difficulty arises when a patient has influenza or influenza with a bacterial superinfection that requires antibiotics.[3]
A recent report showed that bacterial pathogens, including Staphylococcus aureus, were present in 17/53 (32%) of fatal cases of novel H1N1 infection, including 8 in children.[4]
Table 3 summarizes the clinical features of influenza vs influenza with a bacterial superinfection.
Table 3. Detection of Agents of Pneumonia: Influenza vs Influenza + Bacterial Pathogen
Indicator Influenza Influenza + Bacterial Pathogen
Influenza identified Usually found Often found less because later in disease course
Fever Usually found Usually found after a period of defervescence
Respiratory specimen culture Normal flora Pathogen: usually S pneumoniae, S aureus or Group A strep
X-ray Diffuse Lobar consolidation
Onset of respiratory compromise Early: 1-2 days Later: 4-7 days
In regard to antimicrobial selection, these experts recommend coverage for methicillin-resistant Staphylococcus aureus (MRSA) and Streptococcus pneumoniae using a second- or third-generation cephalosporin with the addition of MRSA coverage if there is evidence of necrotizing pneumonia or if a Gram stain or culture of respiratory secretions suggests this pathogen. For outpatients, they suggest amoxicillin-clavulanate or a second- or third-generation cephalosporin.
Commentary. The clinical features suggesting bacterial superinfection are reminders of the well-known report of the 1957-1958 pandemic from NY Hospital-Cornell,[5] when the classic biphasic pattern with typical flu symptoms -- improvement and then rapid deterioration with lobar pneumonia -- was described. The main pathogens then and now are S pneumoniae, S aureus, and group A streptococci. The antibiotics preferred for hospitalized patients with suspected S pneumoniae would be cefotaxime or ceftriaxone. For S aureus (either MRSA or untested), the preference would be for vancomycin dosed to trough levels of 15-20 µg/mL or linezolid (which appears to have better lung penetration).
Tuesday, January 12, 2010
Firecracker Injury to Eye
From Medscape Ophthalmology > Interactive Case Series
A 5-Year-Old With Firecracker Injury to the Eye
Caroline L. Belanger, MD; Kimberly G. Yen, MD; Evelyn A. Paysse, MD
Posted: 12/17/2009
Firecracker damage to the eye can result in mechanical, thermal, and chemical injury. Most firecrackers are made of flash-powder, a mixture of oxidizer and metallic fuel that burns quickly and, if confined, produces a loud noise.[1] Metallic particles, such as aluminum, may be found in firecrackers, and they can appear radio-opaque on CT scans.
The treatment for chemical injury to the eye from a firecracker includes copious irrigation of the eye as soon as the injury is detected.
Any remaining particles in the fornices should be removed because they can cause tissue necrosis.
A shield is recommended to protect the eye and a regimen of cycloplegics and steroid drops or ointments should be started as soon as possible to decrease inflammation. Amniotic membranes are thought to deliver anti-inflammatory factors to the ocular surface, thus reducing scarring and providing a protective structure where the epithelial cells could replicate.
Steroids must be decreased after 1 week of treatment because they can inhibit wound healing and promote infection.
Treatment for the 4 grades of corneal burns must be adjusted according to the severity of injury.
In a grade 1 corneal burn, only corneal epithelial loss is present and no conjunctival ischemia is found. The prognosis is very good.
Grade 2 is associated with some corneal edema and corneal haze; conjunctival ischemia affects less than one third of the limbus and some permanent scarring may occur.
Grade 3 is associated with significant haziness of the cornea, and limbal ischemia is less than one half of the limbus. Prognosis is variable and vision is usually impaired. Finally, a corneal burn is grade 4. The cornea is opaque, and limbal ischemia affects greater than one half of the limbus.
Grade 4 burns may be associated with globe perforation, and the prognosis is poor.
Fireworks-related Injuries
Fireworks are thought to have originated in China[5] and are commonly used throughout the world to celebrate the New Year, Independence Day (United States), Halloween, and many smaller festivals.
In 2006, 9200 people were treated in emergency departments for fireworks-related injuries in the United States.[1] One of every 3 people injured were children younger than 15 years, with boys being affected 3 times more frequently than girls.[1] Some reports state that people actively participating in fireworks-related activities are more frequently and severely injured than bystanders.[1] The body parts most often injured were hands, eyes, and the head, face, and ear.[6] Common injures that occur are blindness, third-degree burns, and permanent scarring.[1]
Burns were the most common injury to all body parts, except the eyes and head, where contusions, lacerations, and foreign bodies in the eye occurred more frequently.[1] Although fewer injuries were associated with items such as sparklers and rockets,[1] one third of the injuries to children younger than 5 years were due to sparklers.[1] Injuries resulting from public fireworks displays are extremely rare. Risk factors for injuries include proximity to the device; lack of physical coordination necessary to safely handle fireworks, such as in the case of younger children; and curiosity, a common factor in children.[1] Alcohol consumption is also admitted in a high percentage of patients with fireworks injuries.[6]
Preventive safety measures when working with firecrackers, such as wearing safety glasses, have been shown to be effective in reducing the number of injuries.[6]
The World Health Organization (1984) has recommended a worldwide ban on the manufacture of all fireworks.
My note: Wear Eye protection when playing with firecrackers - they can blind u!!
A 5-Year-Old With Firecracker Injury to the Eye
Caroline L. Belanger, MD; Kimberly G. Yen, MD; Evelyn A. Paysse, MD
Posted: 12/17/2009
Firecracker damage to the eye can result in mechanical, thermal, and chemical injury. Most firecrackers are made of flash-powder, a mixture of oxidizer and metallic fuel that burns quickly and, if confined, produces a loud noise.[1] Metallic particles, such as aluminum, may be found in firecrackers, and they can appear radio-opaque on CT scans.
The treatment for chemical injury to the eye from a firecracker includes copious irrigation of the eye as soon as the injury is detected.
Any remaining particles in the fornices should be removed because they can cause tissue necrosis.
A shield is recommended to protect the eye and a regimen of cycloplegics and steroid drops or ointments should be started as soon as possible to decrease inflammation. Amniotic membranes are thought to deliver anti-inflammatory factors to the ocular surface, thus reducing scarring and providing a protective structure where the epithelial cells could replicate.
Steroids must be decreased after 1 week of treatment because they can inhibit wound healing and promote infection.
Treatment for the 4 grades of corneal burns must be adjusted according to the severity of injury.
In a grade 1 corneal burn, only corneal epithelial loss is present and no conjunctival ischemia is found. The prognosis is very good.
Grade 2 is associated with some corneal edema and corneal haze; conjunctival ischemia affects less than one third of the limbus and some permanent scarring may occur.
Grade 3 is associated with significant haziness of the cornea, and limbal ischemia is less than one half of the limbus. Prognosis is variable and vision is usually impaired. Finally, a corneal burn is grade 4. The cornea is opaque, and limbal ischemia affects greater than one half of the limbus.
Grade 4 burns may be associated with globe perforation, and the prognosis is poor.
Fireworks-related Injuries
Fireworks are thought to have originated in China[5] and are commonly used throughout the world to celebrate the New Year, Independence Day (United States), Halloween, and many smaller festivals.
In 2006, 9200 people were treated in emergency departments for fireworks-related injuries in the United States.[1] One of every 3 people injured were children younger than 15 years, with boys being affected 3 times more frequently than girls.[1] Some reports state that people actively participating in fireworks-related activities are more frequently and severely injured than bystanders.[1] The body parts most often injured were hands, eyes, and the head, face, and ear.[6] Common injures that occur are blindness, third-degree burns, and permanent scarring.[1]
Burns were the most common injury to all body parts, except the eyes and head, where contusions, lacerations, and foreign bodies in the eye occurred more frequently.[1] Although fewer injuries were associated with items such as sparklers and rockets,[1] one third of the injuries to children younger than 5 years were due to sparklers.[1] Injuries resulting from public fireworks displays are extremely rare. Risk factors for injuries include proximity to the device; lack of physical coordination necessary to safely handle fireworks, such as in the case of younger children; and curiosity, a common factor in children.[1] Alcohol consumption is also admitted in a high percentage of patients with fireworks injuries.[6]
Preventive safety measures when working with firecrackers, such as wearing safety glasses, have been shown to be effective in reducing the number of injuries.[6]
The World Health Organization (1984) has recommended a worldwide ban on the manufacture of all fireworks.
My note: Wear Eye protection when playing with firecrackers - they can blind u!!
Psoriasis
Treatment of Severe Scalp Psoriasis: From the Medical Board of the National Psoriasis Foundation
Chan CS, Van Voorhees AS, Lebwohl MG, et al
J Am Acad Dermatol. 2009;60:962-971
A task force of the National Psoriasis Foundation Medical Board has written a consensus statement on therapy for scalp psoriasis. A MEDLINE search for "scalp psoriasis" was performed and the results were graded on the basis of levels of evidence developed by Shekelle and colleagues.[1] Treatment recommendations within the consensus statement are divided into first- and second-line options, and first-line treatment options are further divided into those that are appropriate for short-term vs long-term use.
The recommended first-line, short-term therapy for scalp psoriasis is topical corticosteroids, which have been the mainstay in the treatment of scalp psoriasis for years. The lowest-strength agent that is efficacious is preferred, although in general high-potency agents can be used safely. A limited number of head-to-head studies have demonstrated the superior efficacy of topical corticosteroids in scalp psoriasis compared with other topical agents. However, the major limitation of these agents is that superpotent topical corticosteroids are approved by the US Food and Drug Administration (FDA) for a maximum of 4 weeks of consecutive use due to the risk for skin atrophy, striae, and telangiectasias. No studies exist supporting the safety of these agents for use on the scalp beyond this time period. Because steroid-sparing medications are associated with fewer long-term risks, agents such as calcipotriene/calcipotriol, salicylic acid, dithranol/anthralin, coal tar, and topical retinoids (ie, tazarotene) are recommended as first-line, long-term therapy for scalp psoriasis. Combination therapy with the aforementioned topical agents has advantages over monotherapy because of enhanced efficacy with minimized toxicity and side effects.
All other treatment options for scalp psoriasis were based on anecdotal evidence. Alternative first-line treatment options include intralesional corticosteroids, which should be used only for localized scalp disease due to the increased risk for side effects associated with this method of administration. Alternative second-line treatment options include phototherapy and systemic medications. Although phototherapy is an effective treatment for nonscalp psoriasis, this modality is difficult to use on the scalp due to the presence of hair, which blocks the adequate penetration of ultraviolet light. To date, no studies exist that have specifically evaluated systemic treatments for scalp psoriasis. However, on the basis of the known efficacy of systemic agents in plaque psoriasis, a therapeutic trial of these agents can be considered when scalp psoriasis has not responded adequately to the aforementioned topical therapies.
Viewpoint
The scalp is the most common area of psoriasis involvement and one of the most difficult to treat. Scalp involvement occurs in approximately 79% of psoriasis patients[2] and historically has been treated with low-potency topical steroids. FDA safety labeling limits the consecutive use of superpotent topical corticosteroids to 4 weeks. However, despite the lack of clinical trial data supporting the use of these agents for more than 4weeks, most -- if not all -- clinicians use long-term dosing of topical corticosteroids in the treatment of scalp psoriasis, especially corticosteroids of less than super potency. Underused options are coal tar, anthralin, and salicylic acid. Coal tar and anthralin are safe and effective for long-term use but often stain hair and may have a distinct, pungent smell. Salicylic acid is effective for the removal of thick scale, which allows for better penetration of other topical agents, rendering them more efficacious. Combination treatment regimens using topical steroids and topical nonsteroidal treatments can minimize or avoid the risk for steroid side effects. Because scalp skin is quite thick, some of the common side effects of topical steroids, such as atrophy, striae, and telangiectasias, are virtually never seen on the scalp. Consequently, the main safety concern with the use of topical steroids on the scalp is adrenal suppression, especially during long-term use of superpotent topical steroids. To minimize such risk, we recommend intermittent use of regimens with potent agents, such as the one we use with clobetasol propionate spray: 2-4 weeks on, followed by 2-4 weeks off, then back to 2-4 weeks on, if necessary, and so on. Used in this way, it is unlikely that the adrenal suppression encountered will be anything more than transient physiologic adrenal suppression rather than pathologic adrenal suppression leading to clinically relevant adrenal insufficiency.
References
Shekelle PG, Woolf SH, Eccles M, Grimshaw J. Clinical guidelines: developing guidelines. BMJ. 1999;318:593-596.
Van de Kerkhof PC, Steegers-Theunissen RP, Kuipers MV. Evaluation of topical drug treatment in psoriasis. Dermatology. 1998;197:31-36. Abstract
Guidelines of Care for the Management of Psoriasis and Psoriatic Arthritis. Section 3. Guidelines of Care for the Management and Treatment of Psoriasis With Topical Therapies
Menter A, Korman NJ, Elmets CA, et al
J Am Acad Dermatol. 2009;60:643-659
A work group of experts in psoriasis is formulating consensus guidelines for the management of psoriasis and psoriatic arthritis. The individual sections of these guidelines focus on different aspects of psoriasis management. Section 3 pertains to the management of psoriasis with topical therapies. It discusses the efficacy and safety of corticosteroids, vitamin D analogs, tazarotene, tacrolimus, pimecrolimus, emollients, salicylic acid, anthralin, and coal tar. Combination therapies are also evaluated.
Data were obtained using an evidence-based model via search of the MEDLINE database from 1960 to 2008. The evaluation of evidence was based on the 3-point numeric grading scale of the Strength of Recommendation Taxonomy used in primary care journals: I = good-quality patient-oriented evidence; II = limited-quality patient-oriented evidence; and III = other evidence, including consensus guidelines, opinion, or case studies.[1] Clinical recommendations were then formulated using the following scale: A = recommendation based on consistent and good-quality evidence; B = recommendation based on inconsistent or limited-quality patient-oriented evidence; C = recommendation based on consensus, opinion, or case studies.
Ultimately, the work group formulated recommendations for the practical clinical use of each of the topical agents and commented on the following aspects: indications, dosing, efficacy, contraindications/adverse reactions, pregnancy/nursing use, and pediatric use. The document is too complex to summarize in this review, but the reader is referred to the especially helpful tables in the article that summarize treatments, strength of recommendation, level of evidence, and supporting references.
Viewpoint
Psoriasis affects approximately 2% of the population, and clinicians need to become familiar with the treatment of this cutaneous disease. The expanding arsenal of agents used to treat this often complex condition is growing constantly. This set of guidelines, presented in an evidence-based approach by top psoriasis experts, is crucial to the care of people with psoriasis. In our opinion, every clinician who treats psoriasis should use this document. Although not every patient presents a straightforward case, these guidelines should be used as a starting point for the creation of treatment regimens based on each patient's unique disease parameters. In our clinical practice, these guidelines are not only an extremely useful reference for patient care but also an essential "textbook" for the education of medical students, residents, and fellows who are attempting to become familiar with the management of psoriasis patients.
Reference
Ebell MH, Siwek J, Weiss BD, et al. Simplifying the language of evidence to improve patient care: strength of recommendation taxonomy (SORT): a patient-centered approach to grading evidence in medical literature. J Fam Pract. 2004;53:111-120. Abstract
Cochrane Review: Topical Treatments for Chronic Plaque Psoriasis
Mason AR, Mason J, Cork M, Dooley G, Edwards G
Cochrane Database Syst Rev. 2009;(2):CD005028. DOI: 10.1002/14651858.CD005028.pub2.
The Cochrane Collaboration is an independent organization that produces quarterly systematic reviews of healthcare interventions called Cochrane Reviews. These reviews seek to address the effectiveness and appropriateness of disease-related treatment regimens in a comprehensive, unbiased, and scientifically validated manner. The purpose is to facilitate the choices made by healthcare providers and policy makers regarding the care of patients. This recent Cochrane Review focuses on topical treatments for plaque psoriasis with 2 goals in mind: (1) to compare the effectiveness, tolerability, and safety of topical treatments for chronic plaque psoriasis with placebo; and (2) to compare vitamin D analogs with other topical treatments.
Results of 13 randomized controlled trials with a total of 21,448 study participants revealed the following regarding the topical treatments for plaque psoriasis:
Vitamin D agents, corticosteroids, anthralin, and tazarotene were each more effective than placebo;
Head-to-head comparisons of vitamin D agents vs potent/very potent corticosteroids showed no statistically significant efficacy differences;
The combination of a vitamin D agent and a steroid was more efficacious than either agent alone;
Vitamin D agents were superior to coal tar;
Vitamin D agents were more effective with occlusion and/or twice-daily application;
Potent corticosteroids were less likely than vitamin D agents to cause local adverse events such as skin irritation; and
There was no difference in frequency of systemic adverse events between placebo and all other topical agents (although the Cochrane authors pointed out that this may be due to absence of evidence rather than evidence of absence).
Viewpoint
The authors recommend that practicing dermatologists become acquainted with the Cochrane Library as a source of sound scientific information for treatment decisions. The discerning reader has the opportunity to appraise the actual data used by the authors to draw conclusions on treatment regimens by reviewing the full document version, while the more time-constrained reader can quickly peruse the summary section for a brief overview.
A quick search for Cochrane Reviews on psoriasis revealed 6 related articles. With the advent of biologic agents, it is impressive that the Cochrane reviewers chose to focus on the use of topical agents in the treatment of psoriasis. Because the majority of psoriasis patients have localized involvement, topical agents are and should remain the first-line agents of choice in most psoriasis cases and will continue to be a mainstay of treatment, except for those with generalized disease.
The obvious limitation of this document is that the information cannot be generalized to long-term maintenance therapy because the studies of these topical agents were, on average, only 6 weeks in duration. One-year safety and efficacy data are available only for vitamin D analogs (calcipotriene cream, calcipotriene plus betamethasone dipropionate ointment, and calcitriol ointment). The results showed that these agents are safe and effective for up to 1 year, and clinical practice suggests that they are safe and effective for even longer use. More long-term studies are needed, especially for agents that are not vitamin D analogs.
Abstract
This activity is supported by an independent educational grant from Galderma.
Chan CS, Van Voorhees AS, Lebwohl MG, et al
J Am Acad Dermatol. 2009;60:962-971
A task force of the National Psoriasis Foundation Medical Board has written a consensus statement on therapy for scalp psoriasis. A MEDLINE search for "scalp psoriasis" was performed and the results were graded on the basis of levels of evidence developed by Shekelle and colleagues.[1] Treatment recommendations within the consensus statement are divided into first- and second-line options, and first-line treatment options are further divided into those that are appropriate for short-term vs long-term use.
The recommended first-line, short-term therapy for scalp psoriasis is topical corticosteroids, which have been the mainstay in the treatment of scalp psoriasis for years. The lowest-strength agent that is efficacious is preferred, although in general high-potency agents can be used safely. A limited number of head-to-head studies have demonstrated the superior efficacy of topical corticosteroids in scalp psoriasis compared with other topical agents. However, the major limitation of these agents is that superpotent topical corticosteroids are approved by the US Food and Drug Administration (FDA) for a maximum of 4 weeks of consecutive use due to the risk for skin atrophy, striae, and telangiectasias. No studies exist supporting the safety of these agents for use on the scalp beyond this time period. Because steroid-sparing medications are associated with fewer long-term risks, agents such as calcipotriene/calcipotriol, salicylic acid, dithranol/anthralin, coal tar, and topical retinoids (ie, tazarotene) are recommended as first-line, long-term therapy for scalp psoriasis. Combination therapy with the aforementioned topical agents has advantages over monotherapy because of enhanced efficacy with minimized toxicity and side effects.
All other treatment options for scalp psoriasis were based on anecdotal evidence. Alternative first-line treatment options include intralesional corticosteroids, which should be used only for localized scalp disease due to the increased risk for side effects associated with this method of administration. Alternative second-line treatment options include phototherapy and systemic medications. Although phototherapy is an effective treatment for nonscalp psoriasis, this modality is difficult to use on the scalp due to the presence of hair, which blocks the adequate penetration of ultraviolet light. To date, no studies exist that have specifically evaluated systemic treatments for scalp psoriasis. However, on the basis of the known efficacy of systemic agents in plaque psoriasis, a therapeutic trial of these agents can be considered when scalp psoriasis has not responded adequately to the aforementioned topical therapies.
Viewpoint
The scalp is the most common area of psoriasis involvement and one of the most difficult to treat. Scalp involvement occurs in approximately 79% of psoriasis patients[2] and historically has been treated with low-potency topical steroids. FDA safety labeling limits the consecutive use of superpotent topical corticosteroids to 4 weeks. However, despite the lack of clinical trial data supporting the use of these agents for more than 4weeks, most -- if not all -- clinicians use long-term dosing of topical corticosteroids in the treatment of scalp psoriasis, especially corticosteroids of less than super potency. Underused options are coal tar, anthralin, and salicylic acid. Coal tar and anthralin are safe and effective for long-term use but often stain hair and may have a distinct, pungent smell. Salicylic acid is effective for the removal of thick scale, which allows for better penetration of other topical agents, rendering them more efficacious. Combination treatment regimens using topical steroids and topical nonsteroidal treatments can minimize or avoid the risk for steroid side effects. Because scalp skin is quite thick, some of the common side effects of topical steroids, such as atrophy, striae, and telangiectasias, are virtually never seen on the scalp. Consequently, the main safety concern with the use of topical steroids on the scalp is adrenal suppression, especially during long-term use of superpotent topical steroids. To minimize such risk, we recommend intermittent use of regimens with potent agents, such as the one we use with clobetasol propionate spray: 2-4 weeks on, followed by 2-4 weeks off, then back to 2-4 weeks on, if necessary, and so on. Used in this way, it is unlikely that the adrenal suppression encountered will be anything more than transient physiologic adrenal suppression rather than pathologic adrenal suppression leading to clinically relevant adrenal insufficiency.
References
Shekelle PG, Woolf SH, Eccles M, Grimshaw J. Clinical guidelines: developing guidelines. BMJ. 1999;318:593-596.
Van de Kerkhof PC, Steegers-Theunissen RP, Kuipers MV. Evaluation of topical drug treatment in psoriasis. Dermatology. 1998;197:31-36. Abstract
Guidelines of Care for the Management of Psoriasis and Psoriatic Arthritis. Section 3. Guidelines of Care for the Management and Treatment of Psoriasis With Topical Therapies
Menter A, Korman NJ, Elmets CA, et al
J Am Acad Dermatol. 2009;60:643-659
A work group of experts in psoriasis is formulating consensus guidelines for the management of psoriasis and psoriatic arthritis. The individual sections of these guidelines focus on different aspects of psoriasis management. Section 3 pertains to the management of psoriasis with topical therapies. It discusses the efficacy and safety of corticosteroids, vitamin D analogs, tazarotene, tacrolimus, pimecrolimus, emollients, salicylic acid, anthralin, and coal tar. Combination therapies are also evaluated.
Data were obtained using an evidence-based model via search of the MEDLINE database from 1960 to 2008. The evaluation of evidence was based on the 3-point numeric grading scale of the Strength of Recommendation Taxonomy used in primary care journals: I = good-quality patient-oriented evidence; II = limited-quality patient-oriented evidence; and III = other evidence, including consensus guidelines, opinion, or case studies.[1] Clinical recommendations were then formulated using the following scale: A = recommendation based on consistent and good-quality evidence; B = recommendation based on inconsistent or limited-quality patient-oriented evidence; C = recommendation based on consensus, opinion, or case studies.
Ultimately, the work group formulated recommendations for the practical clinical use of each of the topical agents and commented on the following aspects: indications, dosing, efficacy, contraindications/adverse reactions, pregnancy/nursing use, and pediatric use. The document is too complex to summarize in this review, but the reader is referred to the especially helpful tables in the article that summarize treatments, strength of recommendation, level of evidence, and supporting references.
Viewpoint
Psoriasis affects approximately 2% of the population, and clinicians need to become familiar with the treatment of this cutaneous disease. The expanding arsenal of agents used to treat this often complex condition is growing constantly. This set of guidelines, presented in an evidence-based approach by top psoriasis experts, is crucial to the care of people with psoriasis. In our opinion, every clinician who treats psoriasis should use this document. Although not every patient presents a straightforward case, these guidelines should be used as a starting point for the creation of treatment regimens based on each patient's unique disease parameters. In our clinical practice, these guidelines are not only an extremely useful reference for patient care but also an essential "textbook" for the education of medical students, residents, and fellows who are attempting to become familiar with the management of psoriasis patients.
Reference
Ebell MH, Siwek J, Weiss BD, et al. Simplifying the language of evidence to improve patient care: strength of recommendation taxonomy (SORT): a patient-centered approach to grading evidence in medical literature. J Fam Pract. 2004;53:111-120. Abstract
Cochrane Review: Topical Treatments for Chronic Plaque Psoriasis
Mason AR, Mason J, Cork M, Dooley G, Edwards G
Cochrane Database Syst Rev. 2009;(2):CD005028. DOI: 10.1002/14651858.CD005028.pub2.
The Cochrane Collaboration is an independent organization that produces quarterly systematic reviews of healthcare interventions called Cochrane Reviews. These reviews seek to address the effectiveness and appropriateness of disease-related treatment regimens in a comprehensive, unbiased, and scientifically validated manner. The purpose is to facilitate the choices made by healthcare providers and policy makers regarding the care of patients. This recent Cochrane Review focuses on topical treatments for plaque psoriasis with 2 goals in mind: (1) to compare the effectiveness, tolerability, and safety of topical treatments for chronic plaque psoriasis with placebo; and (2) to compare vitamin D analogs with other topical treatments.
Results of 13 randomized controlled trials with a total of 21,448 study participants revealed the following regarding the topical treatments for plaque psoriasis:
Vitamin D agents, corticosteroids, anthralin, and tazarotene were each more effective than placebo;
Head-to-head comparisons of vitamin D agents vs potent/very potent corticosteroids showed no statistically significant efficacy differences;
The combination of a vitamin D agent and a steroid was more efficacious than either agent alone;
Vitamin D agents were superior to coal tar;
Vitamin D agents were more effective with occlusion and/or twice-daily application;
Potent corticosteroids were less likely than vitamin D agents to cause local adverse events such as skin irritation; and
There was no difference in frequency of systemic adverse events between placebo and all other topical agents (although the Cochrane authors pointed out that this may be due to absence of evidence rather than evidence of absence).
Viewpoint
The authors recommend that practicing dermatologists become acquainted with the Cochrane Library as a source of sound scientific information for treatment decisions. The discerning reader has the opportunity to appraise the actual data used by the authors to draw conclusions on treatment regimens by reviewing the full document version, while the more time-constrained reader can quickly peruse the summary section for a brief overview.
A quick search for Cochrane Reviews on psoriasis revealed 6 related articles. With the advent of biologic agents, it is impressive that the Cochrane reviewers chose to focus on the use of topical agents in the treatment of psoriasis. Because the majority of psoriasis patients have localized involvement, topical agents are and should remain the first-line agents of choice in most psoriasis cases and will continue to be a mainstay of treatment, except for those with generalized disease.
The obvious limitation of this document is that the information cannot be generalized to long-term maintenance therapy because the studies of these topical agents were, on average, only 6 weeks in duration. One-year safety and efficacy data are available only for vitamin D analogs (calcipotriene cream, calcipotriene plus betamethasone dipropionate ointment, and calcitriol ointment). The results showed that these agents are safe and effective for up to 1 year, and clinical practice suggests that they are safe and effective for even longer use. More long-term studies are needed, especially for agents that are not vitamin D analogs.
Abstract
This activity is supported by an independent educational grant from Galderma.
Thursday, December 31, 2009
rotavirus vaccine
From Medscape Medical News
American Academy of Pediatrics Updates Guidelines for Use of Rotavirus Vaccine
News Author: Laurie Barclay, MD
CME Author: Charles P. Vega, MD, FAAFP
04/30/2009
There are now 2 vaccines against rotavirus licensed in the United States: one derived from 5 human-bovine strains (RV5) and one from a single human strain (RV1). Although both vaccines are live, attenuated oral vaccines, the dosing schedule for the 2 vaccines differs.
RV5 should be administered in 3 doses at ages 2, 4, and 6 months, and RV1 is a 2-dose series delivered at ages 2 and 4 months.
The current policy statement from the AAP examines the efficacy and safety data for both vaccines.
Study Highlights
The AAP does not express a preference for the use of RV5 or RV1.
The vaccines have been evaluated in 11 randomized trials involving more than 146,000 infants worldwide.
Both vaccines are well tolerated. They do not appear to promote fever or severe fever more than placebo. RV5 is associated with a small increase in the incidence of vomiting and diarrhea vs placebo.
Intussusception has not been associated with either vaccine, whether in clinical trials or, in the case of RV5, postmarketing analysis.
Both vaccines result in viral shedding in the stool (9% of children receiving RV5 and 25% of children receiving RV1). However, this viral shedding has not been documented to promote any new infections with rotavirus.
Vaccine efficacy studies demonstrated protection rates of 74% to 87% against any rotavirus disease and 85% to 98% against severe rotavirus disease.
No studies have addressed the interchangeability of the 2 vaccines. Although children should ideally be continued to receive the rotavirus vaccine they began, clinicians should not delay dosing because a product is unavailable. The available vaccine should be used.
A cost-benefit analysis demonstrated that the estimated cost per case of rotavirus averted was $139.00 for RV5 and $94.00 for RV1. However, the researchers cautioned that this cost difference might not be reflected in clinical practice.
Because latex rubber is used in the RV1 applicator, children with severe latex allergy should not receive RV1.
Clinicians should use caution in administering the rotavirus vaccines to children with altered immunocompetence. However, preliminary data suggest that the vaccines may be safe in children with HIV infection in Africa.
Children with moderate to severe acute gastroenteritis or other moderate to severe acute illness may defer the vaccination until a later date. However, children with mild illness should receive the vaccine to avoid failing to complete the series.
No data are available regarding the administration of the vaccines to children with a history of intussusception.
Repeated dosing in children who immediately regurgitate or vomit their dose of rotavirus vaccine is not recommended.
Preterm infants should receive the rotavirus vaccine, and those who are age-eligible should receive the vaccine at the time of discharge from the hospital. This obviates the theoretic risk for transmission of rotavirus in the hospital because of asymptomatic viral shedding after the vaccine.
The maximal age at the first dose of either vaccine is 14 weeks and 6 days, and the maximal age for the last dose of the vaccine is 8 months. The minimal interval between rotavirus vaccines is 4 weeks.
Clinical Implications
RV5 and RV1 are both live, attenuated vaccines, but they are derived from different sources and have different schedules of administration.
The AAP does not recommend one rotavirus vaccine vs the other. Both vaccines are efficacious and do not promote fever more than placebo. Both vaccines may be administered during cases of mild gastroenteritis, but the vaccine should not be readministered when a child regurgitates the dose.
American Academy of Pediatrics Updates Guidelines for Use of Rotavirus Vaccine
News Author: Laurie Barclay, MD
CME Author: Charles P. Vega, MD, FAAFP
04/30/2009
There are now 2 vaccines against rotavirus licensed in the United States: one derived from 5 human-bovine strains (RV5) and one from a single human strain (RV1). Although both vaccines are live, attenuated oral vaccines, the dosing schedule for the 2 vaccines differs.
RV5 should be administered in 3 doses at ages 2, 4, and 6 months, and RV1 is a 2-dose series delivered at ages 2 and 4 months.
The current policy statement from the AAP examines the efficacy and safety data for both vaccines.
Study Highlights
The AAP does not express a preference for the use of RV5 or RV1.
The vaccines have been evaluated in 11 randomized trials involving more than 146,000 infants worldwide.
Both vaccines are well tolerated. They do not appear to promote fever or severe fever more than placebo. RV5 is associated with a small increase in the incidence of vomiting and diarrhea vs placebo.
Intussusception has not been associated with either vaccine, whether in clinical trials or, in the case of RV5, postmarketing analysis.
Both vaccines result in viral shedding in the stool (9% of children receiving RV5 and 25% of children receiving RV1). However, this viral shedding has not been documented to promote any new infections with rotavirus.
Vaccine efficacy studies demonstrated protection rates of 74% to 87% against any rotavirus disease and 85% to 98% against severe rotavirus disease.
No studies have addressed the interchangeability of the 2 vaccines. Although children should ideally be continued to receive the rotavirus vaccine they began, clinicians should not delay dosing because a product is unavailable. The available vaccine should be used.
A cost-benefit analysis demonstrated that the estimated cost per case of rotavirus averted was $139.00 for RV5 and $94.00 for RV1. However, the researchers cautioned that this cost difference might not be reflected in clinical practice.
Because latex rubber is used in the RV1 applicator, children with severe latex allergy should not receive RV1.
Clinicians should use caution in administering the rotavirus vaccines to children with altered immunocompetence. However, preliminary data suggest that the vaccines may be safe in children with HIV infection in Africa.
Children with moderate to severe acute gastroenteritis or other moderate to severe acute illness may defer the vaccination until a later date. However, children with mild illness should receive the vaccine to avoid failing to complete the series.
No data are available regarding the administration of the vaccines to children with a history of intussusception.
Repeated dosing in children who immediately regurgitate or vomit their dose of rotavirus vaccine is not recommended.
Preterm infants should receive the rotavirus vaccine, and those who are age-eligible should receive the vaccine at the time of discharge from the hospital. This obviates the theoretic risk for transmission of rotavirus in the hospital because of asymptomatic viral shedding after the vaccine.
The maximal age at the first dose of either vaccine is 14 weeks and 6 days, and the maximal age for the last dose of the vaccine is 8 months. The minimal interval between rotavirus vaccines is 4 weeks.
Clinical Implications
RV5 and RV1 are both live, attenuated vaccines, but they are derived from different sources and have different schedules of administration.
The AAP does not recommend one rotavirus vaccine vs the other. Both vaccines are efficacious and do not promote fever more than placebo. Both vaccines may be administered during cases of mild gastroenteritis, but the vaccine should not be readministered when a child regurgitates the dose.
Management of Common Childhood Poisonings Reviewed
From Medscape Medical News
News Author: Laurie Barclay, MD
CME Author: Hien T. Nghiem, MD
03/11/2009;
In 2003, more than 2.4 million reports of toxin exposures were received by poison control centers in the United States. Children younger than 6 years accounted for 51% of exposures; of these, 38% involved children 3 years or younger.
Most exposures involved oral ingestion (76%), occurred in the home (93%), and were unintentional (> 80%).
In addition, most ingestions involved nontoxic substances and were managed at home.
The aim of this article was to review the evaluation and treatment of unintentional toxin ingestions in children younger than 12 years.
Study Highlights
The history of patients with suspected toxin ingestions should include age and sex, time and type of probable exposure, and all medications present in the home
Initial evaluation involves determining whether the patient is symptomatic; any patient who has ingested a toxin and who has respiratory, circulatory, or neurologic symptoms should be transported by ambulance to the nearest emergency department
If the ingestion was witnessed, a nontoxic substance was involved, and the patient appears asymptomatic, a prompt examination by the clinician in the office or a period of observation at home may be appropriate; otherwise, poison control should be consulted, and the patient should be evaluated in the clinician's office or in the emergency department.
In the emergency department, rapid triage is crucial, including airway, respiration, and circulation stabilization.
The most toxic substances to a child include iron, antidepressants, hypoglycemics, cardiovascular drugs, salicylates, anticonvulsants, and illicit drugs.
Iron poisoning is one of the most fatal in children younger than 6 years, especially because as few as 5 to 10 adult ferrous fumarate tablets can kill or seriously harm a child.
An asymptomatic child with suspected toxin ingestion may have ingested a delayed-action medication and should be monitored for a longer period
Identifying toxidromes or symptoms that point to toxin exposure is crucial; therefore, the patient's mental status, vital signs, pupil reactivity, skin moisture and color, bowel sounds, powder or vomit around the mouth, and any unusual breath odors should be noted.
Useful laboratory tests usually include bicarbonate levels, blood glucose levels, electrocardiography, electrolytes, prothrombin time, pulse oximetry, serum acetaminophen levels, and urine human chorionic gonadotropin levels in women of childbearing age.
Appropriate supportive or toxin-specific treatment should be initiated with all childhood poisonings.
Gastric decontamination, such as activated charcoal and gastric lavage, is no longer routinely recommended
It is only recommended when performed by a clinician with experience placing orogastric tubes and when administered within 1 hour of the ingestion.
Activated charcoal decreases the absorption of toxins in the stomach and intestinal tract.
It is most likely to help children who have ingested carbamazepine, dapsone, phenobarbital, quinine, theophylline, salicylates, phenytoin, or valproic acid.
The American Academy of Clinical Toxicology discourages the routine use of activated charcoal except within 1 hour of ingestion (
If used, a charcoal-to-drug ratio of 10:1 is recommended or a dose of 1 to 2 g/kg is recommended for children with ingestions of an unknown quantity. Sorbitol is used to improve taste and transit through the intestinal tract.
Syrup of ipecac is no longer recommended.
Hemodialysis may be appropriate for lithium, salicylate, theophylline, methanol, atenolol, phenobarbital, or valproic acid toxicity.
Psychiatric consultation is appropriate in the setting of intentional ingestion.
Pearls for Practice
In 2003, reports of toxin exposure usually involved children younger than 6 years, were unintentional, involved oral ingestion, and occurred in the home.
Gastric decontamination, such as activated charcoal and gastric lavage, is no longer routinely recommended and should be reserved for the most severe cases, with poison control center support.
Management options should consider the type and amount of substance ingested, potential toxicity, time elapsed since ingestion, and symptoms exhibited.
News Author: Laurie Barclay, MD
CME Author: Hien T. Nghiem, MD
03/11/2009;
In 2003, more than 2.4 million reports of toxin exposures were received by poison control centers in the United States. Children younger than 6 years accounted for 51% of exposures; of these, 38% involved children 3 years or younger.
Most exposures involved oral ingestion (76%), occurred in the home (93%), and were unintentional (> 80%).
In addition, most ingestions involved nontoxic substances and were managed at home.
The aim of this article was to review the evaluation and treatment of unintentional toxin ingestions in children younger than 12 years.
Study Highlights
The history of patients with suspected toxin ingestions should include age and sex, time and type of probable exposure, and all medications present in the home
Initial evaluation involves determining whether the patient is symptomatic; any patient who has ingested a toxin and who has respiratory, circulatory, or neurologic symptoms should be transported by ambulance to the nearest emergency department
If the ingestion was witnessed, a nontoxic substance was involved, and the patient appears asymptomatic, a prompt examination by the clinician in the office or a period of observation at home may be appropriate; otherwise, poison control should be consulted, and the patient should be evaluated in the clinician's office or in the emergency department.
In the emergency department, rapid triage is crucial, including airway, respiration, and circulation stabilization.
The most toxic substances to a child include iron, antidepressants, hypoglycemics, cardiovascular drugs, salicylates, anticonvulsants, and illicit drugs.
Iron poisoning is one of the most fatal in children younger than 6 years, especially because as few as 5 to 10 adult ferrous fumarate tablets can kill or seriously harm a child.
An asymptomatic child with suspected toxin ingestion may have ingested a delayed-action medication and should be monitored for a longer period
Identifying toxidromes or symptoms that point to toxin exposure is crucial; therefore, the patient's mental status, vital signs, pupil reactivity, skin moisture and color, bowel sounds, powder or vomit around the mouth, and any unusual breath odors should be noted.
Useful laboratory tests usually include bicarbonate levels, blood glucose levels, electrocardiography, electrolytes, prothrombin time, pulse oximetry, serum acetaminophen levels, and urine human chorionic gonadotropin levels in women of childbearing age.
Appropriate supportive or toxin-specific treatment should be initiated with all childhood poisonings.
Gastric decontamination, such as activated charcoal and gastric lavage, is no longer routinely recommended
It is only recommended when performed by a clinician with experience placing orogastric tubes and when administered within 1 hour of the ingestion.
Activated charcoal decreases the absorption of toxins in the stomach and intestinal tract.
It is most likely to help children who have ingested carbamazepine, dapsone, phenobarbital, quinine, theophylline, salicylates, phenytoin, or valproic acid.
The American Academy of Clinical Toxicology discourages the routine use of activated charcoal except within 1 hour of ingestion (
If used, a charcoal-to-drug ratio of 10:1 is recommended or a dose of 1 to 2 g/kg is recommended for children with ingestions of an unknown quantity. Sorbitol is used to improve taste and transit through the intestinal tract.
Syrup of ipecac is no longer recommended.
Hemodialysis may be appropriate for lithium, salicylate, theophylline, methanol, atenolol, phenobarbital, or valproic acid toxicity.
Psychiatric consultation is appropriate in the setting of intentional ingestion.
Pearls for Practice
In 2003, reports of toxin exposure usually involved children younger than 6 years, were unintentional, involved oral ingestion, and occurred in the home.
Gastric decontamination, such as activated charcoal and gastric lavage, is no longer routinely recommended and should be reserved for the most severe cases, with poison control center support.
Management options should consider the type and amount of substance ingested, potential toxicity, time elapsed since ingestion, and symptoms exhibited.
Saturday, December 26, 2009
Enemas, Oral Laxatives Equally Effective for Childhood Fecal Impaction
MedscapeCME Clinical Briefs
News Author: Laurie Barclay, MD
CME Author: Penny Murata, MD
December 22, 2009 — Enemas and orally administered laxatives are equally effective in treating rectal fecal impaction (RFI) in functional childhood constipation, according to the results of a randomized controlled trial reported in the December issue of Pediatrics.
"Despite a lack of scientific data, rectal enemas have long been advocated as the best first-line treatment for RFI," write Noor-L-Houda Bekkali, MD, from Academic Medical Centre in Amsterdam, Netherlands, and colleagues. "Two studies showed that oral [polyethylene glycol (PEG)] treatment yielded 95% successful disimpaction....This is the first prospective, randomized, controlled trial evaluating disimpaction with either rectal enemas or orally administered laxatives for children with severe RFI attributable to constipation."
The hypothesis tested by this study was that enemas and PEG would be equally effective in treating RFI but that enemas would be less well tolerated and colonic transit time (CTT) would improve during disimpaction.
The study sample consisted of 90 children (from 95 who were eligible), aged 4 to 16 years, with functional constipation and RFI. Rectal examination and first CTT measurement were performed, and symptoms of constipation were recorded 1 week before disimpaction. Patients with RFI were randomly assigned to treatment with once-daily enemas or with PEG (1.5 g/kg per day) for 6 consecutive days.
A second CTT measurement was performed during this treatment, as well as a child's behavior questionnaire. Other outcomes included successful rectal disimpaction, frequencies of defecation and fecal incontinence, and presence of abdominal pain and watery stools.
Mean age was 7.5 ± 2.8 years. Of the 90 participants, 60 were boys; 46 were assigned to enema treatment and 44 to PEG, with 5 dropouts in each group. Disimpaction was successful in 80% of patients in the enema group and 68% of the PEG group (P = .28).
Although fecal incontinence and watery stools occurred more often in the PEG group (P < .01), both groups had similar frequency of defecation (P = .64), abdominal pain (P = .33), behavior scores, and CTT normalization (P = .85).
"Enemas and PEG were equally effective in treating RFI in children," the study authors write. "Compared with enemas, PEG caused more fecal incontinence, with comparable behavior scores. The treatments should be considered equally as first-line therapy for RFI."
Limitations of this study include possible confounding of findings regarding fearful behavior and evaluation of behavior scores only after the start of disimpaction.
"Given the comparable behavior in the 2 groups, disimpaction with enemas should not necessarily be withheld to prevent anxiety," the study authors conclude. "We did not find more fearful behavior in the enema group, which might be explained by the administration of enemas by parents at home instead of by nurses in an unfamiliar environment (hospital), which is more common in practice."
The study authors have disclosed no relevant financial relationships.
Pediatrics. 2009;124:e1108-e1115. Abstract
Clinical Context
The worldwide prevalence of functional constipation in children is 7% to 30%, according to van den Berg and colleagues in the October 2006 issue of the American Journal of Gastroenterology. RFI refers to a large fecal mass on abdominal palpation or rectal examination that is unlikely to be passed on demand, as reported by Benninga and colleagues in the March 2005 issue of the Journal of Pediatric Gastroenterology and Nutrition. Treatment options for RFI include enemas, manual evacuation, and PEG.
This randomized controlled trial assesses the efficacy, effect on CTT, and tolerability of enema vs PEG treatment of RFI in children with functional constipation.
News Author: Laurie Barclay, MD
CME Author: Penny Murata, MD
December 22, 2009 — Enemas and orally administered laxatives are equally effective in treating rectal fecal impaction (RFI) in functional childhood constipation, according to the results of a randomized controlled trial reported in the December issue of Pediatrics.
"Despite a lack of scientific data, rectal enemas have long been advocated as the best first-line treatment for RFI," write Noor-L-Houda Bekkali, MD, from Academic Medical Centre in Amsterdam, Netherlands, and colleagues. "Two studies showed that oral [polyethylene glycol (PEG)] treatment yielded 95% successful disimpaction....This is the first prospective, randomized, controlled trial evaluating disimpaction with either rectal enemas or orally administered laxatives for children with severe RFI attributable to constipation."
The hypothesis tested by this study was that enemas and PEG would be equally effective in treating RFI but that enemas would be less well tolerated and colonic transit time (CTT) would improve during disimpaction.
The study sample consisted of 90 children (from 95 who were eligible), aged 4 to 16 years, with functional constipation and RFI. Rectal examination and first CTT measurement were performed, and symptoms of constipation were recorded 1 week before disimpaction. Patients with RFI were randomly assigned to treatment with once-daily enemas or with PEG (1.5 g/kg per day) for 6 consecutive days.
A second CTT measurement was performed during this treatment, as well as a child's behavior questionnaire. Other outcomes included successful rectal disimpaction, frequencies of defecation and fecal incontinence, and presence of abdominal pain and watery stools.
Mean age was 7.5 ± 2.8 years. Of the 90 participants, 60 were boys; 46 were assigned to enema treatment and 44 to PEG, with 5 dropouts in each group. Disimpaction was successful in 80% of patients in the enema group and 68% of the PEG group (P = .28).
Although fecal incontinence and watery stools occurred more often in the PEG group (P < .01), both groups had similar frequency of defecation (P = .64), abdominal pain (P = .33), behavior scores, and CTT normalization (P = .85).
"Enemas and PEG were equally effective in treating RFI in children," the study authors write. "Compared with enemas, PEG caused more fecal incontinence, with comparable behavior scores. The treatments should be considered equally as first-line therapy for RFI."
Limitations of this study include possible confounding of findings regarding fearful behavior and evaluation of behavior scores only after the start of disimpaction.
"Given the comparable behavior in the 2 groups, disimpaction with enemas should not necessarily be withheld to prevent anxiety," the study authors conclude. "We did not find more fearful behavior in the enema group, which might be explained by the administration of enemas by parents at home instead of by nurses in an unfamiliar environment (hospital), which is more common in practice."
The study authors have disclosed no relevant financial relationships.
Pediatrics. 2009;124:e1108-e1115. Abstract
Clinical Context
The worldwide prevalence of functional constipation in children is 7% to 30%, according to van den Berg and colleagues in the October 2006 issue of the American Journal of Gastroenterology. RFI refers to a large fecal mass on abdominal palpation or rectal examination that is unlikely to be passed on demand, as reported by Benninga and colleagues in the March 2005 issue of the Journal of Pediatric Gastroenterology and Nutrition. Treatment options for RFI include enemas, manual evacuation, and PEG.
This randomized controlled trial assesses the efficacy, effect on CTT, and tolerability of enema vs PEG treatment of RFI in children with functional constipation.
Bruising on Torso and Other Sites Helps Identify Pediatric Trauma Due to Abuse
From Reuters Health Information
NEW YORK (Reuters Health) Dec 07 - In toddlers and small children, bruising on the torso, ear, or neck is suggestive of abuse, according to the developers of a new child abuse screening tool. In infants younger than 4 months, they say, bruising anywhere may be suspicious for abuse.
Dr. Mary Clyde Pierce, from Children's Memorial Hospital, Chicago, and her colleagues were able to create a decision rule that is 97% sensitive and 84% specific in identifying child abuse in bruised youngsters up to four years old.
The rule starts by asking if the bruise is on the torso, ear, or neck (TEN) regions. If so, then the suspicion for abuse is high, provided that an accident in a public setting could not be confirmed. If the bruise is not in a TEN region, then suspicion for abuse is only high if the child is younger than 4 months and an accident in a public setting could not be confirmed.
The findings, which are reported in the December 7th online issue of Pediatrics and will later appear in the January print issue, stem from a study of 95 children, 0 to 48 months of age, who were admitted to a pediatric intensive care unit for trauma. Forty-two of the children had been victims of physical abuse; the other 53 had accidental trauma and served as controls.
Using data on the 71 with bruises - 33 abused children and 38 trauma patients - the researchers derived their bruising clinical decision tool. Twenty-five abused children had bruises in a TEN region compared with just 6 control children.
Abused children also typically had more bruises than did controls. For instance, 18 abused children had more than 4 bruises, while no control children had this many. Among children under 4 months, there were 74 bruises in 14 abused children compared with 9 bruises in 7 controls.
The researchers say their tool correctly identified 32 of 33 abuse victims and 32 of 38 accident victims.
Further studies, the authors conclude, are needed to prospectively test and validate the bruising decision rule.
Pediatrics 2010;125:64-71.
NEW YORK (Reuters Health) Dec 07 - In toddlers and small children, bruising on the torso, ear, or neck is suggestive of abuse, according to the developers of a new child abuse screening tool. In infants younger than 4 months, they say, bruising anywhere may be suspicious for abuse.
Dr. Mary Clyde Pierce, from Children's Memorial Hospital, Chicago, and her colleagues were able to create a decision rule that is 97% sensitive and 84% specific in identifying child abuse in bruised youngsters up to four years old.
The rule starts by asking if the bruise is on the torso, ear, or neck (TEN) regions. If so, then the suspicion for abuse is high, provided that an accident in a public setting could not be confirmed. If the bruise is not in a TEN region, then suspicion for abuse is only high if the child is younger than 4 months and an accident in a public setting could not be confirmed.
The findings, which are reported in the December 7th online issue of Pediatrics and will later appear in the January print issue, stem from a study of 95 children, 0 to 48 months of age, who were admitted to a pediatric intensive care unit for trauma. Forty-two of the children had been victims of physical abuse; the other 53 had accidental trauma and served as controls.
Using data on the 71 with bruises - 33 abused children and 38 trauma patients - the researchers derived their bruising clinical decision tool. Twenty-five abused children had bruises in a TEN region compared with just 6 control children.
Abused children also typically had more bruises than did controls. For instance, 18 abused children had more than 4 bruises, while no control children had this many. Among children under 4 months, there were 74 bruises in 14 abused children compared with 9 bruises in 7 controls.
The researchers say their tool correctly identified 32 of 33 abuse victims and 32 of 38 accident victims.
Further studies, the authors conclude, are needed to prospectively test and validate the bruising decision rule.
Pediatrics 2010;125:64-71.
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