Is the Medium Still the Message? Culture-Independent Diagnosis of Gastrointestinal Infections.

Infectious diarrhea is caused by a variety of pathogens, including viruses, bacteria, and parasitic organisms. Though the causative agent of diarrhea has historically been evaluated via stool cultures, recently, culture-independent diagnostic tests (CIDT) have been developed and utilized with increasing frequency. Current practice guidelines recommend their use as adjuncts to stool cultures for diagnosing acute and chronic diarrhea. The three principal CIDT are microscopy, enzyme-based immunoassays (EIAs), and molecular based polymerase chain reaction (PCR). This review explores the common causes of infectious diarrhea, the basics of stool culture, the diagnostic utility of these three culture-independent modalities, and the strengths and weaknesses of all currently available clinical techniques. It also outlines considerations for specific populations including returning travelers and those with inflammatory bowel disease.

Bradycardia Without Hypertension: Is It a Common Clinical Presentation of Ventriculoperitoneal Shunt Malfunction in Pediatric Patients?

BACKGROUND: Mechanical shunting of cerebrospinal fluid is an effective treatment for hydrocephalus. Some studies suggest that bradycardia without hypertension may also be observed in ventriculoperitoneal (VP) shunt malfunction; however, in our experience, this is not a common presenting sign. OBJECTIVE: The aim of this study was to evaluate whether bradycardia without hypertension was a common sign in patients presenting to the pediatric emergency department (ED) with a VP shunt malfunction. METHODS: A retrospective observational study, from May 2006 to April 2015, which included a random sample of children admitted to the ED with clinical features suggestive of possible VP shunt malfunction. Control patients were defined as those who arrived at our ED with suspected VP shunt malfunction that was later ruled out on further workup. RESULTS: A total of 65 patients were included in this study. A significantly greater number of patients with a confirmed shunt pathology presented with vomiting (P = 0.01) and lethargy/apathy (P = 0.01). In the control group, a significantly greater number of patients presented with fever (P = 0.004) and seizures (P = 0.02). The number of patients presenting with bradycardia was not significantly different between the shunt pathology and control groups (P > 0.05). CONCLUSIONS: Bradycardia is not a common presentation in patients with VP shunt malfunction. Bradycardia is often recognized as a significant sign; however, it is one of the last presenting signs. Educating patients about the early signs must be considered as part of the treatment for VP shunt malfunction.

Publication outcomes of abstracts presented at an international toxicology conference.

INTRODUCTION: The timely and formal publication of material presented at national and international meetings is critical to the dissemination of new information to the medical community. The conversion rates for toxicology abstracts to full-text publications at previous North American toxicology meetings were low. No study has assessed the publication rate from the European Association of Poisons Centers and Clinical Toxicologists (EAPCCT). METHODS: We reviewed 269 abstracts presented at the 2013 EAPCCTcongress. We searched the PubMed, EMBASE, and Medline databases using the first, second, and last authors' names and keywords, through November 2018. RESULTS: Forty-seven of 269 abstracts (17%) subsequently appeared in 29 different peer-reviewed journals, led by Clinical Toxicology (13 out of 47, 28%). Leading countries of origin were the USA (8), UK (7) and Italy (6). The proportions of publications from native English-speaking and non-native English-speaking countries were similarly low (16% vs. 19%). CONCLUSIONS: Fewer than one in six abstracts reached publication within five years of the 2013 EAPCCT meeting. This rate is lower than in other specialty medical societies.

Outpatient Management of Headache after Pediatric Emergency Department Visit: Are we Missing Anything?

BACKGROUND: Headache is a common complaint in children at a pediatric emergency department (PED). The primary objective of this analysis is to describe the outcome of patients presenting with headache to the PED and discharged with neurology follow up. The secondary objective is to describe the diagnostic evaluation children with headache underwent in the PED and to evaluate headache characteristics which are more likely associated with serious, life-threatening conditions. METHODS: A retrospective chart review of children who were discharged from the PED after evaluation for headache, with a scheduled urgent neurology outpatient clinic follow up at the same institution, over a 3.5-year period. RESULTS: During the study period, we identified 300 children whose admitting diagnosis was headache and they were discharged from the PED with a scheduled follow up. None of these patients had papilledema on fundoscopy performed by an ophthalmologist during the PED visit. Following neurology outpatient clinic visit, 62 (21%) were referred to perform brain magnetic resonance imaging. None of the patients had a diagnosis of brain tumor or any anatomic abnormality that could increase intracranial pressure. CONCLUSIONS: No immediate life-threatening cases presented to the follow up neurology clinic for evaluation. A scheduled urgent neurology outpatient clinic follow up in any child with headache who is discharged from the PED, offers a safety net, even when the physical examination including fundoscopy is normal.

Severe disseminated intravascular coagulation in a child envenomated by Echis coloratus and successful treatment with monovalent equine immunoglobulin G antivenom.

BACKGROUND: Echis coloratus (Burton Carpet viper), a highly venomous snake belonging to the family Viperidae, is responsible for a large proportion of the venomous snakebites in Israel and Palestinian Authority. Procoagulant enzymes are present in Echis coloratus venom and significant coagulopathy is typical after envenomation. Here we report a case of envenomation by Echis coloratus that involved severe coagulopathy as the main systemic manifestation with severe bleeding after fasciotomy. CASE DETAILS: A 3-year-old boy was admitted to our pediatric critical care unit after a snakebite to his left hand, 2-3 hours post-bite. Based on the possibility of compartment syndrome, a fasciotomy was performed before administration of antivenom. At our hospital, he had altered prothrombin time (PT) and activated partial thromboplastin time (aPTT), with low fibrinogen levels. The snake responsible for the bite was later identified as a 38-cm long Echis coloratus. Five vials of Israeli monovalent antivenom were subsequently administered with step-wise improvement in hematological abnormalities. Other treatments included massive blood products transfusion (packed RBC, FFP, cryoprecipitate, PLT), inotropes and ventilatory support. After a prolonged hospital course the patient had a positive outcome.

Treatment of pediatric black widow spider envenomation: A national poison center's experience.

BACKGROUND: Black widow species (Latrodectus species) envenomation can produce a syndrome characterized by painful muscle rigidity and autonomic disturbances. Symptoms tend to be more severe in young children and adults. We describe black widow spider exposures and treatment in the pediatric age group, and investigate reasons for not using antivenom in severe cases. METHODS: All black widow exposures reported to the Rocky Mountain Poison Center between January 1, 2012, and December 31, 2015, were reviewed. Demographic data were recorded. Patients were divided into 2 groups. Group 1: contact through families from their place of residence, public schools and/or cases where patients were not referred to healthcare facilities. Group 2: patient contact through healthcare facilities. RESULTS: 93 patients were included. Forty (43%) calls were in Group 1 and 53 (57%) in Group 2. Symptoms were evident in all victims; 43 (46.2%) were grade 1, 16 (17.2%) grade 2 and 34 (36.5%) grade 3, but only 14 patients (41.1%) of this group received antivenom. Antivenom use was associated with improvement of symptoms within minutes, and all treated patients were discharged within hours, without an analgesic requirement or any complications. Reasons for not receiving antivenom included: skin test positive (2/20), strong history of asthma or allergies (2/20), physician preference (2/20), non-availability of the antivenom at the health care facility (14/20). CONCLUSION: In our study, most symptomatic black widow envenomations were minor. Relatively few patients received antivenom, but antivenom use was associated with shorter symptom duration among moderate and major outcome groups.

The changing clinical presentation of hypertrophic pyloric stenosis: the experience of a large, tertiary care pediatric hospital.

The authors reviewed the clinical and laboratory data from cases of hypertrophic pyloric stenosis (HPS) diagnosed at their institution from 2006 to 2008. They assessed and compared presentation of patients with HPS over time at their institution. A total of 118 patients were included in this study. An "olive" was palpated in only 13.6% of cases. This is in contrast to older studies, where more than 50% of the patients were reported to have a palpable "olive" depending on when the study was conducted. In patients from this institution, hypochloremia was present in 23% and alkalosis in 14.4%, which are less frequent than the incidence of these abnormalities in older studies. There was a change in the additional "classical" symptoms, represented by the lower percentage of infants in whom an "olive" was palpated and the lower numbers of patients with severe electrolyte imbalances. The reason for this change appears to be the frequent use of ultrasound.