Systematic review and meta-analysis of the etiology of heavy menstrual bleeding in 2,770 adolescent females.

BACKGROUND: Adolescent heavy menstrual bleeding(HMB), menorrhagia or abnormal uterine bleeding commonly occur in adolescent women. The differential diagnosis can be challenging. The pneumonic: PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified), is commonly used but it does not stratify as to the likelihood of a disorder. We have sought to develop a probability-based differential diagnosis for Adolescent HMB, menorrhagia or abnormal uterine bleeding. METHODS: A comprehensive literature search was conducted using PubMed, EMBASE, and SCOPUS databases. Case series describing adolescents from 10-19 years of age with HMB, menorrhagia or abnormal uterine bleeding was acceptable if: more than 10 patients were included; editorials, case reports, and secondary sources such as review articles, or book chapters were excluded. No language filter was used, but an English abstract was required. The etiology of HMB, menorrhagia or abnormal uterine bleeding, and the country of origin was extracted from articles that met inclusion criteria. Cumulative rate estimates were determined by Bayesian probability modeling. RESULTS: Seventeen full text articles were reviewed in detail; 2,770 patients were included. The most frequent causes of HMB were Ovarian Uterine Disorders (23.7%; 95% CredI 22-25.5%), Coagulation Disorders (19.4%; 95% CredI 17.8-21.1%), and Platelet Disorders (6.23%; 95% CredI 5.27-7.27%) with 45.9% (95% CredI 43.8-47.%9) of the cases of indeterminate origin. CONCLUSIONS: The leading causes of HMB in healthy adolescent females were varied. The sub-analysis identified distinct etiologies, suggesting that multiple factors must be considered in the evaluation of HMB. While PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified) provides us with a comprehensive picture of the possible causes of HMB in females, this systematic review assigns probabilities to the etiologies of HMB in adolescent females, providing physicians with a more focused and efficient pathway to diagnosis.

Derivation and Validation of a Machine Learning Algorithm for Predicting Venous Thromboembolism in Injured Children.

BACKGROUND: Venous thromboembolism (VTE) causes significant morbidity in pediatric trauma patients. We applied machine learning algorithms to the Trauma Quality Improvement Program (TQIP) database to develop and validate a risk prediction model for VTE in injured children. METHODS: Patients ≤18 years were identified from TQIP (2017-2019, n = 383,814). Those administered VTE prophylaxis ≤24 h and missing the outcome (VTE) were removed (n = 347,576). Feature selection identified 15 predictors: intubation, need for supplemental oxygen, spinal injury, pelvic fractures, multiple long bone fractures, major surgery (neurosurgery, thoracic, orthopedic, vascular), age, transfusion requirement, intracranial pressure monitor or external ventricular drain placement, and low Glasgow Coma Scale score. Data was split into training (n = 251,409) and testing (n = 118,175) subsets. Machine learning algorithms were trained, tested, and compared. RESULTS: Low-risk prediction: For the testing subset, all models outperformed the baseline rate of VTE (0.15%) with a predicted rate of 0.01-0.02% (p < 2.2e-16). 88.4-89.4% of patients were classified as low risk by the models. HIGH-RISK PREDICTION: All models outperformed baseline with a predicted rate of VTE ranging from 1.13 to 1.32% (p < 2.2e-16). The performance of the 3 models was not significantly different. CONCLUSION: We developed a predictive model that differentiates injured children for development of VTE with high discrimination and can guide prophylaxis use. LEVEL OF EVIDENCE: Prognostic, Level II. TYPE OF STUDY: Retrospective, Cross-sectional.

The Natural History of Severe Acute Respiratory Syndrome Coronavirus 2-Related Multisystem Inflammatory Syndrome in Children: A Systematic Review.

BACKGROUND: The clinical manifestations and natural history of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related multisystem inflammatory syndrome in children (MIS-C) are poorly defined. Using a systematic review of individual cases and case series and collating elements of the clinical course, the objective of this study was to provide a detailed clinical description and natural history of MIS-C. METHODS: Case reports and series of MIS-C were recovered from repeated MEDLINE searches, a single EMBASE search, and table of contents reviews of major general medicine and pediatric journals performed between June 3 and July 23, 2020. Fever, evidence of inflammation, and evidence of organ dysfunction were required for inclusion. RESULTS: MEDLINE and EMBASE searches produced 129 articles, and 10 articles were identified from journal contents or article bibliographies; 16 reports describing 505 children with MIS-C comprise this review. Thirty-two children (14.7%) had negative results for SARS-CoV-2 by nucleic acid and/or antibody testing. The weighted median age was 9 years (6 months to 20 years). Clinical findings included fever (100%), gastrointestinal symptoms (88.0%), rash (59.2%), conjunctivitis (50.0%), cheilitis/ "strawberry tongue" (55.7%), or extremity edema/erythema (47.5%). Median serum C-reactive protein, ferritin, fibrinogen, and D-dimer concentrations were above the normal range. Intravenous gammaglobulin (78.1%) and methylprednisolone/prednisone (57.6%) were the most common therapeutic interventions; immunomodulation was used in 24.3% of cases. Myocardial dysfunction requiring ionotropic support (57.4%) plus extracorporeal membrane oxygenation (5.3%), respiratory distress requiring mechanical ventilation (26.1%), and acute kidney injury (11.9%) were the major complications; anticoagulation was used commonly (54.4%), but thrombotic events occurred rarely (3.5%). Seven (1.4%) children died. CONCLUSIONS: MIS-C following SARS-CoV-2 infection frequently presents with gastrointestinal complaints and/or rash; conjunctivitis, cheilitis, and/or extremity changes also occur frequently. Serious complications occur frequently and respond to aggressive supportive therapy.

The Differential Diagnosis of Vertigo in Children: A Systematic Review of 2726 Cases.

OBJECTIVES: Vertigo is a relatively common complaint in children with 5.3% of pediatric patients complaining of this symptom. Although the causes of vertigo have been well established in adults, the diagnoses in children have not been well described. The aims of this systematic review are to discover the current information regarding etiologies of vertigo in children and to determine the most common diagnoses that present with vertigo in pediatric patients. METHODS: PubMed, Scopus, and Embase were searched using the PRISMA guidelines. The inclusion and exclusion criteria were established a priori. All results were analyzed using a Bayesian methodology for point estimation and credible interval calculation. RESULTS: From the database searches, 1419 titles were reviewed. Twenty-two studies met inclusion criteria. From these studies, a total of 2726 children aged 2 months to 19 years were reported. The top 4 diagnoses associated with childhood vertigo include vestibular migraine (23.8%; credible interval, 22.3%-25.5%), benign paroxysmal vertigo of childhood (13.7%; credible interval, 12.4%-15%), idiopathic or no identified association (11.7%; credible interval, 10.5%-12.9%), and labyrinthitis/vestibular neuronitis (8.47%, credible interval, 7.46%-9.55%) accounting for approximately 57% of cases. Less common diagnoses included Meniere disease and central nervous system tumors. CONCLUSIONS: Although the most common causes of pediatric vertigo include vestibular migraine and benign paroxysmal vertigo of childhood, the etiologies are myriad. Rates and credible intervals are provided to permit a probabilistic diagnostic approach to these children.

Etiologies of hemoptysis in children: A systematic review of 171 patients.

OBJECTIVE: To provide prevalence rates for the most common causes of hemoptysis in children. DATA SOURCES: A systematic review of articles from PubMed, the OVID Cochrane Reviews (1960-2015), and EMBASE (1991-2015) was undertaken. Additional articles were identified by reviewing the bibliographies of selected studies. Search terms included hemoptysis, children, and humans. STUDY SELECTION: Only case studies and cohorts that examined the causes of hemoptysis in children (birth to 21 years) were included; at least 10 patients were required of each study. DATA EXTRACTION: Inclusion criteria, patient number, age range, patient source, and categorical and specific etiologies of hemoptysis were recorded. DATA SYNTHESIS: From the 1,858 studies identified, seven were selected for inclusion. Eighty-nine percent of participants were found to have a specific etiology for hemoptysis. Of the categorical etiologies identified, infection (37.57%), "other causes" (31.79%), heart disease (6.36%), and neoplasia (4.05%) were the most common. Pneumonia, bronchitis, and pulmonary tuberculosis were the most common specific etiologies identified. LIMITATIONS: By its nature, this study was subject to selection bias and under representation of specific etiologies. CONCLUSIONS: Most pediatric patients presenting with hemoptysis have a specific etiology; pneumonia is the most common. A thorough history, physical exam, and focused laboratory evaluation is recommended for such patients. Pediatr Pulmonol. 2017;52:255-259. © 2016 Wiley Periodicals, Inc.

Tuberculosis and Pregnancy-Maternal, Fetal, and Neonatal Considerations.

The issue of tuberculosis during pregnancy is not simply a historical inquiry but rather an increasingly familiar clinical problem facing industrial nations as well as the developing countries of the world. This review focuses on the maternal aspects of tuberculous infection, as well as transmission to the fetus and newborn.

Factors that Affect Nonurgent Emergency Department Visits in a Publicly Insured Pediatric Population: An Observational Study.

BACKGROUND: Publicly insured children have high rates of nonurgent emergency department visits (LAVs). The factors that drive consumption of these services are unknown. METHODS: Demographics, emergency department visits, hospitalizations, missed preventative care appointments, zip code, and asthma status as factors for LAVs were determined by univariate, multivariate, and classification/regression tree analysis. Subjects were publicly insured and received care between March 1 and December 31, 2011. RESULTS: A total of 4,387 children were identified; 856 (19.5%) had at least 1 nonurgent and 1,173 (26.7%) had at least 1 urgent emergency department visit; 526 (12%) missed ≥2 primary care appointments and 779 children had asthma. By univariate analysis, at least one high acuity emergency department visit, hospitalization during the study period, and asthma were directly associated with LAVs; age was inversely related. Multivariate and classification tree analyses identified children younger than 31.5 months with at least 1 high acuity emergency department visit as the highest risk group (0.807 visits per patient; 95% confidence interval: 0.699-0.916, p < .00001). Missed appointments, asthma status, hospitalizations, zip code of residence, and gender were not significant factors. CONCLUSIONS: Young age and at least one high acuity emergency department visit are associated with high rates of nonurgent emergency department use among publicly insured children.

Etiologies of conjugated hyperbilirubinemia in infancy: a systematic review of 1692 subjects.

BACKGROUND: The etiologies of conjugated hyperbilirubinemia in infancy are diverse. OBJECTIVE: Determine the prevalence rates of the specific etiologies of conjugated hyperbilirubinemia in infancy. DATA SOURCES: EMBASE and Pubmed were searched electronically and the bibliographies of selected studies were search manually. The search was conducted independently by two authors. STUDY SELECTION: (1) prospective or retrospective case series or cohort study with 10 or more subjects; (2) consecutive infants who presented with conjugated hyperbilirubinemia; (3) subjects underwent appropriate diagnostic work-up for conjugated hyperbilirubinemia; (4) no specific diagnoses were excluded in the studied cohort. DATA EXTRACTION: Patient number, age range, country of origin, and categorical and specific etiologies. RESULTS: From 237 studies identified, 17 studies encompassing 1692 infants were selected. Idiopathic neonatal hepatitis (INH) occurred in 26.0% of cases; the most common specific etiologies were extrahepatic biliary atresia (EHBA) (25.89%), infection (11.47%), TPN- associated cholestasis (6.44%), metabolic disease (4.37%), alpha-1 anti-trypsin deficiency (4.14%), and perinatal hypoxia/ischemia (3.66%). CMV was the most common infection identified (31.51%) and galactosemia (36.49%) was the most common metabolic disease identified. LIMITATIONS: Major limitations are: (1) inconsistencies in the diagnostic evaluations among the different studies and (2) variations among the sample populations. CONCLUSIONS: INH is the most common diagnosis for conjugated hyperbilirubinemia in infancy while EHBA and infection are the most commonly identified etiologies. The present review is intended to be a guide to the differential diagnosis and evaluation of the infant presenting with conjugated hyperbilirubinemia.

Intravenous immunoglobulin in the treatment of Stevens-Johnson syndrome and toxic epidermal necrolysis: a meta-analysis with meta-regression of observational studies.

BACKGROUND: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe disorders with significant morbidity and mortality. The therapeutic use of intravenous immunoglobulin (IVIG) is based on limited data. OBJECTIVES: This systematic review evaluates the existing literature to determine if IVIG impacts the standardized mortality rate (SMR) in patients with SJS or TEN. METHODS: The MEDLINE database was searched for the period 1966-2011 for pertinent studies. The bibliographies of selected references were also reviewed for additional studies. Inclusion criteria required the studies to refer to patients who received IVIG for SJS or TEN, the severity of which was determined using the SCORTEN system. Thirteen studies were used in the final analysis. Demographic data, IVIG dosing, SCORTEN score, and mortality rates were extracted. RESULTS: Of the 13 studies, eight included a control group. Meta-analysis revealed that differences in SMRs were not significant (-0.322, 95% confidence interval [CI] -0.766 to 0.122; P = 0.155). The overall SMR point estimate for all 13 studies was 0.814 (95% CI 0.617-1.076). Meta-regression demonstrated a strong inverse correlation between IVIG dosage and SMRs (slope: -0.59, 95% CI -0.14 to -1.03; P = 0.009). CONCLUSIONS: Intravenous IG at dosages of ≥2 g/kg appears to significantly decrease mortality in patients with SJS or TEN.

The Effects of Inhaled Steroids on Recurrent Wheeze After Acute Bronchiolitis: A Systematic Review and Meta-Analysis of 748 Patients.

Background. Acute bronchiolitis infection during infancy is associated with an increased risk of asthma later in life. The objective of this study was to determine if inhaled steroids are effective in preventing the development of recurrent wheeze or asthma following acute bronchiolitis. Methods. Multiple databases and bibliographies of selected references were searched. Inclusion required (a) a randomized controlled trial of inhaled steroids and control group, (b) at least 2 weeks duration of therapy started during the acute phase of disease, and (c) identification of the rate of recurrent wheeze or asthma at least 6 months after therapy. Results. Of 1410 studies reviewed, 8 reports were included in this meta-analysis (748 patients). The overall odds ratio for developing recurrent wheeze or asthma with treatment versus without treatment was 1.02 (95% confidence interval = 0.58-1.81). Conclusions. A course of inhaled steroids after acute bronchiolitis is not effective in preventing recurrent wheeze or asthma.

The etiologies of non-CF bronchiectasis in childhood: a systematic review of 989 subjects.

BACKGROUND: While cystic fibrosis (CF) is the most common cause of bronchiectasis in childhood, non-CF bronchiectasis is associated with a wide variety of disorders. The objective of this study was to determine the relative prevalence and specific etiologies on non-CF bronchiectasis in childhood. METHODS: EMBASE, Medline, OVID Cochrane Reviews, Directory of Open Access Journals, Open Science Directory, EPSCO information services, and OAlster were searched electronically and the bibliographies of selected studies were searched manually. The search was conducted independently by 2 authors. STUDY SELECTION: (1) any clinical trial, observational study or cross-sectional case series of 10 or more patients with a description of the conditions associated with bronchiectasis; (2) subjects aged 21 years or younger; (3) cystic fibrosis was excluded and; (4) the diagnosis was confirmed by computed tomography of the chest. DATA EXTRACTION: Patient number, age range, inclusion criteria, diagnostic criteria, patient source, and categorical and specific etiology. RESULTS: From 491 studies identified, 12 studies encompassing 989 children with non-CF bronchiectasis were selected. Sixty-three percent of the subjects had an underlying disorder. Infectious (17%), primary immunodeficiency (16%), aspiration (10%), ciliary dyskinesia (9%), congenital malformation (3%), and secondary immunodeficiency (3%) were the most common disease categories; 999 etiologies were identified. Severe pneumonia of bacterial or viral etiology and B cell defects were the most common disorders identified. CONCLUSIONS: The majority of children with non-CF bronchiectasis have an underlying disorder. A focused history and laboratory investigated is recommended.

Use of serum procalcitonin in evaluation of febrile infants: a meta-analysis of 2317 patients.

BACKGROUND: Serum procalcitonin (PCT) concentrations have been studied as a diagnostic test for serious bacterial infections (SBIs) in children. However, the utility of a single measurement in the evaluation of SBIs in febrile infants younger than 91 days is not clear. OBJECTIVE: Use a systematic review and meta-analysis to determine: 1) the ability of serum PCT concentrations to identify febrile infants < 91 days of age at high and low risk for SBIs, and 2) to compare its utility with available clinical prediction rules. METHODS: The literature search identified studies of febrile infants segregated into risk groups using serum PCT concentrations. Some authors were contacted to provide subgroups < 91 days of age or to provide data with 0.3 ng/mL PCT cutoff values. Data were combined and validated using standard methodologies. RESULTS: Seven studies encompassing 2317 patients were identified; five of seven studies used a PCT discriminating concentration of 0.3 ng/mL. No heterogeneity or publication bias was identified. The overall relative risk (RR) was 3.97 (95% confidence interval [CI] 3.41-4.62) and was consistent by sensitivity analysis. The RR from a systematic review of clinical prediction rules was 30.6 (95% CI 7.0-68.13) and 8.75 (95% CI 2.29-15.2) for infants untreated and treated with antibiotics, respectively. CONCLUSIONS: Alone, measurement of serum PCT concentrations, though able to identify a group of young infants at risk for SBIs, is inferior to the available clinical prediction rules for identifying young, febrile infants at risk for SBIs. Serum concentrations ≤ 0.3 ng/mL may be helpful as an add-on test to current rules for identifying low-risk, febrile infants.

Utility of adjunctive macrolide therapy in treatment of children with asthma: a systematic review and meta-analysis.

BACKGROUND: The purpose of this study was to investigate macrolides as an adjunct to an asthma controller regimen in children with asthma. METHODS: Prospective clinical trials of macrolide therapy in children with asthma using outcome measures of change in forced expiratory volume in one second (FEV(1)) and/or oral corticosteroid requirement were searched for in PubMed up to December 2009. The reference lists of studies were also included in the analysis, as well as those listed in published meta-analyses. RESULTS: The literature search yielded 116 studies, six of which were included in this meta-analysis. The change in FEV(1) from baseline with adjunctive use of macrolide therapy in all children was not significant (0.25% predicted; 95% confidence interval [CI] -0.37, 0.86 predicted, P = 0.43); however, the change in FEV(1) among children receiving daily oral corticosteroids was significant (3.89% predicted; 95% CI -0.01, 7.79, P = 0.05). Addition of macrolide therapy to the treatment of children with oral corticosteroid-dependent asthma resulted in a statistically significant decrease in daily corticosteroid dosage (-3.45 mg/day; 95% CI -5.79, -1.09 mg/day, P = 0.004). This reduction in daily corticosteroid dosage was directly proportional to the duration of macrolide therapy (-0.17 mg methylprednisolone per week of macrolide therapy; 95% CI -0.33, -0.021, P = 0.025). CONCLUSION: Addition of macrolides to the treatment regimen of children with oral corticosteroid-dependent asthma improves FEV(1) and decreases the daily dosage of corticosteroids required for control in these children. The degree of dose reduction is directly related to the duration of macrolide therapy. Additional large, randomized, placebo-controlled trials of adjunctive macrolide use in children with oral corticosteroid-dependent asthma are required to verify this observation.

Integrating evidence based medicine into undergraduate medical education: combining online instruction with clinical clerkships.

BACKGROUND: Incorporation of evidence based medicine into the undergraduate curriculum varies from school to school. The purpose of this study was to determine if an online course in evidence based medicine run concurrently with the clinical clerkships in the 3rd year of undergraduate medical education provided effective instruction in evidence based medicine (EBM). DESCRIPTION: During the first 18 weeks of the 3rd year, students completed 6 online, didactic modules. Over the next 24 weeks, students developed questions independently from patients seen during clerkships and then retrieved and appraised relevant evidence. Online, faculty mentors reviewed student assignments submitted throughout the course to monitor progress. Mastery of the skills of EBM was assessed prior to and at the conclusion of the course using the Fresno test of competency. EVALUATION: Paired data were available from 139 students. Postcourse test scores (M= 77.7; 95% CI = 59-96.4) were significantly higher than precourse scores (M= 66.6; 95% CI = 46.5-86.7), p< .001. Paired evaluations demonstrated an average improvement of 11.1 +/- 20.0 points. All of the students submitted 4 independently derived questions and successfully retrieved and appraised evidence. CONCLUSIONS: Medical students successfully acquired and independently applied EBM skills following extended, online, faculty mentored instruction. This method of instruction provided uniform instruction across geographic sites and medical specialties and permitted efficient use of faculty time.

Linezolid for tympanostomy tube otorrhea caused by methicillin-resistant Staphylococcus aureus and multiple drug-resistant Streptococcus pneumoniae.

OBJECTIVE: To describe a consecutive series of children with refractory tympanostomy tube otorrhea treated with linezolid and document its clinical effectiveness and adverse effects. DESIGN: Retrospective, single institution case series. METHODS: The records of children treated with linezolid for refractory gram-positive otorrhea from 2003 to 2007 were analyzed for causative organisms, antimicrobial sensitivities, history of prior medical treatments, time to cessation of otorrhea, adverse effects of linezolid and recurrence of infection. RESULTS: Ten episodes of refractory gram-positive otorrhea treated with linezolid were documented among eight children during the study period. Seven were caused by methicillin-resistant Staphylococcus aureus and three by multiple-drug resistant Streptococcus pneumoniae. Prior treatment regimes included clindamycin, trimethoprim-sulfamethoxazole/rifampin, amoxicillin-clavulanate, and/or a third-generation cephalosporin. Seven of eight children had failed extended courses of fluoroquinolone ear drops. All children were free of otorrhea by the 14th day of twice-daily treatment with oral linezolid at 20mg/kg/day. One child developed two additional episodes of S. aureus otorrhea three and 10 months after initial treatment. Each was successfully controlled with linezolid. There were no adverse effects from linezolid treatment. CONCLUSION: Oral linezolid is highly effective in the treatment of refractory otorrhea caused by methicillin-resistant S. aureus and multiple drug-resistant S. pneumoniae. It has a low risk of serious side effects. It is one of only a few oral agents with activity against these organisms and is very expensive. Linezolid should be used only when otorrhea cannot be treated with conventional agents or when complications of otitis media pose a risk to life or function.

The utility of serum C-reactive protein in differentiating bacterial from nonbacterial pneumonia in children: a meta-analysis of 1230 children.

BACKGROUND: Differentiating bacterial from nonbacterial community-acquired pneumonia in children is difficult. Although several studies have evaluated serum concentrations of C-reactive protein (CRP) as a predictor of bacterial pneumonia in this patient population, the utility of this test remains unclear. OBJECTIVE: The purpose of this meta-analysis was to quantitatively define the utility of serum CRP as a predictor of bacterial pneumonia in acutely ill children. METHODS: Multiple databases were searched, bibliographies reviewed, and 2 authorities in the field were queried. Studies were included if: (1) the patient population was between 1 month and 18 years of age; (2) CRP was quantified in all subjects as part of the initial evaluation of a suspected, infectious, pulmonary process; (3) a cutoff serum CRP concentration between 30 and 60 mg/dL was used to distinguish nonbacterial from bacterial pneumonia; (4) some criteria were applied to differentiate bacterial from nonbacterial or viral pneumonia; (5) all patients were acutely ill; and (6) a chest radiograph was obtained as part of the initial evaluation. The quality of each included study was determined across 4 metrics: diagnostic criteria; study design; exclusion of chronically ill or human immunodeficiency virus infected subjects; and exclusion of patients who recently received antibiotics. Data was extracted from each article; the primary outcome measure was the odds ratio of patients with bacterial or mixed etiology pneumonia and serum CRP concentrations exceeding 30-60 mg/L. Heterogeneity among the studies was determined by Cochran's Q statistic; the methods of both Mantel and Haenszel, and DerSimonian and Laird were used to combine the study results. RESULTS: Eight studies fulfilled inclusion criteria. Combining all of the studies demonstrated a pooled study population of 1230 patients with the incidence of bacterial infection of 41%. Children with bacterial pneumonia were significantly more likely to have serum CRP concentrations exceeding 35-60 mg/L than children with nonbacterial infections (odds ratio = 2.58, 95% confidence interval = 1.20-5.55). Sensitivity analysis demonstrated that this difference was robust. There was significant heterogeneity among the 8 studies (Q = 37.7, P < 0.001, I2 = 81.4) that remained throughout the sensitivity analysis. CONCLUSIONS: In children with pneumonia, serum CRP concentrations exceeding 40-60 mg/L weakly predict a bacterial etiology.

Polymorphous hemangioendothelioma in a child with acquired immunodeficiency syndrome (AIDS).

Polymorphous hemangioendotheliomas (PH) are rare and borderline malignant tumors that are among the wide range of vascular tumors. We report here a 13-year-old male presenting with a history of weight loss, opportunistic infections, and lymphadenopathy. He was determined to be HIV positive and to have acquired immunodeficiency syndrome (AIDS). A biopsy of a femoral node was diagnostic of PH. His systemic lymphadenopathy appeared to resolve with anti-retroviral therapy. This tumor should be considered within the differential diagnoses of pediatric and immunocompromised patients.

Effect of initial corticosteroid therapy on coronary artery aneurysm formation in Kawasaki disease: a meta-analysis of 862 children.

OBJECTIVE: Kawasaki disease is an acute vasculitis of infancy and childhood. When untreated, 15% to 25% of patients develop coronary artery aneurysms. Although the use of aspirin and intravenous immune globulin (IVIG) as initial therapy is well established, the role of corticosteroids is uncertain. The objective of this study was to identify clinical trials that compared the rate of coronary aneurysm formation after initial therapy with corticosteroids or an appropriate control and to determine the overall efficacy of corticosteroid therapy for the initial treatment of Kawasaki disease. METHODS: Published studies were identified by searches of the Medline and the Cochrane Central Register of Controlled Trials databases as well as hand searches of selected references. Studies were included when (1) all subjects had a stated diagnosis of Kawasaki disease; (2) a corticosteroid preparation was included as part of the initial management of the disease process; (3) a therapeutically matched control group was included for the entire study, or subsets of patients that received a therapeutic intervention identical to the experimental group except for the inclusion of a corticosteroid compound could be identified; and (4) 2-dimensional echocardiography or coronary artery catheterization was performed at least 2 weeks after therapy to detect the presence of coronary aneurysms. Included studies were evaluated for quality and heterogeneity. Meta-analysis was performed using a fixed-effects model. RESULTS: Eight studies fulfilled criteria for inclusion. Because 2 of these studies provided adequate detail to permit evaluation of 2 subgroups each, a total of 10 groups were available for evaluation. The significant heterogeneity that existed among the 10 studies (Q = 21.9, I2 = 59.0) was eliminated when 2 studies with markedly different study designs were removed (Q = 5.59, I2 = 0.00). Meta-analysis of the remaining 8 studies revealed a significant reduction in the incidence of coronary artery aneurysms among patients who received corticosteroid therapy plus aspirin +/- IVIG compared with aspirin +/- IVIG alone (odds ratio [OR] 0.546; 95% confidence interval [CI]: 0.371-0.803); the benefit of corticosteroid therapy was maintained when study subsets of aspirin alone (OR: 0.601; 95% CI: 0.392-0.921) or aspirin + IVIG (OR: 0.352; 95% CI: 0.136-0.909) were compared with matched regimens that contained corticosteroids. CONCLUSION: The inclusion of corticosteroids in aspirin-containing regimens for the initial treatment of Kawasaki disease reduces the incidence of coronary aneurysms.