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Selections fromJournal Watch Pediatrics and Adolescent medicine

More than a simple headache: pseudotumor cerebri in patients with sickle cell disease ▸

Children with sickle cell disease (SCD) often have headache, a symptom that can be related to the patient’s anemia or cerebrovascular disease. Headache can also be caused by pseudotumor cerebri (PC), or false brain tumor, which is characterized by the buildup of cerebrospinal fluid in the space surrounding the brain. PC is often associated with obesity, and untreated, can lead to blindness.

These authors describe three children with SCD who presented with headache. On ophthalmologic exam, bilateral papilledema was noted in all three patients, which led to a diagnosis of PC. The children received acetazolamide therapy, and symptoms resolved in two patients and improved in the third. None of the children had permanent visual deficits.

Comment ▸

Early recognition of papilledema in patients with SCD and headache can expedite treatment and prevent vision loss. We may tend to attribute all of a patient’s symptoms to his or her known diagnosis; in these children, such an assumption could have delayed diagnosis and resulted in loss of vision. This report highlights the importance of keeping one’s clinical and diagnostic skills in shape, even in an age of protocol-based clinical care. With increased childhood and adolescent obesity, PC may become more common in the pediatric population.

Susan Jay, MD, and Walter M. Jay, MD

Dr. Walter M. Jay is the John M. Krasa Professor of Ophthalmology at Loyola University Medical Center, Maywood, Illinois.

Published in Journal Watch Pediatrics and Adolescent Medicine May 10, 2004

Whither goest thou? Diabetes and mortality ▸

Type 1 diabetes increases the risk for mortality at a young age. Drawing on a database that included information on 0.9 million people in 1968, 1.9 million in 1974, and 2.5 million in 1987, British investigators quantified the risk for mortality in patients younger than 30 years who were hospitalized with type 1 diabetes.

There were 4992 admissions for diabetes from 1968 to 1996, and 58 deaths in the 3 years following admission. The standardized mortality ratio for all deaths was 8.5 (95% confidence interval, 6.5–10.8); among patients admitted with diabetic ketoacidosis or coma, standardized mortality ratios were 27.9 (CI, 14.8–45.2) at 1 year and 12.9 (CI, 7.6–19.5) at 3 years. The most frequent causes of death were diabetes (29 cases), other diseases (14), suicide (9), and accidents (6). Suicide was 12 times more likely in this patient population than in the general population (and 35 times more likely among females).

Comment ▸

When treating patients with diabetes, pediatricians should not only monitor adherence to the usual dietary and medication regimes, but also be sensitive to the potential risk for mortality among hospitalized patients. Asking about possible depression and suicidal feelings after hospitalization is an important addition to our preventive armamentarium.

Elizabeth R. McAnarney, MD

Published in Journal Watch Pediatrics and Adolescent Medicine April 26, 2004

Prevalence of chlamydial and gonococcal infections in young adults ▸

Recommendations for routine chlamydia screening of young women are based on clinic data and public health reports. Now, researchers have analyzed U.S. population-based data from the prospective Add Health survey to determine the prevalence of chlamydial and gonococcal infections in young men and women. A random national sample formed the initial cohort of 18,924 students who were in grades 7 through 12 (1994–1995). At the most recent in-home interviews (2001–2002), the 14,322 remaining participants (53% women, 54% white) were 18 to 26 years old; urine samples were obtained from more than 80%.

The prevalence of chlamydial infections was 4.2% (1.9% in whites, 5.9% in Latinos, and 12.5% in blacks). The prevalence of gonorrheal infections was 0.4% (0.1% in whites, 0.2% in Latinos, and 2.1% in blacks). The prevalence of chlamydial infection was highest among black women (14%); black men had the highest prevalence of gonorrheal infection (2.4%). For both infections, prevalence was greatest in the southern states. More than 95% of chlamydia-positive participants and more than 85% of gonorrhea-positive participants were asymptomatic.

Comment ▸

The authors identify this study as the largest population-based survey of chlamydial and gonococcal infections in young adults. Screening recommendations, which have focused on public health clinics and high-risk groups, apparently have not reduced the overall prevalence of these easily treated infections. Widespread screening seems warranted.

Thomas L. Schwenk, MD

Published in Journal Watch June 1, 2004

Antidepressant use in late pregnancy: neonatal outcomes ▸

For pregnant women with depression, clinicians must weigh the risks of untreated depression for both mother and child against the potential harms of antidepressant use to newborns. To define that potential more clearly, researchers analyzed prospective data on 987 mothers in a Swedish population-based birth registry who had used antidepressants during pregnancies from 1995 to 2001.

About 55% of mothers had started or continued using antidepressants after week 23 of pregnancy, 7% had stopped use before week 24, and timing was unclear in 38%. Tricyclics were used in 40% of cases, and selective serotonin reuptake inhibitors (SSRIs) were used in 57%.

After adjustment for year of birth, maternal age, parity, and maternal smoking in early pregnancy, outcomes for all babies in the registry were compared with outcomes for babies exposed to antidepressants. Exposed babies had significantly higher risks for low Apgar score, respiratory distress, low birth weight, preterm delivery, hypoglycemia, and neonatal convulsions – but not for neonatal jaundice.

Risks usually were higher with tricyclics, which now are used infrequently in the U.S., than with the more prevalent SSRIs. Compared with all babies, the subgroup exposed to SSRIs had significantly higher risks for low Apgar score (odds ratio, 2.28), respiratory distress (OR, 1.97), low birth weight (OR, 1.98), and preterm delivery (OR, 2.06), and borderline higher risk for neonatal convulsions (risk ratio, 3.6). Adequate comparisons among different SSRIs were not possible because of small numbers.

Comment ▸

These results reinforce previous findings that antidepressant use during pregnancy is linked with a neonatal withdrawal syndrome (manifested, for example, in respiratory distress) and perhaps with other harms to newborns. However, potential confounders beyond those that were considered – including depression itself and use of other drugs – make it difficult to generalize the results broadly. Clinicians should tailor decisions to individual pregnant women, weighing the risks of untreated depression against the potential harms of antidepressant use to newborns.

Robert A. Dershewitz, MD, MSc

Published in Journal Watch Psychiatry June 9, 2004

Originally published in Journal Watch April 27, 2004

Treating childhood pneumonia: how many days? ▸

For many childhood illnesses, decisions about duration of antimicrobial therapy are based on limited evidence. In a double-blind randomized trial, researchers in India enrolled 2188 children (age range, 2–59 months) with cough or breathing difficulty and nonsevere pneumonia (defined as an elevated respiratory rate that was adjusted for age). Subjects received thrice-daily oral amoxicillin (31–54 mg/kg daily) for either 3 or 5 days.

The 3- and 5-day treatment groups each had clinical cure rates of 90% on day 5. Treatment failure – defined as development of additional signs or symptoms of disease on day 3 or later, or oxygen saturation <90% on day 3 – showed significant associations with nonadherence to treatment at day 5 (adjusted odds ratio, 11.57), respiratory rate of more than 10 breaths/minute greater than the age-adjusted normal rate (AOR, 2.89), and baseline positivity for respiratory syncytial virus (AOR, 1.95).

Comment ▸

In the U.S., as in this study, most children are diagnosed with pneumonia without the benefit of chest x-rays. Although no treatment group received antibiotics for the traditional 7 to 10 days, nearly all of these children with nonsevere pneumonia (no cyanosis, arousable, with ability to drink) did well with 3 to 5 days of antibiotics. Given that nonadherence was associated with treatment failure, a good compromise might be to prescribe antibiotics for 7 days, with the hope that children will take them for 5. At the time of publication, the full text of the original article was available free of charge.

Howard Bauchner, MD

Published in Journal Watch April 23, 2004

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