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Selections from Journal Watch Pediatrics and Adolescent Medicine Copyright © 2005 Massachusetts Medical Society. All rights reserved.

How significant are asymptomatic gross and microscopic hematuria? ▸

Asymptomatic hematuria (gross or microscopic) is relatively common in children. The estimated prevalence of asymptomatic microscopic hematuria in children is 0.5% to 2.0%; the incidence of asymptomatic gross hematuria is not known. Because the clinical significance of asymptomatic hematuria is uncertain, the traditional approach is to pursue a thorough clinical investigation. To evaluate its clinical significance and determine when diagnostic evaluation is necessary, investigators at Indiana University prospectively evaluated 570 children who were referred for evaluation of asymptomatic hematuria.

Microscopic hematuria (defined as >5 red blood cells/high-powered field) was detected at routine exams. Diagnostic evaluation consisted of personal history (to exclude symptoms), physical exam, blood pressure measurement, and laboratory studies (including complete blood count, urinalysis, serum creatinine and C3 levels, creatinine clearance, protein and calcium excretion, and ultrasonography or intravenous pyelography). Streptozyme titers were measured when hematuria was of less than 6 months’ duration, antinuclear antibody assays were conducted in teenagers, and black children underwent hemoglobin electrophoresis. Urine cultures and renal biopsies were performed selectively (e.g., for persistent hematuria, hypertension, proteinuria, and decreased renal function).

Of 342 children with microscopic hematuria, no cause was discovered in 80%. The most common cause was hypercalciuria (16% of all patients). Four children had poststreptococcal glomerulonephritis, and 4 had structural abnormalities of the urinary tract.

Gross hematuria was a different story: Of 228 children, a cause was detected in 62%, including one Wilms tumor. Hypercalciuria without a history of stone disease was the most common cause (22% of patients), followed by IgA nephropathy (16%) and poststreptococcal nephritis (9%). Twelve patients were hypertensive, and 10 had structural abnormalities.

Comment ▸

Because of the low incidence of significant findings in children with asymptomatic microscopic hematuria (without proteinuria), it seems rational and safe to simply follow such children and to evaluate them further only if hypertension, proteinuria, or other symptoms emerge. Gross hematuria, on the other hand, should always prompt a thorough investigation.

Harlan R. Gephart, MD

Published in Journal Watch Pediatrics and Adolescent Medicine May 6, 2005

Community-acquired MRSA: unraveling its disease spectrum ▸

How widespread are community-acquired infections due to emerging methicillin-resistant Staphylococcus aureus (MRSA) strains, and are these strains responsible for changes in the clinical spectrum of staphylococcal disease? Two reports now begin to supply some answers.

Fridkin and colleagues studied infections identified by a specialized MRSA surveillance project in Atlanta, Baltimore, and several regions of Minnesota. During 2001 and 2002, 2107 MRSA isolates (8%–20% of all MRSA isolates collected) were classified as community-acquired; 1647 of them were associated with clinical illness. Annual incidence of community-associated MRSA disease varied by site, ranging from 18.0 to 25.7 cases per 100,000 population. Rates were significantly higher among children <2 years old than among individuals ⩾2 and, in Atlanta, among blacks than whites. Of the 1647 disease episodes, 77% were infections of skin and soft tissue, and 6% were invasive infections (e.g., bacteremia, septic arthritis, osteomyelitis). Twenty-three percent of patients required hospitalization for MRSA disease; of these, 10% required intensive care. Only one patient died as a result of MRSA infection. Antimicrobial therapy (typically, a β-lactam) inactive against the infecting strain was given to 73% of patients, with no discernible adverse effects on outcomes among patients interviewed (all of whom had skin or soft-tissue infections). Although patients with community-acquired MRSA infections, by definition, lacked established risk factors for MRSA infection, 45% had underlying conditions or circumstances associated with skin infections (see Journal Watch Infectious Diseases Feb 28, 2005) or suggesting contact with the healthcare system.

Miller and colleagues described 14 cases of surgically confirmed necrotizing fasciitis due to community-acquired MRSA, occurring in Los Angeles from January 15, 2003, through April 15, 2004. Necrotizing fasciitis, typically caused by group A streptococcus, Clostridium perfringens, or a mixture of aerobic and anaerobic organisms, had been attributed to a monomicrobial MRSA infection before in only one patient, following surgery. Of the 14 patients (median age, 46 years), all underwent at least one surgical procedure, 10 required intensive care, and 3 had reconstructive plastic surgery; all survived. In most patients, disease onset seemed less acute than in classic necrotizing fasciitis, with symptoms present an average of 6 days before hospitalization. Blood cultures were positive in 4 of 10 patients. All but 4 patients had coexisting conditions or risk factors, including current or past injection-drug use (6 patients), hospitalization within the previous year (6), homelessness (4), a seizure disorder (3), diabetes (3), chronic hepatitis C (3), or earlier MRSA infection (3). Wound cultures from 12 of the 14 patients grew only MRSA. All MRSA isolates were susceptible to clindamycin, trimethoprim-sulfamethoxazole, vancomycin, gentamicin, and rifampin. The five isolates available for analysis belonged to the same genotype and carried Panton-Valentine leukocidin, lukD, and lukE toxin genes.

Comment ▸

Community-acquired MRSA infections are increasing. Although these reports do not address the proportion of community-associated staphylococcal infections that are caused by MRSA strains not originating in hospitals, an editorialist suggests that in Atlanta this figure may exceed 5%. Community-acquired MRSA must be added to the monomicrobial etiologies of necrotizing fasciitis, and clinicians must be alert to the need for antimicrobial therapy directed against these strains, as well as to the necessity for surgical intervention. Although the development of necrotizing fasciitis due to community-acquired MRSA is disturbing, it should be noted that 9 of the 14 reported patients either had been hospitalized within the previous year or had a history of MRSA infection.

Neil R. Blacklow, MD

Published in Journal Watch Infectious Diseases April 22, 2005

Asking about suicide doesn’t increase suicide risk ▸

Screening for suicidality is recommended for suicide prevention in teenagers, but does asking about suicide increase the risk for suicidal ideation? To find out, investigators surveyed 2342 adolescents (age, 13–19; 80% white; 58% male) in six suburban high schools in New York State about current stress, mood, depression, and substance use. Half of the cohort was randomized to receive a survey that also asked about suicide attempts and suicidal ideation; the other half received a survey without suicide questions. All students completed another survey 2 days later that inquired about current stress, suicidal ideation, suicide attempts, and depression.

Students who were asked about suicide in the first survey reported no more suicidal ideation in the follow-up survey than did those who were not asked about suicide in the first survey. Furthermore, high-risk students (i.e., those with histories of depression, substance use, or suicide attempts) who answered suicide questions in the first survey not only weren’t more likely to report suicidal ideation in the follow-up survey, but actually appeared less distressed, depressed, and suicidal than high-risk students who didn’t answer suicide questions in the first survey.

Comment ▸

Although this study was conducted in a largely white cohort enrolled in suburban schools, the findings are reassuring. Screening for depression and suicide risk is an important component of adolescent care. In high-risk teenagers, suicide screening is likely to improve detection of these symptoms and promote immediate action by the provider (i.e., referral or treatment that can lead to a reduction in depressive symptoms and suicidal thoughts).

F. Bruder Stapleton, MD

Additional comment ▸

An unfortunate outcome of the black-box labeling of SSRI agents has been to discourage providers from managing adolescents who present with depressive disorders. In a recent position paper, the Society for Adolescent Medicine strongly supports the appropriate use of antidepressant medication in the treatment of adolescents with depression despite potential adverse events.

M. Susan Jay, MD

Published in Journal Watch Pediatrics and Adolescent Medicine May 6, 2005

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