Charlene K. Mitchell

Primary Care Physician Access and Gatekeeping: A Key to Reducing Emergency Department Use

Use of the Emergency Department (ED) for nonurgent conditions results in increased cost and discontinuous health care. This prospective study evaluated a program (KenPAC) that required 24-hour access to a primary care physician (PCP) with ED gatekeeping responsibility. Following established criteria, medical records were reviewed for appropriateness of ED use by an urban indigent pediatric population. Emergency Department visits declined (10% to 7.6% (P=0.00005) and inappropriate visits dropped (41% to 8%) (P<0.00001) before KenPAC and after KenPAC, respectively. Parental experience, as judged by age and number of children, played a significant role in ED use. The institution of gatekeeping activity contributed to the reduced overall and inappropriate use of the ED.

A simplified table improves the recognition of paediatric hypertension

Aim:  Unrecognised and untreated hypertension can lead to significant morbidity and mortality over time. In a 2003 chart review, we found that our providers only recognised 15% of hypertensive blood pressure (BP). Our objective was to determine whether a simplified BP table improves the recognition of elevated BP in children.

Bodyfat Analysis and Perception of Body Image

Obesity is a common nutritional problem among children. Using the Futrex 5000A method of bodyfat measurement, this prospective study determined the percentage bodyfat in a self-selected, indigent, predominantly black population and the accuracy of perceived body image. Bodyfat exceeded the optimal range in 39% and 67% of female and male children, respectively. Females tended to view themselves as fatter and males perceived themselves as thinner than their actual composition. Parents were more accurate in their perception of obesity in their daughters (88%) than in their sons (52%). Children did not recognize the importance of exercise in preventing obesity. Bodyfat measurement and counseling should be done at an early age to improve this remarkable lack of perception about obesity.

When the picture is fragmented: Vitamin B12deficiency masquerading as thrombotic thrombocytopenic purpura

Thrombotic thrombocytopenic purpura (TTP) has high mortality and necessitates prompt recognition of microangiopathic hemolytic anemia (MAHA) and initiation of plasmapheresis. We present a challenging diagnostic workup and management of a 42-year-old man who presented with anemia, thrombocytopenia, and schistocytes on peripheral smear, all pointing to MAHA. Plasmapheresis and steroid therapy were promptly initiated, but hemolysis continued. Further workup showed megaloblastic anemia, severe Vitamin B12deficiency, high iron saturation, and absent reticulocytosis, none of which could be explained by TTP. Severe Vitamin B12deficiency can lead to hemolytic anemia from the destruction of red cells in the marrow that have failed the process of maturation. However, this should not cause thrombotic microangiopathy. Previous reports of B12deficiency presenting with MAHA and a TTP-like manifestation have identified acute hyperhomocysteinemia as a missing link between B12deficiency and MAHA, so this possibility was further explored. Our patient similarly had significantly elevated serum homocysteine levels, confirming this suspicion of Vitamin B12deficiency. Vitamin B12replacement led to normalization of the elevated levels of homocysteine, the disappearance of schistocytes on the peripheral smear, and resolution of the microangiopathic hemolysis, thereby confirming the diagnosis. It is pertinent that intensivists not only know the importance of early recognition and treatment of TTP but are also familiar with rare conditions that can present in a similar fashion.

An apple-core lesion in the colon: An infectious etiology

Gastrointestinal involvement occurs in about 70% to 90% of histoplasmosis cases but is usually not the initial manifestation. We present the case of a 52-yearold HIV-positive woman who presented with gastrointestinal symptoms and an apple-core lesion on CT scan of the abdomen. The patient had been diagnosed with histoplasma colitis eight months earlier and was started on long-term itraconazole therapy. However, she prematurely discontinued treatment. A colonoscopy during the present hospitalization revealed a 3.5-cm mass, biopsies of which revealed Histoplasma capsulatum. In the present report, we discuss the differential diagnosis of apple-core lesions in the colon and the importance of keeping histoplasmosis on the differential diagnosis, especially in endemic areas like the Ohio River valley. It is equally important to ensure compliance with treatment of histoplasmosis, as well as close follow-up, as progression to colonic obstruction while on medical management has been reported.

Factors Associated With Improved Immunization Rates for Urban Minority Preschool Children

Urban, poor, preschool children are noted for having low immunization rates. To determine factors related to completion of immunization, vaccine records of 479 3-year-old children from an inner-city pediatric clinic were reviewed. Complete immunization was defined as four diphtheria-tetanus-pertussis doses, three oral polio vaccine doses, one measles-mumps-rubella dose, and one Haemophilus influenzae type b vaccine dose. Seventy percent of our patients were up-to-date by 2 years of age. The administration of all age-appropriate vaccines at a single visit for patients 15 months and older, the establishment of a continuous primary-care relationship, earlier age at first immunization, and lower birth weight were significantly associated with higher immunization levels in our study.

A Rare Presentation of Hepatitis A Infection with Extrahepatic Manifestations

Hepatitis A has a variety of associated extrahepatic manifestations that clinicians should be aware of for early diagnosis and treatment. We report a unique case of hepatitis A presenting with multiple extrahepatic manifestations not previously described in a single patient. A 34-year-old male presented with sudden onset of left sided facial pain, swelling, and skin rash, with diffuse body pains and muscle weakness, and was found to be positive for hepatitis A immunoglobulin M (IgM). He was initially started on antibiotics for concerns of bacterial parotitis but did not show any improvement. A punch biopsy of his mandibular rash and swelling was done which showed lymphohistiocytic infiltration with a few eosinophils. A trial of prednisone resulted in improvement of his symptoms. Clinicians should be aware to look for hepatitis A infection in a patient with atypical clinical picture causing a widespread systemic inflammatory response. Treatment with prednisone may result in resolution.

256 PEDIATRIC HYPERTENSION: TOO COMPLICATED TO RECOGNIZE

Purpose To determine whether pediatric providers recognize elevated blood pressures. The hypothesis is that fewer than 50% of elevated blood pressure values in children are recognized. Methods Children aged 3 to 17 years presenting for well visits at two university-based pediatric clinics, from July 31 to August 15, 2003, were included. Height, weight, and systolic blood pressures (SBP) and diastolic (DBP) were obtained. Height and body mass index (BMI) percentiles were determined. Using current table-based standards, SBP and DBP values were categorized as normal (< 90th %), borderline (90% to 94%), or hypertensive (95% or higher). Statistical analysis was done using chi-square test for dichotomous and the Student t-test for continuous variables with p values ≤ .05 considered significant. Results Of the 287 children, 161 (56.1%) had normal BP; 35 (12.2%) were borderline; and 90 (31.4%) were in the hypertensive range. The mean BMI was significantly higher (79%) for children in the hypertensive than in the normotensive (60%) range (p < .001). Only 13 (14.6%) with hypertensive BP were identified as elevated, which is significantly less than 50% recognition (p < .001). The mean BMI percentile was 92 for those recognized compared to 76 for those with unrecognized BP elevations (p = .001). Conclusions While it is likely that most elevated blood pressures obtained in the pediatric office do not represent hypertension, the diagnosis of hypertension is dependent upon the recognition of abnormal values. Given the current complexity for determining hypertension, it is not surprising that only 11% of elevated BP were recognized in this study. Hypertensive values in normal-weight children were recognized significantly less often than in the children with higher BMI percentiles. Future efforts should be directed towards developing a simpler definition of pediatric hypertension, one that is preferably based on the pathophysiological consequences than on statistical patterns.