Michael T. Del Vecchio

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

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.

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.

Route and length of therapy of acute uncomplicated hematogenous osteomyelitis: do we have the answers yet?

Acute hematogenous osteomyelitis (AHOM) is not uncommonly encountered in hospitalized pediatric patients, occurring in 1 in 5000 children per year or 1% of pediatric hospitalizations.1 There are published data regarding the length of antibiotic therapy, with many studies supporting an initial short intravenous (IV) course of therapy followed by an oral course of several weeks. Le Saux2 performed a systematic review that supported short-course IV therapy for AHOM. Peltola3 published the largest prospective study to date addressing treatment of AHOM, which supported short-course IV therapy followed by oral therapy for a total of 20 days. However, in practice, it is not so straightforward. It is not unusual for practitioners to recommend a long IV course of therapy, even in the face of an uncomplicated case of AHOM. Uncomplicated AHOM has been variably defined, but in general it would refer to osteomyelitis in a patient with <14 days of symptoms, no underlying medical conditions, and infection not associated with trauma and not requiring extensive surgical intervention3–6. This review synthesizes the available literature and addresses 2 clinical questions: (1) Is it reasonable to use short-course IV therapy in uncomplicated AHOM in pediatric patients? and (2) What is the appropriate total duration of therapy for uncomplicated AHOM in pediatric patients? AHOM is defined as <2 weeks of clinical symptoms with associated laboratory and imaging findings characteristic of AHOM and without any source for exogenous spread to the bone, such as may occur with penetrating trauma. The Pub Med and Google Scholar databases were used to conduct searches. Google Scholar was used to aid in finding open-access articles that might not be listed in PubMed. The search followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.7 Google scholar search terms included “osteomyelitis …

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

To provide prevalence rates for the most common causes of hemoptysis in children.

The Use of Albuterol in Young Infants Hospitalized with Acute RSV Bronchiolitis

Objective. To evaluate the effects of albuterol use in young infants admitted with respiratory syncytial virus (RSV) bronchiolitis with regards to length of time on supplemental oxygen and length of stay (LOS). To consider the possibility that albuterol use may increase the need for supplemental oxygen and increase LOS. Design, Setting, and Participants. Full-term infants between the ages of 11 days and 90 days (N = 316) were included in this retrospective study. Infants included were hospitalized with a diagnosis of RSV bronchiolitis at a university-affiliated childrens hospital. Results. In 4 of 5 severity groups, patients who received albuterol required more time on supplemental oxygen and had longer LOS. The differences only reached statistical significance in one of the severity groups in regards to LOS. Conclusions. The use of albuterol does not appear to be useful in the treatment of young infants with RSV bronchiolitis and may actually be harmful, in regards to increased supplemental oxygen need.

Systematic Review and Meta-analysis of Seizure Recurrence After a First Unprovoked Seizure in 815 Neurologically and Developmentally Normal Children

Limited data exist for health care providers regarding seizure recurrence after a first unprovoked seizure in previously neurologically and developmentally normal children. A systematic review and meta-analysis was conducted to assess seizure recurrence after a first unprovoked seizure by performing an electronic search in PubMed, Embase, and Scopus. Six studies from 2817 met the inclusion criteria. The sample size consisted of 815 neurologically and developmentally normal children (1 month–17.5 years) on no antiepileptic drugs. This systematic review and meta-analysis estimated a recurrence rate within 3 years of 45% (95% CI: 37%, 60%). This estimate provides a touchstone for health care providers who are managing this particular population of children.

Tetrasomy 13q32.2qter Due to an Apparent Inverted Duplicated Neocentric Marker Chromosome in an Infant with Hemangiomas, Failure to Thrive, Laryngomalacia, and Tethered Cord

BACKGROUND Approximately 100 small supernumerary marker chromosomes (sSMCs) with a non-α-satellite neocentromere structure have been reported in the literature. Of the few derived from chromosome 13, five have consisted of inverted duplicated segment 13q32qter. CASE REPORT We herein describe the sixth case, characterized by genome wide SNP array, conventional cytogenetics and FISH studies. The de novo occurrence of the marker, the poor prognosis and the presence of hemangiomas are consistent with previous cases. CONCLUSION We hereby expand the clinical spectrum of this rare cytogenetic disorder and suggest a possible mechanism for the pathogenesis of associated congenital vascular malformations.

Differential Diagnosis in Pediatrics: A Probabilistic Approach

How physicians arrive at a diagnosis has been the subject of much debate. Pattern recognition is used extensively by experts and is the most common method used by pediatricians. Many of the diagnostic questions posed in certification and self-study examinations developed by the American Board of Pediatrics and the American Academy of Pediatrics require the test taker to recognize a pattern of symptoms and laboratory tests and draw a conclusion about the most likely diagnosis. This method of diagnosis involves paralleling familiar situations independent of explicit hypothesis testing.1 Sackett et al describe this process as “the instantaneous realization that the patient’s presentation conforms to a previously learned picture or pattern of disease.”2 Pattern recognition has several shortcomings. First, the method is highly dependent on the clinician’s experience; novices are at a distinct disadvantage. Second, lists may vary from specialty to specialty. A pediatric infectious disease specialist may have a different list for acute childhood arthritis from that of a pediatric rheumatologist. Finally, the method fails when confronted with a defined clinical problem lacking distinguishing features, such as neonatal …

Etiologies of asymptomatic microscopic hematuria in children – systematic review of 1092 subjects

Abstract Background: Asymptomatic microscopic hematuria is common in children. No systematic review providing an evidence based approach for the differential diagnosis of these children has been performed. Contents: Multiple data bases were search. The PRISMA criteria were followed. Data regarding the etiology of the hematuria were extracted using a standardized extraction tool. Seven studies encompassing 1092 children (857 with isolated microscopic hematuria and 235 with combined microscopic hematuria and proteinuria), comprise this review. A total 42.4% of isolated microscopic and 81.3% of microscopic hematuria and proteinuria subjects had identified etiologies. Thin basement membrane nephritis (15.2%), IgA nephropathy (10.4%), and hypercalciuria without nephrolithiasis (7.7%), were the most common etiologies among children with isolated microscopic hematuria. IgA nephropathy (44.3%), thin basement membrane disease (12.8%), and mesangial proliferative glomerulosclerosis (8.9%) were the most common etiologies among children with combined microscopic hematuria and proteinuria. Conclusion: The present study provides an evidenced based resource, based on a systematic review, for the differential diagnosis of asymptomatic hematuria in children. Additionally, these observations suggest that children with isolated microscopic hematuria should be followed for persistence of hematuria or the development of proteinuria. Children with combined microscopic hematuria and proteinuria should be comprehensively evaluated.

Visual Diagnosis: Fever and Petechial Rash in a 9-year-old Boy

1. Stephanie Eng, MD* 2. Amanda Moon, MD† 3. Christopher Leander, MD‡ 4. Michael Del Vecchio, MD§ 1. *Class of 2012, Temple University School of Medicine, Philadelphia, PA; currently affiliated with A. I. duPont Hospital for Children, Wilmington, DE. 2. †Dermatology Resident, PGY2, University of Rochester, Strong Memorial Hospital, Rochester, NY. 3. ‡Pediatrician, Esperanza Health Center, Philadelphia, PA. 4. §Associate Professor of Pediatrics, Temple University School of Medicine, St. Christopher’s Hospital for Children, Philadelphia, PA. A 9-year-old boy presents to the emergency department in mid-April complaining of subjective fevers for 5 days and a rash for 2 days. The rash had appeared initially on his ankles. The day before, the rash had spread to his feet and began to itch. On the day of presentation, the patient is noted to have a temperature of 102°F. His past history is unremarkable and includes removal of a chalazion. He has no history of exposure to anyone with similar symptoms or any recent travel history or time spent in wooded areas. His twin sister had acquired Rocky Mountain spotted fever 1 year ago. On presentation, the boy is alert, oriented, and in no acute distress. Vital signs are temperature, 37.3°C; blood pressure, 94/62 mm Hg; heart rate, 100 beats per minute; respirations, 20 breaths per minute; and oxygen saturation, 99% on room air. Physical examination reveals petechiae on his right hand, left palm, and both knees. No bruising is noted. There are ∼6 petechiae on his chest, and a coalescing petechial rash is present on the dorsal and pedal surfaces of both feet extending to the ankles (Fig). Figure. Petechialrash on feet and ankles. Initial laboratory values include C-reactive protein level of 1.29 mg/L (normal, 0–5 mg/L), hemoglobin concentration of 11.4 g/dL, and hematocrit level of 32.6%. The patient is leukopenic (white blood cell count, 2.8 × 103/μL) and …