Journal Club

JOURNAL CLUB

What is the impact of head impact?

Three recent reports on the effects and incidence of head injuries among young athletes suggest that multiple mild concussions, and perhaps less serious head injuries, sometimes have lasting adverse effects on cognitive functioning. In addition, mild concussion in a variety of sports may be more common than has been thought.

Investigators studied 393 football players from four universities, comparing baseline and follow-up neuropsychologic measures and concussion symptoms in those with a history of more than one concussion, only one concussion, or no concussions. Players who had more than one concussion were more likely than those who had one concussion or none to have persistent symptoms like headaches and to have difficulty learning words, thinking quickly, and handling complex tasks. Players who had learning disabilities in addition to more than one concussion had a further reduction in cognitive functioning, compared with their teammates (Collins MW et al: JAMA 1999;282:964).

Football also figured prominently in a study of the frequency of mild traumatic brain injury (MTBI) in athletes from 235 United States high schools. Trainers reported injuries in selected sports—football, boys' and girls' basketball, boys' and girls' soccer, wrestling, field hockey, baseball, softball, and girls' volleyball. Football accounted for 773 (63.4%) of 1,219 reported MTBIs during the three-year study period of 74,298 player seasons. It was followed by 128 (10.5%) MTBIs for wrestling, 76 (6.2%) for girls' soccer, 69 (5.7%) for boys' soccer, 63 (5.2%) for girls' basketball, 51 (4.2%) for boys' basketball, 15 (1.2%) for baseball, 13 (1.1%) for field hockey, and six (0.5%) for volleyball (Powell JW et al: JAMA 1999;282:958).

The third report addresses the risks of chronic traumatic brain injury (CTBI) for amateur soccer players, particularly those who "head" a ball or sustain concussions. CTBI represents the cumulative long-term neurologic consequences of repetitive concussive and subconcussive blows to the head. A comparison of results of 16 neuropsychologic tests in 33 amateur soccer players and 27 amateur swimming and track athletes showed that the soccer players performed less well on tests of memory, planning, and attention than amateur athletes in the other sports. In addition, the number of concussions incurred in soccer was inversely related to neuropsychologic performance on six of the tests (Matser EJ et al: JAMA 1999;282:971).

Commentary: These studies will not be the last word on the short- and long-term impact of minor head injury in sports. More work is needed on this subject. If mild head injury results in long-term cognitive problems, even small problems, the impact will be substantial because so many young athletes have these injuries. According to Powell and colleagues, US high school athletes sustain 62,816 MTBIs annually. And Matser and colleagues note that registered soccer players number more than 200 million worldwide.

CLINICAL TIP

A clearer perspective on the thyroid gland

When examining the thyroid gland, I ask children to lie on their back with the neck resting on the edge of the examining table so the head "falls off" the table. Hyperextending the neck in this manner makes it easier both to see and to palpate the thyroid gland. Because the exam is over so quickly, most children do not mind this position.

Hari Cheryl Sachs, MDWashington, DC

Do you have a Clinical Tip to share with colleagues? Let us know; we'll pay $50 for each item accepted for publication. Tips sent by mail should be addressed to Molly Frederick, Clinical Tips Editor, Contemporary Pediatrics, 5 Paragon Drive, Montvale, NJ 07645-1742. If you submit by E-mail (Molly.Frederick@medec.com), please include your mailing address.

Drug mix-up tied to wrong syphilis treatment

An unknown number of patients with syphilis have inadvertently been treated with a form of penicillin that contains only half the recommended dose of long-acting benzathine penicillin, according to a new report. From December 1997 to May 1998, phone orders from a Maryland clinic for sexually transmitted diseases (STDs) for 1,500 doses of Bicillin L-A (2.4 million units of benzathine penicillin G [BPG] were filled not with Bicillin L-A but with Bicillin C-R (a mixture of 1.2 million units of BPG and 1.2 million units of procaine penicillin G). Before the error was discovered, 63 patients, including five pregnant women, might have received Bicillin C-R, whose packaging and label are similar to that of Bicillin L-A.

The Centers for Disease Control and Prevention (CDC) surveyed 65 STD city and state program areas nationwide about unintentional Bicillin C-R use from 1993 through 1998, after it learned of the incident. Four program areas reported unintentional Bicillin C-R use at least once during those years, and in two areas where state health departments mistakenly received the drug it was distributed to STD clinics state-wide. Two other areas reported unintentional use of Bicillin C-R at individual clinics. Thirty one of 55 program areas surveyed were unaware that Bicillin C-R could be confused with Bicillin L-A. The CDC could not determine how many individuals received the wrong regimen for syphilis because of this confusion (MMWR 1999;48[35]:777).

Commentary: Here's a good reminder that treatment of slow-growing Treponema pallidum requires prolonged exposure to penicillin. If you treat syphilis in your office, you may want to check your medication cabinet.

HCV infection in infancy relatively benign

A new report on infection with hepatitis C virus (HCV) in individuals who contracted the virus in infancy suggests that the clinical course of HCV is more benign in those infected early in life than in those infected as adults.

Investigators in Germany screened 458 individuals who had cardiac surgery at a mean age of 2.8 years and 458 age- and sex-matched controls for antibodies to HCV. The subjects in the first group underwent surgery before 1991, when blood-donor screening for HCV was instituted in Germany. At the time of the follow-up study, they were a mean age of 19 years.

Of the patients seen for follow up after cardiac surgery, 67 (14.6%) had HCV antibodies compared with three (0.7%) of the control subjects. Of the 67 surgical patients with antibodies, only 37 (55%) had detectable HCV RNA in their blood and of these 37 all but one had normal levels of liver enzymes. The infection had cleared in the other 30 patients in this group. Liver biopsies were performed in 17 of the 37 patients who were positive for HCV RNA; only three of the 17 had histologic signs of progressive liver damage. Investigators noted that the clinical course of HCV in those who contracted it after cardiac surgery in infancy was more benign than would be expected in people who were infected as adults (Vogt M et al: N Engl J Med 1999;341:866).

Commentary: Unless children with severe hepatitis were lost to long-term follow-up, this is good news about the natural history of hepatitis C in children. Those with the infection were less sick than infected adults and were more likely to clear the virus.

Personalized asthma intervention gets results

A comprehensive, individualized program conducted by social workers trained in asthma management reduces asthma symptoms among children in the inner city, according to a recent report on such a program. The family-focused intervention, designed for children 5 to 11 years old with moderate to severe asthma, was conducted at several inner-city sites. After a training period, asthma counselors (social workers with master's degrees), invited caretakers of 515 subject families to attend two group and one individual asthma education meetings. Counselors also conducted group sessions for children and gave caretakers referrals to community resources for smoking cessation and psychologic and social issues. All families were given pillow and mattress covers and were encouraged to minimize exposure to allergens. After the introductory sessions, counselors and caretakers met every other month and talked on the telephone during the alternate months about issues of most concern to each family. Families in the control group did not receive these interventions.

Investigators assessed the effects of the intervention at two-month intervals during the two-year follow-up. During the first year, participants in the intervention reported having asthma symptoms 3.5 days in the two weeks before each follow-up interview compared with 4.1 days in the control group. Symptom reduction was about three times greater in children with severe asthma than in children with moderate disease. In addition, fewer children in the intervention group than in the control group were hospitalized, though this finding did not reach statistical significance. These improvements continued during the second year of the follow-up, even though participants no longer had access to the asthma counselors (Evans R III et al: J Pediatr 1999;135:332).

Commentary: A decrease of about one-half day of having symptoms in two weeks may not seem clinically important. But, as the authors point out, during the course of a year this respite may add up to an additional half month without symptoms or one and one-half months for severe asthmatics. The study provides more evidence that inroads can be made against the morbidity of asthma, but they won't be easy and they won't be cheap.

CLINICAL TIP

A neat trick to stop dribbling

Many young girls, especially those between 4 and 7 years of age, complain of "dribbling" after urinating. This often occurs because urine is retained between the labia and poor wiping techniques have not removed it. To correct the problem, I suggest that she sit on the toilet facing backwards. This forces the legs apart, separating the labia, and solves the problem of retained urine. If the problem does not resolve after a week or so, consider other causes.

Stacey E. Gallas, MDHouston, TX

Do you have a Clinical Tip to share with colleagues? Let us know; we'll pay $50 for each item accepted for publication. Tips sent by mail should be addressed to Molly Frederick, Clinical Tips Editor, Contemporary Pediatrics, 5 Paragon Drive, Montvale, NJ 07645-1742. If you submit by E-mail (Molly.Frederick@medec.com), please include your mailing address.

A quicker way to screen for UTI?

Uriscreen, a rapid diagnostic test for urinary tract infection (UTI), rules out UTI easily, inexpensively, rapidly, and reliably, according to a new report from Israel, where the test is manufactured. Uriscreen, which detects the enzyme catalase that is present in most of the bacteria responsible for UTI, is not superior to urinalysis or dipstick tests for positive diagnosis, however.

Urine specimens were obtained from 121 children from 1 month to 17 years of age who came to an emergency department with symptoms suggesting UTI. Investigators evaluated the samples for possible UTI by three methods. For the Uriscreen test, they placed urine in a test tube containing the Uriscreen reagent powder, added hydrogen peroxide, and shook the mixture for five seconds. Formation of a complete layer or ring of foam on the surface of the liquid within two minutes indicated a positive finding. The other two diagnostic methods were dipstick tests for nitrite and leukocyte esterase and urinalysis for microscopic pyuria. Investigators used a quantitative urine culture as the reference test for diagnosing UTI.

Of the 121 children, 35 (28.9%) had positive culture results. Compared with urinalysis and dipstick tests, Uriscreen had the highest sensitivity—100% compared with 88.6% and 97.1%, respectively—and the highest negative predictive value—100% compared with 95% and 98.6%. The newer test had the poorest specificity, however (68.6% compared with 88.4% and 82.5%, respectively). Uriscreen also had the worst positive predictive value—56.4% compared with 75.6% for urinalysis and 69.4% for the dipstick test. Investigators concluded that while Uriscreen is excellent for ruling out the diagnosis of UTI and performance of expensive urine cultures, its clinical use for presumptive diagnosis of UTI in children is limited and not significantly superior to urinalysis or the dipstick test (Waisman Y et al: Pediatrics 1999;104[4]:e41).

Commentary: This test might have a role in ruling out urinary tract infection. The high rate of false-positive tests limits its usefulness in office practice, however. I wouldn't rush to order this.

Successful treatment for PANDAS

A new study demonstrates the effectiveness of two new ways to treat exacerbations of tics and obsessive symptoms triggered by streptococcal infection, a condition known as PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections). Investigators hypothesized that plasma exchange and intravenous immunoglobulin (IVIG) would reduce the severity of symptoms by blocking (IVIG) or removing (plasma exchange) the antistreptococcal antibodies that were crossreacting with neuronal tissue.

During a four-year period, they recruited children from 5 to 14 years of age for the study, by writing to pediatricians, neurologists, and psychiatrists. The 30 children entered in the study had exacerbations or onset of obsessive-compulsive disorder (OCD) or tic disorders, including Tourette syndrome, triggered by streptococcal infection. At the start of the study, investigators assessed the children for severity of neuropsychiatric signs and symptoms with several standard tests, including the National Institute of Mental Health rating scales for global functioning, anxiety, and depression. They then assigned the children to treatment with plasma exchange, IVIG, or placebo. Most of the children were taking neuropsychotropic medications and clonidine or neuroleptic medications for tics, which they continued during the study.

At one month after treatment, both the plasma exchange and IVIG produced striking improvements in obsessive-compulsive symptoms, anxiety, depression, emotional lability, and global functioning, whereas placebo had little or no effect. The plasma exchange group improved significantly over the placebo group in tic severity, but the IVIG group did not. At a one-year follow-up assessment, more than 80% of the patients in the treatment groups remained "much" or "very much" improved, and their symptoms were subclinical. The most clinically meaningful improvements were in obsessive-compulsive symptoms, tic severity, and global measures of symptom severity and psychosocial functioning. Plasma exchange appeared better than IVIG, particularly for treating symptoms of OCD. The children also seemed to tolerate plasma exchange better than IVIG, since IVIG side effects—nausea, vomiting, and headache—persisted for 12 to 24 hours, whereas those related to apheresis were brief. Investigators cautioned that these results do not support the routine use of immunomodulatory agents in OCD and tic disorders since the children in the study were chosen on the basis of a history consistent with PANDAS (Perlmutter SJ et al: Lancet 1999;354:1153).

Commentary: True PANDAS is something of a zebra. So the authors are careful to caution against immunomodulatory therapy for every child with OCD or a tic. Still, I will be interested to watch as research on this condition continues.

Also of note

Autonomic dysfunction and cyclic vomiting syndrome. An imbalance in the autonomic nervous system appears to be associated with cyclic vomiting syndrome (CVS), according to a new study. Investigators examined autonomic regulation of neurocardiac signals in 14 children with CVS who ranged in age from 3 to 16 years and compared their findings with those in 38 healthy controls. They obtained electrocardiographic recordings for the 14 at least one week after a vomiting episode to ensure that all symptoms had disappeared. A power spectral analysis of heart-rate variability showed that in contrast with the children in the control group, those with CVS had enhanced sympathetic and diminished parasympathetic vagal modulation of the heart (To J et al: J Pediatr 1999;135:363).

Esophageal coins merit a day of watchful waiting. Investigators conducted a retrospective review of the medical records and radiographs of 116 children and adolescents who visited the emergency department with a coin lodged in the esophagus to determine how often such coins pass spontaneously to the stomach and how long it takes. Follow-up radiographs taken in 58 of the children with simple presentations (no history of esophageal disease, no respiratory compromise, and a radiograph taken within 24 hours of ingestion) showed that the coin had passed spontaneously to the stomach in 16 (28%). The original location of the coin in the esophagus had no bearing on the likelihood of passage, and the time to passage ranged from 2.3 to 12 hours, with a mean of 4.8 hours. By contrast, the coin did not pass spontaneously from the esophagus to the stomach in any of the 14 children with complex presentations in whom radiographs were taken. The authors concluded that observation for 12 to 24 hours of children with simple presentations of esophageal coin ingestion reduces complications and costs (Soprano JV et al: Arch Pediatr Adolesc Med 1999;153:1073).

CLINICAL TIP

Picture this

Photographs of wounds and anomalies taken with an instant photo (Polaroid) camera can provide valuable supplements to your clinical notes. Before taking a picture be sure to get the caregiver's permission with a form that is filled out and signed. Then file the photo(s) in the patient's chart. Instant photos can also serve as legal documentation when you see congenital lesions, such as Mongolian spots and giant nevi, that may be confused with child abuse.

Majdi Abu-Salih, MDHartford, WI

Do you have a Clinical Tip to share with colleagues? Let us know; we'll pay $50 for each item accepted for publication. Tips sent by mail should be addressed to Molly Frederick, Clinical Tips Editor, Contemporary Pediatrics, 5 Paragon Drive, Montvale, NJ 07645-1742. If you submit by E-mail (Molly.Frederick@medec.com), please include your mailing address.

Marian Freedman. Journal Club.

Contemporary Pediatrics

1999;12:134.