Top Papers Of The Month

3 Top Papers You Missed in January 2021

AUTHOR:
Scott T. Vergano, MD
Department of Pediatrics, Children’s Hospital of The King’s Daughters, Norfolk, VA

CITATION:
Vergano ST. 3 top papers you missed in January 2021. Consultant360. Published online: February 3, 2021.

 

With all of the breaking information related to the COVID-19 pandemic, it is easy to overlook the rest of the medical literature. To help fill the gap, here are several articles that I found important over the past month. Please feel free to share with your colleagues, discuss in your offices, and write to editors@consultant360.com with your thoughts and opinions.

Identification and Management of Eating Disorders in Children and Adolescents1

This new statement from the American Academy of Pediatrics’ Committee on Adolescence provides the most up-to-date information on the diagnosis, evaluation, and management of the spectrum of eating disorders in pediatric patients. Notable changes include:

  1. The effort to make the diagnosis of anorexia nervosa more encompassing by eliminating amenorrhea and specific weight percentiles in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) criteria (“significantly low body weight,” fear of weight gain, and distorted body image)  
  2. The addition of avoidant/restrictive food intake disorder, an eating disorder more common in younger children who restrict caloric intake due to reasons other than concern for weight gain

 

The review also provides guidance on the recommended diagnostic testing for patients with a suspected eating disorder, highlights the role of family-based treatment as the preferred approach for most pediatric eating disorders, and substitutes the more inclusive term “relative energy deficiency in sport” for what was previously referred to as the female athlete triad (disordered eating, amenorrhea, and low bone-mineral density).

Having worked in communities with varying degrees of access to resources, I am keenly aware that the role of the pediatrician in the care of these children and adolescents depends on the availability of other professionals and the ability to connect these families with a team of physician specialists, nutritionists, and therapists. The statement specifically assigns the role to the pediatrician of endorsing the message that “food is the medicine that is required for recovery.” It also notes, however, that doing weight checks and endorsing specific weight goals might be a better role for other members of a multidisciplinary team, if available. In my experience, there are some mildly affected patients for whom I can serve in many of these roles and other, more severely affected patients for whom referral is indicated and mandatory. My care has also varied depending on the availability and accessibility of therapists, nutritionists, and adolescent specialists to collaborate with in the care of these patients.

What is available in your community? If you have access to teams with expertise in the treatment of eating disorders, how often do you reach out and communicate with them in the management of your patients? If you do not have sufficient access to these resources, who can you approach in your community to try to build a better network of care for these patients? Although patients with eating disorders can be quite challenging to care for, the successful management of a patient with an eating disorder is always a gratifying and rewarding achievement.

Evolving Issues in the Use of Antibiotics for the Treatment of Uncomplicated Appendicitis2

This editorial overviews a multicenter, randomized clinical trial of adults with uncomplicated acute appendicitis, which yielded a 1-year treatment success rate of 70.2% for patients treated nonoperatively with oral antibiotics alone and 73.8% for patients treated nonoperatively with intravenous antibiotics followed by oral antibiotics. In citing a growing literature of similar results, the authors note that nonoperative management has been associated with less disability and lower complication rates. In their opinion, nonoperative management of uncomplicated acute appendicitis has become an accepted standard of care for both children and adults, and should routinely be offered as a choice to patients and families.

I have always been a skeptic. To me, a success rate of 70% means a failure rate of 30%. If such a significant proportion of patients will need surgery within a year​, I am not certain that a trial of antibiotics makes the most sense. That being said, I conducted a telehealth mental health follow-up visit for a completely well adolescent last Friday morning. When I went to write her note in the electronic health record that night, I saw that she had been admitted to the hospital that evening with acute appendicitis. When I went to visit her the next morning prior to scheduled surgery, the cefoxitin treatment seemed to have made her much better. She was sitting up happily in bed and asking for cheesecake. Her acutely inflamed appendix was successfully removed laparoscopically on Saturday afternoon, but the case did at least make me wonder whether antibiotic treatment would have sufficed for her.

What are your thoughts?  As the authors of the editorial point out, perhaps at this point what is needed are additional studies that help stratify patients and identify those who might most safely benefit from a nonoperative approach.

​Reappraising Medical Syntax: Does Race Belong in the First Line of the Patient History?​3

This note accompanies a research letter from another institution in my home state of Virginia, looking at the mention of race in the first line of the history of present illness (HPI) for a series of 1200 adult patients admitted to an urban academic medical center. The authors found a significant differential identification of race in the HPI between Black patients and White patients. The note suggests that identifying race in the HPI might introduce stereotypes and bias into the clinical evaluation and assessment of patients. They recommend eliminating this element from the HPI and, if relevant, including it in the social history.

In an effort to address structural racism at all levels within our health care system, this seems to be a recommendation that makes sense. I am not certain how many pediatricians continue to identify race at the beginning of a patient presentation or write-up. The authors of the note also said that the practice was less common among younger physicians and Black physicians. I pledge in the upcoming year to be more sensitive to ways in which I might be contributing my unconscious biases to the health care system, the education of trainees, and the care of my patients.

Lastly, I would like to point your attention to 2 state of the art reviews recently published in Pediatrics.4,5 If you care for patients with urinary tract infections or solid organ transplants, I recommend a quick read of each, to verify that the care you are providing matches with the identified standard of care in these reviews.

References

  1. Hornberger LL, Lane MA, the Committee on Adolescence. Identification and management of eating disorders in children and adolescents. Pediatrics. 2021;147(1):e2020040279. https://doi.org/10.1542/peds.2020-040279 
  2. Minneci PC, Deans KJ. Evolving issues in the use of antibiotics for the treatment of uncomplicated appendicitis. JAMA. 2021;325(4):351-352. doi:10.1001/jama.2020.23607
  3. Ikeme JC, Salazar JW, Grant RW. Reappraising medical syntax—does race belong in the first line of the patient history? JAMA Int Med. Published online January 11, 2021. doi:10.1001/jamainternmed.2020.5789
  4. Mattoo TK, Shaikh N, Nelson CP. Contemporary management of urinary tract infection in children. Pediatrics. 2021;147(2):e2020012138. https://doi.org/10.1542/peds.2020-012138
  5. Katz DT, Torres NS, Chatani B, et al. Care of pediatric solic organ transplant recipients: an overview for primary care providers. Pediatrics. 2020;146(6):e20200696. https://doi.org/10.1542/peds.2020-0696