Heavy Menstrual Bleeding Guideline

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by Mona Kulkarni

mona.kulkarni@pemaweb.com

 

Case: 15-year-old otherwise healthy adolescent presents to your office complaining of a menstrual cycle lasting longer than 10 days. She has been changing her sanitary pads hourly at times and passing heavy clots.  Now she’s feeling a bit dizzy.

What is the work up that we need to do?  The Heavy Menstrual Bleeding guideline was created by our team to help guide us in the evaluation.

Heavy Menstrual Bleeding (HMB) is one of the most common adolescent gynecology complaints we see in the ED.  The differential diagnosis is broad including anovulatory cycles, hypothyroidism and underlying bleeding disorders (up to 20% of cases). The importance of early recognition and determination of the underlying cause can positively impact the teen’s quality of life, school attendance and sports participation.

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Behavioral Health ED Visit: Expectations and Limitations

 

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By: Kristin Weinschenk, MD and Michael Lowley, MD

Kristin.Weinschenk@choa.org

The primary goal of the psychiatric evaluation in an ED setting is to assess the safety of the individual, and to connect them with resources at the appropriate level of care. This begins at triage with a screening tool called the ASQ (Ask Suicide-Screening Questions to Everyone in Medical Setting), a five-item questionnaire which flags patients for risk of recent or current thoughts of self-harm. A positive screen will then trigger referral for amore detailed evaluation by either the psychiatric social worker in the ED, or by a member of the Psychiatry Consult Liaison service. The MH professional will conduct a psychosocial assessment, and complete a more detailed suicide risk assessment tool called the BSSA. Once level of risk is established, the treatment plan will reflect the need for appropriate safety and monitoring, whether at an inpatient psychiatric hospital or in a less restrictive care setting.

 

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Head Injury Update 2018

CME CREDIT NOW AVAILABLE-1.0 AMA PRA Category 1 Credit FOR EACH ISSUE (2 ARTICLES)!!!!!!

By Micheal Greenwald

mgreenw@emory.edu

Research continues on a number of fronts regarding head injury evaluation and management.  Below are highlights from 2 of these articles and a summary of a recently published set of guidelines from the CDC.  The articles were exceptionally large studies that pertain to important factors in deciding when to use CT in evaluation of head injury in children. The CDC guidelines explain levels of evidence for a variety of issues regarding diagnosis, prognosis management and treatment of concussion.

Vomiting as a predictor of intracranial injury1

This large sampling (19, 920) of pediatric head injury patients in Australia and New Zealand (2011-14) looked at association of clinically important TBI (ciTBI) and vomiting.  This study supports previous research showing that vomiting is common following head injury, especially under 2 years of age; however, vomiting is rarely an independent predictor of ciTBI.

Patients with skull fractures, altered mental status, and headaches more likely to have ciTBI with vomiting (OR 80.1; 95% CI 43.4–148.0; OR 2.4; 95% CI 1.0–5.5; and OR 2.3; 95% CI 1.3–4.1, respectively).

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Fever and Limp-Review of Children’s Musculoskeletal Guidelines

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BY Mike Mallory

michael.mallory@pemaweb.com

 

A 3-year-old comes to your office with a fever and a limp.  Parents noticed a little discomfort yesterday, but it’s worse today and now the child doesn’t want to bear weight.  What is the work up that we need to do?  That is the question that the recently finalized Musculoskeletal (MSK) Infection clinical practice guideline attempts to answer.

The first question that the guideline asks us is to determine our level of suspicion for risk of MSK infection.  The following historical and exam features should raise suspicion of MSK infection.

History:

Pain, fever, inability to bear weight, gait disturbance/limp, limited use of extremity, immobility of extremity, travel to area with endemic Lyme disease.

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Asking Saves Kids

Kiesha Fraser Doh, MD
kiesha.fraser @emory.edu

 

As of June 14th there have been 23 school shootings this year!  A total of 1,392 children have been killed or injured by firearms. In comparison during the influenza season from October 2017 to May 2018 a total of 172 children died. [1]This year of 2018 has been especially deadly for children, with 547 firearm deaths this year. [2]Thus more children died from firearm injuries this year compared to influenza deaths despite frequent media reports about influenza death compared to firearm injuries.

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Opioid Policies and Pediatrics: When the Pendulum Swings Children Will Get Hurt

Mike Greenwald, MD
mgreenw @emory.edu

 

 

 

 

 

 

Even if you have turned off all news sources over the past 2 years it would be hard to escape the urgent alarms regarding opioid misuse in the US. The statistics are remarkable.

  • Since 1999, overdose deaths involving opioids quadrupled.1
  • 2000-2015:greater than half a million people died from drug overdoses.
  • 91 Americans die every day from an opioid overdose.
  • 1999 to 2010: number of prescription opioids sold to pharmacies, hospitals, and doctors’ offices nearly quadrupled.2,3

This is compelling evidence that we have a problem – perhaps some more than others.  Opioid addiction is a frequent challenge for those caring for adults in the Emergency Department with some centers (e.g. rural) seeing more of this than others. Those who care for injured and ill children are left with 2 important questions: (1) What is the evidence regarding opioid addiction in children? (2) To what extent is the management of acute pain in children contributing to an increase in opioid related morbidity and mortality?

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CHOA EMERGENCY DEPARTMENT EVALUATIONS OF PSYCHIATRIC ILLNESS

 

Swathi Khrishna sakris2@emory.edu

Sonali Bora Sonali.bora@choa.org

Many primary care providers are on the front lines of fielding questions and identifying symptoms of psychiatric illness in children and adolescents in the community setting.  We have put together a quick guide that addresses some common questions and concerns on how to refer non-emergent psychiatric concerns to community outpatient resources and avoid unnecessary and costly ED visits

What kind of services are and are not available to children with psychiatric/behavioral complaints in the ED?

Psychiatric assessments in the medical ED setting are brief and focused.  They are not full psychiatric evaluations and are not meant to provide new diagnosis or start new medications.   They are simply a crisis assessment to evaluate for the child’s safety and the safety of others. If a patient is deemed unsafe to self or others, they will be transferred to a primary psychiatric facility for further treatment.  It is an assumption of many community providers that patients with psychiatric complaints must first be directed to a medical facility for “medical clearance”.  In fact, all psychiatric facilities are emergency receiving facilities and have the resources to provide medical clearance and directly accept healthy patients with behavioral and psychiatric complaints.  Most psychiatric hospitals perform psychiatric assessments 24/7,  and can place a patient on a 1013 or admit them voluntarily. Psychiatric facilities can also refer families to outpatient or lower levels of care if inpatient psychiatric hospitalization is not warranted. PLEASE NOTE CHOA DOES NOT HAVE INPATIENT PSYCHIATRY SERVICES.

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Sedation Services at Children Healthcare of Atlanta

David Banks, MD david.banks@pemaweb.com

In the late 1990’s, as pediatric MRI imaging services came of age, pediatric hospitals were faced with a growing need for quality pediatric sedation services. Many institutions met this need initially by assembling experienced nurses and having them manage the sedations.  By the early 2000’s, the nurse-run services were being replaced by physician services, as the Joint Commission developed new standards for deep sedation services.  In compliance with Joint Commission standards, both Children’s campuses Scottish Rite and Egleston developed physician run sedation services.  Pediatric Sedation Services (PSS) was developed on the Scottish Rite campus by the PEMA physician group, and Children’s Sedation Services (CSS) was formed as a combined effort by the critical care and pediatric emergency medicine teams at the Egleston campus.  Both PSS and CSS have grown in volume and scope of services and, as a system, represent one of the largest pediatric procedural sedation services, performing over 11,000 cases per year.  

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HIV Screening Recommendations in Adolescents

Lauren Middlebrooks, MD
lauren.sullivan. middlebrooks@emory.edu

 

 

 

 

 

 

 

HIV/AIDS
What an illness
My life is meaningless
You make my life lifeless
You make me hopeless
What an illness

You don’t care who you kill
It old and young
Big and small
Bad or good
What an illness

The sky was blue
Now its black
People hate each other
Because of you HIV/AIDS
What an illness

By SN, Primary school KaNyamazane, South Africa

As depicted in the poem above, written by a young child living with HIV in South Africa, HIV and AIDS has carried a reputation deeply rooted in fear, shame, and distrust.  Stigmas have impacted patient disclosure, provider discussion, and have limited early screening and diagnosis of at risk populations1. Once thought of as a disease only extending across international borders, Georgia is now ranked #5 in the United States (U.S.) for some of the highest rates of HIV in our nation.  The rising rates in downtown Atlanta specifically, have been compared to rates of HIV in third world countries, such as “Zimbabwe, Harare or Durban2.”  As if these statistics aren’t alarming enough, adolescents and young adults, ages 13-24, accounted for 22% of all new HIV infections in the U.S. in 2015—that’s roughly 1 in every 5 young people affected by this virus3.  In a 2005 Youth Risk Behavior Surveillance System assessment (YRBS), almost half of high school students surveyed nationwide reported having had sexual intercourse, yet only 11% had ever been tested for HIV4.  Adolescents and young adults quickly became an at-risk cohort, and in response to this new epidemic, the Centers for Disease Control and Prevention (CDC) made national recommends in 2006 for routine, opt-out HIV testing beginning at 13 years of age.  Interestingly, prior studies concluded not only that many clinicians had poor knowledge of these recommendations made over 10 years ago, but that the prevalence of HIV testing did not significantly change amongst high school students between the 2005 and 2015 YRBS’s.

Adolescents and young adults have the most challenges in links to primary care, mainly due to limitations in transportation, health insurance, and concerns for breeched confidentiality.  As a result, approximately 60% of HIV-positive adolescents remain unaware of their status.   Of adolescents who did see a primary provider, only half of primary care physicians even touched on sexual content, and the average amount of time discussing a sexual history was 36 seconds5.  It is our duty as providers to have open conversations with each one of our adolescent patients regarding their sexual history, preferences and practices.  It is also important that they understand the results will remain confidential and that every effort will be made to contact the patient directly with any new positive results. Per official recommendations, all patients 13-64 years of age are recommended to have at least one HIV test in their lifetime.  Persons who frequent high prevalent settings, including homeless shelter, prisons, and adolescent clinics, along with persons engaging in risky sexual behavior (multiple sexual partners, MSM, sex in exchange for money, substance abusers), may be tested at least once per year, or as frequent as every 3-6 months.

The most sensitive and specific tests for HIV are 4th generation antigen-antibody tests.  This is highly encouraged over others as it will more accurately capture true positives as soon as 4 weeks after exposure.  Positive tests should be relayed in person, not over the phone, and those patients can be referred to the Grady Ponce Center for further management and treatment.

Together we can normalize HIV screening in the adolescent and young adult population, reduce stigma associated with HIV/AIDS, and assist in managing this public health crisis.

For more information on the Grady Ponce Center, please visit: https://www.gradyhealth.org/specialty/ponce-de-leon-center/

or Contact Ponce Clinic Nurse-Deborah Ferris-404-516-4340 for any additional questions

References:

  1. 2017 August 29. HIV Stigma and Discrimination.  Retrieved from: https://www.avert.org/professionals/hiv-social-issues/stigma-discrimination
  2. Huddleson D. Atlanta HIV Epidemic Compared to Third World Countries. WSB-TV 2 Atlanta 2016. Retrieved from: http://www.wsbtv.com/news/2-investigates/atlantas-hiv-epidemic-compared-to-third-world-african-countries/263337845
  3. Health TGDoP. HIV Surveillance Fact Sheet, 2014. 2016
  4. Laura Kann P, Tim McManus, MS, William A. Harris, MM, Shari L. Shanklin, MPH, Katherine H. Flint, MA, Joseph Hawkins, MA, Barbara Queen, MS, Richard Lowry, MD, Emily O’Malley Olsen, MSPH, David Chyen, MS, Lisa Whittle, MPH, Jemekia Thornton, MPA, Connie Lim, MPA, Yoshimi Yamakawa, MPH, Nancy Brener, PhD, Stephanie Zaza, MD. Youth Risk Behavior Surveillance-United States 2005. Center for Disease Control and Prevention Morbidity and Mortality Weekly Report 2006;55(SS-5):19-22
  5. Alexander, S. C., Fortenberry, J. D., Pollak, K. I., Bravender, T., Davis, J. K., Ostbye, T., Shields, C. G. (2014). Sexuality Talk During Adolescent Health Maintenance Visits. JAMA Pediatrics, 168(2), 163.doi:10.1001/jamapdiatrics.2013.4338

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The new way to test poop! The GI PCR or FilmArray Gastrointestinal Panel

 

Deborah Bloch, MD
deborah.bloch@emory.edu

Mark Gonzalez, MD
mark.gonzalez@choa.org

Craig Shapiro, MD
cshapi2@emory.ed

FilmArrayTM Gastrointestinal Panel?

The FilmArrayTM Gastrointestinal Panel is a rapid test (~2 hr turnaround time) offered by the CHOA microbiology lab for detection of common gastrointestinal pathogens (see Figure 1), which includes bacteria, viruses and parasites. Because of the comprehensiveness of the panel, in most cases stool culture, ova and parasite (O&P) examination, and antigen testing for Adenovirus 40/41, Rotavirus, Cryptosporidium spp. and Giardia lamblia no longer need to be ordered (see Figure 1 for additional information)

 

When should I order the FilmArrayTM Gastrointestinal Panel?

The panel should be ordered for a patient of any age with diarrhea (> 3 unformed stools in a 24 hour period who is not on a laxative) for whom you are worried about infection with a GI pathogen that may impact patient management or isolation practices. Testing should not be performed on formed stool. Please contact the microbiology lab (404-785-6426) or the ID consult service (404-785-DOCS) with any additional questions.

WHEN TO CONSIDER SENDING GI PCR PANEL FOR A PATIENT WITH DIARRHEA:

  • Fever and frankly bloody/mucusy diarrhea (if concern for C diff, also send stool for C diff toxin – not included in GI PCR panel)
  • Prolonged diarrhea>7 days (or before referral to GI for evaluation)
  • Travel-related diarrhea (if persistent or red flags; if concern for worms, also send stool for ova/parasites)
  • Immunocompromised patient – if concern for non-viral etiology
  • IBD patients- newly suspected or unusual change in stools in established IBD pt

What do the results mean?

For non-severe or prolonged (<7 days) illnesses caused by many of the pathogens detected (e.g. EAEC, EPEC, STEC, non-typhoidal Salmonella, all viral pathogens, Giardia lamblia and Cryptosporidium species), treatment is supportive; however, for patients in certain age groups, and patients with certain comorbidities or immunocompromising conditions, antimicrobial treatment may be indicated.

Because the FilmArrayTM Gastrointestinal Panel detects nucleic acids, it cannot differentiate active infection from treated infection or colonization; this must be done by correlating clinical symptoms. Results can remain positive for weeks or months after an infection especially in young children and immunocompromised patients.

Figure 1. Reported pathogens on the FilmArrayTM Gastrointestinal Panel at CHOA and which reflex to culture.

Should I also order a stool culture to get antimicrobial susceptibility results?

When testing is performed in the CHOA microbiology laboratory, a stool culture order is not necessary as positive panels will automatically reflex to culture, and if the isolate is recovered antimicrobial susceptibility testing will be performed when appropriate (Figure 1).

Should I order an O&P examination? What about for patients who drink and use well water?

O&P examinations should be ordered if you suspect a parasite other than those listed on the panel (e.g., for patients who returned from travel abroad). It should be noted that the top parasitic causes of well water contamination are Giardia and Cryptosporidium, which are tested for on the panel. Maximal sensitivity for parasite detection by O&P examination requires up to three stool specimens collected over a 7-10 day period.\

Should I order C. difficile toxin testing separately?

Yes, but it is not typically recommended for children under 2 year of age due to high rates of colonization. 

Should I reorder the FilmArrayTM Gastrointestinal Panel to test for cure?

No. Nucleic acids detected on the panel may remain positive for an indeterminate amount of time, and the FilmArrayTM Gastrointestinal Panel should only be ordered on unformed stool.