Necrotizing Enterocolitis in an Infant With a History of Twin-Twin Transfusion Syndrome: A Case Report.

This case report describes necrotizing enterocolitis (NEC) in an infant with a history of twin-twin transfusion syndrome (TTTS). TTTS is a volume imbalance where the anastomosis at the vascular equator between the two placentae shifts from the donor to the recipient twin. This causes a higher risk for NEC, a marked inflammation caused by bacterial infection into the intestinal wall, from prematurity and intestinal hypoperfusion. Complications include sepsis, bowel necrosis, perforation, peritonitis, and death. NEC is a leading cause of morbidity in preterm infants. A 3-month-old female with a history of TTTS and prematurity presented with her mother to the pediatric emergency department (ED) for bloody diarrhea, emesis, lack of appetite, and lethargy for 4 days. The pediatrician changed the formula due to a possible milk allergy, however, she continued to have bloody diarrhea. Over the 2 days, the patient had nonbilious and non-bloody emesis and couldn't tolerate oral intake. In the ED, labs showed neutropenia and sepsis. She had a positive fecal occult blood test (FOBT) and an abdominal x-ray that revealed dilated loops of bowel and pneumatosis intestinalis. She was started on intravenous (IV) fluids for maintenance of hydration. She was started on broad-spectrum antibiotics including intravenous (IV) vancomycin and meropenem, and had her feedings temporarily stopped. The patient was transferred to the pediatric intensive care unit (PICU) at a tertiary care/children's hospital that evening where she had a laparotomy performed to resect the diseased intestine. She was discharged 10 days after the surgery for home recovery with clinical follow-up.

Utilizing Infantile Spasm Seizure Activity as a Baseline Vital in the Setting of Acute Pseudomonas aeruginosa Pneumonia.

The objective of this case report is to describe and document a decrease in seizure activity in a 16-year-old female with a past medical history of Aicardi syndrome (AS) and infantile spasms (IS) while being treated for acute Pseudomonas aeruginosa pneumonia with pleural effusion. This patient presented to the pediatric emergency department with a chief complaint of fever, tachycardia, increased nasal secretions, and oxygen requirement at home. She was admitted to the general pediatric medical floor for treatment of an adenovirus infection due to her having a complex medical history and her being medically unstable. On hospital admission day 1, she developed post-viral P. aeruginosa pneumonia. She subsequently had three days of complete clinical seizure cessation without changing her anti-epileptic medications. It was not until the symptomatology related to her pneumonia improved that her seizure activity returned to its baseline frequency. The treating team discovered that the decrease in her frequency of seizure activity related to periods of increased physiologic stress was not new. Her mother reported that she has used the relationship between her daughter's seizures and any acute illness to gauge how her daughter was "feeling" medically. Three weeks prior to this hospital admission, her mother reported that her daughter's seizures ceased for two days during a period in which it was determined that the patient was having renal colic and passed a renal stone. This phenomenon, the decrease in the frequency of seizure activity related to periods of increased physiologic stress, could help primary caretakers assess when significant, new comorbid conditions are present and could aid in the primary assessment of physical health in a particular patient population who are unable to verbalize their current medical status. Utilizing seizure activity as an at-home vital sign could help caretakers recognize when their patient is under an elevated physiologic stress condition. Recognizing the relationship between seizure frequency and acute illness could also help diagnostically, as ISs are difficult to both diagnose and manage. Also, future research on this possible association could explore more understanding of IS and pathophysiology of such phenomenon.

Evidence-based medicine, part 1. An introduction to creating an answerable question and searching the evidence.

This article, the first in a series of six articles, introduces the concept of evidence-based medicine and describes the first two steps of practicing it: formulating an answerable clinical question and searching the available evidence. The types of clinical questions practitioners can ask are examined and a hierarchy of how to search for the best and most authoritative evidence is provided. The skills learned from creating an answerable question and searching the evidence, as outlined in this article, provide a solid basis for life-long learning and improved patient care.

Evidence-based medicine, part 2. An introduction to critical appraisal of articles on therapy.

This article provides an introductory step-by-step process to appraise a therapeutic article. The authors introduce these principles using a systematic approach and case-based format. The process of assessing the validity of a therapeutic article, determining its importance, and applying it to an individual patient is reviewed. The concepts of randomization, blinding, and concealment are discussed to help physicians determine an article's validity. Instruction on calculating relative risk reduction, absolute risk reduction, and number needed to treat is provided and applied to the clinical scenario. Finally, information that is learned from the previous two steps is applied to patient care. The skills learned from appraising a therapeutic article in the manner outlined provides a basis for life-long learning and improved patient care.