First EDition: A-Fib Management Pathway in the ED, more

Linder KE, Nicolau DP, Nailor MD. Epidemiology, treatment, and economics of patients presenting to the emergency department for skin and soft tissue infections. Hosp Pract (1995). 2017;16:1-7. doi:10.1080/21548331.2017.1279519.

Adolescents, Boys, Black Children Most Likely To Be Hospitalized for SJS and TEN

WHITNEY MCKNIGHT

FRONTLINE MEDICAL NEWS

Annual hospitalization rates in the United States for Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) were shown to be higher in adolescents, boys, and black children, in a cross-sectional analysis of discharge records from more than 4,100 hospitals.

Using relevant ICD-9 codes, researchers at Harvard University identified 1,571 patients hospitalized for SJS, TEN, or both in 2009 and 2012, as listed in the Kids Inpatient Database from the Agency for Healthcare Research and Quality. The highest hospitalization rates per 100,000 in each year were for adolescents between ages 15 and 19 years (P = .01), boys (P = .03), and black children (P = .82). The overall risk of death from these conditions was 1.5% in 2009 and 0.3% in 2012. The data were published online in a brief report.

Although the difference in the number of hospitalizations for black children was not significant when compared with other ethnic and racial groups, at 1.03 hospitalizations per 100,000 children (95% confidence interval [CI], 0.80-1.31) in 2009 and 1.06 hospitalizations per 100,000 children (95% CI, 0.86-1.30) in 2012, the rate was greatest in this group. The next highest ratio was in white children at 0.82 hospitalizations per 100,000 (95% CI, 0.74-0.91) in 2009, and 0.95 hospitalizations per 100,000 (95% CI, 0.86-1.05) in 2012.

With the number of SJS- and TEN-related hospitalizations between 0.1 and 1.0 per 100,000, lead author Yusuke Okubo, MD, MPH, and colleagues wrote that their data aligned with previous studies; however, regarding the emphasis on demographic differences, theirs was, to the best of their knowledge, “the first study to reveal these disparities.” Compared with adults, they added, mortality was “remarkably lower” in children.

Okubo Y, Nochioka K, Testa MA. Nationwide survey of Stevens-Johnson syndrome and toxic epidermal necrolysis in children in the United States. Pediatr Dermatol. 2016 Dec 19. doi:10.1111/pde.13050. [Epub ahead of print]

Guidelines Released for Diagnosing TB in Adults, Children

MARY ANN MOON

FRONTLINE MEDICAL NEWS

A clinical practice guideline for diagnosing pulmonary, extrapulmonary, and latent tuberculosis (TB) in adults and children has been released jointly by the American Thoracic Society, the Centers for Disease Control and Prevention, and the Infectious Diseases Society of America.

The American Academy of Pediatrics also provided input to the guideline, which includes 23 evidence-based recommendations. The document is intended to assist clinicians in high-resource countries with a low incidence of TB disease and latent TB infection, such as the United States, said David M. Lewinsohn, MD, PhD, and his associates on the joint task force that wrote the guideline.

There were 9,412 cases of TB disease reported in the United States in 2014, the most recent year for which data are available. This translates to a rate of 3.0 cases per 100,000 persons. Two-thirds of the cases in the United States developed in foreign-born persons. “The rate of disease was 13.4 times higher in foreign-born persons than in US-born individuals [15.3 vs 1.1 per 100,000, respectively],” wrote Dr Lewinsohn of pulmonary and critical care medicine, Oregon Health & Science University, Portland, and colleagues.

Even though the case rate is relatively low in the United States and has declined in recent years, “an estimated 11 million persons are infected with Mycobacterium tuberculosis. Thus…there remains a large reservoir of individuals who are infected. Without the application of improved diagnosis and effective treatment for latent [disease], new cases of TB will develop from within this group,” they noted.

Among the guideline’s strongest recommendations are the following:

• Acid-fast bacilli smear microscopy should be performed in all patients suspected of having pulmonary TB, using at least three sputum samples. A sputum volume of at least 3 mL is needed, but 5 to 10 mL would be better.
• Both liquid and solid mycobacterial cultures should be performed on every specimen from patients suspected of having TB disease, rather than either type alone.
• A diagnostic nucleic acid amplification test should be performed on the initial specimen from patients suspected of having pulmonary TB.
• Rapid molecular drug-susceptibility testing of respiratory specimens is advised for certain patients, with a focus on testing for rifampin susceptibility with or without isoniazid.
• Patients suspected of having extrapulmonary TB also should have mycobacterial cultures performed on all specimens.
• For all mycobacterial cultures that are positive for TB, a culture isolate should be submitted for genotyping to a regional genotyping laboratory.
• For patients aged 5 and older who are suspected of having latent TB infection, an interferon-gamma release assay (IGRA) is advised rather than a tuberculin skin test, especially if the patient is not likely to return to have the test result read. A tuberculin skin test is an acceptable alternative if IGRA is not available, is too expensive, or is too burdensome.