Dr Farber is a pediatrician in Woodbridge, Virginia.

Jon Matthew Farber, MD

Because young adult women with developmental delay may not be able to tolerate a Papanicolaou (Pap) test, investigators assessed how well a blind Pap (a test without a speculum) evaluated the presence of squamous intraepithelial lesions compared with a traditional Pap test.1 The retrospective study, in 14 patients who had a blind Pap test and 214 patients who underwent a traditional Pap test (controls), found that all blind Pap test specimens were adequate for cytology diagnosis. However, the endocervical/transformation zone component was adequate in only 57% of blind Pap test specimens compared with 90% of traditional Pap test specimens.

Patients in the blind Pap group were developmentally delayed and aged no older than 26 years. Their tests were performed without use of a speculum by gently inserting a Q-tip into the vaginal canal until meeting resistance from the vaginal fornix. Practitioners moved from the Q-tip from left to right to feel the cervix through haptic feedback, then rubbed it around this area to contain cervical cells. Women in the control group underwent traditional tests with a speculum and direct visualization of the cervix.

A speculum examination in someone with severe developmental delays can be traumatic. The decreased number of adequate smears when done blindly seems an acceptable trade-off here. I do not routinely give human papillomavirus vaccines to people with severe delays as they are at very low risk, even though it reduces my quality score with insurers.

1. Limbaugh LJ, Winsten MT, Sangi-Haghpekyar H, Dietrich JE. The utility of blind Pap tests in young adults with developmental delay: a pilot study. 

2020;(20):S1083-3188. doi:10.1016/j.jpag.2020.12.010

Articles

For some patients, the traditional Papanicolaou (Pap) test can be a traumatic event that shouldn't happen. An investigation examines whether a blind Pap test, which doesn't use a speculum, could be an adequate substitute.

When traditional Pap test is problematic, a blind Pap is adequate

Brace treatment, not surgery, is the therapy of choice for pectus carinatum (PC), according to the results of a 10- year study.

After initial examination and classification of the PC deformity, most of which were of the chondrogladiolar type, 430 patients were treated with a staged management protocol (bracing first, when possible, followed by surgery if bracing failed), while the other 265 patients were observed. The 365 patients who were amenable to bracing and had appropriate deformities for this protocol were measured for an Argentine brace and fitted at a clinical visit. Clinicians told patients that bracing therapy, with a minimum daily duration of 8 hours, could last for 12 months or longer. Patients were followed up monthly to verify bracing compliance and measure the pressure of correction, and then every 3 to 6 months until investigators observed sternal flattening. At this point, patients wore the brace for progressively fewer hours until the bracing was discontinued. Following brace treatment, patients were assigned to 1 of 3 groups based on outcome: successfully completed therapy, dropout, or brace failure. Bracing was successful in most patients who were compliant, although the degree of success was negatively affected by a large number of dropouts.

Patients in whom bracing therapy was not successful (about 21%), or whose deformity was overcorrected, underwent one of several types of surgery: traditional open repair (67%), the Abramson repair (25%), or Nuss procedure (8%). Open repair entailed segmental costal cartilage resection and sternal osteotomy using a reciprocating saw and osteotome. Initial results were good for all operations. However, 13% of patients who underwent the Abramson operation experienced recurrence compared with none after the open operation. In addition, the Abramson operation, used primarily in patients with a flexible chest wall, was successful in remodeling the chest wall but complication rates were high compared with the open operation, which resulted only in a single wound infection that was treated successfully with antibiotics.

When I first started out, surgery was the only treatment option for this condition. It is good to see that bracing can be quite successful. I also note that, for now at least, this is one area where an open procedure still seems to be better than a laparoscopic one; if your surgical colleague recommends otherwise, explore why with him or her.

1. Kelly RE, Obermeyer RJ, Goretsky MJ, et al. Ten-year experience with staged management of pectus carinatum: results and lessons learned. 

 January 13, 2021. doi:10.1016/j.pedsurg.2021.01.027.

Surgery was the top treatment choice for pectus carinatum, but a long-running study indicates that using a brace is the choice for better outcomes.

10-year study shows brace treatment is best for pectus carinatum

Telephone-based clinician (specialty nurse or pediatric neurology fellow) follow-up of children with epilepsy is effective in identifying critical clinical events related to disease course or drug therapy, according to findings of a study in India.

 Although specialty nurses’ performance lagged behind that of pediatric neurology fellows, nurses still identified most events that required immediate medical concern. During the 2-year study period, 135 participants, who ranged in age from 4 months to 18 years, completed a scheduled hospital appointment via telephone consultation with either a pediatric neurology nurse or a pediatric neurology fellow who wrote up a summary of the consultation. Most caregivers (94%) indicated they were satisfied with the advice provided via telephone. The children’s next appointment was in person with the pediatric neurologist. Investigators then compared the performance of the nurses and fellows with results of the face-to-face consultation (gold standard).

Investigators considered 3 main parameters in evaluating clinician performance: identifying whether the child had a breakthrough seizure or an adverse event, and whether drug compliance was adequate or poor. Pediatric neurology fellows performed excellently in all 3 areas, with a sensitivity of 99%, 97%, and 100%, respectively, and 100% specificity. The specialty nurses performed less well, with a sensitivity and specificity of >80% for the 3 parameters.

Given that children rarely seize in the office and that physical examination is usually unrewarding, it is no surprise that telemedicine works here. To capture the child whose seizures may not be well controlled, ask the parents to try and record suspicious episodes, which has proven more valuable than a verbal description in my experience.

1. Gulati S, Shruthi N.M., Kumar Panda P, et al. Telephone-based follow-up of children with epilepsy: comparison of accuracy between a specialty nurse and a pediatric neurology fellow. 

 2020;83:98-103. doi:10.1016/j.seizure.2020.10.002

Telemedicine has been shown to be an effective way to provide care. A study examines its efficacy in managing epilepsy.

Telemedicine works well for managing epilepsy

In a study in children hospitalized for acute bronchiolitis, findings of lung ultrasounds (LUSs) correlated with those of chest x-rays (CXRs), indicating that LUS is 1 valid technique for diagnosing and evaluating pediatric respiratory diseases.

­ The longitudinal study was performed in 92 full-term infants aged younger than 12 months, 63 of whom were hospitalized for acute bronchiolitis, and 29 for non-respiratory diseases, serving as controls.

All participants with bronchiolitis underwent a clinical evaluation and were assigned a clinical severity score based on respiratory rate, arterial oxygen saturation in room air, presence of retractions, and ability to feed at hospital admission. Participants also were assigned an LUS score based on the LUS they received within the first 24 hours of admission. The LUS probe was placed vertically, obliquely, and horizontally to the ribs in 3 chest projections: anterior, lateral, and posterior. Sonographers viewed the LUSs primarily for B-lines and subpleural consolidation. A posterior-anterior CXR was performed in 23 of the 63 children in the study group to determine the presence or absence of patchy consolidations, diffuse air trapping, and confluent opacities. Demographic, clinical, and laboratory data also were collected for all patients.

Investigators found a significant correlation between clinical severity score and LUS score, as well as a positive correlation between LUS score and days of hospitalization. In addition, patients with higher LUS scores were most likely to require oxygen therapy. LUS findings were lung B-lines, subpleural consolidation, and abnormalities of the pleural line. Lung B-lines, in particular confluent B-lines, were most frequently seen in LUS posterior projection. Subpleural consolidations were present in 54 infants, most often the multiple forms or consolidation. Finally, 13 infants had pleural line abnormalities. In comparing CXR and LUS results, investigators noted a concordance in findings of subpleural lung consolidations as well as a significant correlation between abnormalities of the pleural line and air trapping.

Once again, the ultrasound demonstrates that it can provide a valuable diagnostic tool in a number of areas, whose advantages include its ability to be used at the bedside and being radiation free. However, before you get too excited about the idea of using this routinely in children with bronchiolitis, look at the next abstract.

1. La Regina DP, Bloise S, Pepino D, et al. Lung ultrasound in bronchiolitis

. 2021;56(1):234-239. doi:10.1002/ppul.25156

A study examines whether using lung ultrasound would be an effective way to help diagnose bronchiolitis.

Jon Matthew Farber, MD

Articles

When traditional Pap test is problematic, a blind Pap is adequate

10-year study shows brace treatment is best for pectus carinatum

Telemedicine works well for managing epilepsy

Lung ultrasound: A useful tool for investigating bronchiolitis