Journal Club

May 1, 2007

Teen bariatric procedures * Rocky Mountain spotted fever* Health promotion kiosks

• Teen bariatric procedures increase dramatically

Though bariatric surgery in adolescents remains uncommon, procedure rates in this age group have increased in recent years. According to data obtained from the Nationwide Inpatient Sample, a representative group of US community hospitals, the number of adolescent bariatric surgeries varied little between 1996 and 2000, then more than tripled from 2000 to 2003. Nonetheless, only an estimated 771 bariatric procedures were performed in adolescents in 2003. This number represents fewer than 0.7% of total bariatric surgeries nationwide.

Most adolescent bariatric patients underwent a gastric bypass procedure (rather than vertical banded gastroplasty or adjustable gastric banding). Patients generally were from 15 to 19 years of age; the youngest was 12. Major complications, generally respiratory, developed in 5.5% of patients.

Commentary

As the obesity epidemic continues, these procedures will be coming to a hospital near you. Pediatric organizations should plan ahead by specifying indications for referral and recommending that the procedures be performed in centers that have the expertise and resources to care for the physical and emotional needs of these patients. Primary care pediatricians will need to learn about follow-up care of bariatric patients. At the same time, we should work to prevent obesity through family education, screening for overweight, and learning how to treat overweight children effectively before these procedures are necessary.

• Don't forget Rocky Mountain spotted fever

A retrospective chart review of 92 children with Rocky Mountain spotted fever (RMSF) treated at six institutions in the southeastern and south central US clarifies clinical and laboratory findings associated with this disease, as well as which patient characteristics are independently related to adverse outcomes. Study patients, more than half of whom were female, were younger than 18 years; 90% received an RMSF diagnosis between April and September.

Most patients first sought care from their health care providers after a median of two days of symptoms, which were generally fever, rash, nausea or vomiting, or headache. Fewer than half reported a tick bite. Only four children were prescribed an antirickettsial antibiotic (doxycycline) before admission. Children who visited a health care provider within the first two days of symptoms started antirickettsial therapy significantly later than those who sought care later.

More than one third of the study group spent time in an intensive care unit; 16% were mechanically ventilated, 41% had at least one intravenous fluid bolus, and 17% received inotropic medications. Three children died. All these children had fever, respiratory failure, renal insufficiency, and altered mental status on admission and required mechanical ventilation, inotropic cardiac support, and blood transfusions. Of surviving patients, 15% were discharged with documented neurologic deficits, including speech or swallowing dysfunction, global encephalopathy, ataxia or other gait disturbances, and cortical blindness. Two patients had digital necrosis. Analysis showed that three clinical variables were independently associated with adverse outcome: coma, inotropic support, and receipt of an intravenous fluid bolus. Presence of at least two of these findings was 81% sensitive and 97% specific for an adverse outcome.

At the time of admission, 58% of patients had experienced fever, rash, and headache, and 45% had experienced fever and rash and had a history of tick attachment. Every child had at least one of the findings of fever, rash, or headache, though all three were present in fewer than two thirds of patients. Though most patients had thrombocytopenia, laboratory findings generally were nonspecific and difficult to differentiate from those that would be expected in viral syndromes. Investigators concluded that no constellation of clinical and laboratory abnormalities has adequate sensitivity to exclude the diagnosis of RMSF in a child in whom they are absent (Buckingham SC, et al: J Pediatr 2007;150:180).

Commentary

May is a good time to remind ourselves to be on the lookout for tick-borne disease. These authors remind us to have a low threshold for starting treatment, even without a clear history of tick exposure, a visit to a wooded area, or the textbook physical exam findings of RMSF.