Last week I featured a John Prine song, Summer's End, that was pretty sad and mirrored my own feelings about all the chaos happening with health care policy in the US. A few days later after LSW (my long-suffering wife) had read the post, she told me the song brought tears to her eyes. I now feel a need to counteract that beautiful but downer song and video with a little silliness, ergo the Funky Chicken title. It arises from an epic quest my mechuten and I undertook during a family/clan gathering in Montana the past week. The goal of the quest: sighting the not-so-famous Chico Chicken.
But first, here's the week in pediatric infectious diseases.
Pediatric Tuberculosis in California
Most of the details in this article, like geographic distribution, will be useful only to practitioners in California, but it has some interesting take-home points for the rest of us. The authors mined a California TB registry database for the years 2000 - 2023 for individuals under the age of 25. Unfortunately over those years the types of data saved in the registry changed, so not all elements were available for all 24 years. The good news from the study was that TB rates fell over this time period; the unsurprising bad news was the tremendous ethnic and socioeconomic disparities of TB. Every infectious diseases physician knows that the most disadvantaged populations get the worst infections, with TB being a prime example.
Other study tidbits showed that birth outside the US was more prevalent in older individuals with TB.
While overall TB rates fell, central nervous system TB rates were relatively constant over the time period.
CNS TB accounted for almost half of the deaths from TB in children under 5 years of age. I know from long experience that TB meningitis and other tuberculous CNS infections can be very difficult to diagnose, leading to delays in initiating appropriate therapy and increased morbidity and mortality.
Towards Shortened Treatment for Acute Otitis Media
Initially I was pretty excited to see this quality improvement project to increase compliance with limiting AOM antibiotic treatment to 7 days for children 2-5 years of age without severe symptoms (T>39C, moderate to severe pain, or pain > 48 hours) and to 5-7 days for children 6 and older without severe symptoms. As I dug deeper into the manuscript, I realized it wasn't going to be that useful for the majority of primary care practice settings. It was based in a large "independent practice association of 80 privately owned pediatric practices with approximately 600 physicians, nurse practitioners, and physician assistants serving as pediatric primary care clinicians ... for approximately 350 000 children, with an annual visit volume of 1.4 million." The individual practices were as small as just one clinician, but still the interventions they made, mostly with EMR changes, wouldn't be possible in a smaller setting without shared EMR.
The QI study used standard methodology, including identifying key drivers of antibiotic decisions for AOM and a plan-do-study-act (PDSA) intervention, though just with 2 PDSA cycles. They found that a combination of educational intervention including sharing practitioner compliance numbers compared to the total group, plus embedding preconfigured order sets into their EMR, resulted in a modest improvement in appropriate AOM treatment for the older children without causing much of a backlash of too-short treatment for the kids under 2 years of age.
The criteria for appropriate antibiotic treatment were taken from a now antique AAP clinical practice guideline from 2013 that, among other things, recommends diagnosis of AOM using either pneumatic otoscopy or tympanometry. I don't know many frontline providers who perform those tests routinely for AOM, and this QI study didn't appear to provide any resources for accurate AOM diagnosis to practitioners.
What I really wanted to see but couldn't find was what the history and especially physical exam templates looked like in their EMR. Ideally these would include checkboxes for all the above severity factors plus more detailed checkboxes under the ear exam that would guide clinicians to best practices for diagnosis and serve to further automate the prescription choices.
And, I hope all the clinicians somehow were able to claim maintenance of board certification credit for their participation in this project!
Does Infection With a Common Respiratory Virus Protect Against Covid Infection?
I'll mention this study just briefly. It shouldn't change anyone's clinical practice, but it raises an interesting hypothesis that needs further study, i.e. that infection with human rhinovirus somehow protects against SARS-CoV-2 infection. The study was carried out during early phases of the pandemic, May 2020 to February 2021, in 12 US cities.
It's important to note that standard nasal swab respiratory pathogen panels detect many respiratory pathogens but utilize a combined human rhinovirus/enterovirus (HRV/EV) test that does not distinguish between the 2. The study investigators went a step further on a subset of swabs positive for HRV/EV to differentiate among the 2 virus groups and showed that 97.9% were HRV. Very few people were positive for other non-SARS-CoV-2 respiratory pathogens - remember, this was during a time period of school closures and lockdowns.
HRV infections were clearly much more common in children (in yellow) than in teenagers and adults in panel A.
However, panel B above shows no difference in SARS-CoV-2 infections by age, very different from panel A. Why aren't children, who are clearly being infected with HRV at higher rates than their elders, not also seen to have higher infection rates with SARS-CoV-2? The investigators posit that something about HRV infection is protective; they back this up partially by showing that children had higher rates of expression of putative SARS-CoV-2 protective genes that might be enhanced by HRV infection. We don't know if this extends to other respiratory infections because the others were so rare in this cohort.
As I said, so far this is just a hypothesis needing further testing, but it might have major ramifications for improvement of management and prevention of SARS-CoV-2 infection. Speaking of which ...
What's New With Covid?
Nothing much. Two key trends are still rising. Now I'm waiting with bated breath to see what covid vaccines might be available soon. FDA has approved one Moderna product for high-risk younger children, no movement on Pfizer products. FDA does not have another VRBPAC meeting on the schedule. ACIP still lists an August/September meeting, with dates TBA. I'm not aware of any scientific reason not to plan ahead for these meetings and suspect that political factors are at play.
More on Oseltamivir for Influenza
This is one instance where the editorial comment might be more helpful to clinicians than the study itself. The study basically provided further evidence for what we already knew: pediatric clinicians aren't following national guidelines for influenza treatment of children. The authors used responses from general practice, pediatric emergency medicine, and pediatric ID providers to 4 clinical vignettes. Unfortunately the response rate to the questionnaire was low, 452 out of 1124 (40%), which lessens the reliability of the results. Both inpatient and outpatient vignettes were studied. You might be interested in the outpatient vignettes themselves; there are 5 because the 2 variations for length of symptoms in the 6-year-olds were randomized for distribution. Respondents were asked to choose how likely or unlikely they were to recommend oseltamivir treatment for each scenario.
In next week's post I'll provide the "correct" choices based on the national guidelines.
1.a. A 6-year-old otherwise healthy male presents for a sick visit on his 2nd day of illness with cough, congestion, body aches, and intermittent fevers. In clinic he is afebrile, SpO2 98%, respiratory rate 24, and his lung exam is overall normal despite intermittent coughing fits. His rapid influenza test returns positive.
1.b. A 6-year-old otherwise healthy male presents for a sick visit on his 4th day of illness with cough, congestion, body aches, and intermittent fevers. In clinic he is afebrile, SpO2 98%, respiratory rate 24, and his lung exam is overall normal despite intermittent coughing fits. His rapid influenza test returns positive
2. An 8-year-old female with mild persistent asthma presents to the emergency department with 3 to 4 days of low-grade fevers and cough, now with 1 day of progressive shortness of breath and fast breathing at home. In triage she was found to be in moderate respiratory distress. She responds well to bronchodilators and steroids for her asthma exacerbation and is safe to discharge home. Prior to discharge her rapid influenza test returns positive.
3. A 10-month-old ex-full-term female is seen in urgent care for increased work of breathing. She is on day 5 of illness. She has mild respiratory distress that improves with suctioning, her SpO2 is 95% and respiratory rate is 36. She appears overall comfortable and well hydrated. Her rapid influenza test is positive.
4. A 1-year-old otherwise healthy female presents to urgent care for 2 days of vomiting and diarrhea. She has had slightly decreased oral intake and wet diapers. Her 5-year-old sibling has known influenza, and the infant’s rapid influenza test is also positive. In clinic, the infant is afebrile with stable vitals, well appearing, adequately hydrated, and has a benign respiratory and
abdominal exam.
The editorial summarizes succinctly the key issue - "do we need more evidence for influenza antivirals or do we need better awareness of and compliance with national guidelines?" If you have access to Pediatrics, it's worth a read in its entirety. It notes that it would be tough to perform a study to see if antiviral therapy for flu prevents hospitalization in children - it would require >100,000 participants. We do have good evidence from smaller studies and from meta-analyses that treatment lessens complications like pneumonia that could lead to hospitalization. We also have a lot of data about side effects, including the neuropsychiatric events I discussed in last week's post.
It's a confusing situation on the front lines of pediatric care during flu season. My own bias is that yes, we'd like to have perfect randomized controlled trials that give us answers, including about which subgroups of children benefit most from treatment and how late in the course of illness antivirals maintain effectiveness. Barring that, we need better education and implementation of our existing guidelines which would result in higher treatment rates and, most likely, fewer hospitalizations and days of school and work missed.
An Ultimately Successful Quest
Our recent family/clan event (LSW and I, our youngest son and his wife, and our son's wife's parents, her sister and her husband, and the sister's husband's parents - follow all that?) in Montana was centered around Bozeman and 2 smaller towns of Emigrant and West Yellowstone, as well as Yellowstone Park of course. We had a blast.
Through Atlas Obscura, one of my favorite travel sites, I discovered we were in the neighborhood of a 9-foot tall chicken statue of uncertain provenance, standing in the middle of nowhere. The directions weren't straightforward, and even after asking the souvenir shop workers at the nearby resort, mechuten and I still couldn't locate it after about an hour hiking in the hot sun. I thought my mechuten would quit speaking to me after this fiasco, but instead he became as obsessed as I was with finding the fiberglass fowl. We returned to the fateful area and this time got some more reliable advice from one of the horse stable guides. With a little further wandering, we rounded a corner and ....
So far, neither of us have developed signs or symptoms of bird flu. If you ever find yourself in this part of Montana, just check for directions in the horse stable; exact chicken coordinates are 45 degrees 20 minutes 45 seconds North and 110 degrees 41 minutes 55 seconds West.
I thought my life was complete after locating the cagey free-range Gallus gallus domesticus, but when I returned to Maryland I remembered some associated poultry musical and cinematic favorites. I hadn't heard Rufus Thomas's Do the Funky Chicken in ages. I had even forgotten a great verse:
"Oh, I'm feeling it now, I feel so unnecessary
This is the kind, this is the kind of stuff
To make you feel like you want to do something nasty
Like waste some chicken gravy on your white shirt
Right down front, here we go y'all"
I also remembered a scene from one of my favorite movies, The Blues Brothers, featuring Ray Charles along with Matt "Guitar" Murphy, "Blue" Lou Marini, Steve "The Colonel" Cropper, Donald "Duck" Dunn, Alan "Mr. Fabulous" Rubin, and Tom "Bones" Malone. Watch this if you want to know how to shake your tail feathers (at the 1:37 mark) and catch a couple of quick glimpses of some adorable kids (2:13-2:16 and 2:29-2:31).
If all this chicken craziness doesn't at least make you grin, you might want to seek professional help.
