BONUS EPISODE: Season 1 Recap with The Medical Students

February 19, 2021 | By Justin Berk

Summary

The MS4’s on staff takeover The Cribsiders for a recap of our favorite clinical pearls from Season 1!

Credits

• Writer: Angela Zhang, Edward Corty
• Cover Art: Chris Chiu
• Hosts: Anglea Zhang, Edward Corty, Becca Raymond-Kolker, Shannon Snellgrove, Cleo Reochat
• Editor: Angela Zhang; Clair Morgan of nodderly.com

Clinical Pearls

#1 Cystic Fibrosis

• CF-related diabetes is a combination of absolute insulin deficiency and relative insulin resistance.
• HbA1c tends to underestimate actual blood sugars due to increased RBC turnover in CF, get an oral glucose tolerance test!
• Higher BMI is associated with better lung function.
• 90% of CFTR mutations are now covered by protein modulating medications! 

#2 Bronchiolitis 

• In kids with viral bronchiolitis symptoms, chest x-ray increases use of antibiotics but does not improve outcomes. 
• The AAP guidelines for the treatment of bronchiolitis advise against the use of steroids. 
• The theories behind the mechanism of high-flow nasal cannula are humidifying/warming air, blowing off CO2, providing PEEP. 

#3 Back to School Special 

• The disruption to schools has shone a light on the importance of schools not just as a place for learning but also as a place for socializing, receiving healthcare, and obtaining nutrition. Thinking also about the inequities already existing in school funding, Dr. Sharfstein said we need to recognize how much we have already asked children to sacrifice. Schools should now be the priority. The lack of direction from the top has not helped. 

#4 Things We Do For No Reason in Pediatrics

• At 36 hours, 97% of blood cultures that would grow a pathogenic organism would have already turned positive! Your rate of identifying a contaminant for cultures that turn positive after 36 hours increases 8-fold!

#5 MIS-C

• The most common presentation is gastrointestinal symptoms, but a rare (and underrecognized) presentation is neurological changes.
• Be careful with your fluid resuscitation because these patients can present with decreased cardiac function and are prone to fluid overload!

#6 Pharyngitis

• If your patient has a Centor score of 0 or 1, you do not need to do a Rapid Strep test or give antibiotics.
• A history of a fever (not just presence of fever once in clinic) is just as good in determining the Centor score as a fever recorded in clinic. Take the history of a fever seriously!
• Red Flags for Lemierre’s include rigors, unilateral neck swelling, pulmonary symptoms, no improvement after 5-6 days.

#7 Type 1 Diabetes

• Screening for other autoimmune conditions such as Celiac’s disease, thyroid disease, Addison’s disease, and IBD should be included as part of the diagnostic workup for T1DM.
• The goal is to catch the diagnosis of T1DM before they present in DKA!
• Having negative antibody tests does not exclude a diagnosis of T1DM!

#8 Asthma 

• Per 2020 GINA Treatment Strategies, Adults and adolescents 12+ should use ICS/LABA (i.e. budesonide/formoterol) as initial on-demand therapy. National Heart, Lung, and Blood Institute is saying this can be for step 2 (mild persistent and above) and keep PRN SABA for intermittent asthma. Stay tuned for drama regarding this disagreement.

#9 Anaphylaxis

• Praise parents who have administered an epinephrine auto-injector to their child with anaphylaxis. It’s one of the most difficult drugs to give, but it is life-saving, and parents should be commended for their courage.
• Any notable skin changes can be associated with anaphylaxis, not just hives. 

#10 UTI/UTI Companion episode 

• Race is a social construct and there is no inherent biologic differences across socially constructed racial categories. 
• When you see racial differences/disparities described, like any good scientist do these things:
  • Ask, does this make sense?
  • Interpret the data, how do the authors define race?
  • Use the basic principle of “do no harm” and be aware of the potential harm of race-correction in medicine.

#11 Community-Acquired Pneumonia

• The only clinical findings that have been associated with a diagnosis of CAP are hypoxemia and increased work of breathing
• CXR’s are not great at diagnosing CAP, but a normal CXR can be a super helpful tool to rule it out. 
• High-dose amoxicillin should almost always be the first thing you reach for treating CAP. People often assume cephalosporins are superior, but due to oral pharmacokinetics, high-dose amoxicillin is often the far better choice for the majority of cases. 

#12 Sickle Cell Anemia

• Folic acid is really sweet and many patients with Sickle Cell Anemia and remember this part of their treatment fondly. Knowing this can be an unconventional way to build trust with patients.
• Sickle Cell Anemia is not a race-based disease, but it is in individuals whose ancestry traces back to countries where malaria is endemic. This is due to the sickle cell trait being protective against malaria.  

#13 ADHD

• When choosing what medication to start with for ADHD, just pick your favorite drug from the first line therapies for ADHD. Insurance, geography, and multiple other factors may be the reason you end up choosing which drug out of the classes. 
• The Vanderbilt Assessment Scale should be thought of as a checklist, not diagnostic criteria.  It tells you that your patient has symptoms that resemble ADHD, but whether it is actually ADHD requires further digging. Other diagnoses to keep in mind are trauma, vitamin deficiency, and sleep deficiency, just to name a few.  

#14 Infant Nutrition

• Some families will make an informed choice to use formula feeding; this decision should not be stigmatized. Instead, build trust through communication and support
• We talked about the legacy of health inequities in breastfeeding among Black mothers all the way from wet nursing during slavery and some efforts to reduce those inequities like from non-profits groups like Reaching Our Sisters Everywhere. 

#15 Trauma-informed Care

• Dr. Forkey recommends checking in with the patient first, before addressing trauma.These conversations are personal and can be difficult for both practitioner and patient. Engage first by asking “how are you?” and from there validate the experiences of your patient. Trauma informed care starts with building rapport and relationships. Pediatric providers have an unique opportunity to partner with families towards recovery
• Toxic Stress and trauma is not just about the bad things that happen to you, but rather how well caregivers can buffer those experiences 
• Pediatricians are well suited to address trauma as it presents itself in a child’s life .

Our picks of the year!

Angela

• Tiktok app
• Big Mouth (streaming on Netflix)
• Broken Earth trilogy by N.K Jemisen (https://www.amazon.com/gp/bookseries/B01947LZ8A) 

Edward 

• Strava app
• Together by Vivek Murthy (https://www.amazon.com/Together-Connection-Performance-Greater-Happiness/dp/0062913298) 
• Never Have I Ever (streaming on Netflix)

Becca

• Buffy the Vampire Slayer (streaming on Hulu and Amazon Prime)

Shannon 

• BE by BTS (https://time.com/5914352/bts-be-analysis/) 
• BTS Tiny Desk (home) concert (https://www.youtube.com/watch?v=gFYAXsa7pe8) 

Cleo

• Discovering online versions of board games, like Settlers of Catan! (https://www.catan.com/game/catan-universe)

The Queen’s Gambit (streaming on Netflix)