Journal Reviews

Submitted by Dr. Lis Santana

Prevalence of Anterior Cutaneous Nerve Entrapment Syndrome in a Pediatric Population with Chronic Abdominal Pain

Murid Siawash, Jenneke W.A. de Jager-Kievit, Walther Tjon A. Ten, Rudi M. Roumen, and Marc R. Scheltinga. Journal Pediatric Gastroenterology  Volume 62, Number 3, March 2016

Objective
Anterior cutaneous nerve entrapment syndrome (ACNES) is a frequently overlooked condition causing chronic abdominal pain (CAP). The objective of the present study was to investigate the rate of ACNES in pediatric outpatient cohort with CAP.

Methods
A cross-sectional cohort study was conducted in a population 10 to 18 years of age consulting a pediatric outpatient department with CAP during a two years’ time period. All individuals were identified through a hospital registration system using diagnosis code 3303 (all possible forms of CAP). History, physical examination, diagnosis, and success of treatment were obtained in patients who were diagnosed as having ACNES. The patients were all from the Center of Excellence for Abdominal Wall and Groin Pain from 2011 and 2012 and with ongoing abdominal complaints with normal diagnostic tests performed by the attending pediatrician.

Results
Twelve of 95 adolescents with CAP were found to be experiencing ACNES. Carnett sign was positive at the lateral border of the rectus abdominus muscle in all 12. Altered skin sensation was present in 11 of 12 patients with ACNES. Six weeks after treatment (1–3 injections, n ¼ 5; neurectomy, n ¼ 7), pain was absent in 11 patients.

Conclusions
ACNES is present in one of eight adolescents presenting with CAP to a pediatric outpatient department of a teaching hospital. Simple physical exam  allows for the diagnosis. Treatments including nerve blocks or surgery are beneficial in most. ACNES is usually simply diagnosed using history and physical examination. Pain relief 15 minutes after a local abdominal wall injection using 5 mL of 1% lidocaine strongly supports the suspicion on this condition. Routine diagnostics such as blood tests and imaging do not contribute to the diagnosis of ACNES but may exclude other conditions.

Risk Stratification for Opioid Misuse in Children, Adolescents, and Young Adults: A Quality Improvement Project

Rachel Thienprayoon, MD, MSCS, Kelly Porter, MSN, APRN, CNP, Michelle Tate, RN,  Marshall Ashby, MHSM, MBA, Mark Meyer, MD. Pediatrics  December 15, 2016

Background
The Pediatric Palliative and Comfort Care Team (PACT) at Cincinnati Children’s Hospital Medical Center (CCHMC) provides opioids to a large population of patients in the ambulatory setting. Before this project, PACT had no reliable system to risk stratify patients for opioid misuse.

Methods
The global aim was safe opioid prescribing by the palliative care team. The specific, measurable, achievable, realistic, and timely aim was as follows: “In patients who present for follow up with PACT, we will use the “opioid bundle” to increase risk stratification for opioid misuse from 0% to 90% over five months.” The opioid bundle includes a urine drug screen, Ohio Automated Rx Reporting System report, pill count, and screening history for drug abuse and mental health disorders. The setting was multiple CCHMC ambulatory clinics. Participants included all PACT members.

Results
Since implementing the new system, there was an increased risk stratification for opioid misuse among outpatients from 0% to >90%. Results were sustained for 12 months. Key processes have become reliable: obtaining informed consent and controlled substance agreements for all new patients and obtaining the opioid bundle to enable risk stratification in a consistent and timely fashion. A total of 34% of patients have been stratified as high risk, and an additional 27% have been stratified as moderate risk.

Conclusions
A system to ensure safe opioid prescribing practices to all patients is critical for providers. Identifying key processes and executing them reliably has enabled the palliative care team at CCHMC to risk stratify >90% of patients receiving opioids in the ambulatory setting for opioid misuse.

Parental Perceptions of Pediatric Pain and POTS-Related Disability

Elizabeth M. Keating, MD, Ryan M. Antiel, MD, Karen E. Weiss, PhD, Dustin Wallace, PhD, Seth J. Antie, Philip R. Fischer, MD, Ashley N. Junghans-Rutelonis, PhD, and Cynthia Harbeck-Weber, PhD. Clinical Pediatrics. 2016 Dec. 1-8.

Introduction
Adolescents with postural orthostatic tachycardia syndrome (POTS) often have pain and functional impairment. This study evaluated how parental attributions of children’s symptoms relate to child functional impairment. Adolescents with chronic pain and clinical symptoms suggestive of autonomic dysfunction (fatigue, dizziness, nausea) that attended a multidisciplinary chronic pain clinic completed measures of depression, anxiety, and functioning.

Methods
Parents of 114 of these patients completed the Parent Pain Attribution Questionnaire (PPAQ), a measure indicating the extent they believe physical and psychosocial factors account for their child’s health condition. Patients were retrospectively grouped as to whether or not they had significant POTS on tilt table testing (n = 37).

Results
Greater parental attribution to physical causes was associated with increased levels of functional disability whether patients had POTS (r = 0.45, P = .006) or not (r = 0.25, P = .03).

Conclusion
These results suggest that providers should advocate a more comprehensive family-oriented rehabilitative approach to treatment.