Scenarios wanted! Please add your favorites! [Click on "Easy Edit", above]

Information about each scenario can include, but need not be limited to:

• the case
  
• the PICO'd question
  
• type of question/preferred study design
• suggested search strategies
• teaching tips

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Scenario #1:
Ms. Crosbie has been asked to schedule an appointment for her baby's 18 month needle (MMR). She is very concerned about this as she has heard reports that the MMR needle causes autism. She asks you whether or not there is a link between the MMR vaccine and an increased risk of autism in children?
P: 18 month old child
I: MMR vaccine
C: no MMR vaccine
O: autism / autistic spectrum disorder

Answerable question: In 18 month old children, does receiving the MMR vaccine increase the risk of developing autism?
MeSH: autistic disorder/etiology; Measles-Mumps-Rubella Vaccine/*adverse effects
PubMed keyword: (mmr OR measles mumps rubella) AND autis*
Teaching tips:

• this is a good one for thinking about reasonable limits to set. For example, there is little need to limit this search to children because most articles on MMR and autism are about the 18-month age group.

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Scenario #2:

Role of leukotriene receptor antagonists such as montelukast or zafirlukast in the management of asthma in children.
These are drugs you see advertised on TV sometimes – Singulair (montelukast). There’s interest in them because they have anti-inflammatory effects without being steroids. There have been a number of systematic reviews that mention children, including Cochrane. Good for showing “details,” limiting, therapy and systematic review Clinical Query filter. In this example I limited to child 6-12 only to eliminate the adult studies you’d get with “all child.” Also the limit to Core Clinical Journals. This example was used for a Pediatric Journal Club.

#21Search (#11 AND #17) AND (randomized controlled trial[Publication Type] OR (randomized[Title/Abstract] AND controlled[Title/Abstract] AND trial[Title/Abstract])) Limits: Core clinical journals, Child: 6-12 years 23
#20Search (#11 AND #17) AND (randomized controlled trial[Publication Type] OR (randomized[Title/Abstract] AND controlled[Title/Abstract] AND trial[Title/Abstract])) Limits: Child: 6-12 years 175
#19Search #11 AND #17 Limits: Child: 6-12 years 318
#18Search #11 AND #17 1595
#17Search leukotriene receptor antagonist 3337
#12Search singulair 833
#11Search asthma 98312

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Case: You are seeing a beautiful 1 month old girl for a WCC. Her exam is notable for thrush. You are about to prescribe nystatin orally, your standard practice, when the mom comments that she could never do anything four times a day, and wonders whether she could use a once-daily medicine like fluconazole, which she had taken once for a yeast infection.

Answerable questions: In healthy infants with thrush, is fluconazole one daily as effective as nystatin four times daily?
In healthy infants with thrush, does fluconazole once daily lead to better compliance than nystatin QID, or early resolution?


SEARCH Strategy: thrush AND fluconazole AND nystatin limit: All infant

TEACHING Tips: straightforward question, use limits, show other features of PubMed with this easy question
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Case: You are in Same Day clinic, and have a 7 month old patient with a fever to 103, but no other localizing signs. You want to follow the protocol and get blood (CBCD and blood culture) and urine, but your attending comments that this kid has gotten all of his immunization, including Prevnar.

Answerable questions:
In infants who have received the Prevnar vaccine, and present with fever without signs (fever wtihout source, fever with no localizing signs), what is the prevalence of occult bactermia? UTI?

In infants with fever without signs, what are the sensitivity/specificity and likelihood ratios of a CBC with diff?

SEARCH Strategy:prevnar AND fever AND (bacteremia OR urinary tract infection)--doesn't give you too much to work with, no limits needed
2nd search: (complete blood count AND fever) AND (sensitivity OR specificity) limits: All infants

TEACHING Tips: go to MeSH Database to see that fever explodes to include "fever of unknown origin". NOTE: typing in blood occult will lead you down a strange path, check details to show this
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Case: You are in Same Day Clinic, seeing a 5 yo boy with an asthma exacerbation. He has some impressive increased work of breathing, enough so that you think he may eventually need to be admitted. You order oral prednisolone and albuterol, and are wondering whether you should give ipratroprium (Atrovent) as well.

P asthma
I albuterol
C atrovent
O reduce hospitalization rate
T therapy
T RCT

Answerable question: In children with moderate to severe asthma exacerbation, does Atrovent added to albertol decrease rate of hospital admission?

SEARCH Strategy:(asthma AND atrovent AND albuterol) AND (length of stay OR patient admissions OR hospitalization)
can do therapy narrow clinical query, though not really necessary with the small number of citations retreived

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Case: You are on the floors admitting a 5 year old boy with an asthma exacerbation as he has some impressive increased work of breathing. He is in q2 albuterol and q4 atrovent. Your attending wants to continue the atrovent and wean it with the albuterol (e.g. q3 albuterol/q6 atrovent, then q4 albuterol/q8 atrovent). You wonder whether this really makes a difference in getting this kid home any faster.

Answerable question: In hospitalized children with asthma, does atrovent added to albertol decrease length of stay?

SEARCH Strategy:(asthma AND atrovent AND albuterol) AND (length of stay OR patient admissions OR hospitalization)
can do therapy narrow clinical query, though not really necessary with the small number of citations retreived

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Case: You are seeing a two-month-old baby boy who has been growing well for a well-child exam. No specific concerns per mom. No sweating or problems with feeding. Prenatal course unremarkable and (-) PMH. On exam, P 110, RR 30, BP 80/50 with normal 4 limb BPs, no distress. Lungs clear. Heart RRR with 2-3/6 ejection murmur without radiation. No S3 or S4. No hepatosplenomegaly. No edema. Good femoral pulses. You had not heard the murmur at his other visits and begin to wonder how to evaluate this. You’re thinking about getting a chest x-ray and an EKG.
Question: The question should be something along the lines of: “In children with a heart murmur, what is the usefulness (sensitivity/specificity) of obtaining a chest x-ray in making a diagnosis?”
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Case: You are seeing a 2 month old baby girl for a well-baby exam. In your discussion about feedings, the parents report that their daughter “spits up” after every feeding. It is non-projectile, nonbilious, and non-bloody. They are breast-feeding, but this occurs after bottles also. The baby has otherwise been well and was born full-term. On exam, the baby’s weight is just below the 10th percentile, height at 50th and head circumference at the 50th. The baby generally looks nourished, but smallish. Well-hydrated. Lungs are clear. Abdominal exam is normal. You believe this infant's GE reflux may be interfering with her growth. You recall that many kids are being sent home from the NICU on cisapride and ranitidine and wonder how effective those measures are.
Question: “In infants with gastroesophageal reflux, is there a non-surgical therapy that improves outcome (pick an outcome, like growth)?”