Uncle remus and the cascade effect in clinical medicine: Brer rabbit kicks the tar-baby

To determine in patients who are well-appearing and without a clear etiology after an apparent life-threatening event (ALTE): (1) What historical and physical examination features suggest that a child is at risk for a future adverse event and/or serious underlying diagnosis and would, therefore, benefit from testing or hospitalization? and (2) What testing is indicated on presentation and during hospitalization?

Systematic review of clinical studies, excluding case reports, published from 1970 through 2011 identified using key words for ALTE.

The final analysis was based on 37 studies; 18 prospective observational, 19 retrospective observational. None of the studies provided sufficient evidence to fully address the clinical questions. Risk factors identified from historical and physical examination features included a history of prematurity, multiple ALTEs, and suspected child maltreatment. Routine screening tests for gastroesophageal reflux, meningitis, bacteremia, and seizures are low yield in infants without historical risk factors or suggestive physical examination findings.

Some historical and physical examination features can be used to identify risk in infants who are well-appearing and without a clear etiology at presentation, and testing tailored to these risks may be of value. The true risk of a subsequent event or underlying disorder cannot be ascertained. A more precise definition of an ALTE is needed and further research is warranted. (J Pediatr 2013;163:94-9).

To determine in patients who are well-appearing and without a clear etiology after an apparent life-threatening event (ALTE): (1) What historical and physical examination features suggest that a child is at risk for a future adverse event and/or serious underlying diagnosis and would, therefore, benefit from testing or hospitalization? and (2) What testing is indicated on presentation and during hospitalization?

Systematic review of clinical studies, excluding case reports, published from 1970 through 2011 identified using key words for ALTE.

The final analysis was based on 37 studies; 18 prospective observational, 19 retrospective observational. None of the studies provided sufficient evidence to fully address the clinical questions. Risk factors identified from historical and physical examination features included a history of prematurity, multiple ALTEs, and suspected child maltreatment. Routine screening tests for gastroesophageal reflux, meningitis, bacteremia, and seizures are low yield in infants without historical risk factors or suggestive physical examination findings.

Some historical and physical examination features can be used to identify risk in infants who are well-appearing and without a clear etiology at presentation, and testing tailored to these risks may be of value. The true risk of a subsequent event or underlying disorder cannot be ascertained. A more precise definition of an ALTE is needed and further research is warranted.

Past research has identified social and environmental causes and correlates of behaviors thought to be associated with obesity and weight gain among children and adolescents. Much less research has documented the efficacy of interventions designed to manipulate those presumed causes and correlates. These latter efforts have been inhibited by the predominant biomedical and social science problem-oriented research paradigm, emphasizing reductionist approaches to understanding etiologic mechanisms of diseases and risk factors. The implications of this problem-oriented approach are responsible for leaving many of the most important applied research questions unanswered, and for slowing efforts to prevent obesity and improve individual and population health. An alternative, and complementary, solution-oriented research paradigm is proposed, emphasizing experimental research to identify the causes of improved health. This subtle conceptual shift has significant implications for phrasing research questions, generating hypotheses, designing research studies, and making research results more relevant to policy and practice. The solution-oriented research paradigm encourages research with more immediate relevance to human health and a shortened cycle of discovery from the laboratory to the patient and population. Finally, a “litmus test” for evaluating research studies is proposed, to maximize the efficiency of the research enterprise and contributions to the promotion of health and the prevention and treatment of disease. A research study should only be performed if (1) you know what you will conclude from each possible result (whether positive, negative, or null); and (2) the result may change how you would intervene to address a clinical, policy, or public health problem.

The case of a patient with acute onset of flank pain and hematuria is presented. Initial therapy was directed toward relief of pain believed to be caused by renal colic. It was not until the patient developed atypical features that the true diagnosis, ruptured renal angiomyolipoma, was discovered. The case and discussion emphasize the need to carefully consider a complete differential diagnosis when evaluating patients with flank pain and hematuria who have atypical clinical features or an atypical course.