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Keuning MW, Klarenbeek NN, Bout HJ, Broer A, Draaijer M, Hol J, Hollander N, Merelle M, Nassar-Sheikh Rashid A, Nusman C, Oostenbroek E, Ridderikhof ML, Roelofs M, van Rossem E, van der Schoor SRD, Schouten SM, Taselaar P, Vasse K, van Wermeskerken AM, van der Zande JMJ, Zuurbier R, Bijlsma MW, Pajkrt D, Plötz FB. Prospective multicenter evaluation of adherence to the Dutch guideline for children aged 0-16 years with fever without a source-febrile illness in children (FINCH) study. Eur J Pediatr 2024; 183:2921-2933. [PMID: 38619569 PMCID: PMC11192673 DOI: 10.1007/s00431-024-05553-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 03/30/2024] [Accepted: 04/02/2024] [Indexed: 04/16/2024]
Abstract
Evaluation of guidelines in actual practice is a crucial step in guideline improvement. A retrospective evaluation of the Dutch guideline for children with fever without an apparent source (FWS) showed 50% adherence in young infants. We prospectively evaluated adherence to the Dutch guideline and its impact on management in current practice. Prospective observational multicenter cross-sectional study, including children 3 days to 16 years old presented for FWS at one of seven emergency departments in participating secondary and tertiary care hospitals in the Netherlands. Adherence to the Dutch FWS guideline, adapted from the National Institute for Health and Care Excellence (NICE) guideline, was evaluated, and patterns in non-adherence and the impact of non-adherence on clinical outcomes and resource use were explored. Adherence to the guideline was 192/370 (52%). Adherence was lowest in patients categorized as high risk for severe infection (72/187, 39%), compared to the low-risk group (64/73, 88%). Differences in adherence were significant between risk categories (P < 0.001) but not between age categories. In case of non-adherence, less urinalysis, fewer bacterial cultures (blood, urine, and cerebral spinal fluid), and less empirical antibiotic treatment were performed (P < 0.050). Clinical outcomes were not significantly different between the non-adherence and the adherence group, particularly regarding missed severe infections. CONCLUSIONS We found a high non-adherence rate of 48%, which did not lead to unfavorable clinical outcomes. This substantiates the need for a critical reevaluation of the FWS guideline and its indications for bacterial cultures, viral testing, and antibiotic treatment. WHAT IS KNOWN • Despite the development of national guidelines, variation in practice is still substantial in the assessment of febrile children to distinguish severe infection from mild self-limiting disease. • Previous retrospective research suggests low adherence to national guidelines for febrile children in practice. WHAT IS NEW • In case of non-adherence to the Dutch national guideline, similar to the National Institute for Health and Care Excellence (NICE) guideline from the United Kingdom, physicians have used fewer resources than the guideline recommended without increasing missed severe infections.
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Affiliation(s)
- Maya W Keuning
- Amsterdam UMC, Department of Pediatrics, University of Amsterdam, Emma Children's Hospital, Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | | | - Hidde J Bout
- Amsterdam UMC, Department of Pediatrics, University of Amsterdam, Emma Children's Hospital, Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Amber Broer
- Department of Pediatrics, Spaarne Hospital, Hoofddorp, The Netherlands
| | - Melvin Draaijer
- Department of Pediatrics, Spaarne Hospital, Hoofddorp, The Netherlands
| | - Jeroen Hol
- Department of Pediatrics, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Nina Hollander
- Department of Pediatrics, Flevoziekenhuis, Almere, The Netherlands
| | - Marieke Merelle
- Department of Pediatrics, Spaarne Hospital, Hoofddorp, The Netherlands
| | | | - Charlotte Nusman
- Department of Pediatrics, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Emma Oostenbroek
- Department of Pediatrics, Spaarne Hospital, Hoofddorp, The Netherlands
| | - Milan L Ridderikhof
- Department of Emergency Medicine, Amsterdam, UMC , University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
| | - Manouck Roelofs
- Department of Pediatrics, Zaans Medical Center, Zaandam, The Netherlands
| | - Ellen van Rossem
- Department of Pediatrics, Flevoziekenhuis, Almere, The Netherlands
| | | | - Sarah M Schouten
- Department of Pediatrics, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Pieter Taselaar
- Department of Pediatrics, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Koen Vasse
- Department of Pediatrics, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | | | | | - Roy Zuurbier
- Department of Pediatrics, Tergooi MC, Blaricum, The Netherlands
| | - Merijn W Bijlsma
- Amsterdam UMC, Department of Pediatrics, University of Amsterdam, Emma Children's Hospital, Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Dasja Pajkrt
- Amsterdam UMC, Department of Pediatrics, University of Amsterdam, Emma Children's Hospital, Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Frans B Plötz
- Amsterdam UMC, Department of Pediatrics, University of Amsterdam, Emma Children's Hospital, Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Department of Pediatrics, Tergooi MC, Blaricum, The Netherlands
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Green RS, Sartori LF, Florin TA, Aronson PL, Lee BE, Chamberlain JM, Hunt KM, Michelson KA, Nigrovic LE. Predictors of Invasive Bacterial Infection in Febrile Infants Aged 2 to 6 Months in the Emergency Department. J Pediatr 2024; 270:114017. [PMID: 38508484 DOI: 10.1016/j.jpeds.2024.114017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 02/29/2024] [Accepted: 03/12/2024] [Indexed: 03/22/2024]
Abstract
Our goal was to identify predictors of invasive bacterial infection (ie, bacteremia and bacterial meningitis) in febrile infants aged 2-6 months. In our multicenter retrospective cohort, older age and lower temperature identified infants at low risk for invasive bacterial infection who could safely avoid routine testing.
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Affiliation(s)
- Rebecca S Green
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA.
| | - Laura F Sartori
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Todd A Florin
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Paul L Aronson
- Section of Pediatric Emergency Medicine, Departments of Pediatrics and of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Brian E Lee
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA; Division of Emergency Medicine, Children's National Hospital, Washington, DC
| | - James M Chamberlain
- Division of Emergency Medicine, Children's National Hospital, Washington, DC
| | - Kathryn M Hunt
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Kenneth A Michelson
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
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Geanacopoulos AT, Neuman MI, Michelson KA. Cost of Pediatric Pneumonia Episodes With or Without Chest Radiography. Hosp Pediatr 2024; 14:146-152. [PMID: 38229532 PMCID: PMC10873478 DOI: 10.1542/hpeds.2023-007506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
BACKGROUND AND OBJECTIVES Despite its routine use, it is unclear whether chest radiograph (CXR) is a cost-effective strategy in the workup of community-acquired pneumonia (CAP) in the pediatric emergency department (ED). We sought to assess the costs of CAP episodes with and without CXR among children discharged from the ED. METHODS This was a retrospective cohort study within the Healthcare Cost and Utilization Project State ED and Inpatient Databases of children aged 3 months to 18 years with CAP discharged from any EDs in 8 states from 2014 to 2019. We evaluated total 28-day costs after ED discharge, including the index visit and subsequent care. Mixed-effects linear regression models adjusted for patient-level variables and illness severity were performed to evaluate the association between CXR and costs. RESULTS We evaluated 225c781 children with CAP, and 86.2% had CXR at the index ED visit. Median costs of the 28-day episodes, index ED visits, and subsequent visits were $314 (interquartile range [IQR] 208-497), $288 (IQR 195-433), and $255 (IQR 133-637), respectively. There was a $33 (95% confidence interval [CI] 22-44) savings over 28-days per patient for those who received a CXR compared with no CXR after adjusting for patient-level variables and illness severity. Costs during subsequent visits ($26 savings, 95% CI 16-36) accounted for the majority of the savings as compared with the index ED visit ($6, 95% CI 3-10). CONCLUSIONS Performance of CXR for CAP diagnosis is associated with lower costs when considering the downstream provision of care among patients who require subsequent health care after initial ED discharge.
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Affiliation(s)
- Alexandra T Geanacopoulos
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Mark I Neuman
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Kenneth A Michelson
- Division of Emergency Medicine, Ann & Robert Lurie Children's Hospital of Chicago, Chicago, Illinois
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Rees CA, Kuppermann N, Florin TA. Community-Acquired Pneumonia in Children. Pediatr Emerg Care 2023; 39:968-976. [PMID: 38019716 DOI: 10.1097/pec.0000000000003070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
ABSTRACT Community-acquired pneumonia (CAP) is the most common cause of childhood mortality globally. In the United States, CAP is a leading cause of pediatric hospitalization and antibiotic use and is associated with substantial morbidity. There has been a dramatic shift in microbiological etiologies for CAP in children over time as pneumococcal pneumonia has become less common and viral etiologies have become predominant. There is no commonly agreed on approach to the diagnosis of CAP in children. When indicated, antimicrobial treatment should consist of narrow-spectrum antibiotics. In this article, we will describe the current understanding of the microbiological etiologies, clinical presentation, diagnostic approach, risk factors, treatment, and future directions in the diagnosis and management of pediatric CAP.
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Affiliation(s)
| | - Nathan Kuppermann
- Professor, Departments of Emergency Medicine and Pediatrics, University of California Davis Health, University of California Davis, School of Medicine, Sacramento, CA
| | - Todd A Florin
- Associate Professor, Department of Pediatrics, Northwestern University Feinberg School of Medicine and Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
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Bouënel M, Lefebvre V, Trouillet C, Diesnis R, Pouessel G, Karaca-Altintas Y. Determining clinical predictors to identify non-specific abdominal pain and the added value of laboratory examinations: A prospective derivation study in a paediatric emergency department. Acta Paediatr 2023; 112:2218-2227. [PMID: 37463102 DOI: 10.1111/apa.16911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 07/12/2023] [Accepted: 07/17/2023] [Indexed: 07/20/2023]
Abstract
AIM To develop a model to discriminate non-specific abdominal pain (NSAP) from organic pain in the paediatric emergency department (PED) and evaluate the added value of laboratory markers. METHODS Prospective cohort study in an urban French PED including all patients aged ≥4 years with abdominal pain between November 2020 and May 2021. The outcome was the discrimination between NSAP (patients coded to have only "pain" or "constipation") and organic pain (all other diagnoses) using stepwise backward multivariate logistic regression method with bootstrap resampling. RESULTS The study enrolled 246 patients. Overall, 163 patients (66.2%) had NSAP. Four variables associated with organic pain: pain in the epigastric region (OR 0.48 [0.23-0.99]), worsening pain (0.57 [0.32-0.99]), pain migration (0.42 [0.17-0.99]) and vomiting (0.47 [0.26-0.84]) were integrated in a clinical model. To discriminate NSAP with a probability of 65%, model sensitivity was 71.8% (64.9-78.7), specificity was 53.0% (42.3-63.7), and the Net Benefit (NB) was 15.4%. White Blood Count and C-reactive protein results improved discriminative capacity of the model (AUC 0.708 [0.643-0.773] vs. 0.654 [0.585-0.723], p = 0.01) with a supplementary NB of 12%. Patient follow-up showed 95% diagnostic accuracy. CONCLUSION This study reveals a four-clinical predictor model with a NB of 15% in predicting NSAP. Validation studies are necessary.
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Affiliation(s)
| | - Victoire Lefebvre
- Department of Pediatrics, Children's Hospital, CH Roubaix, Roubaix, France
| | | | - Remy Diesnis
- Department of Emergency Medicine, CH Roubaix, Roubaix, France
| | - Guillaume Pouessel
- Department of Pediatrics, Children's Hospital, CH Roubaix, Roubaix, France
| | - Yasemin Karaca-Altintas
- Department of Pediatrics, Children's Hospital, CH Roubaix, Roubaix, France
- Univ. Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, U1019-UMR 9017-CIIL-Center for Infection and Immunity of Lille, Lille, France
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6
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Guo BC, Chen YT, Chang YJ, Chen CY, Lin WY, Wu HP. Predictors of bacteremia in febrile infants under 3 months old in the pediatric emergency department. BMC Pediatr 2023; 23:444. [PMID: 37679686 PMCID: PMC10483716 DOI: 10.1186/s12887-023-04271-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 08/24/2023] [Indexed: 09/09/2023] Open
Abstract
INTRODUCTION Fever may serve as the primary indicator of underlying infection in children admitted to the pediatric emergency department (PED), especially in high-risk young infants. This study aimed to identify early clinical factors that could help predict bacteremia in young febrile infants. METHODS The study included infants under 90 days of age who were admitted to the PED due to fever. Patients were divided into two groups based on the presence or absence of bacteremia and further divided into three age groups: (1) less than 30 days, (2) 30 to 59 days, and (3) 60 to 90 days. Several clinical and laboratory variables were analyzed, and logistic regression and receiver operating characteristic (ROC) analyses were used to identify potential risk factors associated with bacteremia in young febrile infants. RESULTS A total of 498 febrile infants were included, of whom 6.4% were diagnosed with bacteremia. The bacteremia group had a higher body temperature (BT) at triage, especially in neonates, higher pulse rates at triage, longer fever subsidence time, longer hospital stays, higher neutrophil counts, and higher C-reactive protein (CRP) levels than those of the non-bacteremia group. ROC analysis showed that the best cut-off values for predicting bacteremia in infants with pyrexia were a BT of 38.7 °C, neutrophil count of 57.9%, and CRP concentration of 53.8 mg/L. CONCLUSIONS A higher BT at triage, increased total neutrophil count, and elevated CRP levels may be useful for identifying bacteremia in young febrile infants admitted to the PED.
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Affiliation(s)
- Bei-Cyuan Guo
- Department of Pediatrics, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Yin-Ting Chen
- Division of Neonatology, Department of Pediatrics, Children Hospital, China Medical University, Taichung, Taiwan
| | - Yu-Jun Chang
- Laboratory of Epidemiology and Biostastics, Changhua Christian Hospital, Changhua, Taiwan
| | - Chun-Yu Chen
- Department of Emergency Medicine, Tungs' Taichung MetroHarbor Hospital, Taichung, Taiwan
| | - Wen-Ya Lin
- Department of Pediatric Emergency Medicine, Department of Pediatrics, Taichung Veteran General Hospital, Taichung, Taiwan
| | - Han-Ping Wu
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.
- Department of Pediatrics, Chiayi Chang Gung Memorial Hospital, No. 6, W. Sec., Jiapu Rd, Puzi City, Taiwan.
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7
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Shah P, Voice M, Calvo-Bado L, Rivero-Calle I, Morris S, Nijman R, Broderick C, De T, Eleftheriou I, Galassini R, Khanijau A, Kolberg L, Kolnik M, Rudzate A, Sagmeister MG, Schweintzger NA, Secka F, Thakker C, van der Velden F, Vermont C, Vincek K, Agyeman PK, Cunnington AJ, De Groot R, Emonts M, Fidler K, Kuijpers TW, Mommert-Tripon M, Brengel-Pesce K, Mallet F, Moll H, Paulus S, Pokorn M, Pollard A, Schlapbach LJ, Shen CF, Tsolia M, Usuf E, van der Flier M, von Both U, Yeung S, Zavadska D, Zenz W, Wright V, Carrol ED, Kaforou M, Martinon-Torres F, Fink C, Levin M, Herberg J. Relationship between molecular pathogen detection and clinical disease in febrile children across Europe: a multicentre, prospective observational study. THE LANCET REGIONAL HEALTH. EUROPE 2023; 32:100682. [PMID: 37554664 PMCID: PMC10405323 DOI: 10.1016/j.lanepe.2023.100682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/28/2023] [Accepted: 06/28/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND The PERFORM study aimed to understand causes of febrile childhood illness by comparing molecular pathogen detection with current clinical practice. METHODS Febrile children and controls were recruited on presentation to hospital in 9 European countries 2016-2020. Each child was assigned a standardized diagnostic category based on retrospective review of local clinical and microbiological data. Subsequently, centralised molecular tests (CMTs) for 19 respiratory and 27 blood pathogens were performed. FINDINGS Of 4611 febrile children, 643 (14%) were classified as definite bacterial infection (DB), 491 (11%) as definite viral infection (DV), and 3477 (75%) had uncertain aetiology. 1061 controls without infection were recruited. CMTs detected blood bacteria more frequently in DB than DV cases for N. meningitidis (OR: 3.37, 95% CI: 1.92-5.99), S. pneumoniae (OR: 3.89, 95% CI: 2.07-7.59), Group A streptococcus (OR 2.73, 95% CI 1.13-6.09) and E. coli (OR 2.7, 95% CI 1.02-6.71). Respiratory viruses were more common in febrile children than controls, but only influenza A (OR 0.24, 95% CI 0.11-0.46), influenza B (OR 0.12, 95% CI 0.02-0.37) and RSV (OR 0.16, 95% CI: 0.06-0.36) were less common in DB than DV cases. Of 16 blood viruses, enterovirus (OR 0.43, 95% CI 0.23-0.72) and EBV (OR 0.71, 95% CI 0.56-0.90) were detected less often in DB than DV cases. Combined local diagnostics and CMTs respectively detected blood viruses and respiratory viruses in 360 (56%) and 161 (25%) of DB cases, and virus detection ruled-out bacterial infection poorly, with predictive values of 0.64 and 0.68 respectively. INTERPRETATION Most febrile children cannot be conclusively defined as having bacterial or viral infection when molecular tests supplement conventional approaches. Viruses are detected in most patients with bacterial infections, and the clinical value of individual pathogen detection in determining treatment is low. New approaches are needed to help determine which febrile children require antibiotics. FUNDING EU Horizon 2020 grant 668303.
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Affiliation(s)
- Priyen Shah
- Section of Paediatric Infectious Disease, Department of Infectious Diseases, and Centre for Paediatrics and Child Health, Imperial College, London, UK
| | - Marie Voice
- Micropathology Ltd, University of Warwick, Coventry, UK
| | | | - Irene Rivero-Calle
- Translational Pediatrics and Infectious Diseases, Pediatrics Department, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain
- GENVIP Research Group, Instituto de Investigación Sanitaria de Santiago, Universidad de Santiago de Compostela, Galicia, Spain
| | - Sophie Morris
- Micropathology Ltd, University of Warwick, Coventry, UK
| | - Ruud Nijman
- Section of Paediatric Infectious Disease, Department of Infectious Diseases, and Centre for Paediatrics and Child Health, Imperial College, London, UK
| | - Claire Broderick
- Section of Paediatric Infectious Disease, Department of Infectious Diseases, and Centre for Paediatrics and Child Health, Imperial College, London, UK
| | - Tisham De
- Section of Paediatric Infectious Disease, Department of Infectious Diseases, and Centre for Paediatrics and Child Health, Imperial College, London, UK
| | - Irini Eleftheriou
- 2nd Department of Pediatrics, National and Kapodistrian University of Athens, “P. and A. Kyriakou” Children's Hospital, Thivon and Levadias, Goudi, Athens, Greece
| | - Rachel Galassini
- Section of Paediatric Infectious Disease, Department of Infectious Diseases, and Centre for Paediatrics and Child Health, Imperial College, London, UK
| | - Aakash Khanijau
- Department of Clinical Infection, Microbiology and Immunology, University of Liverpool Institute of Infection, Veterinary and Ecological Sciences, Liverpool, UK
| | - Laura Kolberg
- Division Paediatric Infectious Diseases, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Mojca Kolnik
- Division of Pediatrics and Department of Infectious Diseases, University Medical Centre Ljubljana, Slovenia
| | | | - Manfred G. Sagmeister
- Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Nina A. Schweintzger
- Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Fatou Secka
- Medical Research Council Unit The Gambia at LSHTM, Fajara, The Gambia
| | - Clare Thakker
- Section of Paediatric Infectious Disease, Department of Infectious Diseases, and Centre for Paediatrics and Child Health, Imperial College, London, UK
| | - Fabian van der Velden
- Great North Children's Hospital, Paediatric Immunology, Infectious Diseases & Allergy, Newcastle Upon Tyne Hospitals NHS Foundation Trust, UK
| | - Clementien Vermont
- Department of Paediatric Infectious Diseases & Immunology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Katarina Vincek
- Division of Pediatrics and Department of Infectious Diseases, University Medical Centre Ljubljana, Slovenia
| | - Philipp K.A. Agyeman
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Aubrey J. Cunnington
- Section of Paediatric Infectious Disease, Department of Infectious Diseases, and Centre for Paediatrics and Child Health, Imperial College, London, UK
| | - Ronald De Groot
- Radboud Center for Infectious Diseases, Radboudumc, Nijmegen, the Netherlands and Section Pediatric Infectious Diseases, Laboratory of Medical Immunology, Radboud Institute for Molecular Life Sciences, the Netherlands
| | - Marieke Emonts
- Great North Children's Hospital, Paediatric Immunology, Infectious Diseases & Allergy, Newcastle Upon Tyne Hospitals NHS Foundation Trust, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Katy Fidler
- Royal Alexandra Children's Hospital, Brighton, UK
| | - Taco W. Kuijpers
- Department of Pediatric Immunology, Rheumatology and Infectious Diseases, Amsterdam University Medical Center (AUMC), University of Amsterdam, Amsterdam, the Netherlands
- Sanquin Research Institute, & Landsteiner Laboratory at the AMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Karen Brengel-Pesce
- Open Innovation & Partnerships (OIP), bioMérieux S.A., Marcy l'Etoile, France
| | - Francois Mallet
- Open Innovation & Partnerships (OIP), bioMérieux S.A., Marcy l'Etoile, France
| | - Henriette Moll
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Stéphane Paulus
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Marko Pokorn
- Division of Pediatrics and Department of Infectious Diseases, University Medical Centre Ljubljana, Slovenia
- Department of Pediatrics, Faculty of Medicine, University of Ljubljana, Slovenia
| | - Andrew Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Luregn J. Schlapbach
- Department of Intensive Care and Neonatology, Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Ching-Fen Shen
- Department of Paediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Maria Tsolia
- 2nd Department of Pediatrics, National and Kapodistrian University of Athens, “P. and A. Kyriakou” Children's Hospital, Thivon and Levadias, Goudi, Athens, Greece
| | - Effua Usuf
- Medical Research Council Unit The Gambia at LSHTM, Fajara, The Gambia
| | - Michiel van der Flier
- Radboud Center for Infectious Diseases, Radboudumc, Nijmegen, the Netherlands and Section Pediatric Infectious Diseases, Laboratory of Medical Immunology, Radboud Institute for Molecular Life Sciences, the Netherlands
- Pediatric Infectious Diseases and Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ulrich von Both
- Division Paediatric Infectious Diseases, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
- German Center for Infection Research (DZIF), Partner Site Munich, Munich, Germany
| | - Shunmay Yeung
- Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, UK
| | - Dace Zavadska
- Children's Clinical University Hospital, Riga, Latvia
- Riga Stradins University, Riga, Latvia
| | - Werner Zenz
- Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Victoria Wright
- Section of Paediatric Infectious Disease, Department of Infectious Diseases, and Centre for Paediatrics and Child Health, Imperial College, London, UK
| | - Enitan D. Carrol
- Department of Clinical Infection, Microbiology and Immunology, University of Liverpool Institute of Infection, Veterinary and Ecological Sciences, Liverpool, UK
- Department of Infectious Diseases, Alder Hey Children's Hospital, Eaton Road, Liverpool, UK
| | - Myrsini Kaforou
- Section of Paediatric Infectious Disease, Department of Infectious Diseases, and Centre for Paediatrics and Child Health, Imperial College, London, UK
| | - Federico Martinon-Torres
- Translational Pediatrics and Infectious Diseases, Pediatrics Department, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain
- GENVIP Research Group, Instituto de Investigación Sanitaria de Santiago, Universidad de Santiago de Compostela, Galicia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Colin Fink
- Micropathology Ltd, University of Warwick, Coventry, UK
| | - Michael Levin
- Section of Paediatric Infectious Disease, Department of Infectious Diseases, and Centre for Paediatrics and Child Health, Imperial College, London, UK
| | - Jethro Herberg
- Section of Paediatric Infectious Disease, Department of Infectious Diseases, and Centre for Paediatrics and Child Health, Imperial College, London, UK
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Craig S, Delardes B, Nehme Z, Wilson C, Dalziel S, Nixon GM, Powell C, Graudins A, Babl FE. Acute paediatric asthma treatment in the prehospital setting: a retrospective observational study. BMJ Open 2023; 13:e073029. [PMID: 37349099 PMCID: PMC10314617 DOI: 10.1136/bmjopen-2023-073029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 06/06/2023] [Indexed: 06/24/2023] Open
Abstract
OBJECTIVES To describe the incidence of and patterns of 'escalated care' (care in addition to standard treatment with systemic corticosteroids and inhaled bronchodilators) for children receiving prehospital treatment for asthma. DESIGN Retrospective observational study. SETTING State-wide ambulance service data (Ambulance Victoria in Victoria, Australia, population 6.5 million) PARTICIPANTS: Children aged 1-17 years and given a final diagnosis of asthma by the treating paramedics and/or treated with inhaled bronchodilators from 1 July 2019 to 30 June 2020. PRIMARY AND SECONDARY OUTCOME MEASURES We classified 'escalation of care' as parenteral administration of epinephrine, or provision of respiratory support. We compared clinical, demographic and treatments administered between those receiving and not receiving escalation of care. RESULTS Paramedics attended 1572 children with acute exacerbations of asthma during the 1 year study period. Of these, 22 (1.4%) had escalated care, all receiving parenteral epinephrine. Patients with escalated care were more likely to be older, had previously required hospital admission for asthma and had severe respiratory distress at initial assessment.Of 1307 children with respiratory status data available, at arrival to hospital, the respiratory status of children had improved overall (normal/mild respiratory distress at initial assessment 847 (64.8%), normal/mild respiratory distress at hospital arrival 1142 (87.4%), p<0.0001). CONCLUSIONS Most children with acute exacerbations of asthma did not receive escalated therapy during their pre-hospital treatment from ambulance paramedics. Most patients were treated with inhaled bronchodilators only and clinically improved by the time they arrived in hospital.
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Affiliation(s)
- Simon Craig
- Paediatric Emergency Department, Monash Medical Centre Clayton, Clayton, Victoria, Australia
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - Belinda Delardes
- Ambulance Victoria, Doncaster, Victoria, Australia
- Department of Paramedicine, Monash University, Frankston, Victoria, Australia
| | - Ziad Nehme
- Research and Evaluation, Ambulance Victoria, Blackburn North, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Catherine Wilson
- Emergency Medicine Research Group, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
- Research Group, PREDICT Network, Melbourne, Victoria, Australia
| | - Stuart Dalziel
- Emergency Department, Starship Children's Health, Auckland, New Zealand
- Paediatrics and Surgery, The University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
| | - Gillian M Nixon
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
- Respiratory Medicine, Monash Children's Hospital, Clayton, Victoria, Australia
| | - Colin Powell
- Department of Emergency Medicine, Sidra Medical and Research Center, Doha, Qatar
- Cardiff School of Health Sciences, Cardiff, UK
| | - Andis Graudins
- Dandenong Emergency Department, Monash Health, Clayton, Victoria, Australia
- Department of Medicine, Monash University, Dandenong, Victoria, Australia
| | - Franz E Babl
- Emergency Medicine Research Group, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
- Emergency Department, Royal Childrens Hospital, Melbourne, Victoria, Australia
- Paediatrics, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Victoria, Australia
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9
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Fant C, Marin JR, Ramgopal S, Simon NJE, Richards R, Olsen CS, Alessandrini EA, Alpern ER. Updated Diagnosis Grouping System for Pediatric Emergency Department Visits. Pediatr Emerg Care 2023; 39:299-303. [PMID: 35881008 DOI: 10.1097/pec.0000000000002692] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES This study aims to update the Diagnosis Grouping System (DGS) for International Classification of Disease, Tenth Revision ( ICD-10 ) codes for ongoing use. The DGS was developed in 2010 using ICD-9 codes with 21 major groups and 27 subgroups to facilitate research on pediatric patients presenting to emergency departments and required updated classification for more recent ICD codes. METHODS All emergency department discharges available in the Pediatric Emergency Care Applied Research Network (PECARN) database for 2016 were included to identify ICD-10 codes. These codes were then mapped onto the DGS codes originally derived from ICD-9 . We used ICD-10 codes from the PECARN database from 2017 to 2019 to confirm validity. RESULTS The DGS was updated with ICD-10 codes based on 2016 PECARN data, and this updated DGS was successfully applied to 6,853,479 (97.3%) of all codes from 2017 to 2019. DISCUSSION Using ICD-10 codes from the PECARN Registry, the DGS was updated to reflect ICD-10 codes to facilitate ongoing research.
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Affiliation(s)
- Colleen Fant
- From the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Jennifer R Marin
- Department of Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Sriram Ramgopal
- From the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Norma-Jean E Simon
- From the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | | | | | | | - Elizabeth R Alpern
- From the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
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10
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Foppiano Palacios C, Lemmon E, Donohue KE, Sutherland M, Campbell J. Antibiotic Use and Respiratory Viral PCR Testing Among Pediatric Patients With Nosocomial Fever. Cureus 2023; 15:e37759. [PMID: 37214055 PMCID: PMC10193774 DOI: 10.7759/cureus.37759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2023] [Indexed: 05/23/2023] Open
Abstract
Objective Pediatric patients admitted to the hospital often develop fevers during their inpatient stay, and many children are empirically started on antibiotics. The utility of respiratory viral panel (RVP) polymerase chain reaction (PCR) testing in the evaluation of nosocomial fevers in admitted patients is unclear. We sought to evaluate whether RVP testing is associated with the use of antibiotics among inpatient pediatric patients. Patients and methods We conducted a retrospective chart review of children admitted from November 2015 to June 2018. We included all patients who developed fever 48 hours or more after admission to the hospital and who were not already receiving treatment for a presumed infection (on antibiotics). Results Among 671 patients, there were 833 inpatient febrile episodes. The mean age of children was 6.3 years old, and 57.1% were boys. Out of 99 RVP samples analyzed, 22 were positive (22.2%). Antibiotics were started in 27.8% while 33.5% of patients were already on antibiotics. On multivariate logistic regression, having an RVP sent was significantly associated with increased initiation of antibiotics (aOR 95% CI 1.18-14.18, p=0.03). Furthermore, those with a positive RVP had a shorter course of antibiotics compared to those with a negative RVP (mean 6.8 vs 11.3 days, p=0.019). Conclusions Children with positive RVP had decreased antibiotic exposure compared to those with negative RVP results. RVP testing may be used to promote antibiotic stewardship among hospitalized children.
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Affiliation(s)
- Carlo Foppiano Palacios
- Medicine, Cooper University Hospital, Camden, USA
- Internal Medicine and Pediatrics, University of Maryland Medical Center, Baltimore, USA
| | - Eric Lemmon
- Internal Medicine and Pediatrics, University of Maryland Medical Center, Baltimore, USA
| | - Katelyn E Donohue
- Internal Medicine and Pediatrics, University of Maryland Medical Center, Baltimore, USA
| | - Mark Sutherland
- Emergency Medicine and Critical Care, University of Maryland School of Medicine, Baltimore, USA
| | - James Campbell
- Infectious and Tropical Pediatrics, University of Maryland Medical Center, Baltimore, USA
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11
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Wittmann S, Jorgensen R, Oostenbrink R, Moll H, Herberg J, Levin M, Maconochie I, Nijman R. Heart rate and respiratory rate in predicting risk of serious bacterial infection in febrile children given antipyretics: prospective observational study. Eur J Pediatr 2023; 182:2205-2214. [PMID: 36867236 PMCID: PMC10175419 DOI: 10.1007/s00431-023-04884-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 02/09/2023] [Accepted: 02/16/2023] [Indexed: 03/04/2023]
Abstract
Clinical algorithms used in the assessment of febrile children in the Paediatric Emergency Departments are commonly based on threshold values for vital signs, which in children with fever are often outside the normal range. Our aim was to assess the diagnostic value of heart and respiratory rate for serious bacterial infection (SBI) in children after temperature lowering following administration of antipyretics. A prospective cohort of children presenting with fever between June 2014 and March 2015 at the Paediatric Emergency Department of a large teaching hospital in London, UK, was performed. Seven hundred forty children aged 1 month-16 years presenting with a fever and ≥ 1 warning signs of SBI given antipyretics were included. Tachycardia or tachypnoea were defined by different threshold values: (a) APLS threshold values, (b) age-specific and temperature-adjusted centiles charts and (c) relative difference in z-score. SBI was defined by a composite reference standard (cultures from a sterile site, microbiology and virology results, radiological abnormalities, expert panel). Persistent tachypnoea after body temperature lowering was an important predictor of SBI (OR 1.92, 95% CI 1.15, 3.30). This effect was only observed for pneumonia but not other SBIs. Threshold values for tachypnoea > 97th centile at repeat measurement achieved high specificity (0.95 (0.93, 0.96)) and positive likelihood ratios (LR + 3.25 (1.73, 6.11)) and may be useful for ruling in SBI, specifically pneumonia. Persistent tachycardia was not an independent predictor of SBI and had limited value as a diagnostic test. Conclusion: Among children given antipyretics, tachypnoea at repeat measurement had some value in predicting SBI and was useful to rule in pneumonia. The diagnostic value of tachycardia was poor. Overreliance on heart rate as a diagnostic feature following body temperature lowering may not be justified to facilitate safe discharge. What is Known: • Abnormal vital signs at triage have limited value as a diagnostic test to identify children with SBI, and fever alters the specificity of commonly used threshold values for vital signs. • The observed temperature response after antipyretics is not a clinically useful indicator to differentiate the cause of febrile illness. What is New: • Persistent tachycardia following reduction in body temperature was not associated with an increased risk of SBI and of poor value as a diagnostic test, whilst persistent tachypnoea may indicate the presence of pneumonia.
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Affiliation(s)
- Stefanie Wittmann
- Department of Paediatric Emergency Medicine, Division of Medicine, St. Mary's Hospital-Imperial College NHS Healthcare Trust, London, UK
| | - Rikke Jorgensen
- Department of Paediatric Emergency Medicine, Division of Medicine, St. Mary's Hospital-Imperial College NHS Healthcare Trust, London, UK
| | - Rianne Oostenbrink
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Henriette Moll
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Jethro Herberg
- Faculty of Medicine, Department of Infectious Diseases, Section of Paediatric Infectious Diseases, Imperial College London, London, UK.,Centre for Paediatrics and Child Health, Imperial College London, London, UK
| | - Mike Levin
- Faculty of Medicine, Department of Infectious Diseases, Section of Paediatric Infectious Diseases, Imperial College London, London, UK.,Centre for Paediatrics and Child Health, Imperial College London, London, UK
| | - Ian Maconochie
- Department of Paediatric Emergency Medicine, Division of Medicine, St. Mary's Hospital-Imperial College NHS Healthcare Trust, London, UK
| | - Ruud Nijman
- Department of Paediatric Emergency Medicine, Division of Medicine, St. Mary's Hospital-Imperial College NHS Healthcare Trust, London, UK. .,Faculty of Medicine, Department of Infectious Diseases, Section of Paediatric Infectious Diseases, Imperial College London, London, UK. .,Centre for Paediatrics and Child Health, Imperial College London, London, UK.
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12
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Tan E, Beck S, Haskell L, MacLean A, Rogan A, Than M, Venning B, White C, Yates K, McKinlay CJD, Dalziel SR. Paediatric fever management practices and antipyretic use among doctors and nurses in New Zealand emergency departments. Emerg Med Australas 2022; 34:943-953. [PMID: 35644989 PMCID: PMC9796118 DOI: 10.1111/1742-6723.14022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 04/29/2022] [Accepted: 05/04/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To assess (i) paediatric fever management practices among New Zealand ED doctors and nurses, including adherence to best practice guidelines; and (ii) the acceptability of a randomised controlled trial (RCT) of antipyretics for relief of discomfort in young children. METHODS A cross-sectional survey of doctors and nurses across 11 New Zealand EDs. The primary outcome of adherence to paediatric fever management best practice guidelines was assessed with clinical vignettes and defined as single antipyretic use for the relief of fever-related discomfort. RESULTS Out of 602 participants (243 doctors, 353 nurses and six unknown; response rate 47.5%), only 64 (10.6%, 95% confidence interval [CI] 8.3-13.4%) demonstrated adherence to best practice guidelines. In a febrile settled child with normal fluid intake, the percentage of participants that would use antipyretics doubled with abnormal vital signs (33.7% vs 72.9%, difference -39.2%, 95% CI -44.4% to -34.0%). Most participants would use antipyretics for reduced fluid intake (n = 494, 82.1%, 95% CI 78.8-85.0%) in a febrile settled child. Over half (n = 339, 57.1%, 95% CI 53.0-61.1%) would advise giving antipyretics to prevent febrile convulsions. Most (n = 467, 80.0%, 95% CI 76.5-83.1%) participants agreed that a RCT of antipyretics in febrile children <2 years of age with relief of discomfort as a primary outcome is needed. CONCLUSIONS Just over 10% of New Zealand ED doctors and nurses demonstrated adherence to paediatric fever management best practice guidelines. A RCT of antipyretics in febrile children <2 years of age specifically addressing relief of discomfort as a primary outcome is strongly supported.
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Affiliation(s)
- Eunicia Tan
- Department of Surgery, Faculty of Medical and Health SciencesThe University of AucklandAucklandNew Zealand,Emergency DepartmentMiddlemore HospitalAucklandNew Zealand
| | - Sierra Beck
- Emergency DepartmentDunedin HospitalDunedinNew Zealand,Department of MedicineUniversity of OtagoDunedinNew Zealand
| | - Libby Haskell
- Children's Emergency DepartmentStarship Children's HospitalAucklandNew Zealand,Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health SciencesThe University of AucklandAucklandNew Zealand
| | | | - Alice Rogan
- Emergency DepartmentWellington Regional HospitalWellingtonNew Zealand,Department of Surgery and AnaesthesiaUniversity of OtagoWellingtonNew Zealand
| | - Martin Than
- Emergency DepartmentChristchurch HospitalChristchurchNew Zealand
| | - Bridget Venning
- Emergency DepartmentMiddlemore HospitalAucklandNew Zealand,School of Nursing, Faculty of Medical and Health SciencesThe University of AucklandAucklandNew Zealand
| | | | - Kim Yates
- Emergency DepartmentNorth Shore HospitalAucklandNew Zealand,Emergency DepartmentWaitakere HospitalAucklandNew Zealand,Centre for Medical and Health Science Education, Faculty of Medical and Health SciencesThe University of AucklandAucklandNew Zealand
| | - Christopher JD McKinlay
- Liggins Institute, The University of AucklandAucklandNew Zealand,Kidz First Neonatal CareCounties Manukau HealthAucklandNew Zealand
| | - Stuart R Dalziel
- Department of Surgery, Faculty of Medical and Health SciencesThe University of AucklandAucklandNew Zealand,Children's Emergency DepartmentStarship Children's HospitalAucklandNew Zealand,Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health SciencesThe University of AucklandAucklandNew Zealand
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13
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Colagrossi L, Costabile V, Scutari R, Agosta M, Onori M, Mancinelli L, Lucignano B, Onetti Muda A, Del Baldo G, Mastronuzzi A, Locatelli F, Trua G, Montanari M, Alteri C, Bernaschi P, Perno CF. Evidence of pediatric sepsis caused by a drug resistant Lactococcus garvieae contaminated platelet concentrate. Emerg Microbes Infect 2022; 11:1325-1334. [PMID: 35475418 PMCID: PMC9132404 DOI: 10.1080/22221751.2022.2071174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Owing to an increasing number of infections in adults, Lactococcus (L.) garvieae has gained recognition as an emerging human pathogen, causing bacteraemia and septicaemia. In September 2020, four paediatric onco-hematologic patients received a platelet concentrate from the same adult donor at Bambino Gesù Children’s Hospital IRCCS, Rome. Three of four patients experienced L. garvieae sepsis one day after transfusion. The L. garvieae pediatric isolates and the donor’s platelet concentrates were retrospectively collected for whole-genome sequencing and shot-gun metagenomics, respectively (Illumina HiSeq). By de novo assembly of the L. garvieae genomes, we found that all three pediatric isolates shared a 99.9% identity and were characterized by 440 common SNPs. Plasmid pUC11C (conferring virulence properties) and the temperate prophage Plg-Tb25 were detected in all three strains. Core SNP genome-based maximum likelihood and Bayesian trees confirmed their phylogenetic common origin and revealed their relationship with L. garvieae strains affecting cows and humans (bootstrap values >100 and posterior probabilities = 1.00). Bacterial reads obtained by the donor’s platelet concentrate have been profiled with MetaPhlAn2 (v.2.7.5); among these, 29.9% belonged to Firmicutes, and 5.16% to Streptococcaceae (>97% identity with L. garvieae), confirming the presence of L. garvieae in the platelet concentrate transfusion. These data showed three episodes of sepsis for the first time due to a transfusion-associated transmission of L. garvieae in three pediatric hospitalized hematology patients. This highlights the importance to implement the screening of platelet components with new human-defined pathogens for ensuring the safety of blood supply, and more broadly, for the surveillance of emerging pathogens.
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Affiliation(s)
- Luna Colagrossi
- Department of Laboratories, Unit of Diagnostic Microbiology and Immunology and Multimodal Medicine Area, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Valentino Costabile
- Department of Laboratories, Unit of Diagnostic Microbiology and Immunology and Multimodal Medicine Area, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Rossana Scutari
- Department of Laboratories, Unit of Diagnostic Microbiology and Immunology and Multimodal Medicine Area, Bambino Gesù Children's Hospital IRCCS, Rome, Italy.,Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Marilena Agosta
- Department of Laboratories, Unit of Diagnostic Microbiology and Immunology and Multimodal Medicine Area, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Manuela Onori
- Department of Laboratories, Unit of Diagnostic Microbiology and Immunology and Multimodal Medicine Area, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Livia Mancinelli
- Department of Laboratories, Unit of Diagnostic Microbiology and Immunology and Multimodal Medicine Area, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Barbara Lucignano
- Department of Laboratories, Unit of Diagnostic Microbiology and Immunology and Multimodal Medicine Area, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Andrea Onetti Muda
- Department of Laboratories, Unit of Diagnostic Microbiology and Immunology and Multimodal Medicine Area, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Giada Del Baldo
- Department of Pediatric Hematology/Oncology and Cellular and Gene Therapy, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Angela Mastronuzzi
- Department of Pediatric Hematology/Oncology and Cellular and Gene Therapy, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Franco Locatelli
- Department of Pediatric Hematology/Oncology and Cellular and Gene Therapy, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Guglielmo Trua
- Department of Transfusion Medicine, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Mauro Montanari
- Department of Transfusion Medicine, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Claudia Alteri
- Department of Laboratories, Unit of Diagnostic Microbiology and Immunology and Multimodal Medicine Area, Bambino Gesù Children's Hospital IRCCS, Rome, Italy.,Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Paola Bernaschi
- Department of Laboratories, Unit of Diagnostic Microbiology and Immunology and Multimodal Medicine Area, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Carlo Federico Perno
- Department of Laboratories, Unit of Diagnostic Microbiology and Immunology and Multimodal Medicine Area, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
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14
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Tan E, Haskell L, Beck S, MacLean A, Rogan A, Than M, Venning B, White C, Yates K, McKinlay CJD, Dalziel SR. Use of the Theoretical Domains Framework to explore factors influencing paediatric fever management practices and antipyretic use in New Zealand emergency departments. J Paediatr Child Health 2022; 58:1847-1854. [PMID: 35869746 PMCID: PMC9796887 DOI: 10.1111/jpc.16127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/09/2022] [Accepted: 07/06/2022] [Indexed: 01/07/2023]
Abstract
AIM To explore factors influencing fever management practices and antipyretic use among New Zealand Emergency Department (ED) doctors and nurses using the Theoretical Domains Framework (TDF). METHODS Cross-sectional survey of doctors and nurses across 11 New Zealand EDs. The questionnaire examined eight of 12 TDF domains, based on a generic questionnaire validated to assess TDF-based determinants of health-care professional behaviour. Relevant domains were identified by the frequency of beliefs; the presence of conflicting beliefs within a domain; and the likely strength of impact of a belief on paediatric fever management in the ED. RESULTS About 602 participants (243 doctors, 353 nurses and 6 unknown) completed the survey (response rate 47.5%). Over half (351/591, 59.6%, 95% confidence interval (CI) 55.5-63.5%) knew the content of clinical practice guidelines regarding antipyretic use in febrile children (TDF Domain Knowledge), or had been trained to ensure antipyretics are given to febrile children only if they appear distressed (347/592, 58.6%, 95% CI 54.5-62.6%) (Skills). Over 40% (246/590, 95% CI 37.7-45.8%) aim to reduce the fever before discharge (Goals). Most (444/591, 75.1%, 95% CI 71.4-78.6%) participants felt capable of explaining appropriate antipyretic use to parents/care givers (Beliefs about Capabilities). Only a minority (155/584, 26.5%, 95% CI 23.0-30.3%) thought that they can ensure antipyretics are given to febrile children only if they appear distressed when the ED is busy (Environmental Context and Resources). CONCLUSIONS Using the TDF, we identified factors influencing fever management practices and antipyretic use in the ED. These factors can guide the design of targeted, theory-informed knowledge translation strategies.
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Affiliation(s)
- Eunicia Tan
- Department of Surgery, Faculty of Medical and Health SciencesUniversity of AucklandAucklandNew Zealand,Emergency DepartmentMiddlemore HospitalAucklandNew Zealand
| | - Libby Haskell
- Children's Emergency DepartmentStarship Children's HospitalAucklandNew Zealand,Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health SciencesUniversity of AucklandAucklandNew Zealand
| | - Sierra Beck
- Emergency DepartmentDunedin HospitalDunedinNew Zealand,Department of MedicineUniversity of OtagoDunedinNew Zealand
| | | | - Alice Rogan
- Emergency DepartmentWellington Regional HospitalWellingtonNew Zealand,Department of Surgery and AnaesthesiaUniversity of OtagoWellingtonNew Zealand
| | - Martin Than
- Emergency DepartmentChristchurch HospitalChristchurchNew Zealand
| | - Bridget Venning
- Emergency DepartmentMiddlemore HospitalAucklandNew Zealand,School of Nursing, Faculty of Medical and Health SciencesUniversity of AucklandAucklandNew Zealand
| | | | - Kim Yates
- Emergency DepartmentsNorth Shore and Waitakere HospitalsAucklandNew Zealand,Centre for Medical and Health Science Education, Faculty of Medical & Health SciencesUniversity of AucklandAucklandNew Zealand
| | - Christopher JD McKinlay
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health SciencesUniversity of AucklandAucklandNew Zealand,Kidz First Neonatal CareCounties Manukau HealthAucklandNew Zealand
| | - Stuart R Dalziel
- Department of Surgery, Faculty of Medical and Health SciencesUniversity of AucklandAucklandNew Zealand,Children's Emergency DepartmentStarship Children's HospitalAucklandNew Zealand,Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health SciencesUniversity of AucklandAucklandNew Zealand
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15
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Wagh A, Pan S, Gordon S, Hellerova L, Ji Y, Park H, Tsai S. Pediatric health care use during the COVID‐19 pandemic: Lessons learned from the initial 2020 wave. J Am Coll Emerg Physicians Open 2022; 3:e12814. [PMID: 36172308 PMCID: PMC9467971 DOI: 10.1002/emp2.12814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 07/29/2022] [Accepted: 08/09/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Anju Wagh
- Department of Emergency MedicineColumbia University Irving Medical CenterNew YorkNew YorkUSA
| | - Sharon Pan
- Department of Emergency MedicineColumbia University Irving Medical CenterNew YorkNew YorkUSA
| | - Stephen Gordon
- Department of Emergency MedicineColumbia University Irving Medical CenterNew YorkNew YorkUSA
| | - Lenka Hellerova
- Department of Emergency MedicineColumbia University Irving Medical CenterNew YorkNew YorkUSA
| | - Yeqing Ji
- Mailman School of Public HealthColumbia University Irving Medical CenterNew YorkNew YorkUSA
| | - Henry Park
- Center of Education Research and EvaluationColumbia UniversityNew YorkNew YorkUSA
| | - Shiu‐Lin Tsai
- Department of Emergency MedicineColumbia University Irving Medical CenterNew YorkNew YorkUSA
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16
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Freire GC, Diong C, Gandhi S, Saunders N, Neuman MI, Freedman SB, Friedman JN, Cohen E. Variation in low-value radiograph use for children in the emergency department: a cross-sectional study of administrative databases. CMAJ Open 2022; 10:E889-E899. [PMID: 36220182 PMCID: PMC9578750 DOI: 10.9778/cmajo.20210140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Radiograph use contributes to low-value care for children in emergency departments (EDs), but little is known about systemic factors associated with their use. This study compares low-value radiograph use across ED settings by hospital type, pediatric volumes and physician specialty. METHODS This is a cross-sectional study of routinely collected administrative data. We included children (age 0-18 yr) discharged from EDs in Ontario, Canada, between 2010 and 2019 with diagnoses of bronchiolitis, asthma, abdominal pain and constipation. Multiple clinical practice guidelines recommend against routine radiograph use in these conditions. Logistic regression evaluated odds of low-value radiograph by ED setting (pediatric academic [referent], adult academic, community with or without pediatric consultation services), pediatric volume and physician specialty (pediatric emergency medicine [PEM, referent], emergency medicine [EM], family medicine with EM training, pediatrics, family medicine), adjusting for demographic, clinical and provider characteristics. We used generalized estimating equations to account for clustering by ED. RESULTS Of the total 9 862 787 eligible pediatric ED discharges in Ontario, 60 914 children had bronchiolitis, 141 921 asthma, 333 332 abdominal pain and 110 514 constipation; 26.0% received low-value radiographs. Compared with pediatric EDs and PEM physicians (referents), patients with bronchiolitis were most likely to have a chest radiograph in adult academic EDs (adjusted odds ratio [OR] 5.1 [95% confidence interval (CI) 4.6-5.6]) and by family physicians with EM training (adjusted OR 4.8 [95% CI 4.5-5.1]). Patients with asthma were more likely to have a chest radiograph in adult academic EDs (adjusted OR 3.0 [95% CI 2.8-3.2]) and by EM physicians (adjusted OR 2.8 [95% CI 2.6-3.0]). Patients with abdominal pain and constipation were more likely to have abdominal radiographs in community hospitals with pediatric consultation (adjusted OR 1.6 [95% CI 1.6-1.7] and 2.3 [95% CI 2.3-2.4], respectively) and by family physicians with EM training (adjusted OR 1.6 [95% CI 1.6-1.7] and 2.1 [95% CI 2.0-2.2], respectively). INTERPRETATION Over the decade-long study period, low-value radiograph use was frequent for children with 4 common conditions seen in Ontario EDs. Quality improvement initiatives aimed at reducing unnecessary radiographs in children should focus on EM physicians practising in EDs that primarily treat adult patients.
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Affiliation(s)
- Gabrielle C Freire
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Christina Diong
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Sima Gandhi
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Natasha Saunders
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Mark I Neuman
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Stephen B Freedman
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Jeremy N Friedman
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Eyal Cohen
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta.
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17
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Kratchman DM, Vaughn P, Silverman LB, Campbell KA, Lindberg DM, Anderst JD, Bachim AN, Berger RP, Hymel KP, Letson M, Melville JD, Wood JN. The CAPNET multi-center data set for child physical abuse: Rationale, methods and scope. CHILD ABUSE & NEGLECT 2022; 131:105653. [PMID: 35779985 PMCID: PMC9332134 DOI: 10.1016/j.chiabu.2022.105653] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/17/2022] [Accepted: 04/20/2022] [Indexed: 05/27/2023]
Abstract
BACKGROUND The pediatric subspecialty of Child Abuse Pediatrics (CAP) was certified by the American Board of Medical Subspecialties in 2006. Relative to its impact on pediatric health, CAP-focused research has been relatively under-funded. Multi-center networks related to CAP-focused research have made important advances, but have been limited in scope and duration. CAPNET is multi-center network whose mission is to support CAP-focused research. OBJECTIVE To describe the rationale, development, and scope of the CAPNET research network infrastructure, the CAPNET data registry and associated data resources. METHODS Based on existing priorities for CAP-focused research, we used consensus building and iterative testing to establish inclusion criteria, common data elements, data quality assurance, and data sharing processes for children with concerns of physical abuse. RESULTS We describe the rationale, methods and intended scope for the development of the CAPNET research network and data registry. CAPNET is currently abstracting data for children <10 years (120 months) old who undergo sub-specialty evaluation for physical abuse at 10 US pediatric centers (approximately 4000 evaluations/year total) using an online data capture form. Data domains include: demographics; visit timing and providers, medical/social history, presentation, examination findings, laboratory and radiographic testing, diagnoses, outcomes, and data for contact children. We describe the methods and criteria for collecting and validating data which are broadly available to CAP investigators. CONCLUSIONS CAPNET represents a new data resource for the CAP research community and will increase the quantity and quality of CAP-focused research.
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Affiliation(s)
- Devon M Kratchman
- Safe Place: The Center for Child Protection and Health, PolicyLab, Center for Pediatric Effectiveness and Division of General Pediatrics, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States
| | - Porcia Vaughn
- Department of Pediatrics, Division of Child Protection and Family Health, University of Utah, Salt Lake City, UT 84115, United States; The Center for Safe and Healthy Families, Primary Children's Hospital, Salt Lake City, UT 84115, United States
| | - Ligia Batista Silverman
- Department of Emergency Medicine, The Kempe Center for the Prevention & Treatment of Child Abuse & Neglect, The University of Colorado Anschutz Medical Campus, 12631 E. 17(th) Ave - C326, Aurora, CO, United States
| | - Kristine A Campbell
- Department of Pediatrics, Division of Child Protection and Family Health, University of Utah, Salt Lake City, UT 84115, United States; The Center for Safe and Healthy Families, Primary Children's Hospital, Salt Lake City, UT 84115, United States
| | - Daniel M Lindberg
- Department of Emergency Medicine, The Kempe Center for the Prevention & Treatment of Child Abuse & Neglect, The University of Colorado Anschutz Medical Campus, 12631 E. 17(th) Ave - C326, Aurora, CO, United States
| | - James D Anderst
- Children's Mercy Kansas City, University of Missouri Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO 64108, United States
| | - Angela N Bachim
- Division of Public Health Pediatrics, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, TX, United States
| | - Rachel P Berger
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Safar Center for Resuscitation Research, University of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA, 15224, United States
| | - Kent P Hymel
- Penn State College of Medicine, Hershey, PA, United States
| | - Megan Letson
- Nationwide Children's Hospital, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States
| | - John D Melville
- Division of Child Abuse Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - Joanne N Wood
- Safe Place: The Center for Child Protection and Health, PolicyLab, Center for Pediatric Effectiveness and Division of General Pediatrics, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States.
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18
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Personnic J, Auvin S, Titomanlio L, Dozières-Puyravel B. Investigations in children with seizures visiting a pediatric emergency department: A monocenter study. Eur J Paediatr Neurol 2022; 40:44-50. [PMID: 35933830 DOI: 10.1016/j.ejpn.2022.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 05/02/2022] [Accepted: 06/17/2022] [Indexed: 11/15/2022]
Abstract
AIM Neurological disorders, in particular seizure, are one of the reasons for admission in pediatric emergency departments (PED). We aimed to evaluate the frequency and the relevance of each investigation for seizure management in the PED. METHODS We conducted a one-year retrospective study. Based on predefined criteria, we evaluate the appropriateness of the investigations. Logical regression was used to study the risk factors for acute symptomatic seizure (ASS). RESULTS We identified 691 visits to the PED for an epileptic event over an annual volume of 80,320 visits. Seizures occurring in Children with epilepsy were the most frequent epileptic events seen in the PED (42%). Looking at the investigation performed in the PED, a blood electrolytes analysis was performed in 26%, neuroimaging in 9%, electroencephalography recording in 9% and LP in 5% of patients. ASSs represented 2.1% of the seizures and 0.6% of PED neurological visits. In the multivariate analysis, an initial abnormal neurological examination (OR, 20.92 [4.87; 89.81, p<0.0001) was the only risk factor that remained significantly associated with ASS. A seizure occurring in an epilepsy patient was significantly associated with an unprovoked seizure (OR, 0.12 [0.02; 0.57], p<0.008). INTERPRETATION All ASSs were associated with a positive or abnormal examination. Moreover, there is a significant proportion of investigations requested in cases of an epileptic event that did not lead to a diagnosis or modification of the management. Based on our methods, there seems to be an overuse of investigations for seizure in children with epilepsy.
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Affiliation(s)
- Johan Personnic
- APHP. Service de Neurologie Pédiatrique, Hôpital Robert-Debré, Paris, France; APHP, Service de Pédiatrique, Hôpital Ambroise-Paré, France; APHP. Service des urgences pédiatriques, Hôpital Robert-Debré, Paris, France
| | - Stéphane Auvin
- APHP. Service de Neurologie Pédiatrique, Hôpital Robert-Debré, Paris, France; Université de Paris, INSERM NeuroDiderot, Paris, France; Institut Universitaire de France (IUF), Paris, France
| | - Luigi Titomanlio
- Université de Paris, INSERM NeuroDiderot, Paris, France; APHP. Service des urgences pédiatriques, Hôpital Robert-Debré, Paris, France
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19
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Green RS, Sartori LF, Lee BE, Linn AR, Samuels MR, Florin TA, Aronson PL, Chamberlain JM, Michelson KA, Nigrovic LE. Prevalence and Management of Invasive Bacterial Infections in Febrile Infants Ages 2 to 6 Months. Ann Emerg Med 2022; 80:499-506. [DOI: 10.1016/j.annemergmed.2022.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 06/07/2022] [Accepted: 06/13/2022] [Indexed: 11/01/2022]
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20
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Barreiro-Parrado A, Lopez E, Gomez B, Lejarzegi A, Fernandez-Uria A, Benito J, Mintegi S. Rate of invasive bacterial infection in recently vaccinated young infants with fever without source. Arch Dis Child 2022; 107:archdischild-2022-324379. [PMID: 35896416 DOI: 10.1136/archdischild-2022-324379] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 07/15/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To compare the rates of invasive bacterial infection (IBI) (bacterial pathogen in blood or cerebrospinal fluid) and urinary tract infection (UTI) in febrile infants between 42 and 90 days of age who had and had not been vaccinated in the previous 48 hours. DESIGN Observational study; secondary analysis of a prospective registry-based cohort study. SETTING Paediatric emergency department. PATIENTS Infants 42-90 days of age with fever without source seen between 2010 and 2021. MAIN OUTCOME MEASURES Rates of IBI (bacterial pathogen in blood or cerebrospinal fluid) and UTI (urine culture obtained by an aseptic method yielding growth of ≥10 000 cfu/mL with associated leucocyturia). RESULTS We included 1522 infants, including 185 (12.2%) vaccinated in the previous 48 hours. Overall, 19 (1.25%) were diagnosed with an IBI and 282 (18.5%) with a UTI. No recently immunised infants were diagnosed with an IBI (vs 19, 1.4% of those not recently immunised, p=0.2). The UTI rate was higher in infants not recently immunised (20.1% vs 7.0%, p<0.01; OR: 3.3 (1.9-5.9)). CONCLUSIONS Although the rate of UTI in recently immunised infants 42-90 days old with fever without a source is lower than in those not recently immunised, recommending screening for UTI seems appropriate. If the lower rate of IBI among recently immunised well-appearing infants is confirmed, the recommendation to systematically perform blood tests in these infants should be reconsidered.
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Affiliation(s)
- Ana Barreiro-Parrado
- Pediatric Emergency Department, Hospital Universitario Cruces Urgencias de Pediatria, Barakaldo, Spain
| | - Eider Lopez
- Pediatric Emergency Department, Hospital Universitario Cruces Urgencias de Pediatria, Barakaldo, Spain
| | - Borja Gomez
- Pediatric Emergency Department, Hospital Universitario Cruces Urgencias de Pediatria, Barakaldo, Spain
- Department of Pediatrics, Universidad del Pais Vasco, Bilbao, Basque Country, Spain
| | - Ainara Lejarzegi
- Pediatric Emergency Department, Hospital Universitario Cruces Urgencias de Pediatria, Barakaldo, Spain
| | - Amaia Fernandez-Uria
- Pediatric Emergency Department, Hospital Universitario Cruces Urgencias de Pediatria, Barakaldo, Spain
| | - Javier Benito
- Department of Pediatrics, Universidad del Pais Vasco, Bilbao, Basque Country, Spain
| | - Santiago Mintegi
- Department of Pediatrics, Universidad del Pais Vasco, Bilbao, Basque Country, Spain
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21
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Farrell C, Hannon M, Monuteaux MC, Mannix R, Lee LK. Pediatric Fracture Epidemiology and US Emergency Department Resource Utilization. Pediatr Emerg Care 2022; 38:e1342-e1347. [PMID: 35686967 DOI: 10.1097/pec.0000000000002752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Fractures are common childhood injuries that result in emergency department (ED) visits. National trends in pediatric fracture epidemiology and resource utilization are not well described. Our objective is to analyze national trends in pediatric fracture epidemiology, ED disposition, and ED resource utilization from 2010 to 2015. METHODS This is an epidemiological study of fracture care in US EDs from 2010 to 2015 for children 0 to 18 years old using the Nationwide Emergency Department Sample. We calculated frequencies and national rates using weighted analyses and census data. We used the test for linear trend to analyze incidence, hospital admission, transfer, and procedural sedation over time. Multivariate logistic regression analyses identified encounter- and hospital-level predictors of transfer, admission, operative care, and use of procedural sedation. RESULTS During the study period, from 2010 to 2015, a total of 5,398,827 children received ED care for fractures. The pediatric fracture rate was 11.5 ED visits/1000 persons (95% confidence interval [CI], 10.6-12.5) and decreased over time. The admission rate for pediatric fracture patients was 5% and stable over time. The transfer rate increased from 3.3 to 4.1/100 fracture visits (linear trend: odds ratio, 1.06; 95% CI, 1.03-1.09). Utilization of procedural sedation increased from 1.5% to 2.9% of fracture visits (linear trend: odds ratio, 1.17; 95% CI, 1.09-1.25). Predictors associated with disposition and resource utilization include patient age, fracture location, insurance type, hospital type, and region. CONCLUSIONS The national incidence rate of pediatric fractures decreased slightly. Emergency department resource utilization increased over time. With high national volume, understanding pediatric fracture epidemiology and resource utilization is important to the health care system.
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22
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Pehlivanturk-Kizilkan M, Ozsezen B, Batu ED. Factors Affecting Nonurgent Pediatric Emergency Department Visits and Parental Emergency Overestimation. Pediatr Emerg Care 2022; 38:264-268. [PMID: 35507379 DOI: 10.1097/pec.0000000000002723] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Understanding the factors causing nonurgent visits to the pediatric emergency departments (PED) is essential for developing effective interventions. Sociodemographic factors might have a direct effect, or they might be associated with other potential causal factors such as access, perceived severity, and convenience. Therefore, we aimed to evaluate the factors that might have an effect on nonurgent PED visits and parental overestimation of emergency severity. METHODS Data of a total of 974 patients who have been administered to the PED of a district state hospital were collected with a cross-sectional, self-administered survey. Level 5 was accepted as nonurgent cases according to the Pediatric Canadian Triage and Acuity Scale. Parents' assessment of their child's emergency status was assessed along with the age and sex of the child, the number of children, presence of a chronic illness, presence of fever, admission time, parental age, education status and occupation, transportation method, and living distance to emergency department. RESULTS Sixty-eight percent of visits were nonurgent. Among these visits, 51.6% were perceived as urgent, and 11.5% as extremely urgent by the parents. We identified that infancy age group (P = 0.001), father's unemployment status (P = 0.038), presence of a chronic disease (P = 0.020), and a previous visit to the PED in the last week (P = 0.008) are associated with urgent visits. Having a fever (P = 0.002), younger mother (P = 0.046) and father age (P = 0.007), mother not having an income (P = 0.034), and father's lower level of education (P = 0.036) increased the likelihood of overestimating the emergency severity. CONCLUSIONS Nonurgent visits constitute most of the PED admissions. Several factors were found to be associated with nonurgent visits either by causing a direct effect or by indirectly impacting the perceived severity. Health literacy-based interventions targeting common symptoms like fever and especially younger parent groups might be beneficial in lowering the patient burden of PEDs.
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Affiliation(s)
| | | | - Ezgi Deniz Batu
- Division of Pediatric Rheumatology, Department of Pediatrics, Hacettepe University Medical School, Ankara, Turkey
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23
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Shenoi RP, Linakis JG, Bromberg JR, Casper TC, Richards R, Chun TH, Gonzalez VM, Mello MJ, Spirito A. Association of Physical Activity, Sports, and Screen Time With Adolescent Behaviors in Youth Who Visit the Pediatric Emergency Department. Clin Pediatr (Phila) 2022; 61:335-346. [PMID: 35152770 DOI: 10.1177/00099228221075094] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Moderate to vigorous physical activity (MVPA), sports, and reduced screen time are associated with favorable youth risk profiles. We evaluated the association of MVPA, sports, and screen time with adolescent behaviors among pediatric emergency department youth. Adolescents were assessed for alcohol/drug use, risky behavior, conduct disorder, and depressive mood. MVPA was activity for ≥5 days/week and ≥60 minutes/day. Increased screen time was ≥3 hours/day computer/TV use for non-schoolwork. Multivariable regression studied association between MVPA, sports, and increased screen time and outcomes adjusting for demographics and academic achievement. Older age and lower academic achievement were significantly associated with risky behaviors, conduct disorder, and depression. Youth who endorsed MVPA and sports participation had less depression (odds ratio [OR] = 0.76; confidence interval [CI] = 0.66-0.87). Increased screen time was associated with conduct disorder (OR = 1.6; CI = 1.3-2.1), depression (OR = 1.2; CI = 1.0-1.4), and drug use (OR = 1.8; CI = 1.1-2.8). In pediatric emergency department youth, MVPA and sports participation is associated with less depression. Increased screen time is associated with conduct disorders, depression, and drug use.
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Affiliation(s)
- Rohit P Shenoi
- Baylor College of Medicine, Houston, TX, USA
- Texas Children's Hospital, Houston, TX, USA
| | - James G Linakis
- Brown University, Providence, RI, USA
- Rhode Island Hospital, Providence, RI, USA
| | - Julie R Bromberg
- Brown University, Providence, RI, USA
- Rhode Island Hospital, Providence, RI, USA
| | | | | | - Thomas H Chun
- Brown University, Providence, RI, USA
- Rhode Island Hospital, Providence, RI, USA
| | - Victor M Gonzalez
- Baylor College of Medicine, Houston, TX, USA
- Texas Children's Hospital, Houston, TX, USA
| | - Michael J Mello
- Brown University, Providence, RI, USA
- Rhode Island Hospital, Providence, RI, USA
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24
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Could Ultrasound Be Used as a Triage Tool in Diagnosing Fractures in Children? A Literature Review. Healthcare (Basel) 2022; 10:healthcare10050823. [PMID: 35627960 PMCID: PMC9141044 DOI: 10.3390/healthcare10050823] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/19/2022] [Accepted: 04/27/2022] [Indexed: 12/10/2022] Open
Abstract
Fracture is one of the most frequent causes of emergency department visits in children, conventional radiography being the standard imaging tool used for following procedures and treatment. This imagistic method is irradiating and harmful, especially for children due to their high cell division rate. For this reason, we searched the literature to see if musculoskeletal ultrasound is a good alternative for diagnostic and follow-up regarding fractures in the pediatric population. After searching the databases using MeSH terms and manual filters, 24 articles that compare X-ray and ultrasound regarding their specificity and sensitivity in diagnosing fractures were included in this study. In the majority of the studied articles, the specificity and sensitivity of ultrasound are around 90–100%, and with high PPVs (positive predictive values) and NPVs (negative predictive values). Although it cannot replace conventional radiography, it is a great complementary tool in fracture diagnosis, having a sensitivity of nearly 100% when combined with clinical suspicion of fracture, compared with X-ray.
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25
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Raskas MD, Feuerstein-Mendik GJ, Gerlacher G, Cohen S, Henning S, Cramer JM, Sultan O, Iqbal SF. Epidemiology of 30,000 Pediatric Urgent Care Telemedicine Visits in the Era of COVID-19. Telemed J E Health 2022; 28:1404-1411. [PMID: 35172122 PMCID: PMC9587793 DOI: 10.1089/tmj.2021.0482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: To describe the epidemiology of patients accessing a pediatric urgent care telemedicine platform during the COVID-19 pandemic. Study Design: We conducted a cross-sectional study of the first 30,000 pediatric patients who accessed our pediatric urgent care telemedicine platform during the beginning of the COVID-19 pandemic. The study population came from 15 states and included the dates May 15 through September 16, 2020. We also described the groups of patients referred for in-person evaluation in urgent care or emergency department (ED) settings. Results: Mean patient age was 7.6 ± 5.4 years and 51% of patients were male. Twenty-one percent were publicly insured. More than 60% of patients sought care between 12 and 7 p.m. The most common reasons for seeking care were concerns for COVID-19 (50.5%) and fever (6.8%). Antibiotics were prescribed in 4.3% of visits. Children had an in-person visit to our urgent care offices on the same day in 9% of visits. Less than 1% of children were referred to the ED. Conclusions: In this large series of telemedicine visits during the COVID-19 pandemic, fewer than 10% required escalation to an in-person office visit and fewer than 1% required escalation to an ED.
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Affiliation(s)
- Mordechai D Raskas
- Division of Telemedicine, PM Pediatrics, Lake Success, New York, New York, USA.,Department of Pediatrics, Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Gabriel J Feuerstein-Mendik
- Division of Telemedicine, PM Pediatrics, Lake Success, New York, New York, USA.,Program in Public Health Studies, Krieger School of Arts and Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Gary Gerlacher
- Division of Telemedicine, PM Pediatrics, Lake Success, New York, New York, USA
| | - Sheryl Cohen
- Division of Telemedicine, PM Pediatrics, Lake Success, New York, New York, USA
| | - Shannon Henning
- Division of Telemedicine, PM Pediatrics, Lake Success, New York, New York, USA
| | - Jennifer M Cramer
- Division of Telemedicine, PM Pediatrics, Lake Success, New York, New York, USA
| | - Ora Sultan
- Division of Telemedicine, PM Pediatrics, Lake Success, New York, New York, USA
| | - Sabah F Iqbal
- Division of Telemedicine, PM Pediatrics, Lake Success, New York, New York, USA.,Department of Pediatrics, Georgetown University School of Medicine, Washington, District of Columbia, USA
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26
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Sojar S, Gjelsvik A, Tsao HS, Amanullah S. Do Unmet Health Needs Drive Pediatric Emergency Department Utilization?: A Population-Based Assessment. Pediatr Emerg Care 2022; 38:e569-e574. [PMID: 33635045 DOI: 10.1097/pec.0000000000002319] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Lack of access to basic health services is thought to increase emergency department (ED) utilization. This study assessed the relationship between unmet health care needs and pediatric ED utilization in the United States. METHODS The National Survey of Children's Health was used (2016-2017; n = 71,360). Parent/guardians reported number of ED visits and the presence of unmet health needs (medical, dental, mental health, vision, hearing, other) in the last 12 months. Associations were analyzed using multinomial logistic regression modeling and accounted for the weighting and complex survey design of the National Survey of Children's Health. RESULTS Children with 2 or more unmet health needs had 3.72 times (95% confidence interval, 2.25-6.16) risk of ≥2 ED visits when compared with those with 0 unmet health needs. This risk became nonsignificant when adjusted for race, ethnicity, age, insurance, having asthma, current medication status, health description, number of preventative health visits, and place to go for preventative health (aRR, 1.77; 95% confidence interval, 0.96-3.27). The adjusted association was also nonsignificant for specific types of unmet needs. Race, insurance status, age 0 to 3 years, current medication status, having asthma, ≥2 preventative visits, and poorer health were associated with ≥2 ED visits. CONCLUSIONS Unmet health needs were not found to be a significant driving force for ED utilization. Other factors were found to be more strongly associated with it. Future studies to understand the perception, motives, and complex interaction of various factors leading to ED use in high-risk populations may optimize care for these children.
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Myxovirus Resistance Protein A as a Marker of Viral Cause of Illness in Children Hospitalized with an Acute Infection. Microbiol Spectr 2022; 10:e0203121. [PMID: 35080443 PMCID: PMC8791186 DOI: 10.1128/spectrum.02031-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A biomarker for viral infection could improve the differentiation between viral and bacterial infections and reduce antibiotic overuse. We examined blood myxovirus resistance protein A (MxA) as a biomarker for viral infections in children with an acute infection. We recruited 251 children presenting with a clinical suspicion of serious bacterial infection, determined by need for a blood bacterial culture collection, and 14 children with suspected viral infection at two pediatric emergency departments. All children were aged between 4 weeks and 16 years. We classified cases according to the viral, bacterial, or other etiology of the final diagnosis. The ability of MxA to differentiate between viral and bacterial infections was assessed. The median blood MxA levels were 467 (interquartile range, 235 to 812) μg/L in 39 children with a viral infection, 469 (178 to 827) μg/L in 103 children with viral-bacterial coinfection, 119 (68 to 227) μg/L in 75 children with bacterial infection, and 150 (101 to 212) μg/L in 26 children with bacterial infection and coincidental virus finding (P < 0.001). In a receiver operating characteristics analysis, MxA cutoff level of 256 μg/L differentiated between children with viral and bacterial infections with an area under the curve of 0.81 (95% confidence interval [CI] = 0.73 to 0.90), a sensitivity of 74.4%, and a specificity of 80.0%. In conclusion, MxA protein showed moderate accuracy as a biomarker for symptomatic viral infections in children hospitalized with an acute infection. High prevalence of viral-bacterial coinfections supports the use of MxA in combination with biomarkers of bacterial infection. IMPORTANCE Due to the diagnostic uncertainty concerning the differentiation between viral and bacterial infections, children with viral infections are often treated with antibiotics, predisposing them to adverse effects and contributing to the emerging antibiotic resistance. Since currently available biomarkers only estimate the risk of bacterial infection, a biomarker for viral infection is needed in attempts of reducing antibiotic overuse. Blood MxA protein, which has broad antiviral activity and is rapidly induced in acute, symptomatic viral infections, is a potential biomarker for viral infection. In this diagnostic study of 265 children hospitalized because of an acute infection, blood MxA cutoff level of 256 μg/L discriminated between viral and bacterial infections with a sensitivity of 74% and specificity of 80%. MxA could improve the differential diagnostics of febrile children at the emergency department but, because of frequently detected viral-bacterial coinfections, a combination with biomarkers of bacterial infection may be needed.
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Gnanamanickam ES, Nguyen H, Armfield JM, Doidge JC, Brown DS, Preen DB, Segal L. Child maltreatment and emergency department visits: a longitudinal birth cohort study from infancy to early adulthood. CHILD ABUSE & NEGLECT 2022; 123:105397. [PMID: 34823123 DOI: 10.1016/j.chiabu.2021.105397] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 11/03/2021] [Accepted: 11/08/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Child maltreatment (CM) is a serious global public health issue, with documented impacts on health. OBJECTIVE To examine the association between different levels of CM concern, and Emergency Department (ED) visits from infancy to early adulthood. PARTICIPANTS AND SETTING Individuals born in Adelaide, South Australia from January 1986 to June 2017 (N = 443,754). METHODS Using linked administrative data, we examined frequency and adjusted rate ratios for all-cause and cause specific ED visits among individuals with varying levels of CM concern. RESULTS Cumulative mean ED visits to age 14.5 years were higher for individuals with any CM concern, ranging from 10.2 to 14.8, compared with 6.4 in persons with no recorded CM concern. Adjusted rate ratios for ED visits varied from 1.26 (95% CI: 1.23-1.30) to 1.54 (1.48-1.60) in children (birth to 12 years), 1.98 (CI: 1.92-2.04) to 4.34 (CI: 4.09-4.60) in adolescence and 2.22 (CI: 2.14-3.48) to 3.48 (3.27-3.72) in young adults, increasing with severity of maltreatment concerns. ED visits coded as self-harm or poisoning, injuries, substance use or mental illness were particularly high, with incidence rate ratios mostly 3 to 15 times for mental health/substance related visits and 1.5 to 3.2 for other accidents or injury for individuals with any CM concern versus none. CONCLUSIONS The high rate ratios for ED visits in children with CM concern, especially for self-harm, substance use and mental health during adolescence and adulthood highlights the enduring mental health needs of victims of child maltreatment, providing further impetus for prevention.
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Affiliation(s)
- Emmanuel S Gnanamanickam
- Australian Centre for Precision Health, University of South Australia, Adelaide, South Australia, Australia.
| | - Ha Nguyen
- Australian Centre for Precision Health, University of South Australia, Adelaide, South Australia, Australia; John Walsh Centre for Rehabilitation Research, Sydney Medical School Northern, University of Sydney, Sydney, New South Wales, Australia
| | - Jason M Armfield
- Australian Centre for Precision Health, University of South Australia, Adelaide, South Australia, Australia
| | - James C Doidge
- Australian Centre for Precision Health, University of South Australia, Adelaide, South Australia, Australia; Intensive Care National Audit and Research Centre, London, UK; UCL Great Ormond Institute of Child Health, University College London, London, UK
| | - Derek S Brown
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | - David B Preen
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Leonie Segal
- Australian Centre for Precision Health, University of South Australia, Adelaide, South Australia, Australia
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Zhou AZ, Green RS, Haines EJ, Vazquez MN, Tay ET, Tsung JW. Interobserver Agreement of Inferior Vena Cava Ultrasound Collapse Duration and Correlated Outcomes in Children With Dehydration. Pediatr Emerg Care 2022; 38:13-16. [PMID: 32530838 PMCID: PMC8746903 DOI: 10.1097/pec.0000000000002150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Dehydration is a common concern in children presenting to pediatric emergency departments and other acute care settings. Ultrasound (US) of the inferior vena cava (IVC) may be a fast, noninvasive tool to gauge volume status, but its utility is unclear. Our objectives were to determine the interobserver agreement of IVC collapse and collapse duration, then correlate IVC collapse with the outcome of intravenous (IV) versus oral (PO) rehydration. METHODS We conducted a prospective study by enrolling patients 0 to 21 years old with emesis requiring ondansetron or diarrhea requiring IV hydration. Clinical operators interpreted US examinations in real time to determine whether the IVC was collapsed. Two blinded reviewers interpreted the US videos to determine IVC collapse and collapse duration. Cohen's kappa(κ) was calculated for reviewer-reviewer and reviewer-operator agreement. Primary outcomes were PO versus IV rehydration, and admitted versus discharged. RESULTS One hundred twelve patients were enrolled, and 102 had complete data for analysis. The mean age was 7.2 years with 51% female. Twenty-nine patients received IV hydration. The reviewer-operator agreement for IVC collapse was κ = 0.57 (95% confidence interval [CI], 0.38-0.75) and interreviewer agreement was κ = 0.93 (95% CI, 0.83-1.0). The interreviewer agreement for collapse duration was κ = 0.66 (95% CI, 0.51-0.82). All patients with noncollapsed IVCs tolerated PO hydration. The likelihood of receiving IV hydration was correlated with the duration of IVC collapse (P = 0.034). CONCLUSIONS Based on a novel dynamic measure of IVC collapse duration, children with increasing duration of IVC collapse correlated positively with the need for IV rehydration. Noncollapsing IVCs on US were associated with successful PO rehydration without need for IV fluids or emergency department revisits.
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Affiliation(s)
| | | | - Elizabeth J. Haines
- Emergency Medicine, Icahn School of Medicine at Mount Sinai
- Department of Emergency Medicine, New York University Langone Health, New York, NY
| | | | - Ee T. Tay
- Emergency Medicine, Icahn School of Medicine at Mount Sinai
- Department of Emergency Medicine, New York University Langone Health, New York, NY
| | - James W. Tsung
- From the Departments of Pediatrics
- Emergency Medicine, Icahn School of Medicine at Mount Sinai
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Lipshaw MJ, Florin TA, Krueger S, Belsky MA, Epperson T, Crotty EJ, Lipscomb J, Jacobs J, Rattan MS, Ruddy RM, Shah SS, Ambroggio L. Factors Associated With Antibiotic Prescribing and Outcomes for Pediatric Pneumonia in the Emergency Department. Pediatr Emerg Care 2021; 37:e1033-e1038. [PMID: 31290801 PMCID: PMC6946906 DOI: 10.1097/pec.0000000000001892] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Chest radiographs (CXRs) are often performed in children with respiratory illness to inform the decision to prescribe antibiotics. Our objective was to determine the factors associated with clinicians' plans to treat with antibiotics prior to knowledge of CXR results and the associations between preradiograph plans with antibiotic prescription and return to medical care. METHODS Previously healthy children aged 3 months to 18 years with a CXR for suspected pneumonia were enrolled in a prospective cohort study in the emergency department. Our primary outcomes were antibiotic prescription or administration in the emergency department and medical care sought within 7 to 15 days after discharge. Inverse probability treatment weighting was used to limit bias due to treatment selection. Inverse probability treatment weighting was included in a logistic regression model estimating the association between the intention to give antibiotics and outcomes. RESULTS Providers planned to prescribe antibiotics prior to CXR in 68 children (34.9%). There was no difference in the presence of radiographic pneumonia between those with and without a plan for antibiotics. Children who had a plan for antibiotics were more likely to receive antibiotics than those without (odds ratio [OR], 6.39; 95% confidence interval [CI], 3.7-11.0). This association was stronger than the association between radiographic pneumonia and antibiotic receipt (OR, 3.49; 95% CI, 1.98-6.14). Children prescribed antibiotics were more likely to seek care after discharge than children who were not (OR, 1.85; 95% CI, 1.13-3.05). CONCLUSIONS Intention to prescribe antibiotics based on clinical impression was the strongest predictor of antibiotic prescription in our study. Prescribing antibiotics may lead to subsequent medical care after controlling for radiographic pneumonia.
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Affiliation(s)
- Matthew J Lipshaw
- From the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Todd A Florin
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Sara Krueger
- Department of Pediatrics, University of Cincinnati College of Medicine
| | - Michael A Belsky
- Department of Pediatrics, University of Cincinnati College of Medicine
| | - Thomas Epperson
- Department of Pediatrics, University of Cincinnati College of Medicine
| | | | | | | | | | | | | | - Lilliam Ambroggio
- Sections of Emergency Medicine and Hospital Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado, Denver, CO
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Lavingia R, Mondragon E, McFarlane-Johansson N, Shenoi RP. Improving Opioid Stewardship in Pediatric Emergency Medicine. Pediatrics 2021; 148:183393. [PMID: 34851415 DOI: 10.1542/peds.2020-039743] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Poor opioid stewardship contributes to opioid misuse and adverse health outcomes. We sought to decrease opioid prescriptions in children 0 to 18 years treated for pain after fractures and cutaneous abscess drainage from 13.5% to 8%. Our secondary aims were to reduce opioid prescriptions written for >3 days from 41% to 10%, eliminate codeine prescriptions, increase safe opioid storage and disposal discharge instructions from 0% to 70%, and enroll all emergency department (ED) physicians in the state prescription drug monitoring program. METHODS We implemented an intervention bundle on the basis of 4 key drivers at a pediatric ED: ED-wide education, changes in the electronic medical record, discharge resources, and process standardization. Two plan-do-study-act cycles were performed. Interventions included provider feedback on prescribing, safe opioid storage and disposal instructions, and streamlined electronic medical record functions. Run charts were used to analyze the effect of interventions on outcomes. Our balance measure was return ED or clinic visits for inadequate analgesia within 3 days. RESULTS During the intervention period, 249 of 3402 (7.3%) patients with fractures and cutaneous abscesses were prescribed opioids. The percentage of opioid prescriptions >3 days decreased from 41% to 13.2% (P < .0001), codeine prescription dropped from 1.1% to 0% (P = .09), opioid discharge instructions increased 0% to 100% (P < .0001), and all physicians enrolled in the prescription drug monitoring program. There was no change in return visits for uncontrolled analgesia compared with the baseline (P = .79). CONCLUSIONS A comprehensive opioid stewardship program can improve opioid prescribing practices of ED physicians and deliver information on safe storage and disposal of prescription opioids with a negligible effect on return visits for uncontrolled pain.
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Affiliation(s)
| | | | - Nina McFarlane-Johansson
- Section of Emergency Medicine, Department of Pediatrics.,Baylor College of Medicine, Houston, Texas.,Texas Children's Hospital, Houston, Texas
| | - Rohit P Shenoi
- Section of Emergency Medicine, Department of Pediatrics.,Baylor College of Medicine, Houston, Texas.,Texas Children's Hospital, Houston, Texas
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Berksoy E, Kanik A, Çiçek A, Bardak Ş, Elibol P, Demir G, Yilmaz N, Nalbant T, Gökalp G, Yilmaz Çiftdoğan D. Clinical and laboratory characteristics of children with SARS-CoV-2 infection. Pediatr Pulmonol 2021; 56:3674-3681. [PMID: 34516721 PMCID: PMC8661911 DOI: 10.1002/ppul.25654] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 08/20/2021] [Accepted: 08/25/2021] [Indexed: 01/08/2023]
Abstract
We describe the demographic, clinical, radiological, and laboratory findings of 422 children (0-18 year-of-age) suspected of having severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection admitted to a pediatric emergency department between March 23, and July 23, 2020. We compared the characteristics of SARS-CoV-2-positive patients to SARS-CoV-2-negative patients. SARS-CoV-2 infection was confirmed in 78 (18.4%). Fever (51.2%) and cough (43.5%) were the most commonly reported signs in the SARS-CoV-2-positive patients. Isolated rhinorrhea (7.2%) was reported only in the SARS-CoV-2-negative group (p = .0014). Patients with SARS-CoV-2 infection were classified according to severity, with the percentages of asymptomatic, mild, moderate, severe, and critical cases determined to be 29.5%, 56.4%, 12.9%, 1.2%, and 0%, respectively. Of the 422 children, 128 (30.3%) underwent nasopharyngeal polymerase chain reaction testing for other respiratory viral pathogens; 21 (16.4%) were infected with viral pathogens other than SARS-CoV-2. Only one patient (4.7%) with confirmed coronavirus disease 2019 (COVID-19) disease was coinfected with respiratory syncytial virus and rhinovirus. The results indicate lower median white blood cell, neutrophil, and lymphocyte counts, lower lactate dehydrogenase, d-dimer, and procalcitonin levels in the SARS-CoV-2-positive group (p ≤ .001). Our findings confirm that COVID-19 in children has a mild presentation. In our cohort, no patient with SARS-CoV-2 infection had isolated rhinorrhea.
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Affiliation(s)
- Emel Berksoy
- Pediatric Emergency Departmentİzmir Tepecik Education and Research HospitalİzmirTurkey
| | - Ali Kanik
- Department of Pediatrics, Faculty of Medicineİzmir Katip Çelebi ÜniversityİzmirTurkey
| | - Alper Çiçek
- Pediatric Emergency Departmentİzmir Tepecik Education and Research HospitalİzmirTurkey
| | - Şefika Bardak
- Pediatric Emergency Departmentİzmir Tepecik Education and Research HospitalİzmirTurkey
| | - Pelin Elibol
- Pediatric Emergency Departmentİzmir Tepecik Education and Research HospitalİzmirTurkey
| | - Gülşah Demir
- Pediatric Emergency Departmentİzmir Tepecik Education and Research HospitalİzmirTurkey
| | - Nisel Yilmaz
- Department of Microbiologyİzmir Tepecik Education and Research HospitalİzmirTurkey
| | - Tuğçe Nalbant
- Pediatric Emergency Departmentİzmir Tepecik Education and Research HospitalİzmirTurkey
| | - Gamze Gökalp
- Pediatric Emergency Departmentİzmir Tepecik Education and Research HospitalİzmirTurkey
| | - Dilek Yilmaz Çiftdoğan
- Pediatric Infection Department, Faculty of Medicineİzmir Katip Çelebi ÜniversityİzmirTurkey
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Gerald LB, Gerald JK, VanBuren JM, Lowe A, Guthrie CC, Klein EJ, Morrison A, Startup E, Denninghoff K. Randomized trial of the feasibility of ED-initiated school-based asthma medication supervision (ED-SAMS). Pilot Feasibility Stud 2021; 7:179. [PMID: 34579785 PMCID: PMC8474899 DOI: 10.1186/s40814-021-00913-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 09/07/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While using an inhaled corticosteroid (ICS) in the weeks after an ED visit reduces repeat visits, few children receive a needed prescription. Because a prescription may not be filled or used, dispensing ICS at discharge and supervising its use at school could overcome both barriers until follow-up care is established. To assess the feasibility of such an intervention, we conducted a pilot study among elementary-age school children with persistent asthma who were discharged from the ED following an asthma exacerbation. METHODS Eligible children were randomly assigned to ED-dispensing of ICS with home supervision or ED-dispensing of ICS with home and school supervision. The primary outcomes were ability to recruit and retain participants, ability to initiate school-supervised medication administration within 5 days of discharge, and participant satisfaction. RESULTS Despite identifying 437 potentially eligible children, only 13 (3%) were enrolled with 6 being randomized to the intervention group and 7 to the control group. Eleven (85%) randomized participants completed the 90-day interview (primary outcome) and 8 (62%) completed the 120-day interview (safety endpoint). Four (67%) intervention participants started their school regimen within 5 business days and 2 started within 6 business days. CONCLUSION While our pilot study did not meet its recruitment goal, it did achieve its primary purpose of assessing feasibility before undertaking a larger, more intensive study. Several major recruitment barriers need to be mitigated before EDs can successfully partner with schools to establish supervised ICS treatment. TRIAL REGISTRATION ClinicalTrials.gov , NCT03952286 . Registered 16 May 2019.
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Affiliation(s)
- Lynn B Gerald
- University of Arizona, Tucson, AZ, USA. .,Asthma and Airway Disease Research Center, 1501 N Campbell Avenue, Tucson, AZ, 85724, USA.
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Standardized Headache Therapy in the Pediatric Emergency Department Using Improvement Methodology. Pediatr Qual Saf 2021; 6:e443. [PMID: 34345756 PMCID: PMC8322484 DOI: 10.1097/pq9.0000000000000443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 02/16/2021] [Indexed: 11/25/2022] Open
Abstract
Supplemental Digital Content is available in the text. Introduction: Primary headache is a common cause of pediatric emergency department (PED) visits. Without published guidelines to direct treatment options, various strategies lacking evidence are often employed. This study aims to standardize primary headache treatment in the PED by promoting evidence-based therapies, reducing nonstandard abortive therapies, and introducing dihydroergotamine (DHE) into practice. Methods: A multidisciplinary team developed key drivers, created a clinical care algorithm, and updated electronic medical record order sets. Outcome measures included the percentage of patients receiving evidence-based therapies, nonstandard abortive therapies, DHE given after failed first-line therapies, and overall PED length of stay. Process measures included the percent of eligible patients with the order set usage and medications received within 90 minutes. Balancing measures included hospital admissions and returns to the PED within 72 hours. Annotated control charts depicted results over time. Results: We collected data from July 2017 to December 2019. The percent of patients receiving evidence-based therapies increased from 69% to 73%. The percent of patients receiving nonstandard abortive therapies decreased from 2.5% to 0.6%. The percent of patients receiving DHE after failed first-line therapies increased from 0% to 37.2%. No untoward effects on process or balancing measures occurred, with sustained improvement for 14 months. Conclusion: Standardization efforts for patients with primary headaches led to improved use of evidence-based therapies and reduced nonstandard abortive therapies. This methodology also led to improved DHE use for migraine headache resistant to first-line therapies. We accomplished these results without increasing length of stay, admission, or return visits.
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MacMahon D, Brabyn C, Dalziel SR, McKinlay CJ, Tan E. Fever phobia in caregivers presenting to New Zealand emergency departments. Emerg Med Australas 2021; 33:1074-1081. [PMID: 34142439 PMCID: PMC9291848 DOI: 10.1111/1742-6723.13804] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/01/2021] [Accepted: 05/08/2021] [Indexed: 12/04/2022]
Abstract
Objective To determine the prevalence of fever phobia among caregivers of children presenting to New Zealand EDs. Methods A cross‐sectional survey was administered to caregivers of children <5 years of age presenting to three New Zealand EDs. We defined fever phobia as caregivers having a high level of concern regarding fever or having incorrect beliefs regarding the consequences of fever. Results A total of 502 caregivers completed the survey. Fever phobia was present in 365 (74.3% [95% confidence interval, CI 70.3–78.0%]) respondents, with 242 (49.3% [95% CI 44.9–53.7%]) caregivers reporting a high level of concern regarding fever, and 288 (61.8% [95% CI 57.3–66.1%]) caregivers reporting at least one incorrect belief regarding the consequences of fever. Majority of caregivers (n = 383, 87.6% [95% CI 84.2–90.4%]) knew the correct dosing interval for paracetamol, compared to less than half of caregivers (n = 179, 42.5% [95% CI 37.9–47.3%]) for ibuprofen. Caregivers reported non‐evidence‐based fever management practices such as sponging, always giving paracetamol and/or ibuprofen for fever, and waking children from sleep to give antipyretics. Over one‐third of caregivers identified ED doctors (n = 195, 40.2% [95% CI 34.7–43.2%]) and ED nurses (n = 173, 35.7% [95% CI 31.5–40.0%]) as sources of information regarding fever management. A higher level of education was associated with fever phobia (odds ratio 1.68 [95% CI 1.04–2.72], P = 0.04). Conclusions Fever phobia is prevalent among caregivers of children presenting to New Zealand EDs. Opportunistic caregiver education in the ED in conjunction with public health strategies are needed to dispel undue fears and misconceptions about fever.
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Affiliation(s)
- Donagh MacMahon
- Emergency Department, Middlemore Hospital, Auckland, New Zealand
| | - Christine Brabyn
- Emergency Department, Waikato Hospital, Auckland, New Zealand.,Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand
| | - Stuart R Dalziel
- Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand.,Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.,Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Christopher Jd McKinlay
- Liggins Institute, The University of Auckland, Auckland, New Zealand.,Kidz First Neonatal Care, Counties Manukau Health, Auckland, New Zealand
| | - Eunicia Tan
- Emergency Department, Middlemore Hospital, Auckland, New Zealand.,Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
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Ramgopal S, Pelletier JH, Rakkar J, Horvat CM. Forecast modeling to identify changes in pediatric emergency department utilization during the COVID-19 pandemic. Am J Emerg Med 2021; 49:142-147. [PMID: 34111834 PMCID: PMC8555971 DOI: 10.1016/j.ajem.2021.05.047] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/17/2021] [Accepted: 05/17/2021] [Indexed: 11/23/2022] Open
Abstract
Objective To identify trends in pediatric emergency department (ED) utilization following the COVID-19 pandemic. Methods We performed a cross-sectional study from 37 geographically diverse US children's hospitals. We included ED encounters between January 1, 2010 and December 31, 2020, transformed into time-series data. We constructed ensemble forecasting models of the most common presenting diagnoses and the most common diagnoses leading to admission, using data from 2010 through 2019. We then compared the most common presenting diagnoses and the most common diagnoses leading to admission in 2020 to the forecasts. Results 29,787,815 encounters were included, of which 1,913,085 (6.4%) occurred during 2020. ED encounters during 2020 were lower compared to prior years, with a 65.1% decrease in April relative to 2010–2019. In forecasting models, encounters for depression and diabetic ketoacidosis remained within the 95% confidence interval [CI]; fever, bronchiolitis, hyperbilirubinemia, skin/subcutaneous infections and seizures occurred within the 80–95% CI during the portions of 2020, and all other diagnoses (abdominal pain, otitis media, asthma, pneumonia, trauma, upper respiratory tract infections, and urinary tract infections) occurred below the predicted 95% CI. Conclusion Pediatric ED utilization has remained low following the COVID-19 pandemic, and below forecasted utilization for most diagnoses. Nearly all conditions demonstrated substantial declines below forecasted rates from the prior decade and which persisted through the end of the year. Some declines in non-communicable diseases may represent unmet healthcare needs among children. Further study is warranted to understand the impact of policies aimed at curbing pandemic disease on children.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America.
| | - Jonathan H Pelletier
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States of America
| | - Jaskaran Rakkar
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States of America
| | - Christopher M Horvat
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States of America; Division of Health Informatics, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States of America
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Li E, Dewez JE, Luu Q, Emonts M, Maconochie I, Nijman R, Yeung S. Role of point-of-care tests in the management of febrile children: a qualitative study of hospital-based doctors and nurses in England. BMJ Open 2021; 11:e044510. [PMID: 33972339 PMCID: PMC8112413 DOI: 10.1136/bmjopen-2020-044510] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 03/30/2021] [Accepted: 03/30/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES The use of rapid point-of-care tests (POCTs) has been advocated for improving patient management and outcomes and for optimising antibiotic prescribing. However, few studies have explored healthcare workers' views about their use in febrile children. The aim of this study was to explore the perceptions of hospital-based doctors and nurses regarding the use of POCTs in England. STUDY DESIGN Qualitative in-depth interviews with purposively selected hospital doctors and nurses. Data were analysed thematically. SETTING Two university teaching hospitals in London and Newcastle. PARTICIPANTS 24 participants (paediatricians, emergency department doctors, trainee paediatricians and nurses). RESULTS There were diverse views about the use of POCTs in febrile children. The reported advantages included their ease of use and the rapid availability of results. They were seen to contribute to faster clinical decision-making; the targeting of antibiotic use; improvements in patient care, flow and monitoring; cohorting (ie, the physical clustering of hospitalised patients with the same infection to limit spread) and enhancing communication with parents. These advantages were less evident when the turnaround for results of laboratory tests was 1-2 hours. Factors such as clinical experience and specialty, as well as the availability of guidelines recommending POCT use, were also perceived as influential. However, in addition to their perceived inaccuracy, participants were concerned about POCTs not resolving diagnostic uncertainty or altering clinical management, leading to a commonly expressed preference for relying on clinical skills rather than test results solely. CONCLUSION In this study conducted at two university teaching hospitals in England, participants expressed mixed opinions about the utility of current POCTs in the management of febrile children. Understanding the current clinical decision-making process and the specific needs and preferences of clinicians in different settings will be critical in ensuring the optimal design and deployment of current and future tests.
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Affiliation(s)
- Edmond Li
- Clinical Research Department, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, UK
- Patient Safety Translational Research Centre, Institute of Global Health Innovation, Department of Surgery & Cancer, Imperial College, London, UK
| | - Juan Emmanuel Dewez
- Clinical Research Department, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, UK
| | - Queena Luu
- Clinical Research Department, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, UK
| | - Marieke Emonts
- Department of Paediatric Immunology, Infectious Diseases & Allergy, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Ian Maconochie
- Paediatric Emergency Department, St Mary's Hospital Imperial College Healthcare NHS Trust, London, UK
| | - Ruud Nijman
- Section of Paediatric Infectious Diseases, Faculty of Medicine, Imperial College London, London, UK
| | - Shunmay Yeung
- Clinical Research Department, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, UK
- Department of Paediatric Infectious Disease, St Mary's Hospital Imperial College Healthcare NHS Trust, London, UK
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Personnic J, Titomanlio L, Auvin S, Dozières-Puyravel B. Neurological disorders encountered in a pediatric emergency department. Eur J Paediatr Neurol 2021; 32:86-92. [PMID: 33862442 DOI: 10.1016/j.ejpn.2021.03.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 03/03/2021] [Accepted: 03/29/2021] [Indexed: 11/19/2022]
Abstract
AIM Neurological disorders are one of the reasons for admission in pediatric emergency departments (PEDs). We aimed to evaluate the frequency of neurological disorders seen in a large tertiary PED. METHODS We conducted a one-year retrospective study that included 1471 medical records. Inclusion was based on the main complaint recorded by nurses at triage. We also retrieved the final diagnoses and the investigations performed in the PED. RESULTS About 3.4% of the yearly admissions was based on a neurologic complaint on arrival. The final diagnosis was of a neurologic disorder in 1237 children, 2% of which were admitted to the pediatric intensive care unit. An opinion from a child neurologist was requested for 33% of the children. Seizures were the most frequent reason for admission, followed by headaches. A previous visit to the PED in the past six months was a frequent finding (40%), and about one third of the patients with a neurologic diagnosis (except headaches) was already being followed by a child neurologist. INTERPRETATION Neurological disorders are frequent in our PED and are mainly represented by seizures and headaches. Appropriate training in epileptology might be helpful for healthcare professional working in PEDs.
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Affiliation(s)
- Johan Personnic
- Pediatric Emergency Department, Assistance Publique des Hôpitaux de Paris, Robert Debré Hospital, Boulevard Serrurier, 75019, Paris, France
| | - Luigi Titomanlio
- Pediatric Emergency Department, Assistance Publique des Hôpitaux de Paris, Robert Debré Hospital, Boulevard Serrurier, 75019, Paris, France
| | - Stéphane Auvin
- Pediatric Emergency Department, Assistance Publique des Hôpitaux de Paris, Robert Debré Hospital, Boulevard Serrurier, 75019, Paris, France
| | - Blandine Dozières-Puyravel
- Pediatric Emergency Department, Assistance Publique des Hôpitaux de Paris, Robert Debré Hospital, Boulevard Serrurier, 75019, Paris, France.
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Gao HM, Ambroggio L, Shah SS, Ruddy RM, Florin TA. Predictive Value of Clinician "Gestalt" in Pediatric Community-Acquired Pneumonia. Pediatrics 2021; 147:peds.2020-041582. [PMID: 33903161 PMCID: PMC8086001 DOI: 10.1542/peds.2020-041582] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/13/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Validated prognostic tools for pediatric community-acquired pneumonia (CAP) do not exist. Thus, clinicians rely on "gestalt" in management decisions for children with CAP. We sought to determine the ability of clinician gestalt to predict severe outcomes. METHODS We performed a prospective cohort study of children 3 months to 18 years old presenting to a pediatric emergency department (ED) with lower respiratory infection and receiving a chest radiograph for suspected CAP from 2013 to 2017. Clinicians reported the probability that the patient would develop severe complications of CAP (defined as respiratory failure, empyema or effusion, lung abscess or necrosis, metastatic infection, sepsis or septic shock, or death). The primary outcome was development of severe complications. RESULTS Of 634 children, 37 (5.8%) developed severe complications. Of children developing severe complications after the ED visit, 62.1% were predicted as having <10% risk by the ED clinician. Sensitivity was >90% at the <1% predicted risk threshold, whereas specificity was >90% at the 10% risk threshold. Gestalt performance was poor in the low-intermediate predicted risk category (1%-10%). Clinicians had only fair ability to discriminate children developing complications from those who did not (area under the receiver operator characteristic curve 0.747), with worse performance from less experienced clinicians (area under the receiver operator characteristic curve 0.693). CONCLUSIONS Clinicians have only fair ability to discriminate children with CAP who develop severe complications from those who do not. Clinician gestalt performs best at very low or higher predicted risk thresholds, yet many children fall in the low-moderate predicted risk range in which clinician gestalt is limited. Evidence-based prognostic tools likely can improve on clinician gestalt, particularly when risk is low-moderate.
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Affiliation(s)
- Hans M. Gao
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Lilliam Ambroggio
- Sections of Emergency Medicine and Hospital Medicine, Department of Pediatrics, Children’s Hospital Colorado and University of Colorado, Aurora, Colorado
| | - Samir S. Shah
- Divisions of Hospital Medicine and Infectious Diseases and
| | - Richard M. Ruddy
- Emergency Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and College of Medicine, University of Cincinnati, Cincinnati, Ohio; and
| | - Todd A. Florin
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois;,Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
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Caroselli C, Raffaldi I, Norbedo S, Parri N, Poma F, Blaivas M, Zaccaria E, Dib G, Fiorentino R, Longo D, Biban P, Urbino AF. Accuracy of Point-of-Care Ultrasound in Detecting Fractures in Children: A Validation Study. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:68-75. [PMID: 33097313 DOI: 10.1016/j.ultrasmedbio.2020.09.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 09/08/2020] [Indexed: 06/11/2023]
Abstract
This study sought to compare point-of-care ultrasound (POCUS) and conventional X-rays for detecting fractures in children. This was a prospective, non-randomized, convenience-sample study conducted in five medical centers. It evaluated pediatric patients with trauma. POCUS and X-ray examination results were treated as dichotomous variables with fracture either present or absent. Descriptive statistics were calculated in addition to prevalence, sensitivity, specificity, positive predictive value and negative predictive value, including 95% confidence intervals (CIs). The Cohen κ coefficient was determined as a measurement of the level of agreement. A total of 554 examinations were performed with POCUS and X-ray. On physical examination, swelling, localized hematoma and functional limitation were found in 66.73%, 33.78% and 53.74% of participants, respectively. The most-studied areas were limbs and hands/feet (58.19% and 38.27%), whereas the thorax was less represented (3.54%). Sensitivity of POCUS was 91.67% (95% CI, 76.41-97.82%) for high-skill providers and 71.50 % (95% CI, 64.75-77.43%) for standard-skill providers. Specificity was 88.89% (95% CI, 73.00-96.34%) and 82.91% (95% CI, 77.82-87.06%) for high- and standard-skill providers, respectively. Positive predictive value was 89.19% (95% CI, 73.64-96.48%) and 75.90% (95% CI, 69.16-81.59%) for high- and standard-skill providers, respectively. Negative predictive value was 91.43% (95% CI, 75.81-97.76%) and 79.44% (95% CI, 74.21-83.87%) for high- and standard-skill providers, respectively. The Cohen κ coefficient showed very good agreement (0.81) for high-skill providers, but moderate agreement (0.54) for standard-skill providers. We noted good diagnostic accuracy of POCUS in evaluating fracture, with excellent sensitivity, specificity, and positive and negative predictive value for high-skill providers.
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Affiliation(s)
- Costantino Caroselli
- Acute Geriatric Unit, Geriatric Emergency Room and Aging Research Centre INRCA-IRCCS, Ancona, Italy.
| | - Irene Raffaldi
- Emergency Department, Regina Margherita Children Hospital, Turin, Italy
| | - Stefania Norbedo
- Emergency Department, Pediatric Hospital IRCCS Burlo Garofolo, Trieste, Italy
| | - Niccolò Parri
- Department of Emergency Medicine and Trauma Center, Meyer University Children's Hospital, Florence, Italy
| | - Francesca Poma
- Emergency Department, Regina Margherita Children Hospital, Turin, Italy
| | - Michael Blaivas
- Department of Emergency Medicine, St. Francis Hospital, Columbus, Georgia, USA; Department of Medicine, University of South Carolina School of Medicine, Columbia, South Carolina, USA
| | | | - Giovanni Dib
- Department of Orthopedics and Trauma Surgery, Borgo Trento Hospital, Verona, Italy
| | - Romano Fiorentino
- Emergency Department, Asola Hospital, ASST Carlo Poma, Mantua, Italy
| | | | - Paolo Biban
- Department of Pediatrics and Pediatric Intensive Care Unit, Borgo Trento, Verona, Italy
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Poonai N, Kumar K, Coriolano K, Thompson G, Brahmbhatt S, Dzongowski E, Stevens H, Gupta P, Miller M, Elsie S, Ashok D, Joubert G, Lim R, Bütter A, Ali S. Hyoscine butylbromide versus acetaminophen for nonspecific colicky abdominal pain in children: a randomized controlled trial. CMAJ 2020; 192:E1612-E1619. [PMID: 33257343 DOI: 10.1503/cmaj.201055] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Less than two-thirds of children with abdominal pain in the emergency department receive analgesia. We sought to determine whether hyoscine butylbromide was superior to acetaminophen for children with nonspecific colicky abdominal pain. METHODS We randomly allocated children aged 8-17 years with nonspecific colicky abdominal pain who presented to the pediatric emergency department of London Health Sciences Centre, London, Ontario to receive hyoscine butylbromide, 10 mg given orally, or acetaminophen, 15 mg/kg given orally (maximum 975 mg). We considered the minimal clinically important difference for the primary outcome (self-reported pain at 80 min) to be 13 mm on a 100 mm visual analogue scale. Secondary outcomes included administration of rescue analgesia, adverse effects and pain score less than 30 mm at 80 minutes. RESULTS A total of 236 participants (120 in the hyoscine butylbromide group and 116 in the acetaminophen group) were included in the trial. The mean visual analogue scale scores at 80 minutes were 29 mm (standard deviation [SD] 26 mm) and 30 mm (SD 29 mm) with hyoscine butylbromide and acetaminophen, respectively (adjusted difference 1, 95% confidence interval -7 to 7). Rescue analgesia was administered to 4 participants (3.3%) in the hyoscine butylbromide group and 1 participant (0.9%) in the acetaminophen groups (p = 0.2). We found no significant differences in rates of adverse effects between hyoscine butylbromide (32/116 [27.6%]) and acetaminophen (28/115 [24.3]) (p = 0.5); no serious adverse effects were observed. The proportion with a pain score less than 30 mm at 80 minutes was 66 (55.0%) with hyoscine butylbromide and 63 (54.3%) with acetaminophen (p = 0.9). INTERPRETATION Hyoscine butylbromide was not superior to acetaminophen in this setting. Both agents were associated with clinically important pain reduction, and either can be considered for children presenting to the emergency department with nonspecific colicky abdominal pain. Trial registration: Clinicaltrials.gov, no. NCT02582307.
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Affiliation(s)
- Naveen Poonai
- Division of Emergency Medicine (Poonai, Kumar, Coriolano, Brahmbhatt, Dzongowski, Stevens, Gupta, Miller, Elsie, Joubert, Lim), Department of Paediatrics, and Departments of Internal Medicine (Poonai, Elsie) and Epidemiology and Biostatistics (Poonai, Elsie), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller, Lim), London Health Sciences Centre, London, Ont.; Departments of Pediatrics (Thompson) and Emergency Medicine (Thompson), Cumming School of Medicine, and Alberta Children's Hospital Research Institute (Thompson), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ashok), Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University; Division of Paediatric Surgery (Bütter), Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine & Dentistry, and Women and Children's Health Research Institute (Ali), University of Alberta, Edmonton, Alta.
| | - Kriti Kumar
- Division of Emergency Medicine (Poonai, Kumar, Coriolano, Brahmbhatt, Dzongowski, Stevens, Gupta, Miller, Elsie, Joubert, Lim), Department of Paediatrics, and Departments of Internal Medicine (Poonai, Elsie) and Epidemiology and Biostatistics (Poonai, Elsie), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller, Lim), London Health Sciences Centre, London, Ont.; Departments of Pediatrics (Thompson) and Emergency Medicine (Thompson), Cumming School of Medicine, and Alberta Children's Hospital Research Institute (Thompson), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ashok), Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University; Division of Paediatric Surgery (Bütter), Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine & Dentistry, and Women and Children's Health Research Institute (Ali), University of Alberta, Edmonton, Alta
| | - Kamary Coriolano
- Division of Emergency Medicine (Poonai, Kumar, Coriolano, Brahmbhatt, Dzongowski, Stevens, Gupta, Miller, Elsie, Joubert, Lim), Department of Paediatrics, and Departments of Internal Medicine (Poonai, Elsie) and Epidemiology and Biostatistics (Poonai, Elsie), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller, Lim), London Health Sciences Centre, London, Ont.; Departments of Pediatrics (Thompson) and Emergency Medicine (Thompson), Cumming School of Medicine, and Alberta Children's Hospital Research Institute (Thompson), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ashok), Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University; Division of Paediatric Surgery (Bütter), Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine & Dentistry, and Women and Children's Health Research Institute (Ali), University of Alberta, Edmonton, Alta
| | - Graham Thompson
- Division of Emergency Medicine (Poonai, Kumar, Coriolano, Brahmbhatt, Dzongowski, Stevens, Gupta, Miller, Elsie, Joubert, Lim), Department of Paediatrics, and Departments of Internal Medicine (Poonai, Elsie) and Epidemiology and Biostatistics (Poonai, Elsie), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller, Lim), London Health Sciences Centre, London, Ont.; Departments of Pediatrics (Thompson) and Emergency Medicine (Thompson), Cumming School of Medicine, and Alberta Children's Hospital Research Institute (Thompson), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ashok), Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University; Division of Paediatric Surgery (Bütter), Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine & Dentistry, and Women and Children's Health Research Institute (Ali), University of Alberta, Edmonton, Alta
| | - Shaily Brahmbhatt
- Division of Emergency Medicine (Poonai, Kumar, Coriolano, Brahmbhatt, Dzongowski, Stevens, Gupta, Miller, Elsie, Joubert, Lim), Department of Paediatrics, and Departments of Internal Medicine (Poonai, Elsie) and Epidemiology and Biostatistics (Poonai, Elsie), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller, Lim), London Health Sciences Centre, London, Ont.; Departments of Pediatrics (Thompson) and Emergency Medicine (Thompson), Cumming School of Medicine, and Alberta Children's Hospital Research Institute (Thompson), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ashok), Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University; Division of Paediatric Surgery (Bütter), Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine & Dentistry, and Women and Children's Health Research Institute (Ali), University of Alberta, Edmonton, Alta
| | - Emily Dzongowski
- Division of Emergency Medicine (Poonai, Kumar, Coriolano, Brahmbhatt, Dzongowski, Stevens, Gupta, Miller, Elsie, Joubert, Lim), Department of Paediatrics, and Departments of Internal Medicine (Poonai, Elsie) and Epidemiology and Biostatistics (Poonai, Elsie), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller, Lim), London Health Sciences Centre, London, Ont.; Departments of Pediatrics (Thompson) and Emergency Medicine (Thompson), Cumming School of Medicine, and Alberta Children's Hospital Research Institute (Thompson), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ashok), Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University; Division of Paediatric Surgery (Bütter), Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine & Dentistry, and Women and Children's Health Research Institute (Ali), University of Alberta, Edmonton, Alta
| | - Holly Stevens
- Division of Emergency Medicine (Poonai, Kumar, Coriolano, Brahmbhatt, Dzongowski, Stevens, Gupta, Miller, Elsie, Joubert, Lim), Department of Paediatrics, and Departments of Internal Medicine (Poonai, Elsie) and Epidemiology and Biostatistics (Poonai, Elsie), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller, Lim), London Health Sciences Centre, London, Ont.; Departments of Pediatrics (Thompson) and Emergency Medicine (Thompson), Cumming School of Medicine, and Alberta Children's Hospital Research Institute (Thompson), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ashok), Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University; Division of Paediatric Surgery (Bütter), Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine & Dentistry, and Women and Children's Health Research Institute (Ali), University of Alberta, Edmonton, Alta
| | - Priti Gupta
- Division of Emergency Medicine (Poonai, Kumar, Coriolano, Brahmbhatt, Dzongowski, Stevens, Gupta, Miller, Elsie, Joubert, Lim), Department of Paediatrics, and Departments of Internal Medicine (Poonai, Elsie) and Epidemiology and Biostatistics (Poonai, Elsie), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller, Lim), London Health Sciences Centre, London, Ont.; Departments of Pediatrics (Thompson) and Emergency Medicine (Thompson), Cumming School of Medicine, and Alberta Children's Hospital Research Institute (Thompson), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ashok), Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University; Division of Paediatric Surgery (Bütter), Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine & Dentistry, and Women and Children's Health Research Institute (Ali), University of Alberta, Edmonton, Alta
| | - Michael Miller
- Division of Emergency Medicine (Poonai, Kumar, Coriolano, Brahmbhatt, Dzongowski, Stevens, Gupta, Miller, Elsie, Joubert, Lim), Department of Paediatrics, and Departments of Internal Medicine (Poonai, Elsie) and Epidemiology and Biostatistics (Poonai, Elsie), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller, Lim), London Health Sciences Centre, London, Ont.; Departments of Pediatrics (Thompson) and Emergency Medicine (Thompson), Cumming School of Medicine, and Alberta Children's Hospital Research Institute (Thompson), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ashok), Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University; Division of Paediatric Surgery (Bütter), Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine & Dentistry, and Women and Children's Health Research Institute (Ali), University of Alberta, Edmonton, Alta
| | - Sharlene Elsie
- Division of Emergency Medicine (Poonai, Kumar, Coriolano, Brahmbhatt, Dzongowski, Stevens, Gupta, Miller, Elsie, Joubert, Lim), Department of Paediatrics, and Departments of Internal Medicine (Poonai, Elsie) and Epidemiology and Biostatistics (Poonai, Elsie), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller, Lim), London Health Sciences Centre, London, Ont.; Departments of Pediatrics (Thompson) and Emergency Medicine (Thompson), Cumming School of Medicine, and Alberta Children's Hospital Research Institute (Thompson), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ashok), Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University; Division of Paediatric Surgery (Bütter), Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine & Dentistry, and Women and Children's Health Research Institute (Ali), University of Alberta, Edmonton, Alta
| | - Dhandapani Ashok
- Division of Emergency Medicine (Poonai, Kumar, Coriolano, Brahmbhatt, Dzongowski, Stevens, Gupta, Miller, Elsie, Joubert, Lim), Department of Paediatrics, and Departments of Internal Medicine (Poonai, Elsie) and Epidemiology and Biostatistics (Poonai, Elsie), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller, Lim), London Health Sciences Centre, London, Ont.; Departments of Pediatrics (Thompson) and Emergency Medicine (Thompson), Cumming School of Medicine, and Alberta Children's Hospital Research Institute (Thompson), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ashok), Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University; Division of Paediatric Surgery (Bütter), Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine & Dentistry, and Women and Children's Health Research Institute (Ali), University of Alberta, Edmonton, Alta
| | - Gary Joubert
- Division of Emergency Medicine (Poonai, Kumar, Coriolano, Brahmbhatt, Dzongowski, Stevens, Gupta, Miller, Elsie, Joubert, Lim), Department of Paediatrics, and Departments of Internal Medicine (Poonai, Elsie) and Epidemiology and Biostatistics (Poonai, Elsie), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller, Lim), London Health Sciences Centre, London, Ont.; Departments of Pediatrics (Thompson) and Emergency Medicine (Thompson), Cumming School of Medicine, and Alberta Children's Hospital Research Institute (Thompson), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ashok), Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University; Division of Paediatric Surgery (Bütter), Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine & Dentistry, and Women and Children's Health Research Institute (Ali), University of Alberta, Edmonton, Alta
| | - Rod Lim
- Division of Emergency Medicine (Poonai, Kumar, Coriolano, Brahmbhatt, Dzongowski, Stevens, Gupta, Miller, Elsie, Joubert, Lim), Department of Paediatrics, and Departments of Internal Medicine (Poonai, Elsie) and Epidemiology and Biostatistics (Poonai, Elsie), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller, Lim), London Health Sciences Centre, London, Ont.; Departments of Pediatrics (Thompson) and Emergency Medicine (Thompson), Cumming School of Medicine, and Alberta Children's Hospital Research Institute (Thompson), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ashok), Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University; Division of Paediatric Surgery (Bütter), Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine & Dentistry, and Women and Children's Health Research Institute (Ali), University of Alberta, Edmonton, Alta
| | - Andreana Bütter
- Division of Emergency Medicine (Poonai, Kumar, Coriolano, Brahmbhatt, Dzongowski, Stevens, Gupta, Miller, Elsie, Joubert, Lim), Department of Paediatrics, and Departments of Internal Medicine (Poonai, Elsie) and Epidemiology and Biostatistics (Poonai, Elsie), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller, Lim), London Health Sciences Centre, London, Ont.; Departments of Pediatrics (Thompson) and Emergency Medicine (Thompson), Cumming School of Medicine, and Alberta Children's Hospital Research Institute (Thompson), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ashok), Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University; Division of Paediatric Surgery (Bütter), Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine & Dentistry, and Women and Children's Health Research Institute (Ali), University of Alberta, Edmonton, Alta
| | - Samina Ali
- Division of Emergency Medicine (Poonai, Kumar, Coriolano, Brahmbhatt, Dzongowski, Stevens, Gupta, Miller, Elsie, Joubert, Lim), Department of Paediatrics, and Departments of Internal Medicine (Poonai, Elsie) and Epidemiology and Biostatistics (Poonai, Elsie), Schulich School of Medicine and Dentistry, Western University; Children's Health Research Institute (Poonai, Miller, Lim), London Health Sciences Centre, London, Ont.; Departments of Pediatrics (Thompson) and Emergency Medicine (Thompson), Cumming School of Medicine, and Alberta Children's Hospital Research Institute (Thompson), University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ashok), Department of Paediatrics, Schulich School of Medicine and Dentistry, Western University; Division of Paediatric Surgery (Bütter), Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ont.; Department of Pediatrics (Ali), Faculty of Medicine & Dentistry, and Women and Children's Health Research Institute (Ali), University of Alberta, Edmonton, Alta
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Cost Study of a Cluster Randomized Trial on a Clinical Decision Rule Guiding Antibiotic Treatment in Children With Suspected Lower Respiratory Tract Infections in the Emergency Department. Pediatr Infect Dis J 2020; 39:1026-1031. [PMID: 33075037 DOI: 10.1097/inf.0000000000002794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Children with fever and respiratory symptoms represent a large patient group at the emergency department (ED). A decision rule-based treatment strategy improved targeting of antibiotics in these children in a recent clinical trial. This study aims to evaluate the impact of the decision rule on healthcare and societal costs, and to describe costs of children with suspected lower respiratory tract infections (RTIs) in the ED in general. METHODS In a stepped-wedge, cluster randomized trial, we collected cost data of children 1 month to 5 years of age with fever and cough/dyspnea in 8 EDs in The Netherlands (2016-2018). We calculated medical costs and societal costs per patient, during usual care (n = 597), and when antibiotic prescription was guided by the decision rule (n = 402). We calculated cost-of-illness of this patient group and estimated their annual costs at national level. RESULTS The cost-of-illness of children under 5 years with suspected lower RTIs in the ED was on average &OV0556;2130 per patient. At population level this is &OV0556;15 million per year in The Netherlands (&OV0556;1.7 million/100,000 children under 5). Mean costs per patient in usual care (&OV0556;2300) were reduced to &OV0556;1870 in the intervention phase (P = 0.01). Main cost drivers were hospitalization and lost parental workdays. CONCLUSIONS Implementation of a decision rule-based treatment strategy in children with suspected lower RTI was cost-saving, due to a reduction in hospitalization and parental absenteeism. Given the high frequency of this disease in children, the decision rule has the potential to result in a considerable cost reduction at population level.
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Kharasch S, Duggan NM, Cohen AR, Shokoohi H. Lung Ultrasound in Children with Respiratory Tract Infections: Viral, Bacterial or COVID-19? A Narrative Review. Open Access Emerg Med 2020; 12:275-285. [PMID: 33116963 PMCID: PMC7569078 DOI: 10.2147/oaem.s238702] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 09/18/2020] [Indexed: 12/18/2022] Open
Abstract
Respiratory tract infections (RTIs) are common complaints among patients presenting to the pediatric emergency department. In the diagnostic assessment of children with RTIs, many patients ultimately undergo imaging studies for further evaluation. Point-of-care lung ultrasound (LUS) can be used safely and with a high degree of accuracy in differentiating etiologies of RTIs in pediatric patients. Ultrasonographical features such as an irregular pleural line, subpleural consolidations, focal and lobar consolidation and signs of interstitial involvement can be used to distinguish between several pathologies. This work offers a comprehensive overview of pediatric LUS in cases of the most common pediatric RTIs including bacterial and viral pneumonia, bronchiolitis, and COVID-19.
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Affiliation(s)
- Sigmund Kharasch
- Division of Pediatric Emergency Medicine, Division of Emergency Ultrasound, Department of Pediatrics, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Nicole M Duggan
- Harvard Affiliated Emergency Medicine Residency Program, Harvard Medical School, Boston, MA, USA
| | - Ari R Cohen
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Hamid Shokoohi
- Division of Emergency Ultrasound, Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
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Craig SS, Dalziel SR, Powell CV, Graudins A, Babl FE, Lunny C. Interventions for escalation of therapy for acute exacerbations of asthma in children: an overview of Cochrane Reviews. Cochrane Database Syst Rev 2020; 8:CD012977. [PMID: 32767571 PMCID: PMC8078579 DOI: 10.1002/14651858.cd012977.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Asthma is an illness that commonly affects adults and children, and it serves as a common reason for children to attend emergency departments. An asthma exacerbation is characterised by acute or subacute worsening of shortness of breath, cough, wheezing, and chest tightness and may be triggered by viral respiratory infection, poor compliance with usual medication, a change in the weather, or exposure to allergens or irritants. Most children with asthma have mild or moderate exacerbations and respond well to first-line therapy (inhaled short-acting beta-agonists and systemic corticosteroids). However, the best treatment for the small proportion of seriously ill children who do not respond to first-line therapy is not well understood. Currently, a large number of treatment options are available and there is wide variation in management. OBJECTIVES Main objective - To summarise Cochrane Reviews with or without meta-analyses of randomised controlled trials on the efficacy and safety of second-line treatment for children with acute exacerbations of asthma (i.e. after first-line treatments, titrated oxygen delivery, and administration of intermittent inhaled short-acting beta2-agonists and oral corticosteroids have been tried and have failed) Secondary objectives - To identify gaps in the current evidence base that will inform recommendations for future research and subsequent Cochrane Reviews - To categorise information on reported outcome measures used in trials of escalation of treatment for acute exacerbations of asthma in children, and to make recommendations for development and reporting of standard outcomes in future trials and reviews - To identify relevant randomised controlled trials that have been published since the date of publication of each included review METHODS: We included Cochrane Reviews assessing interventions for children with acute exacerbations of asthma. We searched the Cochrane Database of Systematic Reviews. The search is current to 28 December 2019. We also identified trials that were potentially eligible for, but were not currently included in, published reviews. We assessed the quality of included reviews using the ROBIS criteria (tool used to assess risk of bias in systematic reviews). We presented an evidence synthesis of data from reviews alongside an evidence map of clinical trials. Primary outcomes were length of stay, hospital admission, intensive care unit admission, and adverse effects. We summarised all findings in the text and reported data for each outcome in 'Additional tables'. MAIN RESULTS We identified 17 potentially eligible Cochrane Reviews but extracted data from, and rated the quality of, 13 reviews that reported results for children alone. We excluded four reviews as one did not include any randomised controlled trials (RCTs), one did not provide subgroup data for children, and the last two had been updated and replaced by subsequent reviews. The 13 reviews included 67 trials; the number of trials in each review ranged from a single trial up to 27 trials. The vast majority of comparisons included between one and three trials, involving fewer than 100 participants. The total number of participants included in reviews ranged from 40 to 2630. All studies included children; 16 (24%) included children younger than two years of age. Most of the reviews reported search dates older than four years. We have summarised the published evidence as outlined in Cochrane Reviews. Key findings, in terms of our primary outcomes, are that (1) intravenous magnesium sulfate was the only intervention shown to reduce hospital length of stay (high-certainty evidence); (2) no evidence suggested that any intervention reduced the risk of intensive care admission (low- to very low-certainty evidence); (3) the risk of hospital admission was reduced by the addition of inhaled anticholinergic agents to inhaled beta2-agonists (moderate-certainty evidence), the use of intravenous magnesium sulfate (high-certainty evidence), and the use of inhaled heliox (low-certainty evidence); (4) the addition of inhaled magnesium sulfate to usual bronchodilator therapy appears to reduce serious adverse events during hospital admission (moderate-certainty evidence); (5) aminophylline increased vomiting compared to placebo (moderate-certainty evidence) and increased nausea and nausea/vomiting compared to intravenous beta2-agonists (low-certainty evidence); and (6) the addition of anticholinergic therapy to short-acting beta2-agonists appeared to reduce the risk of nausea (high-certainty evidence) and tremor (moderate-certainty evidence) but not vomiting (low-certainty evidence). We considered 4 of the 13 reviews to be at high risk of bias based on the ROBIS framework. In all cases, this was due to concerns regarding identification and selection of studies. The certainty of evidence varied widely (by review and also by outcome) and ranged from very low to high. AUTHORS' CONCLUSIONS This overview provides the most up-to-date evidence on interventions for escalation of therapy for acute exacerbations of asthma in children from Cochrane Reviews of randomised controlled trials. A vast majority of comparisons involved between one and three trials and fewer than 100 participants, making it difficult to assess the balance between benefits and potential harms. Due to the lack of comparative studies between various treatment options, we are unable to make firm practice recommendations. Intravenous magnesium sulfate appears to reduce both hospital length of stay and the risk of hospital admission. Hospital admission is also reduced with the addition of inhaled anticholinergic agents to inhaled beta2-agonists. However, further research is required to determine which patients are most likely to benefit from these therapies. Due to the relatively rare incidence of acute severe paediatric asthma, multi-centre research will be required to generate high-quality evidence. A number of existing Cochrane Reviews should be updated, and we recommend that a new review be conducted on the use of high-flow nasal oxygen therapy. Important priorities include development of an internationally agreed core outcome set for future trials in acute severe asthma exacerbations and determination of clinically important differences in these outcomes, which can then inform adequately powered future trials.
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Affiliation(s)
- Simon S Craig
- Department of Paediatrics, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia
- Emergency Research, Murdoch Children's Research Institute, Parkville, Australia
- Paediatric Emergency Department, Monash Medical Centre, Monash Emergency Service, Monash Health, Clayton, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, Australia
| | - Stuart R Dalziel
- Departments of Surgery and Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, Australia
- Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand
| | - Colin Ve Powell
- Department of Emergency Medicine, Sidra Medciine, Doha, Qatar
- School of Medicine, Cardiff University, Cardiff, UK
| | - Andis Graudins
- Department of Medicine, Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, Australia
- Monash Emergency Service, Monash Health, Dandenong Hospital, Dandenong, Australia
| | - Franz E Babl
- Emergency Research, Murdoch Children's Research Institute, Parkville, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, Australia
- Emergency Department, Royal Children's Hospital, Parkville, Australia
- Department of Paediatrics and Centre for Integrated Critical Care, University of Melbourne, Parkville, Australia
| | - Carole Lunny
- Cochrane Hypertension Group, Faculty of Medicine, University of British Columbia, Vancouver, Canada
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Jackson JM, Williams DM. Chasing Fevers: An Interactive Exercise for Pediatrics Residents on Triaging and Assessing Inpatients With Fever. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2020; 16:10907. [PMID: 32656328 PMCID: PMC7331960 DOI: 10.15766/mep_2374-8265.10907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 11/08/2019] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Pediatrics residents are frequently tasked with triaging fevers in pediatric inpatients. The variety of clinical scenarios in the inpatient setting-patients with a multitude of diseases and a spectrum of risk for invasive infection-makes this task challenging. To enhance our residents' training on this topic, we developed an activity providing explicit instruction on how to approach these patient scenarios. METHODS The 45-minute activity began with an interactive discussion on approaching pediatric inpatient fevers, followed by a case-based exercise where small groups were assigned one of six clinical scenarios involving inpatients with fever. Learners discovered new information about their patient by drawing paper slips out of a container. Each slip could take their patient's story in a different direction. Small groups discussed decision-making options for their assigned case at each step. Among the potential events were rapid response calls-acute issues requiring immediate assessment-in which learners competed for limited seats to determine who would respond to the call. The activity concluded with a discussion about treatment of inpatient fevers. RESULTS Respondents to the postevent evaluation rated the activity as highly engaging, effective in helping them achieve its learning objectives, highly relevant to their career, and effective in simulating real-life clinical decision-making situations. DISCUSSION This instructional technique offers a unique, engaging, case-based approach to teaching about inpatient fever management in which instructors facilitate and support learners' articulation of clinical reasoning. Future directions include using this technique for other common clinical problems and with other learner groups.
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Affiliation(s)
- Jennifer M. Jackson
- Associate Professor, Department of Pediatrics, Wake Forest School of Medicine
| | - Donna M. Williams
- Associate Professor, Department of Internal Medicine, Wake Forest School of Medicine
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Geanacopoulos AT, Porter JJ, Monuteaux MC, Lipsett SC, Neuman MI. Trends in Chest Radiographs for Pneumonia in Emergency Departments. Pediatrics 2020; 145:peds.2019-2816. [PMID: 32079719 DOI: 10.1542/peds.2019-2816] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES National guidelines recommend against routine use of chest radiography (CXR) for community-acquired pneumonia (CAP) diagnosis in the pediatric emergency department (ED). Given that CXR is often used to exclude the diagnosis of CAP, a reduction in CXR use may result in overdiagnosis of CAP. We sought to evaluate trends in CXR use and assess the association between CXR performance and CAP diagnosis among children discharged from pediatric EDs. METHODS Children 3 months to 18 years of age discharged from 30 US EDs with (1) CAP or (2) fever or respiratory illness between 2008 and 2018 were included. Temporal trends in CXR use and rates of CAP diagnoses among patients with fever or respiratory illness were assessed. Correlation between hospital-level CXR use and CAP diagnosis rates were evaluated by using Spearman's correlation weighted by hospital volume. RESULTS CXR usage decreased from 86.6% to 80.4% (P < .001) for patients with CAP and from 30.4% to 18.6% (P < .001) for children with fever or respiratory illness over the 10-year study period. CAP diagnosis rates also declined from 7.8% to 5.9% (P < .001). Hospital-level CXR use was correlated with pneumonia diagnosis rates (correlation coefficient 0.58; P < .001). CONCLUSIONS Over the past decade, there has been a decline in CXR use in the ED among children with pneumonia and respiratory illnesses, with a decrease in pneumonia diagnoses over the same time period. Future studies are needed to assess the role of CXR in the evaluation of children with possible pneumonia in the ED setting.
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Affiliation(s)
- Alexandra T Geanacopoulos
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - John J Porter
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; and.,Division of Emergency Medicine and
| | - Michael C Monuteaux
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts.,Division of Emergency Medicine and
| | - Susan C Lipsett
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts.,Division of Emergency Medicine and
| | - Mark I Neuman
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; and .,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts.,Division of Emergency Medicine and
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Craig S, Babl FE, Dalziel SR, Gray C, Powell C, Al Ansari K, Lyttle MD, Roland D, Benito J, Velasco R, Hoeffe J, Moldovan D, Thompson G, Schuh S, Zorc JJ, Kwok M, Mahajan P, Johnson MD, Sapien R, Khanna K, Rino P, Prego J, Yock A, Fernandes RM, Santhanam I, Cheema B, Ong G, Chong SL, Graudins A. Acute severe paediatric asthma: study protocol for the development of a core outcome set, a Pediatric Emergency Reserarch Networks (PERN) study. Trials 2020; 21:72. [PMID: 31931862 PMCID: PMC6956506 DOI: 10.1186/s13063-019-3785-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 10/09/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Acute severe childhood asthma is an infrequent, but potentially life-threatening emergency condition. There is a wide range of different approaches to this condition, with very little supporting evidence, leading to significant variation in practice. To improve knowledge in this area, there must first be consensus on how to conduct clinical trials, so that valid comparisons can be made between future studies. We have formed an international working group comprising paediatricians and emergency physicians from North America, Europe, Asia, the Middle East, Africa, South America, Central America, Australasia and the United Kingdom. METHODS/DESIGN A 5-stage approach will be used: (1) a comprehensive list of outcomes relevant to stakeholders will be compiled through systematic reviews and qualitative interviews with patients, families, and clinicians; (2) Delphi methodology will be applied to reduce the comprehensive list to a core outcome set; (3) we will review current clinical practice guidelines, existing clinical trials, and literature on bedside assessment of asthma severity. We will then identify practice differences in tne clinical assessment of asthma severity, and determine whether further prospective work is needed to achieve agreement on inclusion criteria for clinical trials in acute paediatric asthma in the emergency department (ED) setting; (4) a retrospective chart review in Australia and New Zealand will identify the incidence of serious clinical complications such as intubation, ICU admission, and death in children hospitalized with acute severe asthma. Understanding the incidence of such outcomes will allow us to understand how common (and therefore how feasible) particular outcomes are in asthma in the ED setting; and finally (5) a meeting of the Pediatric Emergency Research Networks (PERN) asthma working group will be held, with invitation of other clinicians interested in acute asthma research, and patients/families. The group will be asked to achieve consensus on a core set of outcomes and to make recommendations for the conduct of clinical trials in acute severe asthma. If this is not possible, the group will agree on a series of prioritized steps to achieve this aim. DISCUSSION The development of an international consensus on core outcomes is an important first step towards the development of consensus guidelines and standardised protocols for randomized controlled trials (RCTs) in this population. This will enable us to better interpret and compare future studies, reduce risks of study heterogeneity and outcome reporting bias, and improve the evidence base for the management of this important condition.
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Affiliation(s)
- Simon Craig
- Paediatric Emergency Department, Monash Medical Centre, 246 Clayton Rd, Clayton, Victoria 3168 Australia
- Department of Paediatrics, School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia
| | - Franz E. Babl
- Emergency Department, Royal Children’s Hospital, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
- Murdoch Children’s Research Institute, Melbourne, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT) Network, Melbourne, Australia
| | - Stuart R. Dalziel
- Paediatric Research in Emergency Departments International Collaborative (PREDICT) Network, Melbourne, Australia
- Starship Children’s Hospital, Auckland, New Zealand
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Charmaine Gray
- Paediatric Research in Emergency Departments International Collaborative (PREDICT) Network, Melbourne, Australia
- Women’s & Children’s Hospital, Adelaide, Australia
- University of Adelaide, Adelaide, Australia
| | - Colin Powell
- Emergency Department, Sidra Medicine, Doha, Qatar
- School of Medicine, Cardiff University, Cardiff, UK
- Pediatric Emergency Research Qatar (PERQ) Network, ., Qatar
| | - Khalid Al Ansari
- Emergency Department, Sidra Medicine, Doha, Qatar
- Pediatric Emergency Research Qatar (PERQ) Network, ., Qatar
| | - Mark D. Lyttle
- Bristol Royal Hospital for Children, Bristol, UK
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
- Paediatric Emergency Research in the United Kingdom and Ireland (PERUKI), ., UK
| | - Damian Roland
- Paediatric Emergency Research in the United Kingdom and Ireland (PERUKI), ., UK
- SAPPHIRE Group, Health Sciences, Leicester University, Leicester, UK
- Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Children’s Emergency Department, Leicester Royal Infirmary, Leicester, UK
| | - Javier Benito
- Pediatric Emergency Department, Cruces University Hospital, Bilbao, Spain
- Department of Pediatrics, Basque Country University, San Sebastian, Spain
- Red de Investigación SEUP (Sociedad Española de Urgencias Pediátricas) Network, Madrid, Spain
| | - Roberto Velasco
- Red de Investigación SEUP (Sociedad Española de Urgencias Pediátricas) Network, Madrid, Spain
- Pediatric Emergency Unit, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Julia Hoeffe
- University of Switzerland, ., Switzerland
- Inselspital, University Hospital of Berne, Berne, Switzerland
- Research in European Pediatric Emergency Medicine (REPEM) Network, Leicester, UK
| | - Diana Moldovan
- Research in European Pediatric Emergency Medicine (REPEM) Network, Leicester, UK
- Emergency Department, Tirgu Mures Emergency Clinical County Hospital, Targu Mures, Romania
| | - Graham Thompson
- Alberta Children’s Hospital Research Institute, Calgary, AB Canada
- Departments of Pediatrics and Emergency Medicine, University of Calgary, Calgary, AB Canada
- Pediatric Emergency Research Canada (PERC) Network, Calgary, Alberta Canada
| | - Suzanne Schuh
- Pediatric Emergency Research Canada (PERC) Network, Calgary, Alberta Canada
- Division of Pediatric Emergency Medicine, Hospital for Sick Children, Toronto, Canada
- SickKids Research Institute, Toronto, Canada
- University of Toronto, Toronto, Canada
| | - Joseph J. Zorc
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Maria Kwok
- Columbia University Medical Center, New York, USA
- Pediatric Emergency Care Applied Research Network (PECARN), New York, USA
| | - Prashant Mahajan
- Department of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, MI USA
- Pediatric Care Applied Research Network (PECARN), Utah, USA
| | - Michael D. Johnson
- Pediatric Emergency Care Applied Research Network (PECARN), New York, USA
- University of Utah, Utah, USA
| | - Robert Sapien
- Pediatric Emergency Care Applied Research Network (PECARN), New York, USA
- University of New Mexico, Albuquerque, NM USA
| | - Kajal Khanna
- Department of Emergency Medicine, Stanford University, Stanford, CA USA
- Global Pediatric Emergency Equity Lab at Stanford University, Stanford CA, USA
- Pediatric Emergency Medicine Collaborative Research Committee (PEMCRC), Itasca, Illinois USA
| | - Pedro Rino
- Hospital de Pediatría “Prof. Dr. Juan P. Garrahan”, Buenos Aries, Argentina
- Universidad de Buenos Aires, Buenos Aries, Argentina
- Red de Investigación y Desarrollo de la Emergencia Pediátrica Latinoamericana (RIDEPLA), Leicester, UK
| | - Javier Prego
- Red de Investigación y Desarrollo de la Emergencia Pediátrica Latinoamericana (RIDEPLA), Leicester, UK
- Centro Hospitalario Pereira Rossell de Montevideo, Montevideo, Uruguay
| | - Adriana Yock
- Red de Investigación y Desarrollo de la Emergencia Pediátrica Latinoamericana (RIDEPLA), Leicester, UK
- Hospital Nacional de Niños “Dr. Carlos Saenz Herrera”, San José, Costa Rica
| | - Ricardo M. Fernandes
- Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
- Laboratório de Farmacologia Clinica e Terapêutica, Faculdade de Medicina, Instituto de Medicina Molecular, Universidade de Lisboa, Lisbon, Portugal
| | | | - Baljit Cheema
- Emergency Medical Services, Western Cape Health, Belville, South Africa
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Gene Ong
- KK Women’s and Children’s Hospital, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Shu-Ling Chong
- KK Women’s and Children’s Hospital, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Andis Graudins
- Department of Paediatrics, School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT) Network, Melbourne, Australia
- Emergency Medicine Service, Monash Health, Melbourne, Australia
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The Practice of Obtaining a Chest X-Ray in Pediatric Patients Presenting With Their First Episode of Wheezing in the Emergency Department: A Survey of Attending Physicians. Pediatr Emerg Care 2020; 36:16-20. [PMID: 31851079 DOI: 10.1097/pec.0000000000002015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Routine use of chest X-ray (CXR) in pediatric patients presenting with their first episode of wheezing was recommended by many authors. Although recent studies conclude that a CXR is not routinely indicated in these children, there continues to be reports of overuse. OBJECTIVE To examine the attitudes of practicing physicians in ordering CXRs in pediatric patients presenting with their first episode of wheezing to an emergency department (ED) and the factors that influence this practice by surveying ED physicians. METHODS A survey targeting pediatric emergency medicine (PEM) and general emergency medicine attending physicians was distributed electronically to the nearly 3000 members of the PEM Brown listserve and the Pediatric Section of American College of Emergency Physicians listserve. The 14-item survey included closed ended and free text questions to assess the respondent's demographic characteristics, their belief and current practice of obtaining a CXR in pediatric patients presenting with their first episode of wheezing. Data were analyzed using descriptive statistics and χ test. RESULTS Of the 537 attending physicians who participated, their primary residency training was: 42% pediatrics, 54% emergency medicine, and 4% other. Seventy-two percent of participating physicians supervise residents, 54% were board-eligible or -certified in PEM. Thirty percent (95% confidence interval [CI], 26-34) of participants indicated that they would always obtain a CXR in pediatric patients presenting with their first episode of wheezing. Eighty-one percent (95% CI, 75-87) of those who always obtain a CXR believe that it is the standard of care. Of the 376 physicians who do not always obtain a CXR, 18% (95% CI, 15-23) always obtain a CXR under certain age (2 weeks to 12 years, median of 1 year). Physicians who report a primary residency in pediatrics, who supervise residents, who were board-eligible or -certified in PEM, and who were practicing for greater than 5 years were less likely to obtain a CXR (P < 0.001, P < 0.001, P < 0.001, P = 0.001). CONCLUSIONS In our study, a significant number of practicing ED physicians routinely obtain a CXR in children with their first episode of wheezing presenting to the ED. The factors influencing this practice are primary residency training, fellowship training, resident supervision, and years of independent practice. This identifies a target audience that would benefit from education to decrease the overuse of CXRs in children with wheezing.
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Measuring vital signs in children with fever at the emergency department: an observational study on adherence to the NICE recommendations in Europe. Eur J Pediatr 2020; 179:1097-1106. [PMID: 32036433 PMCID: PMC7314716 DOI: 10.1007/s00431-020-03601-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 01/27/2020] [Accepted: 02/02/2020] [Indexed: 11/07/2022]
Abstract
Vital signs can help clinicians identify children at risk of serious illness. The NICE guideline for fever in under-fives recommends a routine measurement of temperature, heart rate, capillary refill and respiratory rate in all febrile children visiting the emergency department (ED). This study aims to evaluate the measurement of paediatric vital signs in European EDs, with specific attention to adherence to this NICE guideline recommendation. In a prospective observational study, we included 4560 febrile children under 16 years from the ED of 28 hospitals in 11 European countries (2014-2016). Hospitals were academic (n = 17), teaching (n = 10) and non-teaching (n = 1) and ranged in annual paediatric ED visits from 2700 to 88,000. Fifty-four percent were male, their median age was 2.4 years (IQR 1.1-4.7). Temperature was measured most frequently (97%), followed by capillary refill (86%), heart rate (73%), saturation (56%) and respiratory rate (51%). In children under five (n = 3505), a complete measurement of the four NICE-recommended vital signs was performed in 48% of patients. Children under 1 year of age, those with an urgent triage level and with respiratory infections had a higher likelihood of undergoing complete measurements. After adjustment for these factors, variability between countries remained. Conclusion: Measuring vital signs in children with fever in the ED occurs with a high degree of practice variation between different European hospitals, and adherence to the NICE recommendation is moderate. Our study is essential as a benchmark for current clinical practice, in order to tailor implementation strategies to different European settings.What is Known:• Vital signs can quickly provide information on disease severity in children in the emergency department (ED), and the NICE guideline for fever in under-fives recommends to routinely measure temperature, heart rate, capillary refill and respiratory rate.• Data regarding measurement of vital signs in routine practice across European EDs is currently unavailable.What is New:• Measurement of vital signs in febrile children is highly variable across European EDs and across patient subgroups, and compliance to the NICE recommendation is <50%.• Children under 1 year of age, those with an urgent triage level and with respiratory infections had a higher likelihood of undergoing complete measurements.
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Wang X, Nijman R, Camuzeaux S, Sands C, Jackson H, Kaforou M, Emonts M, Herberg JA, Maconochie I, Carrol ED, Paulus SC, Zenz W, Van der Flier M, de Groot R, Martinon-Torres F, Schlapbach LJ, Pollard AJ, Fink C, Kuijpers TT, Anderson S, Lewis MR, Levin M, McClure M. Plasma lipid profiles discriminate bacterial from viral infection in febrile children. Sci Rep 2019; 9:17714. [PMID: 31776453 PMCID: PMC6881435 DOI: 10.1038/s41598-019-53721-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 11/03/2019] [Indexed: 11/16/2022] Open
Abstract
Fever is the most common reason that children present to Emergency Departments. Clinical signs and symptoms suggestive of bacterial infection are often non-specific, and there is no definitive test for the accurate diagnosis of infection. The 'omics' approaches to identifying biomarkers from the host-response to bacterial infection are promising. In this study, lipidomic analysis was carried out with plasma samples obtained from febrile children with confirmed bacterial infection (n = 20) and confirmed viral infection (n = 20). We show for the first time that bacterial and viral infection produces distinct profile in the host lipidome. Some species of glycerophosphoinositol, sphingomyelin, lysophosphatidylcholine and cholesterol sulfate were higher in the confirmed virus infected group, while some species of fatty acids, glycerophosphocholine, glycerophosphoserine, lactosylceramide and bilirubin were lower in the confirmed virus infected group when compared with confirmed bacterial infected group. A combination of three lipids achieved an area under the receiver operating characteristic (ROC) curve of 0.911 (95% CI 0.81 to 0.98). This pilot study demonstrates the potential of metabolic biomarkers to assist clinicians in distinguishing bacterial from viral infection in febrile children, to facilitate effective clinical management and to the limit inappropriate use of antibiotics.
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Affiliation(s)
- Xinzhu Wang
- Department of Infectious Disease, Imperial College London, London, W2 1PG, United Kingdom
| | - Ruud Nijman
- Department of Infectious Disease, Imperial College London, London, W2 1PG, United Kingdom
| | - Stephane Camuzeaux
- National Phenome Centre and Imperial Clinical Phenotyping Centre, Department of Metabolism, Digestion and Reproduction, IRDB Building, Du Cane Road, Imperial College London, London, W12 0NN, United Kingdom
| | - Caroline Sands
- National Phenome Centre and Imperial Clinical Phenotyping Centre, Department of Metabolism, Digestion and Reproduction, IRDB Building, Du Cane Road, Imperial College London, London, W12 0NN, United Kingdom
| | - Heather Jackson
- Department of Infectious Disease, Imperial College London, London, W2 1PG, United Kingdom
| | - Myrsini Kaforou
- Department of Infectious Disease, Imperial College London, London, W2 1PG, United Kingdom
| | - Marieke Emonts
- Great North Children's Hospital, Paediatric Immunology, Infectious Diseases & Allergy, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE1 4LP, United Kingdom
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, NE2 4HH, United Kingdom
- NIHR Newcastle Biomedical Research Centre based at Newcastle upon Tyne Hospitals NHS Trust and Newcastle University, Newcastle upon Tyne, NE4 5PL, United Kingdom
| | - Jethro A Herberg
- Department of Infectious Disease, Imperial College London, London, W2 1PG, United Kingdom
| | - Ian Maconochie
- Department of Paediatric Emergency Medicine, St Mary's Hospital, Imperial College NHS Healthcare Trust, London, W2 1NY, United Kingdom
| | - Enitan D Carrol
- Institute of Infection and Global Health, University of Liverpool, Liverpool, L69 7BE, United Kingdom
- Department of Infectious Diseases, Alder Hey Children's NHS Foundation Trust, Liverpool, L12 2AP, United Kingdom
- Liverpool Health Partners, Liverpool, L3 5TF, United Kingdom
| | - Stephane C Paulus
- Department of Infectious Diseases, Alder Hey Children's NHS Foundation Trust, Liverpool, L12 2AP, United Kingdom
- Liverpool Health Partners, Liverpool, L3 5TF, United Kingdom
| | - Werner Zenz
- Department of General Paediatrics, Medical University of Graz, Graz, Auenbruggerplatz 34/2, 8036, Graz, Austria
| | - Michiel Van der Flier
- Pediatric Infectious Diseases and Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, 3508 AB, The Netherlands
- Pediatric Infectious Diseases and Immunology, Amalia Children's Hospital, and Section Pediatric Infectious Diseases, Laboratory of Medical Immunology, Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, 6500 HB, The Netherlands
| | - Ronald de Groot
- Pediatric Infectious Diseases and Immunology, Amalia Children's Hospital, and Section Pediatric Infectious Diseases, Laboratory of Medical Immunology, Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, 6500 HB, The Netherlands
| | - Federico Martinon-Torres
- Genetic, Vaccines and Pediatric Infectious Diseases Research Group (GENVIP), Instituto de Investigación Sanitaria de Santiago and Universidad de Santiago de Compostela (USC), Galicia, Spain
- Translational Pediatrics and Infectious Diseases, Department of Pediatrics, Hospital Clínico Universitario de Santiago de Compostela, Galicia, 15706, Spain
| | - Luregn J Schlapbach
- Paediatirc Criticial Care Research Group, Child Health Research Centre, The University of Queensland and Paediatric Intensive Care Research Group, Queensland Children's Hospital, Brisbane, Australia
| | - Andrew J Pollard
- Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford, OX3 9DU, United Kingdom
| | - Colin Fink
- Micropathology Ltd, University of Warwick, Warwick, CV4 7EZ, United Kingdom
| | - Taco T Kuijpers
- Division of Pediatric Hematology, Immunology and Infectious diseases, Emma Children's Hospital Academic Medical Center, Amsterdam, 1105 AZ, The Netherlands
| | - Suzanne Anderson
- Medical Research Council Unit at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Matthew R Lewis
- National Phenome Centre and Imperial Clinical Phenotyping Centre, Department of Metabolism, Digestion and Reproduction, IRDB Building, Du Cane Road, Imperial College London, London, W12 0NN, United Kingdom
| | - Michael Levin
- Department of Infectious Disease, Imperial College London, London, W2 1PG, United Kingdom
| | - Myra McClure
- Department of Infectious Disease, Imperial College London, London, W2 1PG, United Kingdom.
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