Predicting Delayed Shock in Multisystem Inflammatory Disease in Children: A Multicenter Analysis From the New York City Tri-State Region

OBJECTIVES

Patients with multisystem inflammatory disease in children (MIS-C) are at risk of developing shock. Our objectives were to determine independent predictors associated with development of delayed shock (≥3 hours from emergency department [ED] arrival) in patients with MIS-C and to derive a model predicting those at low risk for delayed shock.

METHODS

We conducted a retrospective cross-sectional study of 22 pediatric EDs in the New York City tri-state area. We included patients meeting World Health Organization criteria for MIS-C and presented April 1 to June 30, 2020. Our main outcomes were to determine the association between clinical and laboratory factors to the development of delayed shock and to derive a laboratory-based prediction model based on identified independent predictors.

RESULTS

Of 248 children with MIS-C, 87 (35%) had shock and 58 (66%) had delayed shock. A C-reactive protein (CRP) level greater than 20 mg/dL (adjusted odds ratio [aOR], 5.3; 95% confidence interval [CI], 2.4-12.1), lymphocyte percent less than 11% (aOR, 3.8; 95% CI, 1.7-8.6), and platelet count less than 220,000/uL (aOR, 4.2; 95% CI, 1.8-9.8) were independently associated with delayed shock. A prediction model including a CRP level less than 6 mg/dL, lymphocyte percent more than 20%, and platelet count more than 260,000/uL, categorized patients with MIS-C at low risk of developing delayed shock (sensitivity 93% [95% CI, 66-100], specificity 38% [95% CI, 22-55]).

CONCLUSIONS

Serum CRP, lymphocyte percent, and platelet count differentiated children at higher and lower risk for developing delayed shock. Use of these data can stratify the risk of progression to shock in patients with MIS-C, providing situational awareness and helping guide their level of care.

The Additive Value of Pelvic Examinations to History in Predicting Sexually Transmitted Infections for Young Female Patients With Suspected Cervicitis or Pelvic Inflammatory Disease

STUDY OBJECTIVE

We evaluate the additive value of pelvic examinations in predicting sexually transmitted infection for young female patients with suspected cervicitis or pelvic inflammatory disease in a pediatric emergency department (ED).

METHODS

This was a prospective observational study of female patients aged 14 to 20 years who presented to an urban academic pediatric ED with a complaint of vaginal discharge or lower abdominal pain. Enrolled patients provided a urine sample for chlamydia, gonorrhea, and trichomonas testing, which served as the criterion standard for diagnosis. A practitioner (pediatric ED attending physician, emergency medicine or pediatric resident, pediatric ED fellow, or advanced practice provider) obtained a standardized history from the patient to assess for cervicitis or pelvic inflammatory disease according to the Centers for Disease Control and Prevention criteria. They then recorded the likelihood of cervicitis or pelvic inflammatory disease on a 100-mm visual analog scale. The same practitioner then performed a pelvic examination and again recorded the likelihood of cervicitis or pelvic inflammatory disease on a visual analog scale with this additional information. Using the results of the urine sexually transmitted infection tests, the practitioner calculated and compared the test characteristics of history alone and history with pelvic examination.

RESULTS

Two hundred eighty-eight patients were enrolled, of whom 79 had positive urine test results for chlamydia, gonorrhea, or trichomonas, with a sexually transmitted infection rate of 27.4% (95% confidence interval [CI] 22.6% to 32.8%). The sensitivity of history alone in diagnosis of cervicitis or pelvic inflammatory disease was 54.4% (95% CI 42.8% to 65.5%), whereas the specificity was 59.8% (95% CI 52.8% to 66.4%). The sensitivity of history with pelvic examination in diagnosis of cervicitis or pelvic inflammatory disease was 48.1% (95% CI 36.8% to 59.5%), whereas the specificity was 60.7% (95% CI 53.8% to 67.3%). The information from the pelvic examination changed management in 71 cases; 35 of those cases correlated with the sexually transmitted infection test and 36 did not.

CONCLUSION

For young female patients with suspected cervicitis or pelvic inflammatory disease, the pelvic examination does not increase the sensitivity or specificity of diagnosis of chlamydia, gonorrhea, or trichomonas compared with taking a history alone. Because the test characteristics for the pelvic examination are not adequate, its routine performance should be reconsidered.

Pediatric emergency medicine point-of-care ultrasound: summary of the evidence

The utility of point-of-care ultrasound is well supported by the medical literature. Consequently, pediatric emergency medicine providers have embraced this technology in everyday practice. Recently, the American Academy of Pediatrics published a policy statement endorsing the use of point-of-care ultrasound by pediatric emergency medicine providers.  To date, there is no standard guideline for the practice of point-of-care ultrasound for this specialty. This document serves as an initial step in the detailed “how to” and description of individual point-of-care ultrasound examinations.  Pediatric emergency medicine providers should refer to this paper as reference for published research, objectives for learners, and standardized reporting guidelines.

Point-of-Care Ultrasound in Pediatric Clinical Care

IMPORTANCE

Point-of-care (POC) ultrasound has been used by a variety of nonradiologist physicians. Recently, POC ultrasound use by pediatricians has received increased attention with the practice of both established and novel applications.

OBJECTIVES

To review various uses of ultrasound by pediatricians, discuss challenges and potential pitfalls as pediatric physicians seek to use ultrasound in their practices, and consider various areas of research needs and opportunities.

EVIDENCE REVIEW

Available English-language publications from 1970 through December 31, 2014.

FINDINGS

Limited research supports the notion that many POC ultrasound applications practiced by nonradiologist pediatricians can assist in clinical decision making and procedural success. Future challenges include the need for institutions to train and credential large numbers of health care professionals in the use of pediatric POC ultrasound, as well as the necessity of diverse research efforts, including the establishment of pediatric-specific norms, consideration of optimal educational strategies, and inquiry intended to identify best practices for clinical effectiveness and efficiency.

CONCLUSIONS AND RELEVANCE

Although considerable effort needs to be devoted to the continued development of pediatric POC ultrasound, there is potential for useful application in a variety of clinical and educational settings.

A comparison of cosmetic outcomes of lacerations on the extremities and trunk using absorbable versus nonabsorbable sutures

OBJECTIVES

The primary objective was to compare the cosmetic outcomes of traumatic trunk and extremity lacerations repaired using absorbable versus nonabsorbable sutures. The secondary objective was to compare complication rates between the two groups.

METHODS

This was a randomized controlled trial comparing wounds repaired with Vicryl Rapide and Prolene sutures. Pediatric and adult patients with lacerations were enrolled in the study. At a 10-day follow-up, the wounds were evaluated for infection and dehiscence. After 3 months, patients returned to have the wounds photographed. Two plastic surgeons blinded to the method of closure rated the cosmetic outcome of each wound using a 100-mm visual analog scale (VAS). Using a noninferiority design, a VAS score of 13 mm or greater was considered to be a clinically significant difference. We used a Student's t-test to compare differences between mean VAS scores and odds ratios (ORs) to compare differences in complication rates between the two groups.

RESULTS

Of the 115 patients enrolled, 73 completed the study including 35 in the Vicryl Rapide group and 38 in the Prolene group. The mean (±SD) age of patients who completed the study was 22.1 (±15.5) years, and 39 were male. We found no significant differences in the age, race, sex, length of wound, number of sutures, or layers of repair in the two groups. The observer's mean VAS for the Vicryl Rapide group was 54.1 mm (95% confidence interval [CI] = 44.5 to 67.0 mm) and for the Prolene group was 54.5 mm (95% CI = 45.7 to 66.3 mm). The resulting mean difference was 0.5 mm (95% CI = -12.1 to 17.2 mm; p = 0.9); thus noninferiority was established. Statistical testing showed no differences in the rates of complications between the two groups, but a higher percentage of the Vicryl Rapide wounds developed complications.

CONCLUSIONS

The use of absorbable sutures for the repair of simple lacerations on the trunk and extremities should be considered as an alternative to nonabsorbable suture repair.

Evaluation of acute appendicitis by pediatric emergency physician sonography

STUDY OBJECTIVE

We investigate the accuracy of pediatric emergency physician sonography for acute appendicitis in children.

METHODS

We prospectively enrolled children requiring surgical or radiology consultation for suspected acute appendicitis at an urban pediatric emergency department. Pediatric emergency physicians performed focused right lower-quadrant sonography after didactics and hands-on training with a structured scanning algorithm, including the graded-compression technique. We compared their sonographic interpretations with clinical and radiologic findings, as well as clinical outcomes as defined by follow-up or pathologic findings.

RESULTS

Thirteen pediatric emergency medicine sonographers performed 264 ultrasonographic studies, including 85 (32%) in children with pathology-verified appendicitis. Bedside sonography had a sensitivity of 85% (95% confidence interval [CI] 75% to 95%), specificity of 93% (95% CI 85% to 100%), positive likelihood ratio of 11.7 (95% CI 6.9 to 20), and negative likelihood ratio of 0.17 (95% CI 0.1 to 0.28).

CONCLUSION

With focused ultrasonographic training, pediatric emergency physicians can diagnose acute appendicitis with substantial accuracy.

Evaluation of hypertrophic pyloric stenosis by pediatric emergency physician sonography

OBJECTIVES

The objective was to evaluate the accuracy of pediatric emergency physician (EP) sonography for infants with suspected hypertrophic pyloric stenosis (HPS).

METHODS

This was a prospective observational pilot study in an urban academic pediatric emergency department (PED). Patients were selected if the treating physician ordered an ultrasound (US) in the department of radiology for the evaluation of suspected HPS.

RESULTS

Sixty-seven patients were enrolled from August 2009 through April 2012. When identifying the pylorus, pediatric EPs correctly identified all 10 positive cases, with a sensitivity of 100% (95% confidence interval [CI] = 62% to 100%) and specificity of 100% (95% CI = 92% to 100%). There was no statistical difference between the measurements obtained by pediatric EPs and radiology staff for pyloric muscle width or length (p = 0.5 and p = 0.79, respectively).

CONCLUSIONS

Trained pediatric EPs can accurately assess the pylorus with US in the evaluation of HPS with good specificity.

Chicken repeat 1 (CR1) elements, which define an ancient family of vertebrate non-LTR retrotransposons, contain two closely spaced open reading frames

Chicken repeat 1 (CR1) elements comprise a family of non-long terminal repeat (LTR) retrotransposons that have several noteworthy features. For example, whereas most other non-LTR elements have poly(A) tracts or other simple A-rich repeats at their 3' ends, the 3' ends of CR1 elements conform to the consensus [(CATTCTRT)(GATTCTRT)1-3]. CR1 elements also display an unusual bias for severe 5' truncations: only approx. 30 (out of a total of approx. 30 000) CR1 elements in the chicken genome include significant portions of the pol-like open reading frame (ORF) that we previously identified and partially sequenced [Burch et al. (1993) Proc. Natl. Acad. Sci. USA 90, 8199-8203]. In the present study we derived a consensus sequence for this entire ORF (ORF2) as well as an upstream ORF (ORF1) and part of a 5' untranslated region (UTR). The conceptual translation product of ORF2 is predicted to contain an endonuclease domain in addition to a reverse transcriptase domain. These results suggest that CR1 elements retrotranspose using a "nick and prime" mechanism similar (but not identical) to other families of non-LTR elements.