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Levine DA, Oh PS, Nash KA, Simmons W, Grinspan ZM, Abramson EL, Platt SL, Green C. Pediatric Mental Health Emergencies During 5 COVID-19 Waves in New York City. Pediatrics 2023; 152:e2022060553. [PMID: 37860839 DOI: 10.1542/peds.2022-060553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/14/2023] [Indexed: 10/21/2023] Open
Abstract
OBJECTIVES To describe the proportion of pediatric mental health emergency department (MH-ED) visits across 5 COVID-19 waves in New York City (NYC) and to examine the relationship between MH-ED visits, COVID-19 prevalence, and societal restrictions. METHODS We conducted a time-series analysis of MH-ED visits among patients ages 5 to 17 years using the INSIGHT Clinical Research Network, a database from 5 medical centers in NYC from January 1, 2016, to June 12, 2022. We estimated seasonally adjusted changes in MH-ED visit rates during the COVID-19 pandemic, compared with predicted prepandemic levels, specific to each COVID-19 wave and stratified by mental health diagnoses and sociodemographic characteristics. We estimated associations between MH-ED visit rates, COVID-19 prevalence, and societal restrictions measured by the Stringency Index. RESULTS Of 686 500 ED visits in the cohort, 27 168 (4.0%) were MH-ED visits. The proportion of MH-ED visits was higher during each COVID-19 wave compared with predicted prepandemic trends. Increased MH-ED visits were seen for eating disorders across all waves; anxiety disorders in all except wave 3; depressive disorders and suicidality/self-harm in wave 2; and substance use disorders in waves 2, 4, and 5. MH-ED visits were increased from expected among female, adolescent, Asian race, high Child Opportunity Index patients. There was no association between MH-ED visits and NYC COVID-19 prevalence or NY State Stringency Index. CONCLUSIONS The proportion of pediatric MH-ED visits during the COVID-19 pandemic was higher during each wave compared with the predicted prepandemic period, with varied increases among diagnostic and sociodemographic subgroups. Enhanced pediatric mental health resources are essential to address these findings.
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Affiliation(s)
- Deborah A Levine
- Departments of Emergency Medicine and Weill Cornell Medicine, Cornell University and New York-Presbyterian Hospital, New York, New York
| | - P Stephen Oh
- Department of Surgery, Weill Cornell Medicine, Cornell University and New York-Presbyterian Hospital, New York, New York
| | - Katherine A Nash
- Department of Pediatrics, New York Presbyterian Morgan Stanley Childrens Hospital, Columbia University, New York City, New York
| | - Will Simmons
- Department of Population Health, Weill Cornell Medicine, Cornell University and New York-Presbyterian Hospital, New York, New York
| | - Zachary M Grinspan
- Department of Pediatrics, Weill Cornell Medicine, Cornell University and New York-Presbyterian Hospital, New York, New York
| | - Erika L Abramson
- Department of Pediatrics, Weill Cornell Medicine, Cornell University and New York-Presbyterian Hospital, New York, New York
| | - Shari L Platt
- Departments of Emergency Medicine and Weill Cornell Medicine, Cornell University and New York-Presbyterian Hospital, New York, New York
| | - Cori Green
- Department of Pediatrics, Weill Cornell Medicine, Cornell University and New York-Presbyterian Hospital, New York, New York
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Levine DA, Uy V, Krief W, Bornstein C, Daswani D, Patel D, Kriegel M, Jamal N, Patel K, Liang T, Arroyo A, Strother C, Lim CA, Langhan ML, Hassoun A, Chamdawala H, Kaplan CP, Waseem M, Tay ET, Mortel D, Sivitz AB, Kelly C, Lee HJ, Qiu Y, Gorelik M, Platt SL, Dayan P. Predicting Delayed Shock in Multisystem Inflammatory Disease in Children: A Multicenter Analysis From the New York City Tri-State Region. Pediatr Emerg Care 2023; 39:555-561. [PMID: 36811547 DOI: 10.1097/pec.0000000000002914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
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.
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Affiliation(s)
- Deborah A Levine
- From the Departments of Emergency Medicine and Pediatrics, NewYork-Presbyterian/Weill Cornell Medicine, New York
| | - Vincent Uy
- From the Departments of Emergency Medicine and Pediatrics, NewYork-Presbyterian/Weill Cornell Medicine, New York
| | - William Krief
- Department of Pediatrics, Hofstra-Northwell School of Medicine/Cohen's Children's Medical Center, Queens
| | - Cara Bornstein
- Department of Pediatrics, Hofstra-Northwell School of Medicine/Cohen's Children's Medical Center, Queens
| | - Dina Daswani
- Departments of Pediatrics and Emergency Medicine, Maria Fareri Children's Hospital/Westchester Medical Center Health Network, Valhalla, NY
| | - Darshan Patel
- Departments of Pediatrics and Emergency Medicine, Maria Fareri Children's Hospital/Westchester Medical Center Health Network, Valhalla, NY
| | - Marni Kriegel
- Department of Emergency Medicine and Pediatrics, Hackensack University Medical Center/Hackensack Meridian School of Medicine, Hackensack, NJ
| | - Nazreen Jamal
- Department of Emergency Medicine and Pediatrics, NewYork-Presbyterian/Columbia University Valegos College of Physicians and Surgeons
| | - Kavita Patel
- Departments of Emergency Medicine and Pediatrics, New York University Grossman School of Medicine, New York
| | - Tian Liang
- Departments of Emergency Medicine and Pediatrics, New York University Grossman School of Medicine, New York
| | - Alexander Arroyo
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn
| | - Christopher Strother
- Departments of Emergency Medicine and Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Czer Anthoney Lim
- Departments of Emergency Medicine and Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Melissa L Langhan
- Departments of Pediatrics and Emergency Medicine, Yale University School of Medicine, New Haven CT
| | - Ameer Hassoun
- Department of Emergency Medicine, NewYork-Presbyterian Queens/Weill Cornell Medicine, Flushing
| | - Haamid Chamdawala
- Department of Pediatrics, Jacobi Hospital Center/North Central Bronx Hospital, The Bronx
| | - Carl Philip Kaplan
- Departments of Pediatrics and Emergency Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook
| | - Muhammad Waseem
- Departments of Emergency Medicine and Pediatrics, Lincoln Medical Center/Weill Cornell Medicine, The Bronx
| | - Ee Tein Tay
- Departments of Emergency Medicine and Pediatrics, New York University Grossman School of Medicine/Bellevue Hospital Center
| | - David Mortel
- Departments of Emergency Medicine and Pediatrics, Harlem Hospital Center, New York
| | - Adam B Sivitz
- Departments of Emergency Medicine and Pediatrics, Newark Beth Israel Medical Center/Children's Hospital of New Jersey, New Jersey Medical School, Rutgers University, Newark
| | - Christopher Kelly
- Department of Emergency Medicine, NewYork-Presbyterian/Brooklyn Methodist Hospital, Brooklyn
| | | | | | | | - Shari L Platt
- From the Departments of Emergency Medicine and Pediatrics, NewYork-Presbyterian/Weill Cornell Medicine, New York
| | - Peter Dayan
- Emergency Medicine, NewYork-Presbyterian/Columbia University Valegos College of Physicians and Surgeons, New York, NY
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Gerber N, Vella A, Racine-Brzostek S, Platt SL. Rapid Absolute Neutrophil Count Testing Guides Targeted Antimicrobial Therapy in Febrile Pediatric Oncology Patients. Pediatr Emerg Care 2022; 38:e743-e745. [PMID: 35100772 DOI: 10.1097/pec.0000000000002354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES It is well established that early antibiotic administration leads to improved outcomes in febrile neutropenic patients. To achieve this, many institutions administer empiric antibiotics to all febrile oncology patients in the emergency setting, before knowing their neutropenic status. This study evaluates the role of rapid absolute neutrophil count (ANC) testing in the targeted antimicrobial management of nonneutropenic febrile oncology patients. METHODS We conducted a retrospective review of patients 19 years or younger presenting to the pediatric emergency service with an oncologic process and fever or history of fever. We examined the administration of antibiotics and outcomes in nonneutropenic patients. RESULTS We included 101 patient encounters, representing 62 distinct patients. The rapid ANC test influenced antibiotic management in 94% (95/101) of patient encounters and resulted in no antibiotics or targeted antibiotic therapy in 88% (60/68) of nonneutropenic patients. Use of the rapid ANC test to guide treatment would have spared antibiotic administration in 68% (46/68) of well-appearing nonneutropenic patients with no alternate indication. No well-appearing, nonneutropenic patient had a positive blood culture, and only 1 required hospital admission on a repeat visit. CONCLUSIONS The rapid ANC is a useful tool to balance the goal of early antibiotic administration in febrile neutropenic oncology patients while promoting antibiotic stewardship in this vulnerable population.
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Affiliation(s)
| | - Adam Vella
- From the Department of Emergency Medicine
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Abstract
OBJECTIVES This study aims to determine the prevalence of and identify predictors associated with burnout in pediatric emergency medicine (PEM) physicians and to construct a predictive model for burnout in this population to stratify risk. METHODS We conducted a cross-sectional electronic survey study among a random sample of board-certified or board-eligible PEM physicians throughout the United States and Canada. Our primary outcome was burnout assessed using the Maslach Burnout Inventory on 3 subscales: emotional exhaustion, depersonalization, and personal accomplishment. We defined burnout as scoring in the high-degree range on any 1 of the 3 subscales. The Maslach Burnout Inventory was followed by questions on personal demographics and work environment. We compared PEM physicians with and without burnout using multivariable logistic regression. RESULTS We studied a total of 416 PEM board-certified/eligible physicians (61.3% women; mean age, 45.3 ± 8.8 years). Surveys were initiated by 445 of 749 survey recipients (59.4% response rate). Burnout prevalence measured 49.5% (206/416) in the study cohort, with 34.9% (145/416) of participants scoring in the high-degree range for emotional exhaustion, 33.9% (141/416) for depersonalization, and 20% (83/416) for personal accomplishment. A multivariable model identified 6 independent predictors associated with burnout: 1) lack of appreciation from patients, 2) lack of appreciation from supervisors, 3) perception of an unfair clinical work schedule, 4) dissatisfaction with promotion opportunities, 5) feeling that the electronic medical record detracts from patient care, and 6) working in a nonacademic setting (area under the receiver operating characteristic curve, 0.77). A predictive model demonstrated that physicians with 5 or 6 predictors had an 81% probability of having burnout, whereas those with zero predictors had a 28% probability of burnout. CONCLUSIONS Burnout is prevalent in PEM physicians. We identified 6 independent predictors for burnout and constructed a scoring system that stratifies probability of burnout. This predictive model may be used to guide organizational strategies that mitigate burnout and improve physician well-being.
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Affiliation(s)
- Janienne E Kondrich
- From the Division of Pediatric Emergency Medicine, Departments of Emergency Medicine and Pediatrics, NewYork-Presbyterian and Weill Cornell Medicine, Komansky Children's Hospital, New York, NY
| | - Reintine Han
- Department of Family Medicine, Hackensack Meridian Mountainside Medical Center, Verona, NJ
| | - Sunday Clark
- Department of Emergency Medicine, NewYork-Presbyterian and Weill Cornell Medicine, New York, NY
| | - Shari L Platt
- From the Division of Pediatric Emergency Medicine, Departments of Emergency Medicine and Pediatrics, NewYork-Presbyterian and Weill Cornell Medicine, Komansky Children's Hospital, New York, NY
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Abstract
OBJECTIVE Prior studies show that staffing a physician at triage expedites care in the emergency department. Our objective was to describe the novel application and effect of a telemedicine medical screening evaluation (Tele-MSE) at triage on quality metrics in the pediatric emergency department (PED). METHODS We conducted a retrospective quasi-experimental pre-post intervention study of patients presenting to an urban PED from December 2017 to November 2019 who received a Tele-MSE at triage. We analyzed 4 diagnostic cohorts: gastroenteritis, psychiatry evaluation, burn injury, and extremity fracture. We matched cases with controls who received standard triage, from December 2015 to November 2017, by age, diagnosis, weekday versus weekend, and season of presentation. Outcome measures included door-to-provider time, time-to-intervention order, and PED length of stay (LOS). RESULTS We included 557 patients who received Tele-MSE during the study period. Compared with controls, patients who received a Tele-MSE at triage had a shorter median door-to-provider time (median difference [MD], 8.4 minutes; 95% confidence interval [CI], 6.0-11.0), time-to-medication order (MD, 27.3 minutes; 95% CI, 22.9-35.2), time-to-consult order (MD, 10.0 minutes; 95% CI, 5.3-12.7), and PED LOS (MD, 0.4 hours; 95% CI, 0.3-0.6). CONCLUSIONS A Tele-MSE is an innovative modality to expedite the initiation of emergency care and reduce PED LOS for children. This novel intervention offers potential opportunities to optimize provider and patient satisfaction and safety during the COVID-19 pandemic.
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Affiliation(s)
- Jonathan Friedman
- From the Division of Pediatric Emergency Medicine, Department of Pediatrics, New York City Health and Hospitals, Jacobi Medical Center; Division of Pediatric Emergency Medicine, Departments of
| | | | - Sunday Clark
- Department of Emergency Medicine, NewYork-Presbyterian, Weill Cornell Medicine, New York, NY
| | - Kriti Gogia
- Department of Emergency Medicine, NewYork-Presbyterian, Weill Cornell Medicine, New York, NY
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Lame M, Leyden D, Platt SL. Geocode Maps Spotlight Disparities in Telehealth Utilization During the COVID-19 Pandemic in New York City. Telemed J E Health 2021; 27:251-253. [DOI: 10.1089/tmj.2020.0297] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Maria Lame
- Department of Emergency Medicine, NewYork-Presbyterian and Weill Cornell Medicine, New York, New York, USA
| | - David Leyden
- Department of Emergency Medicine, NewYork-Presbyterian and Weill Cornell Medicine, New York, New York, USA
| | - Shari L. Platt
- Department of Emergency Medicine, NewYork-Presbyterian and Weill Cornell Medicine, New York, New York, USA
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Affiliation(s)
- Rachel H Kowalsky
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Department of Pediatrics, New York Presbyterian Hospital-Weill Cornell Medicine, New York.,Cornell Center for Health Equity, New York, New York
| | - Ashley C Rondini
- Department of Sociology, Franklin & Marshall College, Lancaster, Pennsylvania
| | - Shari L Platt
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Department of Pediatrics, New York Presbyterian Hospital-Weill Cornell Medicine, New York
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8
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Affiliation(s)
- Deborah A Levine
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, NY
| | - Susan Fraymovich
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, NY
| | - Shari L Platt
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, NY.
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Kowalsky RH, Rondini AC, Platt SL. The Case for Removing Race From the American Academy of Pediatrics Clinical Practice Guideline for Urinary Tract Infection in Infants and Young Children With Fever. JAMA Pediatr 2020; 174:229-230. [PMID: 31930353 DOI: 10.1001/jamapediatrics.2019.5242] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Rachel H Kowalsky
- Division of Pediatric Emergency Medicine, Departments of Emergency Medicine and Pediatrics, New York Presbyterian Hospital-Weill Cornell Medicine, New York.,Cornell Center for Health Equity, New York, New York
| | - Ashley C Rondini
- Department of Sociology, Franklin & Marshall College, Lancaster, Pennsylvania
| | - Shari L Platt
- Division of Pediatric Emergency Medicine, Departments of Emergency Medicine and Pediatrics, New York Presbyterian Hospital-Weill Cornell Medicine, New York
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Krief WI, Levine DA, Platt SL, Macias CG, Dayan PS, Zorc JJ, Feffermann N, Kuppermann N. Influenza virus infection and the risk of serious bacterial infections in young febrile infants. Pediatrics 2009; 124:30-9. [PMID: 19564280 DOI: 10.1542/peds.2008-2915] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE We aimed to determine the risk of SBIs in febrile infants with influenza virus infections and compare this risk with that of febrile infants without influenza infections. PATIENTS AND METHODS We conducted a multicenter, prospective, cross-sectional study during 3 consecutive influenza seasons. All febrile infants <or=60 days of age evaluated at any of 5 participating pediatric EDs between October and March of 1998 through 2001 were eligible. We determined influenza virus status by rapid antigen detection. We evaluated infants with blood, urine, cerebrospinal fluid, and stool cultures. Urinary tract infection (UTI) was defined by single-pathogen growth of either >or=5 x 10(4) colony-forming units per mL or >or=10(4) colony-forming units per mL in association with a positive urinalysis. Bacteremia, bacterial meningitis, and bacterial enteritis were defined by growth of a known bacterial pathogen. SBI was defined as any of the 4 above-mentioned bacterial infections. RESULTS During the 3-year study period, 1091 infants were enrolled. A total of 844 (77.4%) infants were tested for the influenza virus, of whom 123 (14.3%) tested positive. SBI status was determined in 809 (95.9%) of the 844 infants. Overall, 95 (11.7%) of the 809 infants tested for influenza virus had an SBI. Infants with influenza infections had a significantly lower prevalence of SBI (2.5%) and UTI (2.4%) when compared with infants who tested negative for the influenza virus. Although there were no cases of bacteremia, meningitis, or enteritis in the influenza-positive group, the differences between the 2 groups for these individual infections were not statistically significant. CONCLUSIONS Febrile infants <or=60 days of age with influenza infections are at significantly lower risk of SBIs than febrile infants who are influenza-negative. Nevertheless, the rate of UTI remains appreciable in febrile, influenza-positive infants.
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Affiliation(s)
- William I Krief
- Department of Pediatrics and Emergency Medicine, Schneider Children's Hospital/Long Island Jewish Medical Center, New Hyde Park, NY 11040, USA.
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Shah SS, Zorc JJ, Levine DA, Platt SL, Kuppermann N. Sterile cerebrospinal fluid pleocytosis in young infants with urinary tract infections. J Pediatr 2008; 153:290-2. [PMID: 18639733 DOI: 10.1016/j.jpeds.2008.02.044] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2007] [Revised: 01/29/2008] [Accepted: 02/25/2008] [Indexed: 10/21/2022]
Abstract
In a multicenter prospective study, 91 of 1025 febrile infants <or=60 days of age had urinary tract infections. Among patients with urinary tract infections and without traumatic lumbar punctures, sterile cerebrospinal fluid pleocytosis was uncommon (0%-8%, depending on the definition) in contrast to earlier studies reporting this association.
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Affiliation(s)
- Samir S Shah
- Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
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Platt SL. Pneumonia. Pediatric Emergency Medicine 2008. [PMCID: PMC7170194 DOI: 10.1016/b978-141600087-7.50061-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Zorc JJ, Levine DA, Platt SL, Dayan PS, Macias CG, Krief W, Schor J, Bank D, Shaw KN, Kuppermann N. Clinical and demographic factors associated with urinary tract infection in young febrile infants. Pediatrics 2005; 116:644-8. [PMID: 16140703 DOI: 10.1542/peds.2004-1825] [Citation(s) in RCA: 142] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Previous research has identified clinical predictors for urinary tract infection (UTI) to guide urine screening in febrile children <24 months of age. These studies have been limited to single centers, and few have focused on young infants who may be most at risk for complications if a UTI is missed. The objective of this study was to identify clinical and demographic factors associated with UTI in febrile infants who are < or =60 days of age using a prospective multicenter cohort. METHODS We conducted a multicenter, prospective, cross-sectional study during consecutive bronchiolitis seasons. All febrile (> or =38 degrees C) infants who were < or =60 days of age and seen at any of 8 pediatric emergency departments from October through March 1999-2001 were eligible. Clinical appearance was evaluated using the Yale Observation Scale. UTI was defined as growth of a known bacterial pathogen from a catheterized specimen at a level of (1) > or =50000 cfu/mL or (2) > or =10000 cfu/mL in association with a positive dipstick test or urinalysis. We used bivariate tests and multiple logistic regression to identify demographic and clinical factors that were associated with the likelihood of UTI. RESULTS A total of 1025 (67%) of 1513 eligible patients were enrolled; 9.0% of enrolled infants received a diagnosis of UTI. Uncircumcised male infants had a higher rate of UTI (21.3%) compared with female (5.0%) and circumcised male (2.3%) infants. Infants with maximum recorded temperature of > or =39 degrees C had a higher rate of UTI (16.3%) than other infants (7.2%). After multivariable adjustment, UTI was associated with being uncircumcised (odds ratio: 10.4; bias-corrected 95% confidence interval: 4.7-31.4) and maximum temperature (odds ratio: 2.4 per degrees C; 95% confidence interval: 1.5-3.6). Factors that were reported previously to be associated with risk for UTI in infants and toddlers, such as white race and ill appearance, were not significantly associated with risk for UTI in this cohort of young infants. CONCLUSIONS Being uncircumcised and height of fever were associated with UTI in febrile infants who were < or =60 days of age. Uncircumcised male infants were at particularly high risk and may warrant a different approach to screening and management.
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Affiliation(s)
- Joseph J Zorc
- Department of Pediatrics, University of Pennsylvania School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
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Abstract
PURPOSE OF REVIEW A variety of pharmacologic agents used for procedural sedation in children to reduce pain and anxiety may produce respiratory depression and hypotension. Although standard monitoring guidelines include oxygen saturation, this measurement is limited as a guide to respiratory function. This review discusses two new monitoring techniques recently introduced to the pediatric emergency department that facilitate procedural sedation and reduce potential adverse effects of the medications administered. RECENT FINDINGS Capnography via an end-tidal carbon dioxide monitor measures carbon dioxide concentrations during ventilation. This measurement is independent of oxygen saturation and thereby aids the clinician in identifying hypoventilation and apnea in the sedated patient at an earlier stage than conventional monitoring. The bispectral index monitor objectively measures the depth of sedation by analyzing electroencephalogram signals from a cutaneous probe. This tool enables the physician to titrate sedative medications to a desired effect and thereby reduce the risks associated with oversedation. SUMMARY Studies have illustrated the use of both devices as adjuncts to current standard monitoring of children in the outpatient setting. These modalities will facilitate the efficacy of procedural sedation in children and improve safety by enabling early recognition of hypoventilation and by reducing the risk of oversedation in children undergoing procedural sedation.
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Affiliation(s)
- Deborah A Levine
- Departments of Pediatrics and Emergency Medicine, New York University School of Medicine, Bellevue Hospital Center, New York, New York 10016, USA.
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Levine DA, Platt SL, Dayan PS, Macias CG, Zorc JJ, Krief W, Schor J, Bank D, Fefferman N, Shaw KN, Kuppermann N. Risk of serious bacterial infection in young febrile infants with respiratory syncytial virus infections. Pediatrics 2004; 113:1728-34. [PMID: 15173498 DOI: 10.1542/peds.113.6.1728] [Citation(s) in RCA: 240] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The evaluation of young febrile infants is controversial, in part because it is unclear whether clinical evidence of a viral infection significantly reduces the risk of serious bacterial infections (SBIs). Specifically, it remains unclear whether the risk of SBI is altered in a meaningful way in the presence of respiratory syncytial virus (RSV) infections. OBJECTIVE The objective of this study was to determine the risk of SBI in young febrile infants who are infected with RSV compared with those without RSV infections. METHODS We conducted a 3-year multicenter, prospective, cross-sectional study. All febrile (> or =38 degrees C) infants who were < or =60 days of age and presented to any of 8 pediatric emergency departments from October through March 1998-2001 were eligible. General clinical appearance was evaluated using the Yale Observational Scale. We determined RSV status by antigen testing of nasopharyngeal secretions. We defined bronchiolitis as either wheezing alone or chest retractions in association with an upper respiratory infection. We evaluated infants with blood, urine, cerebrospinal fluid, and stool cultures. Urinary tract infection (UTI) was defined by single pathogen growth of > or =5 x 10(4) cfu/mL, or > or =10(4) cfu/mL in association with a positive urinalysis in a catheterized specimen, or > or = 10(3) cfu/mL in a suprapubic aspirate. Bacteremia, bacterial meningitis, and bacterial enteritis were defined by growth of a known bacterial pathogen. SBI was defined as any of the above-mentioned 4 bacterial infections. RESULTS We enrolled 1248 patients, including 269 (22%) with RSV infections. The overall SBI status could be determined in 1169 (94%) of the 1248 patients, and the rate of SBIs was 11.4% (133 of 1169; 95% confidence interval [CI]: 9.6%-13.3%). The rate of SBIs in the RSV-positive infants was 7.0% (17 of 244; 95% CI: 4.1%-10.9%) compared with 12.5% (116 of 925; 95% CI: 10.5%-14.8%) in the RSV-negative infants (risk difference: 5.5%; 95% CI: 1.7%-9.4%). The rate of UTI in the RSV-positive infants was 5.4% (14 of 261; 95% CI: 3.0%-8.8%) compared with 10.1% (98 of 966; 95% CI: 8.3%-12.2%) in the RSV-negative infants (risk difference: 4.7%; 95% CI: 1.4%-8.1%). The RSV-positive infants had a lower rate of bacteremia than the RSV-negative infants (1.1% vs 2.3%; risk difference: 1.2%; 95% CI: -0.4% to 2.7%). No RSV-positive infant had bacterial meningitis (0 of 251; 95% CI: 0%-1.2%); however, the differences between the 2 groups with regard to bacteremia and bacterial meningitis did not achieve statistical significance. CONCLUSIONS Febrile infants who are < or =60 days of age and have RSV infections are at significantly lower risk of SBI than febrile infants without RSV infection. Nevertheless, the rate of SBIs, particularly as a result of UTI, remains appreciable in febrile RSV-positive infants.
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Affiliation(s)
- Deborah A Levine
- Department of Pediatrics, New York University School of Medicine/Bellevue Hospital Center, New York, New York 10016, USA.
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Abstract
OBJECTIVE To describe a series of nonmotorized scooter-related injuries to children to increase public awareness and encourage prevention of such injuries. DESIGN A descriptive study of a consecutive series of patients. SETTING The pediatric emergency service of a municipal hospital. PARTICIPANTS All children <18 years old who presented to the Pediatric Emergency Service (PES) with a scooter-related injury from July through September 2000. METHODS Patients were identified by review of the PES medical records. Charts were reviewed for patient data including age, place of injury, use of protective gear, adult supervision, injury sustained, medical management, and disposition. RESULTS There were 15 children treated in the PES for scooter-related injuries. The mean age was 7.8 years, 73% were male. Approximately 90% of injuries occurred as a result of falling off a scooter. Irregular pavement caused 3 falls and tandem riding caused 2 falls. Inability to use the foot brake caused 1 collision, and 1 child was hit by a motor vehicle while crossing the street. Injuries occurred in a park (33%), on a sidewalk (47%), in a home (13%), and on the street (7%). Adult supervision was present in half of the cases. Only 2 children were wearing helmets at the time of injury; none wore protective padding. Five children (33%) suffered head trauma; 1 lost consciousness, and 2 suffered amnesia. Three children required a head computed tomography scan, and 1 required cervical spine radiographs. All radiographs were negative. None of these 5 children were wearing helmets. Seven children (47%) sustained facial injuries, and 4 of these children required laceration repair. Seven children (47%) sustained extremity trauma, including 1 laceration and 6 fractures (1 supracondylar, 1 distal radius, 2 radius/ulnar, 1 tibia/fibula, and 1 patella). Four fractures involved the upper extremity. Four fractures were managed by closed reduction; 2 required operative repair. One child required splinting of an avulsed tooth. Three of the children (20%) were admitted. The 5 children with head trauma were observed and released. CONCLUSION The use of nonmotorized scooters by children may result in serious injury, particularly in the young child. Although not life-threatening, these injuries require significant medical intervention and may result in permanent functional and cosmetic deformity. These injuries are potentially preventable with the proper use of protective gear and supervision. Public and parental awareness and education are essential to prevent additional injuries.
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Affiliation(s)
- D A Levine
- Departments of Pediatrics and Emergency Medicine/Surgery, New York University School of Medicine, Bellevue Hospital Center, New York, New York 10016, USA.
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Abstract
OBJECTIVE Escalator-related trauma is uncommon but can cause significant injury. This study reviewed escalator-related injuries in children to determine risk factors, types of injuries, medical interventions, and long-term outcomes. DESIGN AND SETTING Retrospective clinical patient series, Municipal Hospital Pediatric Emergency Service. Participants. All children less than 18 years of age who presented to the Pediatric Emergency Service with an escalator-related injury from August 1990 through February 1995. METHODS We reviewed the chart and interviewed the parent of each child by telephone. We collected the following information: age, gender, child's supervision and activity while on the escalator, escalator location, direction of motion, presence of escalator defects, nature and extent of injury, medical interventions, and outcome. RESULTS Twenty-six children had escalator-related injuries. The average age was 6 years (range, 2-16). Thirteen children (50%) were 2 to 4 years old. There were 15 (57%) boys. Eighteen children (69%) were accompanied by an adult. All children 7 years and younger were accompanied by an adult; however, 50% were not holding the hand of their guardian. Eight children (31%) were injured while riding improperly, ie, walking, running, playing, or sitting on the escalator, and among these, all who were standing fell down before the injury. Six (23%) children were injured while stepping off the escalator. Of 9 children less than 4 years old, 7 (78%) were riding the escalator properly. Of 9 children 4 years or older, only 3 (33%) were riding properly. Circumstances of injury included falling down with subsequent blunt trauma, falling down with subsequent entrapment of an extremity, and entrapment of an extremity not related to falling down. Locations of entrapment were between two steps, between a step and the side-rail, and between the last step and the comb plate. Twenty-one (81%) injuries occurred in rail or subway stations. Eight escalators were reported to have functional or structural problems. Seventeen (65%) children sustained lower extremity injuries and 8 (31%) sustained upper extremity injuries. Injuries included lacerations, avulsions and degloving injuries of the extremities, tendon and nerve lacerations, and digit fractures and amputations. Thirteen (50%) children were admitted to the hospital for operative management; the average length of hospitalization was 13 days (range 1-29). Four children (15%) suffered significant functional loss, and 12 (46%) sustained permanent cosmetic deformities. CONCLUSION Children are at risk for sustaining severe injuries on escalators. Young age, inadequate adult supervision, improper activity while riding on the escalator, and escalator-related mechanical problems all increase the risk of injury. Public and parent education directed toward escalator safety issues may help to reduce escalator-related injuries in children.
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Affiliation(s)
- S L Platt
- Department of Pediatrics, New York University School of Medicine and the Pediatric Emergency Service, Bellevue Hospital Center, New York, NY 10016, USA
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Affiliation(s)
- S L Platt
- Department of Pediatrics, New York Hospital-Cornell Medical Center, NY 10021
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