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Milliren CE, Ozonoff A, Fournier KA, Welcher J, Landschaft A, Kimia AA. Enhancing Pressure Injury Surveillance Using Natural Language Processing. J Patient Saf 2024; 20:119-124. [PMID: 38147064 PMCID: PMC10922576 DOI: 10.1097/pts.0000000000001193] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2023]
Abstract
OBJECTIVE This study assessed the feasibility of nursing handoff notes to identify underreported hospital-acquired pressure injury (HAPI) events. METHODS We have established a natural language processing-assisted manual review process and workflow for data extraction from a corpus of nursing notes across all medical inpatient and intensive care units in a tertiary care pediatric center. This system is trained by 2 domain experts. Our workflow started with keywords around HAPI and treatments, then regular expressions, distributive semantics, and finally a document classifier. We generated 3 models: a tri-gram classifier, binary logistic regression model using the regular expressions as predictors, and a random forest model using both models together. Our final output presented to the event screener was generated using a random forest model validated using derivation and validation sets. RESULTS Our initial corpus involved 70,981 notes during a 1-year period from 5484 unique admissions for 4220 patients. Our interrater human reviewer agreement on identifying HAPI was high ( κ = 0.67; 95% confidence interval [CI], 0.58-0.75). Our random forest model had 95% sensitivity (95% CI, 90.6%-99.3%), 71.2% specificity (95% CI, 65.1%-77.2%), and 78.7% accuracy (95% CI, 74.1%-83.2%). A total of 264 notes from 148 unique admissions (2.7% of all admissions) were identified describing likely HAPI. Sixty-one described new injuries, and 64 describe known yet possibly evolving injuries. Relative to the total patient population during our study period, HAPI incidence was 11.9 per 1000 discharges, and incidence rate was 1.2 per 1000 bed-days. CONCLUSIONS Natural language processing-based surveillance is proven to be feasible and high yield using nursing handoff notes.
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Affiliation(s)
- Carly E. Milliren
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, MA
| | - Al Ozonoff
- Division of Infectious Diseases, Boston Children’s Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kerri A. Fournier
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, MA
| | - Jennifer Welcher
- Department of Ophthalmology, Boston Children’s Hospital, Boston, MA
| | - Assaf Landschaft
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA
| | - Amir A. Kimia
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA
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2
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Rudloff JR, El Helou R, Landschaft A, Harper MB, Ahmad FA, Kimia AA. Bacteremia in Patients With Fever and Acute Lower Extremity Pain in a Non-Lyme Endemic Region. Pediatrics 2024; 153:e2023064095. [PMID: 38093653 PMCID: PMC10752821 DOI: 10.1542/peds.2023-064095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/11/2023] [Indexed: 12/30/2023] Open
Affiliation(s)
| | | | | | | | - Fahd A. Ahmad
- Washington University in St Louis, St Louis, Missouri
| | - Amir A. Kimia
- Connecticut Children’s Hospital, Hartford, Connecticut
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3
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Chafjiri FMA, Reece L, Voke L, Landschaft A, Clark J, Kimia AA, Loddenkemper T. Natural language processing for identification of refractory status epilepticus in children. Epilepsia 2023; 64:3227-3237. [PMID: 37804085 DOI: 10.1111/epi.17789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 10/03/2023] [Accepted: 10/03/2023] [Indexed: 10/08/2023]
Abstract
OBJECTIVE Pediatric status epilepticus is one of the most frequent pediatric emergencies, with high mortality and morbidity. Utilizing electronic health records (EHRs) permits analysis of care approaches and disease outcomes at a lower cost than prospective research. However, reviewing EHR manually is time intensive. We aimed to compare refractory status epilepticus (rSE) cases identified by human EHR review with a natural language processing (NLP)-assisted rSE screen followed by a manual review. METHODS We used the NLP screening tool Document Review Tool (DrT) to generate regular expressions, trained a bag-of-words NLP classifier on EHRs from 2017 to 2019, and then tested our algorithm on data from February to December 2012. We compared results from manual review to NLP-assisted search followed by manual review. RESULTS Our algorithm identified 1528 notes in the test set. After removing notes pertaining to the same event by DrT, the user reviewed a total number of 400 notes to find patients with rSE. Within these 400 notes, we identified 31 rSE cases, including 12 new cases not found in manual review, and 19 of the 20 previously identified cases. The NLP-assisted model found 31 of 32 cases, with a sensitivity of 96.88% (95% CI = 82%-99.84%), whereas manual review identified 20 of 32 cases, with a sensitivity of 62.5% (95% CI = 43.75%-78.34%). SIGNIFICANCE DrT provided a highly sensitive model compared to human review and an increase in patient identification through EHRs. The use of DrT is a suitable application of NLP for identifying patients with a history of recent rSE, which ultimately contributes to the implementation of monitoring techniques and treatments in near real time.
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Affiliation(s)
- Fatemeh Mohammad Alizadeh Chafjiri
- Department of Neurology, Division of Epilepsy and Clinical Neurophysiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Latania Reece
- Department of Neurology, Division of Epilepsy and Clinical Neurophysiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Nexamp, Boston, Massachusetts, USA
| | - Lillian Voke
- Department of Neurology, Division of Epilepsy and Clinical Neurophysiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Justice Clark
- Department of Neurology, Division of Epilepsy and Clinical Neurophysiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Amir A Kimia
- Department of Medicine, Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Connecticut Children's Hospital, Hartford, Connecticut, USA
| | - Tobias Loddenkemper
- Department of Neurology, Division of Epilepsy and Clinical Neurophysiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Abstract
BACKGROUND AND OBJECTIVES Blood cultures (BCxs) are often obtained in the initial evaluation of children with fever and acute lower extremity pain; however, their yield in this population is unknown. We aim to describe the prevalence of bacteremia among children presenting to the emergency department (ED) with fever and acute lower extremity pain and identify predictors of bacteremia. METHODS Cross-sectional review of children aged 1 to 18 years presenting to the ED with fever and acute lower extremity pain between 2010 and 2020. We excluded patients with trauma within the previous 24 hours, orthopedic comorbidity, immunocompromised status, or antibiotic pretreatment. We identified our cohort using a Natural Language Processing-assisted model with manual review and abstracted clinical data. Our primary outcome was a BCx positive for a pathogen. RESULTS We screened 478 979 ED notes and identified 689 patients who met inclusion criteria. Median age was 5.3 years (interquartile range 2.7-8.8); 39.5% were female. BCxs were obtained from 75.9% (523/689) of patients, of which 510 were available for review. BCxs were positive in 70/510 (13.7%; 95% CI, confidence interval [CI], 10.9-17.0) of children and in 70/689 (10.2%; 95% CI, 8.0-12.7%) of the entire cohort. The most common pathogens were methicillin-susceptible Staphylococcus aureus (71.6%) and methicillin-resistant Staphylococcus aureus (15.7%). Predictors of bacteremia include C-reactive protein ≥3 mg/dL (odds ratio, 4.5; 95% CI, 2.1-9.6) and localizing examination findings (odds ratio, 3.3; 95% CI, 1.4-7.9). CONCLUSIONS The prevalence of bacteremia among children presenting to the ED with fever and acute lower extremity pain is high. Routine BCx should be considered in the initial evaluation of this population.
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Affiliation(s)
- Rachelle El Helou
- Boston Children's Hospital, Boston, Massachusetts; and
- American University of Beirut Medical Center, Beirut, Lebanon
| | | | | | - Amir A Kimia
- Boston Children's Hospital, Boston, Massachusetts; and
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5
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Ozonoff A, Milliren CE, Fournier K, Welcher J, Landschaft A, Samnaliev M, Saluvan M, Waltzman M, Kimia AA. Electronic surveillance of patient safety events using natural language processing. Health Informatics J 2022; 28:14604582221132429. [PMID: 36330784 DOI: 10.1177/14604582221132429] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Objective We describe our approach to surveillance of reportable safety events captured in hospital data including free-text clinical notes. We hypothesize that a) some patient safety events are documented only in the clinical notes and not in any other accessible source; and b) large-scale abstraction of event data from clinical notes is feasible. Materials and Methods We use regular expressions to generate a training data set for a machine learning model and apply this model to the full set of clinical notes and conduct further review to identify safety events of interest. We demonstrate this approach on peripheral intravenous (PIV) infiltrations and extravasations (PIVIEs). Results During Phase 1, we collected 21,362 clinical notes, of which 2342 were reviewed. We identified 125 PIV events, of which 44 cases (35%) were not captured by other patient safety systems. During Phase 2, we collected 60,735 clinical notes and identified 440 infiltrate events. Our classifier demonstrated accuracy above 90%. Conclusion Our method to identify safety events from the free text of clinical documentation offers a feasible and scalable approach to enhance existing patient safety systems. Expert reviewers, using a machine learning model, can conduct routine surveillance of patient safety events.
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Affiliation(s)
- Al Ozonoff
- Boston Children’s Hospital, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | | | | | | | - Mihail Samnaliev
- Boston Children’s Hospital, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | - Mark Waltzman
- Boston Children’s Hospital, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Amir A Kimia
- Boston Children’s Hospital, MA, USA
- Harvard Medical School, Boston, MA, USA
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Al-Samkari H, Ozonoff A, Landschaft A, Kimia R, Harper MB, Croteau SE, Kimia AA. Utility of Blood Cultures and Empiric Antibiotics in Febrile Pediatric Hemophilia Patients With Central Venous Access Devices. Pediatr Emerg Care 2021; 37:e1531-e1534. [PMID: 32349076 DOI: 10.1097/pec.0000000000002106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Children with hemophilia frequently require long-term central venous access devices (CVADs) for regular infusion of factor products. Hemophilia patients are not immunocompromised, but the presence and use of CVADs are associated with infections including bacteremia. Currently, the utility of blood cultures in evaluation of the febrile hemophilia patient with an indwelling CVAD is unknown, nor is optimal empiric antibiotic use. METHODS We performed a retrospective cross-sectional study of febrile immunocompetent hemophilia patients with CVADs presenting to a large academic urban pediatric emergency department from 1995 to 2017. We used a natural language processing electronic search, followed by manual chart review to construct the cohort. We analyzed rate of pathogen recovery from cultures of blood in subgroups of hemophilia patients, the pathogen profile, and the reported pathogen susceptibilities to ceftriaxone. RESULTS Natural language processing electronic search identified 181 visits for fever among hemophilia patients with indwelling CVADs of which 147 cases from 44 unique patients met study criteria. Cultures of blood were positive in 56 (38%) of 147 patients (95% confidence interval, 30%-47%). Seventeen different organisms were isolated (10 pathogens and 7 possible pathogens) with Staphylococcus aureus and coagulase-negative Staphylococcus species as the most common. Thirty-four percent of isolates were reported as susceptible to ceftriaxone. Positive blood cultures were more common in cases involving patients with inhibitors (n = 71) versus those without (n = 76), odds ratio, 7.4 (95% confidence interval, 3.5-15.9). This was observed irrespective of hemophilia type. CONCLUSIONS Febrile immunocompetent hemophilia patients with indwelling CVADs have high rates of bacteremia. Empiric antimicrobial therapy should be targeted to anticipated pathogens and take into consideration local susceptibility patterns for Staphylococcus aureus.
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Barak-Corren Y, Agarwal I, Michelson KA, Lyons TW, Neuman MI, Lipsett SC, Kimia AA, Eisenberg MA, Capraro AJ, Levy JA, Hudgins JD, Reis BY, Fine AM. Prediction of patient disposition: comparison of computer and human approaches and a proposed synthesis. J Am Med Inform Assoc 2021; 28:1736-1745. [PMID: 34010406 DOI: 10.1093/jamia/ocab076] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/20/2021] [Accepted: 04/09/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To compare the accuracy of computer versus physician predictions of hospitalization and to explore the potential synergies of hybrid physician-computer models. MATERIALS AND METHODS A single-center prospective observational study in a tertiary pediatric hospital in Boston, Massachusetts, United States. Nine emergency department (ED) attending physicians participated in the study. Physicians predicted the likelihood of admission for patients in the ED whose hospitalization disposition had not yet been decided. In parallel, a random-forest computer model was developed to predict hospitalizations from the ED, based on data available within the first hour of the ED encounter. The model was tested on the same cohort of patients evaluated by the participating physicians. RESULTS 198 pediatric patients were considered for inclusion. Six patients were excluded due to incomplete or erroneous physician forms. Of the 192 included patients, 54 (28%) were admitted and 138 (72%) were discharged. The positive predictive value for the prediction of admission was 66% for the clinicians, 73% for the computer model, and 86% for a hybrid model combining the two. To predict admission, physicians relied more heavily on the clinical appearance of the patient, while the computer model relied more heavily on technical data-driven features, such as the rate of prior admissions or distance traveled to hospital. DISCUSSION Computer-generated predictions of patient disposition were more accurate than clinician-generated predictions. A hybrid prediction model improved accuracy over both individual predictions, highlighting the complementary and synergistic effects of both approaches. CONCLUSION The integration of computer and clinician predictions can yield improved predictive performance.
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Affiliation(s)
- Yuval Barak-Corren
- Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Isha Agarwal
- Harvard Medical School, Boston, Massachusetts, USA.,Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Kenneth A Michelson
- Harvard Medical School, Boston, Massachusetts, USA.,Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Todd W Lyons
- Harvard Medical School, Boston, Massachusetts, USA.,Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mark I Neuman
- Harvard Medical School, Boston, Massachusetts, USA.,Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Susan C Lipsett
- Harvard Medical School, Boston, Massachusetts, USA.,Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Amir A Kimia
- Harvard Medical School, Boston, Massachusetts, USA.,Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Matthew A Eisenberg
- Harvard Medical School, Boston, Massachusetts, USA.,Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Andrew J Capraro
- Harvard Medical School, Boston, Massachusetts, USA.,Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jason A Levy
- Harvard Medical School, Boston, Massachusetts, USA.,Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Joel D Hudgins
- Harvard Medical School, Boston, Massachusetts, USA.,Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ben Y Reis
- Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew M Fine
- Harvard Medical School, Boston, Massachusetts, USA.,Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
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8
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Kimia R, Voskoboynik B, Hudgins JD, Harper MB, Landschaft A, Kupiec JK, Kimia AA. Is lymphangitic streaking associated with different pathogens? Am J Emerg Med 2021; 46:34-37. [PMID: 33714052 DOI: 10.1016/j.ajem.2021.02.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 02/21/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Little is known regarding the differences in microbiology associated with cellulitis or abscess with or without lymphangitic streaking. The objective of our study is to assess whether there are differences in the pathogens identified from wound cultures of patients with paronychia with and without associated lymphangitis. METHODS Retrospective cross-sectional study at a tertiary pediatric emergency department over 25 years. We opted to assess patients with paronychia of the finger, assuming that these cases will have a greater variety of causative pathogens compared to other cases of cellulitis and soft tissue abscess that are associated with nail biting. Case identification was conducted using a computerized text-screening search that was refined by manual chart review. We included patients from 1 month to 20 years of age who underwent an incision and drainage (I&D) of a paronychia and had a culture obtained. The presence or absence of lymphangitis was determined from the clinical narrative in the medical record. We excluded patients treated with antibiotics prior to I&D as well as immune-compromised patients. We used descriptive statistics for prevalence and χ2 tests for categorical variables. RESULTS Two hundred sixty-six patients met inclusion criteria. The median age was 9.7 years [IQR 4.7, 15.4] and 45.1% were female. Twenty-two patients (8.3%) had lymphangitic streaking associated with their paronychia. Patients with lymphangitis streaking were similar to those without lymphangitis in terms of age and sex (p = 0.52 and p = 0.82, respectively). Overall, the predominant bacteria was MSSA (40%) followed by MRSA (26%). No significant differences were found between the pathogens in the 22 patients with associated lymphangitis compared to the 244 patients without. CONCLUSION Staphylococcus aureus represent the majority of pathogens in paronychia, although streptococcal species and gram-negative bacteria were also common. Among patients with paronychia of the finger, there seems to be no association between pathogen type and presence of lymphangitic streaking.
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Affiliation(s)
- Rotem Kimia
- Boston Children's Hospital, Department of Emergency Medicine, USA
| | | | - Joel D Hudgins
- Boston Children's Hospital, Department of Emergency Medicine, USA
| | - Marvin B Harper
- Boston Children's Hospital, Department of Emergency Medicine, USA; Boston Children's Hospital, Department of Pediatric Infectious Diseases, USA
| | - Assaf Landschaft
- Boston Children's Hospital, Department of Emergency Medicine, USA
| | | | - Amir A Kimia
- Boston Children's Hospital, Department of Emergency Medicine, USA.
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9
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Guedj R, Marini M, Kossowsky J, Berde CB, Kimia AA, Fleegler EW. Racial and Ethnic Disparities in Pain Management of Children With Limb Fractures or Suspected Appendicitis: A Retrospective Cross-Sectional Study. Front Pediatr 2021; 9:652854. [PMID: 34414139 PMCID: PMC8369476 DOI: 10.3389/fped.2021.652854] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 07/06/2021] [Indexed: 11/30/2022] Open
Abstract
Objective: To evaluate whether racial/ethnical differences in analgesia administration existed in two different cohorts of children with painful conditions: children with either limb fracture or suspected appendicitis. Methods: Retrospective cross-sectional analysis of children visiting a pediatric emergency department (Boston Children Hospital) for limb fracture or suspected appendicitis from 2011 to 2015. We computed the proportion of children that received any analgesic treatment and any opioid analgesia. We performed multivariable logistic regressions to investigate race/ethnicity differences in analgesic and opioid administration, after adjusting for pain score, demographics and visit covariates. Results: Among the 8,347 children with a limb fracture and the 4,780 with suspected appendicitis, 65.0 and 60.9% received any analgesic treatment, and 35.9 and 33.4% an opioid analgesia, respectively. Compared to White non-Hispanic Children, Black non-Hispanic children and Hispanic children were less likely to receive opioid analgesia in both the limb fracture cohort [Black: aOR = 0.61 (95% CI, 0.50-0.75); Hispanic aOR = 0.66 (95% CI, 0.55-0.80)] and in the suspected appendicitis cohort [Black: aOR = 0.75 (95% CI, 0.58-0.96); Hispanic aOR = 0.78 (95% CI, 0.63-0.96)]. In the limb fracture cohort, Black non-Hispanic children and Hispanic children were more likely to receive any analgesic treatment (non-opioid or opioid) than White non-Hispanic children [Black: aOR = 1.63 (95% CI, 1.33-2.01); Hispanic aOR = 1.43 (95% CI, 1.19-1.72)]. Conclusion: Racial and ethnic disparities exist in the pain management of two different painful conditions, which suggests true inequities in health care delivery. To provide equitable analgesic care, emergency departments should monitor variation in analgesic management and develop appropriate universal interventions.
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Affiliation(s)
- Romain Guedj
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, United States.,Department of Pediatric Emergency Medicine, Trousseau Hospital, Assistance Publique des Hôpitaux de Paris, Sorbonne Université, Paris, France.,Obstetrical, Perinatal, and Pediatric Epidemiology Research Team, Epidemiology and Statistics Research Center, Université de Paris, INSERM, Paris, France
| | - Maddalena Marini
- Istituto Italiano di Tecnologia, Center for Translational Neurophysiology, Ferrara, Italy
| | - Joe Kossowsky
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, United States.,Department of Anaesthesia, Harvard Medical School, Boston, MA, United States
| | - Charles B Berde
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, United States.,Department of Anaesthesia, Harvard Medical School, Boston, MA, United States
| | - Amir A Kimia
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States.,Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA, United States
| | - Eric W Fleegler
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States.,Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA, United States
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10
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Waltzman ML, Lee LK, Ozonoff A, Kupiec JK, Landschaft A, Kimia AA. Treadmill injuries in children. Am J Emerg Med 2020; 46:495-498. [PMID: 33261949 DOI: 10.1016/j.ajem.2020.10.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/24/2020] [Accepted: 10/28/2020] [Indexed: 11/15/2022] Open
Affiliation(s)
- Mark L Waltzman
- Boston Children's Hospital, Department of Emergency Medicine, Boston, USA
| | - Lois K Lee
- Boston Children's Hospital, Department of Emergency Medicine, Boston, USA
| | - Al Ozonoff
- Boston Children's Hospital, Department of Pediatirc Infectious Disaeses, Boston, USA
| | - Jennifer K Kupiec
- Boston Children's Hospital, Department of Emergency Medicine, Boston, USA
| | - Assaf Landschaft
- Boston Children's Hospital, Department of Emergency Medicine, Boston, USA
| | - Amir A Kimia
- Boston Children's Hospital, Department of Emergency Medicine, Boston, USA.
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11
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Delaney AC, Velarde A, Harper MB, Lebel A, Landschaft A, Monuteaux M, Heidary G, Kimia AA. Predictors of Primary Intracranial Hypertension in Children Using a Newly Suggested Opening Pressure Cutoff of 280 mm H 2O. Pediatr Neurol 2019; 91:27-33. [PMID: 30573329 DOI: 10.1016/j.pediatrneurol.2018.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 09/19/2018] [Accepted: 09/26/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES We assessed the clinical characteristics of primary intracranial hypertension (PIH) in children using a newly recommended threshold for cerebrospinal fluid opening pressure (280 mm H2O). METHOD Cross-sectional study of patients age ≤21 years who had a lumbar puncture done for evaluation of PIH. Patients were excluded if lumbar puncture was done for a suspected infection, seizure, mental status changes, multiple sclerosis, or Guillain-Barre syndrome. Cases were identified using a text-search module followed by manual review. We performed χ2 analysis for categorical data and Mann-Whitney U test for continuous data, followed by a binary logistic regression. RESULTS We identified 374 patients of whom 67% were female, median age was 13 years interquartile range (11 to 16 years), and admission rate was 24%. Using an opening pressure cutoff of 250 mm H2O, 127 patients (34%) were identified as having PIH, whereas using the new cutoff 105 patients (28%) met PIH criteria. Predictors for PIH included optic disc edema or sixth nerve palsy using both old, odds ratio (OR) 7.6 (4.3, 13.5), and new cutoffs, OR 9.7 (95% confidence interval 5.1, 18.5). Headache duration ≤61 days is predictive of PIH using the new cutoff OR 4.1 (95% confidence interval 1.3, 12.8). A model is presented which stratifies patients into groups with low (7%), medium (18%), and high (greater than 42%) risk of PIH. CONCLUSIONS A higher cerebrospinal fluid opening pressure threshold in the criteria of PIH is associated with PIH patients with a different symptom profile. Children with optic disc edema, bulging fontanel or sixth nerve palsy, are at increased risk for PIH.
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Affiliation(s)
- Atima C Delaney
- Department of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Aynslee Velarde
- Department of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Marvin B Harper
- Department of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Alyssa Lebel
- Department of Anesthesia/Neurology, Boston Children's Hospital, Boston, Massachusetts
| | - Assaf Landschaft
- Department of IT, Boston Children's Hospital, Boston, Massachusetts
| | - Michael Monuteaux
- Department of Biostat, Boston Children's Hospital, Boston, Massachusetts
| | - Gena Heidary
- Department of Neuro-Ophthalmology, Boston Children's Hospital, Boston, Massachusetts
| | - Amir A Kimia
- Department of Emergency Medicine, Department of Informatics, Boston Children's Hospital, Boston, Massachusetts.
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12
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Stewart AM, Kanak MM, Gerald AM, Kimia AA, Landschaft A, Sandel MT, Lee LK. Pediatric Emergency Department Visits for Homelessness After Shelter Eligibility Policy Change. Pediatrics 2018; 142:peds.2018-1224. [PMID: 30323107 DOI: 10.1542/peds.2018-1224] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [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] [Accepted: 08/02/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES In 2012, Massachusetts changed its emergency shelter eligibility policy for homeless families. One new criterion to document homelessness was staying in a location "not meant for human habitation," and the emergency department (ED) fulfilled this requirement. Our aim for this study is to analyze the frequency and costs of pediatric ED visits for homelessness before and after this policy. METHODS This is a retrospective study of ED visits for homelessness at a children's hospital from March 2010 to February 2016. A natural language processing tool was used to identify cases, which were manually reviewed for inclusion. We compared demographic and homelessness circumstance characteristics and conducted an interrupted time series analysis to compare ED visits by homeless children before and after the policy. We compared the change in ED visits for homelessness to the number of homeless children in Massachusetts. We analyzed payment data for each visit. RESULTS There were 312 ED visits for homelessness; 95% (n = 297) of visits were after the policy. These visits increased 4.5 times after the policy (95% confidence interval: 1.33 to 15.23). Children seen after the policy were more likely to have no medical complaint (rate ratio: 3.27; 95% confidence interval: 1.18 to 9.01). Although the number of homeless children in Massachusetts increased 1.4 times over the study period, ED visits for homelessness increased 13-fold. Payments (average: $557 per visit) were >4 times what a night in a shelter would cost; 89% of payments were made through state-based insurance plans. CONCLUSIONS A policy change to Massachusetts' shelter eligibility was associated with increased pediatric ED visits for homelessness along with substantial health care costs.
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Affiliation(s)
- Amanda M Stewart
- Division of Emergency Medicine and .,Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Mia M Kanak
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Boston Medical Center, Boston, Massachusetts; and
| | | | - Amir A Kimia
- Division of Emergency Medicine and.,Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Assaf Landschaft
- Division of Emergency Medicine and.,Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Megan T Sandel
- Department of Pediatrics, Boston Medical Center, Boston, Massachusetts; and.,School of Medicine, Boston University, Boston, Massachusetts
| | - Lois K Lee
- Division of Emergency Medicine and.,Harvard Medical School, Harvard University, Boston, Massachusetts
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Olson H, Rudloe T, Loddenkemper T, Harper MB, Kimia AA. Should patients with complex febrile seizure be admitted for further management? Am J Emerg Med 2018; 36:1386-1390. [DOI: 10.1016/j.ajem.2017.12.059] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 11/27/2017] [Accepted: 12/27/2017] [Indexed: 11/17/2022] Open
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Kimia AA, Rudloe TF, Aprahamian N, McNamara J, Roberson D, Landschaft A, Vaughn J, Harper MB. Predictors of a drainable suppurative adenitis among children presenting with cervical adenopathy. Am J Emerg Med 2018; 37:109-113. [PMID: 29754963 DOI: 10.1016/j.ajem.2018.05.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 04/25/2018] [Accepted: 05/05/2018] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES We sought to identify predictors for a drainable suppurative adenitis [DSA] among patients presenting with acute cervical lymphadenitis. METHODS A retrospective cross sectional study of all patients admitted to an urban pediatric tertiary care emergency department over a 15 year period. Otherwise healthy patients who underwent imaging for an evaluation of cervical lymphadenitis were included. Cases were identified using a text-search module followed by manual review. We excluded immunocompromised patients and those with lymphadenopathy felt to be not directly infected (i.e. reactive) or that was not acute (symptom duration >28 days). Data collected included: age, gender, duration of symptoms, highest recorded temperature, physical exam findings, laboratory and imaging results, and surgical findings. A DSA was defined as >1.5 cm in diameter on imaging. We performed binary logistic regression to determine independent clinical predictors of a DSA. RESULTS Three hundred sixty-one patients met inclusion criteria. Three hundred six patients (85%) had a CT scan, 55 (15%) had an ultrasound and 33 (9%) had both. DSA was identified in 71 (20%) patients. Clinical features independently associated with a DSA included absence of clinical pharyngitis, WBC >15,000/mm3, age ≤3 years, anterior cervical chain location, largest palpable diameter on exam >3 cm and prior antibiotic treatment of >24 h. The presence of fever, skin erythema, or fluctuance on examination, was not found to be predictive of DSA. CONCLUSIONS We identified independent predictors of DSA among children presenting with cervical adenitis. Risk can be stratified into risk groups based on these clinical features.
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Paydar-Darian N, Kimia AA, Lantos PM, Fine AM, Gordon CD, Gordon CR, Landschaft A, Nigrovic LE. Diagnostic Lumbar Puncture Among Children With Facial Palsy in a Lyme Disease Endemic Area. J Pediatric Infect Dis Soc 2017; 6:205-208. [PMID: 27422867 DOI: 10.1093/jpids/piw036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 06/01/2016] [Indexed: 11/13/2022]
Abstract
We identified 620 children with peripheral facial palsy of which 211 (34%) had Lyme disease. The 140 children who had a lumbar puncture performed were more likely to be hospitalized (73% LP performed vs 2% no LP) and to receive parenteral antibiotics (62% LP performed vs 6% no LP).
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Affiliation(s)
| | - Amir A Kimia
- Division of Emergency Medicine, Boston Children's Hospital, Massachusetts
| | - Paul M Lantos
- Divisions of General Internal Medicine and Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, and
| | - Andrew M Fine
- Division of Emergency Medicine, Boston Children's Hospital, Massachusetts
| | - Caroline D Gordon
- Division of Emergency Medicine, Boston Children's Hospital, Massachusetts
| | - Catherine R Gordon
- Division of Emergency Medicine, Boston Children's Hospital, Massachusetts
| | | | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital, Massachusetts
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Abstract
OBJECTIVE The objective of this study was to identify a relationship between cerebrospinal fluid (CSF) volume removal and change in CSF pressure in children with suspected idiopathic intracranial hypertension (IIH). METHODS We performed a cross-sectional study of children 22 years and younger who underwent a lumbar puncture (LP) and had a documented opening pressure, closing pressure, and volume removed. Relationship between volume removal and pressure change was determined using a fractional polynomial regression procedure. RESULTS In the 297 patients who met the inclusion criteria, CSF pressure decreased by 1 cm H2O for every 0.91 mL of CSF removed if the maximum change in pressure was less than 15 cm H2O ( R2 = 0.38). CONCLUSION A linear relationship exists between the volume of CSF removed and the amount of pressure relieved when the desired pressure change is less than 15 cm H2O.
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Affiliation(s)
- Son H McLaren
- 1 Division of Pediatric Emergency Medicine, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Michael C Monuteaux
- 1 Division of Pediatric Emergency Medicine, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Atima C Delaney
- 1 Division of Pediatric Emergency Medicine, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Assaf Landschaft
- 1 Division of Pediatric Emergency Medicine, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Amir A Kimia
- 1 Division of Pediatric Emergency Medicine, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
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Lyons TW, Johnson KB, Michelson KA, Nigrovic LE, Loddenkemper T, Prabhu SP, Kimia AA. Yield of emergent neuroimaging in children with new-onset seizure and status epilepticus. Seizure 2015; 35:4-10. [PMID: 26773658 DOI: 10.1016/j.seizure.2015.12.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 12/16/2015] [Accepted: 12/17/2015] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To determine the yield of emergent neuroimaging among children with new-onset seizures presenting with status epilepticus. METHOD We performed a cross-sectional study of children seen at a single ED between 1995 and 2012 with new-onset seizure presenting with status epilepticus. We defined status epilepticus as a single seizure or multiple seizures without regaining consciousness lasting 30 min or longer. Our primary outcome was urgent or emergent intracranial pathology identified on neuroimaging. We categorized neuroimaging results as emergent if they would have changed acute management as assessed by a blinded neuroradiologist and neurologist. To ensure abnormalities were not missed, we review neuroimaging results for 30 days following the initial episode of SE. RESULTS We included 177 children presenting with new-onset seizure with status epilepticus, of whom 170 (96%) had neuroimaging performed. Abnormal findings were identified on neuroimaging in 64/177 (36%, 95% confidence interval 29-43%) children with 15 (8.5%, 95% confidence interval 5.2-14%) children having urgent or emergent pathology. Four (27%) of the 15 children with urgent or emergent findings had a normal non-contrast computed tomography scan and a subsequently abnormal magnetic resonance image. Longer seizure duration and older age were associated with urgent or emergent intracranial pathology. CONCLUSION A substantial minority of children with new-onset seizures presenting with status epilepticus have urgent or emergent intracranial pathology identified on neuroimaging. Clinicians should strongly consider emergent neuroimaging in these children. Magnetic resonance imaging is the preferred imaging modality when available and safe.
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Affiliation(s)
- Todd W Lyons
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States.
| | - Kara B Johnson
- Duke University Hospital, Duke University School of Medicine, Durham, NC, United States.
| | - Kenneth A Michelson
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States.
| | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States.
| | - Tobias Loddenkemper
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States.
| | - Sanjay P Prabhu
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States.
| | - Amir A Kimia
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States.
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18
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Rudloe T, Prabhu SP, Gorman MP, Nigrovic LE, Harper MB, Landschaft A, Kimia AA. The Yield of Neuroimaging in Children Presenting to the Emergency Department With Acute Ataxia in the Post-Varicella Vaccine Era. J Child Neurol 2015; 30:1333-9. [PMID: 25535060 DOI: 10.1177/0883073814561300] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 10/08/2014] [Indexed: 11/17/2022]
Abstract
To determine the yield of neuroimaging in children presenting to the emergency department with acute ataxia in the post-varicella vaccine era, we conducted a cross-sectional study between 1995 and 2013 at a single pediatric tertiary care center. We included children aged 1-18 years evaluated for acute ataxia of <7 days' duration. The main outcome was clinically urgent intracranial pathology defined as a radiologic finding that changed initial management. We identified 364 children, among whom neuroimaging was obtained in 284 (78%). Forty-two children had clinically urgent intracranial pathology (13%, 95% confidence interval 9%-17%); tumors and acute disseminated encephalomyelitis were the leading findings. Age ≤3 years and symptoms ≤3 days of duration were predictors of low risk (0.7%, 95% confidence interval 0%-4.4%). In conclusion, neuroimaging may be indicated for most patients presenting with acute ataxia. Neuroimaging may be deferred in younger children with short duration of symptoms contingent on close follow-up.
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Affiliation(s)
- Tiffany Rudloe
- Division of Emergency Medicine, Department of Medicine, Children's Hospital Boston, Boston, MA, USA
| | | | - Mark P Gorman
- Neurology, Children's Hospital Boston, Boston, MA, USA
| | - Lise E Nigrovic
- Division of Emergency Medicine, Department of Medicine, Children's Hospital Boston, Boston, MA, USA
| | - Marvin B Harper
- Division of Emergency Medicine, Department of Medicine, Children's Hospital Boston, Boston, MA, USA Infectious Diseases, Children's Hospital Boston, Boston, MA, USA
| | - Assaf Landschaft
- Division of Emergency Medicine, Department of Medicine, Children's Hospital Boston, Boston, MA, USA
| | - Amir A Kimia
- Division of Emergency Medicine, Department of Medicine, Children's Hospital Boston, Boston, MA, USA
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Lessenich EM, Kimia AA, Mandeville K, Li J, Landschaft A, Tsai A, Bachur RG. The Frequency of Postreduction Interventions After Successful Enema Reduction of Intussusception. Acad Emerg Med 2015; 22:1042-7. [PMID: 26292193 DOI: 10.1111/acem.12741] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 03/13/2015] [Accepted: 04/17/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The objective was to determine the frequency of postreduction, hospital-level interventions among children with successful reduction of ileocolic intussusception and identify factors that predict the need for such interventions. METHODS This was a retrospective cross-sectional study of children who underwent successful enema reduction for ileocolic intussusception at a single emergency department. Hospital-level interventions were included if they occurred within 24 hours of reduction and were further classified as either major (recurrence or possible perforation) or minor (imaging for suspected recurrence or administration of parenteral narcotics or antiemetics). Binary logistic regression was used to identify predictors for hospital-level interventions. RESULTS A total of 464 children underwent enema reduction. The median age was 1.7 years (interquartile range [IQR] = 0.8 to 2.5 years), and 66% were male. A total of 435 (94%) were hospitalized with a median hospital stay of 25 hours (IQR = 19 to 34 hours). Nineteen percent (95% confidence interval [CI] = 15% to 22%) needed postreduction interventions, including 6% (95% CI = 4% to 9%) who required major interventions. The median time to any hospital intervention was 9.9 hours (IQR = 6.3 to 16.4 hours). We identified two independent predictors for hospital-level interventions: duration of symptoms > 24 hours (adjusted odds ratio [OR] = 2.1, 95% CI = 1.3 to 3.4) and location of the intussusception tip at (or proximal to) the hepatic flexure (adjusted OR = 1.9, 95% CI = 1.1 to 3.3); the latter factor was also a predictor of a major intervention. None of the children (95% CI = 0 to 1.0%) had an acute decompensation after an initially successful enema reduction. CONCLUSIONS Clinical decompensation is rare and recurrence is relatively low after an uncomplicated reduction of ileocolic intussusception. However, one in five children required hospital-level interventions after reduction. Children with the intussusception tip at (or proximal to) the hepatic flexure, and those with symptoms for longer than 24 hours, are more likely to require subsequent interventions. Although outpatient management appears safe after a period of observation, caregivers should be counseled about the risk of ongoing symptoms and recurrence.
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Affiliation(s)
| | - Amir A. Kimia
- Division of Emergency Medicine; Department of Medicine; Children's Hospital Boston; Boston MA
| | - Katherine Mandeville
- Division of Emergency Medicine; Department of Medicine; Children's Hospital Boston; Boston MA
| | - Joyce Li
- Division of Emergency Medicine; Department of Medicine; Children's Hospital Boston; Boston MA
| | - Assaf Landschaft
- Division of Emergency Medicine; Department of Medicine; Children's Hospital Boston; Boston MA
| | - Andy Tsai
- Department of Radiology; Children's Hospital Boston; Boston MA
| | - Richard G. Bachur
- Division of Emergency Medicine; Department of Medicine; Children's Hospital Boston; Boston MA
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20
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Pingree EW, Kimia AA, Nigrovic LE. The effect of traumatic lumbar puncture on hospitalization rate for febrile infants 28 to 60 days of age. Acad Emerg Med 2015; 22:240-3. [PMID: 25640087 DOI: 10.1111/acem.12582] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 08/13/2014] [Accepted: 09/09/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The authors measured the effect of a traumatic or unsuccessful lumbar puncture (LP) on the management of febrile infants. METHODS This was a 10-year retrospective cross-sectional study of low-risk infants by the "Boston" criteria 28 to 60 days of age presenting to the emergency department for evaluation of fever. "Normal LP" infants had cerebrospinal fluid (CSF) WBC < 10 × 10(6) cells/L. "Traumatic" or "unsuccessful LP" infants had CSF red blood cell count ≥ 10 × 10(9) cells/L or no CSF cell counts obtained, respectively. A serious bacterial infection (SBI) was defined as growth of a bacterial pathogen from culture. The hospitalization and SBI rates were compared between infants with normal versus traumatic or unsuccessful LPs. RESULTS Of the 929 study infants, 756 (81.4%) had normal LPs, and 173 (18.6%) had traumatic or unsuccessful LPs. Infants with traumatic or unsuccessful LPs had a higher hospitalization rate (72.3% traumatic or unsuccessful LP vs. 18.1% normal LP; difference = 54.1%; 95% confidence interval [CI] = 46.4% to 60.8%), but a similar SBI rate (2.9% vs. 4.1%; difference = 1.2%; 95% CI = -2.7% to 3.6%). No infant had proven bacterial meningitis (0% risk, 95% CI = 0 to 0.3%). CONCLUSIONS Low-risk infants aged 28 to 60 days with traumatic or unsuccessful LPs are more frequently hospitalized, although SBI rates were similar to those of infants with normal LPs.
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Affiliation(s)
- Elizabeth W. Pingree
- Department of Medicine; Boston Children's Hospital; Boston MA
- Division of General Pediatrics; Boston Children's Hospital; Boston MA
| | - Amir A. Kimia
- Division of Emergency Medicine; Boston Children's Hospital; Boston MA
| | - Lise E. Nigrovic
- Division of Emergency Medicine; Boston Children's Hospital; Boston MA
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Johnson KB, Michelson KA, Lyons TW, Nigrovic LE, Landschaft A, Loddenkemper T, Kimia AA. Pediatric status epilepticus: How common is cerebrospinal fluid pleocytosis in the absence of infection? Seizure 2014; 23:573-5. [DOI: 10.1016/j.seizure.2014.03.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Revised: 03/25/2014] [Accepted: 03/26/2014] [Indexed: 11/29/2022] Open
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Abstract
OBJECTIVES To compare the accuracy of rapid cranial magnetic resonance imaging (MRI) with that of computed tomography (CT) for diagnosing ventricular shunt malfunction. METHODS We performed a single-center, retrospective cohort study of children ≤21 years of age who underwent either rapid cranial MRI or cranial CT in the emergency department (ED) for evaluation of possible ventricular shunt malfunction. Each neuroimaging study was classified as "normal" (unchanged or decreased ventricle size) or "abnormal" (increased ventricle size). We classified a patient as having a ventricular shunt malfunction if operative revision for relief of mechanical causes of altered shunt flow was needed within 72 hours of initial ED evaluation. Our primary analysis tested noninferiority of the accuracy of rapid cranial MRI to CT for diagnosing shunt malfunction (noninferiority margin 10%). RESULTS We included 698 ED visits for 286 unique patients, with a median age at visit of 10.0 years (interquartile range 5.9-15.5 years). Patients underwent CT in 336 (48%) or rapid cranial MRI in 362 (52%) of ED visits for evaluation of possible shunt malfunction. Patients had operative revision for ventricular shunt malfunction in 140 ED visits (20%). The accuracy of rapid cranial MRI was not inferior to that of CT scan for diagnosing ventricular shunt malfunction (81.8% MRI vs 82.4% CT; risk difference 2.0%; 95% confidence interval, -4.2% to 8.2%). CONCLUSIONS Rapid cranial MRI was not inferior to CT for diagnosing ventricular shunt malfunction and offers the advantage of sparing a child ionizing radiation exposure.
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Affiliation(s)
| | - Michael J Paldino
- Department of Pediatric Radiology, Texas Children's Hospital, Houston, Texas
| | | | | | - Joseph R Madsen
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts; and
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Deanehan JK, Kimia AA, Tan Tanny SP, Milewski MD, Talusan PG, Smith BG, Nigrovic LE. Distinguishing Lyme from septic knee monoarthritis in Lyme disease-endemic areas. Pediatrics 2013; 131:e695-701. [PMID: 23420916 DOI: 10.1542/peds.2012-2531] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [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: 12/24/2022] Open
Abstract
OBJECTIVE Because Lyme and septic arthritis may present similarly, we sought to identify children with knee monoarthritis at low risk for septic arthritis who may not require arthrocentesis. METHODS We performed a retrospective study of children with knee monoarthritis presenting to 1 of 2 pediatric centers, both located in Lyme disease-endemic areas. Septic arthritis was defined by a positive result on synovial fluid culture or synovial fluid pleocytosis with a positive blood culture result. Lyme arthritis was defined as a positive Lyme serologic result or physician-documented erythema migrans rash. All other children were considered to have other inflammatory arthritis. A clinical prediction model was derived by using recursive partitioning to identify children at low risk for septic arthritis, and the model was then externally validated. RESULTS We identified 673 patients with knee monoarthritis; 19 (3%) had septic arthritis, 341 (51%) had Lyme arthritis, and 313 (46%) had other inflammatory arthritis. The following predictors of knee septic arthritis were identified: peripheral blood absolute neutrophil count ≥10 × 10(3) cells per mm(3) and an erythrocyte sedimentation rate ≥40 mm/hour. In the validation population, no child with a absolute neutrophil count <10 × 10(3) cells per mm(3) and an erythrocyte sedimentation rate <40 mm/hour had septic arthritis (sensitivity: 6 of 6 [100%], 95% confidence interval [CI]: 54-100; specificity: 87 of 160 [54%], 95% CI: 46-62). Overall, none of the 19 children with septic arthritis were classified as low risk (10%, 95% CI: 0-17). CONCLUSIONS Laboratory criteria can be used to identify children with knee monoarthritis at low risk for septic arthritis who may not require diagnostic arthrocentesis.
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Affiliation(s)
- Julia K Deanehan
- Division of Emergency Medicine, Boston Children’s Hospital andHarvard Medical School, Boston, MA 02115, USA
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Fine AM, Brownstein JS, Nigrovic LE, Kimia AA, Olson KL, Thompson AD, Mandl KD. Integrating spatial epidemiology into a decision model for evaluation of facial palsy in children. ACTA ACUST UNITED AC 2011; 165:61-7. [PMID: 21199982 DOI: 10.1001/archpediatrics.2010.250] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To develop a novel diagnostic algorithm for Lyme disease among children with facial palsy by integrating public health surveillance data with traditional clinical predictors. DESIGN Retrospective cohort study. SETTING Children's Hospital Boston emergency department, 1995-2007. PATIENTS Two hundred sixty-four children (aged <20 years) with peripheral facial palsy who were evaluated for Lyme disease. MAIN OUTCOME MEASURES Multivariate regression was used to identify independent clinical and epidemiologic predictors of Lyme disease facial palsy. RESULTS Lyme diagnosis was positive in 65% of children from high-risk counties in Massachusetts during Lyme disease season compared with 5% of those without both geographic and seasonal risk factors. Among patients with both seasonal and geographic risk factors, 80% with 1 clinical risk factor (fever or headache) and 100% with 2 clinical factors had Lyme disease. Factors independently associated with Lyme disease facial palsy were development from June to November (odds ratio, 25.4; 95% confidence interval, 8.3-113.4), residence in a county where the most recent 3-year average Lyme disease incidence exceeded 4 cases per 100,000 (18.4; 6.5-68.5), fever (3.9; 1.5-11.0), and headache (2.7; 1.3-5.8). Clinical experts correctly treated 68 of 94 patients (72%) with Lyme disease facial palsy, but a tool incorporating geographic and seasonal risk identified all 94 cases. CONCLUSIONS Most physicians intuitively integrate geographic information into Lyme disease management, but we demonstrate quantitatively how formal use of geographically based incidence in a clinical algorithm improves diagnostic accuracy. These findings demonstrate potential for improved outcomes from investments in health information technology that foster bidirectional communication between public health and clinical settings.
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Affiliation(s)
- Andrew M Fine
- Division of Emergency Medicine, Children's Hospital Boston, Boston, MA 02115, USA.
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Abstract
OBJECTIVES Computed tomography (CT) is used often in the evaluation of orbital infections to identify children who are most likely to benefit from surgical intervention. Our objective was to identify predictors for intraorbital or intracranial abscess among children who present with signs or symptoms of periorbital infection. These predictors could be used to better target patients for emergent CT. METHODS This was a retrospective cohort study of all patients admitted to an urban pediatric tertiary care emergency department between 1995 and 2008. We included otherwise healthy patients with suspected acute clinical periorbital or orbital cellulitis without a history of craniofacial surgery, trauma, or external source of infection. Immunocompromised patients and patients with noninfectious causes of periorbital swelling were excluded. Variables analyzed included age, duration of symptoms, highest recorded temperature, previous antibiotic therapy, physical examination findings, laboratory results, and interpretation of imaging. CT scans of the orbit were reread by a neuroradiologist. RESULTS Nine hundred eighteen patients were included; 298 underwent a CT scan, and of those, 111 were shown to have an abscess. Although proptosis, pain with external ocular movement, and ophthalmoplegia were associated with presence of an abscess, 56 (50.5%) patients with abscess did not experience these symptoms. Other variables associated with the presence of an abscess in multivariate analysis were a peripheral blood neutrophil count greater than 10,000/microL, absence of infectious conjunctivitis, periorbital edema, age greater than 3 years, and previous antibiotic therapy (P < .05 for all). Our recursive partitioning model identified all high-risk (44%) patients as well as a low-risk (0.4%-2%) group (Rsq = 0.27). CONCLUSIONS We confirmed that patients with proptosis and/or pain or limitation of extraocular movements are at high risk for intraorbital abscess, yet many do not have these predictors. Other features can identify patients who do not have such obvious predictors but do have significant risk of disease. A recursive partitioning model is presented.
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Affiliation(s)
- Tiffany F Rudloe
- Division of Emergency Medicine, Children's Hospital Boston, 300 Longwood Ave, Boston, MA 02115, USA.
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Kimia AA, Capraro AJ, Hummel D, Johnston P, Harper MB. Utility of lumbar puncture for first simple febrile seizure among children 6 to 18 months of age. Pediatrics 2009; 123:6-12. [PMID: 19117854 DOI: 10.1542/peds.2007-3424] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [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
OBJECTIVES American Academy of Pediatrics consensus statement recommendations are to consider strongly for infants 6 to 12 months of age with a first simple febrile seizure and to consider for children 12 to 18 months of age with a first simple febrile seizure lumbar puncture for cerebrospinal fluid analysis. Our aims were to determine compliance with these recommendations and to assess the rate of bacterial meningitis detected among these children. METHODS A retrospective cohort review was performed for patients 6 to 18 months of age who were evaluated for first simple febrile seizure in a pediatric emergency department between October 1995 and October 2006. RESULTS First simple febrile seizure accounted for 1% of all emergency department visits for children of this age, with 704 cases among 71 234 eligible visits during the study period. Twenty-seven percent (n = 188) of first simple febrile seizure visits were for infants 6 to 12 months of age, and 73% (n = 516) were for infants 12 to 18 months of age. Lumbar puncture was performed for 38% of the children (n = 271). Samples were available for 70% of children 6 to 12 months of age (131 of 188 children) and 25% of children 12 to 18 months of age (129 of 516 children). Rates of lumbar puncture decreased significantly over time in both age groups. The cerebrospinal fluid white blood cell count was elevated in 10 cases (3.8%). No pathogen was identified in cerebrospinal fluid cultures. Ten cultures (3.8%) yielded a contaminant. No patient was diagnosed as having bacterial meningitis. CONCLUSIONS The risk of bacterial meningitis presenting as first simple febrile seizure at ages 6 to 18 months is very low. Current American Academy of Pediatrics recommendations should be reconsidered.
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Affiliation(s)
- Amir A Kimia
- Division of Emergency Medicine, Children's Hospital Boston, Boston, MA 02115, USA.
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