A community-based volunteer service to reduce COVID-19 vaccination inequities in New York City

OBJECTIVES

We describe our experiences and challenges as community volunteers in assisting individuals in scheduling initial COVID-19 vaccine appointments and highlight disparities and barriers in vaccine access in New York City (NYC).

METHODS

Priority for assistance was given to individuals who were eligible for vaccination in NYC and New York State with the following barriers: technological, language, medical, physical and undocumented immigrants. Volunteers in NYC performed outreach and created program to assist in scheduling appointments.

RESULTS

In sum, 2101 requests were received to schedule COVID-19 vaccine appointments from 28 February to 30 April 2021. Vaccinations were successfully scheduled for 1935 (92%) individuals. Challenges in this project included limited community outreach, language barriers, transportation difficulties and safety concerns travelling to vaccination sites. Spanish (40.5%) and Chinese (35.6%) were the primary languages spoken by appointment requesters. Most requests came from residents of Queens (40%) and Brooklyn (27.2%).

CONCLUSIONS

The older population, public-facing workers, non-English speakers, undocumented immigrants and the medically complicated population experienced challenges in vaccine appointment access. In-person services and early website access in languages in addition to English may have reduced barriers in appointment navigation. While volunteers faced numerous obstacles when assisting individuals in scheduling vaccine appointments, most found the work fulfilling and rewarding.

Interpretation of Cardiac Standstill in Children Using Point-of-Care Ultrasound

STUDY OBJECTIVE

This study aimed to determine the level of agreement among pediatric emergency medicine (PEM) physicians in whether various point-of-care ultrasound (POCUS) video clips represent cardiac standstill in children and to highlight the factors that may be associated with the lack of agreement.

METHODS

A single, online, cross-sectional, convenience sample survey was administered to PEM attendings and fellows with variable ultrasound experience. PEM attendings with an experience of 25 cardiac POCUS scans or more were the primary subgroup based on ultrasound proficiency set by the American College of Emergency Physicians. The survey contained 11 unique, 6-second video clips of cardiac POCUS performed during pulseless arrest in pediatric patients and asked the respondent if the video clip represented a cardiac standstill. The level of interobserver agreement was determined using the Krippendorff's α (Kα) coefficient across the subgroups.

RESULTS

A total of 263 PEM attendings and fellows completed the survey (9.9% response rate). Of the 263 total responses, 110 responses were from the primary subgroup of experienced PEM attendings with at least 25 previously seen cardiac POCUS scans. Across all video clips, PEM attendings with 25 scans or more had an acceptable agreement (Kα=0.740; 95% CI 0.735 to 0.745). The agreement was the highest for video clips wherein the wall motion corresponded to the valve motion. However, the agreement fell to unacceptable levels (Kα=0.304; 95% CI 0.287 to 0.321) across video clips wherein the wall motion occurred without the valve motion.

CONCLUSION

There is an overall acceptable interobserver agreement when interpreting cardiac standstill among PEM attendings with an experience of at least 25 previously reported cardiac POCUS scans. However, factors that may influence the lack of agreement include discordances between the wall and valve motion, suboptimal views, and the lack of a formal reference standard. More specific consensus reference standards of pediatric cardiac standstill may help to improve interobserver agreement moving forward and should include more specific details regarding the wall and valve motion.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Association of Pediatric Emergency Medicine Physicians' Self-Identified Skills in Suicide Risk Assessment and Management With Training in Mental Health

OBJECTIVE

Because changes to pediatric emergency medicine (PEM) education may help address barriers to youth suicide risk screening programs, this study aimed to understand the impact of formal training in areas that likely include suicide-related practices, developmental-behavioral pediatrics (DBP) and adolescent medicine (AM), on PEM physician-perceived level of training, attitudes, and confidence assessing and managing youth suicide risk.

METHODS

Twenty-seven PEM attendings and trainees completed an online survey and were divided into 2 groups: those who had completed DBP and AM rotations (DBP/AM+; n = 20) and those who had not completed either rotation (DBP/AM-; n = 7). We compared perceived level of training, attitudes, and confidence in assessing and managing suicide risk across groups. We also examined the relationship between perceived level of training and confidence. Finally, we conducted exploratory analyses to evaluate the effect of an additional formal rotation in child psychiatry.

RESULTS

The DBP/AM+ and DBP/AM- groups did not differ on perceived level of training or on attitudes and confidence in suicide risk assessment or management. Perceived level of training in assessment and management predicted confidence in both assessing and managing suicide risk. Additional training in child psychiatry was not associated with increased perceived level of training or confidence.

CONCLUSIONS

The DBP and AM rotations were not associated with higher perceived levels of suicide risk training or greater confidence; however, perceived level of training predicted physician confidence, suggesting continued efforts to enhance formal PEM education in mental health would be beneficial.

A "madd"-ening confounding: fruit seeds mimicking enteral drug concealment by computed tomography

OBJECTIVE

To highlight the similarity between madd fruit seeds and enteral drug concealment ("body packing") on computed tomography when evaluated by Hounsfield Units.

CASE REPORT

A 13-year-old girl from Senegal presented to the Emergency Department with severe abdominal pain. Examination showed right lower quadrant tenderness with rebound. Computed tomography scan of the abdomen and pelvis revealed smooth, well circumscribed, multiple intraluminal foreign bodies measuring up to 2 cm in size with Hounsfield Units measuring up to 200. The emergency department radiologist reported that these were suspicious for "body packer packets" of either opioids or cocaine, based on their appearance and Hounsfield Unit characteristics. Dietary history later revealed consuption of madd fruit (Saba senegalensis) seeds, which can cause bezoar formation and intestinal obstruction.

CONCLUSION

Madd fruit seeds may appear similar to drug packets on computed tomography with similar Hounsfield Unit characteristics. History and clinical context are paramount to avoid misdiagnosis.

Multisystem Inflammatory Syndrome in Children

Multisystem inflammatory syndrome in children (MIS-C) is an uncommon but emerging syndrome related to SARS-CoV-2 infection. While the presentation of MIS-C is generally delayed after exposure to the virus that causes coronavirus 2019, both MIS-C and Kawasaki disease (KD) share similar clinical features. Multisystem inflammatory syndrome in children poses a diagnostic and therapeutic challenge given the lack of definitive diagnostic tests and a paucity of evidence regarding treatment modalities. We review the clinical presentation, diagnostic evaluations, and management of MIS-C and compare its clinical features to those of KD.

Pediatric emergency care in New York City during the COVID-19 pandemic shutdown and reopening periods

Objective

New York City (NYC) is home to the largest public healthcare system in the United States and was an early epicenter of coronavirus disease 2019 (COVID-19) infections. This system serves as the safety net for underserved and marginalized communities disproportionately affected by the pandemic. Prior studies reported substantial declines in pediatric emergency department (ED) volume during the initial pandemic surge, but few describe the ongoing impact of COVID-19 throughout the year. We evaluated the characteristics of pediatric ED visits to NYC public hospitals during the pandemic lockdown and reopening periods of 2020 compared to the prior year.

Methods

Retrospective cross-sectional analysis of pediatric ED visits from 11 NYC public hospitals from January 2019–December 2020. Visit demographics, throughput times, and diagnosis information during the early (3/7/20–6/7/20) and late (6/8/20–12/31/20) pandemic periods coinciding with the New York State of emergency declaration (3/7/20) and the first reopening date (6/7/20) were compared to similar time periods in 2019. Findings were correlated with key pandemic shutdown and reopening events.

Results

There was a 47% decrease in ED volume in 2020 compared to 2019 (125,649 versus 238,024 visits). After reopening orders began in June 2020, volumes increased but peaked at <60% of 2019 volumes. Admission rates, triage acuity, and risk of presenting with a serious medical illness were significantly higher in 2020 versus 2019 (P < 0.001). Time-to-provider times decreased however provider-to-disposition times increased during the pandemic (P < 0.001). Infectious and asthma diagnoses declined >70% during the pandemic in contrast to the year prior. After reopening periods began, penetrating traumatic injuries significantly increased compared to 2019 [+34%, Relative Risk: 3.2 (2.6, 3.8)].

Conclusions

NYC public hospitals experienced a sharp decrease in pediatric volume but an increase in patient acuity during both the initial pandemic surge and through the reopening periods. As COVID-19 variants emerge, the threat of the current pandemic expanding remains. Understanding its influence on pediatric ED utilization can optimize resource allocation and ensure equitable care for future surge events.

Barriers to Universal Suicide Risk Screening for Youth in the Emergency Department

OBJECTIVE

Given the increasing rates of youth suicide, it is important to understand the barriers to suicide screening in emergency departments. This review describes the current literature, identifies gaps in existing research, and suggests recommendations for future research.

METHODS

A search of PubMed, MEDLINE, CINAHL, PsycInfo, and Web of Science was conducted. Data extraction included study/sample characteristics and barrier information categorized based on the Exploration, Preparation, Implementation, Sustainment model.

RESULTS

All studies focused on inner context barriers of implementation and usually examined individuals' attitudes toward screening. No study looked at administrative, policy, or financing issues.

CONCLUSIONS

The lack of prospective, systematic studies on barriers and the focus on individual adopter attitudes reveal a significant gap in understanding the challenges to implementation of universal youth suicide risk screening in emergency departments.

Point-of-Care Ultrasound on Management of Cellulitis Versus Local Angioedema in the Pediatric Emergency Department

OBJECTIVES

To evaluate whether ultrasound can differentiate between cellulitis and angioedema from insect bites in pediatric patients.

METHODS

A prospective, pre-post study in an urban pediatric emergency department of patients younger than 21 years with soft tissue swelling from insect bites without abscesses were enrolled. Treating physician's pretest opinions regarding the diagnosis and need for antibiotics were determined. Ultrasound of the affected areas was performed, and effects on management were recorded. Further imaging, medications, and disposition were at the discretion of the enrolling physician. Phone call follow-ups were made within a week of presentation.

RESULTS

Among 103 patients enrolled with soft tissue swelling secondary to insect bites, ultrasound changed the management in 27 (26%) patients (95% confidence interval [CI], 18-35%). Of the patients who were indeterminate or believed to require antibiotics, ultrasound changed management in 6 (23%) of 26 patients (95% CI, 6%-40%). In those patients who were believed not to require antibiotics, ultrasound changed management in 12 (16%) 77 patients (95% CI, 7%-24%). Patients with diagnosis of local angioedema achieved symptom resolution 1.4 days sooner than patients diagnosed with cellulitis (mean, -1.389; 95% CI, -2.087 to -0.690; P < 0.001). No patient who was initially diagnosed as local angioedema received antibiotics upon patient follow-up.

CONCLUSIONS

Point-of-care ultrasound changed physician management in 1 of 4 patients in the pediatric emergency department with soft tissue swelling secondary to insect bites. Ultrasound may guide the management in these patients and lead to improved antibiotic stewardship in conjunction with history and physical examination.

Universal Suicide Risk Screening for Youths in the Emergency Department: A Systematic Review

OBJECTIVES

To address escalating youth suicide rates, universal suicide risk screening has been recommended in pediatric care settings. The emergency department (ED) is a particularly important setting for screening. However, EDs often fail to identify and treat mental health symptoms among youths, and data on implementation of suicide risk screening in EDs are limited. A systematic review was conducted to describe the current literature on universal suicide risk screening in EDs, identify important gaps in available studies, and develop recommendations for strategies to improve youth screening efforts.

METHODS

A systematic literature search of PubMed, MEDLINE, CINAHL, PsycINFO, and Web of Science was conducted. Studies focused on universal suicide risk screening of youths served in U.S. EDs that presented screening results were coded, analyzed, and evaluated for reporting quality. Eleven studies were included.

RESULTS

All screening efforts occurred in teaching or children's hospitals, and research staff administered suicide screens in eight studies. Thus scant information was available on universal screening in pediatric community ED settings. Large variation was noted across studies in participation rates (17%-86%) and in positive screen rates (4.1%-50.8%), although positive screen rates were influenced by type of presenting concern (psychiatric versus nonpsychiatric). Only three studies concurrently examined barriers to screening, providing little direction for effective implementation. STROBE guidelines were used to rate reporting quality, which ranged from 51.9% to 87.1%, with three studies having ratings over 80%.

CONCLUSIONS

Research is needed to better inform practice guidelines and clinical pathways and to establish sustainable screening programs for youths presenting for care in EDs.

Multisystem Inflammatory Syndrome in Children

Background

Multisystem inflammatory syndrome in children (MIS-C) is a newly recognized condition affecting children with recent infection or exposure to coronavirus disease 2019 (COVID-19). MIS-C has symptoms that affect multiple organs systems, with some clinical features resembling Kawasaki disease (KD) and toxic shock syndrome (TSS).

Objective of the Review

Our goal was to review the current literature and describe the evaluation and treatment algorithms for children suspected of having MIS-C who present to the emergency department.

Discussion

MIS-C has a wide clinical spectrum and diagnosis is based on a combination of both clinical and laboratory findings. The exact mechanism of immune dysregulation of MIS-C is not well understood. Physical findings may evolve and do not necessarily appear at the same time. Gastrointestinal, cardiac, inflammatory, and coagulopathy manifestations and dysfunction are seen frequently in MIS-C.

Conclusions

The diagnosis of MIS-C is based on clinical presentation and specific laboratory findings. In the emergency setting, a high level of suspicion for MIS-C is required in patients exposed to COVID-19. Early diagnosis and prompt initiation of therapy offer the best chance for optimal outcomes.

Point-of-care ultrasound for confirmation of gastrostomy tube replacement in the pediatric emergency department

Gastrostomy tubes (G-tubes) are frequently used in children for feeding and nutrition. Complications related to G-tubes (and G-buttons) in children represent a common presentation to the emergency department (ED). G-tube replacement is usually performed by pediatric emergency medicine physicians. Misplacement may lead to tract disruption, perforation, fistula tract formation, or feeding into the peritoneum. Contrast-enhanced radiographs are traditionally used for confirmation. In addition to a longer length-of-stay, repeat ED visits result in repeated radiation exposure. The use of point-of-care ultrasound (POCUS) instead of radiography avoids this exposure to ionizing radiation. Here, we describe three patients who presented with G-tube complications in whom POCUS alone performed by pediatricians was used for confirmation of the tubes' replacement. Two children presented to the ED with G-tube dislodgement, and one child presented with a ruptured balloon. In all three cases, a new G-tube was replaced at the bedside using POCUS guidance without the need for further radiographic studies. There were no known ED or clinic returns for G-tube complaints over the next 30 days. This is the first report of pediatricians using POCUS to guide and confirm G-tube replacement in children. The success of these cases suggests the technique's feasibility. Future prospective studies are needed to evaluate the learning curves, diagnostic accuracy, ED length-of-stay, and use of confirmatory imaging.

Vertical nystagmus as isolated presentation in a patient with new diagnosis of multiple sclerosis

Multiple sclerosis (MS) is a progressive demyelinating disease of the central nervous system with a wide array of symptoms. We present a healthy young woman who came to the Emergency Department with two days of isolated vertical nystagmus and was subsequently diagnosed with MS on imaging. Although bilateral vertical nystagmus is not a common presentation of MS, its presence should prompt inclusion of this disease process in the differential diagnosis.

Tick-borne illnesses: identification and management in the emergency department

Tick-borne illnesses are increasing in prevalence and geographic reach. Because the presentation of these illnesses is sometimes nonspecific, they can often be misdiagnosed, especially in the early stages of illness. A detailed history with questions involving recent activities and travel and a thorough physical examination will help narrow the diagnosis. While some illnesses can be diagnosed on clinical findings alone, others require confirmatory testing, which may take days to weeks to result. This issue reviews the emergency department presentation of 9 common tick-borne illnesses and evidence-based recommendations for identification, testing, and treatment.

Necrotizing fasciitis with pulmonary septic emboli following an infected insect bite

Although systemic infections originating from skin infections caused by insect bites are uncommon, it is imperative to maintain a broad differential diagnosis should patients develop systemic symptoms. Necrotizing fasciitis is a rare diagnosis, and progression to septic pulmonary emboli is even less common. Emergent identification and aggressive treatment of these two disease processes are imperative as both carry high rates of morbidity and mortality.

Dripped Lidocaine: A Novel Approach to Needleless Anesthesia for Mucosal Lacerations

BACKGROUND

Oral lacerations represent a unique challenge for anesthesia in the emergency department. Many options exist for local anesthesia, but these options are often associated with pain from injections or anxiety from anticipated needle injection.

CASE SERIES

We introduce a novel and needleless approach to achieving local anesthesia for oral mucosa repair by dripping injectable lidocaine directly onto mucosal wounds prior to repair. This method is well tolerated and achieves appropriate anesthesia without undesirable side effects. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Dripped injectable lidocaine may be an alternative method for mucosal anesthesia in the pediatric population.

Evaluating the risk of appendiceal perforation when using ultrasound as the initial diagnostic imaging modality in children with suspected appendicitis

BACKGROUND

Ultrasound scan has gained attention for diagnosing appendicitis due to its avoidance of ionizing radiation. However, studies show that ultrasound scan carries inferior sensitivity to computed tomography scan. A non-diagnostic ultrasound scan could increase the time to diagnosis and appendicectomy, particularly if follow-up computed tomography scan is needed. Some studies suggest that delaying appendicectomy increases the risk of perforation.

OBJECTIVE

To investigate the risk of appendiceal perforation when using ultrasound scan as the initial diagnostic imaging modality in children with suspected appendicitis.

METHODS

We retrospectively reviewed 1411 charts of children ≤17 years old diagnosed with appendicitis at two urban academic medical centers. Patients who underwent ultrasound scan first were compared to those who underwent computed tomography scan first. In the sub-group analysis, patients who only received ultrasound scan were compared to those who received initial ultrasound scan followed by computed tomography scan. Main outcome measures were appendiceal perforation rate and time from triage to appendicectomy.

RESULTS

In 720 children eligible for analysis, there was no significant difference in perforation rate between those who had initial ultrasound scan and those who had initial computed tomography scan (7.3% vs. 8.9%, p = 0.44), nor in those who had ultrasound scan only and those who had initial ultrasound scan followed by computed tomography scan (8.0% vs. 5.6%, p = 0.42). Those patients who had ultrasound scan first had a shorter triage-to-incision time than those who had computed tomography scan first (9.2 (IQR: 5.9, 14.0) vs. 10.2 (IQR: 7.3, 14.3) hours, p = 0.03), whereas those who had ultrasound scan followed by computed tomography scan took longer than those who had ultrasound scan only (7.8 (IQR: 5.3, 11.6) vs. 15.1 (IQR: 10.6, 20.6), p < 0.001). Children < 12 years old receiving ultrasound scan first had lower perforation rate (p = 0.01) and shorter triage-to-incision time (p = 0.003).

CONCLUSION

Children with suspected appendicitis receiving ultrasound scan as the initial diagnostic imaging modality do not have increased risk of perforation compared to those receiving computed tomography scan first. We recommend that children <12 years of age receive ultrasound scan first.

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

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

Feasibility and Safety of Substituting Lung Ultrasonography for Chest Radiography When Diagnosing Pneumonia in Children: A Randomized Controlled Trial

BACKGROUND

Chest radiography (CXR) is the test of choice for diagnosing pneumonia. Lung ultrasonography (LUS) has been shown to be accurate for diagnosing pneumonia in children and may be an alternative to CXR. Our objective was to determine the feasibility and safety of substituting LUS for CXR when evaluating children suspected of having pneumonia.

METHODS

We conducted a randomized control trial comparing LUS with CXR in 191 children from birth to 21 years of age suspected of having pneumonia in an ED. Patients in the investigational arm underwent LUS. If there was clinical uncertainty after ultrasonography, physicians had the option to perform CXR. Patients in the control arm underwent sequential imaging with CXR followed by LUS. The primary outcome was the rate of CXR reduction; secondary outcomes were missed pneumonia, subsequent unscheduled health-care visits, and adverse events between the investigational and control arms.

RESULTS

There was a 38.8% reduction (95% CI, 30.0%-48.9%) in CXR among investigational subjects compared with no reduction (95% CI, 0.0%-3.6%) in the control group. Novice and experienced physician-sonologists achieved 30.0% and 60.6% reduction in CXR use, respectively. There were no cases of missed pneumonia among all study participants (investigational arm, 0.0%: 95% CI, 0.0%-2.9%; control arm, 0.0%: 95% CI, 0.0%-3.0%), or differences in adverse events, or subsequent unscheduled health-care visits between arms.

CONCLUSIONS

It may be feasible and safe to substitute LUS for CXR when evaluating children suspected of having pneumonia with no missed cases of pneumonia or increase in rates of adverse events.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT01654887; URL: www.clinicaltrials.gov.

Sonographic appearance of angioedema in local allergic reactions to insect bites and stings

Soft tissue infections and angioedema from insect bites and stings may be difficult to differentiate by inspection. We present sonographic findings of 4 cases of soft tissue swelling from insect bites and stings suggestive of angioedema. Sonographic features of soft tissue angioedema consist of thickened subcutaneous tissue layers with multiple linear, horizontal, striated, and hypoechoic lines following the tissue planes between soft tissue layers. In addition to the history and physical examination, sonographic findings may assist in differentiating between local allergic reactions and cellulitis in patients with insect bites and stings. Further study is warranted for clinical application.

The effect of point-of-care ultrasonography on emergency department length of stay and computed tomography utilization in children with suspected appendicitis

OBJECTIVES

The role of clinician-performed ultrasonography (US) for suspected appendicitis is unclear. Published data conclude that US has high specificity to rule in the diagnosis of appendicitis, with variable sensitivity to rule it out. Newer data suggest that point-of-care (POC) US may have similar test characteristics. Our objective was to evaluate the effect of POC US in children with suspected appendicitis and its effect on emergency department (ED) length of stay (LOS) and computed tomography (CT) utilization.

METHODS

This was a prospective observational convenience sample of children with suspected appendicitis requiring imaging evaluation that adhered to the Standards for the Reporting of Diagnostic accuracy studies (STARD) criteria. Outcomes were determined by operative or pathology report in those who had appendicitis, and 3-week phone follow-up in those patients who were nonoperative. Differences in ED LOS were analyzed by one-way analysis of variance (ANOVA) between patients who received dispositions after POC US, radiology US, or CT. Test performance characteristics were calculated for all imaging modalities.

RESULTS

Among 150 enrolled patients, 50 had appendicitis (33.3%). There were no missed cases of appendicitis in discharged patients at 3-week phone follow-up, nor negative laparotomies in those who went to the operating room. Those who had dispositions after POC US (n = 25) had a significantly decreased mean ED LOS (154 minutes, 95% confidence interval [CI] = 115 to 193 minutes) compared with those requiring radiology US (288 minutes, 95% CI = 257 to 319 minutes) or CT scan (487 minutes; 95% CI = 434 to 540 minutes). Baseline CT rate was 44.2% (95% CI = 30.7% to 57.7%) prior to study start and decreased to 27.3% (95% CI = 20.17% to 34.43%) during the study. CTs were avoided in four patients with conclusive POC US results and inconclusive radiology US results. The sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) for POC US were 60% (95% CI = 46% to 72%), 94% (95% CI = 88% to 97%), 10 (95% CI = 4 to 23), and 0.4 (95% CI = 0.3 to 0.6). For radiology US they were 63% (95% CI = 48% to 75%), 99% (95% CI = 94% to 99%), 94 (95% CI = 6 to 1,500), and 0.4 (95% CI = 0.3 to 0.6); and for CT they were 83% (95% CI = 58% to 95%), 98% (95% CI = 85% to 99%), 45 (95% CI = 3 to 707), and 0.2 (95% CI = 0.05 to 0.5).

CONCLUSIONS

It may be feasible to reduce ED LOS and avoid CT scan when using POC US to evaluate children with suspected appendicitis. Test characteristics for POC US have high specificity to rule in appendicitis, similar to radiology US. Addition of POC US prior to sequential radiology imaging was safe, without missed cases of appendicitis or negative laparotomies.

Nebulizer and spacer device maintenance in children with asthma

OBJECTIVE

To evaluate inhalation device cleaning practices of children with asthma and its effect on their asthma morbidity.

METHODS

A survey of patients aged 4 to 18 years admitted to an urban pediatric emergency department (ED) with an acute asthma exacerbation. Questions included demographics, asthma history, preference of delivery devices, and frequency of device cleaning. Patients were followed until their disposition from the ED, or until the end of their hospitalization, if admitted.

RESULTS

220 subjects completed the survey. Mean age was 9.2 (+/- 3.9) years-old. One hundred and four (47.3%) patients used both nebulizers and spacer devices, while 18 (8.1%) used spacers only and 98 (44.5%) used nebulizers alone. Seventy-seven (38.1%; 95%CI: 31.7%-45.0%) patients cleaned their nebulizers and 57 (46.7%; 95%CI: 38.1%-55.4%) cleaned their spacer devices after each use as recommended by the Centers for Disease Control. There were no detectable differences in visit admission rate, total number of previous admissions, number of asthma exacerbations per year, and number of ED visits in one year between users who cleaned their devices after every, or every other use, compared to those who cleaned their devices less frequently.

CONCLUSION

Although the majority of patients did not follow accepted guidelines for inhalation device cleaning, further studies are necessary to correlate cleaning practices to patients' clinical outcome.

Ingested magnets: the force within

Foreign body ingestion is a common occurrence in children. Morbidity associated with ingestion is rare and is dependent on the type of foreign body ingested. We report a case of a 9-year-old boy who developed intestinal obstruction and perforation following ingestion of magnetic-backed earrings.

Neuroprotective and memory-related actions of novel alpha-7 nicotinic agents with different mixed agonist/antagonist properties

The goals of this study were to develop compounds that were selective and highly efficacious agonists at alpha-7 receptors, while varying in antagonist activity; and to test the hypothesis that these compounds had memory-related and neuroprotective actions associated with both agonist and antagonist alpha-7 receptor activities. Three compounds were identified; E,E-3-(cinnamylidene)anabaseine (3-CA), E,E-3-(2-methoxycinnamylidene) anabaseine (2-MeOCA) and E,E-3-(4-methoxycinnamylidene) anabaseine (4-MeOCA) each displaced [125I]alpha-bungarotoxin binding from rat brain membranes and activated rat alpha-7 receptors in a Xenopus oocyte expression system fully efficaciously. The potency series for binding and receptor activation was 2-MeOCA > 4-MeOCA = 3-CA and 2-MeOCA = 3-CA > 4-MeOCA, respectively. No compound significantly activated oocyte-expressed alpha-4beta-2 receptors. Although each cinnamylidene-anabaseine caused a long-term inhibition of alpha-7 receptors, as measured by ACh-application 5 min later, this inhibition ranged considerably, from less than 20% (3-CA) to 90% (2-MeOCA) at an identical concentration (10 microM). These compounds improved passive avoidance behavior in nucleus basalis lesioned rats, with 2-MeOCA most potent in this respect. In contrast, only 3-CA was neuroprotective against neurite loss during nerve growth factor deprivation in differentiated rat pheochromocytoma (PC12) cells. Choline, an efficacious alpha-7 agonist without antagonist activity, was also protective in this model. These results suggest that the neurite-protective action of alpha-7 receptor agonists may be more sensitive to potential long-term antagonist properties than acute behavioral actions are.

3-[2,4-Dimethoxybenzylidene]anabaseine (DMXB) selectively activates rat alpha7 receptors and improves memory-related behaviors in a mecamylamine-sensitive manner

The alpha7 nicotinic receptor agonist 3-[2,4-dimethoxybenzylidene]anabaseine (DMXB; GTS-21) was investigated for its ability to: (1) activate a variety of nicotinic receptor subtypes in Xenopus oocytes; (2) improve passive avoidance and spatial Morris water task performances in mecamylamine-sensitive manners in bilaterally nucleus basalis lesioned rats; and (3) elevate high-affinity [3H]acetylcholine (ACh) and high-affinity alpha-[125I]bungarotoxin binding in rat neocortex following 2 weeks of daily injections. DMXB (100 microM) activated alpha7 homo-oligomeric receptors, without significant activity at alpha2-, alpha3- and alpha4-containing subtypes. Mecamylamine blocked rat alpha7 receptors weakly if co-administered with agonist, but much more potently when pre-applied. Bilateral ibotenic acid lesions of the nucleus basalis interfered with passive avoidance and spatial memory-related behaviors. DMXB (0.5 mg/kg, i.p.) improved passive avoidance behavior in lesioned animals in a mecamylamine-sensitive manner. DMXB (0.5 mg/kg 15 min before each session) also improved performance in the training and probe components of the Morris water task. DMXB-induced improvement in the probe component but not the training phase was mecamylamine-sensitive. [3H]ACh binding was elevated after 14 days of daily i.p. injections with 0.2 mg/kg nicotine but not after 1 mg/kg DMXB. Neither drug elevated high-affinity alpha-[125I]bungarorotoxin binding over this interval.