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Lefchak B, Bergmann KR, Lammers S, Hester GZ. Piloting a Mobile Clinical Decision Support Application for Pediatric Clinical Guidelines. Clin Pediatr (Phila) 2024; 63:822-830. [PMID: 37649259 DOI: 10.1177/00099228231197078] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Mobile Clinical Decision Support Systems (CDSSs) represent an increasingly utilized technology to promote clinical guideline use. We sought to explore clinician guideline use and access preferences during implementation of a mobile guideline app at a free-standing children's hospital integrating 23 guidelines. Surveys included demographic variables and access preferences among anonymous onboarded clinicians in January 2022. Response rate was 21.8% (57/261) among onboarded users, mostly attending (59.6%) and resident/fellow physicians (21.1%) in inpatient (42.1%) and emergency department (31.6%) settings. Onboarded users accessed guidelines on over half of shifts (68.4%) and quickly (80.7%, <1 minute). Overall, most users reported favorable patterns for adoption of mobile CDSSs as useful adjuncts to existing formats. Users reported more ease of access and frequent guideline usage, particularly for younger clinicians. Guidelines related to antibiotic decision-making or newer disease processes were most useful. Further study is needed on electronic health record incorporation, adherence, and patient outcomes.
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Affiliation(s)
- Brian Lefchak
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN, USA
| | - Kelly R Bergmann
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN, USA
| | - Shea Lammers
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN, USA
| | - Gabrielle Z Hester
- Department of Value and Clinical Excellence, Children's Minnesota, Minneapolis, MN, USA
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2
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Florin TA, Freedman SB, Xie J, Funk AL, Tancredi DJ, Kim K, Neuman MI, Yock-Corrales A, Bergmann KR, Breslin KA, Finkelstein Y, Ahmad FA, Avva UR, Lunoe MM, Chaudhari PP, Shah NP, Plint AC, Sabhaney VJ, Sethuraman U, Gardiner MA, Sartori LF, Wright B, Navanandan N, Mintegi S, Gangoiti I, Borland ML, Chong SL, Kwok MY, Eckerle M, Poonai N, Romero CMA, Waseem M, Nebhrajani JR, Bhatt M, Caperell K, Campos C, Becker SM, Morris CR, Rogers AJ, Kam AJ, Pavlicich V, Palumbo L, Dalziel SR, Morrison AK, Rino PB, Cherry JC, Salvadori MI, Ambroggio L, Klassen TP, Payne DC, Malley R, Simon NJ, Kuppermann N. Features Associated With Radiographic Pneumonia in Children with SARS-CoV-2. J Pediatric Infect Dis Soc 2024; 13:257-259. [PMID: 38391389 DOI: 10.1093/jpids/piae015] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Indexed: 02/24/2024]
Abstract
14% of children with SARS-CoV-2 infections had radiographic pneumonia. Hypoxemia, cough, higher temperature, and older age were associated with pneumonias. In children tested, SARS-CoV-2 test results were not associated with radiographic pneumonia.
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Affiliation(s)
- Todd A Florin
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Jianling Xie
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Anna L Funk
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | | | - Kelly Kim
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Mark I Neuman
- Division of Emergency Medicine, Department of Pediatrics, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Adriana Yock-Corrales
- Department of Emergency Medicine, Hospital Nacional de Niños "Dr. Carlos Sáenz Herrera", CCSS, San José, Costa Rica
| | - Kelly R Bergmann
- Department of Emergency Medicine, Children's Minnesota, Minneapolis, USA
| | - Kristen A Breslin
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia, USA
| | - Yaron Finkelstein
- Divisions of Emergency Medicine, and Clinical Pharmacology and Toxicology, Department of Pediatrics Hospital for Sick Children, Toronto, Canada
| | - Fahd A Ahmad
- Department of Pediatrics, Washington University School of Medicine, St. Louis, USA
| | - Usha R Avva
- Department of Emergency Medicine, Montefiore-Nyack Hospital, Nyack, New York, USA
| | - Maren M Lunoe
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, USA
| | - Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles and Keck School of Medicine of the University of Southern California, Los Angeles, USA
| | - Nipam P Shah
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, USA
| | - Amy C Plint
- Division of Emergency Medicine, Children's Hospital of Eastern Ontario, Department of Pediatrics, University of Ottawa, Ottawa, Canada
| | - Vikram J Sabhaney
- Department of Paediatrics, University of British Columbia, Vancouver, Canada
| | - Usha Sethuraman
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, USA
| | - Michael A Gardiner
- Department of Pediatrics, Rady Children's Hospital, University of California San Diego, San Diego, USA
| | - Laura F Sartori
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Bruce Wright
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Alberta, Stollery Children's Hospital, Women's and Children's Health Research Institute, Edmonton, Canada
| | - Nidhya Navanandan
- Section of Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, USA
| | - Santiago Mintegi
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
| | - Iker Gangoiti
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
| | - Meredith L Borland
- Divisions of Emergency Medicine and Paediatrics, School of Medicine, Perth Children's Hospital, University of Western Australia, Perth, Australia
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Pediatrics Academic Clinical Programme, Emergency Medicine Academic Clinical Programme, Duke-NUS Medical School, Singapore
| | - Maria Y Kwok
- Department of Emergency Medicine, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, NY, New York, USA
| | - Michelle Eckerle
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital, Cincinnati, USA
| | - Naveen Poonai
- Department of Pediatrics, Schulich School of Medicine & Dentistry, London, Canada
| | | | - Muhammad Waseem
- Department of Pediatrics, Lincoln Medical Center, New York City, Bronx, New York, USA
| | | | - Maala Bhatt
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada
| | - Kerry Caperell
- Division of Emergency Medicine, Department of Pediatrics, University of Louisville, Norton Children's Hospital, Louisville, USA
| | - Carmen Campos
- Pediatric Emergency Department, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Sarah M Becker
- Department of Pediatrics, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, USA
| | - Claudia R Morris
- Division of Emergency Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, USA
| | - Alexander J Rogers
- Departments of Emergency Medicine and Pediatrics, University of Michigan School of Medicine, Ann Arbor, USA
| | - April J Kam
- Division of Emergency Medicine, Department of Pediatrics, McMaster Children's Hospital, Hamilton, Canada
| | - Viviana Pavlicich
- Departamento de Emergencia Pediátrica, Facultad de Medicina, Hospital General Pediátrico Niños de Acosta Ñu, Universidad Privada del Pacífico, San Lorenzo, Paraguay
| | - Laura Palumbo
- Department of Pediatrics, ASST Spedali Civili di Brescia - Pronto soccorso pediatrico, Brescia, Italy
| | - Stuart R Dalziel
- Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand
- Departments of Surgery and Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Andrea K Morrison
- Division of Emergency Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, USA
| | - Pedro B Rino
- Department of Pediatrics, Hospital de Pediatría "Prof. Dr. Juan P. Garrahan", RIDEPLA, Buenos Aires, Argentina
| | - Jonathan C Cherry
- Department of Pediatric Emergency Medicine, IWK Health Centre, Dalhousie University, Halifax, Canada
| | | | - Lilliam Ambroggio
- Section of Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, USA
| | - Terry P Klassen
- Department of Pediatrics and Child Health, Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, Canada
| | - Daniel C Payne
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Richard Malley
- Division of Infectious Diseases, Boston Children's Hospital and Harvard Medical School, Boston, USA
| | - Norma-Jean Simon
- Data Analytics and Reporting and Division of Emergency Medicine, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, University of California, Davis School of Medicine, Sacramento, USA
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Shapiro DJ, Hall M, Ramgopal S, Alpern ER, Chaudhari PP, Eltorki M, Badaki-Makun O, Bergmann KR, Macy ML, Foster CC, Neuman MI. Acute care utilization for ambulatory care-sensitive conditions among publicly insured children. Acad Emerg Med 2024; 31:346-353. [PMID: 38385565 PMCID: PMC11014776 DOI: 10.1111/acem.14867] [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: 08/23/2023] [Revised: 12/01/2023] [Accepted: 12/27/2023] [Indexed: 02/23/2024]
Abstract
BACKGROUND Although characteristics of preventable hospitalizations for ambulatory care-sensitive conditions (ACSCs) have been described, less is known about patterns of emergency and other acute care utilization for ACSCs among children who are not hospitalized. We sought to describe patterns of utilization for ACSCs according to the initial site of care and to determine characteristics associated with seeking initial care in an acute care setting rather than in an office. A better understanding of the sequence of health care utilization for ACSCs may inform efforts to shift care for these common conditions to the medical home. METHODS We performed a retrospective analysis of pediatric encounters for ACSCs between 2017 and 2019 using data from the IBM Watson MarketScan Medicaid database. The database includes insurance claims for Medicaid-insured children in 10 anonymized states. We assessed the initial sites of care for ACSC encounters, which were defined as either acute care settings (emergency or urgent care) or office-based settings. We used generalized estimating equations clustered on patient to identify associations between encounter characteristics and the initial site of care. RESULTS Among 7,128,515 encounters for ACSCs, acute care settings were the initial site of care in 27.9%. Diagnoses with the greatest proportion of episodes presenting to acute care settings were urinary tract infection (52.0% of episodes) and pneumonia (44.6%). Encounters on the weekend (adjusted odds ratio [aOR] 6.30, 95% confidence interval [CI] 6.27-6.34 compared with weekday) and among children with capitated insurance (aOR 1.55, 95% CI 1.54-1.56 compared with fee for service) were associated with increased odds of seeking care first in an acute care setting. CONCLUSIONS Acute care settings are the initial sites of care for more than one in four encounters for ACSCs among publicly insured children. Expanded access to primary care on weekends may shift care for ACSCs to the medical home.
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Affiliation(s)
- Daniel J Shapiro
- Division of Pediatric Emergency Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas, USA
| | - Sriram Ramgopal
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Elizabeth R Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Mohamed Eltorki
- Division of Pediatric Emergency Medicine, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Oluwakemi Badaki-Makun
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Center for Data Science in Emergency Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Kelly R Bergmann
- Department of Pediatric Emergency Medicine, Children's Hospital Minnesota, South Minneapolis, Minnesota, USA
| | - Michelle L Macy
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Carolyn C Foster
- Division of Advanced Pediatrics and Primary Care, Ann & Robert H. Lurie Children's Hospital of Chicago and Northwestern University, Chicago, Illinois, USA
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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4
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Funk A, Florin TA, Kuppermann N, Finkelstein Y, Kazakoff A, Baldovsky M, Tancredi DJ, Breslin K, Bergmann KR, Gardiner M, Pruitt CM, Liu DR, Neuman MI, Wilkinson M, Ambroggio L, Pang XL, Cauchemez S, Malley R, Klassen TP, Lee BE, Payne DC, Mahmud SM, Freedman SB. Household Transmission Dynamics of Asymptomatic SARS-CoV-2-Infected Children: A Multinational, Controlled Case-Ascertained Prospective Study. Clin Infect Dis 2024:ciae069. [PMID: 38530249 DOI: 10.1093/cid/ciae069] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND Asymptomatic SARS-CoV-2 infection in children is highly prevalent but its acute and chronic implications have been minimally described. METHODS In this controlled case-ascertained household transmission study, we recruited asymptomatic children <18 years with SARS-CoV-2 nucleic acid testing performed at 12 tertiary care pediatric institutions in Canada and the United States. We attempted to recruit all test-positive children and 1 to 3 test-negative, site-matched controls. After 14 days' follow-up we assessed the clinical (ie, symptomatic) and combined (ie, test-positive, or symptomatic) secondary attack rates (SARs) among household contacts. Additionally, post-COVID-19 condition (PCC) was assessed in SARS-CoV-2-positive participating children after 90 days' follow-up. RESULTS A total of 111 test-positive and 256 SARS-CoV-2 test-negative asymptomatic children were enrolled between January 2021 and April 2022. After 14 days, excluding households with co-primary cases, the clinical SAR among household contacts of SARS-CoV-2-positive and -negative index children was 10.6% (19/179; 95% CI: 6.5%-16.1%) and 2.0% (13/663; 95% CI: 1.0%-3.3%), respectively (relative risk = 5.4; 95% CI: 2.7-10.7). In households with a SARS-CoV-2-positive index child, age <5 years, being pre-symptomatic (ie, developed symptoms after test), and testing positive during Omicron and Delta circulation periods (vs earlier) were associated with increased clinical and combined SARs among household contacts. Among 77 asymptomatic SARS-CoV-2-infected children with 90-day follow-up, 6 (7.8%; 95% CI: 2.9%-16.2%) reported PCC. CONCLUSIONS Asymptomatic SARS-CoV-2-infected children, especially those <5 years, are important contributors to household transmission, with 1 in 10 exposed household contacts developing symptomatic illness within 14 days. Asymptomatic SARS-CoV-2-infected children may develop PCC.
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Affiliation(s)
- Anna Funk
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Todd A Florin
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital Chicago, Chicago, Illinois, USA
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, California, USA
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento, California, USA
| | - Yaron Finkelstein
- Divisions of Emergency Medicine and Clinical Pharmacology and Toxicology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Alissa Kazakoff
- Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Michael Baldovsky
- Division of Pediatric Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Daniel J Tancredi
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento, California, USA
| | - Kristen Breslin
- Division of Emergency Medicine, Children's National Hospital, Washington, D.C., USA
| | - Kelly R Bergmann
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota, USA
| | - Michael Gardiner
- Department of Pediatrics, University of California, San Diego School of Medicine, San Diego, California, USA
- Division of Emergency Medicine, Rady Children's Hospital, San Diego, California, USA
| | - Christopher M Pruitt
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Deborah R Liu
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital Los Angeles, Keck USC School of Medicine, Los Angeles, California, USA
| | - Mark I Neuman
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Matthew Wilkinson
- Department of Pediatrics, University of Texas at Austin, Dell Medical School, Austin, Texas, USA
| | - Lilliam Ambroggio
- Department of Pediatrics, University of Colorado, Aurora, Colorado, USA
- Section of Emergency Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Xiao-Li Pang
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Simon Cauchemez
- Mathematical Modelling of Infectious Diseases Unit, Institut Pasteur, Université Paris Cité, CNRS UMR 2000, Paris, France
| | - Richard Malley
- Division of Infectious Diseases, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Terry P Klassen
- Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Bonita E Lee
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Daniel C Payne
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Salaheddin M Mahmud
- Dept of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Stephen B Freedman
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Section of Gastroenterology, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Raschein TS, Lammers S, Nickel A, Louie JP, Bergmann KR. Racial and Ethnic Differences in Hospital Admission and Diagnostic Evaluation for Febrile Seizures in the Emergency Department. J Pediatr 2024:113960. [PMID: 38369236 DOI: 10.1016/j.jpeds.2024.113960] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Received: 11/30/2023] [Revised: 01/25/2024] [Accepted: 02/13/2024] [Indexed: 02/20/2024]
Abstract
OBJECTIVE To examine differences in hospital admission and diagnostic evaluation for febrile seizure by race and ethnicity. STUDY DESIGN We conducted a cross-sectional study among children 6 months to 6 years with simple or complex febrile seizure between January 1, 2016, and December 31, 2021, utilizing data from the Pediatric Health Information System. The primary outcome was hospital admission. Secondary outcomes included the proportion of encounters with neuroimaging or lumbar puncture. We used mixed-effects logistic regression model with random intercept for hospital and patient to estimate the association between outcomes and race and ethnicity after adjusting for covariates, including seizure type. RESULTS In total, 94,884 encounters were included. Most encounters occurred among children of non-Hispanic White (37.0%), Black (23.9%), and Hispanic/Latino (24.6%) race and ethnicity. Black and Hispanic/Latino children had 29% (aOR 0.71; 95% CI: 0.66, 0.75) and 26% (aOR 0.74; 95% CI: 0.69, 0.80) lower odds of hospital admission compared with non-Hispanic White children, respectively. Black and Hispanic/Latino children had 21% (aOR 0.79; 95% CI: 0.73, 0.86) and 22% (aOR 0.78; 95% CI: 0.71, 0.85) lower adjusted odds of neuroimaging compared with non-Hispanic White children. For complex febrile seizure, the adjusted odds of lumbar puncture was significantly higher among Asian children (aOR 2.12; 95% CI: 1.19, 3.77) compared with non-Hispanic White children. There were no racial differences in the odds of lumbar puncture for simple febrile seizure. CONCLUSIONS Compared with non-Hispanic White children, Black and Hispanic/Latino children with febrile seizures are less likely to be hospitalized or receive neuroimaging.
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Affiliation(s)
- Taryn S Raschein
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN
| | - Shea Lammers
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN
| | - Amanda Nickel
- Department of Research and Sponsored Programs, Children's Minnesota, Minneapolis, MN
| | - Jeffrey P Louie
- Division of Emergency Medicine, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Kelly R Bergmann
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN;.
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Gutman CK, Aronson PL, Singh NV, Pickett ML, Bouvay K, Green RS, Roach B, Kotler H, Chow JL, Hartford EA, Hincapie M, St. Pierre-Hetz R, Kelly J, Sartori L, Hoffmann JA, Corboy JB, Bergmann KR, Akinsola B, Ford V, Tedford NJ, Tran TT, Gifford S, Thompson AD, Krack A, Piroutek MJ, Lucrezia S, Chung S, Chowdhury N, Jackson K, Cheng T, Pulcini CD, Kannikeswaran N, Truschel LL, Lin K, Chu J, Molyneaux ND, Duong M, Dingeldein L, Rose JA, Theiler C, Bhalodkar S, Powers E, Waseem M, Lababidi A, Yan X, Lou XY, Fernandez R, Lion KC. Race, Ethnicity, Language, and the Treatment of Low-Risk Febrile Infants. JAMA Pediatr 2024; 178:55-64. [PMID: 37955907 PMCID: PMC10644247 DOI: 10.1001/jamapediatrics.2023.4890] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 08/02/2023] [Indexed: 11/14/2023]
Abstract
Importance Febrile infants at low risk of invasive bacterial infections are unlikely to benefit from lumbar puncture, antibiotics, or hospitalization, yet these are commonly performed. It is not known if there are differences in management by race, ethnicity, or language. Objective To investigate associations between race, ethnicity, and language and additional interventions (lumbar puncture, empirical antibiotics, and hospitalization) in well-appearing febrile infants at low risk of invasive bacterial infection. Design, Setting, and Participants This was a multicenter retrospective cross-sectional analysis of infants receiving emergency department care between January 1, 2018, and December 31, 2019. Data were analyzed from December 2022 to July 2023. Pediatric emergency departments were determined through the Pediatric Emergency Medicine Collaborative Research Committee. Well-appearing febrile infants aged 29 to 60 days at low risk of invasive bacterial infection based on blood and urine testing were included. Data were available for 9847 infants, and 4042 were included following exclusions for ill appearance, medical history, and diagnosis of a focal infectious source. Exposures Infant race and ethnicity (non-Hispanic Black, Hispanic, non-Hispanic White, and other race or ethnicity) and language used for medical care (English and language other than English). Main Outcomes and Measures The primary outcome was receipt of at least 1 of lumbar puncture, empirical antibiotics, or hospitalization. We performed bivariate and multivariable logistic regression with sum contrasts for comparisons. Individual components were assessed as secondary outcomes. Results Across 34 sites, 4042 infants (median [IQR] age, 45 [38-53] days; 1561 [44.4% of the 3516 without missing sex] female; 612 [15.1%] non-Hispanic Black, 1054 [26.1%] Hispanic, 1741 [43.1%] non-Hispanic White, and 352 [9.1%] other race or ethnicity; 3555 [88.0%] English and 463 [12.0%] language other than English) met inclusion criteria. The primary outcome occurred in 969 infants (24%). Race and ethnicity were not associated with the primary composite outcome. Compared to the grand mean, infants of families that use a language other than English had higher odds of the primary outcome (adjusted odds ratio [aOR]; 1.16; 95% CI, 1.01-1.33). In secondary analyses, Hispanic infants, compared to the grand mean, had lower odds of hospital admission (aOR, 0.76; 95% CI, 0.63-0.93). Compared to the grand mean, infants of families that use a language other than English had higher odds of hospital admission (aOR, 1.08; 95% CI, 1.08-1.46). Conclusions and Relevance Among low-risk febrile infants, language used for medical care was associated with the use of at least 1 nonindicated intervention, but race and ethnicity were not. Secondary analyses highlight the complex intersectionality of race, ethnicity, language, and health inequity. As inequitable care may be influenced by communication barriers, new guidelines that emphasize patient-centered communication may create disparities if not implemented with specific attention to equity.
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Affiliation(s)
- Colleen K. Gutman
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville
- Department of Pediatrics, University of Florida College of Medicine, Gainesville
| | - Paul L. Aronson
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Nidhi V. Singh
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Kamali Bouvay
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Rebecca S. Green
- Division of Emergency Medicine, Department of Pediatrics, Harvard Medical School and Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Britta Roach
- Division of Pediatric Emergency Medicine, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee
| | - Hannah Kotler
- Division of Emergency Medicine, The George Washington University School of Medicine and Health Sciences and Children’s National Health System, Washington, DC
| | - Jessica L. Chow
- Division of Emergency Medicine, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Emergency Medicine, University of California, Los Angeles
| | - Emily A. Hartford
- Department of Pediatrics, University of Washington School of Medicine and Seattle Children’s Hospital, Seattle
| | - Mark Hincapie
- Department of Pediatrics, University of Pittsburgh Medical Center and Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Division of Pediatric Emergency Medicine, Nicklaus Children’s Hospital, Miami, Florida
| | - Ryan St. Pierre-Hetz
- Department of Pediatrics, University of Pittsburgh Medical Center and Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jessica Kelly
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Laura Sartori
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jennifer A. Hoffmann
- Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jacqueline B. Corboy
- Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kelly R. Bergmann
- Department of Pediatric Emergency Medicine, Children’s Minnesota, Minneapolis, Minnesota
| | - Bolanle Akinsola
- Department of Pediatrics and Emergency Medicine, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Vanessa Ford
- Department of Pediatrics and Emergency Medicine, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Natalie J. Tedford
- Division of Pediatric Emergency Medicine, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City
| | - Theresa T. Tran
- Division of Pediatric Emergency Medicine, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City
| | - Sasha Gifford
- Ronald O. Perelman Department of Emergency Medicine/New York University Langone Health, New York, New York
- Department of Emergency Medicine, Weill Cornell Medical College, New York, New York
| | - Amy D. Thompson
- Department of Pediatrics, Nemours Children’s Hospital of Delaware, Wilmington
| | - Andrew Krack
- Department of Pediatrics, School of Medicine, Section of Emergency Medicine, University of Colorado and Children’s Hospital Colorado, Aurora
| | - Mary Jane Piroutek
- Department of Emergency Medicine, University of California Irvine and Children’s Hospital of Orange County, Orange
| | - Samantha Lucrezia
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky
| | - SunHee Chung
- Department of Emergency Medicine, Oregon Health and Science University, Portland
- Department of Pediatrics, Oregon Health and Science University, Portland
| | - Nabila Chowdhury
- Division of Pediatric Emergency Medicine, Johns Hopkins Children’s Center, Baltimore, Maryland
| | - Kathleen Jackson
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Medical University of South Carolina, Charleston
| | - Tabitha Cheng
- Department of Emergency Medicine, Harbor University of California Los Angeles Medical Center and the David Geffen School of Medicine at the University of California, Los Angeles
| | - Christian D. Pulcini
- Department of Pediatrics, University of Vermont Larner College of Medicine, Burlington
- Department of Emergency Medicine, University of Vermont Larner College of Medicine, Burlington
| | - Nirupama Kannikeswaran
- Department of Pediatrics, Central Michigan University College of Medicine and Children’s Hospital of Michigan, Detroit
| | - Larissa L. Truschel
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Karen Lin
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Jamie Chu
- Department of Emergency Medicine, McGovern Medical School, UTHealth Houston, Houston, Texas
- Texas Children’s Pediatrics, Houston
| | - Neh D. Molyneaux
- Department of Emergency Medicine, McGovern Medical School, UTHealth Houston, Houston, Texas
| | - Myto Duong
- Division of Pediatric Emergency Medicine, Southern Illinois University, Carbondale
| | - Leslie Dingeldein
- Rainbow Babies and Children’s Hospital and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jerri A. Rose
- Rainbow Babies and Children’s Hospital and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Carly Theiler
- Department of Emergency Medicine, University of Iowa, Iowa City
| | - Sonali Bhalodkar
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Emily Powers
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Muhammad Waseem
- Department of Pediatrics, Lincoln Medical Center, Bronx, New York
- Department of Emergency Medicine, Lincoln Medical Center, Bronx, New York
| | - Ahmed Lababidi
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville
- Department of Pediatrics, University of Florida College of Medicine, Gainesville
| | - Xinyu Yan
- Department of Biostatistics, University of Florida College of Medicine and College of Public Health and Health Professions, Gainesville
| | - Xiang-Yang Lou
- Department of Biostatistics, University of Florida College of Medicine and College of Public Health and Health Professions, Gainesville
| | - Rosemarie Fernandez
- Department of Emergency Medicine and the Center for Experiential Learning and Simulation, University of Florida College of Medicine, Gainesville
| | - K. Casey Lion
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky
- Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, Washington
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7
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Riggs A, Bergmann KR, Zagel AL. Self-Reported Anxiety and Perception of Safety Following School Lockdown Drills among Adolescent Youth. J Sch Health 2023; 93:1129-1136. [PMID: 37489107 DOI: 10.1111/josh.13362] [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] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 06/20/2023] [Accepted: 06/22/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Lockdown drills are mandated within many educational settings in the US; they may contribute to adverse mental health and there is little to suggest their effectiveness. We describe factors associated with post-drill anxiety and perceived effectiveness of drills. METHODS We surveyed youth-caregiver dyads presenting to the pediatric emergency department. Nonparametric tests compared factors across groups of child anxiety and caregiver perceived effectiveness of drills. Kappa statistics (κ) measured child-caregiver agreement on post-drill anxiety and depression symptoms. RESULTS 108 child-caregiver dyads were included. Post-lockdown drill anxiety was reported by 27% of children; those reporting anxiety were more likely to have histories of bullying or skipping school for safety (p = 0.0004). Of caregivers, 47% believed drills effectively prevent firearm injury. There was a significant disparity between child and caregiver report of post-drill mental health symptomatology (κ anxiety = 0.19; κ depression = 0.30). Implications for School Health, Policy, Practice, and Equity: Understanding factors contributing to anxiety surrounding lockdown drills and perception of drill effectiveness may aid policy decisions and resource allocation. CONCLUSIONS Lockdown drills may increase mental health symptoms in children, while caregivers may not recognize this occurrence. Studies to identify risk factors of acute and chronic post-lockdown drill anxiety will help determine how to better serve youth.
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Affiliation(s)
- Alexandra Riggs
- Department of Emergency Medicine, Children's Medical Center Plano, 7601 Preston Rd, Plano, TX, 75024
| | - Kelly R Bergmann
- Department of Emergency Medicine, Children's Minnesota, 2525 Chicago Ave. S, Minneapolis, MN, 55404
| | - Alicia L Zagel
- Pharmacy Services, M Health Fairview, 711 Kasota Ave. SE, Minneapolis, MN, 55414
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8
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Xie J, Kuppermann N, Florin TA, Tancredi DJ, Funk AL, Kim K, Salvadori MI, Yock-Corrales A, Shah NP, Breslin KA, Chaudhari PP, Bergmann KR, Ahmad FA, Nebhrajani JR, Mintegi S, Gangoiti I, Plint AC, Avva UR, Gardiner MA, Malley R, Finkelstein Y, Dalziel SR, Bhatt M, Kannikeswaran N, Caperell K, Campos C, Sabhaney VJ, Chong SL, Lunoe MM, Rogers AJ, Becker SM, Borland ML, Sartori LF, Pavlicich V, Rino PB, Morrison AK, Neuman MI, Poonai N, Simon NJE, Kam AJ, Kwok MY, Morris CR, Palumbo L, Ambroggio L, Navanandan N, Eckerle M, Klassen TP, Payne DC, Cherry JC, Waseem M, Dixon AC, Ferre IB, Freedman SB. Impact of SARS-CoV-2 Infection on the Association Between Laboratory Tests and Severe Outcomes Among Hospitalized Children. Open Forum Infect Dis 2023; 10:ofad485. [PMID: 37869403 PMCID: PMC10588618 DOI: 10.1093/ofid/ofad485] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/28/2023] [Indexed: 10/24/2023] Open
Abstract
Background To assist clinicians with identifying children at risk of severe outcomes, we assessed the association between laboratory findings and severe outcomes among severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected children and determined if SARS-CoV-2 test result status modified the associations. Methods We conducted a cross-sectional analysis of participants tested for SARS-CoV-2 infection in 41 pediatric emergency departments in 10 countries. Participants were hospitalized, had laboratory testing performed, and completed 14-day follow-up. The primary objective was to assess the associations between laboratory findings and severe outcomes. The secondary objective was to determine if the SARS-CoV-2 test result modified the associations. Results We included 1817 participants; 522 (28.7%) SARS-CoV-2 test-positive and 1295 (71.3%) test-negative. Seventy-five (14.4%) test-positive and 174 (13.4%) test-negative children experienced severe outcomes. In regression analysis, we found that among SARS-CoV-2-positive children, procalcitonin ≥0.5 ng/mL (adjusted odds ratio [aOR], 9.14; 95% CI, 2.90-28.80), ferritin >500 ng/mL (aOR, 7.95; 95% CI, 1.89-33.44), D-dimer ≥1500 ng/mL (aOR, 4.57; 95% CI, 1.12-18.68), serum glucose ≥120 mg/dL (aOR, 2.01; 95% CI, 1.06-3.81), lymphocyte count <1.0 × 109/L (aOR, 3.21; 95% CI, 1.34-7.69), and platelet count <150 × 109/L (aOR, 2.82; 95% CI, 1.31-6.07) were associated with severe outcomes. Evaluation of the interaction term revealed that a positive SARS-CoV-2 result increased the associations with severe outcomes for elevated procalcitonin, C-reactive protein (CRP), D-dimer, and for reduced lymphocyte and platelet counts. Conclusions Specific laboratory parameters are associated with severe outcomes in SARS-CoV-2-infected children, and elevated serum procalcitonin, CRP, and D-dimer and low absolute lymphocyte and platelet counts were more strongly associated with severe outcomes in children testing positive compared with those testing negative.
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Affiliation(s)
| | - Nathan Kuppermann
- Davis School of Medicine, University of California, Sacramento, California, USA
| | - Todd A Florin
- Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University, Chicago, Illinois, USA
| | - Daniel J Tancredi
- Davis School of Medicine, University of California, Sacramento, California, USA
| | - Anna L Funk
- University of Calgary, Calgary, Alberta, Canada
| | - Kelly Kim
- University of Calgary, Calgary, Alberta, Canada
| | | | | | - Nipam P Shah
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | | | | | - Fahd A Ahmad
- Washington University School of Medicine, St.Louis, Missouri, USA
| | | | - Santiago Mintegi
- University of the Basque Country, UPV/EHU Bilbao, Basque Country, Spain
| | - Iker Gangoiti
- University of the Basque Country, UPV/EHU Bilbao, Basque Country, Spain
| | - Amy C Plint
- University of Ottawa, Ottawa, Ontario, Canada
| | - Usha R Avva
- Montefiore-Nyack Hospital, Nyack, NewYork, New York, USA
| | | | | | | | | | - Maala Bhatt
- Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | | | | | - Carmen Campos
- Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - Shu-Ling Chong
- Duke-NUS Medical School, SingHealth Duke-NUS Global Health Institute, Singapore
| | - Maren M Lunoe
- UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Sarah M Becker
- Primary Children’s Hospital, Intermountain Healthcare, Salt Lake City, Utah, USA
| | | | - Laura F Sartori
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Pedro B Rino
- Hospital de Pediatría “Prof. Dr. Juan P. Garrahan,” RIDEPLA, Buenos Aires, Argentina
| | | | | | - Naveen Poonai
- Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Norma-Jean E Simon
- Ann and Robert H Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - April J Kam
- McMaster Children’s Hospital, Hamilton, Ontario, Canada
| | - Maria Y Kwok
- Columbia University Irving Medical Center, NewYork, New York, USA
| | - Claudia R Morris
- Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Laura Palumbo
- ASST Spedali Civili di Brescia—Pronto Soccorso Pediatrico, Brescia, Italy
| | | | | | - Michelle Eckerle
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | | | - Daniel C Payne
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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9
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Bergmann KR, Lefchak B, Nickel A, Lammers S, Watson D, Hester GZ. Variation in Organizational Clinical Practice Guidelines for Croup. Hosp Pediatr 2023; 13:e241-e245. [PMID: 37545472 DOI: 10.1542/hpeds.2023-007221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
BACKGROUND Croup is one of the most common respiratory complaints in pediatric emergency departments (EDs), yet little is known about clinical practice guidelines (CPGs) for this condition. OBJECTIVES To describe variation in CPGs across US children's hospitals. METHODS We describe the prevalence and features of CPGs among hospitals that submit data to the Pediatric Health Information System. Each hospital was contacted between January 10, 2022, and April 25, 2022, for their most recent croup CPG and any revisions. Characteristics reported were based on the most recent CPG revision. Characteristics included treatment recommendations, utilization measures, ED observation times, and admission criteria. Interrater reliability between reviewers was reported as percentage agreement. RESULTS Thirty-eight hospitals (79.2%) responded to our query, of which 20 (52.6%) had croup CPGs. Interrater reliability was moderate-high for categorizing the indication for racemic epinephrine (RE) (19 of 20; 95%), the minimum number of RE doses recommended before admission (15 of 20; 75%), and ED observation time (19 of 20; 95%), and was 100% for all other characteristics. Three CPGs (15.0%) recommended 1 RE dose, 14 (70.0%) recommended 2 RE doses, and 3 (15.0%) recommended 3 RE doses before hospital admission. Thirteen (65%) CPGs recommended RE for stridor at rest, whereas 7 (30%) recommended RE for any degree of stridor. Fourteen (70%) CPGs recommended an ED observation time <2 hours, 3 (15%) recommended 2 to 4 hours, and 2 (10%) recommended >4 hours. Few CPGs (15%) recommended use of standardized croup clinical scores. CONCLUSIONS Substantial variation exists among croup CPGs. Our results may inform future efforts to standardize croup CPGs across centers.
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Affiliation(s)
- Kelly R Bergmann
- Departments of Pediatric Emergency Medicine
- Value and Clinical Excellence, Children's Minnesota, Minneapolis Minnesota
| | - Brian Lefchak
- Departments of Pediatric Emergency Medicine
- Value and Clinical Excellence, Children's Minnesota, Minneapolis Minnesota
| | - Amanda Nickel
- Children's Minnesota Research Institute, Minneapolis, Minnesota
| | - Shea Lammers
- Departments of Pediatric Emergency Medicine
- Value and Clinical Excellence, Children's Minnesota, Minneapolis Minnesota
| | - Dave Watson
- Children's Minnesota Research Institute, Minneapolis, Minnesota
| | - Gabrielle Z Hester
- Value and Clinical Excellence, Children's Minnesota, Minneapolis Minnesota
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10
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Lefchak B, Nickel A, Lammers S, Watson D, Hester GZ, Bergmann KR. Impact of Clinical Guidelines on Hospital Utilization in Children With Croup. Hosp Pediatr 2023; 13:768-774. [PMID: 37545468 DOI: 10.1542/hpeds.2023-007181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
OBJECTIVES To assess the impact of croup guidelines on healthcare utilization and association between guideline-recommended racemic epinephrine (RE) treatments and admission. METHODS Cross-sectional study of children ≥3 months to ≤8 years with croup diagnosis (International Classification of Diseases, 10th Revision) from 38 hospitals within the Pediatric Health Information System between January 1, 2019 and June 30, 2022. Guidelines were categorized by minimum number of RE treatments recommended before admission. Exclusion criteria included complex chronic or croup mimicking conditions, alternate respiratory diagnoses, and direct admissions or transfers. Primary outcomes were admission rates and standardized costs. Outcomes were compared by guideline availability and different admission thresholds. Mixed effects regression was adjusted for age, sex, race, payer, previous croup encounters, and year. RESULTS Twenty hospitals (52.6%) had guidelines. Fourteen recommended 2 RE treatments and 3 recommended 3 RE treatment before admission. Among 121 284 croup encounters, overall mean admission rate was 5.7% (range 0.6% to 18.5%). Hospitals with guidelines demonstrated lower unadjusted admission rate (4.6% vs 6.6%; mean difference -2.0, 95% confidence interval -2.3 to -1.7) and higher costs ($704 vs $651; mean difference 53, 95% confidence interval 43 to 63) compared with hospitals without guidelines. Hospitals with guidelines recommending 3 RE treatments demonstrated similar unadjusted mean admission rate (5.1%) and lower costs ($658 vs $713) compared with hospitals with guidelines recommending 2 RE treatments. After adjustment, all above-mentioned differences were not statistically significant. CONCLUSIONS Many children's hospitals lack guidelines for croup. Admission rates and costs were not significantly different between hospitals with or without guidelines after adjusting for confounders.
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Affiliation(s)
| | - Amanda Nickel
- Children's Minnesota Research Institute, Children's Minnesota, Minneapolis, Minnesota
| | | | - Dave Watson
- Children's Minnesota Research Institute, Children's Minnesota, Minneapolis, Minnesota
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11
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Scribner-O'Pray M, Taylor ED, Krause E, Nickel A, Bergmann KR. Factors Associated With Low Procedural Pain Scores Among 1- to 5-Year-Old Patients Undergoing Facial Laceration Repair. Pediatr Emerg Care 2023; 39:135-141. [PMID: 35608526 DOI: 10.1097/pec.0000000000002744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Our objectives were to quantify pain experienced by young children undergoing facial laceration repair and identify factors associated with low procedural pain scores. METHODS We conducted a prospective cohort study of children's distress among a convenience sample of children aged 1 to 5 years undergoing facial or scalp laceration repair in 2 pediatric emergency departments. We reviewed video recordings and documented pain scores at 15-second intervals using the Face, Leg, Activity, Cry, Consolability-Revised (FLACC-r) scale. We dichotomized FLACC-r into low/high scores (≤3 and >3) to evaluate practice variables. RESULTS We included 11,474 FLACC-r observations from 258 procedures in the analysis. Two-thirds of 3- to 5-year-olds completed their laceration repair without the use of restraint, sedation, or anxiolytics. Mean distress scores were low (≤2.5 out of 10) across all procedure phases for 2- to 5-year-old patients. One-year-old patients experienced significantly more distress than their older counterparts (mean ≤4.2 out of 10). Odds of having low FLACC scores (≤3) were greater for patients with an expert clinician (adjusted odds ratio [aOR]: 1.72; 95% confidence interval [CI], 1.05-2.84). Wound infiltration (aOR, 0.35; 95% CI, 0.13-0.93), patient observation of a needle (aOR, 0.21; 95% CI, 0.14-0.33), and restraint (aOR, 0.04; 95% CI, 0.02-0.06) were negatively associated with low FLACC score. CONCLUSION The majority of 3- to 5-year-old patients were able to undergo facial laceration repair without restraint, sedation, or anxiolytics and with low mean distress scores. Our findings suggest that children's risk of experiencing moderate and severe distress during facial and scalp laceration repair may be reduced by prioritizing wound closure by expert-level clinicians, ensuring effective lidocaine-epinephrine-tetracaine application, avoiding restraint, and concealing needles from patient view.
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Affiliation(s)
| | | | - Ernest Krause
- Research and Sponsored Programs, Children's Minnesota, Minneapolis, MN
| | - Amanda Nickel
- Research and Sponsored Programs, Children's Minnesota, Minneapolis, MN
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12
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Bergmann KR, Boes M, Velden HV, Abuzzahab MJ, Watson D. Intravenous Fluid Bolus Volume and Resolution of Acute Kidney Injury in Children With Diabetic Ketoacidosis. Pediatr Emerg Care 2023; 39:67-73. [PMID: 36719386 DOI: 10.1097/pec.0000000000002616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To describe trends in creatinine and acute kidney injury (AKI) in children who present with diabetic ketoacidosis (DKA) and receive low versus high intravenous (IV) fluid bolus volumes. Further, to determine whether resolution of AKI is hastened by low versus high bolus volumes. METHODS We conducted an observational retrospective cohort study between January 2012 and March 2020 among children ≤21 years presenting with DKA. Acute kidney injury was defined by the Kidney Disease/Improving Global Outcomes creatinine criteria, using the Schwartz estimating equation to calculate an expected baseline creatinine. Bolus volume was categorized as low (<15 mL/kg) or high (≥15 mL/kg). Generalized additive mixed models were used to model trends of creatinine ratios. Estimated mean creatinine ratios and differences by bolus volumes were assessed at the time of bolus, and 12, 24, 36, 48 hours. Cox proportional hazard models were used to estimate the association between resolution of AKI and bolus volume after adjustment for confounders. RESULTS We identified 708 eligible encounters with DKA, of which 169 (23.9%) had AKI at presentation and 10 (1.4%) developed AKI after hospitalization. Comparing patients who received low versus high bolus volumes, the proportion of encounters with AKI on presentation was similar (P = 0.364) as was the mean difference in creatinine ratios over time. In adjusted analysis, treatment with high IV fluid bolus volume was only associated with a 6.2% faster resolution of AKI (hazard ratio, 1.062; 95% confidence interval, 0.61-1.87). CONCLUSIONS Intravenous fluid bolus volume was not associated with resolution of AKI in our cohort of children with DKA.
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Affiliation(s)
| | - Morgan Boes
- Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis
| | | | - M Jennifer Abuzzahab
- Department of Pediatric Endocrinology and McNeely Diabetes Center, Children's Minnesota, St. Paul
| | - David Watson
- Department of Research and Sponsored Programs, Children's Minnesota, Minneapolis, MN
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13
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Snelling PJ, Shefrin AE, Moake MM, Bergmann KR, Constantine E, Deanehan JK, Dessie AS, Elkhunovich MA, Gold DL, Kornblith AE, Lin‐Martore M, Nti B, Pade KH, Parri N, Sivitz A, Lam SHF. Establishing the international research priorities for pediatric emergency medicine point-of-care ultrasound: A modified Delphi study. Acad Emerg Med 2022; 29:1338-1346. [PMID: 36043227 PMCID: PMC9826219 DOI: 10.1111/acem.14588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/23/2022] [Accepted: 08/26/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND The Pediatric Emergency Medicine (PEM) Point-of-care Ultrasound (POCUS) Network (P2Network) was established in 2014 to provide a platform for international collaboration among experts, including multicenter research. The objective of this study was to use expert consensus to identify and prioritize PEM POCUS topics, to inform future collaborative multicenter research. METHODS Online surveys were administered in a two-stage, modified Delphi study. A steering committee of 16 PEM POCUS experts was identified within the P2Network, with representation from the United States, Canada, Italy, and Australia. We solicited the participation of international PEM POCUS experts through professional society mailing lists, research networks, social media, and "word of mouth." After each round, responses were refined by the steering committee before being reissued to participants to determine the ranking of all the research questions based on means and to identify the high-level consensus topics. The final stage was a modified Hanlon process of prioritization round (HPP), which emphasized relevance, impact, and feasibility. RESULTS Fifty-four eligible participants (16.6%) provided 191 items to Survey 1 (Round 1). These were refined and consolidated into 52 research questions by the steering committee. These were issued for rating in Survey 2 (Round 2), which had 45 participants. At the completion of Round 2, all questions were ranked with six research questions reaching high-level consensus. Thirty-one research questions with mean ratings above neutral were selected for the HPP round. Highly ranked topics included clinical applications of POCUS to evaluate and manage children with shock, cardiac arrest, thoracoabdominal trauma, suspected cardiac failure, atraumatic limp, and intussusception. CONCLUSIONS This consensus study has established a research agenda to inform future international multicenter PEM POCUS trials. This study has highlighted the ongoing need for high-quality evidence for PEM POCUS applications to guide clinical practice.
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Affiliation(s)
- Peter J. Snelling
- Department of Emergency MedicineGold Coast University Hospital and Griffith UniversitySouthportQueenslandAustralia
| | - Allan E. Shefrin
- Department of PediatricsChildren's Hospital of Eastern OntarioOttawaOntarioCanada
| | - Matthew M. Moake
- Department of Pediatric Emergency MedicineMedical University of South CarolinaCharlestonSouth CarolinaUSA
| | - Kelly R. Bergmann
- Department of Pediatric Emergency MedicineChildren's MinnesotaMinneapolisMinnesotaUSA
| | - Erika Constantine
- Division of Pediatric Emergency MedicineHasbro Children's Hospital/Rhode Island Hospital and Brown UniversityProvidenceRhode IslandUSA
| | - J. Kate Deanehan
- Division of Pediatric Emergency MedicineJohns Hopkins Children's Center BaltimoreBaltimoreMarylandUSA
| | - Almaz S. Dessie
- Department of Emergency MedicineColumbia University Vagelos College of Physicians and SurgeonsNew YorkNew YorkUSA
| | - Marsha A. Elkhunovich
- Division of Emergency and Transport MedicineChildren's Hospital Los AngelesLos AngelesCaliforniaUSA
| | - Delia L. Gold
- Division of Emergency MedicineNationwide Children's Hospital and Ohio State UniversityColumbusOhioUSA
| | - Aaron E. Kornblith
- Department of Emergency MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Margaret Lin‐Martore
- Department of PediatricsUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Benjamin Nti
- Riley Hospital for Children at Indiana University HealthIndianapolisIndianaUSA
| | - Kathryn H. Pade
- Division of Pediatric Emergency MedicineRady Children's Hospital San Diego and University of California at San DiegoSan DiegoCaliforniaUSA
| | - Niccolò Parri
- Department of Emergency MedicineMeyer University Children's HospitalFlorenceItaly
| | - Adam Sivitz
- Children's Hospital of New JerseyNewark Beth Israel Medical CenterNewarkNew JerseyUSA
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14
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Bergmann KR. Neighborhood Opportunity and Life Expectancy at Birth. JAMA Netw Open 2022; 5:e2235923. [PMID: 36239945 DOI: 10.1001/jamanetworkopen.2022.35923] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Kelly R Bergmann
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis
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15
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Bergmann KR, Khant M, Lammers S, Arroyo AC, Avendano P, Chaudoin L, Cohen SG, Deanehan JK, Kornblith AE, Lam SHF, Lin-Martore M, Malia L, Pade KH, Park DB, Sivitz A, Shahar-Nissan K, Snelling PJ, Tessaro MO, Thomas-Mohtat R, Whitcomb V, Yock-Corrales A, Walsh P, Watson D, Madhok M. Accuracy and Interrater Reliability of Point-of-Care Ultrasonography Image Interpretation for Intussusception. Pediatr Emerg Care 2022; 38:442-447. [PMID: 36040465 DOI: 10.1097/pec.0000000000002786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of this study was to determine the accuracy and interrater reliability of (1) point-of-care ultrasound (POCUS) image interpretation for identification of intussusception and (2) reliability of secondary signs associated with intussusception among experts compared with novice POCUS reviewers. METHODS We conducted a planned secondary analysis of a prospective, convenience sample of children aged 3 months to 6 years who were evaluated with POCUS for intussusception across 17 international pediatric emergency departments between October 2018 and December 2020. A random sample of 100 POCUS examinations was reviewed by novice and expert POCUS reviewers. The primary outcome was identification of the presence or absence of intussusception. Secondary outcomes included intussusception size and the presence of trapped free fluid or echogenic foci. Accuracy was summarized using sensitivity and specificity, which were estimated via generalized mixed effects logistic regression. Interrater reliability was summarized via Light's κ statistics with bootstrapped standard errors (SEs). Accuracy and reliability of expert and novice POCUS reviewers were compared. RESULTS Eighteen expert and 16 novice POCUS reviewers completed the reviews. The average expert sensitivity was 94.5% (95% confidence interval [CI], 88.6-97.5), and the specificity was 94.3% (95% CI, 90.3-96.7), significantly higher than the average novice sensitivity of 84.7% (95% CI, 74.3-91.4) and specificity of 80.4% (95% CI, 72.4, 86.7). κ was significantly greater for expert (0.679, SE 0.039) compared with novice POCUS reviewers (0.424, SE 0.044; difference 0.256, SE 0.033). For our secondary outcome measure of intussusception size, κ was significantly greater for experts (0.661, SE 0.038) compared with novices (0.397, SE 0.041; difference 0.264, SE 0.029). Interrater reliability was weak for expert and minimal for novice reviewers regarding the detection of trapped free fluid and echogenic foci. CONCLUSIONS Expert POCUS reviewers demonstrate high accuracy and moderate interrater reliability when identifying intussusception via image interpretation and perform better than novice reviewers.
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Affiliation(s)
- Kelly R Bergmann
- From the Department of Emergency Medicine, Children's Minnesota, Minneapolis, MN
| | - Marshal Khant
- From the Department of Emergency Medicine, Children's Minnesota, Minneapolis, MN
| | - Shea Lammers
- From the Department of Emergency Medicine, Children's Minnesota, Minneapolis, MN
| | - Alexander C Arroyo
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY
| | - Pablo Avendano
- Division of Pediatric Emergency Medicine, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Lindsey Chaudoin
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, NC
| | - Stephanie G Cohen
- Department of Pediatrics and Emergency Medicine, Children's Healthcare Atlanta and Emory University, Atlanta, GA
| | - J Kate Deanehan
- Department of Pediatric Emergency Medicine, Johns Hopkins Children's Center, Baltimore, MD
| | - Aaron E Kornblith
- Departments of Emergency Medicine and Pediatrics, University of California, San Francisco, San Francisco
| | - Samuel H F Lam
- Department of Emergency Medicine, Sutter Medical Center Sacramento, Sacramento, CA
| | - Margaret Lin-Martore
- Departments of Emergency Medicine and Pediatrics, University of California, San Francisco, San Francisco
| | - Laurie Malia
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York Presbyterian-Morgan Stanley Children's Hospital, New York, NY
| | - Kathryn H Pade
- Department of Pediatrics, University of California, San Diego, CA
| | - Daniel B Park
- Department of Pediatrics and Emergency Medicine, University of North Carolina, Chapel Hill, NC
| | - Adam Sivitz
- Department of Emergency Medicine, Newark Beth Israel Medical Center, Newark, NJ
| | - Keren Shahar-Nissan
- Department of Emergency Medicine, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Peter J Snelling
- Department of Pediatric Emergency Medicine, Gold Coast University Hospital and Griffith University, Southport, Queensland, Australia
| | - Mark O Tessaro
- Division of Pediatric Emergency Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rosemary Thomas-Mohtat
- Department of Pediatric Emergency Medicine, Children's National Hospital, Washington, DC
| | - Valerie Whitcomb
- From the Department of Emergency Medicine, Children's Minnesota, Minneapolis, MN
| | - Adriana Yock-Corrales
- Department of Emergency Medicine, Hospital Nacional de Niños "Dr. Carlos Sáenz Herrera," CCSS, San José, Costa Rica
| | - Paige Walsh
- Department of Research and Sponsored Programs, Children's Minnesota, Minneapolis, MN
| | - Dave Watson
- Department of Research and Sponsored Programs, Children's Minnesota, Minneapolis, MN
| | - Manu Madhok
- From the Department of Emergency Medicine, Children's Minnesota, Minneapolis, MN
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16
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Hester G, Nickel AJ, Watson D, Maalouli W, Bergmann KR. Use of a Clinical Guideline and Orderset to Reduce Hospital Admissions for Croup. Pediatrics 2022; 150:188776. [PMID: 35970819 DOI: 10.1542/peds.2021-053507] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Received: 05/27/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Studies have found infrequent interventions after croup admission. Our objectives were to achieve 25% reduction in (1) admission rate and (2) neck radiograph utilization among patients presenting to the emergency department. METHODS At our tertiary children's hospital, we implemented clustered interventions including education, guideline, and orderset integration. We included patients 3 months to 8 years old with an emergency department, observation, or inpatient encounter for croup. We excluded patients with direct or ICU admissions, complex chronic conditions, or concurrent asthma, pneumonia, or bronchiolitis. We reviewed a random sample of 60% of encounters from baseline (October 1, 2017 to September 30, 2019) and implementation (October 1, 2019 to September 30, 2020) periods. We conducted a posthoc analysis from October 1, 2017 to December 1, 2021 to assess sustainment during coronavirus disease 2019. Interrupted time series analysis was used to evaluate changes in outcome, process, and balancing measures. RESULTS There were 2906 (2123 baseline and 783 implementation) encounters included. Extrapolating preintervention trend estimates, the baseline admission rate of 8.7% decreased to 5.5% postintervention (relative decrease 37% [95% confidence interval: 8 to 66]) and sustained over 26 months after implementation. Admission rate in patients receiving 2 or fewer racemic epinephrine was significantly lower in implementation (1.7%) compared with baseline (6.3%), relative decrease of 72% (95% confidence interval: 68 to 88). There were no significant changes in neck radiographs, length of stay, or revisits. CONCLUSIONS Croup quality improvement interventions were associated with a significant decrease in hospital admissions with no increase in revisits.
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Affiliation(s)
| | | | | | - Walid Maalouli
- University of Minnesota Masonic Children's Hospital, Minneapolis, Mennesota
| | - Kelly R Bergmann
- Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota
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17
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Cutler GJ, Bergmann KR, Doupnik SK, Hoffmann JA, Neuman MI, Rodean J, Zagel AL, Zima BT. Pediatric Mental Health Emergency Department Visits and Access to Inpatient Care: A Crisis Worsened by the COVID-19 Pandemic. Acad Pediatr 2022; 22:889-891. [PMID: 35351651 PMCID: PMC8957359 DOI: 10.1016/j.acap.2022.03.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/17/2022] [Accepted: 03/23/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Gretchen J Cutler
- Children's Minnesota Research Institute, Children's Minnesota (GJ Cutler), Minneapolis, Minn.
| | - Kelly R Bergmann
- Department of Pediatric Emergency Medicine, Children's Minnesota (KR Bergmann), Minneapolis, Minn
| | - Stephanie K Doupnik
- Division of General Pediatrics, PolicyLab, and Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia (SK Doupnik), Philadelphia, Pa
| | - Jennifer A Hoffmann
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago (JA Hoffmann), Chicago, Ill
| | - Mark I Neuman
- Division of Emergency Medicine, Department of Medicine, Boston Children's Hospital, Harvard Medical School (MI Neuman), Boston, Mass
| | | | - Alicia L Zagel
- Fairview Pharmacy Services (AL Zagel), Minneapolis, Minn
| | - Bonnie T Zima
- UCLA Semel Institute for Neuroscience and Human Behavior, University of California at Los Angeles (BT Zima), Los Angeles, Calif
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18
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Maalouli W, Petersen A, Strutt J, Bergmann KR, Axelrod A, Lee G, Hester GZ. Prediction Model for Croup Admission Need. Hosp Pediatr 2022; 12:711-718. [PMID: 35788350 DOI: 10.1542/hpeds.2021-006389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES This study aims to generate a predictive model stratifying the probability of requiring hospitalization and inpatient respiratory intervention for croup patients presenting to the emergency department (ED), and secondarily to compare the model's performance with that of ED providers. METHODS Retrospective data was collected on croup patients presenting to the EDs of 2 pediatric and 1 community hospital from 2019 to 2020, including demographics, preexisting conditions, and history of croup. The ED length of stay, previous dexamethasone administration, time to ED dexamethasone, number of ED racemic epinephrine doses, viral testing, and ED revisits were also recorded. Westley croup scores were derived at ED presentation and final disposition. For admitted patients, any respiratory interventions were recorded. Admission need was defined as either admitted and required an inpatient intervention or not admitted with ED revisit. A prediction model for admission need was fit using L1-penalized logistic regression. RESULTS We included 2951 patients in the study, 68 (2.3%) of which needed admission. The model's predictors were disposition Westley croup scores, number of ED racemic epinephrine doses, previous dexamethasone administration, and history of intubation. The model's sensitivity was 66%, specificity was 91%, positive predictive value was 15%, and negative predictive value was 99%. ED providers' performance had a sensitivity of 72%, a specificity of 94%, a positive predictive value of 23%, and a negative predictive value of 99%. CONCLUSIONS The croup admission need predictive model appears to support clinical decision making in the ED, with the potential to improve decision making when pediatric expertise is limited.
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Affiliation(s)
| | | | | | | | | | - Grace Lee
- University of Minnesota, Minneapolis, Minnesota
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19
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Funk AL, Kuppermann N, Florin TA, Tancredi DJ, Xie J, Kim K, Finkelstein Y, Neuman MI, Salvadori MI, Yock-Corrales A, Breslin KA, Ambroggio L, Chaudhari PP, Bergmann KR, Gardiner MA, Nebhrajani JR, Campos C, Ahmad FA, Sartori LF, Navanandan N, Kannikeswaran N, Caperell K, Morris CR, Mintegi S, Gangoiti I, Sabhaney VJ, Plint AC, Klassen TP, Avva UR, Shah NP, Dixon AC, Lunoe MM, Becker SM, Rogers AJ, Pavlicich V, Dalziel SR, Payne DC, Malley R, Borland ML, Morrison AK, Bhatt M, Rino PB, Beneyto Ferre I, Eckerle M, Kam AJ, Chong SL, Palumbo L, Kwok MY, Cherry JC, Poonai N, Waseem M, Simon NJ, Freedman SB. Post-COVID-19 Conditions Among Children 90 Days After SARS-CoV-2 Infection. JAMA Netw Open 2022; 5:e2223253. [PMID: 35867061 PMCID: PMC9308058 DOI: 10.1001/jamanetworkopen.2022.23253] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Little is known about the risk factors for, and the risk of, developing post-COVID-19 conditions (PCCs) among children. OBJECTIVES To estimate the proportion of SARS-CoV-2-positive children with PCCs 90 days after a positive test result, to compare this proportion with SARS-CoV-2-negative children, and to assess factors associated with PCCs. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study, conducted in 36 emergency departments (EDs) in 8 countries between March 7, 2020, and January 20, 2021, included 1884 SARS-CoV-2-positive children who completed 90-day follow-up; 1686 of these children were frequency matched by hospitalization status, country, and recruitment date with 1701 SARS-CoV-2-negative controls. EXPOSURE SARS-CoV-2 detected via nucleic acid testing. MAIN OUTCOMES AND MEASURES Post-COVID-19 conditions, defined as any persistent, new, or recurrent health problems reported in the 90-day follow-up survey. RESULTS Of 8642 enrolled children, 2368 (27.4%) were SARS-CoV-2 positive, among whom 2365 (99.9%) had index ED visit disposition data available; among the 1884 children (79.7%) who completed follow-up, the median age was 3 years (IQR, 0-10 years) and 994 (52.8%) were boys. A total of 110 SARS-CoV-2-positive children (5.8%; 95% CI, 4.8%-7.0%) reported PCCs, including 44 of 447 children (9.8%; 95% CI, 7.4%-13.0%) hospitalized during the acute illness and 66 of 1437 children (4.6%; 95% CI, 3.6%-5.8%) not hospitalized during the acute illness (difference, 5.3%; 95% CI, 2.5%-8.5%). Among SARS-CoV-2-positive children, the most common symptom was fatigue or weakness (21 [1.1%]). Characteristics associated with reporting at least 1 PCC at 90 days included being hospitalized 48 hours or more compared with no hospitalization (adjusted odds ratio [aOR], 2.67 [95% CI, 1.63-4.38]); having 4 or more symptoms reported at the index ED visit compared with 1 to 3 symptoms (4-6 symptoms: aOR, 2.35 [95% CI, 1.28-4.31]; ≥7 symptoms: aOR, 4.59 [95% CI, 2.50-8.44]); and being 14 years of age or older compared with younger than 1 year (aOR, 2.67 [95% CI, 1.43-4.99]). SARS-CoV-2-positive children were more likely to report PCCs at 90 days compared with those who tested negative, both among those who were not hospitalized (55 of 1295 [4.2%; 95% CI, 3.2%-5.5%] vs 35 of 1321 [2.7%; 95% CI, 1.9%-3.7%]; difference, 1.6% [95% CI, 0.2%-3.0%]) and those who were hospitalized (40 of 391 [10.2%; 95% CI, 7.4%-13.7%] vs 19 of 380 [5.0%; 95% CI, 3.0%-7.7%]; difference, 5.2% [95% CI, 1.5%-9.1%]). In addition, SARS-CoV-2 positivity was associated with reporting PCCs 90 days after the index ED visit (aOR, 1.63 [95% CI, 1.14-2.35]), specifically systemic health problems (eg, fatigue, weakness, fever; aOR, 2.44 [95% CI, 1.19-5.00]). CONCLUSIONS AND RELEVANCE In this cohort study, SARS-CoV-2 infection was associated with reporting PCCs at 90 days in children. Guidance and follow-up are particularly necessary for hospitalized children who have numerous acute symptoms and are older.
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Affiliation(s)
- Anna L Funk
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento
| | - Todd A Florin
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Daniel J Tancredi
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento
| | - Jianling Xie
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kelly Kim
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Yaron Finkelstein
- Division of Emergency Medicine, Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Clinical Pharmacology and Toxicology, Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mark I Neuman
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | | | - Adriana Yock-Corrales
- Emergency Department, Hospital Nacional de Niños "Dr. Carlos Sáenz Herrera," CCSS, San José, Costa Rica
| | - Kristen A Breslin
- Department of Emergency Medicine and Trauma Services, Children's National Hospital, Washington, DC
| | - Lilliam Ambroggio
- Department of Pediatrics, University of Colorado, Aurora
- Section of Emergency Medicine, Children's Hospital Colorado, Aurora
| | - Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles and Keck School of Medicine of the University of Southern California, Los Angeles
| | - Kelly R Bergmann
- Department of Emergency Medicine, Children's Minnesota, Minneapolis
| | - Michael A Gardiner
- Department of Pediatrics, University of California, San Diego, Rady Children's Hospital, San Diego
| | | | - Carmen Campos
- Pediatric Emergency Department, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Fahd A Ahmad
- Department of Pediatrics, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Laura F Sartori
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nidhya Navanandan
- Department of Pediatrics, University of Colorado, Aurora
- Section of Emergency Medicine, Children's Hospital Colorado, Aurora
| | - Nirupama Kannikeswaran
- Division of Emergency Medicine, Children's Hospital of Michigan, Detroit
- Department of Pediatrics, Central Michigan University, Mt Pleasant
| | - Kerry Caperell
- Department of Pediatrics, University of Louisville, Louisville, Kentucky
- Department of Pediatrics, Norton Children's Hospital, Louisville, Kentucky
| | - Claudia R Morris
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Santiago Mintegi
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU Bilbao, Basque Country, Spain
| | - Iker Gangoiti
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU Bilbao, Basque Country, Spain
| | - Vikram J Sabhaney
- Department of Paediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Amy C Plint
- Division of Emergency Medicine, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Terry P Klassen
- Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Usha R Avva
- Department of Emergency Medicine, Montefiore-Nyack Hospital, Nyack, New York
| | - Nipam P Shah
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Alabama at Birmingham
| | - Andrew C Dixon
- University of Alberta, Stollery Children's Hospital, Women's and Children's Health Research Institute, Edmonton, Alberta, Canada
| | - Maren M Lunoe
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sarah M Becker
- Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, Utah
| | - Alexander J Rogers
- Department of Emergency Medicine, University of Michigan School of Medicine, Ann Arbor
- Department of Pediatrics, University of Michigan School of Medicine, Ann Arbor
| | - Viviana Pavlicich
- Departamento de Emergencia Pediátrica, Hospital General Pediátrico Niños de Acosta Ñu, Facultad de Medicina, Universidad Privada del Pacífico, San Lorenzo, Paraguay
| | - Stuart R Dalziel
- Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand
- Department of Surgery, University of Auckland, Auckland, New Zealand
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Daniel C Payne
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Richard Malley
- Division of Infectious Diseases, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Meredith L Borland
- Emergency Department, Perth Children's Hospital, Perth, Western Australia
- Division of Emergency Medicine, School of Medicine, University of Western Australia, Perth, Australia
- Division of Paediatrics, School of Medicine, University of Western Australia, Perth, Australia
| | - Andrea K Morrison
- Division of Emergency Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee
| | - Maala Bhatt
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Pedro B Rino
- Hospital de Pediatría "Prof Dr. Juan P. Garrahan," RIDEPLA, Buenos Aires, Argentina
| | | | - Michelle Eckerle
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Pediatric Emergency Medicine, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - April J Kam
- Department of Pediatrics, Division of Emergency Medicine, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Duke-NUS Medical School, SingHealth Duke-NUS Global Health Institute, Singapore
| | - Laura Palumbo
- ASST Spedali Civili di Brescia-Pronto soccorso pediatrico, Brescia, Italy
| | - Maria Y Kwok
- Department of Emergency Medicine, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, New York
| | - Jonathan C Cherry
- Department of Pediatric Emergency Medicine, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Naveen Poonai
- Department of Pediatrics, Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Muhammad Waseem
- Department of Emergency Medicine, Lincoln Medical Center, New York, New York
| | - Norma-Jean Simon
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
- Data Analytics and Reporting, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Stephen B Freedman
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Section of Gastroenterology, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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20
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Abstract
This cross-sectional study investigates the association of dominant SARS-CoV-2 variants with COVID-19–related croup.
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Affiliation(s)
- Brian Lefchak
- Department of Pediatric Emergency Medicine, Children’s Minnesota, Minneapolis
| | - Amanda Nickel
- Children’s Minnesota Research Institute, Children’s Minnesota, Minneapolis
| | - Shea Lammers
- Department of Pediatric Emergency Medicine, Children’s Minnesota, Minneapolis
| | - Dave Watson
- Children’s Minnesota Research Institute, Children’s Minnesota, Minneapolis
| | - Gabrielle Z. Hester
- Department of Value and Clinical Excellence, Children’s Minnesota, Minneapolis
| | - Kelly R. Bergmann
- Department of Pediatric Emergency Medicine, Children’s Minnesota, Minneapolis
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21
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Bergmann KR, Nickel A, Hall M, Cutler G, Abuzzahab MJ, Bretscher B, Lammers S, Watson D, Hester GZ. Association of Neighborhood Resources and Race and Ethnicity With Readmissions for Diabetic Ketoacidosis at US Children's Hospitals. JAMA Netw Open 2022; 5:e2210456. [PMID: 35511179 PMCID: PMC9073568 DOI: 10.1001/jamanetworkopen.2022.10456] [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] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 03/17/2022] [Indexed: 02/04/2023] Open
Abstract
Importance The Child Opportunity Index 2.0 (COI) assesses neighborhood resources and conditions that influence health. It is unclear whether the COI scores are associated with health outcomes by race and ethnicity among children with type 1 diabetes (T1D). Objective To determine whether COI categories are associated with diabetes-related outcomes by race and ethnicity, including readmissions for diabetic ketoacidosis (DKA) and co-occurring acute kidney injury (AKI) or cerebral edema (CE). Design, Setting, and Participants This cross-sectional study included children discharged with a primary diagnosis of T1D with DKA between January 1, 2009, and December 31, 2018. Merged data were obtained from the Pediatric Health Information System and COI. Participants included children and adolescents younger than 21 years with an encounter for DKA. Data were analyzed from April 29, 2021, to January 5, 2022. Exposures Neighborhood opportunity, measured with the COI as an ordered, categorical score (where a higher score indicates more opportunity), and race and ethnicity. Main Outcomes and Measures The primary outcome was readmission for DKA within 30 and 365 days from an index visit. Secondary outcomes included the proportion of encounters with AKI or CE. Mixed-effects logistic regression was used to generate probabilities of readmission, AKI, and CE for each quintile of COI category by race and ethnicity. Results A total of 72 726 patient encounters were identified, including 38 924 (53.5%) for girls; the median patient age was 13 (IQR, 9-15) years. In terms of race and ethnicity, 600 (0.8%) of the encounters occurred in Asian patients, 9969 (13.7%) occurred in Hispanic patients, 16 876 (23.2%) occurred in non-Hispanic Black (hereinafter Black) patients, 40 129 (55.2%) occurred in non-Hispanic White (hereinafter White) patients, and 5152 (7.1%) occurred in patients of other race or ethnicity. The probability of readmission within 365 days was significantly higher among Black children with a very low COI category compared with Hispanic children (risk difference, 7.8 [95% CI, 6.0-9.6] percentage points) and White children (risk difference, 7.5 [95% CI, 5.9-9.1] percentage points) at the same COI category. Similar differences were seen for children with very high COI scores and across racial groups. The COI category was not associated with AKI or CE. However, race and ethnicity constituted a significant factor associated with AKI across all COI categories. The probability of AKI was 6.8% among Black children compared with 4.2% among Hispanic children (risk difference, 2.5 [95% CI, 1.7-3.3] percentage points) and 4.8% among White children (risk difference, 2.0 [95% CI, 1.3-2.6] percentage points). Conclusions and Relevance These results suggest that Black children with T1D experience disparities in health outcomes compared with other racial and ethnic groups with similar COI categories. Measures to prevent readmissions for DKA should include interventions that target racial disparities and community factors.
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Affiliation(s)
- Kelly R. Bergmann
- Department of Pediatric Emergency Medicine, Children’s Minnesota, Minneapolis
| | - Amanda Nickel
- Department of Research and Sponsored Programs, Children’s Minnesota, Minneapolis
| | - Matt Hall
- Department of Analytics, Children’s Hospital Association, Overland Park, Kansas
| | - Gretchen Cutler
- Department of Pediatric Emergency Medicine, Children’s Minnesota, Minneapolis
| | | | - Brianna Bretscher
- Department of Pediatric Emergency Medicine, Children’s Minnesota, Minneapolis
| | - Shea Lammers
- Department of Pediatric Emergency Medicine, Children’s Minnesota, Minneapolis
| | - Dave Watson
- Department of Research and Sponsored Programs, Children’s Minnesota, Minneapolis
| | - Gabrielle Z. Hester
- Department of Value and Clinical Excellence, Children’s Minnesota, Minneapolis
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22
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Kaplan RL, Cruz AT, Freedman SB, Smith K, Freeman J, Lane RD, Michelson KA, Marble RD, Middelberg LK, Bergmann KR, McAneney C, Noorbakhsh KA, Pruitt C, Shah N, Badaki-Makun O, Schnadower D, Thompson AD, Blackstone MM, Abramo TJ, Srivastava G, Avva U, Samuels-Kalow M, Morientes O, Kannikeswaran N, Chaudhari PP, Strutt J, Vance C, Haines E, Khanna K, Gerard J, Bajaj L. Omphalitis and Concurrent Serious Bacterial Infection. Pediatrics 2022; 149:186812. [PMID: 35441224 DOI: 10.1542/peds.2021-054189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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] [Accepted: 01/25/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Describe the clinical presentation, prevalence of concurrent serious bacterial infection (SBI), and outcomes among infants with omphalitis. METHODS Within the Pediatric Emergency Medicine Collaborative Research Committee, 28 sites reviewed records of infants ≤90 days of age with omphalitis seen in the emergency department from January 1, 2008, to December 31, 2017. Demographic, clinical, laboratory, treatment, and outcome data were summarized. RESULTS Among 566 infants (median age 16 days), 537 (95%) were well-appearing, 64 (11%) had fever at home or in the emergency department, and 143 (25%) had reported fussiness or poor feeding. Blood, urine, and cerebrospinal fluid cultures were collected in 472 (83%), 326 (58%), and 222 (39%) infants, respectively. Pathogens grew in 1.1% (95% confidence interval [CI], 0.3%-2.5%) of blood, 0.9% (95% CI, 0.2%-2.7%) of urine, and 0.9% (95% CI, 0.1%-3.2%) of cerebrospinal fluid cultures. Cultures from the site of infection were obtained in 320 (57%) infants, with 85% (95% CI, 80%-88%) growing a pathogen, most commonly methicillin-sensitive Staphylococcus aureus (62%), followed by methicillin-resistant Staphylococcus aureus (11%) and Escherichia coli (10%). Four hundred ninety-eight (88%) were hospitalized, 81 (16%) to an ICU. Twelve (2.1% [95% CI, 1.1%-3.7%]) had sepsis or shock, and 2 (0.4% [95% CI, 0.0%-1.3%]) had severe cellulitis or necrotizing soft tissue infection. There was 1 death. Serious complications occurred only in infants aged <28 days. CONCLUSIONS In this multicenter cohort, mild, localized disease was typical of omphalitis. SBI and adverse outcomes were uncommon. Depending on age, routine testing for SBI is likely unnecessary in most afebrile, well-appearing infants with omphalitis.
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Affiliation(s)
- Ron L Kaplan
- Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Andrea T Cruz
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Stephen B Freedman
- Departments of Pediatrics and Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Kathleen Smith
- Department of Pediatrics, Rady Children's Hospital San Diego, San Diego, California
| | - Julia Freeman
- Department of Pediatrics, Children's Hospital Colorado/University of Colorado School of Medicine, Aurora, Colorado
| | - Roni D Lane
- Department of Pediatrics, University of Utah, Primary Children's Hospital, Salt Lake City, Utah
| | - Kenneth A Michelson
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Richard D Marble
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Leah K Middelberg
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kelly R Bergmann
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota
| | - Constance McAneney
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kathleen A Noorbakhsh
- Department of Pediatrics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Christopher Pruitt
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Nipam Shah
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - David Schnadower
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Amy D Thompson
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Mercedes M Blackstone
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Thomas J Abramo
- Pediatric Emergency Medicine Associates, Children's Hospital of Atlanta, Atlanta, Georgia
| | | | - Usha Avva
- Department of Pediatrics, Joseph M Sanzari Children's Hospital, Hackensack Meridian Health, Hackensack, New Jersey
| | | | - Oihane Morientes
- Pediatric Emergency Department, Cruces University Hospital, Bilbao, Spain
| | - Nirupama Kannikeswaran
- Department of Pediatrics, Central Michigan University, Children's Hospital of Michigan, Detroit, Michigan
| | - Pradip P Chaudhari
- Department of Pediatrics, University of Southern California, Children's Hospital Los Angeles, Los Angeles, California
| | - Jonathan Strutt
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Cheryl Vance
- Departments of Emergency Medicine and Pediatrics, University of California, Davis School of Medicine, Sacramento, California
| | - Elizabeth Haines
- Ronald O. Perelman Department of Emergency Medicine/NYU Langone Health, New York, New York
| | - Kajal Khanna
- Department of Emergency Medicine, Stanford University, Stanford, California
| | - James Gerard
- Department of Pediatrics, Saint Louis University School of Medicine, St. Louise, Missouri
| | - Lalit Bajaj
- Department of Pediatrics, Children's Hospital Colorado/University of Colorado School of Medicine, Aurora, Colorado
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Becker CR, Bergmann KR, Vazquez‐Benitez G, Bretscher BM, Kharbanda AB. Resource utilization and outcomes among children risk stratified by pediatric appendicitis risk calculator at a tertiary pediatric center. Acad Emerg Med 2022; 29:415-422. [PMID: 34942048 DOI: 10.1111/acem.14433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 12/08/2021] [Accepted: 12/19/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Appendicitis is a common pediatric condition requiring surgery. The pediatric appendicitis risk calculator (pARC) was recently developed to guide clinical care. The objective of this study is to describe resource utilization and clinical outcomes among children with appendix ultrasound (US) scans risk stratified by pARC score. METHODS Prospective enrolled observational cohort single-center study of children aged 5-18, who had an US for suspected appendicitis. We estimated the rate of appendicitis, rate of equivocal US scans, and resource utilization by pARC score strata. Total adjusted charges were determined for low-risk pARC patients compared to discharged emergency department (ED) patients with abdominal pain and complete blood count (CBC) obtained without advanced abdominal imaging. RESULTS Over the 13-month study period, 407 children were enrolled. The overall rate of appendicitis was 33.4%, and 199 (49%) were male. The observed rate of appendicitis was 3.3% in those with a pARC score of <15% and 96.8% in those with a pARC score of ≥85%. Of enrolled patients, 152 (37.3%) had a pARC score <15%. Of those with a pARC score of <15%, the negative appendectomy rate was 28.6%, and the rate of equivocal US was 49.3%. The rate of CT scans and hospitalizations was 19% and 23%, respectively. Median total charges for patients with pARC <15% with usual care were $3756. Median total charges for patients presenting to the ED with abdominal pain who had a CBC but no advanced abdominal imaging performed was $2484, indicating a potential savings of $1272 per patient. CONCLUSIONS There is a high rate of resource utilization among patients who are low appendicitis risk by pARC score. Outcome variation by pARC scores presents future opportunity to selectively reduce resource utilization in pediatric patients.
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Affiliation(s)
- Callie R. Becker
- Division of Pediatric Emergency Medicine Department of Pediatrics M Health Fairview Masonic Children’s Hospital Minneapolis Minnesota USA
| | - Kelly R. Bergmann
- Department of Emergency Medicine Children’s Minnesota Minneapolis Minnesota USA
| | | | | | - Anupam B. Kharbanda
- Department of Emergency Medicine Children’s Minnesota Minneapolis Minnesota USA
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Kornblith AE, Addo N, Plasencia M, Shaahinfar A, Lin-Martore M, Sabbineni N, Gold D, Bellman L, Berant R, Bergmann KR, Brenkert TE, Chen A, Constantine E, Deanehan JK, Dessie A, Elkhunovich M, Fischer J, Gravel CA, Kharasch S, Kwan CW, Lam SHF, Neal JT, Pade KH, Rempell R, Shefrin AE, Sivitz A, Snelling PJ, Tessaro MO, White W. Development of a Consensus-Based Definition of Focused Assessment With Sonography for Trauma in Children. JAMA Netw Open 2022; 5:e222922. [PMID: 35302632 PMCID: PMC8933745 DOI: 10.1001/jamanetworkopen.2022.2922] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 01/30/2022] [Indexed: 11/14/2022] Open
Abstract
Importance The wide variation in the accuracy and reliability of the Focused Assessment With Sonography for Trauma (FAST) and the extended FAST (E-FAST) for children after blunt abdominal trauma reflects user expertise. FAST and E-FAST that are performed by experts tend to be more complete, better quality, and more often clinically valuable. Objective To develop definitions of a complete, high-quality, and accurate interpretation for the FAST and E-FAST in children with injury using an expert, consensus-based modified Delphi technique. Design, Setting, and Participants This consensus-based qualitative study was conducted between May 1 to June 30, 2021. It used a scoping review and iterative Delphi technique and involved 2 rounds of online surveys and a live webinar to achieve consensus among a 26-member panel. This panel consisted of international experts in pediatric emergency point-of-care ultrasonography. Main Outcomes and Measures Definitions of complete, high-quality, and accurate FAST and E-FAST studies for children after injury. Results Of the 29 invited pediatric FAST experts, 26 (15 men [58%]) agreed to participate in the panel. All 26 panelists completed the 2 rounds of surveys, and 24 (92%) participated in the live and asynchronous online discussions. Consensus was reached on FAST and E-FAST study definitions, and the panelists rated these 5 anatomic views as important and appropriate for a complete FAST: right upper-quadrant abdominal view, left upper-quadrant abdominal view, suprapubic views (transverse and sagittal), and subxiphoid cardiac view. For E-FAST, the same FAST anatomic views with the addition of the lung or pneumothorax view were deemed appropriate and important. In addition, the panelists rated a total of 32 landmarks as important for assessing completeness. Similarly, the panelists rated 14 statements on quality and 20 statements on accurate interpretation as appropriate. Conclusions and Relevance This qualitative study generated definitions for complete FAST and E-FAST studies with high image quality and accurate interpretation in children with injury. These definitions are similar to those in adults with injury and may be used for future education, quality assurance, and research. Future research may focus on interpretation of trace volumes of abdominal free fluid and the use of serial FAST.
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Affiliation(s)
- Aaron E. Kornblith
- Department of Pediatrics, University of California, San Francisco, San Francisco
- Department of Emergency Medicine, University of California, San Francisco, San Francisco
| | - Newton Addo
- Department of Emergency Medicine, University of California, San Francisco, San Francisco
- Department of Medicine, University of California, San Francisco, San Francisco
| | - Monica Plasencia
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco
- Department of Bioengineering, University of California, Berkeley, Berkeley
| | - Ashkon Shaahinfar
- Department of Pediatrics, University of California, San Francisco, San Francisco
- Department of Emergency Medicine, University of California, San Francisco, San Francisco
| | - Margaret Lin-Martore
- Department of Pediatrics, University of California, San Francisco, San Francisco
- Department of Emergency Medicine, University of California, San Francisco, San Francisco
| | - Naina Sabbineni
- Department of Emergency Medicine, University of California, San Francisco, San Francisco
| | - Delia Gold
- Department of Pediatrics, Division of Emergency Medicine, Nationwide Children’s Hospital, Columbus, Ohio
| | - Lily Bellman
- Division of Pediatric Emergency Medicine, Department of Pediatric Emergency Medicine, Harbor-UCLA (University of California, Los Angeles) Medical Center, California Pacific Medical Center, Los Angeles
| | - Ron Berant
- Department of Emergency Medicine, Schneider Children’s Medical Center of Israel, Petah Tikva, Israel
| | - Kelly R. Bergmann
- Department of Pediatric Emergency Medicine, Children’s Minnesota, Minneapolis
| | - Timothy E. Brenkert
- Division of Pediatric Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Aaron Chen
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Erika Constantine
- Division of Pediatric Emergency Medicine, Hasbro Children’s Hospital, Rhode Island Hospital, Providence
| | - J. Kate Deanehan
- Division of Pediatric Emergency Medicine, Johns Hopkins Children’s Center, Baltimore, Maryland
| | - Almaz Dessie
- Department of Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Marsha Elkhunovich
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, California
| | - Jason Fischer
- Division of Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Cynthia A. Gravel
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Sig Kharasch
- Department of Pediatrics, Massachusetts General Hospital, Boston
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
| | - Charisse W. Kwan
- Department of Pediatric Emergency Medicine, London Health Sciences Centre Children's Hospital, Western University, London, Ontario, Canada
| | - Samuel H. F. Lam
- Department of Emergency Medicine, Sutter Medical Center Sacramento, Sacramento, California
| | - Jeffrey T. Neal
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Kathyrn H. Pade
- Department of Emergency Medicine, Rady Children’s Hospital, University of California, San Diego, San Diego
| | - Rachel Rempell
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Allan E. Shefrin
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Adam Sivitz
- Department of Pediatric Emergency Medicine, Children’s Hospital of New Jersey, Newark Beth Israel Medical Center, Newark
| | - Peter J. Snelling
- Department of Pediatric Emergency Medicine, Gold Coast University Hospital, Griffith University, Brisbane, Queensland, Australia
| | - Mark O. Tessaro
- Division of Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - William White
- Division of Pediatric Emergency Medicine, Department of Pediatric Emergency Medicine, Harbor-UCLA (University of California, Los Angeles) Medical Center, California Pacific Medical Center, Los Angeles
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Leuche VT, Cutler GJ, Nelson SC, Jin J, Bergmann KR. Emergency Department Health Care Utilization and Opioid Administration Among Pediatric Patients With Sickle Cell Vasoocclusive Pain Crisis and Coexisting Mental Health Illness. Pediatr Emerg Care 2022; 38:e664-e669. [PMID: 33969978 DOI: 10.1097/pec.0000000000002322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine whether patients with sickle cell disease (SCD) who present to the emergency department (ED) with vasoocclusive pain crises (VOC), and have coexisting mental health (MH) diagnoses, are more likely to have increased health care utilization and more frequent opioid administration compared with those without coexisting MH conditions. METHODS This is a retrospective study of patients aged 5 to 18 years with SCD who presented to a tertiary care ED with a primary complaint of VOC between January 1, 2013, and December 31, 2017. We excluded patients with sickle cell trait and without a pain management plan in the electronic medical record. Outcomes included ED length of stay (LOS), admission rate, and opioid administration in the ED. Morphine equivalents were used to standardize opioid dosing. Mann-Whitney U and χ2 tests were used for univariate analysis. Multivariable logistic was performed for categorical and continuous outcomes, respectively, after adjusting for confounding factors. RESULTS We identified 978 encounters. We excluded 196 without a pain management plan and one with inaccurate ED LOS, resulting in 781 encounters (148 patients) for analysis. Coexisting MH diagnoses were present in 75.0% of encounters, with anxiety (83.0%) and depressive disorders (55.9%) being most common. Compared with SCD patients without coexisting MH diagnoses, those with coexisting MH diagnoses had significantly longer ED LOS (252 ± 139 minutes vs 232 ± 145 minutes, P = 0.03), longer median hospital LOS (1.4 ± 3.2 days vs 0.3 ± 2.4 days, P < 0.001) in univariate analyses, but these differences were no longer significant in adjusted regression models. Patients with coexisting MH diagnoses had higher frequency of opioid administration in the ED (85.6% vs 71.4%, P < 0.0001) and higher odds of receiving opioids (adjusted odds ratio, 2.07; 95% confidence interval, 1.28-3.33). CONCLUSIONS Patients with SCD and coexisting MH diagnoses presenting with VOC have greater odds of receiving opioids compared with patients with SCD without coexisting MH diagnoses. Our results indicate a need for more MH resources in this vulnerable population and may help guide future management strategies.
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Affiliation(s)
| | | | - Stephen C Nelson
- Department of Hematology and Oncology, Children's Minnesota, Minneapolis, MN
| | - Jing Jin
- Children's Minnesota Research Institute
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Funk AL, Florin TA, Kuppermann N, Tancredi DJ, Xie J, Kim K, Neuman MI, Ambroggio L, Plint AC, Mintegi S, Klassen TP, Salvadori MI, Malley R, Payne DC, Simon NJ, Yock-Corrales A, Nebhrajani JR, Chaudhari PP, Breslin KA, Finkelstein Y, Campos C, Bergmann KR, Bhatt M, Ahmad FA, Gardiner MA, Avva UR, Shah NP, Sartori LF, Sabhaney VJ, Caperell K, Navanandan N, Borland ML, Morris CR, Gangoiti I, Pavlicich V, Kannikeswaran N, Lunoe MM, Rino PB, Kam AJ, Cherry JC, Rogers AJ, Chong SL, Palumbo L, Angelats CM, Morrison AK, Kwok MY, Becker SM, Dixon AC, Poonai N, Eckerle M, Wassem M, Dalziel SR, Freedman SB. Outcomes of SARS-CoV-2-Positive Youths Tested in Emergency Departments: The Global PERN-COVID-19 Study. JAMA Netw Open 2022; 5:e2142322. [PMID: 35015063 PMCID: PMC8753506 DOI: 10.1001/jamanetworkopen.2021.42322] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
IMPORTANCE Severe outcomes among youths with SARS-CoV-2 infections are poorly characterized. OBJECTIVE To estimate the proportion of children with severe outcomes within 14 days of testing positive for SARS-CoV-2 in an emergency department (ED). DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study with 14-day follow-up enrolled participants between March 2020 and June 2021. Participants were youths aged younger than 18 years who were tested for SARS-CoV-2 infection at one of 41 EDs across 10 countries including Argentina, Australia, Canada, Costa Rica, Italy, New Zealand, Paraguay, Singapore, Spain, and the United States. Statistical analysis was performed from September to October 2021. EXPOSURES Acute SARS-CoV-2 infection was determined by nucleic acid (eg, polymerase chain reaction) testing. MAIN OUTCOMES AND MEASURES Severe outcomes, a composite measure defined as intensive interventions during hospitalization (eg, inotropic support, positive pressure ventilation), diagnoses indicating severe organ impairment, or death. RESULTS Among 3222 enrolled youths who tested positive for SARS-CoV-2 infection, 3221 (>99.9%) had index visit outcome data available, 2007 (62.3%) were from the United States, 1694 (52.6%) were male, and 484 (15.0%) had a self-reported chronic illness; the median (IQR) age was 3 (0-10) years. After 14 days of follow-up, 735 children (22.8% [95% CI, 21.4%-24.3%]) were hospitalized, 107 (3.3% [95% CI, 2.7%-4.0%]) had severe outcomes, and 4 children (0.12% [95% CI, 0.03%-0.32%]) died. Characteristics associated with severe outcomes included being aged 5 to 18 years (age 5 to <10 years vs <1 year: odds ratio [OR], 1.60 [95% CI, 1.09-2.34]; age 10 to <18 years vs <1 year: OR, 2.39 [95% CI 1.38-4.14]), having a self-reported chronic illness (OR, 2.34 [95% CI, 1.59-3.44]), prior episode of pneumonia (OR, 3.15 [95% CI, 1.83-5.42]), symptoms starting 4 to 7 days prior to seeking ED care (vs starting 0-3 days before seeking care: OR, 2.22 [95% CI, 1.29-3.82]), and country (eg, Canada vs US: OR, 0.11 [95% CI, 0.05-0.23]; Costa Rica vs US: OR, 1.76 [95% CI, 1.05-2.96]; Spain vs US: OR, 0.51 [95% CI, 0.27-0.98]). Among a subgroup of 2510 participants discharged home from the ED after initial testing and who had complete follow-up, 50 (2.0%; 95% CI, 1.5%-2.6%) were eventually hospitalized and 12 (0.5%; 95% CI, 0.3%-0.8%) had severe outcomes. Compared with hospitalized SARS-CoV-2-negative youths, the risk of severe outcomes was higher among hospitalized SARS-CoV-2-positive youths (risk difference, 3.9%; 95% CI, 1.1%-6.9%). CONCLUSIONS AND RELEVANCE In this study, approximately 3% of SARS-CoV-2-positive youths tested in EDs experienced severe outcomes within 2 weeks of their ED visit. Among children discharged home from the ED, the risk was much lower. Risk factors such as age, underlying chronic illness, and symptom duration may be useful to consider when making clinical care decisions.
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Affiliation(s)
- Anna L. Funk
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Todd A. Florin
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Emergency Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, University of California, Davis School of Medicine, Sacramento
| | - Daniel J. Tancredi
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento
| | - Jianling Xie
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kelly Kim
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mark I. Neuman
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Lilliam Ambroggio
- Section of Emergency Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora
| | - Amy C. Plint
- Children’s Hospital of Eastern Ontario, Division of Emergency Medicine, Departments of Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Santiago Mintegi
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
| | - Terry P. Klassen
- Children’s Hospital Research Institute of Manitoba, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Richard Malley
- Division of Infectious Diseases, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel C. Payne
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Norma-Jean Simon
- Data Analytics and Reporting, Division of Emergency Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | | | | | - Pradip P. Chaudhari
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, California
- Keck School of Medicine of the University of Southern California, Los Angeles, California
| | | | - Yaron Finkelstein
- Divisions of Emergency Medicine and Clinical Pharmacology and Toxicology, Department of Pediatrics Hospital for Sick Children, Toronto, Ontario, Canada
| | - Carmen Campos
- Hospital Universitario Miguel Servet, Pediatric Emergency Department, Zaragoza, Spain
| | - Kelly R. Bergmann
- Department of Emergency Medicine, Children’s Minnesota, Minneapolis, Minnesota
| | - Maala Bhatt
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Fahd A. Ahmad
- Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Michael A. Gardiner
- Rady Children’s Hospital, Department of Pediatrics, University of California, San Diego, San Diego, California
| | - Usha R. Avva
- School of Medicine Hackensack Meridian Health, Hackensack, New Jersey
| | - Nipam P. Shah
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham
| | - Laura F. Sartori
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Vikram J. Sabhaney
- Department of Paediatrics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Kerry Caperell
- Norton Children’s Hospital, University of Louisville, Louisville, Kentucky
| | - Nidhya Navanandan
- Section of Emergency Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora
| | - Meredith L. Borland
- Perth Children’s Hospital, Divisions of Emergency Medicine and Paediatrics, School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Claudia R. Morris
- Department of Pediatrics, Division of Emergency Medicine, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Iker Gangoiti
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
| | - Viviana Pavlicich
- Departamento de Emergencia Pediátrica, Hospital General Pediátrico Niños de Acosta Ñu, Facultad de Medicina, Universidad Privada del Pacífico, San Lorenzo, Paraguay
| | | | - Maren M. Lunoe
- UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Pedro B. Rino
- Hospital de Pediatría “Prof Dr Juan P. Garrahan”, RIDEPLA, Buenos Aires, Argentina
| | - April J. Kam
- Department of Pediatrics, Division of Emergency Medicine, McMaster Children’s Hospital, Hamilton, Ontario, Canada
| | - Jonathan C. Cherry
- Department of Pediatric Emergency Medicine, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Alexander J. Rogers
- Departments of Emergency Medicine and Pediatrics, University of Michigan School of Medicine, Ann Arbor
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women’s and Children’s Hospital, Duke-NUS Medical School, SingHealth Duke-NUS Global Health Institute, Singapore
| | - Laura Palumbo
- ASST Spedali Civili di Brescia - Pronto soccorso pediatrico, Brescia, Italy
| | | | - Andrea K. Morrison
- Division of Emergency Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Maria Y. Kwok
- Department of Emergency Medicine, New York Presbyterian Morgan Stanley Children’s Hospital, Columbia University Irving Medical Center, New York
| | - Sarah M. Becker
- University of Utah School of Medicine and Primary Children’s Hospital, Salt Lake City, Utah
| | - Andrew C. Dixon
- University of Alberta, Stollery Children’s Hospital, Women’s and Children’s Health Research Institute, Edmonton, Alberta, Canada
| | - Naveen Poonai
- Child Health Research Institute, Division of Paediatric Emergency Medicine, Departments of Pediatrics, Internal Medicine, Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Michelle Eckerle
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Pediatric Emergency Medicine, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | | | - Stuart R. Dalziel
- Children’s Emergency Department, Starship Children’s Hospital, Auckland, New Zealand
- Departments of Surgery and Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Stephen B. Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Campbell M, Zagel AL, Ortega H, Kreykes N, Tu A, Linabery AM, Plasencia L, Krause E, Bergmann KR. Quality Indicators for Children With Traumatic Brain Injury After Transition to an American College of Surgeons Level I Pediatric Trauma Center. Pediatr Emerg Care 2022; 38:e329-e336. [PMID: 33109937 DOI: 10.1097/pec.0000000000002276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to compare quality indicators, including frequency of acute surgical and emergent interventions, and resource utilization before and after American College of Surgeons (ACS) level I trauma verification among children with moderate or severe traumatic brain injury (TBI). METHODS This is a retrospective review of patients younger than 18 years treated for moderate or severe TBI, as determined by International Classification of Disease codes. Our institution obtained ACS level I trauma verification in 2013. Outcomes during the pre-ACS (June 2003-May 2008), interim (June 2008-May 2013), and post-ACS (June 2013-May 2018) periods were compared via nonparametric tests. Tests for linear trend were conducted using Cochran-Armitage tests for categorical data and by linear regression for continuous variables. RESULTS There were 677 children with moderate or severe TBIs (pre-ACS, 125; interim, 198; post-ACS, 354). Frequency of any surgical intervention increased significantly in the post-ACS period (12.2%) compared with interim (5.1%) and pre-ACS periods (5.6%, P = 0.007). More children in the post-ACS period required intracranial pressure monitoring (P = 0.017), external ventricular drain placement (P = 0.003), or endotracheal intubation (P = 0.001) compared with interim and pre-ACS periods. There was no significant change in time to operating room (P = 0.514), frequency of decompression (P = 0.096), or time to decompression (P = 0.788) between study periods. The median time to head CT decreased significantly in the post-ACS period (26 minutes; interquartile range [IQR], 9-60) compared with interim (36 minutes; IQR, 21-69) and pre-ACS periods (53 minutes; IQR, 36-89; P < 0.001). Frequency of repeat head computed tomography decreased significantly in the post-ACS period (30.2%) compared with interim (56.1%) and pre-ACS periods (64.0%, Ptrend = 0.044). CONCLUSIONS Transition to an ACS level I trauma verification was associated with improvements in quality indicators for children with moderate or severe TBI.
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Affiliation(s)
- Maryellen Campbell
- From the Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL
| | | | | | | | - Albert Tu
- Division of Pediatric Neurosurgery, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
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Bergmann KR, Orchard PJ, Roback MG, Gaillard P, Furnival RA. Outcomes of Children Who Present to the Emergency Department After Hematopoietic Cell Transplantation. Pediatr Emerg Care 2021; 37:e1402-e1408. [PMID: 32097376 DOI: 10.1097/pec.0000000000002060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Our primary objective was to describe emergency department (ED) presentation, treatment, and outcomes for children after hematopoietic cell transplantation (HCT). Our secondary objective was to identify factors associated with serious infection in this population. METHODS This is a retrospective review of HCT patients who presented to our university children's hospital ED from January 1, 2011, to June 30, 2013. Emergency department presentation, treatment, and outcomes were described. Descriptive statistics were used to compare children with definite serious infection with those without serious infection. Multiple binary logistic regression was performed for risk factors associated with definite serious infection. RESULTS Fifty-four HCT patients (132 encounters) presented to our ED. Most were transplanted for a malignant (46%) or metabolic (36%) diagnosis and were recipients of bone marrow (51%) or umbilical cord blood (45%). Fever was the most common complaint (25%). Emergency department laboratory (64%) or imaging (58%) studies were frequently obtained. Admission was common (n = 70/132, 53%), with 79% (n = 55) of admissions to intensive care or bone marrow transplant units. Thirty-five encounters had definite serious infection, 5 had probable serious infection, and 92 had no serious infection. Fever (P < 0.001) and high-risk white blood cell (WBC) count of less than 5 or greater than 15 k/μL (P < 0.001) were associated with definite serious infection. Fever (odds ratio = 8.84, 95% confidence interval = 2.92-26.73) and high-risk WBC (odds ratio = 6.67, 95% confidence interval = 2.24-19.89) remained significantly associated with definite serious infection in our regression model. CONCLUSIONS Children presenting to the ED after HCT require extensive support and resources, with more than half requiring admission. Fever and high-risk WBC are associated with serious infection.
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Affiliation(s)
| | - Paul J Orchard
- Division of Blood and Marrow Transplantation, Department of Pediatrics
| | - Mark G Roback
- Division of Emergency Medicine, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
| | - Philippe Gaillard
- Department of Mathematics and Statistics, Auburn University, Auburn, AL
| | - Ronald A Furnival
- Division of Emergency Medicine, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
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Abstract
BACKGROUND The objective with this study was to explore factors associated with nonadherence to national bronchiolitis guidelines at 52 children's hospitals. METHODS We included patients 1 month to 2 years old with emergency department (ED) or admission encounters between January 2016 and December 2018 and bronchiolitis diagnoses in the Pediatric Health Information System database. We excluded patients with any intensive care, stay >7 days, encounters in the preceding 30 days, chronic medical conditions, croup, pneumonia, or asthma. Guideline nonadherence was defined as receiving any of 5 tests or treatments: bronchodilators, chest radiographs, systemic steroids, antibiotics, and viral testing. Nonadherence outcomes were modeled by using mixed effects logistic regression with random effects for providers and hospitals. Adjusted odds ratio (aOR) >1 indicates greater likelihood of nonadherence. RESULTS A total of 198 028 encounters were included (141 442 ED and 56 586 admission), and nonadherence was 46.1% (ED: 40.2%, admissions: 61.0%). Nonadherence increased with patient age, with both ED and hospital providers being more likely to order tests and treatments for children 12 to 24 months compared with infants 1 ot 2 months (ED: aOR, 3.39; 95% confidence interval [CI], 3.20-3.60; admissions: aOR, 2.97; CI, 2.79-3.17]). Admitted non-Hispanic Black patients were more likely than non-Hispanic white patients to receive guideline nonadherent care (aOR, 1.16; CI, 1.10-1.23), a difference driven by higher use of steroids (aOR, 1.29; CI, 1.17-1.41) and bronchodilators (aOR, 1.39; CI, 1.31-1.48). Hospital effects were prominent for viral testing in ED and admission encounters (intraclass correlation coefficient of 0.35 and 0.32, respectively). CONCLUSIONS Multiple factors are associated with national bronchiolitis guideline nonadherence.
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Affiliation(s)
| | | | | | - Kelly R Bergmann
- Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota
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Bergmann KR, Riera A, Whitcomb V, Toney AG, Tessaro MO. Point-of-Care Ultrasound Identification of Right-Sided Cardiac Chamber Collapse Associated With Pericardial Effusions Without Hypotension: A Case Series. Pediatr Emerg Care 2021; 37:480-483. [PMID: 34463664 DOI: 10.1097/pec.0000000000002405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT We present a case series of 6 children in whom point-of-care ultrasound revealed a pericardial effusion with right atrial or ventricular collapse, and show how this may heighten concern for development of pericardial tamponade and expedite care.
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Affiliation(s)
- Kelly R Bergmann
- From the Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN
| | - Antonio Riera
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Valerie Whitcomb
- From the Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN
| | - Amanda G Toney
- Department of Emergency Medicine, Denver Health Medical Center, University of Colorado, Aurora, CO
| | - Mark O Tessaro
- Division of Pediatric Emergency Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
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Bergmann KR, Arroyo AC, Tessaro MO, Nielson J, Whitcomb V, Madhok M, Yock-Corrales A, Guerrero-Quesada G, Chaudoin L, Berant R, Shahar-Nissan K, Deanehan JK, Lam SHF, Snelling PJ, Avendano P, Cohen SG, Friedman N, Ekpenyong A, Pade KH, Park DB, Lin-Martore M, Kornblith AE, Montes-Amaya G, Thomas-Mohtat R, Jin J, Watson D, Sivitz A. Diagnostic Accuracy of Point-of-Care Ultrasound for Intussusception: A Multicenter, Noninferiority Study of Paired Diagnostic Tests. Ann Emerg Med 2021; 78:606-615. [PMID: 34226072 DOI: 10.1016/j.annemergmed.2021.04.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/13/2021] [Accepted: 04/27/2021] [Indexed: 01/09/2023]
Abstract
STUDY OBJECTIVE To determine the diagnostic accuracy of point-of-care ultrasound (POCUS) performed by experienced clinician sonologists compared to radiology-performed ultrasound (RADUS) for detection of clinically important intussusception, defined as intussusception requiring radiographic or surgical reduction. METHODS We conducted a multicenter, noninferiority, observational study among a convenience sample of children aged 3 months to 6 years treated in tertiary care emergency departments across North and Central America, Europe, and Australia. The primary outcome was diagnostic accuracy of POCUS and RADUS with respect to clinically important intussusception. Sample size was determined using a 4-percentage-point noninferiority margin for the absolute difference in accuracy. Secondary outcomes included agreement between POCUS and RADUS for identification of secondary sonographic findings. RESULTS The analysis included 256 children across 17 sites (35 sonologists). Of the 256 children, 58 (22.7%) had clinically important intussusception. POCUS identified 60 (23.4%) children with clinically important intussusception. The diagnostic accuracy of POCUS was 97.7% (95% confidence interval [CI] 94.9% to 99.0%), compared to 99.3% (95% CI 96.8% to 99.9%) for RADUS. The absolute difference between the accuracy of RADUS and that of POCUS was 1.5 percentage points (95% CI -0.6 to 3.6). Sensitivity for POCUS was 96.6% (95% CI 87.2% to 99.1%), and specificity was 98.0% (95% CI 94.7% to 99.2%). Agreement was high between POCUS and RADUS for identification of trapped free fluid (83.3%, n=40/48) and decreased color Doppler signal (95.7%, n=22/23). CONCLUSION Our findings suggest that the diagnostic accuracy of POCUS performed by experienced clinician sonologists may be noninferior to that of RADUS for detection of clinically important intussusception. Given the limitations of convenience sampling and spectrum bias, a larger randomized controlled trial is warranted.
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Affiliation(s)
- Kelly R Bergmann
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN.
| | - Alexander C Arroyo
- Department of Pediatric Emergency Medicine, Maimonides Medical Center, Brooklyn, NY
| | - Mark O Tessaro
- Division of Pediatric Emergency Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jonathan Nielson
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN
| | - Valerie Whitcomb
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN
| | - Manu Madhok
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN
| | - Adriana Yock-Corrales
- Department of Emergency Medicine, Hospital Nacional de Niños: "Dr. Carlos Sáenz Herrera," CCSS, San José, Costa Rica
| | - German Guerrero-Quesada
- Department of Surgery, Hospital Nacional de Niños: "Dr. Carlos Sáenz Herrera," CCSS, San José, Costa Rica
| | - Lindsey Chaudoin
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, NC
| | - Ron Berant
- Department of Emergency Medicine, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Keren Shahar-Nissan
- Department of Emergency Medicine, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - J Kate Deanehan
- Department of Pediatric Emergency Medicine, Johns Hopkins Children's Center, Baltimore, MD
| | - Samuel H F Lam
- Department of Emergency Medicine, Sutter Medical Center Sacramento, Sacramento, CA
| | - Peter J Snelling
- Department of Pediatric Emergency Medicine, Gold Coast University Hospital and Griffith University, Southport, Queensland, Australia
| | - Pablo Avendano
- Division of Pediatric Emergency Medicine, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Stephanie G Cohen
- Department of Pediatrics and Emergency Medicine, Children's Healthcare Atlanta and Emory University, Atlanta, GA
| | - Nir Friedman
- Department of Pediatric Emergency Medicine, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel
| | - Atim Ekpenyong
- Department of Pediatrics, University of California, San Diego, CA
| | - Kathryn H Pade
- Department of Pediatrics, University of California, San Diego, CA
| | - Daniel B Park
- Department of Pediatrics and Emergency Medicine, University of North Carolina, Chapel Hill, NC
| | - Margaret Lin-Martore
- Department of Emergency Medicine and Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Aaron E Kornblith
- Department of Emergency Medicine and Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Gerardo Montes-Amaya
- Department of Pediatric Emergency Medicine, Hospital Infantil Ciudad Juárez, Chihuahua, Mexico
| | - Rosemary Thomas-Mohtat
- Department of Pediatric Emergency Medicine, Children's National Hospital, Washington, DC
| | - Jing Jin
- Department of Research and Sponsored Programs, Children's Minnesota, Minneapolis, MN
| | - Dave Watson
- Department of Research and Sponsored Programs, Children's Minnesota, Minneapolis, MN
| | - Adam Sivitz
- Department of Emergency Medicine, Newark Beth Israel Medical Center, Newark, NJ
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Kaplan RL, Cruz AT, Michelson KA, McAneney C, Blackstone MM, Pruitt CM, Shah N, Noorbakhsh KA, Abramo TJ, Marble RD, Middelberg L, Smith K, Kannikeswaran N, Schnadower D, Srivastava G, Thompson AD, Lane RD, Freeman JF, Bergmann KR, Morientes O, Gerard J, Badaki-Makun O, Avva U, Chaudhari PP, Freedman SB, Samuels-Kalow M, Haines E, Strutt J, Khanna K, Vance C, Bajaj L. Neonatal Mastitis and Concurrent Serious Bacterial Infection. Pediatrics 2021; 148:peds.2021-051322. [PMID: 34187909 DOI: 10.1542/peds.2021-051322] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Describe the clinical presentation, prevalence, and outcomes of concurrent serious bacterial infection (SBI) among infants with mastitis. METHODS Within the Pediatric Emergency Medicine Collaborative Research Committee, 28 sites reviewed records of infants aged ≤90 days with mastitis who were seen in the emergency department between January 1, 2008, and December 31, 2017. Demographic, clinical, laboratory, treatment, and outcome data were summarized. RESULTS Among 657 infants (median age 21 days), 641 (98%) were well appearing, 138 (21%) had history of fever at home or in the emergency department, and 63 (10%) had reported fussiness or poor feeding. Blood, urine, and cerebrospinal fluid cultures were collected in 581 (88%), 274 (42%), and 216 (33%) infants, respectively. Pathogens grew in 0.3% (95% confidence interval [CI] 0.04-1.2) of blood, 1.1% (95% CI 0.2-3.2) of urine, and 0.4% (95% CI 0.01-2.5) of cerebrospinal fluid cultures. Cultures from the site of infection were obtained in 335 (51%) infants, with 77% (95% CI 72-81) growing a pathogen, most commonly methicillin-resistant Staphylococcus aureus (54%), followed by methicillin-susceptible S aureus (29%), and unspecified S aureus (8%). A total of 591 (90%) infants were admitted to the hospital, with 22 (3.7%) admitted to an ICU. Overall, 10 (1.5% [95% CI 0.7-2.8]) had sepsis or shock, and 2 (0.3% [95% CI 0.04-1.1]) had severe cellulitis or necrotizing soft tissue infection. None received vasopressors or endotracheal intubation. There were no deaths. CONCLUSIONS In this multicenter cohort, mild localized disease was typical of neonatal mastitis. SBI and adverse outcomes were rare. Evaluation for SBI is likely unnecessary in most afebrile, well-appearing infants with mastitis.
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Affiliation(s)
- Ron L Kaplan
- Department of Pediatrics, School of Medicine, University of Washington and Seattle Children's Hospital, Seattle, Washington
| | - Andrea T Cruz
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Kenneth A Michelson
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Constance McAneney
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Mercedes M Blackstone
- Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher M Pruitt
- Department of Pediatrics, College of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Nipam Shah
- Department of Pediatrics, School of Medicine, University of Alabama at Birmingham and Children's Hospital of Alabama, Birmingham, Alabama
| | - Kathleen A Noorbakhsh
- Department of Pediatrics, School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Thomas J Abramo
- Pediatric Emergency Medicine Associates, Children's Hospital of Atlanta, Atlanta, Georgia
| | - Richard D Marble
- Ann & Robert H. Lurie Children's Hospital of Chicago and Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Leah Middelberg
- Ann & Robert H. Lurie Children's Hospital of Chicago and Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Kathleen Smith
- Department of Pediatrics, School of Medicine, University of California, San Diego and Rady Children's Hospital San Diego, San Diego, California
| | - Nirupama Kannikeswaran
- Department of Pediatrics, College of Medicine, Central Michigan University and Children's Hospital of Michigan, Detroit, Michigan
| | - David Schnadower
- Department of Pediatrics, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | | | - Amy D Thompson
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Roni D Lane
- Department of Pediatrics, School of Medicine, University of Utah and Primary Children's Hospital, Salt Lake City, Utah
| | - Julia F Freeman
- Children's Hospital Colorado and Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Kelly R Bergmann
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota
| | - Oihane Morientes
- Pediatric Emergency Department, Cruces University Hospital, Bilbao, Spain
| | - James Gerard
- Department of Pediatrics, School of Medicine, Saint Louis University and SSM Health Cardinal Glennon Children's Hospital, St Louis, Missouri
| | | | - Usha Avva
- Department of Pediatrics, Joseph M. Sanzari Children's Hospital, Hackensack University Medical Center, Hackensack Meridian Health, Hackensack, New Jersey
| | - Pradip P Chaudhari
- Department of Pediatrics, Kerk School of Medicine, University of Southern California and Children's Hospital Los Angeles, Los Angeles, California
| | - Stephen B Freedman
- Departments of Pediatrics and Emergency Medicine, Cumming School of Medicine, University of Calgary and Alberta Children's Hospital, Alberta, Canada
| | | | - Elizabeth Haines
- Ronald O. Perelman Department of Emergency Medicine, Grossman School of Medicine, New York University and New York University Langone Health, New York, New York
| | - Jonathan Strutt
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Kajal Khanna
- Department of Emergency Medicine, School of Medicine, Stanford University, Stanford, California
| | - Cheryl Vance
- Department of Pediatrics and Emergency Medicine, School of Medicine, University of California, Davis, Sacramento, California
| | - Lalit Bajaj
- Children's Hospital Colorado and Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
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Lin CY, Xie J, Freedman SB, McKee R, Schnadower D, Tarr PI, Finkelstein Y, Desai NM, Lane RD, Bergmann KR, Kaplan RL, Hariharan S, Cruz AT, Cohen DM, Dixon A, Ramgopal S, Powell EC, Kilgar J, Michelson KA, Bitzan M, Yen K, Meckler GD, Plint AC, Balamuth F, Bradin S, Gouin S, Kam AJ, Meltzer J, Hunley TE, Avva U, Porter R, Fein DM, Louie JP, Tarr GA. Predicting Adverse Outcomes for Shiga Toxin-Producing Escherichia coli Infections in Emergency Departments. J Pediatr 2021; 232:200-206.e4. [PMID: 33417918 PMCID: PMC8084908 DOI: 10.1016/j.jpeds.2020.12.077] [Citation(s) in RCA: 2] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 12/29/2020] [Accepted: 12/30/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess the performance of a hemolytic uremic syndrome (HUS) severity score among children with Shiga toxin-producing Escherichia coli (STEC) infections and HUS by stratifying them according to their risk of adverse events. The score has not been previously evaluated in a North American acute care setting. STUDY DESIGN We reviewed medical records of children <18 years old infected with STEC and treated in 1 of 38 participating emergency departments in North America between 2011 and 2015. The HUS severity score (hemoglobin [g/dL] plus 2-times serum creatinine [mg/dL]) was calculated using first available laboratory results. Children with scores >13 were designated as high-risk. We assessed score performance to predict severe adverse events (ie, dialysis, neurologic complication, respiratory failure, and death) using discrimination and net benefit (ie, threshold probability), with subgroup analyses by age and day-of-illness. RESULTS A total of 167 children had HUS, of whom 92.8% (155/167) had relevant data to calculate the score; 60.6% (94/155) experienced a severe adverse event. Discrimination was acceptable overall (area under the curve 0.71, 95% CI 0.63-0.79) and better among children <5 years old (area under the curve 0.77, 95% CI 0.68-0.87). For children <5 years, greatest net benefit was achieved for a threshold probability >26%. CONCLUSIONS The HUS severity score was able to discriminate between high- and low-risk children <5 years old with STEC-associated HUS at a statistically acceptable level; however, it did not appear to provide clinical benefit at a meaningful risk threshold.
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Affiliation(s)
- Chu Yang Lin
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Jianling Xie
- Section of Pediatric Emergency Medicine, Department of Pediatric, Alberta Children Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta
| | - Stephen B. Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine, Alberta Children’s Hospital and Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta
| | - Ryan McKee
- Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - David Schnadower
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Phillip I. Tarr
- Division of Gastroenterology, Hepatology, & Nutrition, Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Yaron Finkelstein
- Divisions of Emergency Medicine and Clinical Pharmacology & Toxicology, Hospital for Sick Children, University of Toronto, Toronto, Ontario
| | - Neil M. Desai
- British Columbia Children’s Hospital Division of Pediatric Emergency Medicine
| | - Roni D. Lane
- Division of Pediatric Emergency Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | | | - Ron L. Kaplan
- Department of Pediatrics, Division of Emergency Medicine, University of Washington School of Medicine, Seattle Children’s Hospital, Seattle, WA
| | - Selena Hariharan
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Andrea T. Cruz
- Pediatric Emergency Medicine and Pediatric Infectious Diseases, Baylor College of Medicine
| | - Daniel M. Cohen
- Professor of Clinical Pediatrics, Nationwide Children’s, Professor of Clinical Pediatrics, Nationwide Children’s Hospital & The Ohio State University, Columbus, OH
| | - Andrew Dixon
- University of Alberta, Stollery Children’s Hospital, Women’s and Children’s Health Research Institute
| | - Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Elizabeth C. Powell
- Professor of Pediatrics, Northwestern University Feinberg School of Medicine; Ann & Robert H. Lurie Children’s Hospital of Chicago; Division of Emergency Medicine
| | - Jennifer Kilgar
- Department or Pediatrics & Division of Emergency Medicine, Children’s Hospital, Schulich School of Medicine and Dentistry, Western University, London, Ontario
| | | | - Martin Bitzan
- Division of Nephrology, Montreal Children’s Hospital, McGill University Health Centre, Montreal, Canada; A1 Jalila Children’s Hospital, Kidney Centre of Excellence, Dubai, UAE
| | - Kenneth Yen
- Pediatric Emergency Medicine, Children’s Medical Center, UT Southwestern
| | - Garth D. Meckler
- Pediatrics and Emergency Medicine; University of British Columbia, Vancouver, BC
| | - Amy C. Plint
- Departments of Pediatrics and Emergency Medicine, University of Ottawa and the Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Fran Balamuth
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine; Division of Emergency Medicine, Children’s Hospital of Philadelphia
| | - Stuart Bradin
- Children’s Emergency Services, Department of Emergency Medicine, University of Michigan Medical School
| | - Serge Gouin
- Professor, Departments of Pediatric Emergency Medicine & Pediatrics, CHU Sainte-Justine, Universite de Montreal, QC, Canada
| | - April J. Kam
- Department of Pediatrics, McMaster Children’s Hospital, McMaster University
| | - James Meltzer
- Division of Emergency Medicine; Department of Pediatrics; Jacobi Medical Center
| | - Tracy E. Hunley
- Division of Pediatric Nephrology, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee
| | - Usha Avva
- Department of Pediatrics, Joseph M Sanzari Women and Children’s Hospital, Hackensack University Medical Center
| | - Robert Porter
- Discipline of Pediatrics, Memorial University of Newfoundland
| | - Daniel M. Fein
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children’s Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY
| | - Jeffrey P. Louie
- Division of Emergency Medicine, University of Minnesota, Masonic Children’s Hospital
| | - Gillian A.M. Tarr
- Division of Environmental Health Sciences, University of Minnesota, Minneapolis, MN
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Bergmann KR, Abuzzahab MJ, Nowak J, Arms J, Cutler G, Christensen E, Finch M, Kharbanda A. Resuscitation With Ringer's Lactate Compared With Normal Saline for Pediatric Diabetic Ketoacidosis. Pediatr Emerg Care 2021; 37:e236-e242. [PMID: 30020245 DOI: 10.1097/pec.0000000000001550] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The aims of this study were to describe the use of Ringer's lactate (LR) or normal saline (NS) for resuscitation among children with diabetic ketoacidosis (DKA) and compare the effect of fluid type on cost, length of stay, and rate of cerebral edema (CE). METHODS This is a retrospective study of 49,737 children aged 0 to 17 years with DKA between January 1, 2005, and September 30, 2015, using data from the Pediatric Health Information System. Treatment with LR or NS was identified. Our primary outcomes were total adjusted cost and length of stay. Our secondary outcome was CE rate per 1000 episodes. RESULTS The majority of patients were treated with NS (n = 43,841 [88%]) compared with LR (n = 1762 [4%]) or both NS and LR (n = 4134 [8%]). Hospital-year-specific practice patterns were used to investigate the effect of fluid type across resuscitation fluid groups. Total adjusted cost was $1160 less (95% confidence interval, -1468 to -852), or -14.2%, for cases with any episode of LR compared with NS only. Length of stay was not different across groups. The rate of cerebral edema per 1000 episodes was 12.7 for cases with any episode of LR compared with 34.6 NS only (difference, -21.9; 95% confidence interval, -30.4 to -13.3). CONCLUSIONS Ringer's lactate was infrequently used for resuscitation of pediatric DKA patients. However, resuscitation with LR compared with NS was associated with lower total cost and rates of CE. Further investigation using patient-level clinical and laboratory data is needed to evaluate factors that drive cost and risk of CE development with each fluid.
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Affiliation(s)
- Kelly R Bergmann
- From the Department of Emergency Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis
| | - M Jennifer Abuzzahab
- Department of Pediatric Endocrinology and McNeely Diabetes Center, Children's Hospitals and Clinics of Minnesota, St Paul
| | | | - Joe Arms
- From the Department of Emergency Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis
| | - Gretchen Cutler
- From the Department of Emergency Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis
| | - Eric Christensen
- Research and Sponsored Programs, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN
| | - Mike Finch
- Research and Sponsored Programs, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN
| | - Anupam Kharbanda
- From the Department of Emergency Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis
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Otto ME, Bergmann KR, Jacobs G, van Esdonk MJ. Predictive performance of parent-metabolite population pharmacokinetic models of (S)-ketamine in healthy volunteers. Eur J Clin Pharmacol 2021; 77:1181-1192. [PMID: 33575848 PMCID: PMC8275530 DOI: 10.1007/s00228-021-03104-1] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 02/01/2021] [Indexed: 11/06/2022]
Abstract
Purpose The recent repurposing of ketamine as treatment for pain and depression has increased the need for accurate population pharmacokinetic (PK) models to inform the design of new clinical trials. Therefore, the objectives of this study were to externally validate available PK models on (S)-(nor)ketamine concentrations with in-house data and to improve the best performing model when necessary. Methods Based on predefined criteria, five models were selected from literature. Data of two previously performed clinical trials on (S)-ketamine administration in healthy volunteers were available for validation. The predictive performances of the selected models were compared through visual predictive checks (VPCs) and calculation of the (root) mean (square) prediction errors (ME and RMSE). The available data was used to adapt the best performing model through alterations to the model structure and re-estimation of inter-individual variability (IIV). Results The model developed by Fanta et al. (Eur J Clin Pharmacol 71:441–447, 2015) performed best at predicting the (S)-ketamine concentration over time, but failed to capture the (S)-norketamine Cmax correctly. Other models with similar population demographics and study designs had estimated relatively small distribution volumes of (S)-ketamine and thus overpredicted concentrations after start of infusion, most likely due to the influence of circulatory dynamics and sampling methodology. Model predictions were improved through a reduction in complexity of the (S)-(nor)ketamine model and re-estimation of IIV. Conclusion The modified model resulted in accurate predictions of both (S)-ketamine and (S)-norketamine and thereby provides a solid foundation for future simulation studies of (S)-(nor)ketamine PK in healthy volunteers after (S)-ketamine infusion. Supplementary Information The online version contains supplementary material available at 10.1007/s00228-021-03104-1.
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Affiliation(s)
- M E Otto
- Centre for Human Drug Research, Leiden, The Netherlands.,Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - K R Bergmann
- Centre for Human Drug Research, Leiden, The Netherlands
| | - G Jacobs
- Centre for Human Drug Research, Leiden, The Netherlands.,Department of Psychiatry, Leiden University Medical Centre, Leiden, The Netherlands
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Hester GZ, Nickel AJ, Watson D, Swanson G, Laine JC, Bergmann KR. Improving Care and Outcomes for Pediatric Musculoskeletal Infections. Pediatrics 2021; 147:peds.2020-0118. [PMID: 33414235 DOI: 10.1542/peds.2020-0118] [Citation(s) in RCA: 3] [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: 07/06/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Pediatric musculoskeletal infection (MSKI) is a common cause of hospitalization with associated morbidity. To improve the care of pediatric MSKI, our objectives were to achieve 3 specific aims within 24 months of our quality improvement (QI) interventions: (1) 50% reduction in peripherally inserted central catheter (PICC) use, (2) 25% reduction in sedations per patient, and (3) 50% reduction in empirical vancomycin administration. METHODS We implemented 4 prospective QI interventions at our tertiary children's hospital: (1) provider education, (2) centralization of admission location, (3) coordination of radiology-orthopedic communication, and (4) implementation of an MSKI infection algorithm and order set. We included patients 6 months to 18 years of age with acute osteomyelitis, septic arthritis, or pyomyositis and excluded patients with complex chronic conditions or ICU admission. We used statistical process control charts to analyze outcomes over 2 general periods: baseline (January 2015-October 17, 2016) and implementation (October 18, 2016-April 2019). RESULTS In total, 224 patients were included. The mean age was 6.1 years, and there were no substantive demographic or clinical differences between baseline and implementation groups. There was an 81% relative reduction in PICC use (centerline shift 54%-11%; 95% confidence interval 70-92) and 33% relative reduction in sedations per patient (centerline shift 1.8-1.2; 95% confidence interval 21-46). Empirical vancomycin use did not change (centerline 20%). CONCLUSIONS Our multidisciplinary MSKI QI interventions were associated with a significant decrease in the use of PICCs and sedations per patient but not empirical vancomycin administration.
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Affiliation(s)
| | - Amanda J Nickel
- Research Institute, Children's Minnesota, Minneapolis, Minnesota; and
| | - David Watson
- Research Institute, Children's Minnesota, Minneapolis, Minnesota; and
| | | | - Jennifer C Laine
- Orthopedic Surgery, and.,Gillette Children's Specialty Healthcare, St Paul, Minnesota
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37
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McKee RS, Schnadower D, Tarr PI, Xie J, Finkelstein Y, Desai N, Lane RD, Bergmann KR, Kaplan RL, Hariharan S, Cruz AT, Cohen DM, Dixon A, Ramgopal S, Rominger A, Powell EC, Kilgar J, Michelson KA, Beer D, Bitzan M, Pruitt CM, Yen K, Meckler GD, Plint AC, Bradin S, Abramo TJ, Gouin S, Kam AJ, Schuh A, Balamuth F, Hunley TE, Kanegaye JT, Jones NE, Avva U, Porter R, Fein DM, Louie JP, Freedman SB. Predicting Hemolytic Uremic Syndrome and Renal Replacement Therapy in Shiga Toxin-producing Escherichia coli-infected Children. Clin Infect Dis 2021; 70:1643-1651. [PMID: 31125419 DOI: 10.1093/cid/ciz432] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [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: 04/01/2019] [Accepted: 05/23/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Shiga toxin-producing Escherichia coli (STEC) infections are leading causes of pediatric acute renal failure. Identifying hemolytic uremic syndrome (HUS) risk factors is needed to guide care. METHODS We conducted a multicenter, historical cohort study to identify features associated with development of HUS (primary outcome) and need for renal replacement therapy (RRT) (secondary outcome) in STEC-infected children without HUS at initial presentation. Children aged <18 years who submitted STEC-positive specimens between January 2011 and December 2015 at a participating study institution were eligible. RESULTS Of 927 STEC-infected children, 41 (4.4%) had HUS at presentation; of the remaining 886, 126 (14.2%) developed HUS. Predictors (all shown as odds ratio [OR] with 95% confidence interval [CI]) of HUS included younger age (0.77 [.69-.85] per year), leukocyte count ≥13.0 × 103/μL (2.54 [1.42-4.54]), higher hematocrit (1.83 [1.21-2.77] per 5% increase) and serum creatinine (10.82 [1.49-78.69] per 1 mg/dL increase), platelet count <250 × 103/μL (1.92 [1.02-3.60]), lower serum sodium (1.12 [1.02-1.23 per 1 mmol/L decrease), and intravenous fluid administration initiated ≥4 days following diarrhea onset (2.50 [1.14-5.46]). A longer interval from diarrhea onset to index visit was associated with reduced HUS risk (OR, 0.70 [95% CI, .54-.90]). RRT predictors (all shown as OR [95% CI]) included female sex (2.27 [1.14-4.50]), younger age (0.83 [.74-.92] per year), lower serum sodium (1.15 [1.04-1.27] per mmol/L decrease), higher leukocyte count ≥13.0 × 103/μL (2.35 [1.17-4.72]) and creatinine (7.75 [1.20-50.16] per 1 mg/dL increase) concentrations, and initial intravenous fluid administration ≥4 days following diarrhea onset (2.71 [1.18-6.21]). CONCLUSIONS The complex nature of STEC infection renders predicting its course a challenge. Risk factors we identified highlight the importance of avoiding dehydration and performing close clinical and laboratory monitoring.
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Affiliation(s)
- Ryan S McKee
- Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City
| | - David Schnadower
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Ohio
| | - Phillip I Tarr
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Jianling Xie
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary
| | - Yaron Finkelstein
- Divisions of Emergency Medicine, and Clinical Pharmacology and Toxicology, Hospital for Sick Children, University of Toronto, Ontario
| | - Neil Desai
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Roni D Lane
- Division of Pediatric Emergency Medicine, University of Utah School of Medicine, Salt Lake City
| | - Kelly R Bergmann
- Department of Emergency Medicine, Children's Minnesota, Minneapolis
| | - Ron L Kaplan
- Department of Pediatrics, Division of Emergency Medicine, University of Washington School of Medicine, Seattle Children's Hospital
| | - Selena Hariharan
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Andrea T Cruz
- Sections of Pediatric Emergency Medicine and Pediatric Infectious Diseases, Baylor College of Medicine, Houston, Texas
| | - Daniel M Cohen
- Division of Emergency Medicine, Nationwide Children's Hospital and Ohio State University, Columbus
| | - Andrew Dixon
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Stollery Children's Hospital, Women and Children's Research Institute, University of Alberta, Edmonton, Canada
| | - Sriram Ramgopal
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine Children's Hospital, Pennsylvania
| | - Annie Rominger
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Louisville, Kentucky
| | - Elizabeth C Powell
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jennifer Kilgar
- Department of Pediatrics and Division of Emergency Medicine, Children's Hospital, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | | | - Darcy Beer
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Martin Bitzan
- Division of Nephrology, Department of Pediatrics, McGill University Health Centre, Montreal, Québec, Canada
| | - Christopher M Pruitt
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Alabama at Birmingham
| | - Kenneth Yen
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Texas Southwestern, Children's Health, Dallas
| | - Garth D Meckler
- Division of Pediatric Emergency Medicine, Departments of Pediatrics and Emergency Medicine, University of British Columbia, Vancouver
| | - Amy C Plint
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Ottawa, Ontario, Canada
| | - Stuart Bradin
- Departments of Pediatrics and Emergency Medicine, University of Michigan Health System, Ann Arbor
| | - Thomas J Abramo
- Departments of Pediatrics and Emergency Medicine, University of Arkansas School of Medicine, Arkansas Children's Hospital Research Institute, Little Rock
| | - Serge Gouin
- Departments of Pediatric Emergency Medicine and Pediatrics, Université de Montréal, Québec
| | - April J Kam
- Division of Pediatric Emergency Medicine, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Abigail Schuh
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee
| | - Fran Balamuth
- University of Pennsylvania Perelman School of Medicine, Children's Hospital of Philadelphia
| | - Tracy E Hunley
- Division of Pediatric Nephrology, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - John T Kanegaye
- Department of Pediatrics, University of California, San Diego School of Medicine, La Jolla.,Rady Children's Hospital San Diego, California
| | - Nicholas E Jones
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Georgia
| | - Usha Avva
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Hackensack Meridian School of Medicine at Seton Hall, Joseph M. Sanzari Children's Hospital, New Jersey
| | - Robert Porter
- Discipline of Pediatrics, Faculty of Medicine, Memorial University of Newfoundland, St John's, Newfoundland and Labrador, Canada
| | - Daniel M Fein
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Jeffrey P Louie
- Department of Pediatrics, Division of Emergency Medicine, University of Minnesota, Masonic Children's Hospital, Minneapolis
| | - Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital and Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada
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McLaren SH, Cruz AT, Yen K, Lipshaw MJ, Bergmann KR, Mistry RD, Gutman CK, Ahmad FA, Pruitt CM, Thompson GC, Steimle MD, Zhao X, Schuh AM, Thompson AD, Hanson HR, Ulrich SL, Meltzer JA, Dunnick J, Schmidt SM, Nigrovic LE, Waseem M, Velasco R, Ali S, Cullen DL, Gomez B, Kaplan RL, Khanna K, Strutt J, Aronson PL, Taneja A, Sheridan DC, Chen CC, Bogie AL, Wang A, Dayan PS. Invasive Bacterial Infections in Afebrile Infants Diagnosed With Acute Otitis Media. Pediatrics 2021; 147:peds.2020-1571. [PMID: 33288730 DOI: 10.1542/peds.2020-1571] [Citation(s) in RCA: 3] [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: 09/24/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To determine the prevalence of invasive bacterial infections (IBIs) and adverse events in afebrile infants with acute otitis media (AOM). METHODS We conducted a 33-site cross-sectional study of afebrile infants ≤90 days of age with AOM seen in emergency departments from 2007 to 2017. Eligible infants were identified using emergency department diagnosis codes and confirmed by chart review. IBIs (bacteremia and meningitis) were determined by the growth of pathogenic bacteria in blood or cerebrospinal fluid (CSF) culture. Adverse events were defined as substantial complications resulting from or potentially associated with AOM. We used generalized linear mixed-effects models to identify factors associated with IBI diagnostic testing, controlling for site-level clustering effect. RESULTS Of 5270 infants screened, 1637 met study criteria. None of the 278 (0%; 95% confidence interval [CI]: 0%-1.4%) infants with blood cultures had bacteremia; 0 of 102 (0%; 95% CI: 0%-3.6%) with CSF cultures had bacterial meningitis; 2 of 645 (0.3%; 95% CI: 0.1%-1.1%) infants with 30-day follow-up had adverse events, including lymphadenitis (1) and culture-negative sepsis (1). Diagnostic testing for IBI varied across sites and by age; overall, 278 (17.0%) had blood cultures, and 102 (6.2%) had CSF cultures obtained. Compared with infants 0 to 28 days old, older infants were less likely to have blood cultures (P < .001) or CSF cultures (P < .001) obtained. CONCLUSION Afebrile infants with clinician-diagnosed AOM have a low prevalence of IBIs and adverse events; therefore, outpatient management without diagnostic testing may be reasonable.
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Affiliation(s)
- Son H McLaren
- Department of Emergency Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York;
| | - Andrea T Cruz
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Kenneth Yen
- Department of Pediatrics, University of Texas Southwestern, Dallas, Texas
| | - Matthew J Lipshaw
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Kelly R Bergmann
- Department of Emergency Services, Children's Minnesota, Minneapolis, Minnesota
| | - Rakesh D Mistry
- Department of Pediatrics, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado
| | | | - Fahd A Ahmad
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | | | - Graham C Thompson
- Department of Pediatrics, University of Calgary and Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Matthew D Steimle
- Department of Pediatrics, Division of Pediatric Emergency Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Xian Zhao
- Department of Pediatrics, Division of Emergency Medicine, Children's National Health System, Washington, DC
| | - Abigail M Schuh
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Amy D Thompson
- Department of Pediatrics, Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Holly R Hanson
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Stacey L Ulrich
- Department of Pediatrics, Rady Children's Hospital San Diego, San Diego, California
| | - James A Meltzer
- Department of Pediatrics, Jacobi Medical Center, Bronx, New York
| | - Jennifer Dunnick
- Department of Pediatrics, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Suzanne M Schmidt
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Muhammad Waseem
- Department of Pediatrics and Emergency Medicine, Lincoln Medical Center, Bronx, New York
| | - Roberto Velasco
- Pediatric Emergency Unit, Rio Hortega University Hospital, Valladolid, Spain
| | - Samina Ali
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Danielle L Cullen
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Borja Gomez
- Pediatric Emergency Department, Cruces University Hospital, Bilbao, Spain
| | - Ron L Kaplan
- Department of Pediatrics, School of Medicine, University of Washington and Seattle Children's Hospital, Seattle, Washington
| | - Kajal Khanna
- Department of Emergency Medicine, Stanford University, Stanford, California
| | - Jonathan Strutt
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Paul L Aronson
- Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Ankita Taneja
- Department of Pediatrics, University of Florida, Jacksonville, Jacksonville, Florida
| | - David C Sheridan
- Department of Emergency Medicine and Pediatrics, Oregon Health and Science University, Portland, Oregon
| | - Carol C Chen
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California
| | - Amanda L Bogie
- Department of Pediatrics, University of Oklahoma, Oklahoma City, Oklahoma; and
| | - Aijin Wang
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York
| | - Peter S Dayan
- Department of Emergency Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
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Bergmann KR, Whitcomb V. Ventricular tachycardia in an adolescent with severe diabetic ketoacidosis. Am J Emerg Med 2020; 45:683.e1-683.e3. [PMID: 33376006 DOI: 10.1016/j.ajem.2020.12.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 12/04/2020] [Revised: 12/10/2020] [Accepted: 12/11/2020] [Indexed: 11/18/2022] Open
Abstract
Diabetic ketoacidosis (DKA) occurs frequently among children and adolescents with type 1 diabetes. Although a number of complications may occur during episodes of DKA, significant cardiac arrhythmias are uncommon. We present the case of an adolescent who presented with severe DKA and wide complex tachycardia that was unresponsive to multiple doses of adenosine and ultimately required synchronized cardioversion. This case reminds the clinician of the importance of cardiac monitoring in children with DKA, particularly in the setting of hyperkalemia.
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Affiliation(s)
- Kelly R Bergmann
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN, USA.
| | - Valerie Whitcomb
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN, USA
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Bergmann KR, Abuzzahab MJ, Arms J, Cutler G, Vander Velden H, Simper T, Christensen E, Watson D, Kharbanda A. A Quality Improvement Initiative to Reduce Hospitalizations for Low-risk Diabetic Ketoacidosis. Pediatrics 2020; 145:peds.2019-1104. [PMID: 32054821 DOI: 10.1542/peds.2019-1104] [Citation(s) in RCA: 4] [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: 11/20/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Children with established type 1 diabetes (T1D) who present to the emergency department (ED) with mild diabetic ketoacidosis (DKA) are often hospitalized, although outpatient management may be appropriate. Our aim was to reduce hospitalization rates for children with established T1D presenting to our ED with mild DKA who were considered low risk for progression of illness. METHODS We conducted a quality improvement initiative between January 1, 2012, and December 31, 2018 among children and young adults ≤21 years of age with established T1D presenting to our tertiary care ED with low-risk DKA. Children transferred to our institution were excluded. DKA severity was classified as low, medium, or high risk on the basis of laboratory and clinical criteria. Our quality improvement initiative consisted of development and implementation of an evidence-based treatment guideline after review by a multidisciplinary team. Our primary outcome was hospitalization rate, and our balancing measure was 3-day ED revisits. Statistical process control methods were used to evaluate outcome changes. RESULTS We identified 165 patients presenting with low-risk DKA. The baseline preimplementation hospitalization rate was 74% (95% confidence interval 64%-82%), and after implementation, this decreased to 55% (95% confidence interval 42%-67%) (-19%; P = .011). The postimplementation hospitalization rate revealed special cause variation. One patient in the postimplementation period returned to the ED within 3 days but did not have DKA and was not hospitalized. CONCLUSIONS Hospitalization rates for children and young adults presenting to the ED with low-risk DKA can be safely reduced without an increase in ED revisits.
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Affiliation(s)
| | - M Jennifer Abuzzahab
- Pediatric Endocrinology and McNeely Diabetes Center, Children's Minnesota, St Paul, Minnesota; and
| | - Joe Arms
- Departments of Emergency Medicine
| | | | | | | | - Eric Christensen
- College of Continuing and Professional Studies, University of Minnesota, Minneapolis, Minnesota
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Hester GZ, Watson D, Nickel AJ, Ryan N, Jepson B, Gray J, Bergmann KR. Identifying Patients With Kawasaki Disease Safe for Early Discharge: Development of a Risk Prediction Model at a US Children's Hospital. Hosp Pediatr 2019; 9:749-756. [PMID: 31501220 DOI: 10.1542/hpeds.2019-0049] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To develop a model to predict risk of intravenous immunoglobulin (IVIg) nonresponse in patients with Kawasaki disease (KD) to assist in early discharge decision-making. METHODS Retrospective cohort study of 430 patients 0 to 18 years old discharged from a US children's hospital January 1, 2010, through July 31, 2017 with a diagnosis of KD. IVIg nonresponse was defined as at least 1 of the following: temperature ≥38.0°C between 36 hours and 7 days after initial IVIg dose, receipt of a second IVIg dose after a temperature ≥38.0°C at least 20 hours after initial IVIg dose, or readmission within 7 days with administration of a second IVIg dose. Backward stepwise logistic regression was used to select a predictive model. RESULTS IVIg nonresponse occurred in 19% (81 of 430) of patients. We identified a multivariate model (which included white blood cell count, hemoglobin level, platelet count, aspartate aminotransferase level, sodium level, albumin level, temperature within 6 hours of first IVIg dose, and incomplete KD) with good predictive ability (optimism-adjusted concordance index: 0.700) for IVIg nonresponse. Stratifying into 2 groups by a predictive probability cutoff of 0.10, we identified 26% of patients at low risk for IVIg nonresponse, with a sensitivity and specificity of 90% and 30%, respectively, and a negative predictive value of 93%. CONCLUSIONS We developed a model with good predictive value for identifying risk of IVIg nonresponse in patients with KD at a US children's hospital. Patients at lower risk may be considered for early discharge by using shared decision-making. Our model may be used to inform implementation of electronic health record tools and future risk prediction research.
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Affiliation(s)
| | - David Watson
- Children's Research Institute, Children's Minnesota, Minneapolis, Minnesota
| | - Amanda J Nickel
- Children's Research Institute, Children's Minnesota, Minneapolis, Minnesota
| | | | - Bryan Jepson
- Pediatric Residency Program, University of Minnesota, Minneapolis, Minnesota; and
| | - James Gray
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Bergmann KR, Reardon RF, Flores G, Whitcomb V, Christensen EW, Watson D, Kharbanda A. Trends in Medical Claims and Utilization of Limited Ultrasonography Among Emergency Physicians and Radiologists Within a Large Health Plan Provider. J Ultrasound Med 2019; 38:1279-1286. [PMID: 30208239 DOI: 10.1002/jum.14808] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 08/18/2018] [Accepted: 08/08/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES The goal of this study was to evaluate trends in medical claim submissions for limited ultrasound studies performed (1) during emergency department (ED) encounters and (2) by ED providers compared to radiologists. METHODS We conducted a retrospective, descriptive study using medical claims data from Medica Health Plans from January 1, 2011 to December 31, 2015. Current procedural terminology codes were abstracted for limited ultrasound applications performed during an ED visit and further stratified by studies performed by ED providers compared with radiologists. We excluded claims for which we could not determine provider specialty. RESULTS We identified 42,576 encounters with limited US claims, of which, 32,666 were submitted by ED providers (N = 9649) or radiologists (N = 23,017). Among ED providers, there was a significant linear increase in the annual number of claims for retroperitoneal (P < .001) and nonlinear increases for thoracic, soft tissue, cardiac, transvaginal genitourinary (GU) and transabdominal GU claims (all P < .001). Compared with radiologists, there was a linear increase in the annual proportion of claims submitted for retroperitoneal (P = .023), transabdominal GU (P = .003), and transvaginal GU (P < .001) studies by ED providers. There was a nonlinear decrease in the annual proportion of limited abdomen claims (P < .001) submitted by ED providers compared with radiologists. CONCLUSIONS Using data from a large health plan provider, we show that medical claims for many limited ultrasound studies are increasing among ED providers. Compared with radiologists, ED providers are increasingly submitting claims for retroperitoneal, soft tissue, and transabdominal GU studies.
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Affiliation(s)
- Kelly R Bergmann
- Department of Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota, USA
| | - Robert F Reardon
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Glenn Flores
- Division of Research, Connecticut Children's Medical Center, Hartford, Connecticut, USA
- Department of Pediatrics, University of Connecticut Health Center, Farmington, Connecticut, USA
| | - Valerie Whitcomb
- Department of Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota, USA
| | - Eric W Christensen
- College of Continuing Education and Professional Studies, University of Minnesota, St. Paul, Minnesota, USA
| | - Dave Watson
- Department of Research and Sponsored Programs, Children's Minnesota, Minneapolis, Minnesota, USA
| | - Anupam Kharbanda
- Department of Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota, USA
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Cutler GJ, Rodean J, Zima BT, Doupnik SK, Zagel AL, Bergmann KR, Hoffmann JA, Neuman MI. Trends in Pediatric Emergency Department Visits for Mental Health Conditions and Disposition by Presence of a Psychiatric Unit. Acad Pediatr 2019; 19:948-955. [PMID: 31175994 PMCID: PMC7122010 DOI: 10.1016/j.acap.2019.05.132] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 05/11/2019] [Accepted: 05/31/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To examine trends in mental health (MH) visits to pediatric emergency departments (EDs) and identify whether ED disposition varies by presence of a hospital inpatient psychiatric unit (IPU). STUDY DESIGN Cross-sectional study of 8,479,311 ED visits to 35 children's hospitals from 2012 to 2016 for patients aged 3 to 21 years with a primary MH or non-MH diagnosis. Multivariable generalized estimating equations and bivariate Rao-Scott chi-square tests were used to examine trends in ED visits and ED disposition by IPU status, adjusted for clustering by hospital. RESULTS From 2012 to 2016, hospitals experienced a greater increase in ED visits with a primary MH versus non-MH diagnosis (50.7% vs 12.7% cumulative increase, P < .001). MH visits were associated with patients who were older, female, white non-Hispanic, and privately insured compared with patients of non-MH visits (all P < .001). Forty-four percent of MH visits in 2016 had a primary diagnosis of depressive disorders or suicide or self-injury, and the increase in visits was highest for these diagnosis groups (depression: 109.8%; suicide or self-injury: 110.2%). Among MH visits, presence of a hospital IPU was associated with increased hospitalizations (34.6% vs 22.5%, P < .001) and less transfers (9.2% vs 16.2%, P < .001). CONCLUSION The increase in ED MH visits from 2012 to 2016 was 4 times greater than non-MH visits at US children's hospitals and was primarily driven by patients diagnosed with depressive disorders and suicide or self-injury. Our findings have implications for strategic planning in tertiary children's hospitals dealing with a rising demand for acute MH care.
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Affiliation(s)
- Gretchen J Cutler
- Children's Minnesota Research Institute (CJ Cutler, AL Zagel), Children's Minnesota, Minneapolis, Minn.
| | | | - Bonnie T Zima
- UCLA Semel Institute for Neuroscience and Human Behavior (B Zima), University of California at Los Angeles, Los Angeles, Calif
| | - Stephanie K Doupnik
- Division of General Pediatrics (SK Doupnik), PolicyLab, and Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Alicia L Zagel
- Children's Minnesota Research Institute (CJ Cutler, AL Zagel), Children's Minnesota, Minneapolis, Minn
| | - Kelly R Bergmann
- Department of Pediatric Emergency Medicine (KR Bergman), Children's Minnesota, South, Minneapolis, Minn
| | - Jennifer A Hoffmann
- Division of Emergency Medicine (JA Hoffmann, MI Neuman), Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Mark I Neuman
- Division of Emergency Medicine (JA Hoffmann, MI Neuman), Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Mass
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Vajdic T, Bergmann KR, Zagel A, Ortega H. Fishing-Related Injuries Among Pediatric Patients Treated in United States Emergency Departments, 1997 to 2016. Clin Pediatr (Phila) 2018; 57:1656-1663. [PMID: 30282474 DOI: 10.1177/0009922818803406] [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] [Indexed: 11/15/2022]
Abstract
An estimated 14.8 million youth under the age of 25 years participate in recreational fishing. Despite its popularity, fishing can be associated with injuries ranging from mild to severe trauma. There is a paucity of research available that describes characteristics of fishing-related injuries among youth. We examined the National Electronic Injury Surveillance System 1997-2016 to describe injury patterns by age and sex. Linear regressions estimated changes in injuries over time. There were an estimated 412 171 pediatric patients treated in US emergency departments for fishing-related injuries. The majority of injuries occurred in males (81.4% [95% confidence interval [CI]: 80.3-82.6]) and in youth ages 11 to 18 years (53.7% [95% CI: 51.0-56.5]). Injuries were most likely due to hooks and lures (79.7% [95% CI: 75.7-83.7]), and the arm/hand accounted for 43.9% of injuries (95% CI: 42.5-45.2). Based on these findings, we suggest that injury prevention efforts should be focused on older male children and wearing appropriate clothing.
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Affiliation(s)
- Tyler Vajdic
- 1 Department of Emergency Medicine, Children's Minnesota, Minneapolis, MN, USA
| | - Kelly R Bergmann
- 1 Department of Emergency Medicine, Children's Minnesota, Minneapolis, MN, USA
| | - Alicia Zagel
- 2 Children's Research Institute, Children's Minnesota, Minneapolis, MN, USA
| | - Henry Ortega
- 1 Department of Emergency Medicine, Children's Minnesota, Minneapolis, MN, USA
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Johnson RM, Bergmann KR, Manaloor JJ, Yu X, Slaven JE, Kharbanda AB. Pediatric Kawasaki Disease and Adult Human Immunodeficiency Virus Kawasaki-Like Syndrome Are Likely the Same Malady. Open Forum Infect Dis 2016; 3:ofw160. [PMID: 27704015 PMCID: PMC5047405 DOI: 10.1093/ofid/ofw160] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 07/19/2016] [Indexed: 11/14/2022] Open
Abstract
Background. Pediatric Kawasaki disease (KD) and human immunodeficiency virus (HIV)+ adult Kawasaki-like syndrome (KLS) are dramatic vasculitides with similar physical findings. Both syndromes include unusual arterial histopathology with immunoglobulin (Ig)A+ plasma cells, and both impressively respond to pooled Ig therapy. Their distinctive presentations, histopathology, and therapeutic response suggest a common etiology. Because blood is in immediate contact with inflamed arteries, we investigated whether KD and KLS share an inflammatory signature in serum. Methods. A custom multiplex enzyme-linked immunosorbent assay (ELISA) defined the serum cytokine milieu in 2 adults with KLS during acute and convalescent phases, with asymptomatic HIV+ subjects not taking antiretroviral therapy serving as controls. We then prospectively collected serum and plasma samples from children hospitalized with KD, unrelated febrile illnesses, and noninfectious conditions, analyzing them with a custom multiplex ELISA based on the KLS data. Results. Patients with KLS and KD subjects shared an inflammatory signature including acute-phase reactants reflecting tumor necrosis factor (TNF)-α biologic activity (soluble TNF receptor I/II) and endothelial/smooth muscle chemokines Ccl1 (Th2), Ccl2 (vascular inflammation), and Cxcl11 (plasma cell recruitment). Ccl1 was specifically elevated in KD versus febrile controls, suggesting a unique relationship between Ccl1 and KD/KLS pathogenesis. Conclusions. This study defines a KD/KLS inflammatory signature mirroring a dysfunctional response likely to a common etiologic agent. The KD/KLS inflammatory signature based on elevated acute-phase reactants and specific endothelial/smooth muscle chemokines was able to identify KD subjects versus febrile controls, and it may serve as a practicable diagnostic test for KD.
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Affiliation(s)
| | - Kelly R Bergmann
- Department of Pediatric Emergency Medicine , Children's Hospitals and Clinics of Minnesota , Minneapolis
| | - John J Manaloor
- Ryan White Center for Pediatric Infectious Diseases and Global Health
| | - Xiaoqing Yu
- Biostatistics , Yale University School of Medicine , New Haven, Connecticut
| | - James E Slaven
- Biostatistics , Indiana University School of Medicine , Indianapolis
| | - Anupam B Kharbanda
- Department of Pediatric Emergency Medicine , Children's Hospitals and Clinics of Minnesota , Minneapolis
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Bergmann KR, Milner DM, Voulgaropoulos C, Cutler GJ, Kharbanda AB. Optic Nerve Sheath Diameter Measurement During Diabetic Ketoacidosis: A Pilot Study. West J Emerg Med 2016; 17:531-41. [PMID: 27625716 PMCID: PMC5017836 DOI: 10.5811/westjem.2016.6.29939] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 05/26/2016] [Accepted: 06/13/2016] [Indexed: 11/11/2022] Open
Affiliation(s)
- Kelly R Bergmann
- Children's Hospitals and Clinics of Minnesota, Department of Pediatric Emergency Medicine, Minneapolis, Minnesota
| | - Donna M Milner
- Children's Hospitals and Clinics of Minnesota, Department of Pediatric Emergency Medicine, Minneapolis, Minnesota
| | - Constantinos Voulgaropoulos
- Children's Hospitals and Clinics of Minnesota, McNeely Pediatric Diabetes Center and Endocrinology Clinic, Minneapolis, Minnesota
| | - Gretchen J Cutler
- Children's Hospitals and Clinics of Minnesota, Department of Pediatric Emergency Medicine, Minneapolis, Minnesota
| | - Anupam B Kharbanda
- Children's Hospitals and Clinics of Minnesota, Department of Pediatric Emergency Medicine, Minneapolis, Minnesota
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Bergmann KR, Schloff S, Schiff J. Contralateral recurrence of idiopathic orbital inflammatory syndrome in a pediatric patient. Minn Med 2014; 97:46-47. [PMID: 25651640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Bergmann KR, McCabe J, Smith TR, Guillaume DJ, Sarafoglou K, Gupta S. Late-onset ornithine transcarbamylase deficiency: treatment and outcome of hyperammonemic crisis. Pediatrics 2014; 133:e1072-6. [PMID: 24616362 DOI: 10.1542/peds.2013-1324] [Citation(s) in RCA: 9] [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] [Indexed: 11/24/2022] Open
Abstract
Hyperammonemic crises in ornithine transcarbamylase deficiency (OTC) can be associated with devastating cerebral edema resulting in severe long-term neurologic impairment and death. We present an 8-year-old boy who had late-onset OTC deficiency in which early and aggressive management of hyperammonemia and associated cerebral edema, including therapeutic hypothermia and barbiturate-induced coma, resulted in favorable neurologic outcome. Our patient presented with vomiting and altered mental status, and was found to have a significantly elevated serum ammonia level of 1561 μmol/L. Hyperammonemia was managed with hemodialysis, 10% sodium phenylacetate, 10% sodium benzoate, L-arginine, intravenous 10% dextrose, intralipids, and protein restriction. He developed significant cerebral edema with intracranial pressures >20 mm Hg, requiring treatment with 3% saline and mannitol. Despite this treatment our patient continued to have elevated intracranial pressures, which were treated aggressively with non-conventional modalities including therapeutic hypothermia, barbiturate-induced coma, and external ventricular drainage. This therapy resulted in stabilization of hyperammonemia and resolution of cerebral edema. Molecular testing later revealed a hemizygous mutation within the OTC gene. Neuropsychological testing 1 year after discharge showed normal intelligence with no visual-motor deficits, minor deficits in working memory and processing speed, and slightly below average processing speed and executive functioning.
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Bergmann KR, Liu SXL, Tian R, Kushnir A, Turner JR, Li HL, Chou PM, Weber CR, De Plaen IG. Bifidobacteria stabilize claudins at tight junctions and prevent intestinal barrier dysfunction in mouse necrotizing enterocolitis. Am J Pathol 2013; 182:1595-606. [PMID: 23470164 DOI: 10.1016/j.ajpath.2013.01.013] [Citation(s) in RCA: 164] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Revised: 01/02/2013] [Accepted: 01/07/2013] [Indexed: 02/07/2023]
Abstract
Whether intestinal barrier disruption precedes or is the consequence of intestinal injury in necrotizing enterocolitis (NEC) remains unknown. Using a neonatal mouse NEC model, we examined the changes in intestinal permeability and specific tight-junction (TJ) proteins preceding NEC and asked whether these changes are prevented by administration of Bifidobacterium infantis, a probiotic known to decrease NEC incidence in humans. Compared with dam-fed controls, pups submitted to the NEC protocol developed i) significantly increased intestinal permeability at 12 and 24 hours (as assessed by 70-kDa fluorescein isothiocyanate-dextran transmucosal flux); ii) occludin and claudin 4 internalization at 12 hours (as assessed by immunofluorescence and low-density membrane fraction immunoblotting); iii) increased claudin 2 expression at 6 hours and decreased claudin 4 and 7 expression at 24 hours; and iv) increased claudin 2 protein at 48 hours. Similar results were seen in human NEC, with claudin 2 protein increased. In mice, administration of B. infantis micro-organisms attenuated increases in intestinal permeability, preserved claudin 4 and occludin localization at TJs, and decreased NEC incidence. Thus, an increase in intestinal permeability precedes NEC and is associated with internalization of claudin 4 and occludin. Administration of B. infantis prevents these changes and reduces NEC incidence. The beneficial effect of B. infantis is, at least in part, due to its TJ and barrier-preserving properties.
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Affiliation(s)
- Kelly R Bergmann
- Division of Neonatology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago Research Center, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
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De Plaen IG, Liu SXL, Tian R, Bergmann KR, Turner JR, Kushnir A. B. infantis
administration preserves the distribution of occludin and claudin 2 and 4 at tight junctions in a neonatal mouse model of necrotizing enterocolitis. FASEB J 2011. [DOI: 10.1096/fasebj.25.1_supplement.1066.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - Shirley XL Liu
- Pediatrics (Neonatology)Children's Memorial Research CenterChicagoIL
| | - Runlan Tian
- Pediatrics (Neonatology)Children's Memorial Research CenterChicagoIL
| | - Kelly R Bergmann
- Pediatrics (Neonatology)Children's Memorial Research CenterChicagoIL
| | | | - Anna Kushnir
- Pediatrics (Neonatology)Children's Memorial Research CenterChicagoIL
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