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Holmes JF, Yen K, Ugalde IT, Ishimine P, Chaudhari PP, Atigapramoj N, Badawy M, McCarten-Gibbs KA, Nielsen D, Sage AC, Tatro G, Upperman JS, Adelson PD, Tancredi DJ, Kuppermann N. PECARN prediction rules for CT imaging of children presenting to the emergency department with blunt abdominal or minor head trauma: a multicentre prospective validation study. Lancet Child Adolesc Health 2024; 8:339-347. [PMID: 38609287 DOI: 10.1016/s2352-4642(24)00029-4] [Citation(s) in RCA: 1] [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] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 01/30/2024] [Accepted: 02/01/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND The intra-abdominal injury and traumatic brain injury prediction rules derived by the Pediatric Emergency Care Applied Research Network (PECARN) were designed to reduce inappropriate use of CT in children with abdominal and head trauma, respectively. We aimed to validate these prediction rules for children presenting to emergency departments with blunt abdominal or minor head trauma. METHODS For this prospective validation study, we enrolled children and adolescents younger than 18 years presenting to six emergency departments in Sacramento (CA), Dallas (TX), Houston (TX), San Diego (CA), Los Angeles (CA), and Oakland (CA), USA between Dec 27, 2016, and Sept 1, 2021. We excluded patients who were pregnant or had pre-existing neurological disorders preventing examination, penetrating trauma, injuries more than 24 h before arrival, CT or MRI before transfer, or high suspicion of non-accidental trauma. Children presenting with blunt abdominal trauma were enrolled into an abdominal trauma cohort, and children with minor head trauma were enrolled into one of two age-segregated minor head trauma cohorts (younger than 2 years vs aged 2 years and older). Enrolled children were clinically examined in the emergency department, and CT scans were obtained at the attending clinician's discretion. All enrolled children were evaluated against the variables of the pertinent PECARN prediction rule before CT results were seen. The primary outcome of interest in the abdominal trauma cohort was intra-abdominal injury undergoing acute intervention (therapeutic laparotomy, angiographic embolisation, blood transfusion, intravenous fluid for ≥2 days for pancreatic or gastrointestinal injuries, or death from intra-abdominal injury). In the age-segregated minor head trauma cohorts, the primary outcome of interest was clinically important traumatic brain injury (neurosurgery, intubation for >24 h for traumatic brain injury, or hospital admission ≥2 nights for ongoing symptoms and CT-confirmed traumatic brain injury; or death from traumatic brain injury). FINDINGS 7542 children with blunt abdominal trauma and 19 999 children with minor head trauma were enrolled. The intra-abdominal injury rule had a sensitivity of 100·0% (95% CI 98·0-100·0; correct test for 145 of 145 patients with intra-abdominal injury undergoing acute intervention) and a negative predictive value (NPV) of 100·0% (95% CI 99·9-100·0; correct test for 3488 of 3488 patients without intra-abdominal injuries undergoing acute intervention). The traumatic brain injury rule for children younger than 2 years had a sensitivity of 100·0% (93·1-100·0; 42 of 42) for clinically important traumatic brain injuries and an NPV of 100·0%; 99·9-100·0; 2940 of 2940), whereas the traumatic brain injury rule for children aged 2 years and older had a sensitivity of 98·8% (95·8-99·9; 168 of 170) and an NPV of 100·0% (99·9-100·0; 6015 of 6017). The two children who were misclassified by the traumatic brain injury rule were admitted to hospital for observation but did not need neurosurgery. INTERPRETATION The PECARN intra-abdominal injury and traumatic brain injury rules were validated with a high degree of accuracy. Their implementation in paediatric emergency departments can therefore be considered a safe strategy to minimise inappropriate CT use in children needing high-quality care for abdominal or head trauma. FUNDING The Eunice Kennedy Shriver National Institute of Child Health and Human Development.
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Affiliation(s)
- James F Holmes
- Department of Emergency Medicine, School of Medicine, University of California Davis, Sacramento, CA, USA.
| | - Kenneth Yen
- Division of Pediatric Emergency Medicine, Department of Pediatrics, School of Medicine, University of Texas Southwestern, Dallas, TX, USA; Children's Health, University of Texas Southwestern, Dallas, TX, USA
| | - Irma T Ugalde
- Department of Emergency Medicine, McGovern Medical School, Houston, TX, USA
| | - Paul Ishimine
- Department of Emergency Medicine and Department of Pediatrics, School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Nisa Atigapramoj
- Department of Emergency Medicine, UCSF Benioff Children's Hospital, Oakland, CA, USA
| | - Mohamed Badawy
- Division of Pediatric Emergency Medicine, Department of Pediatrics, School of Medicine, University of Texas Southwestern, Dallas, TX, USA; Children's Health, University of Texas Southwestern, Dallas, TX, USA
| | | | - Donovan Nielsen
- Department of Emergency Medicine, School of Medicine, University of California Davis, Sacramento, CA, USA
| | - Allyson C Sage
- Department of Emergency Medicine, School of Medicine, University of California Davis, Sacramento, CA, USA
| | - Grant Tatro
- Virginia Commonwealth School of Medicine, Richmond, VA, USA
| | - Jeffrey S Upperman
- Department of Pediatric Surgery, Vanderbilt University, Nashville, TN, USA
| | - P David Adelson
- Department of Neurosurgery, School of Medicine and Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA
| | - Daniel J Tancredi
- Department of Pediatrics, School of Medicine, University of California Davis, Sacramento, CA, USA
| | - Nathan Kuppermann
- Department of Emergency Medicine, School of Medicine, University of California Davis, Sacramento, CA, USA; Department of Pediatrics, School of Medicine, University of California Davis, Sacramento, CA, USA
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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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Ramgopal S, Sepanski RJ, Gorski JK, Chaudhari PP, Spurrier RG, Horvat CM, Macy ML, Cash R, Martin-Gill C. Centiles for the shock index among injured children in the prehospital setting. Am J Emerg Med 2024; 80:149-155. [PMID: 38608467 DOI: 10.1016/j.ajem.2024.03.030] [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] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 03/28/2024] [Indexed: 04/14/2024] Open
Abstract
OBJECTIVE The shock index (SI), the ratio of heart rate to systolic blood pressure, is a clinical tool for assessing injury severity. Age-adjusted SI models may improve predictive value for injured children in the out-of-hospital setting. We sought to characterize the proportion of children in the prehospital setting with an abnormal SI using established criteria, describe the age-based distribution of SI among injured children, and determine prehospital interventions by SI. METHODS We performed a multi-agency retrospective cross-sectional study of children (<18 years) in the prehospital setting with a scene encounter for suspected trauma and transported to the hospital between 2018 and 2022 using the National Emergency Medical Services (EMS) Information System datasets. Our exposure of interest was the first calculated SI. We identified the proportion of children with an abnormal SI when using the SI, pediatric age-adjusted (SIPA); and the pediatric SI (PSI) criteria. We developed and internally validated an age-based distributional model for the SI using generalized additive models for location, scale, and shape to describe the age-based distribution of the SI as a centile or Z-score. We evaluated EMS interventions (basic airway interventions, advanced airway interventions, cardiac interventions, vascular access, intravenous fluids, and vasopressor use) in relation to both the SIPA, PSI, and distributional SI values. RESULTS We analyzed 1,007,863 pediatric EMS trauma encounters (55.0% male, median age 13 years [IQR, 8-16 years]). The most common dispatch complaint was for traffic/transport related injury (32.9%). When using the PSI and SIPA, 13.1% and 16.3% were classified as having an abnormal SI, respectively. There were broad differences in the percentage of encounters classified as having an abnormal SI across the age range, varying from 5.1 to 22.8% for SIPA and 3.7-20.1% for PSI. The SIPA values ranged from the 75th to 95th centiles, while the PSI corresponded to an SI greater than the 90th centile, except in older children. The centile distribution for SI declined during early childhood and stabilized during adolescence and demonstrated a difference of <0.1% at cutoff values. An abnormal PSI, SIPA and higher SI centiles (>90th centile and >95th centiles) were associated with interventions related to basic and advanced airway management, cardiac procedures, vascular access, and provision of intravenous fluids occurred with greater frequency at higher SI centiles. Some procedures, including airway management and vascular access, had a smaller peak at lower (<10th) centiles. DISCUSSION We describe the empiric distribution of the pediatric SI across the age range, which may overcome limitations of extant criteria in identifying patients with shock in the prehospital setting. Both high and low SI values were associated with important, potentially lifesaving EMS interventions. Future work may allow for more precise identification of children with significant injury using cutpoint analysis paired to outcome-based criteria. These may additionally be combined with other physiologic and mechanistic criteria to assist in triage decisions.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Robert J Sepanski
- Department of Quality and Safety, Children's Hospital of The King's Daughters, Department of Pediatrics, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Jillian K Gorski
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Ryan G Spurrier
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital Los Angeles, Keck School of Medicine of the University of Southern California Los Angeles, Los Angeles, CA, USA
| | - Christopher M Horvat
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michelle L Macy
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Rebecca Cash
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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4
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Chen SY, Garcia I, Ourshalimian S, Lowery C, Chaudhari PP, Spurrier RG. Childhood opportunity and appropriate use of child safety restraints in motor vehicle collisions. World J Pediatr Surg 2024; 7:e000703. [PMID: 38571719 PMCID: PMC10989117 DOI: 10.1136/wjps-2023-000703] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 02/01/2024] [Indexed: 04/05/2024] Open
Abstract
Objectives Safety restraints reduce injuries from motor vehicle collisions (MVCs) but are often improperly applied or not used. The Childhood Opportunity Index (COI) reflects social determinants of health and its study in pediatric trauma is limited. We hypothesized that MVC patients from low-opportunity neighborhoods are less likely to be appropriately restrained. Methods A retrospective cross-sectional study was performed on children/adolescents ≤18 years old in MVCs between January 1, 2011 and December 31, 2021. Patients were identified from the Children's Hospital Los Angeles trauma registry. The outcome was safety restraint use (appropriately restrained, not appropriately restrained). COI levels by home zip codes were stratified as very low, low, moderate, high, and very high. Multivariable regression controlling for age identified factors associated with safety restraint use. Results Of 337 patients, 73.9% were appropriately restrained and 26.1% were not appropriately restrained. Compared with appropriately restrained patients, more not appropriately restrained patients were from low-COI (26.1% vs 20.9%), high-COI (14.8% vs 10.8%) and very high-COI (10.2% vs 3.6%) neighborhoods. Multivariable analysis demonstrated no significant associations in appropriate restraint use and COI. There was a non-significant trend that children/adolescents from moderate-COI neighborhoods were more likely than those from very low-COI neighborhoods to be appropriately restrained (OR=1.82, 95% CI 0.78, 4.28). Conclusion Injury prevention initiatives focused on safety restraints should target families of children from all neighborhood types. Level of evidence III.
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Affiliation(s)
- Stephanie Y Chen
- Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Iris Garcia
- Injury Prevention Program, Children's Hospital Los Angeles, Los Angeles, California, USA
| | | | - Chantel Lowery
- Injury Prevention Program, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Pradip P Chaudhari
- Emergency and Transport Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA
- Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Ryan G Spurrier
- Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California, USA
- Surgery, University of Southern California Keck School of Medicine, Los Angeles, California, 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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Gorski JK, Chaudhari PP, Spurrier RG, Goldstein SD, Zeineddin S, Martin-Gill C, Sepanski RJ, Stey AM, Ramgopal S. Comparison of Vital Sign Cutoffs to Identify Children With Major Trauma. JAMA Netw Open 2024; 7:e2356472. [PMID: 38363566 PMCID: PMC10873773 DOI: 10.1001/jamanetworkopen.2023.56472] [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] [Received: 10/17/2023] [Accepted: 12/26/2023] [Indexed: 02/17/2024] Open
Abstract
Importance Vital signs are essential components in the triage of injured children. The Advanced Trauma Life Support (ATLS) and Pediatric Advanced Life Support (PALS) physiologic criteria are frequently used for trauma assessments. Objective To evaluate the performance of ATLS and PALS criteria vs empirically derived criteria for identifying major trauma in children. Design, Setting, and Participants This retrospective cohort study used 2021 American College of Surgeons Trauma Quality Improvement Program (TQIP) data contributed by US trauma centers. Included encounters involved pediatric patients (aged <18 years) with severe injury, excluding those who experienced out-of-hospital cardiac arrest, were receiving mechanical ventilation, or were transferred from another facility. Data were analyzed between April 9 and December 21, 2023. Exposure Initial hospital vital signs, including heart rate, respiratory rate, and systolic blood pressure (SBP). Main Outcome and Measures Major trauma, determined by the Standard Triage Assessment Tool, a composite measure of injury severity and interventions performed. Multivariable models developed from PALS and ATLS vital sign criteria were compared with models developed from the empirically derived criteria using the area under the receiver operating characteristic curve. Validation of the findings was performed using the 2019 TQIP dataset. Results A total of 70 748 patients (median [IQR] age, 11 [5-15] years; 63.4% male) were included, of whom 3223 (4.6%) had major trauma. The PALS criteria classified 31.0% of heart rates, 25.7% of respiratory rates, and 57.4% of SBPs as abnormal. The ATLS criteria classified 25.3% of heart rates, 4.3% of respiratory rates, and 1.1% of SBPs as abnormal. Among children with all 3 vital signs documented (64 326 [90.9%]), PALS had a sensitivity of 88.4% (95% CI, 87.1%-89.3%) and specificity of 25.1% (95% CI, 24.7%-25.4%) for identifying major trauma, and ATLS had a sensitivity of 54.5% (95% CI, 52.7%-56.2%) and specificity of 72.9% (95% CI, 72.6%-73.3%). The empirically derived cutoff vital sign z scores had a sensitivity of 80.0% (95% CI, 78.5%-81.3%) and specificity of 48.7% (95% CI, 48.3%-49.1%) and area under the receiver operating characteristic curve of 70.9% (95% CI, 69.9%-71.8%), which was similar to PALS criteria (69.6%; 95% CI, 68.6%-70.6%) and greater than ATLS criteria (65.4%; 95% CI, 64.4%-66.3%). Validation using the 2019 TQIP database showed similar performance to the derivation sample. Conclusions and Relevance These findings suggest that empirically derived vital sign criteria strike a balance between the sensitivity of PALS criteria and the specificity of ATLS criteria in identifying major trauma in children. These criteria may help to identify children at greatest risk of trauma-related morbidity and mortality.
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Affiliation(s)
- Jillian K. Gorski
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Pradip P. Chaudhari
- Division of Emergency and Transport Medicine, Department of Pediatrics, Children’s Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Ryan G. Spurrier
- Division of Pediatric Surgery, Department of Surgery, Children’s Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Seth D. Goldstein
- Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Suhail Zeineddin
- Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert J. Sepanski
- Department of Quality and Safety, Children’s Hospital of The King’s Daughters, Norfolk, Virginia
- Department of Pediatrics, Eastern Virginia Medical School, Norfolk
| | - Anne M. Stey
- Department of Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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O'Guinn ML, Martino AM, Ourshalimian S, Holliday-Carroll MC, Chaudhari PP, Spurrier R. Association Between Hospital Arrival Time and Avoidable Transfer in Pediatric Trauma. J Pediatr Surg 2024; 59:310-315. [PMID: 37973422 DOI: 10.1016/j.jpedsurg.2023.10.023] [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: 10/02/2023] [Accepted: 10/13/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Avoidable transfers (AT) in pediatric trauma can increase strain on healthcare resources and families. We sought to identify characteristics of patients and their injuries that are associated with AT. METHODS A multicenter retrospective cross-sectional study of the regional Trauma Registry was conducted from 1/1/10-12/31/21 of children <18 years-old who experienced an interfacility transfer. AT was defined as receiving hospital length of stay (LOS) < 48 hrs without procedure or intervention performed. Patient demographics, mechanism of injury, and arrival time were analyzed with descriptive statistics. A multivariable logistic regression was performed to analyze demographic and clinical factors associated with AT. RESULTS We included 5438 trauma transfers, of which 2187 (40.2%) were AT. Patients experiencing AT had a median [IQR] age of 5 years [1-12] and most were male (67%) and Hispanic/Latino (46.3%). The odds of experiencing AT decreased as age increased and were less likely in females and Non-Hispanic Black children. Injuries from falls (ground level (OR = 2.48; 95%CI = 1.89-3.28) and >10 ft (OR = 3.20; 95%CI = 2.35-4.39)), sports/recreational activities (OR = 2.36; 95%CI = 1.78-3.16), MVCs (OR = 1.44; 95%CI = 1.05-1.98), and firearms (OR = 1.74; 95%CI = 1.15-2.62) were associated with an increased odds of AT. Time of arrival at the receiving facility in early hours (00:00-07:59) (OR = 1.48; 95%CI = 1.24-1.76) and evening hours (17:00-23:59) (OR = 1.75; 95%CI = 1.47-2.07) were associated with an increased odds of AT. CONCLUSION Younger patients, injuries from falls, sports/recreational activities, MVCs, and firearms as well as arrival time outside of standard work hours are more likely to result in AT. Knowing these results, we can begin working with our referral centers to improve communication and strengthen institutional transfer criteria for pediatric trauma patients. Further investigation will then be needed to determine if the changes implemented have influenced care and lowered rates of avoidable transfer. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- MaKayla L O'Guinn
- Children's Hospital Los Angeles, Division of Pediatric Surgery, 4650 W Sunset Blvd, Los Angeles, CA 90027, USA
| | - Alice M Martino
- Children's Hospital Los Angeles, Division of Pediatric Surgery, 4650 W Sunset Blvd, Los Angeles, CA 90027, USA
| | - Shadassa Ourshalimian
- Children's Hospital Los Angeles, Division of Pediatric Surgery, 4650 W Sunset Blvd, Los Angeles, CA 90027, USA
| | - Mary C Holliday-Carroll
- Children's Hospital Los Angeles, Division of Pediatric Surgery, 4650 W Sunset Blvd, Los Angeles, CA 90027, USA
| | - Pradip P Chaudhari
- Children's Hospital Los Angeles, Division of Emergency Medicine &Transport Medicine, 4650 W Sunset Blvd, Los Angeles, CA 90027, USA; Keck School of Medicine of University of Southern California, Department of Pediatrics, 1975 Zonal Ave, Los Angeles, CA 90033, USA
| | - Ryan Spurrier
- Children's Hospital Los Angeles, Division of Pediatric Surgery, 4650 W Sunset Blvd, Los Angeles, CA 90027, USA; Keck School of Medicine of University of Southern California, Department of Surgery, 1975 Zonal Ave, Los Angeles, CA 90033, USA.
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O'Guinn ML, Vojvodic V, Ourshalimian S, Garcia I, Chaudhari PP, Spurrier R. Seasonality and temporal variation of pediatric trauma in Southern California. Injury 2024; 55:111266. [PMID: 38141391 DOI: 10.1016/j.injury.2023.111266] [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: 08/13/2023] [Revised: 12/01/2023] [Accepted: 12/02/2023] [Indexed: 12/25/2023]
Abstract
INTRODUCTION Seasonality of pediatric trauma has been previously described, although the association of season with hour of presentation is less understood. Both factors have potential implications for resource allocation and team preparedness. METHODS A multicenter retrospective study was conducted to analyze the records of injured children <18 years-old who presented to one of the 15 trauma centers within Los Angeles County. Data from the County Trauma and Emergency Medicine Information System Registry was abstracted from 1/1/10 to 12/31/21. Patient demographics, mechanism of injury (MOI) and time of presentation by season were analyzed using Kruskal Wallis tests and chi-square tests. RESULTS A total of 30,444 pediatric trauma presentations were included. Both the time of presentation and the MOI differed significantly by season with p < 0.001. Autumn had a higher incidence of pedestrian injuries during hours of 08:00 and 15:0020:00, and sports injuries from 16:00 to 21:00. In the Summer there were more burns between 17:00 and 23:00 and falls from greater than 10 ft after 13:00. The mode of transport used was also different across seasons (p = 0.03), with the use of both air and ground EMS greatest during summer and least during winter. The hours of greatest utilization remained relatively constant for all seasons for air transport (18:00-19:00 h) and ground transport (19:00-20:00 h). CONCLUSION These data demonstrate the significant seasonal and temporal variation within pediatric trauma. These findings could be used to inform improvements in emergency response, and resource allocation in particular.
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Affiliation(s)
- MaKayla L O'Guinn
- Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA 90027, United States
| | - Vanya Vojvodic
- Keck School of Medicine of University of Southern California, 1975 Zonal Ave, Los Angeles, CA 90033, United States
| | - Shadassa Ourshalimian
- Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA 90027, United States
| | - Iris Garcia
- Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA 90027, United States
| | - Pradip P Chaudhari
- Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA 90027, United States; Keck School of Medicine of University of Southern California, 1975 Zonal Ave, Los Angeles, CA 90033, United States
| | - Ryan Spurrier
- Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA 90027, United States; Keck School of Medicine of University of Southern California, 1975 Zonal Ave, Los Angeles, CA 90033, United States; University of Southern California, 3470 Trousdale Parkway, Los Angeles, CA 90089, United States.
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Ross EE, Ourshalimian S, Spurrier RG, Chaudhari PP. Trends and Variation in Cervical Spine Imaging Utilization Across Children's Hospitals for Pediatric Trauma. J Trauma Acute Care Surg 2024:01586154-990000000-00609. [PMID: 38197643 DOI: 10.1097/ta.0000000000004242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
BACKGROUND Cervical spine evaluation is a critical component in trauma evaluation, and though several pediatric cervical spine evaluation algorithms have been developed, none has been widely implemented. Here, we assess rates of cervical spine imaging use across children's hospitals, specifically temporal trends in imaging use, variation across hospitals in imaging used, and timing of magnetic resonance imaging in admitted patients. METHODS Data from the Children's Hospital Associations Pediatric Health Information System was abstracted from 2015 to 2020. Patients less than 18 years of age seen in the emergency department with an International Classification of Diseases (ICD)-10 code indicative of trauma and cervical spine plain radiograph or computed tomography in the emergency department were included. Data visualization and descriptive statistics were used to assess rates of imaging use by age, year, hospital, injury severity, and day of service. Changes in rates of imaging use over time were evaluated via Chi-square test. RESULTS Across 25,238 patient encounters at 35 children's hospitals, there was an increase in use of cervical spine computed tomography from 2015 to 2020 (28.5 to 36.5%). There was substantial inter-institutional variation in rates of use of plain radiographs versus computed tomography for initial evaluation of the cervical spine across all age groups and regardless of rates of severe injury across institutions. Magnetic resonance imaging was obtained more than three days after admission in 31.5% of intensive care patients who received this imaging. CONCLUSIONS Increasing use of computed tomography, substantial inter-institutional variation in rates of use of plain radiographs versus computed tomography, and heterogenous timing of magnetic resonance imaging for evaluation of the pediatric cervical spine demonstrate the growing need for development and implementation of an age-specific cervical spine evaluation algorithm to guide judicious use of diagnostic resources. LEVEL OF EVIDENCE Level III, Epidemiologic.
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Hoffmann JA, Carter CP, Olsen CS, Chaudhari PP, Chaudhary S, Duffy S, Glomb N, Goyal MK, Grupp-Phelan J, Haasz M, Ketabchi B, Kravitz-Wirtz N, Lerner EB, Shihabuddin B, Wendt W, Cook LJ, Alpern ER. Pediatric Firearm Injury Emergency Department Visits From 2017 to 2022: A Multicenter Study. Pediatrics 2023; 152:e2023063129. [PMID: 37927086 PMCID: PMC10842699 DOI: 10.1542/peds.2023-063129] [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] [Accepted: 08/30/2023] [Indexed: 11/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Pediatric firearm injuries increased during the coronavirus disease 2019 pandemic, but recent trends in firearm injury emergency department (ED) visits are not well described. We aimed to assess how pediatric firearm injury ED visits during the pandemic differed from expected prepandemic trends. METHODS We retrospectively studied firearm injury ED visits by children <18 years old at 9 US hospitals participating in the Pediatric Emergency Care Applied Research Network Registry before (January 2017 to February 2020) and during (March 2020 to November 2022) the pandemic. Multivariable Poisson regression models estimated expected visit rates from prepandemic data. We calculated rate ratios (RRs) of observed to expected visits per 30 days, overall, and by sociodemographic characteristics. RESULTS We identified 1904 firearm injury ED visits (52.3% 15-17 years old, 80.0% male, 63.5% non-Hispanic Black), with 694 prepandemic visits and 1210 visits during the pandemic. Death in the ED/hospital increased from 3.1% prepandemic to 6.1% during the pandemic (P = .007). Firearm injury visits per 30 days increased from 18.0 prepandemic to 36.1 during the pandemic (RR 2.09, 95% CI 1.63-2.91). Increases beyond expected rates were seen for 10- to 14-year-olds (RR 2.61, 95% CI 1.69-5.71), females (RR 2.46, 95% CI 1.55-6.00), males (RR 2.00, 95% CI 1.53-2.86), Hispanic children (RR 2.30, 95% CI 1.30-9.91), and Black non-Hispanic children (RR 1.88, 95% CI 1.34-3.10). CONCLUSIONS Firearm injury ED visits for children increased beyond expected prepandemic trends, with greater increases among certain population subgroups. These findings may inform firearm injury prevention efforts.
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Affiliation(s)
- Jennifer A Hoffmann
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Camille P Carter
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Cody S Olsen
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - 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
| | - Sofia Chaudhary
- Division of Emergency Medicine, Department of Pediatrics and Department of Emergency Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Susan Duffy
- Departments of Emergency Medicine and Pediatrics, Brown University, Hasbro Children's Hospital, Providence, Rhode Island
| | - Nicolaus Glomb
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, University of California, San Francisco, San Francisco, California
| | - Monika K Goyal
- Division of Emergency Medicine, Children's National Hospital, George Washington University, Washington, District of Columbia
| | - Jacqueline Grupp-Phelan
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, University of California, San Francisco, San Francisco, California
| | - Maya Haasz
- Department of Pediatrics, Section of Emergency Medicine, Children's Hospital Colorado, University of Colorado, Aurora, Colorado
| | - Bijan Ketabchi
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Nicole Kravitz-Wirtz
- Department of Emergency Medicine, University of California, Davis, Sacramento, California
| | - E Brooke Lerner
- Department of Emergency Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
| | - Bashar Shihabuddin
- Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Wendi Wendt
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lawrence J Cook
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - 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, IL
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11
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Michelson KA, Bachur RG, Cruz AT, Grubenhoff JA, Reeves SD, Chaudhari PP, Monuteaux MC, Dart AH, Finkelstein JA. Multicenter evaluation of a method to identify delayed diagnosis of diabetic ketoacidosis and sepsis in administrative data. Diagnosis (Berl) 2023; 10:383-389. [PMID: 37340621 PMCID: PMC10679849 DOI: 10.1515/dx-2023-0019] [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: 02/16/2023] [Accepted: 06/07/2023] [Indexed: 06/22/2023]
Abstract
OBJECTIVES To derive a method of automated identification of delayed diagnosis of two serious pediatric conditions seen in the emergency department (ED): new-onset diabetic ketoacidosis (DKA) and sepsis. METHODS Patients under 21 years old from five pediatric EDs were included if they had two encounters within 7 days, the second resulting in a diagnosis of DKA or sepsis. The main outcome was delayed diagnosis based on detailed health record review using a validated rubric. Using logistic regression, we derived a decision rule evaluating the likelihood of delayed diagnosis using only characteristics available in administrative data. Test characteristics at a maximal accuracy threshold were determined. RESULTS Delayed diagnosis was present in 41/46 (89 %) of DKA patients seen twice within 7 days. Because of the high rate of delayed diagnosis, no characteristic we tested added predictive power beyond the presence of a revisit. For sepsis, 109/646 (17 %) of patients were deemed to have a delay in diagnosis. Fewer days between ED encounters was the most important characteristic associated with delayed diagnosis. In sepsis, our final model had a sensitivity for delayed diagnosis of 83.5 % (95 % confidence interval 75.2-89.9) and specificity of 61.3 % (95 % confidence interval 56.0-65.4). CONCLUSIONS Children with delayed diagnosis of DKA can be identified by having a revisit within 7 days. Many children with delayed diagnosis of sepsis may be identified using this approach with low specificity, indicating the need for manual case review.
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Affiliation(s)
| | - Richard G. Bachur
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA, USA
| | - Andrea T. Cruz
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Joseph A. Grubenhoff
- Section of Pediatric Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Children’s Hospital Colorado, Aurora, CO, USA
| | - Scott D. Reeves
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Pradip P. Chaudhari
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, CA, USA
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | | | - Arianna H. Dart
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA, USA
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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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Chaudhari PP, Durham S, Bachur RG, Goodhue CJ, Levitt D, Semple-Hess J, Gao L, Pineda J, Khemani RG. Critical Emergency Department Interventions and Clinical Deterioration in Children With Nonsevere Traumatic Intracranial Hemorrhage. Pediatr Emerg Care 2023:00006565-990000000-00340. [PMID: 37770069 PMCID: PMC10978551 DOI: 10.1097/pec.0000000000003057] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
OBJECTIVE Substantial practice variation exists in the management of children with nonsevere traumatic intracranial hemorrhage (tICH). A comprehensive understanding of rates and timing of clinically important tICH, including critical interventions and deterioration, along with associated clinical and neuroradiographic characteristics, will inform accurate risk stratification. METHODS We conducted a single-center retrospective cohort study of children aged younger than 18 years evaluated in the emergency department (ED) from May 1, 2014 to February 28, 2020 with tICH and initial Glasgow Coma Scale (GCS) score of higher than 8. We determined rates of clinically important tICH after injury and within 96 hours of ED arrival, defined as immediate ED interventions (intubation, hyperosmotic agents, or neurosurgery within 4 hours of arrival) or clinically important deterioration (signs/symptoms with change in management). Associations between outcome and clinical and neuroradiographic characteristics were calculated using individual logistic regression models. RESULTS Our sample included 135 children. Clinically important tICH was observed in 13.3% (n = 18); 9 (6.7%) underwent immediate ED interventions and 9 (6.7%) developed deterioration. Most (93.3%, n = 127) presented with an initial GCS ≥ 14, including all children who later deteriorated. Initial GCS (P = 0.001) and nonaccidental trauma (P = 0.024) mechanism were associated with the outcome. None of the 71 (52.6%) children with initial GCS ≥ 14, isolated, nonepidural hemorrhage after accidental injury developed clinically important tICH. CONCLUSIONS Clinically important tICH occurred in 13% of children with nonsevere tICH, and 7% of children who did not undergo immediate ED interventions later deteriorated, all of whom had an initial GCS ≥ 14. However, a subgroup of children was identified as low risk based on clinical and neuroradiographic characteristics.
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Affiliation(s)
| | | | - Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | | | | | - Leland Gao
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Jose Pineda
- Division of Pediatric Critical Care Medicine, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA
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Sarnthiyakul S, Ross EE, Ourshalimian S, Spurrier RG, Chaudhari PP. Neighborhood deprivation and childhood opportunity indices are associated with violent injury among children in Los Angeles County. J Trauma Acute Care Surg 2023; 95:397-402. [PMID: 36728330 DOI: 10.1097/ta.0000000000003860] [Citation(s) in RCA: 1] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Previous research has demonstrated mixed relationships between individual neighborhood socioeconomic factors and incidences of violence, such as poverty level, population density, and income inequality. We used the Childhood Opportunity Index and Area Disadvantage Index to evaluate the relationship between neighborhood characteristics and the number of incidents of violence among children across the zip codes of Los Angeles (LA) County. METHODS We performed a retrospective cross-sectional study of children younger than 18 years from 2017 to 2019 who were entered in the LA County Trauma and Emergency Medicine Information System registry with violent mechanisms of injury, including gunshot, stabbing, or assault. Mechanisms classified as self-inflicted injuries were excluded from the study. The number of incidences of violent mechanism per 100,000 persons younger than 18 years for each zip code was calculated using population data from the US Census American Community Survey 5-Year estimates from 2019. The incidences of violence per capita younger than 18 years for each zip code was compared with the zip code Area Deprivation Index and Childhood Opportunity Index using logistic regression models. RESULTS There were 6,791 trauma activations in LA County over the study period, 12.8% (n = 866) of which were due to violence. The mean prevalence of pediatric violent mechanism of injury per zip code was 4 cases per 100,000 persons younger than 18 years. Most injuries were the result of firearms (n = 345 [60.4%]) and occurred among Hispanic/Latino children (n = 362 [57.1%]). There were significantly greater rates of violent injury among children from highest disadvantage (odds ratio, 8.84) and lowest opportunity (odds ratio, 42.48) zip codes. CONCLUSION Children living in high disadvantage or low opportunity zip codes had greater rates of violent injury. Further study of neighborhood factors is needed to develop targeted effective interventions to reduce violent injuries among children living in low opportunity areas. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Affiliation(s)
- Sasithorn Sarnthiyakul
- From the Fielding School of Public Health (S.S.), University of California, Los Angeles; Department of Medical Education (E.E.R.), Keck School of Medicine, University of Southern California; Division of Pediatric Surgery, Department of Surgery (S.O., R.G.S.) and Division of Emergency and Transport Medicine (P.P.C.), Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California
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15
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O'Guinn ML, Siddiqui S, Ourshalimian S, Chaudhari PP, Spurrier R. Firearm Injuries in Lower Opportunity Neighborhoods During the COVID Pandemic. Pediatrics 2023; 152:e2023062530. [PMID: 37599643 DOI: 10.1542/peds.2023-062530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2023] [Indexed: 08/22/2023] Open
Abstract
OBJECTIVES We aimed to describe changes in pediatric firearm injury rates, severity, and outcomes after the coronavirus disease 2019 stay-at-home order in Los Angeles (LA) County. METHODS A multicenter, retrospective, cross-sectional study was conducted on firearm injuries involving children aged <18-years in LA County before and after the pandemic. Trauma activation data of 15 trauma centers in LA County from the Trauma and Emergency Medicine Information System Registry were abstracted from January 1, 2018, to December 31, 2021. The beginning of the pandemic was set as March 19, 2020, the date the county stay-at-home order was issued, separating the prepandemic and during-pandemic periods. Rates of firearm injuries, severity, discharge capacity, and Child Opportunity Index (COI) were compared between the groups. Analysis was performed with χ2 tests and segmented regression. RESULTS Of the 7693 trauma activations, 530 (6.9%) were from firearm injuries, including 260 (49.1%) in the prepandemic group and 270 (50.9%) in the during-pandemic group. No increase was observed in overall rate of firearm injuries after the stay-at-home order was issued (P = .13). However, firearm injury rates increased in very low COI neighborhoods (P = .01). Mechanism of injury, mortality rates, discharge capacity, and injury severity score did not differ between prepandemic and during-pandemic periods (all P values ≥.05). CONCLUSIONS Although there was no overall increase in pediatric firearm injuries during the pandemic, there was a disproportionate increase in areas of very low neighborhood COI. Further examination of community disparity should be a focus for education, intervention, and development.
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Affiliation(s)
- MaKayla L O'Guinn
- Department of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Sami Siddiqui
- Department of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Shadassa Ourshalimian
- Department of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Pradip P Chaudhari
- Department of Pedicatrics, Keck School of Medicine of University of Southern California, Los Angeles, California
- Division of Emergency Medicine & Transport Medicine, Children's Hospital Los Angeles, 4650 W Sunset Blvd, Los Angeles, California
| | - Ryan Spurrier
- Department of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
- Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California
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Michelson KA, Bachur RG, Grubenhoff JA, Cruz AT, Chaudhari PP, Reeves SD, Porter JJ, Monuteaux MC, Dart AH, Finkelstein JA. OUTCOMES OF MISSED DIAGNOSIS OF PEDIATRIC APPENDICITIS, NEW-ONSET DIABETIC KETOACIDOSIS, AND SEPSIS IN FIVE PEDIATRIC HOSPITALS. J Emerg Med 2023; 65:e9-e18. [PMID: 37355425 PMCID: PMC10527892 DOI: 10.1016/j.jemermed.2023.04.006] [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: 12/12/2022] [Revised: 03/15/2023] [Accepted: 04/10/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Missed diagnosis can predispose to worse condition-specific outcomes. OBJECTIVE To determine 90-day complication rates and hospital utilization after a missed diagnosis of pediatric appendicitis, new-onset diabetic ketoacidosis (DKA), and sepsis. METHODS We evaluated patients under 21 years of age visiting five pediatric emergency departments (EDs) with a study condition. Case patients had a preceding ED visit within 7 days of diagnosis and underwent case review to confirm a missed diagnosis. Control patients had no preceding ED visit. We compared complication rates and utilization between case and control patients after adjusting for age, sex, and insurance. RESULTS We analyzed 29,398 children with appendicitis, 5366 with DKA, and 3622 with sepsis, of whom 429, 33, and 46, respectively, had a missed diagnosis. Patients with missed diagnosis of appendicitis or DKA had more hospital days and readmissions; there were no significant differences for those with sepsis. Those with missed appendicitis were more likely to have abdominal abscess drainage (adjusted odds ratio [aOR] 3.0, 95% confidence interval [CI] 2.4-3.6) or perforated appendicitis (aOR 3.1, 95% CI 2.5-3.8). Those with missed DKA were more likely to have cerebral edema (aOR 4.6, 95% CI 1.5-11.3), mechanical ventilation (aOR 13.4, 95% CI 3.8-37.1), or death (aOR 28.4, 95% CI 1.4-207.5). Those with missed sepsis were less likely to have mechanical ventilation (aOR 0.5, 95% CI 0.2-0.9). Other illness complications were not significantly different by missed diagnosis. CONCLUSIONS Children with delayed diagnosis of appendicitis or new-onset DKA had a higher risk of 90-day complications and hospital utilization than those with a timely diagnosis.
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Affiliation(s)
- Kenneth A Michelson
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Joseph A Grubenhoff
- Section of Pediatric Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado; Children's Hospital Colorado, Aurora, Colorado
| | - Andrea T Cruz
- Divisions of Pediatric Emergency Medicine and Infectious Diseases, Baylor College of Medicine, Houston, Texas
| | - 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
| | - Scott D Reeves
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Ohio
| | - John J Porter
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Arianna H Dart
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Jonathan A Finkelstein
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
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Ramgopal S, Rodean J, Alpern ER, Hall M, Chaudhari PP, Marin JR, Shah SS, Freedman SB, Eltorki M, Badaki-Makun O, Shapiro DJ, Rhine T, Morse RB, Neuman MI. Ambulatory follow-up among publicly insured children discharged from the emergency department. Acad Emerg Med 2023; 30:721-730. [PMID: 36809681 DOI: 10.1111/acem.14704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 02/13/2023] [Accepted: 02/17/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND While children discharged from the emergency department (ED) are frequently advised to follow up with ambulatory care providers, the extent to which this occurs is unknown. We sought to characterize the proportion of publicly insured children who have an ambulatory visit following ED discharge, identify factors associated with ambulatory follow-up, and evaluate the association of ambulatory follow-up with subsequent hospital-based health care utilization. METHODS We performed a cross-sectional study of pediatric (<18 years) encounters during 2019 included in the IBM Watson Medicaid MarketScan claims database from seven U.S. states. Our primary outcome was an ambulatory follow-up visit within 7 days of ED discharge. Secondary outcomes were 7-day ED return visits and hospitalizations. Logistic regression and Cox proportional hazards were used for multivariable modeling. RESULTS We included 1,408,406 index ED encounters (median age 5 years, IQR 2-10 years), for which a 7-day ambulatory visit occurred in 280,602 (19.9%). Conditions with the highest proportion of 7-day ambulatory follow-up included seizures (36.4%); allergic, immunologic, and rheumatologic diseases (24.6%); other gastrointestinal diseases (24.5%); and fever (24.1%). Ambulatory follow-up was associated with younger age, Hispanic ethnicity, weekend ED discharge, ambulatory encounters prior to the ED visit, and diagnostic testing performed during the ED encounter. Ambulatory follow-up was inversely associated with Black race and ambulatory care-sensitive or complex chronic conditions. In Cox models, ambulatory follow-up was associated with a higher hazard ratio (HR) of subsequent ED return (HR range 1.32-1.65) visit and hospitalization (HR range 3.10-4.03). CONCLUSIONS One-fifth of children discharged from the ED have an ambulatory visit within 7 days, which varied by patient characteristics and diagnoses. Children with ambulatory follow-up have a greater subsequent health care utilization, including subsequent ED visit and/or hospitalization. These findings identify the need to further research the role and costs associated with routine post-ED visit follow-up.
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Affiliation(s)
- 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
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas, 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
| | - Jennifer R Marin
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - 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
| | - Daniel J Shapiro
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Tara Rhine
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Rustin B Morse
- Department of Pediatrics, Center for Clinical Excellence, Nationwide Children's Hospital, The Ohio State University College of Medicine, Ohio, Columbus, USA
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
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Cushing AM, Michelson KA, Chaudhari PP. Consider R Codes for Undiagnosed Serious Pediatric Behavior Problems-Reply. JAMA Pediatr 2023:2803172. [PMID: 37010853 DOI: 10.1001/jamapediatrics.2023.0337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Affiliation(s)
- Anna M Cushing
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Kenneth A Michelson
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Los Angeles, California
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Michelson KA, Bachur RG, Dart AH, Chaudhari PP, Cruz AT, Grubenhoff JA, Reeves SD, Monuteaux MC, Finkelstein JA. Identification of delayed diagnosis of paediatric appendicitis in administrative data: a multicentre retrospective validation study. BMJ Open 2023; 13:e064852. [PMID: 36854600 PMCID: PMC9980351 DOI: 10.1136/bmjopen-2022-064852] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Abstract
OBJECTIVE To derive and validate a tool that retrospectively identifies delayed diagnosis of appendicitis in administrative data with high accuracy. DESIGN Cross-sectional study. SETTING Five paediatric emergency departments (EDs). PARTICIPANTS 669 patients under 21 years old with possible delayed diagnosis of appendicitis, defined as two ED encounters within 7 days, the second with appendicitis. OUTCOME Delayed diagnosis was defined as appendicitis being present but not diagnosed at the first ED encounter based on standardised record review. The cohort was split into derivation (2/3) and validation (1/3) groups. We derived a prediction rule using logistic regression, with covariates including variables obtainable only from administrative data. The resulting trigger tool was applied to the validation group to determine area under the curve (AUC). Test characteristics were determined at two predicted probability thresholds. RESULTS Delayed diagnosis occurred in 471 (70.4%) patients. The tool had an AUC of 0.892 (95% CI 0.858 to 0.925) in the derivation group and 0.859 (95% CI 0.806 to 0.912) in the validation group. The positive predictive value (PPV) for delay at a maximal accuracy threshold was 84.7% (95% CI 78.2% to 89.8%) and identified 87.3% of delayed cases. The PPV at a stricter threshold was 94.9% (95% CI 87.4% to 98.6%) and identified 46.8% of delayed cases. CONCLUSIONS This tool accurately identified delayed diagnosis of appendicitis. It may be used to screen for potential missed diagnoses or to specifically identify a cohort of children with delayed diagnosis.
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Affiliation(s)
| | - Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Arianna H Dart
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Andrea T Cruz
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Joseph A Grubenhoff
- Section of Pediatric Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Children's Hospital Colorado, Aurora, CO, USA
| | - Scott D Reeves
- Division of Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Cushing AM, Liberman DB, Pham PK, Michelson KA, Festekjian A, Chang TP, Chaudhari PP. Mental Health Revisits at US Pediatric Emergency Departments. JAMA Pediatr 2023; 177:168-176. [PMID: 36574251 PMCID: PMC9856860 DOI: 10.1001/jamapediatrics.2022.4885] [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: 08/08/2022] [Accepted: 10/11/2022] [Indexed: 12/29/2022]
Abstract
Importance Pediatric emergency department (ED) visits for mental health crises are increasing. Patients who frequently use the ED are of particular concern, as pediatric mental health ED visits are commonly repeat visits. Better understanding of trends and factors associated with mental health ED revisits is needed for optimal resource allocation and targeting of prevention efforts. Objective To describe trends in pediatric mental health ED visits and revisits and to determine factors associated with revisits. Design, Setting, and Participants In this cohort study, data were obtained from 38 US children's hospital EDs in the Pediatric Health Information System between October 1, 2015, and February 29, 2020. The cohort included patients aged 3 to 17 years with a mental health ED visit. Exposures Characteristics of patients, encounters, hospitals, and communities. Main Outcomes and Measures The primary outcome was a mental health ED revisit within 6 months of the index visit. Trends were assessed using cosinor analysis and factors associated with time to revisit using mixed-effects Cox proportional hazards regression. Results There were 308 264 mental health ED visits from 217 865 unique patients, and 13.2% of patients had a mental health revisit within 6 months. Mental health visits increased by 8.0% annually (95% CI, 4.5%-11.4%), whereas all other ED visits increased by 1.5% annually (95% CI, 0.1%-2.9%). Factors associated with mental health ED revisits included psychiatric comorbidities, chemical restraint use, public insurance, higher area measures of child opportunity, and presence of an inpatient psychiatric unit at the presenting hospital. Patients with psychotic disorders (hazard ratio [HR], 1.42; 95% CI, 1.29-1.57), disruptive or impulse control disorders (HR, 1.36; 95% CI, 1.30-1.42), and neurodevelopmental disorders (HR, 1.22; 95% CI, 1.14-1.30) were more likely to revisit. Patients with substance use disorders (HR, 0.60; 95% CI, 0.55-0.66) were less likely to revisit. Conclusions and Relevance Markers of disease severity and health care access were associated with mental health revisits. Directing hospital and community interventions toward identified high-risk patients is needed to help mitigate recurrent mental health ED use and improve mental health care delivery.
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Affiliation(s)
- Anna M. Cushing
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, California
| | - Danica B. Liberman
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles
- Department of Population and Public Health Sciences, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Phung K. Pham
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, California
| | - Kenneth A. Michelson
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Ara Festekjian
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Todd P. Chang
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Pradip P. Chaudhari
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles
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21
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Schiff J, Schmidt AR, Pham PK, Pérez JB, Pannaraj PS, Chaudhari PP, Liberman DB. Parental attitudes in the pediatric emergency department about the COVID-19 vaccine. Vaccine 2022; 40:7328-7334. [PMID: 36344362 PMCID: PMC9597585 DOI: 10.1016/j.vaccine.2022.10.046] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 10/11/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND COVID-19 vaccinations are now recommended in the United States (U.S.) for children ≥ 6 months old. However, pediatric vaccination rates remain low, particularly in the Hispanic/Latinx population. OBJECTIVE Using the 4C vaccine hesitancy framework (calculation, complacency, confidence, convenience), we examined parental attitudes in the emergency department (ED) towards COVID-19 vaccination, identified dimensions of parental vaccine hesitancy, and assessed parental willingness to have their child receive the COVID-19 vaccine. METHODS As part of a larger multi-methods study examining influenza vaccine hesitancy, we conducted interviews that included questions about COVID-19 vaccine authorization for children. We used directed content analysis to extract qualitative themes from 3 groups of parents in the ED: Hispanic/Latinx Spanish speaking (HS), Hispanic/Latinx English speaking (HE), non-Hispanic/non-Latinx White English speaking (WE). Themes were triangulated with the Parent Attitudes about Childhood Vaccines (PACV) survey, where higher scores indicate increased vaccine hesitancy. RESULTS Factors influencing vaccine hesitancy were mapped to the 4C framework from 58 sets of interviews and PACVs. HE and HS parents, compared to WE parents, had less knowledge about COVID-19 and its vaccine, and more beliefs in COVID-19 vaccine myths. However, both HS and HE parent groups were more inclined to endorse COVID-19 vaccine effectiveness as a reason to have their children vaccinated. HS parents felt that COVID-19 increased their fear of illnesses in general and were worried about confusing COVID-19 with other infections. Median PACV scores of HS (Mdn = 20) and HE (Mdn = 20) parent groups were higher than of WE parents (Mdn = 10), but parental willingness to have their child receive COVID-19 vaccination was similar across groups. CONCLUSIONS Higher COVID-19 vaccine hesitancy among HS and HE parents compared to WE parents may be attributed to insufficient knowledge about COVID-19, its vaccine, along with COVID-19 vaccine myths. Efforts to provide targeted vaccine education to different populations is warranted.
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Affiliation(s)
- Jared Schiff
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, CA, USA,Corresponding author at: Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, 4650 Sunset Blvd. Mailstop #113, Los Angeles, CA, USA
| | - Anita R. Schmidt
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - Phung K. Pham
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, CA, USA,Division of Behavioral and Organizational Sciences, Claremont Graduate University of the Claremont Colleges, Claremont, CA, USA
| | - Jocelyn B. Pérez
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - Pia S. Pannaraj
- Division of Infectious Disease, Children’s Hospital Los Angeles, Los Angeles, CA, USA,Department of Pediatrics and Molecular Microbiology and Immunology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Pradip P. Chaudhari
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, CA, USA,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Danica B. Liberman
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, CA, USA,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA,Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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22
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Ugalde IT, Chaudhari PP, Badawy M, Ishimine P, McCarten-Gibbs KA, Yen K, Atigapramoj NS, Sage A, Nielsen D, Adelson PD, Upperman J, Tancredi D, Kuppermann N, Holmes JF. Validation of Prediction Rules for Computed Tomography Use in Children With Blunt Abdominal or Blunt Head Trauma: Protocol for a Prospective Multicenter Observational Cohort Study. JMIR Res Protoc 2022; 11:e43027. [PMID: 36422920 PMCID: PMC9732756 DOI: 10.2196/43027] [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] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/09/2022] [Accepted: 11/12/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Traumatic brain injuries (TBIs) and intra-abdominal injuries (IAIs) are 2 leading causes of traumatic death and disability in children. To avoid missed or delayed diagnoses leading to increased morbidity, computed tomography (CT) is used liberally. However, the overuse of CT leads to inefficient care and radiation-induced malignancies. Therefore, to maximize precision and minimize the overuse of CT, the Pediatric Emergency Care Applied Research Network (PECARN) previously derived clinical prediction rules for identifying children at high risk and very low risk for IAIs undergoing acute intervention and clinically important TBIs after blunt trauma in large cohorts of children who are injured. OBJECTIVE This study aimed to validate the IAI and age-based TBI clinical prediction rules for identifying children at high risk and very low risk for IAIs undergoing acute intervention and clinically important TBIs after blunt trauma. METHODS This was a prospective 6-center observational study of children aged <18 years with blunt torso or head trauma. Consistent with the original derivation studies, enrolled children underwent routine history and physical examinations, and the treating clinicians completed case report forms prior to knowledge of CT results (if performed). Medical records were reviewed to determine clinical courses and outcomes for all patients, and for those who were discharged from the emergency department, a follow-up survey via a telephone call or SMS text message was performed to identify any patients with missed IAIs or TBIs. The primary outcomes were IAI undergoing acute intervention (therapeutic laparotomy, angiographic embolization, blood transfusion, or intravenous fluid for ≥2 days for pancreatic or gastrointestinal injuries) and clinically important TBI (death from TBI, neurosurgical procedure, intubation for >24 hours for TBI, or hospital admission of ≥2 nights due to a TBI on CT). Prediction rule accuracy was assessed by measuring rule classification performance, using standard point and 95% CI estimates of the operational characteristics of each prediction rule (sensitivity, specificity, positive and negative predictive values, and diagnostic likelihood ratios). RESULTS The project was funded in 2016, and enrollment was completed on September 1, 2021. Data analyses are expected to be completed by December 2022, and the primary study results are expected to be submitted for publication in 2023. CONCLUSIONS This study will attempt to validate previously derived clinical prediction rules to accurately identify children at high and very low risk for clinically important IAIs and TBIs. Assuming successful validation, widespread implementation is then indicated, which will optimize the care of children who are injured by better aligning CT use with need. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR1-10.2196/43027.
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Affiliation(s)
- Irma T Ugalde
- Department of Emergency Medicine, Children's Memorial Hermann Hospital, McGovern Medical School at UTHealth Houston, Houston, TX, United States
| | - Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
| | - Mohamed Badawy
- Department of Pediatrics, University of Texas Southwestern, Dallas, TX, United States
| | - Paul Ishimine
- Department of Emergency Medicine and Pediatrics, University of California San Diego School of Medicine, Rady Children's Hospital, San Diego, CA, United States
| | - Kevan A McCarten-Gibbs
- Department of Emergency Medicine, University of California San Francisco Benioff Children's Hospital, Oakland, CA, United States
| | - Kenneth Yen
- Department of Pediatrics, University of Texas Southwestern, Dallas, TX, United States
| | - Nisa S Atigapramoj
- Department of Emergency Medicine, University of California San Francisco Benioff Children's Hospital, Oakland, CA, United States
| | - Allyson Sage
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, CA, United States
| | - Donovan Nielsen
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, CA, United States
| | - P David Adelson
- Barrow Neurological Institute of Phoenix Children's Hospital, Department of Child Health, Division of Pediatric Neurosurgery, University of Arizona College of Medicine, Phoenix, AZ, United States
| | - Jeffrey Upperman
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Daniel Tancredi
- Department of Pediatrics, University of California Davis School of Medicine, Sacramento, CA, United States
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, CA, United States
| | - James F Holmes
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, CA, United States
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23
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Pakyurek M, Badawy M, Ugalde IT, Ishimine P, Chaudhari PP, McCarten-Gibbs K, Nobari O, Kuppermann N, Holmes JF. Does attention-deficit/hyperactivity disorder increase the risk of minor blunt head trauma in children? J Child Adolesc Psychiatr Nurs 2022; 35:356-361. [PMID: 35962779 PMCID: PMC9637762 DOI: 10.1111/jcap.12390] [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: 01/29/2022] [Revised: 06/07/2022] [Accepted: 07/28/2022] [Indexed: 11/27/2022]
Abstract
PROBLEM It is unclear if attention-deficit hyperactivity disorder (ADHD) increases the risk of head trauma in children. METHODS We conducted a multicenter prospective observational study of children with minor blunt head trauma. Guardians were queried, and medical records were reviewed as to whether the patient had previously been diagnosed with ADHD. Enrolled patients were categorized based on their mechanism of injury, with a comparison of those with motor vehicle collision (MVC) versus non-MVC mechanisms. FINDINGS A total of 3410 (84%) enrolled children had ADHD status available, and 274 (8.0%; 95% confidence interval, CI: 7.1, 9.0%) had been diagnosed with ADHD. The mean age was 9.2 ± 3.5 years and 64% were males. Rates of ADHD for specific mechanisms of injury were: assaults: 23/131 (17.6%; 95% CI 11.5, 25.2%), automobile versus pedestrian 23/173 (13.3%; 95% CI: 8.6, 19.3%), bicycle crashes 26/148 (17.6%; 95% CI: 11.8, 24.7%), falls 107/1651 (6.5%; 95% 5.3, 7.8%), object struck head 31/421 (7.4%; 5.1, 10.3%), motorized vehicle crashes (e.g., motorcycle, motor scooter) 11/148 (7.4%; 3.8, 12.9%), and MVCs 46/704 (6.5%; 95% CI: 4.8, 8.6%). CONCLUSION Children with ADHD appear to be at increased risk of head trauma from certain mechanisms of injury including assaults, auto versus pedestrian, and bicycle crashes but are not at an increased risk for falls.
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Affiliation(s)
- Murat Pakyurek
- Department of Psychiatry and Behavioral Sciences, School of Medicine, UC Davis, Sacramento, California, USA
| | - Mohamed Badawy
- Department of Pediatrics, UT Southwestern, Dallas, Texas, USA
| | - Irma T Ugalde
- Department of Emergency Medicine, McGovern Medical School at UTHealth Houston, Houston, Texas, USA
| | - Paul Ishimine
- Department of Emergency Medicine and Pediatrics, School of Medicine, University of California, San Diego, La Jolla, California, USA
| | - Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Keck School of Medicine of USC, Los Angeles, California, USA
| | - Kevan McCarten-Gibbs
- Department of Emergency Medicine, UCSF Benioff Children's Hospital, Oakland, California, USA
| | - Ozra Nobari
- Department of Psychiatry and Behavioral Sciences, School of Medicine, UC Davis, Sacramento, California, USA
| | - Nathan Kuppermann
- Department of Emergency Medicine and Pediatrics, School of Medicine, UC Davis, Sacramento, California, USA
| | - James F Holmes
- Department of Emergency Medicine, School of Medicine, UC Davis, Sacramento, California, USA
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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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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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Chaudhari PP, Rodean J, Spurrier RG, Hall M, Marin JR, Ramgopal S, Alpern ER, Shah SS, Freedman SB, Cohen E, Morse RB, Neuman MI. Epidemiology and management of abdominal injuries in children. Acad Emerg Med 2022; 29:944-953. [PMID: 35373473 DOI: 10.1111/acem.14497] [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] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 03/28/2022] [Accepted: 03/29/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although more guideline-adherent care has been described in pediatric compared to adult trauma centers, we aimed to provide a more detailed characterization of management and resource utilization of children with intra-abdominal injury (IAI) within pediatric centers. Our primary objective was to describe the epidemiology, diagnostic evaluation, and management of children with IAI across U.S. children's hospitals. Our secondary objective was to describe the interhospital variation in surgical management of children with IAI. METHODS We conducted a cross-sectional study of 33 hospitals in the Pediatric Health Information System. We included children aged <18 years evaluated in the emergency department from 2010 to 2019 with IAI, as defined by ICD coding, and who underwent an abdominal computed tomography (CT). Our primary outcome was abdominal surgery. We categorized IAI by organ system and described resource utilization data. We used generalized linear regression to calculate adjusted hospital-level proportions of abdominal surgery, with a random effect for hospital. RESULTS We studied 9265 children with IAI. Median (IQR) age was 9.0 (6.0-13.0) years. Abdominal surgery was performed in 16% (n = 1479) of children, with the lowest proportion of abdominal surgery observed in children aged <5 years. Liver (38.6%) and spleen (32.1%) were the most common organs injured. A total of 3.1% of children with liver injuries and 2.8% with splenic injuries underwent abdominal surgery. Although there was variation in rates of surgery across hospitals (p < 0.001), only three of 33 hospitals had rates that were statistically different from the aggregate mean of 16%. CONCLUSIONS Most children with IAI are managed nonoperatively, and most children's hospitals manage children with IAI similarly. These data can be used to inform future benchmarking efforts across hospitals to assess concordance with guidelines for the management of children with IAI.
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Affiliation(s)
- 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 California USA
| | | | - Ryan G. Spurrier
- Division of Pediatric Surgery, Department of Surgery Children's Hospital Los Angeles and Keck School of Medicine of the University of Southern California Los Angeles California USA
| | - Matt Hall
- Children's Hospital Association Lenexa Kansas USA
| | - Jennifer R. Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology University of Pittsburgh School of Medicine Pittsburgh Pennsylvania 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
| | - Samir S. Shah
- Divisions of Hospital Medicine and Infectious Diseases, Department of Pediatrics Cincinnati Children's Hospital Medical Center Cincinnati Ohio USA
| | - Stephen B. Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital, Alberta Children's Hospital Research Institute Cumming School of Medicine, University of Calgary Calgary Alberta Canada
| | - Eyal Cohen
- Division of Pediatric Medicine and Child Health Evaluative Sciences, The Hospital for Sick Children and Department of Pediatrics and Institute of Health Policy, Management & Evaluation The University of Toronto and ICES Toronto Ontario Canada
| | - Rustin B. Morse
- Center for Clinical Excellence Nationwide Children's Hospital Columbus Ohio USA
| | - Mark I. Neuman
- Division of Emergency Medicine Boston Children's Hospital and Harvard Medical School Boston Massachusetts USA
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27
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Chaudhari PP, Anderson M, Ourshalimian S, Goodhue C, Sudharshan R, Valadez S, Spurrier R. Epidemiology of pediatric trauma during the coronavirus disease-2019 pandemic. J Pediatr Surg 2022; 57:284-290. [PMID: 34742575 PMCID: PMC8500847 DOI: 10.1016/j.jpedsurg.2021.09.054] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 09/27/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND/PURPOSE We aimed to describe the epidemiology of trauma activations and variations in injury patterns, injury severity, and hospital length-of-stay for injured children in Los Angeles (LA) County during the coronavirus-disease-19 (COVID-19) pandemic. METHODS We conducted a retrospective cross-sectional study of children aged < 18-years evaluated in 15 trauma centers from 2019 to 2020 and entered in the LA County trauma registry. We defined 01/01/2019-03/18/2020 as pre-pandemic and 03/19/2020-12/31/2020 as the pandemic period. Our primary outcome was pediatric trauma activations. We analyzed demographic and clinical data, including types and severity of injuries sustained. We conducted unadjusted bivariate analyzes of injury patterns between periods. Segmented linear regression models were used to test rates (per 100,000 LA County children) of trauma activations pre-pandemic versus the pandemic period. RESULTS We studied 4399 children with trauma activations, 2695 of which occurred pre-pandemic and 1701 in the pandemic period. Motor vehicle collisions, gunshot wounds, and burns increased during the pandemic (all p-values< 0.05), while sports injuries decreased (p < 0.001). Median injury severity scores (p = 0.323) and Glasgow Coma Scales (p = 0.558) did not differ between periods, however mortality (p = 0.023) decreased during the pandemic. Segmented linear regression estimates demonstrated that rates of trauma activations pre-pandemic were similar to the pandemic period (p = 0.384). CONCLUSION Pediatric trauma activations in LA County did not significantly differ during the COVID-19 pandemic, but types and severity of injuries varied between pre-pandemic and pandemic periods. With lockdown restrictions being lifted and novel SARS-CoV-2 variants circulating, our investigation describes this recent epidemiologic phenomenon to aid future preparation for healthcare systems. LEVEL OF EVIDENCE Level III TYPE OF STUDY: Retrospective cross-sectional study.
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Affiliation(s)
- Pradip P. Chaudhari
- Division of Emergency and Transport Medicine, Department of Pediatrics, Children's Hospital Los Angeles, 4650 Sunset Blvd, Mail Stop 113, Los Angeles, CA 90027, USA,Keck School of Medicine of the University of Southern California, 1975 Zonal Ave, Los Angeles, CA 90033, USA,Corresponding author at: Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd, Mail Stop 113, Los Angeles, CA 90027, USA
| | - Melissa Anderson
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA 90027, USA
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA 90027, USA
| | - Catherine Goodhue
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA 90027, USA
| | - Rasika Sudharshan
- Keck School of Medicine of the University of Southern California, 1975 Zonal Ave, Los Angeles, CA 90033, USA
| | - Sara Valadez
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA 90027, USA
| | - Ryan Spurrier
- Keck School of Medicine of the University of Southern California, 1975 Zonal Ave, Los Angeles, CA 90033, USA,Division of Pediatric Surgery, Department of Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA 90027, USA
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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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Hernandez CS, Monuteaux MC, Bachur RG, Hall JE, Chaudhari PP. Trends in ED Resource Use for Infants 0 to 60 Days Evaluated for Serious Bacterial Infection. Hosp Pediatr 2021; 11:hpeds.2021-005966. [PMID: 34808663 DOI: 10.1542/hpeds.2021-005966] [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 We examined trends in resource use for infants undergoing emergency department evaluation for serious bacterial infection, including lumbar puncture (LP), antibiotic administration, hospitalization, and procalcitonin testing, as well as the association between procalcitonin testing and LP, administration of parenteral antibiotics, and hospitalization. METHODS We performed a cross-sectional study of infants aged 0 to 60 days who underwent emergency department evaluation for serious bacterial infection with blood and urine cultures from 2010 to 2019 in 27 hospitals in the Pediatric Health Information System. We examined temporal trends in LP, antibiotic administration, hospitalization, and procalcitonin testing from 2010 to 2019. We also estimated multivariable logistic regression models for 2017-2019, adjusted for demographic factors and stratified by age (<28 and 29-60 days), with LP, antibiotic administration, and hospitalization as dependent variables and hospital-level procalcitonin testing as the independent variable. RESULTS We studied 106 547 index visits. From 2010 to 2019, rates of LP, antibiotic administration, and hospitalization decreased more for infants aged 29 to 60 days compared with infants aged 0 to 28 days (annual decrease in odds of LP, antibiotics administration, and hospitalization: 0 to 28 days: 5%, 5%, and 3%, respectively; 29-60 days: 15%, 12%, and 7%, respectively). Procalcitonin testing increased significantly each calendar year (odds ratio per calendar year 2.19; 95% confidence interval 1.82-2.62), with the majority (91.1%) performed during 2017-2019. From 2017 to 2019, there was no association between hospital-level procalcitonin testing and any outcome studied (all P values > .05). CONCLUSIONS Rates of LP, antibiotic administration, and hospitalization decreased significantly for infants 29 to 60 days during 2010-2019. Although procalcitonin testing increased during 2017-2019, we found no association with hospital-level procalcitonin testing and patterns of resource use.
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Affiliation(s)
- Christina S Hernandez
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Jeanine E Hall
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California
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LaQuaglia MJ, Anderson M, Goodhue CJ, Bautista-Durand M, Spurrier R, Ourshalimian S, Lai L, Stanley P, Chaudhari PP, Bliss D. Variation in radiation dosing among pediatric trauma patients undergoing head computed tomography scan. J Trauma Acute Care Surg 2021; 91:566-570. [PMID: 34137741 DOI: 10.1097/ta.0000000000003318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 11/26/2022]
Abstract
BACKGROUND When head injured children undergo head computed tomography (CT), radiation dosing can vary considerably between institutions, potentially exposing children to excess radiation, increasing risk for malignancies later in life. We compared radiation delivery from head CTs at a level 1 pediatric trauma center (PTC) versus scans performed at referring adult general hospitals (AGHs). We hypothesized that children at our PTC receive a significantly lower radiation dose than children who underwent CT at AGHs for similar injury profiles. METHODS We retrospectively reviewed the charts of all patients younger than 18 years who underwent CT for head injury at our PTC or at an AGH before transfer between January 1 and December 31, 2019. We analyzed demographic and clinical data. Our primary outcome was head CT radiation dose, as calculated by volumetric CT dose index (CTDIvol) and dose-length product (DLP; the product of CTDIvol and scan length). We used unadjusted bivariate and multivariable linear regression (adjusting for age, weight, sex) to compare doses between Children's Hospital Los Angeles and AGHs. RESULTS Of 429 scans reviewed, 193 were performed at our PTC, while 236 were performed at AGHs. Mean radiation dose administered was significantly lower at our PTC compared with AGHs (CTDIvol 20.3/DLP 408.7 vs. CTDIvol 30.6/DLP 533, p < 0.0001). This was true whether the AGH was a trauma center or not. After adjusting for covariates, findings were similar for both CTDIvol and DLP. Patients who underwent initial CT at an AGH and then underwent a second CT at our PTC received less radiation for the second CT (CTDIvol 25.6 vs. 36.5, p < 0.0001). CONCLUSIONS Head-injured children consistently receive a lower radiation dose when undergoing initial head CT at a PTC compared with AGHs. This provides a basis for programs aimed at establishing protocols to deliver only as much radiation as necessary to children undergoing head CT. LEVEL OF EVIDENCE Care Management/Therapeutic, level IV.
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Affiliation(s)
- Michael J LaQuaglia
- From the Division of Pediatric Surgery (M.J.L., R.S., S.O., D.B.), Children's Hospital Los Angeles; Department of Surgery (M.J.L., R.S., S.O., D.B.), Keck School of Medicine, University of Southern California; Division of Pediatric Surgery (M.A., C.J.G., M.B.-D.) and Department of Radiology (L.L., P.S.), Children's Hospital Los Angeles; Department of Radiology (L.L., P.S.), Keck School of Medicine, University of Southern California; and Division of Emergency and Transport Medicine (P.P.C.), Children's Hospital Los Angeles, California
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31
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Michelson KA, Reeves SD, Grubenhoff JA, Cruz AT, Chaudhari PP, Dart AH, Finkelstein JA, Bachur RG. Clinical Features and Preventability of Delayed Diagnosis of Pediatric Appendicitis. JAMA Netw Open 2021; 4:e2122248. [PMID: 34463745 PMCID: PMC8408667 DOI: 10.1001/jamanetworkopen.2021.22248] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [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: 12/11/2022] Open
Abstract
IMPORTANCE Delayed diagnosis of appendicitis is associated with worse outcomes than timely diagnosis, but clinical features associated with diagnostic delay are uncertain, and the extent to which delays are preventable is unclear. OBJECTIVE To determine clinical features associated with delayed diagnosis of pediatric appendicitis, assess the frequency of preventable delay, and compare delay outcomes. DESIGN, SETTING, AND PARTICIPANTS This case-control study included 748 children treated at 5 pediatric emergency departments in the US between January 1, 2010, and December 31, 2019. Participants were younger than 21 years and had a diagnosis of appendicitis. EXPOSURES Individual features of appendicitis and pretest likelihood of appendicitis were measured by the Pediatric Appendicitis Risk Calculator (pARC). MAIN OUTCOMES AND MEASURES Case patients had a delayed diagnosis of appendicitis, defined as 2 emergency department visits leading to diagnosis and a case review showing the patient likely had appendicitis at the first visit. Control patients had a single emergency department visit yielding a diagnosis. Clinical features and pARC scores were compared by case-control status. Preventability of delay was assessed as unlikely, possible, or likely. The proportion of children with indicated imaging based on an evidence-based cost-effectiveness threshold was determined. Outcomes of delayed diagnosis were compared by case-control status, including hospital length of stay, perforation, and multiple surgical procedures. RESULTS A total of 748 children (mean [SD] age, 10.2 [4.3] years; 392 boys [52.4%]; 427 White children [57.1%]) were included in the study; 471 (63.0%) had a delayed diagnosis of appendicitis, and 277 (37.0%) had no delay in diagnosis. Children with a delayed diagnosis were less likely to have pain with walking (adjusted odds ratio [aOR], 0.16; 95% CI, 0.10-0.25), maximal pain in the right lower quadrant (aOR, 0.12; 95% CI, 0.07-0.19), and abdominal guarding (aOR, 0.33; 95% CI, 0.21-0.51), and were more likely to have a complex chronic condition (aOR, 2.34; 95% CI, 1.05-5.23). The pretest likelihood of appendicitis was 39% to 52% lower in children with a delayed vs timely diagnosis. Among children with a delayed diagnosis, 109 cases (23.1%) were likely to be preventable, and 247 (52.4%) were possibly preventable. Indicated imaging was performed in 104 (22.0%) to 289 (61.3%) children with delayed diagnosis, depending on the imputation method for missing data on white blood cell count. Patients with delayed diagnosis had longer hospital length of stay (mean difference between the groups, 2.8 days; 95% CI, 2.3-3.4 days) and higher perforation rates (OR, 7.8; 95% CI, 5.5-11.3) and were more likely to undergo 2 or more surgical procedures (OR, 8.0; 95% CI, 2.0-70.4). CONCLUSIONS AND RELEVANCE In this case-control study, delayed appendicitis was associated with initially milder symptoms but worse outcomes. These findings suggest that a majority of delayed diagnoses were at least possibly preventable and that many of these patients did not undergo indicated imaging, suggesting an opportunity to prevent delayed diagnosis of appendicitis in some children.
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Affiliation(s)
- Kenneth A. Michelson
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Scott D. Reeves
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Joseph A. Grubenhoff
- Section of Pediatric Emergency Medicine, University of Colorado School of Medicine, Aurora
- Children's Hospital Colorado, Aurora
| | - Andrea T. Cruz
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - 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
| | - Arianna H. Dart
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | | | - Richard G. Bachur
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
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Marin JR, Rodean J, Mannix RC, Hall M, Alpern ER, Aronson PL, Chaudhari PP, Cohen E, Freedman SB, Morse RB, Peltz A, Samuels-Kalow M, Shah SS, Simon HK, Neuman MI. Association of Clinical Guidelines and Decision Support with Computed Tomography Use in Pediatric Mild Traumatic Brain Injury. J Pediatr 2021; 235:178-183.e1. [PMID: 33894265 DOI: 10.1016/j.jpeds.2021.04.026] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/22/2021] [Accepted: 04/14/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To examine whether the presence of clinical guidelines and clinical decision support (CDS) for mild traumatic brain injury (mTBI) are associated with lower use of head computed tomography (CT). STUDY DESIGN We conducted a cross-sectional study of 45 pediatric emergency departments (EDs) in the Pediatric Hospital Information System from 2015 through 2019. We included children discharged with mTBI and surveyed ED clinical directors to ascertain the presence and implementation year of clinical guidelines and CDS. The association of clinical guidelines and CDS with CT use was assessed, adjusting for relevant confounders. As secondary outcomes, we evaluated ED length of stay and rates of 3-day ED revisits and admissions after revisits. RESULTS There were 216 789 children discharged with mTBI, and CT was performed during 20.3% (44 114/216 789) of ED visits. Adjusted hospital-specific CT rates ranged from 11.8% to 34.7% (median 20.5%, IQR 17.3%, 24.3%). Of the 45 EDs, 17 (37.8%) had a clinical guideline, 9 (20.0%) had CDS, and 19 (42.2%) had neither. Compared with EDs with neither a clinical guideline nor CDS, visits to EDs with CDS (aOR 0.52 [0.47, 0.58]) or a clinical guideline (aOR 0.83 [0.78, 0.89]) had lower odds of including a CT for mTBI. ED length of stay and revisit rates did not differ based on the presence of a clinical guideline or CDS. CONCLUSIONS Clinical guidelines for mTBI, and particularly CDS, were associated with lower rates of head CT use without adverse clinical outcomes.
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Affiliation(s)
- Jennifer R Marin
- Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA.
| | | | - Rebekah C Mannix
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Matt Hall
- Children's Hospital Association, Lenexa, KS
| | - 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, IL
| | - Paul L Aronson
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Yale School of Medicine, New Haven, CT
| | - Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles and Keck School of Medicine of the USC, Los Angeles, CA
| | - Eyal Cohen
- Division of Pediatric Medicine and Child Health Evaluative Sciences, The Hospital for Sick Children and Department of Pediatrics, Toronto, Ontario, Canada; Institute of Health Policy, Management & Evaluation, The University of Toronto, Toronto, Ontario, Canada
| | - Stephen B Freedman
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Alon Peltz
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, MA
| | | | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Harold K Simon
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA; Children's Healthcare of Atlanta, Atlanta, GA
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
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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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Chaudhari PP, Pineda J, Bachur RG, Khemani RG. Epidemiology of Critical Interventions in Children With Traumatic Intracranial Hemorrhage. Pediatr Emerg Care 2021; 37:e196-e202. [PMID: 33780412 DOI: 10.1097/pec.0000000000002352] [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
OBJECTIVE To estimate rates of critical medical and neurosurgical interventions and resource utilization for children with traumatic intracranial hemorrhage (ICH). METHODS This was a retrospective study of children younger than 18 years hospitalized in 1 of 35 hospitals in the Pediatric Health Information System from 2009 to 2019 for ICH. We defined critical intervention as a critical medical (hyperosmotic agents and intubation) or neurosurgical intervention. We determined rates of critical interventions, intensive care unit (ICU) admission, and repeat neuroimaging. We used hierarchical logistic regression to identify high-level factors associated with undergoing critical interventions, controlling for hospital-level effects. RESULTS There were 12,714 children with ICH included in the study. Median (interquartile range) age was 4.3 (0.7-11.0) years. Twelve percent (n = 1470) of children underwent a critical clinical intervention. Critical medical interventions occurred in 10% (n = 1219), and neurosurgical interventions occurred in 3% (n = 419). Intensive care unit admission occurred in 44% (n = 5565), whereas repeat neuroimaging occurred in 40% (n = 5072). Among ICU patients, 79% (n = 4366) did not undergo a critical intervention. Of the 11,244 children with no critical interventions, 39% (n = 4366) underwent ICU admission, and 37% (n = 4099) repeat neuroimaging. After controlling for hospital, children with isolated subdural (P = 0.013) and isolated subarachnoid (P < 0.001) hemorrhage were less likely to receive critical interventions. CONCLUSIONS Critical medical interventions occurred in 10% of children with ICH, and neurosurgical interventions occurred in 3%. Intensive care unit admission and repeat neuroimaging are common, even among those who did not undergo critical interventions. Selective utilization of ICU admission and repeat neuroimaging in children who are at low risk of requiring critical interventions could improve overall quality of care and decrease unnecessary resource utilization.
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Affiliation(s)
| | | | - Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
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Chaudhari PP, Pineda JA, Bachur RG, Khemani RG. Trends and variation in repeat neuroimaging for children with traumatic intracranial hemorrhage. J Am Coll Emerg Physicians Open 2021; 2:e12400. [PMID: 33733248 PMCID: PMC7936793 DOI: 10.1002/emp2.12400] [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: 12/10/2020] [Revised: 01/22/2021] [Accepted: 02/12/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES We aimed to determine trends and institutional variation in repeat neuroimaging in children with traumatic intracranial hemorrhage and to identify factors associated with neuroimaging modality (subsequent magnetic resonance imaging [MRI] vs computed tomography [CT]). METHODS We conducted a retrospective cross-sectional study of 35 hospitals in the Pediatric Health Information System database. We included children <18 years of age hospitalized from 2010-2019 with intracranial hemorrhage and who underwent a brain CT. We calculated repeat neuroimaging rates by modality and used regression analyses to examine temporal trends. We used hierarchical logistic regression to identify factors associated with subsequent MRI versus repeat CT, controlling for hospital. RESULTS We identified 12,714 children with intracranial hemorrhage, of which 5072 with repeat neuroimaging were studied. Of the 5072 children with repeat neuroimaging, repeat CT was performed in 67.6% (n = 3429) and subsequent MRI in 32.4% (n = 1643). Overall repeat neuroimaging with either a CT or MRI remained similar from 2010-2019 (P = 0.431); however, repeat CT scans significantly decreased (P = 0.001); whereas, MRIs significantly increased (P < 0.001). Repeat neuroimaging by hospital ranged from 20%-80%. After controlling for institution, subsequent MRI was more likely to be used in younger children and children who did not receive hyperosmotic agents, neurosurgical interventions, or intensive care unit admission (all P-values <0.001). CONCLUSIONS We found that repeat neuroimaging rates for children with intracranial hemorrhage vary substantially by institution. We also found that although MRI was increasingly used to re-image these children, overall repeat neuroimaging rates (CT or MRI) have not decreased over the past decade. Future work to implement optimal utilization of neuroimaging in these children is needed.
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Affiliation(s)
- Pradip P. Chaudhari
- Division of Emergency and Transport MedicineChildren's Hospital Los AngelesLos AngelesCaliforniaUSA
- Keck School of Medicine of the University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Jose A. Pineda
- Keck School of Medicine of the University of Southern CaliforniaLos AngelesCaliforniaUSA
- Department of Anesthesia and Critical Care MedicineChildren's Hospital Los AngelesLos AngelesCaliforniaUSA
| | - Richard G. Bachur
- Division of Emergency MedicineBoston Children's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Robinder G. Khemani
- Keck School of Medicine of the University of Southern CaliforniaLos AngelesCaliforniaUSA
- Department of Anesthesia and Critical Care MedicineChildren's Hospital Los AngelesLos AngelesCaliforniaUSA
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Cavallaro SC, Monuteaux MC, Chaudhari PP, Michelson KA. Use of Neuroimaging for Children With Seizure in General and Pediatric Emergency Departments. J Emerg Med 2021; 60:478-484. [PMID: 33419652 DOI: 10.1016/j.jemermed.2020.10.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 08/04/2020] [Revised: 10/07/2020] [Accepted: 10/19/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Seizure is a common reason for children to visit the emergency department (ED). Pediatric and general EDs may obtain computed tomography (CT) scans of the head for seizure at different rates. OBJECTIVE To compare rates of head CT for pediatric seizure between general and pediatric EDs. METHODS This was a retrospective cohort study using the National Hospital Ambulatory Medical Care Survey for patients <21 years of age presenting to an ED with a chief complaint or diagnosis of seizure between 2006 to 2017. Of these patients, we compared head CT use between general and pediatric EDs among patients with fever, trauma, and co-diagnosis of epilepsy using univariable risk differences and in a multivariable logistic regression model. RESULTS More than 5 (5.4) million (78.8%) and 1.5 million (21.2%) pediatric patients with seizure presented to general and pediatric EDs, respectively. Of those, 22.4% (1.21 million) and 13.2% (192,357) underwent CT scans of the head, respectively, a risk difference of 9.2% (95% confidence interval [CI] 2.3-16.1). General EDs obtained CT scans of the head more often in patients with epilepsy (risk difference 17.9% [95% CI 4.0-31.9]), without fever (12.2% [95% CI 3.1-21.4]), and without trauma (10.6% [95% CI 4.4-16.8]). Presenting to a general ED, being afebrile, or having trauma were associated with head CT with adjusted odds ratios of 1.7 (95% CI 1.0-3.2), 4.9 (95% CI 2.6-9.2), and 2.0 (95% CI 1.2-3.4), respectively. Age, gender, and epilepsy were not associated with head CT among all patients with seizure. CONCLUSIONS Children with seizure are more likely to undergo CT scans of the head at general EDs compared with pediatric EDs.
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Affiliation(s)
- Sarah C Cavallaro
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - 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, California
| | - Kenneth A Michelson
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
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Marin JR, Rodean J, Hall M, Alpern ER, Aronson PL, Chaudhari PP, Cohen E, Freedman SB, Morse RB, Peltz A, Samuels-Kalow M, Shah SS, Simon HK, Neuman MI. Racial and Ethnic Differences in Emergency Department Diagnostic Imaging at US Children's Hospitals, 2016-2019. JAMA Netw Open 2021; 4:e2033710. [PMID: 33512517 PMCID: PMC7846940 DOI: 10.1001/jamanetworkopen.2020.33710] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [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: 11/14/2022] Open
Abstract
IMPORTANCE Diagnostic imaging is frequently performed as part of the emergency department (ED) evaluation of children. Whether imaging patterns differ by race and ethnicity is unknown. OBJECTIVE To evaluate racial and ethnic differences in the performance of common ED imaging studies and to examine patterns across diagnoses. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study evaluated visits by patients younger than 18 years to 44 US children's hospital EDs from January 1, 2016, through December 31, 2019. EXPOSURES Non-Hispanic Black and Hispanic compared with non-Hispanic White race/ethnicity. MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of visits for each race/ethnicity group with at least 1 diagnostic imaging study, defined as plain radiography, computed tomography, ultrasonography, and magnetic resonance imaging. The major diagnostic categories classification system was used to examine race/ethnicity differences in imaging rates by diagnoses. RESULTS A total of 13 087 522 visits by 6 230 911 children and adolescents (mean [SD] age, 5.8 [5.2] years; 52.7% male) occurred during the study period. Diagnostic imaging was performed during 3 689 163 visits (28.2%). Imaging was performed in 33.5% of visits by non-Hispanic White patients compared with 24.1% of visits by non-Hispanic Black patients (odds ratio [OR], 0.60; 95% CI, 0.60-0.60) and 26.1% of visits by Hispanic patients (OR, 0.66; 95% CI, 0.66-0.67). Adjusting for confounders, visits by non-Hispanic Black (adjusted OR, 0.82; 95% CI, 0.82-0.83) and Hispanic (adjusted OR, 0.87; 95% CI, 0.87-0.87) patients were less likely to include any imaging study compared with visits by non-Hispanic White patients. Limiting the analysis to only visits by nonhospitalized patients, the adjusted OR for imaging was 0.79 (95% CI, 0.79-0.80) for visits by non-Hispanic Black patients and 0.84 (95% CI, 0.84-0.85) for visits by Hispanic patients. Results were consistent in analyses stratified by public and private insurance groups and did not materially differ by diagnostic category. CONCLUSIONS AND RELEVANCE In this study, non-Hispanic Black and Hispanic children were less likely to receive diagnostic imaging during ED visits compared with non-Hispanic White children. Further investigation is needed to understand and mitigate these potential disparities in health care delivery and to evaluate the effect of these differential imaging patterns on patient outcomes.
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Affiliation(s)
- Jennifer R. Marin
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Matt Hall
- Children’s Hospital Association, Lenexa, Kansas
| | - 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
| | - Paul L. Aronson
- Section of Pediatric Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Pradip P. Chaudhari
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Eyal Cohen
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Stephen B. Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Emergency Medicine, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rustin B. Morse
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - Alon Peltz
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | | | - Samir S. Shah
- Divisions of Hospital Medicine and Infectious Diseases, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Harold K. Simon
- Division of Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Mark I. Neuman
- Division of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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Marin JR, Rodean J, Hall M, Alpern ER, Aronson PL, Chaudhari PP, Cohen E, Freedman SB, Morse RB, Peltz A, Samuels-Kalow M, Shah SS, Simon HK, Neuman MI. Trends in Use of Advanced Imaging in Pediatric Emergency Departments, 2009-2018. JAMA Pediatr 2020; 174:e202209. [PMID: 32761186 PMCID: PMC7400208 DOI: 10.1001/jamapediatrics.2020.2209] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance There is increased awareness of radiation risks from computed tomography (CT) in pediatric patients. In emergency departments (EDs), evidence-based guidelines, improvements in imaging technology, and availability of nonradiating modalities have potentially reduced CT use. Objective To evaluate changes over time and hospital variation in advanced imaging use. Design, Setting, and Participants This cross-sectional study assessed 26 082 062 ED visits by children younger than 18 years from the Pediatric Health Information System administrative database from January 1, 2009, through December 31, 2018. Exposures Imaging. Main Outcomes and Measures The primary outcome was the change in CT, ultrasonography, and magnetic resonance imaging (MRI) rates from January 1, 2009, to December 31, 2018. Imaging for specific diagnoses was examined using all patient-refined diagnosis related groups. Secondary outcomes were hospital admission and 3-day ED revisit rates and ED length of stay. Results There were a total of 26 082 062 visits by 9 868 406 children (mean [SD] age, 5.59 [5.15] years; 13 842 567 [53.1%] male; 9 273 181 [35.6%] non-Hispanic white) to 32 US pediatric EDs during the 10-year study period, with 1 or more advanced imaging studies used in 1 919 283 encounters (7.4%). The proportion of ED encounters with any advanced imaging increased from 6.4% (95% CI, 6.2%-6.2%) in 2009 to 8.7% (95% CI, 8.7%-8.8%) in 2018. The proportion of ED encounters with CT decreased from 3.9% (95% CI, 3.9%-3.9%) to 2.9% (95% CI, 2.9%-3.0%) (P < .001 for trend), with ultrasonography increased from 2.5% (95% CI, 2.5%-2.6%) to 5.8% (95% CI, 5.8%-5.9%) (P < .001 for trend), and with MRI increased from 0.3% (95% CI, 0.3%-0.4%) to 0.6% (95% CI, 0.6%-0.6%) (P < .001 for trend). The largest decreases in CT rates were for concussion (-23.0%), appendectomy (-14.9%), ventricular shunt procedures (-13.3%), and headaches (-12.4%). Factors associated with increased use of nonradiating imaging modalities included ultrasonography for abdominal pain (20.3%) and appendectomy (42.5%) and MRI for ventricular shunt procedures (17.9%) (P < .001 for trend). Across the study period, EDs varied widely in the use of ultrasonography for appendectomy (median, 57.5%; interquartile range [IQR], 40.4%-69.8%) and MRI (median, 15.8%; IQR, 8.3%-35.1%) and CT (median, 69.5%; IQR, 54.5%-76.4%) for ventricular shunt procedures. Overall, ED length of stay did not change, and hospitalization and 3-day ED revisit rates decreased during the study period. Conclusions and Relevance This study found that use of advanced imaging increased from 2009 to 2018. Although CT use decreased, this decrease was accompanied by a greater increase in the use of ultrasonography and MRI. There appears to be substantial variation in practice and a need to standardize imaging practices.
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Affiliation(s)
- Jennifer R. Marin
- Division of Pediatric Emergency Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Matt Hall
- Children’s Hospital Association, Lenexa, Kansas
| | - 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
| | - Paul L. Aronson
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut,Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Pradip P. Chaudhari
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles
| | - Eyal Cohen
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Stephen B. Freedman
- Alberta Children’s Hospital Research Institute, Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada ,Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Rustin B. Morse
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - Alon Peltz
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | | | - Samir S. Shah
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Division of Infectious Diseases, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Harold K. Simon
- Department of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia,Department of Emergency Medicine, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Mark I. Neuman
- Division of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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Chaudhari PP, Monuteaux MC, Bachur RG. Management of Urinary Tract Infections in Young Children: Balancing Admission With the Risk of Emergency Department Revisits. Acad Pediatr 2019; 19:203-208. [PMID: 29864523 DOI: 10.1016/j.acap.2018.05.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 01/09/2018] [Revised: 05/27/2018] [Accepted: 05/29/2018] [Indexed: 10/14/2022]
Abstract
OBJECTIVE Oral antibiotics effectively treat most pediatric urinary tract infections (UTIs); however, children with UTIs are frequently admitted. We examined variation and trends in admission for children with UTIs plus investigated the relationship between admission and emergency department (ED) revisits for those initially managed on an outpatient basis. We hypothesized that hospitals would have similar 3-day revisit rates regardless of the admission rate at the index visit. METHODS This was a retrospective analysis of 36 hospitals in the Pediatric Health Information System. ED visits for children aged <2 years presenting with UTI between 2010 and 2016 were studied. Main outcomes were age-stratified and included admission and 3-day ED revisit rates. Regression analyses were used to test hospital-level associations between outcomes and linear temporal trends. RESULTS A total of 41,792 visits were studied. The overall admission rate was 27%. The admission rate was 89% for children aged <2 months and 15% for those aged 2 to 24 months. Interhospital admission rates varied from 6% to 64%. Admission and revisit rates were inversely related (mean change, -0.07; 95% confidence interval [CI], -0.13 to -0.02 per 1% increase in admission rate); however, lower admission rates were not associated with increased revisits leading to admission (mean change, -0.02; 95% CI, -0.07 to 0.03). Over the study period, admission rates were stable (test for linear trend: adjusted odds ratio [aOR], 0.99; 95% CI, 0.95-1.02); however, among infants aged <2 months, admissions decreased (aOR, 0.92; 95% CI, 0.88-0.97). CONCLUSIONS A substantial variation in admission rates exists for children with UTI. Although hospitals with lower admission rates had higher revisit rates, those hospitals did not have an increase in revisits with subsequent admission, supporting the goal of outpatient management.
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Affiliation(s)
- 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, Calif (PP Chaudhari); and Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Mass (MC Monuteaux and RG Bachur).
| | - Michael C Monuteaux
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles and Keck School of Medicine of the University of Southern California, Los Angeles, Calif (PP Chaudhari); and Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Mass (MC Monuteaux and RG Bachur)
| | - Richard G Bachur
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles and Keck School of Medicine of the University of Southern California, Los Angeles, Calif (PP Chaudhari); and Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Mass (MC Monuteaux and RG Bachur)
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Neuman MI, Chaudhari PP. Should the Diagnosis of UTI in Young Febrile Infants Require a Positive Urinalysis? J Hosp Med 2019; 14:131-132. [PMID: 30785424 DOI: 10.12788/jhm.3139] [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: 11/20/2022]
Affiliation(s)
- Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA. mark.neuman@ childrens.harvard.edu
| | - Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA
- Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
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Chaudhari PP, Monuteaux MC, Bachur RG. Microscopic Bacteriuria Detected by Automated Urinalysis for the Diagnosis of Urinary Tract Infection. J Pediatr 2018; 202:238-244.e1. [PMID: 30172436 DOI: 10.1016/j.jpeds.2018.07.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [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: 03/21/2018] [Revised: 06/20/2018] [Accepted: 07/03/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To evaluate the test performance of microscopic bacteriuria by automated urinalysis for presumptive urinary tract infection (UTI) in young children. STUDY DESIGN This is a retrospective cross-sectional study of children aged <2 years evaluated for UTI in a single large emergency department with paired automated microscopic urinalysis and culture. Test characteristics were calculated for automated microscopic bacteriuria and pyuria, and a practical diagnostic threshold of bacteriuria was determined. Standard test performance measures and receiver operator characteristic curves were generated. The diagnostic performance of bacteriuria was compared with microscopic pyuria. RESULTS Two thousand five hundred fifty-four children with a median age of 6.1 months were studied, 19% of whom had a positive urine culture. Automated microscopic bacteriuria ≥1+ resulted in a positive likelihood ratio (LR+) of 4.5 (95% CI, 3.9-5.2) and negative LR (LR-) of 0.52 (95% CI, 0.47-0.57). Pyuria alone (≥5 WBC/high-power field) had a LR+ of 4.5 (95% CI, 4.1-5.0) and a LR- of 0.14 (95% CI, 0.11-0.18), whereas the addition of automated microscopic bacteriuria ≥1+ improved the LR+ to 16.3 (95% CI, 12.6-21.1) but raised the LR- to 0.51 (95% CI, 0.47-0.56). Test performance of automated microscopic bacteriuria measured by area under the curve analysis was lower (0.73; 95% CI, 0.70-0.76) than for pyuria (0.92; 95% CI, 0.90-0.93). Isolated automated microscopic bacteriuria without pyuria occurred in only 204 patients (8.0%), among whom only 20 (9.8%) had a positive urine culture. CONCLUSIONS Microscopic bacteriuria measured by automated urinalysis augments the diagnostic value of pyuria for identifying presumptive UTI in young children aged <2 years. Bacteriuria is diagnostically inferior to microscopic pyuria, and in children with bacteriuria without pyuria, presumptive UTI is unlikely.
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Affiliation(s)
- Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles and Keck School of Medicine of the USC, Los Angeles, CA
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
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Chaudhari PP, Monuteaux MC, Bachur RG. Emergency Department Revisits After an Initial Parenteral Antibiotic Dose for UTI. Pediatrics 2018; 142:peds.2018-0900. [PMID: 30131437 DOI: 10.1542/peds.2018-0900] [Citation(s) in RCA: 3] [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: 06/08/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Although oral antibiotics are recommended for the management of most urinary tract infections (UTIs), the administration of parenteral antibiotics before emergency department (ED) discharge is common. We investigated the relationship between the administration of a single dose of parenteral antibiotics before ED discharge and revisits requiring admission among children with UTIs. METHODS A retrospective analysis of administrative data from 36 pediatric hospitals was performed. Patients aged 29 days to 2 years who were evaluated in the ED with a UTI between 2010 and 2016 were studied. Primary outcome was adjusted 3-day ED revisit rates resulting in admission. All revisits, regardless of disposition, served as a secondary outcome. Average treatment effects were estimated by using inverse probability weighted regression, with adjustment for demographic factors, diagnostic testing, ED medications, and hospital-level factors. RESULTS We studied 29 919 children with a median age of 8.6 (interquartile range: 5.1-13.8) months. Of those studied, 36% of the children received parenteral antibiotics before discharge. Patients who received parenteral antibiotics had similar adjusted rates of revisits leading to admission as those who did not receive parenteral antibiotics (1.3% vs 1.0%, respectively; risk difference: 0.3% [95% confidence interval: -0.01% to 0.6%]), although overall revisit rates were higher among patients who received parenteral antibiotics (4.8% vs 3.3%; risk difference 1.5% [95% confidence interval: 0.9% to 2.1%]). CONCLUSIONS Among discharged patients, a parenteral dose of antibiotics did not reduce revisits leading to admission, supporting the goal of discharging patients with oral antibiotics alone for most children with UTIs.
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Affiliation(s)
- Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California; and
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
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Abstract
BACKGROUND Varying urine white blood cell (WBC) thresholds have been recommended for the presumptive diagnosis of urinary tract infection (UTI) among young infants. These thresholds have not been studied with newer automated urinalysis systems that analyze uncentrifuged urine that might be influenced by urine concentration. Our objective was to determine the optimal urine WBC threshold for UTI in young infants by using an automated urinalysis system, stratified by urine concentration. METHODS Retrospective cross-sectional study of infants aged <3 months evaluated for UTI in the emergency department with paired urinalysis and urine culture. UTI was defined as ≥50 000 colony-forming units/mL from catheterized specimens. Test characteristics were calculated across a range of WBC and leukocyte esterase (LE) cut-points, dichotomized into specific gravity groups (dilute <1.015; concentrated ≥1.015). RESULTS Twenty-seven thousand infants with a median age of 1.7 months were studied. UTI prevalence was 7.8%. Optimal WBC cut-points were 3 WBC/high-power field (HPF) in dilute urine (likelihood ratio positive [LR+] 9.9, likelihood ratio negative [LR‒] 0.15) and 6 WBC/HPF (LR+ 10.1, LR‒ 0.17) in concentrated urine. For dipstick analysis, positive LE has excellent test characteristics regardless of urine concentration (LR+ 22.1, LR‒ 0.12 in dilute urine; LR+ 31.6, LR‒ 0.22 in concentrated urine). CONCLUSIONS Urine concentration should be incorporated into the interpretation of automated microscopic urinalysis in young infants. Pyuria thresholds of 3 WBC/HPF in dilute urine and 6 WBC/HPF in concentrated urine are recommended for the presumptive diagnosis of UTI. Without correction of specific gravity, positive LE by automated dipstick is a reliably strong indicator of UTI.
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Affiliation(s)
- Pradip P Chaudhari
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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