1
|
Lentz B, Kharasch S, Goldsmith AJ, Brown J, Duggan NM, Nagdev A. Diaphragmatic Excursion as a Novel Objective Measure of Serratus Anterior Plane Block Efficacy: A Case Series. Clin Pract Cases Emerg Med 2022; 6:276-279. [PMID: 36427038 PMCID: PMC9697884 DOI: 10.5811/cpcem.2022.7.57457] [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: 05/19/2022] [Accepted: 07/21/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Pain scales are often used in peripheral nerve block studies but are problematic due to their subjective nature. Ultrasound-measured diaphragmatic excursion is an easily learned technique that could provide a much-needed objective measure of pain control over time with serial measurements. CASE SERIES We describe three cases where diaphragmatic excursion was used as an objective measure of decreased pain and improved respiratory function after serratus anterior plane block in emergency department patients with anterior or lateral rib fractures. CONCLUSION Diaphragmatic excursion may be an ideal alternative to pain scores to evaluate serratus anterior plane block efficacy. More data will be needed to determine whether this technique can be applied to other ultrasound-guided nerve blocks.
Collapse
Affiliation(s)
- Brian Lentz
- Highland Hospital-Alameda Health System, Department of Emergency Medicine, Oakland, California
| | - Sigmund Kharasch
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Andrew J. Goldsmith
- Brigham and Women’s Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Joseph Brown
- University of Colorado, Department of Emergency Medicine, Aurora, Colorado
| | - Nicole M. Duggan
- Brigham and Women’s Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Arun Nagdev
- Highland Hospital-Alameda Health System, Department of Emergency Medicine, Oakland, California
| |
Collapse
|
2
|
Goldsmith AJ, Al Saud A, Duggan NM, Ma IW, Huang CK, Eke O, Kapur T, Kharasch S, Liteplo A, Shokoohi H. Point-of-Care Lung Ultrasound for Differentiating COVID-19 From Influenza. Cureus 2022; 14:e21116. [PMID: 35165573 PMCID: PMC8830436 DOI: 10.7759/cureus.21116] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2022] [Indexed: 12/15/2022] Open
Abstract
Background and objectives Patients infected with influenza and COVID-19 exhibit similar clinical presentations; thus, a point-of-care test to differentiate between the diseases is needed. Here, we sought to identify features of point-of-care lung ultrasound (LUS) that can discriminate between influenza and COVID-19. Methods In this prospective, cross-sectional study, LUS clips of patients presenting to the emergency department (ED) with viral-like symptoms were collected via a 10-zone scanning protocol. Deidentified clips were interpreted by emergency ultrasound fellows blinded to patients’ clinical context and influenza or COVID-19 diagnosis. Modified Soldati scores were calculated for each lung zone. Logistic regression identified the association of pulmonary pathologies with each disease. Results Ultrasound fellows reviewed LUS clips from 165 patients, of which 30.9% (51/165) had confirmed influenza, 33.9% (56/165) had confirmed COVID-19, and 35.1% (58/165) had neither disease. Patients with COVID-19 were more likely to have irregular pleura and B-lines in all lung zones (p<0.01). The median-modified Soldati score for influenza patients was 0/20 (IQR 0-2), 9/20 (IQR 2.5-15.5) for COVID-19 patients, and 2/20 (IQR 0-8) for patients with neither disease (p<0.0001). In multivariate regression analysis adjusted for age, sex, and congestive heart failure (CHF), the presence of B-lines (OR = 1.29, 95% CI 1.09-1.53) was independently associated with COVID-19 diagnosis. The presence of pleural effusion was inversely associated with COVID-19 (OR = 0.09, 95% CI 0.01-0.65). Conclusions LUS may help providers preferentially identify the presence of influenza versus COVID-19 infection both visually and by calculating a modified Soldati score. Further studies assessing the utility of LUS in differentiating viral illnesses in patients with variable illness patterns and those with variable illness severity are warranted.
Collapse
|
3
|
Schleifer J, Shokoohi H, Selame LAJ, Liteplo A, Kharasch S. The Use of Angle-Independent M-Mode in the Evaluation of Diaphragmatic Excursion: Towards Improved Accuracy. Cureus 2021; 13:e17284. [PMID: 34567851 PMCID: PMC8450169 DOI: 10.7759/cureus.17284] [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] [Accepted: 08/18/2021] [Indexed: 11/24/2022] Open
Abstract
Assessment of diaphragmatic function has been well described in the intensive care setting as well as in emergency medicine and pediatrics. Conventional M-mode evaluation of diaphragmatic excursion is frequently associated with over and under-estimations of diaphragmatic excursion. Angle-independent M-mode allows free rotation and movement of the analysis line to obtain M-mode images in a direction that more accurately reflects diaphragmatic excursion. In order to provide a standardized approach to the evaluation of diaphragmatic excursion with angle-independent M-mode, we propose a landmark-based approach utilizing the spine in order to target the same diaphragmatic segment consistently throughout the diaphragmatic analysis. While the proposed approach is not intended to replace current methods, it may improve accuracy and inter-rater reliability. The relevant background, as well as three patient cases, are presented demonstrating the use of a landmark-based approach in the emergency department. Angle-independent M-mode may provide a more accurate and consistent evaluation of diaphragmatic excursion, an examination that can be used to guide clinical care and anticipate outcomes.
Collapse
Affiliation(s)
- Jessica Schleifer
- Department of Anesthesia and Intensive Care Medicine, University Hospital Bonn, Bonn, DEU
| | - Hamid Shokoohi
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, USA
| | | | - Andrew Liteplo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, USA
| | - Sigmund Kharasch
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, USA
| |
Collapse
|
4
|
Kharasch S, Duggan NM, Cohen AR, Shokoohi H. Lung Ultrasound in Children with Respiratory Tract Infections: Viral, Bacterial or COVID-19? A Narrative Review. Open Access Emerg Med 2020; 12:275-285. [PMID: 33116963 PMCID: PMC7569078 DOI: 10.2147/oaem.s238702] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [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: 08/06/2020] [Accepted: 09/18/2020] [Indexed: 12/18/2022] Open
Abstract
Respiratory tract infections (RTIs) are common complaints among patients presenting to the pediatric emergency department. In the diagnostic assessment of children with RTIs, many patients ultimately undergo imaging studies for further evaluation. Point-of-care lung ultrasound (LUS) can be used safely and with a high degree of accuracy in differentiating etiologies of RTIs in pediatric patients. Ultrasonographical features such as an irregular pleural line, subpleural consolidations, focal and lobar consolidation and signs of interstitial involvement can be used to distinguish between several pathologies. This work offers a comprehensive overview of pediatric LUS in cases of the most common pediatric RTIs including bacterial and viral pneumonia, bronchiolitis, and COVID-19.
Collapse
Affiliation(s)
- Sigmund Kharasch
- Division of Pediatric Emergency Medicine, Division of Emergency Ultrasound, Department of Pediatrics, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Nicole M Duggan
- Harvard Affiliated Emergency Medicine Residency Program, Harvard Medical School, Boston, MA, USA
| | - Ari R Cohen
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Hamid Shokoohi
- Division of Emergency Ultrasound, Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
5
|
Shokoohi H, Al Saud A, Goldsmith A, Schulwolf S, Eke O, Al Mulhim A, Huang C, Kharasch S, Liteplo A. 161 Cardiopulmonary Ultrasound in Risk Stratification of Patients With Influenza. Ann Emerg Med 2020. [DOI: 10.1016/j.annemergmed.2020.09.173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
6
|
Shokoohi H, Goldsmith A, Negishi K, Herrala JR, Diamond E, Kharasch S, Blaivas M, Liteplo AS. A novel measure for characterizing ultrasound device use and wear. J Am Coll Emerg Physicians Open 2020; 1:865-870. [PMID: 33145533 PMCID: PMC7593474 DOI: 10.1002/emp2.12051] [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] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 02/22/2020] [Accepted: 02/25/2020] [Indexed: 11/09/2022] Open
Abstract
Point-of-care ultrasound (POCUS) equipment management is critical in optimizing daily clinical operations in emergency departments (EDs). Traditional consultative ultrasound laboratories are well practiced at operations management, but this is not the case for POCUS programs, because machine upgrade and replacement metrics have not been developed or tested. We present a data-driven method for assessment of POCUS equipment maintenance and replacement named the ULTrA (a data-driven approach to point-of-care ultrasound upgrade) score. This novel model of assessing each ultrasound machine by quantitative scoring in each of four mostly objective categories: use (U), likeability (L), trustworthiness (Tr), and age (A). We propose the ULTrA model as a method to identify underperforming devices which could be upgraded or eliminated, and to compare relative performance amongst a group of departmental ultrasound machines. This composite score may be a useful objective tool that could replace individual proxies for clinical effectiveness, such as age, use, or individual provider preference. Additional research in multiple centers would be needed to refine and validate the ULTrA score. Once fully developed, the ULTrA score could be deployed in EDs and other clinical settings where POCUS is used to help streamline resources to maintain a functional and state-of-the-art fleet of ultrasound machines over time.
Collapse
Affiliation(s)
- Hamid Shokoohi
- Harvard Medical SchoolMassachusetts General HospitalMassachusettsBostonUSA
| | - Andrew Goldsmith
- Harvard Medical SchoolMassachusetts General HospitalMassachusettsBostonUSA
| | - Kay Negishi
- Harvard Medical SchoolMassachusetts General HospitalMassachusettsBostonUSA
| | | | - Eden Diamond
- Harvard Medical SchoolMassachusetts General HospitalMassachusettsBostonUSA
| | - Sigmund Kharasch
- Harvard Medical SchoolMassachusetts General HospitalMassachusettsBostonUSA
| | - Michael Blaivas
- St. Francis HospitalUniversity of South Carolina School of MedicineColumbusGeorgia
| | - Andrew S. Liteplo
- Harvard Medical SchoolMassachusetts General HospitalMassachusettsBostonUSA
| |
Collapse
|
7
|
Goldsmith AJ, Eke OF, Alhassan Al Saud A, Al Mulhim A, Kharasch S, Huang C, Liteplo AS, Shokoohi H. Remodeling Point-of-care Ultrasound Education in the Era of COVID-19. AEM Educ Train 2020; 4:321-324. [PMID: 32704607 PMCID: PMC7369489 DOI: 10.1002/aet2.10475] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 05/28/2023]
Affiliation(s)
- Andrew J. Goldsmith
- From theHarvard Medical SchoolBostonMAUSA
- and theDepartment of Emergency MedicineMassachusetts General HospitalBostonMAUSA
| | - Onyinyechi F. Eke
- From theHarvard Medical SchoolBostonMAUSA
- and theDepartment of Emergency MedicineMassachusetts General HospitalBostonMAUSA
| | - Ahad Alhassan Al Saud
- From theHarvard Medical SchoolBostonMAUSA
- and theDepartment of Emergency MedicineMassachusetts General HospitalBostonMAUSA
| | - Abdullah Al Mulhim
- From theHarvard Medical SchoolBostonMAUSA
- and theDepartment of Emergency MedicineMassachusetts General HospitalBostonMAUSA
| | - Sigmund Kharasch
- From theHarvard Medical SchoolBostonMAUSA
- and theDepartment of Emergency MedicineMassachusetts General HospitalBostonMAUSA
| | - Calvin Huang
- From theHarvard Medical SchoolBostonMAUSA
- and theDepartment of Emergency MedicineMassachusetts General HospitalBostonMAUSA
| | - Andrew S. Liteplo
- From theHarvard Medical SchoolBostonMAUSA
- and theDepartment of Emergency MedicineMassachusetts General HospitalBostonMAUSA
| | - Hamid Shokoohi
- From theHarvard Medical SchoolBostonMAUSA
- and theDepartment of Emergency MedicineMassachusetts General HospitalBostonMAUSA
| |
Collapse
|
8
|
Kharasch S, Jansson P, Liteplo A, Gouker S, Longacre M, Shokoohi H, Schleifer J. 347 Point-Of-Care Ultrasound to Evaluate Pulsus Paradoxus in Children with Asthma. Ann Emerg Med 2019. [DOI: 10.1016/j.annemergmed.2019.08.306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
9
|
Schleifer J, Liteplo AS, Kharasch S. Point-of-Care Ultrasound in a Child with Chest Wall Pain and Rib Osteomyelitis. J Emerg Med 2019; 57:550-553. [PMID: 31591072 DOI: 10.1016/j.jemermed.2019.03.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 03/12/2019] [Accepted: 03/27/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Diagnosis of acute osteomyelitis in young children can be challenging due to the lack of specific clinical signs and symptoms. Prompt diagnosis and treatment is essential to prevent complications and to improve long-term prognosis and reduce the need for operative intervention. Point-of-care ultrasound (POCUS) may be a useful tool to detect early changes associated with osteomyelitis. CASE REPORT A 26-month-old boy presented with 6 days of fever and 3 days of focal pain over the right anterior lower ribs without swelling, erythema, or bony deformity, and negative chest x-ray study. A POCUS was performed by the ultrasound fellows and revealed deep soft tissue swelling, periosteal elevation, and increased vascular flow with color Doppler. The patient was admitted to the pediatric service with infectious disease consultation and started on antibiotics. Magnetic resonance imaging confirmed the diagnosis of a right seventh anterior rib osteomyelitis, and the patient subsequently improved and was discharged home. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In this case, the use of POCUS in the emergency department heightened the suspicion for acute osteomyelitis in a rare location and guided early diagnosis and treatment.
Collapse
Affiliation(s)
- Jessica Schleifer
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Andrew S Liteplo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Sigmund Kharasch
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
10
|
Ruest SM, Stephan AM, Masiakos PT, Biddinger PD, Camargo CA, Kharasch S. Substance use patterns and in-hospital care of adolescents and young adults attending music concerts. Addict Sci Clin Pract 2018; 13:1. [PMID: 29370875 PMCID: PMC5784532 DOI: 10.1186/s13722-017-0105-x] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 12/15/2017] [Indexed: 11/16/2022] Open
Abstract
Background Few studies describe medical complaints and substance use patterns related to attending music concerts. As such, the objective of this study is to describe patient demographics, substance use and intoxication patterns, and medical interventions provided to adolescents and young adults assessed in an emergency department (ED) for complaints directly related to concert attendance. Methods A retrospective chart review of patients 13–30 years old who were transported to the ED directly from music concerts between January 2011 and December 2015 was conducted. Descriptive statistics and logistic regression were used to analyze patient demographic, intervention, and substance use data. Results There were 115 concerts identified, of which 48 (42%) were linked to 142 relevant ED visits; the total number of attendees at each concert is unknown. The mean age of the 142 described patients was 19.5 years (SD 3.3) with 72% < 21 and 33% < 18; 71% of patients were female and 96% of visits were substance-use related. Mean blood alcohol level was 242 mg/dL (range 104–412, SD 70). Glasgow Coma Scale (GCS) scores ranged from 3 to 15, with a mean of 14. Two patients required intubation and 61% of patients received interventions, including medications (47%), intravenous fluids (46%), specialty consultation (20%), restraints (14%), imaging (6%), and laceration repair (3%). Attendance at pop and electronic dance music concerts was associated with the widest ranges of GCS scores (8–15 and 6–14 respectively), mass casualty incident declarations, and among the highest mean blood alcohol levels (246 and 244 mg/dL, respectively). Conclusions Substance use is the predominant reason for music concert related ED visits and patients may have serious levels of intoxication, receiving multiple medical interventions. These data demonstrate the need for additional large-scale studies to confirm trends and increase awareness of this important public health problem.
Collapse
Affiliation(s)
- Stephanie M Ruest
- Section of Pediatric Emergency Medicine, Hasbro Children's Hospital, Alpert Medical School of Brown University, 593 Eddy St, Claverick 2, Providence, RI, 02903, USA.
| | - Alexander M Stephan
- Department of Pediatrics, Massachusetts General Hospital for Children, Harvard Medical School, 55 Fruit St, Boston, MA, 02114, USA
| | - Peter T Masiakos
- Division of Pediatric Surgery, Massachusetts General Hospital for Children, Harvard Medical School, 55 Fruit St, Boston, MA, 02114, USA
| | - Paul D Biddinger
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, 02114, USA
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, 02114, USA
| | - Sigmund Kharasch
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, 02114, USA
| |
Collapse
|
11
|
Gardner K, Kharasch S, Raja A, Balza R, Bhatia K, Miller ES. Back Pain in a Healthy Teenager. J Emerg Med 2017; 53:907-911. [PMID: 28684061 DOI: 10.1016/j.jemermed.2017.04.034] [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] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 04/25/2017] [Indexed: 06/07/2023]
Affiliation(s)
- Kelly Gardner
- Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Sigmund Kharasch
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Ali Raja
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Rene Balza
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts; Department of Radiology, Harvard Medical School, Boston, Massachusetts
| | - Kriti Bhatia
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Emily S Miller
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
12
|
|
13
|
Longacre M, Kharasch S, Liteplo A. Letter to the Editor regarding recent American Journal of Emergency Medicine article in press: "Point of care lung ultrasound of children with acute asthma exacerbations in the pediatric emergency department" by Dankoff et al. Am J Emerg Med 2017; 35:1575-1576. [PMID: 28457764 DOI: 10.1016/j.ajem.2017.04.046] [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] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 04/19/2017] [Indexed: 10/19/2022] Open
Affiliation(s)
| | - Sigmund Kharasch
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine and Emergency Ultrasound, Massachusetts General Hospital, Boston, MA, United States
| | - Andrew Liteplo
- Department of Emergency Medicine, Division of Emergency Ultrasound, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| |
Collapse
|
14
|
Armstrong-Javors A, Pratt J, Kharasch S. Wernicke Encephalopathy in Adolescents After Bariatric Surgery: Case Report and Review. Pediatrics 2016; 138:peds.2016-1039. [PMID: 27940680 DOI: 10.1542/peds.2016-1039] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [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: 08/26/2016] [Indexed: 11/24/2022] Open
Abstract
Roughly 1% of all weight loss surgery is performed in adolescents. There is strong evidence demonstrating significant postsurgical weight loss, improvement in quality of life, and reduction in comorbidities such as hypertension and diabetes. Reports of postoperative complications in adolescents are few because of the small sample size in most series. Despite vitamin supplementation, nutritional deficiencies requiring hospitalization occur occasionally after Roux-en-Y gastric bypass. Wernicke encephalopathy, a triad of ophthalmoplegia, ataxia, and altered mental status, is a serious consequence of thiamine (vitamin B1) deficiency. Few cases of Wernicke encephalopathy after weight loss surgery have been reported in the literature and even fewer in the pediatric population. Here we describe a teenage girl who develops vomiting after Roux-en-Y gastric bypass and presented with nystagmus, irritability, and ataxia. The clinical presentation, diagnosis, and treatment of Wernicke encephalopathy in adolescents after bariatric surgery are discussed.
Collapse
Affiliation(s)
| | | | - Sigmund Kharasch
- Division of Pediatric Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
15
|
Breuer O, Blich O, Cohen-Cymberknoh M, Averbuch D, Kharasch S, Shoseyov D, Kerem E. Antibiotic treatment for children hospitalized with community-acquired pneumonia after oral therapy. Pediatr Pulmonol 2015; 50:495-502. [PMID: 25652187 DOI: 10.1002/ppul.23159] [Citation(s) in RCA: 9] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 12/26/2014] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To compare the outcome of treatment with narrow spectrum versus broad spectrum antibiotics in children hospitalized with community-acquired pneumonia (CAP) who received oral antibiotic treatment prior to their hospitalization. DESIGN, SETTING, AND PATIENTS A review of all previously healthy children from 3 months to 18 years with non-complicated CAP who received an oral antibiotic course in the community and were admitted from 2003 to 2008 to our pediatric departments. MAIN OUTCOME MEASURES Clinical course and outcome parameters were compared for treatment with narrow and broad spectrum antibiotics. RESULTS Of the 337 children admitted with non-complicated CAP after an oral antibiotic treatment course in the community, 235 were treated with broad spectrum, and 102 with narrow spectrum antibiotics. The two groups were similar regarding age, sex, days of fever prior to admission, type of preadmission oral antibiotic treatment, and laboratory indices at admission (P > 0.1). The broad spectrum-treated group had significantly better outcomes in terms of number of febrile days (1.2 ± 1.1 vs. 1.7 ± 1.6, P < 0.001), number of days treated with intravenous antibiotics (3.1 ± 1.3 vs. 3.9 ± 2.0, P < 0.001), and days of hospitalization (3.5 ± 1.5 vs. 4.2 ± 2.0, P < 0.001). The odds ratio for remaining hospitalized at 72 hr and 7 days was significantly higher for the narrow spectrum group (2.0 and 5.5 respectively, P < 0.05). CONCLUSIONS In previously healthy children hospitalized with CAP after oral antibiotic treatment in the community treatment with broad spectrum antibiotics showed better outcome. Prospective studies are needed for appropriate recommendation.
Collapse
Affiliation(s)
- Oded Breuer
- Pediatric Pulmonology, Departments of Pediatrics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | | | | | | | | | | | | |
Collapse
|
16
|
Dinur-Schejter Y, Kharasch S, Kerem E. Reply: To PMID 22431471. Pediatr Pulmonol 2013; 48:410. [PMID: 22782657 DOI: 10.1002/ppul.22611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2012] [Indexed: 11/10/2022]
|
17
|
Dinur-Schejter Y, Cohen-Cymberknoh M, Tenenbaum A, Brooks R, Averbuch D, Kharasch S, Kerem E. Antibiotic treatment of children with community-acquired pneumonia: comparison of penicillin or ampicillin versus cefuroxime. Pediatr Pulmonol 2013; 48:52-8. [PMID: 22431471 DOI: 10.1002/ppul.22534] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2011] [Accepted: 01/24/2012] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Adherence to current guidelines for treatment of non-complicated community-acquired pneumonia (CAP) in children, recommending penicillin or ampicillin as first-line treatment, has been poor. Our objective was to examine whether cefuroxime confers an advantage over penicillin or ampicillin for the treatment of children hospitalized with non-complicated CAP. PATIENTS AND METHODS All children aged 3 months to 2 years with non-complicated CAP treated with penicillin or ampicillin or cefuroxime, admitted during 2003-2008, in the Departments of Pediatrics, Hadassah University Medical Center were included. Presenting signs, symptoms, laboratory findings at presentation, clinical parameters including number of days with IV antibiotics, oxygen treatment, length of hospital stay, change of antibiotics, and clinical course 72 hr and 1 week after admission, were compared. RESULTS Of the 319 children admitted for non-complicated CAP, 66 were treated with IV penicillin or ampicillin, 253 with IV cefuroxime. Number of days of IV treatment, days of oxygen requirement, and days of hospitalization were similar (2.36 ± 1.6 days vs. 2.59 ± 1.6 days, 0.31 ± 1.2 days vs. 0.64 ± 1.3 days, and 2.67 ± 1.4 days vs. 2.96 ± 1.7 days, respectively). Treatment failure was not significantly different (7.6% vs. 4.7%). The number of patients who were febrile or required oxygen 72 hr after admission was similar (13.0% vs. 16.5% and 8.7% vs. 20.9%, respectively). One week after admission no difference between the two groups was seen. CONCLUSIONS In previously healthy children, parenteral penicillin or ampicillin for treatment of non-complicated CAP in-hospital is as effective as cefuroxime, and should remain the recommended first-line therapy.
Collapse
Affiliation(s)
- Yael Dinur-Schejter
- Departments of Pediatrics, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | | | | | | | | | | | | |
Collapse
|
18
|
Eisenstein EM, Ben-Yehuda Y, Shemesh N, Kharasch S. Investigation of unexplained infant deaths in Israel: time for a different approach. Isr Med Assoc J 2012; 14:695-699. [PMID: 23240378] [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] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Eli M Eisenstein
- Department of Pediatrics, Hadassah-Hebrew University Medical Center, Mount Scopus Campus, Jerusalem, Israel.
| | | | | | | |
Collapse
|
19
|
Mehta SD, Hall J, Lyss SB, Skolnik PR, Pealer LN, Kharasch S. Adult and pediatric emergency department sexually transmitted disease and HIV screening: programmatic overview and outcomes. Acad Emerg Med 2007; 14:250-8. [PMID: 17331918 DOI: 10.1197/j.aem.2006.10.106] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVES To measure the prevalence of gonorrhea, chlamydia, and human immunodeficiency virus (HIV) infection among emergency department (ED) patients who accept screening, and to assess treatment outcomes and risks for infection. METHODS Research staff offered voluntary testing for gonorrhea and chlamydia (by urine transcription-mediated amplification) and HIV (by enzyme immunoassay/Western blot of oral mucosal transudate) to ED patients. Pediatric (15-21 years) and adult (22-29 years) patients were eligible for gonorrhea and chlamydia testing; patients aged 15-54 years were eligible for HIV testing. The authors surveyed behavioral risks of patients accepting HIV testing. RESULTS From November 2003 to May 2004, 497 of 791 eligible pediatric patients (63%) and 1,000 of 2,180 eligible adult patients (46%) accepted screening for gonorrhea, chlamydia, and/or HIV. There were 41 patients infected with gonorrhea, chlamydia, or both among 380 pediatric patients (10.8%) and 11 of 233 adult patients (4.7%); 14 of 52 patients (27%) were treated presumptively by ED clinicians. Through study efforts, 33 of the 38 remaining patients were treated (90% overall treatment). Eight HIV infections were diagnosed: seven of 969 adult patients (0.7%) and one of 459 pediatric patients (0.2%); five HIV-infected patients (63%) received test results, and three (38%) attended an HIV clinic. Gonorrhea or chlamydia infection in pediatric patients was associated with multiple sex partners, same-sex intercourse, and suspicion of sexually transmitted diseases by the ED clinician. CONCLUSIONS The high prevalence of gonorrhea and/or chlamydia infection among pediatric ED patients tested supports consideration of expanded screening. Targeted HIV screening with rapid tests merits exploration in the authors' ED, given the low-moderate numbers of patients identified through screening, receiving test results, and linked to care.
Collapse
Affiliation(s)
- Supriya D Mehta
- Department of Epidemiology and Biostatistics, University of Chicago, Chicago, IL, USA.
| | | | | | | | | | | |
Collapse
|
20
|
Mehta SD, Hall J, Lyss SB, Skolnik PR, Pealer LN, Kharasch S. Adult and pediatric emergency department sexually transmitted disease and HIV screening: programmatic overview and outcomes. Acad Emerg Med 2007; 14:250-258. [PMID: 17331918 DOI: 10.1111/j.1553-2712.2007.tb01782.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVES To measure the prevalence of gonorrhea, chlamydia, and human immunodeficiency virus (HIV) infection among emergency department (ED) patients who accept screening, and to assess treatment outcomes and risks for infection. METHODS Research staff offered voluntary testing for gonorrhea and chlamydia (by urine transcription-mediated amplification) and HIV (by enzyme immunoassay/Western blot of oral mucosal transudate) to ED patients. Pediatric (15-21 years) and adult (22-29 years) patients were eligible for gonorrhea and chlamydia testing; patients aged 15-54 years were eligible for HIV testing. The authors surveyed behavioral risks of patients accepting HIV testing. RESULTS From November 2003 to May 2004, 497 of 791 eligible pediatric patients (63%) and 1,000 of 2,180 eligible adult patients (46%) accepted screening for gonorrhea, chlamydia, and/or HIV. There were 41 patients infected with gonorrhea, chlamydia, or both among 380 pediatric patients (10.8%) and 11 of 233 adult patients (4.7%); 14 of 52 patients (27%) were treated presumptively by ED clinicians. Through study efforts, 33 of the 38 remaining patients were treated (90% overall treatment). Eight HIV infections were diagnosed: seven of 969 adult patients (0.7%) and one of 459 pediatric patients (0.2%); five HIV-infected patients (63%) received test results, and three (38%) attended an HIV clinic. Gonorrhea or chlamydia infection in pediatric patients was associated with multiple sex partners, same-sex intercourse, and suspicion of sexually transmitted diseases by the ED clinician. CONCLUSIONS The high prevalence of gonorrhea and/or chlamydia infection among pediatric ED patients tested supports consideration of expanded screening. Targeted HIV screening with rapid tests merits exploration in the authors' ED, given the low-moderate numbers of patients identified through screening, receiving test results, and linked to care.
Collapse
Affiliation(s)
- Supriya D Mehta
- Department of Epidemiology and Biostatistics, University of Chicago, Chicago, IL, USA.
| | | | | | | | | | | |
Collapse
|
21
|
Affiliation(s)
- Sigmund Kharasch
- Department of Pediatrics, Boston Medical Center, Boston University School of Medicine, 91 E Concord St, Sixth Floor, Boston, MA 02118, USA.
| | | | | |
Collapse
|
22
|
Sege RD, Kharasch S, Perron C, Supran S, O'Malley P, Li W, Stone D. Pediatric violence-related injuries in Boston: results of a city-wide emergency department surveillance program. Arch Pediatr Adolesc Med 2002; 156:73-6. [PMID: 11772194 DOI: 10.1001/archpedi.156.1.73] [Citation(s) in RCA: 22] [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] [Indexed: 11/14/2022]
Abstract
CONTEXT Violence-related injuries among children are common, but age-based incidence data are not easily available. OBJECTIVES To describe injuries due to violence in a population-based case series of children and to estimate injury incidence. DESIGN Prospective surveillance of children residing in Boston, Mass, who received pediatric emergency department treatment for violence-related injury during a 4-year period beginning April 15, 1995. SETTING Pediatric emergency departments in Boston. PATIENTS Children aged 3 through 18 years who came to a hospital emergency department between April 1995 and April 1999. Violence-related injuries were defined as those resulting from a situation of conflict involving 2 or more persons with intent to harm, as assessed by health care personnel caring for the patients. Self-inflicted injuries and injuries caused by child abuse (including any injury resulting from a conflict with a parent or guardian) were excluded. Homicides of Boston children aged 3 through 18 years who were killed during the study period were included based on police data. MAIN OUTCOME MEASURE Population-based violence-related injury rates. RESULTS There were 2035 injury-related visits caused by violence, which reflects a rate of 52.7 (95% confidence interval, 50.5-54.9) per 10 000 person-years. Most injuries were relatively minor; 6.4% of visits resulted in admission. The youth violence-related injury rate in Boston declined at an average rate of 12% annually during the period studied. CONCLUSION Pediatric emergency department monitoring of violence-related injury in Boston suggests that childhood injuries due to violence declined during the late 1990s.
Collapse
Affiliation(s)
- Robert D Sege
- Pediatric and Adolescent Health Research Center, the Floating Hospital for Children's National Medical Center, New England Medical Center, Boston, MA, USA.
| | | | | | | | | | | | | |
Collapse
|
23
|
Babl FE, Cooper ER, Kastner B, Kharasch S. Prophylaxis against possible human immunodeficiency virus exposure after nonoccupational needlestick injuries or sexual assaults in children and adolescents. Arch Pediatr Adolesc Med 2001; 155:680-2. [PMID: 11386957 DOI: 10.1001/archpedi.155.6.680] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Nonoccupational human immunodeficiency virus (HIV) postexposure prophylaxis (PEP) for adults has been described, although the Centers for Disease Control and Prevention, Atlanta, Ga, offer no specific recommendations. There is limited information about its use in children and adolescents. OBJECTIVE To describe the current practices of physicians in pediatric infectious disease (PID) and pediatric emergency medicine (PEM) departments regarding nonoccupational HIV PEP for children and adolescents. DESIGN Survey. PARTICIPANTS Directors of all PID and PEM departments with fellowship programs in the United States and Canada between July and November 1998. MAIN OUTCOME MEASURES General questions regarding HIV PEP and questions concerning 2 scenarios (5-year-old with a needlestick injury and a 15-year-old after sexual assault). RESULTS The return rate was 67 (78%) of 86 for PID and 36 (75%) of 48 for PEM physicians. Fewer than 20% of physicians reported institutional policies for nonoccupational HIV PEP; 33% had ever initiated nonoccupational HIV PEP. In both scenarios, PID physicians were more likely than PEM physicians to recommend or offer HIV PEP in the first 24 hours after the incident (55 [83%] of 66 vs 20 [56%] of 36 for needlestick injuries [odds ratio, 4.0; 95% confidence interval, 1.6-10.1] and 47 [72%] of 65 vs 16 [50%] of 32 for sexual assault [odds ratio, 2.6; 95% confidence interval, 1.1-6.3]). Seven different antiretroviral agents in single, dual, or triple drug regimens administered for 2 to 12 weeks were suggested. CONCLUSIONS Although few physicians reported institutional policies, and only one third had ever initiated HIV PEP, many would offer or recommend HIV PEP for children and adolescents within 24 hours after possible HIV exposure. A wide variation of regimens have been suggested. There is a need for a national consensus for nonoccupational HIV PEP.
Collapse
Affiliation(s)
- F E Babl
- Division of Pediatric Infectious Diseases, Finland 5, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA 02118, USA.
| | | | | | | |
Collapse
|
24
|
Abstract
HIV postexposure prophylaxis (PEP) is now a well-established part of the management of health care workers after occupational exposures to HIV. Use of PEP for adults exposed to HIV after sexual contact or injection drug use in nonoccupational settings remains controversial with limited data available. There is even less information available concerning HIV PEP for children and adolescents after accidental needlestick injuries or sexual assault. The objective was to describe the current practice of and associated problems with HIV PEP for children and adolescents at an urban academic pediatric emergency department. A retrospective review of all children and adolescents offered HIV PEP between June 1997-June 1998 was conducted. Ten pediatric and adolescent patients were offered HIV PEP, six patients after sexual assault, four patients after needle stick injuries. There were two small children 2 and 3 years of age and eight adolescents. Of these 10 patients, eight were started on HIV PEP. The regimens used for PEP varied; zidovudine, lamivudine, and indinavir were prescribed for in seven patients and zidovudine, lamivudine, and nelfinavir for one other. All 10 patients were HIV negative by serology at baseline testing and all available for follow-up testing (5 of 10) remained HIV negative at 4 to 28 weeks. Only two patients completed the full course of 4 weeks of antiretroviral therapy. Financial concerns, side effects, additional psychiatric and substance abuse issues as well as the degree of parental involvement influenced whether PEP and clinical follow-up was completed. HIV PEP in the nonoccupational setting for children and adolescents presents a medical and management challenge, and requires a coordinated effort at the initial presentation to the health care system and at follow-up. The difficulties encountered in the patients in our series need to be considered before initiating prophylaxis. A provisional management approach to HIV PEP in children and adolescents is proposed.
Collapse
Affiliation(s)
- F E Babl
- Division of Pediatric Emergency Medicine, Boston University School of Medicine, Boston Medical Center, MA 02118, USA.
| | | | | | | | | | | |
Collapse
|
25
|
Kharasch S, Vinci R, Reece R. Esophagitis, epiglottitis, and cocaine alkaloid ("crack"): "accidental" poisoning or child abuse? Pediatrics 1990; 86:117-9. [PMID: 2359667] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- S Kharasch
- Dept of Pediatrics, Boston City Hospital, MA
| | | | | |
Collapse
|