Alan L. Nager

Pediatric myocarditis: presenting clinical characteristics

OBJECTIVE The objective of the study was to characterize the clinical profiles of pediatric patients with acute myocarditis and dilated cardiomyopathy (DCM) before diagnosis. METHODS A retrospective cross-sectional study was conducted to identify patients with myocarditis and DCM who presented over a 10-year span at 2 tertiary care pediatric hospitals. Patients were identified based on the International Classification of Diseases, Ninth Revision, diagnostic codes. RESULTS A total of 693 charts were reviewed. Sixty-two patients were enrolled in the study. Twenty-four (39%) patients had a final diagnosis of myocarditis, and 38 (61%) had DCM. Of the 62 patients initially evaluated, 10 were diagnosed with myocarditis or DCM immediately, leaving 52 patients who required subsequent evaluation before a diagnosis was determined. Study patients had a mean age of 3.5 years, 47% were male, and 53% were female. Common primary complaints were shortness of breath, vomiting, poor feeding, upper respiratory infection (URI), and fever. Common examination findings were tachypnea, hepatomegaly, respiratory distress, fever, and abnormal lung examination result. Sixty-three percent had cardiomegaly on chest x-ray, and all had an abnormal electrocardiogram results. CONCLUSIONS These data suggest children with acute myocarditis and DCM most commonly present with difficulty breathing. Myocarditis and DCM may mimic other respiratory or viral illnesses, but hepatomegaly or the finding of cardiomegaly and an abnormal electrocardiogram result may help distinguish these diagnoses from other more common pediatric illnesses.

Diagnosing pediatric appendicitis: usefulness of laboratory markers

OBJECTIVE This study aimed to evaluate the utility of C-reactive protein (CRP), procalcitonin (PCT), D-lactate, and white blood cell (WBC) count as an aid to distinguish appendicitis from other diagnoses. METHODS This prospective, observational study was conducted at an urban tertiary academic pediatric emergency department (ED). Subjects aged 1 to 18 years presenting with abdominal pain suspicious for acute appendicitis were enrolled. Data included history, physical examination, laboratory data (complete blood count, CRP, D-lactate, PCT [semiquantitative]), laboratory results, x-rays, surgical consultation notes, histopathology, and admission data. Stepwise logistic regression analysis was performed to identify independent risk factors. RESULTS Two hundred nine subjects (59% male, 41% female) were enrolled over 6 months. One hundred fifteen subjects were histologically diagnosed with appendicitis; 94 subjects did not have appendicitis and were used as controls. Mean values of WBC, CRP, PCT, and absolute neutrophil count in subjects with definitive appendicitis were significantly higher than in subjects with no definitive appendicitis. D-Lactate levels were noncorrelative. Significant independent risk factors identified for definitive appendicitis included WBC count more than 12 cells × 1000/mm(3) (adjusted odds ratio [AOR], 6.54), CRP level greater than 3 mg/dL (AOR, 3.44), presence of hopping pain (AOR, 2.69), and presence of pain with walking (AOR, 2.56). Odds ratio for definitive appendicitis and its 95% confidence interval was found to be 7.75 for subjects with both WBC more than 12 cells × 1000/mm(3) and CRP greater than 3 mg/dL. CONCLUSIONS C-reactive protein with WBC is useful in distinguishing appendicitis from other diagnoses in pediatric subjects presenting to the ED. White blood cell count greater than >12 cells × 1000/mm(3) and CRP greater than 3 mg/dL increases the likelihood of appendicitis. D-Lactate is not a useful laboratory adjunct.

Urine specific gravity and other urinary indices: Inaccurate tests for dehydration

Objective: Urine output, specific gravity, and ketones (urinary indices) are commonly used as an objective means to assess for dehydration and gastroenteritis severity; however, their utility has not been established. The study was designed to evaluate the accuracy of urinary indices as diagnostic tests to identify acute dehydration. Methods: We completed a prospective cohort study in the Emergency Department of an urban pediatric hospital. Seventy-nine subjects ages 3 months to 36 months with gastroenteritis, clinically suspected moderate dehydration, and the need for intravenous rehydration were enrolled in the trial. Urine specific gravity and urine ketone levels were determined with bedside calorimetric (dipstick) testing, and urine output during rehydration and observation was measured by commonly used techniques. An internally validated, weight-based criterion standard for the percent dehydration on enrollment was used to identify the cohort of dehydrated subjects. Correlation statistics were calculated for urine output, specific gravity, and ketones. In addition, multilevel tables were created to determine the sensitivity, specificity, and likelihood ratio at varying test cutoff values to detect 3% and 5% dehydration. Results: Urine specific gravity (r = −0.06, P = 0.64), urine ketones (r = 0.08, P = 0.52), and urine output during rehydration (r = 0.01, P = 0.96) did not correlate with the initial degree of dehydration present. Clinically useful cutoff values for urine specific gravity and ketones to increase or decrease the likelihood of dehydration at the time of enrollment could not be identified. Conclusions: Urinary indices are not useful diagnostic tests to identify the presence of dehydration during the initial assessment of children with gastroenteritis.

The Utility of Safety Counseling in a Pediatric Emergency Department

Objective. Pediatric injuries have a significant impact on the medical system, costing lives and disabling many survivors. Although injury-prevention measures do exist, they are underutilized. A majority of families do not consistently receive counseling by a primary care provider (PCP). We attempted to demonstrate the efficacy of counseling families who presented to a pediatric emergency department with unrelated medical complaints. Methods. A self-report questionnaire was administered to assess the home safety of patients 2 weeks to 12 years old presenting to the emergency department. Targeted counseling on areas noted to be unsafe was provided, and a 2-week follow-up telephone call was made to assess the effectiveness of the counseling. Information on previous counseling by a PCP was also collected and analyzed. Logistic regression was performed to determine significance and calculate odds ratios. Results. Thirty-seven percent of caregivers recalled receiving any counseling at a PCP visit. Caregivers who had received prior counseling by a PCP were significantly more likely to have a safe home environment. Patients who were English speaking were significantly more likely to have received safety counseling than their Spanish-speaking counterparts. One hundred fifty families received counseling in the emergency department, and 117 were eligible for follow-up. Of these families, 39% made a positive change in the safety of their childs environment at the 2-week telephone follow-up. Conclusions. Caregivers receiving counseling by a PCP are more likely to provide a safe home environment for their children. Spanish-speaking patients are at particularly high risk of not receiving counseling. Of caregivers reporting unsafe practices during an unrelated emergency-department encounter, targeted counseling made a positive impact on behavior after discharge.

Using robotic telecommunications to triage pediatric disaster victims

PURPOSE During a disaster, hospitals may be overwhelmed and have an insufficient number of pediatric specialists available to care for injured children. The aim of this study was to determine the feasibility of remotely providing pediatric expertise via a robot to treat pediatric victims. METHODS In 2008, Los Angeles County held 2 drills involving telemedicine. The first was the Tri-Hospital drill in which 3 Los Angeles County hospitals, one being a pediatric hospital, participated. The disaster scenario involved a Metrolink train crash, resulting in a large surge of traumatic injuries. The second drill involved multiple agencies and was called the Great California Shakeout, a simulated earthquake exercise. The telemedicine equipment installed is an InTouch Health, Inc, Santa Barbara, CA robotic telecommunications system. We used mixed-methods to evaluate the use of telemedicine during these drills. RESULTS Pediatric specialists successfully provided remote triage and treatment consults of victims via the robot. The robot proved to be a useful means to extend resources and provide expert consult if pediatric specialists were unable to physically be at the site. CONCLUSION Telemedicine can be used in the delayed treatment areas as well as for training first receivers to collaborate with specialists in remote locations to triage and treat seriously injured pediatric victims.

Emergency department surge: models and practical implications

BACKGROUND Emergency Department crowding has long been described. Despite the daily challenges of managing emergency department volume and acuity; a surge response during a disaster entails even greater challenges including collaboration, intervention, and resourcefulness to effectively carry out pediatric disaster management. Understanding surge and how to respond with appropriate planning will lead to success. To achieve this, we sought to analyze models of surge; review regional and national data outlining surge challenges and factors that impact surge; and to outline potential solutions. METHODS We conducted a systemic review and included articles and documents that best described the theoretical and practical basis of surge response. We organized the systematic review according to the following questions: What are the elements and models that are delineated by the concept of surge? What is the basis for surge response based on regional and national published sources? What are the broad global solutions? What are the major lessons observed that will impact effective surge capacity? RESULTS Multiple models of surge are described including public health, facility-based and community-based; a 6-tiered response system; and intrinsic or extrinsic surge capacity. In addition, essential components (4 Ss of surge response) are described along with regional and national data outlining surge challenges, impacting factors, global solutions, and lesions observed. CONCLUSIONS There are numerous shortcomings regionally and nationally affecting our ability to provide an effective and coordinated surge response. Planning, education, and training will lead to an effective pediatric disaster management response.

Dehydration treatment practices among pediatrics-trained and non-pediatrics trained emergency physicians.

Objectives We sought to survey emergency physicians in the United States regarding the management of pediatric dehydration secondary to acute gastroenteritis. We hypothesized that responses from physicians with dedicated pediatric training (PT), that is, board certification in pediatrics or pediatric emergency medicine, would differ from responses of physicians with no dedicated pediatric training (non-PT). Methods An anonymous survey was mailed to randomly selected members of the American College of Emergency Physicians and sent electronically to enrollees of Brown University pediatric emergency medicine listserv. The survey consisted of 17 multiple-choice questions based on a clinical scenario depicting a 2-year-old with acute gastroenteritis and moderate dehydration. Questions asked related to treatment preferences, practice setting, and training information. Results One thousand sixty-nine surveys were received: 997 surveys were used for data analysis, including 269 PT physicians and 721 non-PT physicians. Seventy-nine percent of PT physicians correctly classified the scenario patient as moderately dehydrated versus 71% of non-PT physicians (P = 0.063). Among those who correctly classified the patient, 121 PT physicians (58%) and 350 non-PT physicians (68%) would initially hydrate the patient with intravenous fluids. Pediatrics-trained physicians were more likely to initially choose oral or nasogastric hydration compared with non-PT physicians (P = 0.0127). Pediatrics-trained physicians were less likely to perform laboratory testing compared with the non-PT group (n = 92, 45%, vs n = 337, 66%; P < 0.0001). Conclusions Contrary to established recommendations for the management of moderately dehydrated children, significantly more PT physicians, compared with non-PT physicians, follow established guidelines.

Pediatric Advance Directives: Parents’ Knowledge, Experience, and Preferences

OBJECTIVES: To explore parents’ and caregivers’ experience, knowledge, and preferences regarding advance directives (ADs) for children who have chronic illness. METHODS: We conducted a prospective, cross-sectional survey of parents and caregivers of children who have chronic illness. During ambulatory medical visits, participants were asked about previous AD experience and knowledge, future preferences regarding AD discussions, their child’s past and current health status, and family demographics. RESULTS: Among 307 participants surveyed, previous AD experience was low, with 117 (38.1%) having heard of an AD, 54 (17.6%) having discussed one, and 77 (25.1%) having known someone who had an AD. Furthermore, 27 (8.8%) participants had an AD or living will of their own, and 8 (2.6%) reported that their chronically ill child had an AD. Previous AD knowledge was significantly more likely among parents and caregivers who had a college degree than those who did not have a high school diploma, yet significantly less likely among primarily Spanish-speaking parents and caregivers than those primarily English-speaking. Interest in creating an AD for the child was reported by 151 (49.2%) participants, and was significantly more likely among families who had more frequent emergency department visits over the previous year. CONCLUSIONS: The limited AD experience and knowledge of parents and caregivers of children who have chronic illness and their interest in creating an AD suggest an unmet need among families of children who have chronic illness, and an opportunity to enhance communication between families and medical teams regarding ADs and end-of-life care.

Pediatric fingertip injuries: do prophylactic antibiotics alter infection rates?

Study objective: Fingertip injuries are common in the pediatric population. Considerable controversy exists as to whether prophylactic antibiotics are necessary after repair of these injuries. Our goal was to compare the rate of bacterial infections among subgroups treated with and without prophylactic antibiotics. The study hypothesis was that infection rates were similar in the 2 groups. Methods: This was a prospective randomized control trial of pediatric patients presenting to an urban childrens hospital with trauma to the distal fingertip, requiring repair. Patients were randomized to 2 groups: group 1 received no antibiotics, and group 2 received antibiotics (cephalexin). Repairs were performed in a standardized fashion, and all patients were reevaluated in the same emergency department in 48 hours and again by phone 7 days after repair. The primary outcome measure was the rate of infection at 7 days after repair. Results: One hundred forty-six patients were initially enrolled in the study, 11 patients were withdrawn before study completion, 69 subjects were randomized to the no-antibiotic group, and 66 subjects were randomized to the antibiotic group. There was 1 infection in each group at 7 days after repair. The infection rate was 1.45% (95% confidence interval, 0.04%-7.81%) for the no-antibiotic group and was 1.52% (95% confidence interval, 0.04%-8.16%) for the antibiotic group, not statistically significant (P = 1.00). Conclusions: This study suggests that routine prophylactic antibiotics do not reduce the rate of infection after repair of distal fingertip injuries.

An upsurge in pertussis: epidemiology and trends.

Objective The objective of the study was to review the 2010 pertussis upsurge occurring within California and recent experiences at a large tertiary care children’s hospital within California. Methods A retrospective review of all specimens submitted for Bordetella pertussis polymerase chain reaction assay from the emergency department at a large tertiary care children’s hospital from January 2009 to August 2010. Outcome measures were the number of specimens submitted, the number of positive specimens, and the percentage of positive specimens. Results The last peak incidence of pertussis, in the Unite States, was seen in 2005 with an annual incidence of 25,616 reported cases. Comparing 2010 with 2009 during the same period, the total number of positive cases increased from 13 to 94, a 723% increase at our institution. The median monthly number of positive specimen was 1.5 for 2009 and 6.5 for 2010 (P = 0.0169). Conclusions Hospitals, private practitioners, and the California Department of Public Health need to emphasize prompt diagnosis and treatment of this contagious infection to limit the spread to susceptible individuals. A more widespread safe and effective vaccination program will hopefully enhance protection against pertussis infection.