Ara Festekjian

Incidence and predictors of invasive candidiasis associated with candidaemia in children

Risk factors for invasive candidiasis in children with candidaemia are poorly defined. We performed a retrospective cohort study of all children with candidaemia at our tertiary children’s hospital from 2000 to 2006. Invasive candidiasis was diagnosed by review of the medical record and standardised EORTC/MSG criteria. A variety of risk factors for invasive candidiasis were explored. Of 194 episodes of candidaemia in the microbiology laboratory database, 180 clinical records were available. Evaluation for invasive candidiasis consisted of 174 (97%) echocardiograms, 167 (93%) dilated ophthalmological examinations, 136 (76%) chest CT scans and 108 (60%) abdominal ultrasounds (complete, hepatosplenic or renal). Of the 180 patients, 15 (8%) were identified with invasive candidiasis (4 proven, 1 probable, 10 possible). Prematurity <32 weeks (P < 0.01), an underlying immunocompromising disorder (P < 0.01), and ≥2 days of candidaemia (P = 0.05) were significantly associated with invasive candidiasis. Invasive candidiasis, especially proven or probable, in the setting of candidaemia was not common in our hospital, but premature infants and immunocompromised children were at significantly higher risk. Based on our findings, extensive imaging and examination by an ophthalmologist were particularly low‐yield for invasive candidiasis in immunocompetent children beyond infancy.

The Role of Morphine in a Rat Model of Hypoxic-ischemic Injury

We investigated whether morphine plays a neuroprotective role in a neonatal rat pup model of bilateral carotid artery occlusion with hypoxia. At postnatal day 10, rats received either morphine (n = 7), naloxone (n = 7), or saline placebo (n = 15) after hypoxic-ischemic injury. Survival (days), weight gain and animal testing (negative geotaxis, surface righting, and rotarod) were compared between treatment groups. Lesion volume was delineated with magnetic resonance imaging at days 7 and 28-57 after injury. Survival in rats treated with morphine, naloxone, or saline was, respectively, 14, 29, and 73%. Median number of days of survival after bilateral carotid artery occlusion with hypoxia treated with morphine was 4 (95% confidence interval 4 to 22), with naloxone was 3 (95% confidence interval -1.4 to 21), and with placebo was 28 (95% confidence interval 18 to 28). There were no statistically significant differences in magnetic resonance imaging-derived ischemic lesion volumes, weight gain, or behavioral testing measures between the groups. Morphine was ineffective as a neuroprotectant in rat pups with severe hypoxic-ischemic injury and may have contributed to their decreased survival.

Implementation of a Standardized Pediatric Emergency Medicine Transfer of Care Sign- out Guide: A Feasibility Study

This is a feasibility study to determine if a standardized transfer of care (TOC) sign-out guide for Pediatric Emergency Department (PED) patients improves resident satisfaction. Residents from various training programs (Emergency Medicine, Pediatrics, and Family Medicine) voluntarily reported their TOC sign-out satisfaction [100mm Visual Analog Scale (VAS)] and duration (minutes) preand post-implementation of a sign-out guide. Pre-intervention data collection occurred from September 2011 to January 2012, and post-intervention data collection occurred from February to May 2012. The guide included the following prompts: chief complaint, past medical history, history of present illness, admission reason, triage and final vital signs, pertinent positive and negative exam findings, and if applicable, medications, fluids, radiographic studies, consultant recommendations, and noted improvements (or lack of). A final section of the guide prompted the PED resident to ask if the receiving team had any questions. Resident satisfaction and TOC sign-out duration pre-and post-implementation of the sign-out guide were analyzed (n=292, 167 preand 125 post-implementation). Use of the sign-out guide improved resident satisfaction [Satisfaction (100mm VAS): Pre-implementation – 80 (95% Confidence Interval (CI) 70 – 83); Postimplementation – 95 (95% CI 87 – 99, p-value 0.02] without a statistically significant difference in sign-out duration [Duration: Pre-implementation – 5 minutes (95% CI 4.2 – 6.8); Post implementation – 5 minutes (95% CI 4.7– 5.8), p-value 0.3]. A standardized sign-out guide successfully allowed residents to convey important patient care information regarding TOC and improved resident satisfaction.

Novel Transfer of Care Sign-out Assessment Tool in a Pediatric Emergency Department

OBJECTIVE Transfer of care sign-outs (TOCS) for admissions from a pediatric emergency department have unique challenges. Standardized and reliable assessment tools for TOCS remain elusive. We describe the development, reliability, and validity of a TOCS assessment tool. METHODS Video recordings of resident TOCS were assessed to capture 4 domains: completeness, synopsis, foresight, and professionalism. In phase 1, 56 TOCS were used to modify the tool and improve reliability. In phase 2, 91 TOCS were used to examine validity. Analyses included Cronbachs alpha for internal structure, intraclass correlation and Cohens kappa for interrater reliability, Pearsons correlation for relationships between variables, and 95% confidence interval of the mean for resident group comparisons. RESULTS Cronbachs alpha was 0.52 for internal structure of the tools subjective rating scale. Intraclass correlation for the subjective rating scale items ranged from 0.70 to 0.80. Cohens kappa for most objective checklist items ranged from 0.43 to 1. Content completeness was significantly correlated with synopsis, foresight, and professionalism (Pearsons r ranged from 0.36 to 0.62, P values were <0.001). House staff senior residents scored higher (on average) than interns and rotating senior residents in synopsis and foresight. Also, house staff interns scored higher (on average) than rotating senior residents in professionalism. House staff senior residents scored higher (on average) than rotating senior residents in content completeness. CONCLUSIONS We provide validity evidence to support using scores from the TOCS tool to assess higher-level transfer of care comprehension and communication by pediatric emergency department residents and to test interventions to improve TOCS.

Clinical Predictors of Shigella and Campylobacter Infection in Children in the United States

Abstract Background Infectious gastroenteritis is a major cause of morbidity and mortality among children worldwide. While most episodes are self-limiting, for select pathogens such as Shigella and Campylobacter, etiological diagnosis may allow effective antimicrobial therapy and aid public health interventions. Unfortunately, clinical predictors of such pathogens are not well established and are based on small studies using bacterial culture for identification. Methods We used prospectively collected data from a multi-center study of pediatric gastroenteritis employing multi-pathogen molecular diagnostics to determine clinical predictors associated with 1) Shigella and 2) Shigella or Campylobacter infection. We used machine learning algorithms for clinical predictor identification, then performed logistic regression on features extracted plus pre-selected variables of interest. Results Of 993 children enrolled with acute diarrhea, we detected Shigella spp. in 56 (5.6%) and Campylobacter spp. in 24 (2.4%). Compared with children who had neither pathogen detected (of whom, >70% had ≥1 potential pathogen identified), bloody diarrhea (odds ratio 4.0), headache (OR 2.2), fever (OR 7.1), summer (OR 3.3), and sick contact with GI illness (OR 2.2), were positively associated with Shigella, and out-of-state travel (OR 0.3) and vomiting and/or nausea (OR 0.4) were negatively associated (Table). For Shigella or Campylobacter, predictors were similar but season was no longer significantly associated with infection. Conclusion These results can create prediction models and assist clinicians with identifying patients who would benefit from diagnostic testing and earlier antibiotic treatment. This may curtail unnecessary antibiotic use, and help to direct and target appropriate use of stool diagnostics. Disclosures A. Leber, BioFIre Diagnostics: Research Contractor and Scientific Advisor, Research support, Speaker honorarium and Travel expenses J. Daly, Biofire: Grant Investigator, Grant recipient R. Selvarangan, BioFire Diagnostics: Board Member and Investigator, Consulting fee and Research grant Luminex Diagnostics: Investigator, Research grant J. Dien Bard, BioFire: Consultant and Investigator, Research grant and Speaker honorarium K. Holmberg, BioFire Diagnostics: Employee, Salary K. Bourzac, BioFire Diagnostics: Employee, Salary K. C. Chapin, BioFire Diagnstics: Investigator, Research support A. Pavia, BioFire Diagnostics: Grant Investigator, Research grant

Radiologic discrepancies in children with special healthcare needs in a pediatric emergency department

Background: After‐hours radiologic interpretation by nonradiology attendings or resident radiologists introduces the risk of discrepancies. Clinical outcomes following radiologic discrepancies among pediatric emergency department (ED) patients are poorly described. In particular, children with special healthcare needs (CSHCN), have more opportunities for discrepancies and potential consequences than non‐ CSHCN. Our objective was to determine the rates and types of radiologic discrepancies, and to compare CSHCN to non‐CSHCN. Methods: From July 2014 to February 2015, all children who underwent a diagnostic imaging study at a free‐standing childrens ED were included. Data collected included radiologic studies ‐ type and location – and clinical details ‐ chief complaint and CSHCN type. Differences between preliminary reads and final pediatric radiology attending reads were defined as discrepancies, and categorized by clinical significance. Descriptive statistics, z‐tests, and chi‐square were used. Results: Over 8 months, 8310 visits (7462 unique patients) had radiologic studies (2620 CSHCN, 5690 non‐CSHCN). A total of 198 (2.4%) radiologic discrepancies [56 (28.3%) CSHCN, 142 (71.7%) non‐CSHCN] were found. Chief complaints for CSCHN were more often within the cardiac, pulmonary and neurologic systems (p < 0.001 for each), whereas non‐CSHCN presented with more trauma (p < 0.001). The rates of discrepancies (CSHCN 2.1%, non‐ CSHCN 2.5%, p = 0.3) and severity of clinical consequences (p = 0.6) were not significantly different between CSHCN and non‐CSHCN. Conclusion: Though the frequency and type of radiologic studies performed between CSHCN and non‐CSHCN were different, we found no significant difference in the rate of radiologic discrepancies or the rate of clinically significant radiologic discrepancies.

Point-of-Care Thoracic Ultrasonography in the Diagnosis and Management of Kaposiform Lymphangiomatosis

Abstract Kaposiform lymphangiomatosis is a generalized lymphatic disorder complicated by consumptive coagulopathy and pericardial and pleural effusions. We present the case of a 13-year-old female adolescent given a diagnosis of a large pleural effusion by point-of-care thoracic ultrasonography, which led to further evaluation and diagnosis of this rare disorder. We review the use of point-of-care thoracic ultrasonography for the diagnosis of pleural effusion.

Introducing Teamwork Challenges in Simulation Using Game Cards.

Summary Statement Poor teamwork and communication during resuscitations are linked to patient safety problems and poorer outcomes. We present a novel simulation-based educational intervention using game cards to introduce challenges in teamwork. This intervention uses sets of game cards that designate roles, limitations, or communication challenges designed to introduce common communication or teamwork problems. Game cards are designed to be applicable for any simulation-based scenario and are independent from patient physiology. In our example, participants were pediatric emergency medicine fellows undergoing simulation training for orientation. We describe the use of card sets in different scenarios with increasing teamwork challenge and difficulty. Both postscenario and summative debriefings were facilitated to allow participants to reflect on their performance and discover ways to apply their strategies to real resuscitations. In this article, we present our experience with the novel use of game cards to modify simulation scenarios to improve communication and teamwork skills.