David L. Jaffe

Intramuscular versus oral antibiotic therapy for the prevention of meningitis and other bacterial sequelae in young, febrile children at risk for occult bacteremia

Because studies of the treatment of children with occult bacteremia have yielded conflicting results, we compared ceftriaxone with amoxicillin for therapy. Inclusion criteria were age 3 to 36 months, temperature > or = 39 degrees C, an acute febrile illness with no focal findings or with otitis media (6/10 centers), and culture of blood. Subjects were randomly assigned to receive either ceftriaxone, 50 mg/kg intramuscularly, or amoxicillin, 20 mg/kg/dose orally for six doses. Of 6733 patients enrolled, 195 had bacteremia and 192 were evaluable: 164 Streptococcus pneumoniae, 9 Haemophilus influenzae type b, 7 Salmonella, 2 Neisseria meningitidis, and 10 other. After treatment, three patients receiving amoxicillin had the same organism isolated from their blood (two H. influenzae type b, one Salmonella) and two from the spinal fluid (two H. influenzae type b), compared with none given ceftriaxone. Probable or definite infections occurred in three children treated with ceftriaxone and six given amoxicillin (adjusted odds ratio 0.43, 95% confidence interval 0.08 to 1.82, p = 0.31). The five children with definite bacterial infections (three meningitis, one pneumonia, one sepsis) received amoxicillin (adjusted odds ratio 0.00, 95% confidence interval 0.00 to 0.52, p = 0.02). Fever persisted less often with ceftriaxone (adjusted odds ratio 0.52, 95% confidence interval 0.28 to 0.94, p = 0.04). Although the difference in total infections was not significant, ceftriaxone eradicated bacteremia, prevented significantly more definite focal bacterial complications, and was associated with less persistent fever.

Percutaneous Gastrostomy Device for the Treatment of Class II and Class III Obesity: Results of a Randomized Controlled Trial

Objectives:The AspireAssist System (AspireAssist) is an endoscopic weight loss device that is comprised of an endoscopically placed percutaneous gastrostomy tube and an external device to facilitate drainage of about 30% of the calories consumed in a meal, in conjunction with lifestyle (diet and exercise) counseling.Methods:In this 52-week clinical trial, 207 participants with a body-mass index (BMI) of 35.0–55.0 kg/m2 were randomly assigned in a 2:1 ratio to treatment with AspireAssist plus Lifestyle Counseling (n=137; mean BMI was 42.2±5.1 kg/m2) or Lifestyle Counseling alone (n=70; mean BMI was 40.9±3.9 kg/m2). The co-primary end points were mean percent excess weight loss and the proportion of participants who achieved at least a 25% excess weight loss.Results:At 52 weeks, participants in the AspireAssist group, on a modified intent-to-treat basis, had lost a mean (±s.d.) of 31.5±26.7% of their excess body weight (12.1±9.6% total body weight), whereas those in the Lifestyle Counseling group had lost a mean of 9.8±15.5% of their excess body weight (3.5±6.0% total body weight) (P<0.001). A total of 58.6% of participants in the AspireAssist group and 15.3% of participants in the Lifestyle Counseling group lost at least 25% of their excess body weight (P<0.001). The most frequently reported adverse events were abdominal pain and discomfort in the perioperative period and peristomal granulation tissue and peristomal irritation in the postoperative period. Serious adverse events were reported in 3.6% of participants in the AspireAssist group.Conclusions:The AspireAssist System was associated with greater weight loss than Lifestyle Counseling alone.

Revisiting the emergency medicine services for children research agenda: Priorities for multicenter research in pediatric emergency care

OBJECTIVES To describe the creation of an Emergency Medical Services for Children (EMSC) research agenda specific to multicenter research. Given the need for multicenter research in EMSC and the unique opportunity afforded by the creation of the Pediatric Emergency Care Applied Research Network (PECARN), the authors revisited existing EMSC research agendas to develop a PECARN-specific research agenda. They sought to prioritize PECARN research efforts, to guide investigators planning to conduct research in PECARN, and to describe the creation of a prioritized EMSC research agenda specific for multicenter research. METHODS The authors used the Nominal Group Process and Hanlon Process of Prioritization (HPP), which are recognized research prioritization methods incorporating both quantitative and qualitative data collection in group settings. The formula used to generate the final priority list heavily weighted practicality of conduct in a multicenter research network. By using size, seriousness, and practicality measures of each health priority, PECARN was able to identify factors that could be scored individually and were weighted relative to each other. RESULTS The prioritization processes resulted in a ranked list of 16 multicenter EMSC research topics. Top among these priorities were 1) respiratory illnesses/asthma, 2) prediction rules for high-stakes/low-likelihood diseases, 3) medication error reduction, 4) injury prevention, and 5) urgency and acuity scaling. CONCLUSIONS The PECARN prioritization process identified high-priority EMSC research topics specific to multicenter research. PECARN has the capacity to answer long-standing, important clinical controversies in EMSC, largely due to its ability to conduct randomized controlled trials and observational studies on a large scale.

Endoscopic retrograde cholangiopancreatography in the pediatric population is safe and efficacious

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is increasingly being used in the evaluation and management of biliary and pancreatic disorders in children. The aim of this study was to review the pediatric ERCP experience of a large academic referral center affiliated with a tertiary care childrens hospital. Methods: This is a retrospective review of medical records, endoscopic and operative reports, and radiography of those patients ages 0 to 21 years who underwent ERCP for any indication between 1993 and 2011 at a tertiary referral center affiliated with a large urban pediatric hospital. ERCP technical success was defined as cannulation of the desired duct. Serious adverse events included bleeding, perforation, pancreatitis, or death. Results: Four hundred twenty-nine ERCPs were performed on 296 patients. The mean age was 14.9 ± 4.8 years (3 months–21 years); 51.1% were boys. Patients with a history of previous liver transplant comprised 13.1% (56) of all ERCPs. Abnormal liver chemistries or suspected choledocholithiasis accounted for half of the indications. A therapeutic intervention was performed in 64.1%. Technical success was achieved in 95.2% of ERCPs. Serious adverse events occurred in 7.7%. Conclusions: Pediatric ERCP is highly efficacious in the pediatric population, with the rates of technical success and use of therapeutic interventions mirroring those in adults. There is a low overall rate of serious adverse events. The overall efficacy and safety support the performance of pediatric ERCP by experienced endoscopists at high-volume centers.

Lack of a discriminatory function for endoscopy skills on a computer-based simulator

BackgroundComputer-based endoscopy simulators have been developed to enable trainees to learn and gain technical endoscopic skills before operating on patients. However, these simulators have not been validated as models of patient-based endoscopy. This study aimed to determine whether a computer-based simulator can accurately represent an actual esophagogastroduodenoscopy (EGD) and colonoscopy and to evaluate its ability to discriminate between varying levels of expertise in performing endoscopic procedures based on objective parameters.MethodsIn a prospective, observational trial, five first-year gastroenterology fellows and six gastroenterology attendings from a single academic center completed six endoscopy cases on the Simbionix GI Mentor II endoscopy simulator. The cases were selected to represent common clinical scenarios. The performance parameters were collected by the simulator. The 13 performance parameters measured by the endoscopy simulator were compared between the two study groups. After the simulator cases, the participants completed a survey evaluating the realism of the simulator.ResultsNovices and experts were able to complete the tasks in the simulated cases with no significant overall differences between the two groups. The computer-based simulator was able to discriminate levels of expertise only for parameters related to the time spent on the procedure (total time, time to reach the second duodenum, time to reach the cecum, and efficiency of screening). No statistically significant differences were found for the other nine performance parameters measured by the simulator. Based on the survey data, expert opinion concluded that the simulator does not offer a realistic simulation of human endoscopy.ConclusionsThe computer-based endoscopy simulator displays a lack of ability to discriminate between novices and experts in terms of endoscopic skills based on measured objective performance parameters. The findings of this study suggest that the computer-based simulator lacks fidelity and that upgrades are necessary to increase the simulator’s ability to reproduce human endoscopy more accurately.

Poor discriminatory function for endoscopic skills on a computer-based simulator

BACKGROUND Computer-based endoscopy simulators may enable trainees to learn and develop technical skills before performing on patients. Simulators require validation as adequate models of live endoscopy before being used for training or assessment purposes. OBJECTIVE To evaluate content and criterion validity of the CAE EndoscopyVR Simulator colonoscopy and EGD modules as predictors of clinical endoscopic skills. DESIGN Prospective, observational, non-randomized, parallel cohort study. SETTING Single academic center with accredited gastroenterology training program. PARTICIPANTS Five novice first-year gastroenterology fellows and 6 expert gastroenterology attending physicians. INTERVENTION Participants performed 18 simulated colonoscopies and 6 simulated EGDs. The simulator recorded objective performance parameters. Participants then completed feedback surveys. MAIN OUTCOME MEASUREMENTS The 57 objective performance parameters measured by the endoscopy simulator were compared between the two study groups. Novice and expert survey responses were analyzed. RESULTS Significant differences between novice and expert performance were detected in only 19 of 57 (33%) performance metrics. Eight of these 19 (42%) were time-related metrics, such as total procedure time, time to anatomic landmarks, and time spent in contact with GI mucosa. Of 49 non-time related measures, the few additional statistically significant differences between novices and experts involved air insufflation, sedation management, endoscope force, and patient comfort. These findings are of uncertain clinical significance. Survey data found multiple aspects of the simulation to be unrealistic compared with human endoscopy. LIMITATIONS Small sample size. CONCLUSION The CAE EndoscopyVR Simulator displays poor content and criterion validity and is thereby incapable of predicting skill during in vivo endoscopy.

Pediatric emergency medicine fellowships: a survey

A survey of 24 existing pediatric emergency medicine fellowship programs as of December 1987 was conducted in order to characterize the following attributes of training in pediatric emergency medicine: amount of clinical time, required and elective rotations, didactic and research experience, patient volume, and staffing. Time spent in the emergency department varies between three and 10 months annually, with a mean of 34.5 hours per week. Twenty-two (92%) of the programs have required rotations. All responding programs require research and some degree of didactic education. Patient volume varies between 20,000 and 70,000, with a median of 41,000. The data offered should act as a reference for the further development of new and existing programs.

Endoscopic Diagnosis of Bleeding Meckel's Diverticulum in a Multivisceral Transplant Recipient

Small bowel transplantation has become a life‐saving procedure for patients with intestinal failure who fail conventional therapy. Meckels diverticulum is a rare cause of occult gastrointestinal bleeding that has not been reported in patients receiving intestinal allografts. We report a case in which transplantation of an asymptomatic Meckels diverticulum as part of a multivisceral allograft led to intestinal bleeding requiring surgical intervention. Endoscopy identified the actual bleeding diverticulum. Diverticulectomy at the time of transplant was not performed due to the difficult operative course, and the need for frequent surveillance ileoscopy, which would be performed across a fresh intestinal anastomosis. The patient underwent resection of the diverticulum, along with 40 cm of ileum, and did not experience further bleeding.

Therapeutic Endoscopy for the Control of Nonvariceal Upper Gastrointestinal Bleeding in Children: A Case Series

Objectives: Gastrointestinal bleeding is one of the most common indications for urgent endoscopy in the pediatric setting. The majority of these procedures are performed for control of variceal bleeding, with few performed for nonvariceal upper gastrointestinal (NVUGI) bleeding. The data on therapeutic endoscopy for NVUGI are sparse. The aims of our study were to review our experience with NVUGI bleeding, describe technical aspects and outcomes of therapeutic endoscopy, and determine gastroenterology fellows’ training opportunities according to the national training guidelines. Methods: We performed a retrospective review of endoscopy database (Endoworks, Olympus Inc, Center Valley, PA) from January 2009 to December 2014. The search used the following keywords: bleeding, hematemesis, melena, injection, epinephrine, cautery, clip, and argon plasma coagulation. The collected data included demographics, description of bleeding lesion and medical/endoscopic therapy, rate of rebleeding, relevant laboratories, physical examination, and need for transfusion and surgery. The study was approved by the institutional review board. Results: During the study period 12,737 upper endoscopies (esophagogastroduodenoscopies) were performed. A total of 15 patients underwent 17 esophagogastroduodenoscopies that required therapeutic intervention to control bleeding (1:750 procedures). The mean ± standard deviation (median) age of patients who required endoscopic intervention was 11.6 ± 6.0 years (14.0 years). Seven out of 17 patients received dual therapy to control the bleeding lesions. All but 3 patients received medical therapy with intravenous proton pump inhibitor, and 3 received octreotide infusions. Six of the patients experienced rebleeding (40%), with 4 out of 6 initially only receiving single modality therapy. Two of these patients eventually required surgical intervention to control bleeding and both patients presented with bleeding duodenal ulcers. There were no cases of aspiration, perforation, or deaths. There were a total of 24 fellows trained in our program during the study period. Less than 1 therapeutic endoscopy per fellow for NVUGI bleeding was performed. Conclusions: NVUGI bleeding requiring therapeutic endoscopic intervention is rare in pediatrics. A high rate (40%) of rebleeding was noted with a large proportion (66%) of patients receiving single modality therapy. Two patients required surgical intervention to control bleeding and both presented with bleeding duodenal ulcers. An insufficient number of therapeutic procedures is available for adequate fellow training requiring supplemental simulator and hands-on animal model, or adult endoscopy unit training.

INDEPENDENT PREDICTORS OF OCCULT PNEUMOCOCCAL BACTEREMIA (OPB) IN YOUNG FEBRILE CHILDREN. |[bull]| 797

OPB occurs in 3% of children 3-36 months of age with fever≥39°C without source (FWS) or with otitis media (OM). 6% of these patients who are not treated with antibiotics will develop meningitis. Previous predictive models of OPB have mainly employed univariate statistics. In order to identify independent predictors of OPB, we developed a multiple logistic regression model. 6607 patients (pts) age 3-36 months with fever ≥39°C without source or with OM were prospectively evaluated. We compared the 164 pts with OPB to the 6415 pts whose blood cultures did not grow a pathogen (NEG). All pts were assigned a Yale Observational Score (YOS), and had a blood culture drawn. 5836 patients had a complete blood count, of whom 5478 had a manual differential performed. The following 6 variables were evaluated for their association with OPB: age, temperature (temp), YOS, white blood cell count(WBC), absolute neutrophil count (ANC), and absolute band count (ABC). Variables which were significantly associated with OPB (p<.05) were then entered into a stepwise logistic regression analysis. Variables which retained a significant association with OPB were considered independent predictors of OPB. Pts with OPB were similar in age to NEG pts (mean±S.D.;15.0±7.2 vs 14.2 ±8.2 months, P=.14). Pts with OPB, however, had a higher mean temp (40.0 ±.57 vs 39.8 ±.55°C, P<.001), YOS(7.0±1.8 vs 6.6±1.6, P<.01), WBC (21.4±7.9 vs 12.9±6.5 ×103/mm3, P<.001), ANC (14.7±6.9 vs 7.3±4.9 ×103/mm3, P<.001) and ABC(1.9±2.1 vs 1.0±1.2 ×103/mm3, P<.001) than NEG pts. Logistic regression identified only ANC and temp as independent predictors of OPB: 7.8% of the 1301 pts with ANC≥10,000/mm3 had OPB. 9.1% of the 617 pts with both ANC≥10,000/mm3 and temperature≥40°C had OPB. In contrast, OPB occurred in 0.8% of 4176 pts withANC<10,000/mm3, and in 0.7% of 2713 pts with both ANC<10,000/mm3 and temp <40°C. Table