David M. Spiro

Parental Knowledge and Use of Preventive Asthma Care Measures in Two Pediatric Emergency Departments

Objectives: Parents of children who visit the pediatric emergency department (PED) for asthma exacerbations may have inadequate knowledge of preventive asthma care. The primary objective of this study was to assess knowledge and use of preventive asthma care measures among parents of children with asthma who present to the PED with asthma exacerbations. The secondary objective was to identify variables that predict adherence to four key preventive care measures. Methods: The authors administered a 38-item questionnaire to 229 parents of children ages 2 to 18 years with asthma exacerbations who presented to two urban PEDs, one in the southeast and one in the northwest United States. Descriptive statistics were calculated to assess parental knowledge of preventive care. Multivariable logistic regression was used to identify variables associated with the use of four key preventive care measures. Results: Thirty-two percent of the children had an action plan, and 52% received the influenza vaccine within the preceding year. Sixty-six percent of the children had persistent asthma by National Institutes of Health (NIH) criteria. Of these, 51% received daily inhaled corticosteroids (ICSs). When parents were asked how an ICS medicine worked, 29% (64/221) responded “immediately opens the airway,” and 24% (53/221) responded “I do not know.” Daily use of ICS in these children was significantly associated with parent education level beyond high school (odds ratio [OR] = 2.81; 95% confidence interval [CI]: 1.26, 6.24; p = .011). Non-African Americans were more likely to have received an action plan than African Americans (OR = 2.18; 95% CI: 1.17, 4.06; p = .014). A secondary analysis of the parents perception of his/her ability to provide care during an asthma exacerbation was significantly associated with receipt of an action plan in a multivariable proportional odds model (OR = 3.63; 95% CI: 1.99, 6.62; p <.001). Conclusions: Parents of children with persistent asthma presenting to urban tertiary care PEDs with asthma exacerbations frequently have inadequate understanding of appropriate ICS use. Parents with less than a high school education, in particular, may benefit from focused educational interventions that address the importance of daily ICS use in asthma control. Parents who receive a written action plan are more confident in their ability to provide care for their child during an asthma exacerbation.

The Association of Overweight and Ankle Injuries in Children

OBJECTIVES Overweight children are at increased risk for many medical problems. Trauma is the leading etiology of childhood morbidity and mortality. No previous study has evaluated the association between overweight and acute ankle injuries in children. We hypothesized that being overweight is associated with an increased risk of ankle injury in children. METHODS We conducted a case-control study in an urban pediatric emergency department. Subjects aged 5 to 19 years were recruited from June 2005 through July 2006. Children with acute ankle trauma were enrolled as cases. A convenience sample of children with a chief complaint of fever, headache, or sore throat was enrolled as controls. Demographic information and anthropometric measurements were obtained. Age- and gender-specific body mass index percentiles (BMI-Ps) were calculated using pediatric norms. Multivariate unconditional logistic regression was used to assess the relationship between overweight and ankle injury, adjusting for demographic variables. Through medical records, we obtained demographic information and weight, but not height, of all cases that were not enrolled. This allowed us to conduct a sensitivity analysis in which we combined the enrolled and nonenrolled cases into a single case group and made increasingly more unlikely assumptions about the height percentiles of the nonenrolled cases. RESULTS One hundred eighty cases and 180 controls were enrolled in the study. We observed a significant association between overweight and ankle injury (multivariate-adjusted odds ratio 3.26, 95% confidence interval, 1.86-5.72; P value for trend <.0001). Although this result may be an overestimate of the magnitude of the association due to a possible bias in the selection of cases, sensitivity analysis demonstrated the robustness of the statistical significance of the finding. CONCLUSIONS Overweight children may be at increased risk of ankle injury.

Diagnostic Testing and Treatment of Pediatric Headache in the Emergency Department

OBJECTIVE To describe the variability in diagnostic testing and treatment of headaches in children presenting to the emergency department (ED) with use of a nationally representative sample. STUDY DESIGN This was a retrospective cohort study using the National Hospital Ambulatory Medical Care Survey during 2005-2009. To assess the use of evidence-based treatment, we analyzed all patients <18 years old in 2 groups: (1) primary discharge diagnosis of headache and (2) discharge diagnosis of migraine. RESULTS Four hundred forty-eight sampled ED visits from 2005-2009 represented a national estimate of 1.7 million visits with a discharge diagnosis of headache. A total of 95 visits represented a national estimate of 340 000 visits with a discharge diagnosis of migraine. Median age was 13.1 years and 60% were female with a primary diagnosis of headache. In this group, neuroimaging was performed in 37% of patients and 39% underwent blood tests. Nonsteroidal anti-inflammatory drugs and opioids were most commonly used for treatment. For children with a discharge diagnosis of migraine, approximately 40% of patients received non-evidence-based treatment, most commonly with opioid medications, and >20% of patients underwent computed tomography scanning. CONCLUSIONS There is significant variability in the evaluation and treatment of pediatric headache in the ED. Despite evidence-based clinical guidelines for migraine headache, a large number of children continue to receive opioids and ionizing radiation in the ED.

The concept and practice of a wait-and-see approach to acute otitis media

Purpose of review We review the contemporary management of acute otitis media, including symptomatic care, the rationale and literature for utilizing the wait-and-see approach, and the indications for immediate therapy with antibiotics. Recent findings Current guidelines recommend selective use of observation in children diagnosed with acute otitis media. Recent evidence suggests that a wait-and-see approach will reduce the use of antibiotics and decrease adverse events associated with their use. Earlier studies found that antimicrobials reduce pain and discomfort in the acute phase of illness compared with placebo. A recently published trial, however, suggests that when analgesics are utilized there may be minimal or no difference in otalgia whether antibiotics are prescribed or withheld. Summary Treatment of acute otitis media is the most frequent indication for prescribing antibiotics in the pediatric population. Evidence suggests there is marginal benefit from antibiotics for most children diagnosed with AOM. Based on current data, we propose an algorithm for the management of children with AOM that includes a wait-and-see approach with specific indications for immediate treatment with antibiotics. A wait-and-see approach to acute otitis media that empowers families by using a shared decision-making model will reduce the use of antibiotics and will decrease resistance to antimicrobials.

A novel biomarker panel to rule out acute appendicitis in pediatric patients with abdominal pain

OBJECTIVES To identify a biomarker panel with sufficient sensitivity and negative predictive value to identify children with abdominal pain at low risk for acute appendicitis in order to avoid unnecessary imaging. METHODS We prospectively enrolled 503 subjects aged two to 20 years with <72 hours of abdominal pain consistent with appendicitis. Blood samples from each patient were analyzed for CBC, differential, and 5 candidate proteins. Biomarker values were evaluated using principal component, recursive partitioning and logistic regression to select the combination that best discriminated between those subjects with and without disease. RESULTS The prevalence of acute appendicitis was 28.6%. A mathematical combination of three inflammation-related markers in a panel comprised of white blood cell count (WBC), C-reactive protein (CRP), and myeloid-related protein 8/14 complex (MRP 8/14) provided the best discrimination. This panel exhibited a sensitivity of 96.5% (95% CI, 92-99%), a negative predictive value of 96.9% (95% CI, 93-99%), a negative likelihood ratio of 0.08 (95% CI, 0.03- 0.19), and a specificity of 43.2% (95% CI, 38-48%) for acute appendicitis. Sixty of 185 CT scans (32.4%) were done for patients with negative biomarker panel results which, if deferred, would have reduced CT utilization at initial presentation by one third at the cost of missing five of 144 (3.5%) patients with appendicitis. CONCLUSION This panel may be useful in identifying pediatric patients with signs and symptoms suggestive of acute appendicitis who are at low risk and can be followed clinically, potentially sparing them exposure to the ionizing radiation of CT.

Low-Dose Propofol for the Abortive Treatment of Pediatric Migraine in the Emergency Department

Objective Limited progress has been made in the past decade for abortive treatment of migraine headache in the pediatric emergency department (PED). Propofol, a general anesthetic, has been reported to be effective in the treatment of refractory headaches in adults at subanesthetic doses but never in the pediatric population. The goal of this study was to review our institution’s experience with subanesthetic doses of propofol for the abortive treatment of pediatric migraine and compare propofol with standard abortive therapy in the PED. Methods Retrospective review of all patients discharged from the Oregon Health and Science University PED with a diagnosis of migraine headache from January 2010 to July 2011. Patients treated with subanesthetic doses of propofol were compared with matched controls who received standard abortive migraine therapy, defined as the combined use of a nonsteroidal anti-inflammatory medication, diphenhydramine, and prochlorperazine. Outcome variables of interest included reduction of pain as measured on a self-reported visual analog scale and length of stay after administration of initial abortive medication. Results Patients who received subanesthetic doses of propofol achieved significantly greater reduction in pain scores (80.1% vs 61.1%; P < 0.05) compared with matched controls as well as shorter stay (122 minutes vs 203 minutes; P = 0.2) after treatment. No adverse effects (hypotension, respiratory depression, or hypoxia) were recorded in either group. Conclusions Propofol seems to be effective for the abortive treatment of pediatric migraine headache in the PED. Further prospective trials are warranted to either support or refute these initial findings.

Mental Health Utilization in a Pediatric Emergency Department

Objective Mental health complaints are frequent in the pediatric emergency department (PED). The objective of this study was to describe trends over time in PED utilization for mental health care at in a single pediatric tertiary care hospital. It is our hypothesis that the resources used by this patient population are high and that mental health-related visits have increased over the most recent decade. Methods This was a retrospective study of all pediatric mental health presentations to the PED from January 2009 to July 2013 at a single pediatric hospital. All patients aged 1 to 19 years with an International Classification of Diseases, Ninth Revision code of 291, 292, 295 to 309, and 311 to 314 were included. Data collected included demographic data, medications received, restraint use, suicidality, length of stay (LOS), charges incurred, final disposition, and daily PED operation variables. Trends over time in presentation, charges, and LOS were analyzed using multiple mixed effects regression models after adjusting for potential patient and PED level confounding variables and clustering of multiple visits within patients. Results A total of 732 PED visits from 2009 to 2013 were identified representing 646 unique patients. The average age was 13.8 years, and 53% were male. Approximately 25% of the patients expressed suicidal ideation, and 44% of those had attempted suicide before arrival. Behavioral or chemical restraints were used in 33% of patients during their PED visit. There were statistically significant increases in annual visits, LOS, and charges over this period (P < 0.05). Increased charges were significantly associated with longer LOS (P = 0.0062). Charges (P = 0.46) and LOS (P = 0.62) were not significantly different between suicidal and nonsuicidal patients. Approximately 21% of patients were admitted or transferred to another facility. Conclusions In this single-center study, we found evidence that the resources required to care for pediatric patients with mental health complaints have increased significantly over time both by increased number of annual visits and an increasing LOS. Further research is necessary to determine if our data are consistent with national trends to further our understanding of the problem and improve resource allocation.

Estimation of airway obstruction using oximeter plethysmograph waveform data

BackgroundValidated measures to assess the severity of airway obstruction in patients with obstructive airway disease are limited. Changes in the pulse oximeter plethysmograph waveform represent fluctuations in arterial flow. Analysis of these fluctuations might be useful clinically if they represent physiologic perturbations resulting from airway obstruction. We tested the hypothesis that the severity of airway obstruction could be estimated using plethysmograph waveform data.MethodsUsing a closed airway circuit with adjustable inspiratory and expiratory pressure relief valves, airway obstruction was induced in a prospective convenience sample of 31 healthy adult subjects. Maximal change in airway pressure at the mouthpiece was used as a surrogate measure of the degree of obstruction applied. Plethysmograph waveform data and mouthpiece airway pressure were acquired for 60 seconds at increasing levels of inspiratory and expiratory obstruction. At each level of applied obstruction, mean values for maximal change in waveform area under the curve and height as well as maximal change in mouth pressure were calculated for sequential 7.5 second intervals. Correlations of these waveform variables with mouth pressure values were then performed to determine if the magnitude of changes in these variables indicates the severity of airway obstruction.ResultsThere were significant relationships between maximal change in area under the curve (P < .0001) or height (P < 0.0001) and mouth pressure.ConclusionThe findings suggest that mathematic interpretation of plethysmograph waveform data may estimate the severity of airway obstruction and be of clinical utility in objective assessment of patients with obstructive airway diseases.

Evaluation of a novel pediatric appendicitis pathway using high- and low-risk scoring systems.

Objectives This study aimed to determine the test characteristics of a pathway for pediatric appendicitis and its effects on emergency department (ED) length of stay, imaging, and admissions. Methods Children age 3 to 18 years with suspicion for appendicitis at 1 tertiary care ED were prospectively enrolled, using validated low- and high-risk scoring systems incorporating history, physical examination, and white blood cell count. Low-risk patients were discharged or observed in the ED. High-risk patients were admitted. Those meeting neither low-risk nor high-risk criteria were evaluated by surgery, with imaging at their discretion. Chart review or telephone follow-up was conducted 2 weeks after the visit. A retrospective study before and after was also performed. Charts of a random sample of patients evaluated for appendicitis in the 8 months before and after the pathway implementation were reviewed. Results Appendicitis was diagnosed in 65 of 178 patients. Of those with appendicitis, 63 were not low-risk (sensitivity, 96.9%; specificity, 40.7%). The high-risk criteria had a sensitivity of 75.3% and specificity of 75.2%. We reviewed 292 visits before and 290 after the pathway implementation. Emergency department length of stay was similar (253 minutes before vs 257 minutes after, P = 0.77). Computed tomography was used in 12.7% of visits before and 6.9% of visits after (P = 0.02). Use of ultrasound was not significantly different (47.3% vs 53.7%). Admission rates were not significantly different (45.5% vs 42.7%). Conclusions The low-risk criteria had good sensitivity in ruling out appendicitis. The high-risk criteria could be used to guide referral or admission. Neither outperformed the a priori judgment of experienced providers.

Portable spirometry during acute exacerbations of asthma in children.

Background. Spirometry is the gold standard for assessment of asthma and is objective and non-invasive. This is a pilot study to evaluate whether portable spirometry can be successfully performed by children in the pediatric emergency department for acute exacerbations of asthma. Methods. We enrolled children more than 6 years of age presenting to an urban pediatric emergency department with a history of asthma during an acute exacerbation. On arrival and after each bronchodilator treatment, vital signs and a clinical score were recorded. Portable spirometry was then performed. Attempts were continued until acceptable and reproducible measurements were obtained or until the patient was unable to perform further attempts. Outcomes included success at spirometry and correlation of spirometry with clinical signs. Results. Thirty-four subjects were enrolled with a median age of 12 years. Ninety-one percent of subjects completed at least one attempt at spirometry. Seventy-three percent of all spirometry attempts were reproducible. Portable spirometry demonstrated increased severity of the exacerbation in comparison to clinical signs and peak expiratory flow. Percent of predicted forced expiratory volume in 1 second, ratio of forced expiratory volume in 1 second to forced vital capacity, and peak expiratory flow are all poorly correlated with degree of wheezing, clinical score, respiratory rate, and oxygen saturation (r < 0.5). Conclusion. Portable spirometry can be successfully performed by children with acute exacerbations of asthma in the emergency department and demonstrated greater degrees of airway obstruction than did clinical signs. Spirometry provides objective, non-invasive measurements of the severity of airway obstruction in the emergency department for children with acute exacerbations of asthma.