James M. Chamberlain

Epidemiology of a pediatric emergency medicine research network: the PECARN Core Data Project.

Objective: To examine the epidemiology of pediatric patient visits to emergency departments (ED). Methods: We conducted a cross-sectional study of pediatric ED visits at the participating Pediatric Emergency Care Applied Research Network (PECARN) hospitals in 2002. We provide descriptive characteristics of pediatric ED visits and a comparison of the study database to the National Hospital Ambulatory Medical Care Survey (NHAMCS). Bivariate analyses were calculated to assess characteristics associated with hospital admission, death in the ED, and length of ED visit. We also performed multivariate regression to model the likelihood of admission to the hospital. Results: Mean patient age was 6.2 years; 53.5% were boys; 47.5% black; and 43.2% had Medicaid insurance. The most common ED diagnoses were fever, upper respiratory infection, asthma, otitis media, and viral syndromes. The inpatient admission rate was 11.6%. The most common diagnoses requiring hospitalization were asthma, dehydration, fever, bronchiolitis, and pneumonia. In multivariate analysis, patients who were black or Hispanic, had Medicaid insurance or were uninsured, or were older than 1 year were less likely to be hospitalized. Demographics of the PECARN population were similar to NHAMCS, with notable exceptions of a larger proportion of black patients and of admitted patients from the PECARN EDs. Conclusion: We describe previously unavailable epidemiological information about childhood illnesses and injuries that can inform development of future studies on the effectiveness, outcomes, and quality of emergency medical services for children. Most pediatric ED patients in our study sought care for infectious causes or asthma and were discharged from the ED. Hospital admission rate differed according to age, payer type, race/ethnicity, and diagnosis.

Determination of Normal Ear Temperature with an Infrared Emission Detection Thermometer

STUDY OBJECTIVE To determine normal body temperature with an infrared emission detection ear thermometer. DESIGN Cross-sectional convenience sample. SETTING Four acute and long-term health care facilities. PARTICIPANTS Subjects who denied recent potentially febrile illness and ingestion of medications affecting normal body temperature. RESULTS Two thousand four hundred forty-seven subjects aged 12 hours to 103 years were enrolled. Ear temperatures were normally distributed for each of eight age groups. There were differences in mean temperature among different age groups (P < .001, by ANOVA) and a striking cutoff at adolescence; the mean temperature for children aged 3 days to 10 years was 36.78 +/- 0.47 degrees C, as compared to 36.51 +/- 0.46 degrees C for subjects 11 years and older (P < .001, by t test). Temperatures were higher in female subjects and showed the characteristic diurnal variation of normal body temperature in five subjects studied longitudinally. The reproducibility of the ear thermometer was better than that of a commonly used electronic thermometer at the oral and axillary sites. CONCLUSION The infrared emission detection ear thermometer is an accurate means of assessing normal body temperature without using corrective offsets to estimate temperature at other body sites. On the basis of these data, the 95th percentile for infrared emission detection temperature in children younger than 11 years old was 37.6 degrees C. The 99th percentile was 37.9 degrees C for children younger than 11 years old and 37.6 degrees C for people 11 years or older. Because only 1% of normal people have an infrared emission detection temperature higher than these values, these may represent appropriate cutoffs for fever screening using this device.

A comprehensive review of naloxone for the emergency physician.

Naloxone has enjoyed long-standing success as a safe and effective opioid antagonist and has been invaluable in defining the role of endogenous opioid pathways in the response to pathological states such as sepsis and hypovolemia. We look forward to exciting research to further elucidate these pathways and to improve outcome by modulating the patients physiological response to these stresses.

Racial and ethnic disparities in pediatric appendicitis rupture rate

OBJECTIVES To determine if there are racial/ethnic differences in the rates of appendiceal rupture among the children of two large states. Because rupture is primarily due to delayed diagnosis, differences would suggest disparities in timely access to quality emergency care. METHODS This was an observational, cross-sectional analysis of full-year samples of acute appendicitis cases from California and New York children 4 to 18 years old. Racial/ethnic groups were compared for risk of appendiceal rupture adjusted for biological factors both before and after adjustment for the following socioeconomic, hospital, and admission characteristics: income, insurance, hospital type, and admission source. Results were interpreted in light of census data on the proportion of immigrants in each racial/ethnic group. RESULTS Compared with white children with acute appendicitis, Hispanic and Asian children have higher odds of rupture in California, whereas Asian and black/African American children have higher odds in New York. These differences roughly parallel the within-state proportion of immigrant children in these groups. Adjustments for family, socioeconomic, and hospital characteristics attenuate but do not eliminate disparities. CONCLUSIONS The authors found evidence of significant racial/ethnic disparities in rate of appendiceal rupture, an important and preventable outcome, in two large but dissimilar states. Immigrant groups may be most at risk for delayed emergency care. Future research should focus on immigration and acculturation as risk factors for appendicitis rupture in children.

Pseudotumor Cerebri and Coma in Vitamin D — Dependent Rickets:

Correspondence to: Dr. G. Alpan, Department of Pediatrics, St. Luke’s-Roosevelt Hospital Center, Amsterdam Avenue at 114th Street, New York, New York 10025, U.S.A. Pseudotumor cerebri (PC) is characterized by increased intracranial pressure, normal cerebrospinal fluid (CSF) and the exclusion of intracranial space-occupying lesions, hydrocephalus or obstruction of cranial venous drainage. PC occurs with a variety of conditions including chronic hypoxia, postinfectious states, following head trauma or otitis media.’ Endocrinopathies sometimes associated with PC include: prolonged steroid therapy, rapid reduction in steroid dosage,3 hyperthyroidism,4 initiation of levothyroxine therapy for hypothyroidism,l hypoparathyroidism,l and adrenal insufficiency.’ We report the unusual occurrence of PC in a 20-month old infant with vitamin D-

Lorazepam vs Diazepam for Pediatric Status Epilepticus: A Randomized Clinical Trial

IMPORTANCE Benzodiazepines are considered first-line therapy for pediatric status epilepticus. Some studies suggest that lorazepam may be more effective or safer than diazepam, but lorazepam is not Food and Drug Administration approved for this indication. OBJECTIVE To test the hypothesis that lorazepam has better efficacy and safety than diazepam for treating pediatric status epilepticus. DESIGN, SETTING, AND PARTICIPANTS This double-blind, randomized clinical trial was conducted from March 1, 2008, to March 14, 2012. Patients aged 3 months to younger than 18 years with convulsive status epilepticus presenting to 1 of 11 US academic pediatric emergency departments were eligible. There were 273 patients; 140 randomized to diazepam and 133 to lorazepam. INTERVENTIONS Patients received either 0.2 mg/kg of diazepam or 0.1 mg/kg of lorazepam intravenously, with half this dose repeated at 5 minutes if necessary. If status epilepticus continued at 12 minutes, fosphenytoin was administered. MAIN OUTCOMES AND MEASURES The primary efficacy outcome was cessation of status epilepticus by 10 minutes without recurrence within 30 minutes. The primary safety outcome was the performance of assisted ventilation. Secondary outcomes included rates of seizure recurrence and sedation and times to cessation of status epilepticus and return to baseline mental status. Outcomes were measured 4 hours after study medication administration. RESULTS Cessation of status epilepticus for 10 minutes without recurrence within 30 minutes occurred in 101 of 140 (72.1%) in the diazepam group and 97 of 133 (72.9%) in the lorazepam group, with an absolute efficacy difference of 0.8% (95% CI, -11.4% to 9.8%). Twenty-six patients in each group required assisted ventilation (16.0% given diazepam and 17.6% given lorazepam; absolute risk difference, 1.6%; 95% CI, -9.9% to 6.8%). There were no statistically significant differences in secondary outcomes except that lorazepam patients were more likely to be sedated (66.9% vs 50%, respectively; absolute risk difference, 16.9%; 95% CI, 6.1% to 27.7%). CONCLUSIONS AND RELEVANCE Among pediatric patients with convulsive status epilepticus, treatment with lorazepam did not result in improved efficacy or safety compared with diazepam. These findings do not support the preferential use of lorazepam for this condition. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00621478.

Epidemiology of Psychiatric-Related Visits to Emergency Departments in a Multicenter Collaborative Research Pediatric Network

Objectives: Describe the epidemiology of pediatric psychiatric-related visits to emergency departments participating in the Pediatric Emergency Care Applied Research Network. Methods: Retrospective analysis of emergency department presentations for psychiatric-related visits (International Classification of Diseases, Ninth Revision, codes 290.0-314.90) for years 2003 to 2005 at 24 participating Pediatric Emergency Care Applied Research Network hospitals. All patients who had psychiatric-related emergency department visits aged 19 years or younger were eligible. Age, sex, race, ethnicity, insurance status, mode of arrival, length of stay, and disposition were described for psychiatric-related visits and compared with non-psychiatric-related visits. Results: Pediatric psychiatric-related visits accounted for 3.3% of all participating emergency department visits (84,973/2,580,299). Patients with psychiatric-related visits were older (mean ± SD age, 12.7 ± 3.9 years vs. 5.9 ± 5.6 years, P < 0.001), had a higher rate ambulance arrival (19.4% vs 8.2%, P < 0.0001), had a longer median length of stay (3.2 vs 2.1 hours, P < 0.0001), and had a higher rate of admission (30.5% vs 11.2%, P < 0.0001) when compared with non-psychiatric-related patient presentations. Older age, female sex, white race, ambulance arrival, and governmental insurance were factors independently associated with admission or transfer from the emergency department for psychiatric-related visits in multivariate regression analyses. Conclusions: Pediatric psychiatric-related visits require more prehospital and emergency department resources and have higher admission/transfer rates than non-psychiatric-related visits within a large national pediatric emergency network.

The established status epilepticus trial 2013.

Benzodiazepine‐refractory status epilepticus (established status epilepticus, ESE) is a relatively common emergency condition with several widely used treatments. There are no controlled, randomized, blinded clinical trials to compare the efficacy and tolerability of currently available treatments for ESE. The ESE treatment trial is designed to determine the most effective and/or the least effective treatment of ESE among patients older than 2 years by comparing three arms: fosphenytoin (fPHT) levetiracetam (LVT), and valproic acid (VPA). This is a multicenter, randomized, double‐blind, Bayesian adaptive, phase III comparative effectiveness trial. Up to 795 patients will be randomized initially 1:1:1, and response‐adaptive randomization will occur after 300 patients have been recruited. Randomization will be stratified by three age groups, 2–18, 19–65, and 66 and older. The primary outcome measure is cessation of clinical seizure activity and improving mental status, without serious adverse effects or further intervention at 60 min after administration of study drug. Each subject will be followed until discharge or 30 days from enrollment. This trial will include interim analyses for early success and futility. This trial will be considered a success if the probability that a treatment is the most effective is >0.975 or the probability that a treatment is the least effective is >0.975 for any treatment. Proposed total sample size is 795, which provides 90% power to identify the most effective and/or the least effective treatment when one treatment arm has a true response rate of 65% and the true response rate is 50% in the other two arms.

Emergency Department Quality: An Analysis of Existing Pediatric Measures

OBJECTIVES The Institute of Medicine (IOM) has recommended the development of national standards for the measurement of emergency care performance. The authors undertook this study with the goals of enumerating and categorizing existing performance measures relevant to pediatric emergency care. METHODS Potential performance measures were identified through a survey of 1) the peer-reviewed literature, 2) websites of organizations and societies pertaining to quality improvement, and 3) emergency department (ED) directors. Performance measures were enumerated and categorized, using consensus methods, on three dimensions: 1) the IOM quality domains; 2) Donabedians structure/process/outcome framework; and 3) general, cross-cutting, or disease-specific measures. RESULTS A total of 405 performance measures were found for potential use for pediatric emergency care. When categorized by IOM domain, nearly half of the measures were related to effectiveness, while only 6% of measures addressed patient-centeredness. In the Donabedian dimension, 67% of measures were categorized as process measures, with 29% outcome and 4% structure measures. Finally, 31% of measures were general measures relevant to every ED visit. Although 225 measures (55%) were disease-specific, the majority (56%) of these measures related to only five common conditions. CONCLUSIONS A wide range of performance measures relevant to pediatric emergency care are available. However, measures lack a systematic and comprehensive approach to evaluate the quality of care provided.

Racial Disparities in Pain Management of Children With Appendicitis in Emergency Departments

IMPORTANCE Racial disparities in use of analgesia in emergency departments have been previously documented. Further work to understand the causes of these disparities must be undertaken, which can then help inform the development of interventions to reduce and eradicate racial disparities in health care provision. OBJECTIVE To evaluate racial differences in analgesia administration, and particularly opioid administration, among children diagnosed as having appendicitis. DESIGN, SETTING, AND PARTICIPANTS Repeated cross-sectional study of patients aged 21 years or younger evaluated in the emergency department who had an International Classification of Diseases, Ninth Revision diagnosis of appendicitis, using the National Hospital Ambulatory Medical Care Survey from 2003 to 2010. We calculated the frequency of both opioid and nonopioid analgesia administration using complex survey weighting. We then performed multivariable logistic regression to examine racial differences in overall administration of analgesia, and specifically opioid analgesia, after adjusting for important demographic and visit covariates, including ethnicity and pain score. MAIN OUTCOMES AND MEASURES Receipt of analgesia administration (any and opioid) by race. RESULTS An estimated 0.94 (95% CI, 0.78-1.10) million children were diagnosed as having appendicitis. Of those, 56.8% (95% CI, 49.8%-63.9%) received analgesia of any type; 41.3% (95% CI, 33.7%-48.9%) received opioid analgesia (20.7% [95% CI, 5.3%-36.0%] of black patients vs 43.1% [95% CI, 34.6%-51.4%] of white patients). When stratified by pain score and adjusted for ethnicity, black patients with moderate pain were less likely to receive any analgesia than white patients (adjusted odds ratio = 0.1 [95% CI, 0.02-0.8]). Among those with severe pain, black patients were less likely to receive opioids than white patients (adjusted odds ratio = 0.2 [95% CI, 0.06-0.9]). In a multivariable model, there were no significant differences in the overall rate of analgesia administration by race. However, black patients received opioid analgesia significantly less frequently than white patients (12.2% [95% CI, 0.1%-35.2%] vs 33.9% [95% CI, 0.6%-74.9%], respectively; adjusted odds ratio = 0.2 [95% CI, 0.06-0.8]). CONCLUSIONS AND RELEVANCE Appendicitis pain is undertreated in pediatrics, and racial disparities with respect to analgesia administration exist. Black children are less likely to receive any pain medication for moderate pain and less likely to receive opioids for severe pain, suggesting a different threshold for treatment.