Jennifer Trainor

Risk factors for cerebral edema in children with diabetic ketoacidosis

BACKGROUND Cerebral edema is an uncommon but devastating complication of diabetic ketoacidosis in children. Risk factors for this complication have not been clearly defined. METHODS In this multicenter study, we identified 61 children who had been hospitalized for diabetic ketoacidosis within a 15-year period and in whom cerebral edema had developed. Two additional groups of children with diabetic ketoacidosis but without cerebral edema were also identified: 181 randomly selected children and 174 children matched to those in the cerebral-edema group with respect to age at presentation, onset of diabetes (established vs. newly diagnosed disease), initial serum glucose concentration, and initial venous pH. Using logistic regression we compared the three groups with respect to demographic characteristics and biochemical variables at presentation and compared the matched groups with respect to therapeutic interventions and changes in biochemical values during treatment. RESULTS A comparison of the children in the cerebral-edema group with those in the random control group showed that cerebral edema was significantly associated with lower initial partial pressures of arterial carbon dioxide (relative risk of cerebral edema for each decrease of 7.8 mm Hg [representing 1 SD], 3.4; 95 percent confidence interval, 1.9 to 6.3; P<0.001) and higher initial serum urea nitrogen concentrations (relative risk of cerebral edema for each increase of 9 mg per deciliter [3.2 mmol per liter] [representing 1 SD], 1.7; 95 percent confidence interval, 1.2 to 2.5; P=0.003). A comparison of the children with cerebral edema with those in the matched control group also showed that cerebral edema was associated with lower partial pressures of arterial carbon dioxide and higher serum urea nitrogen concentrations. Of the therapeutic variables, only treatment with bicarbonate was associated with cerebral edema, after adjustment for other covariates (relative risk, 4.2; 95 percent confidence interval, 1.5 to 12.1; P=0.008). CONCLUSIONS Children with diabetic ketoacidosis who have low partial pressures of arterial carbon dioxide and high serum urea nitrogen concentrations at presentation and who are treated with bicarbonate are at increased risk for cerebral edema.

Development and evaluation of a simulation-based pediatric emergency medicine curriculum

Purpose The infrequency of severe childhood illness limits opportunities for emergency medicine (EM) providers to learn from real-world experience. Simulation offers an evidence-based educational approach to develop and practice clinical skills. Method This was a two-phase, randomized trial with a wait-list control condition. The development phase (2005–2006) involved systematic curriculum and rating checklist creation, producing a six-case, simulation-based curriculum linked to three evaluation cases. In the validation phase (2006–2007), the authors randomized 69 residents from two EM residencies to either an intervention group that received the curriculum one month before the first assessment of all participants or a wait-list control group that received the identical curriculum three months later. A final assessment of all residents followed one month after that. Two raters evaluated all residents. Primary outcome measures are percentages of items completed correctly. The authors assessed rater agreement using intraclass correlation (ICC) and compared group performance using mixed-model analysis of variance. Results ICCs surpassed 0.78. The instructional intervention produced a statistically significant effect for two of three evaluation cases for the validation phase of the study, a case × occasion interaction. Training year was significantly associated with better performance. In a multivariate analysis, training year and session correlated with score, but study group did not. Conclusions A one-day, simulation-based pediatric EM curriculum produced limited results. The evaluation approach is reasonable and reproducible for the population studied. Instructional dose strength and factors may have limited curriculum effectiveness. Focused, frequent, and effortful instructional interventions are necessary to achieve substantial performance improvements.

Comparison of checklist and anchored global rating instruments for performance rating of simulated pediatric emergencies.

Purpose: To compare the psychometric performance of two rating instruments used to assess trainee performance in three clinical scenarios. Methods: This study was part of a two-phase, randomized trial with a wait-list control condition assessing the effectiveness of a pediatric emergency medicine curriculum targeting general emergency medicine residents. Residents received 6 hours of instruction either before or after the first assessment. Separate pairs of raters completed either a dichotomous checklist for each of three cases or the Global Performance Assessment Tool (GPAT), an anchored multidimensional scale. A fully crossed person × rater × case generalizability study was conducted. The effect of training year on performance is assessed using multivariate analysis of variance. Results: The person and person × case components accounted for most of the score variance for both instruments. Using either instrument, scores demonstrated a small but significant increase as training level increased when analyzed using a multivariate analysis of variance. The inter-rater reliability coefficient was >0.9 for both instruments. Conclusions: We demonstrate that our checklist and anchored global rating instrument performed in a psychometrically similar fashion with high reliability. As long as proper attention is given to instrument design and testing and rater training, checklists and anchored assessment scales can produce reproducible data for a given population of subjects. The validity of the data arising for either instrument type must be assessed rigorously and with a focus, when practicable, on patient care outcomes.

Foreign body removal from the external auditory canal in a pediatric emergency department

Objectives: To describe the experience with external auditory canal foreign body removal in a pediatric emergency department. To identify factors associated with procedural complications and/or failed removal. Methods: Retrospective case series of patients treated in the emergency department over a 5-year period. Primary outcomes include success and complication rates. Secondary outcomes include removal rates in the otolaryngology clinic and operating room. Results: Physicians in our pediatric emergency department successfully removed 204 (80%) of 254 foreign bodies. In 30 cases (12%), there was a complication. Multiple attempts at removal were associated with failure (relative risk [RR], 6.0; 95% confidence interval [CI], 3.0-12.0) and complications (RR, 3.1; 95% CI, 1.5-6.3). The use of multiple instruments was also associated with failure (RR, 5.4; 95% CI, 2.7-10.8) and complications (RR, 4.0; 95% CI, 2.0-7.6). Of the 244 patients in whom emergency department attempts at removal were made, 26 were successfully removed in otolaryngology clinic, and 14 were removed in the operating room. Foreign bodies present in the canal for more than 24 hours were not at higher risk of failed removal or complications. Patients younger than 4 years also were not at increased risk of having failed removal or complications. Conclusions: Physicians in a pediatric emergency department remove most foreign bodies from the external auditory canal successfully with minimal complications and need for operative removal. These data suggest that referral to otolaryngology be considered if more than 1 attempt or instrument is needed for removal.

Comparison of the incidence, etiology, and management of anaphylaxis over time.

Background Failure to promptly recognize and treat anaphylaxis can result in death. Understanding the incidence, etiology, and management is imperative. A previous pediatric study identified latex as the most common anaphylaxis allergen. We aim to describe the incidence, etiology, and management of anaphylaxis prelatex and postlatex-precaution implementation. Methods Retrospective review of inpatient and emergency department (ED) records of pediatric anaphylaxis patients seen at 1 institution between 1986 and 1990 or 2002 and 2006 was performed. Patients with 2 systemic symptoms (gastrointestinal, respiratory, hypotension/syncope, oropharyngeal, altered mental status) or 1 systemic symptom plus 1 cutaneous symptom (urticaria, edema, or flushing) were included. Results Fifty-three episodes were included from 1986 to 1990. A total of 117 episodes were included from 2002 to 2006. Approximately 80% of cases presented to the ED. From 1986 to 1990, we noted 30.5 cases per 100,000 ED visits versus 38 cases per 100,000 ED visits from 2002 to 2006. Food allergens were most common in both groups (43%). Latex accounted for only 1.9% of cases in 1986 to 1990 versus 1.7% postlatex precautions. Prehospital epinephrine use was poor. Patients in 2002 to 2006 were more likely to receive steroids, H2-blockers, epinephrine autoinjectors, and allergist referrals but less likely to receive epinephrine. Conclusions The etiology of pediatric anaphylaxis has not significantly changed over time but seems to differ across regions because latex was not a significant allergen at this institution in either period. The incidence of anaphylaxis has increased slightly. Anaphylaxis remains underdiagnosed and undertreated. Improved education of patients/caregivers and health care providers is needed.

A Brief Boot Camp for 4th-Year Medical Students Entering into Pediatric and Family Medicine Residencies

The transition from medical student to intern is a challenging process characterized by a steep learning curve. Focused courses targeting skills necessary for success as a resident have increased self-perceived preparedness, confidence, and medical knowledge. Our aim was to create a brief educational intervention for 4th-year medical students entering pediatric, family practice, and medicine/pediatric residencies to target skills necessary for an internship. The curriculum used a combination of didactic presentations, small group discussions, role-playing, facilitated debriefing, and simulation-based education. Participants completed an objective structured clinical exam requiring synthesis and application of multiple boot camp elements before and after the elective. Participants completed anonymous surveys assessing self-perceived preparedness for an internship, overall and in regards to specific skills, before the elective and after the course. Participants were asked to provide feedback about the course. Using checklists to assess performance, students showed an improvement in performing infant lumbar punctures (47.2% vs 77.0%; p < 0.01, 95% CI for the difference 0.2, 0.4%) and providing signout (2.5 vs. 3.9 (5-point scale) p < 0.01, 95% CI for the difference 0.6, 2.3). They did not show an improvement in communication with a parent. Participants demonstrated an increase in self-reported preparedness for all targeted skills, except for obtaining consults and interprofessional communication. There was no increase in reported overall preparedness. All participants agreed with the statements, “The facilitators presented the material in an effective manner,” “I took away ideas I plan to implement in internship,” and “I think all students should participate in a similar experience.” When asked to assess the usefulness of individual modules, all except order writing received a mean Likert score > 4. A focused boot camp addressing key knowledge and skills required for pediatric-related residencies was well received and led to improved performance of targeted skills and increased self-reported preparedness in many targeted domains.

Use of Simulation-Based Education: A National Survey of Pediatric Clerkship Directors

OBJECTIVE To document the prevalence of simulation-based education (SBE) for third- and fourth-year medical students; to determine the perceived importance of SBE; to characterize the barriers associated with establishing SBE. METHODS A 27-item survey regarding simulation was distributed to members of the Council on Medical Student Education in Pediatrics (COMSEP) as part of a larger survey in 2012. RESULTS Seventy-one (48%) of 147 clerkship directors (CD) at COMSEP institutions responded to the survey questions regarding the use of SBE. Eighty-nine percent (63 of 71) of CDs reported use of SBE in some form: 27% of those programs (17 of 63) reported only the use of the online-based Computer-Assisted Learning in Pediatrics Program, and 73% (46 of 63) reported usage of other SBE modalities. Fifty-four percent of CDs (38 of 71) agreed that SBE is necessary to meet the requirements of the Liaison Committee on Medical Education (LCME). Multiple barriers were reported in initiating and implementing an SBE program. CONCLUSIONS SBE is commonly used for instruction during pediatric undergraduate medical education in North American medical schools. Barriers to the use of SBE remain despite the perception that it is needed to meet requirements of the LCME.

Serious Bacterial Infections in Febrile Outpatient Pediatric Kidney Transplant Recipients

Background: The purpose of this study was to describe the incidence of serious bacterial infections in febrile outpatient pediatric kidney transplant recipients and to assess the utility of using white blood cell indices to identify patients at low risk for bacteremia. Methods: A retrospective study was conducted on all kidney transplant recipients followed at a single childrens hospital. All outpatient visits from January 1, 1995 to June 6, 2007 in which fever was evaluated were reviewed. Patients with history of a primary immunodeficiency, receiving concurrent chemotherapy, or a stem cell or small bowel transplant were excluded. Demographic, historical, physical examination, laboratory, and radiographic data were then recorded. Results: In all, 101 patients had 251 individual episodes of fever evaluation. In 209 visits, a blood culture was drawn with results available. There were 21 (10.0%) true positive blood cultures and 3 (1.4%) false positives. Two-thirds of the true positive blood cultures occurred in patients with indwelling hardware. There was a positive urine culture in 52/192 (27.1%) visits. Pneumonia was diagnosed in 14/74 (18.9%) visits. In nonill-appearing children without indwelling central lines or focal bacterial infections, the incidence of bacteremia was zero. No practical decision rule based on white blood cell indices could be derived. Conclusions: The majority of bacteremic cases in febrile outpatient pediatric kidney transplant patients occurred in patients with indwelling hardware. We did not detect any occult cases of bacteremia in this study cohort. A larger prospective multicenter study is required to confirm the low incidence of bacteremia in this patient subset.

Fever without a localizing source

F ever is one of the most common reasons for a visit to the primary care provider. Often, fever is associated with other symptoms, which make the diagnosis obvious. However, fever without a localizing source is a problem that is perplexing to health care providers and parents. In this article, we focus on fever in older infants and toddlers (3 to 36 months) because the management of fever in the neonate has been reviewed extensively elsewhere. As pediatricians know, fever is not a disease itself, but rather a symptom of an underlying illness. In the first several years of life, the average child will experience multiple infections per year, frequently accompanied by fever. With increasing numbers of children in childcare facilities and parents who work outside the home, the desire to identify and eradicate the source of fever as quickly as pos1. Review the current incidence of occult bacteremia in children.

Development and Evaluation of a Learning Intervention Targeting First-Year Resident Defibrillation Skills

Objectives The aim of the study was to evaluate an educational intervention targeting the acquisition and retention of critical core skills of defibrillation in first-year pediatric residents using simulation-based training and deliberate practice. Methods From January 2011 to April 2012, a total of 23 first-year pediatric residents participated in a pretest-posttest study. An initial survey evaluated previous experience, training, and comfort. The scoring tool was designed and validated using a standard setting procedure and 60% was determined to be the minimum passing score. The 1-hour educational intervention included a brief video describing the defibrillator, 10 to 15 minutes of hands-on time with the defibrillator, and 30 minutes of simulation-based scenarios using deliberate practice with real-time feedback. Results The number of subjects who achieved competency in defibrillation skills increased from 8 to 16 of 23 (35% vs 70%, P < 0.05), pretest versus posttest, with the posttest occurring 4 months after the intervention. There was a significant improvement in checklist score (53% vs 68%, P < 0.05) and time to defibrillation (282-189 s, P < 0.05). For those who initiated chest compressions, there was a nonsignificant improvement in time to compressions (50 vs 33 s, P = 0.08). Previous Pediatric Advanced Life Support training was not associated with performance on pretest or posttest. Conclusions This brief educational intervention was shown to be effective 4 months after instruction in achieving and retaining competency of defibrillation skills by first-year pediatric residents. In the process, we uncovered educational gaps in cardiopulmonary resuscitation and other resuscitation skills that need to be addressed in future educational interventions and training.