M. Olivia Titus

Cranial Magnetic Resonance Imaging Examination of Normal Term Neonates: A Pilot Study

This pilot studys aim was to determine, using magnetic resonance imaging (MRI), if and to what extent asymptomatic intracranial hemorrhage occurs in normal term neonates after uncomplicated vaginal deliveries. Eight normal, term, vaginally delivered infants and three cesarean-section deliveries used as controls underwent cranial MRI. No sedation was administered. Small subdural hematomas of the falx cerebri or tentorium cerebelli were found in half of those with an uneventful vaginal delivery. Pediatric follow-up, on average 3.9 years after the MRI study was performed, demonstrated normal growth and development. It appears that more data is needed to confirm the observation that the intracranial hemorrhages described should not be considered the etiology for neurologic abnormalities present in symptomatic neonates. (J Child Neurol 1999;14:708-710).

Gastrostomy tube-related complaints in the pediatric emergency department: identifying opportunities for improvement.

Objective: To describe the pediatric emergency medicine management of patients who present with gastrostomy tube (G-tube)-related complaints and identify opportunities for improving care and preventing G-tube complications. Methods: Retrospective cross-sectional descriptive study of patients (aged <18 years) who received care at an urban childrens hospital (110 beds) emergency department (ED) for G-tube-related complaints. Results: Over a 23-month period, there were 181 ED patient visits by 77 patients for G-tube-related complaints. The mean number of visits per patient was 2.4. There were 159 (88%) G-tube and 22 (12%) gastrojejunostomy tube (GJ-tube) patient visits. The standard type of G-tube used at the study site ED was an adjustable-length tube. The most common complaint for G-tubes was dislodgement (99, 62%); and for GJ-tubes, malfunction (11, 50%). There were 119 patient visits (75%) needing G-tube replacement. Of these, 115 (97%) were successfully replaced in the ED, 85 (74%) by the pediatric emergency medicine attending physician, and 30 (26%) by the pediatric surgery service. The method of securing or documenting the intragastric depth of the adjustable-length tubes was documented in 15 (10%) of the 157 patients who had G-tubes or foley catheters at the time of ED disposition. The most common major G-tube complication was gastric outlet obstruction (3), and the most common major GJ-tube complication was aspiration pneumonia (3) secondary to gastric malposition (2) or dislodgement (1) of the GJ-tube. Only 9 patient visits (5%) resulted in hospitalization, and there were no deaths. Conclusions: Patients with G-tubes had approximately 1.25 mean ED visits per year for G-tube complaints. The most common G-tube complaint was dislodgement. Most dislodged G-tubes were replaced by ED physicians without the assistance of surgeons, but documentation of management and methods of securing the tubes was often incomplete. There were few major complications or hospitalizations. Treatment guidelines are presented that emphasize documentation of confirming G-tube location at the time of disposition from the ED.

Temporal Artery Thermometry Utilization in Pediatric Emergency Care

Objective To determine the effectiveness of temporal artery thermometry (TAT) as an alternative for temperature assessment of children 1 to 4 years of age in the pediatric emergency department. Methods Prospective cross-sectional study conducted at an urban childrens hospital emergency department. TAT and rectal temperatures are compared in a convenience sample of children 1 to 4 years of age. Comparison of the temperatures is performed using Pearson correlation coefficient and regression analysis. Results TAT and rectal temperatures are measured in 42 children 1 to 4 years of age. TAT predicts 83% of rectal temperatures. A receiver operating characteristic curve analysis shows that a cutoff of 37.7°C or greater for fever in TAT is equivalent to rectal temperature greater than or equal to 38.3°C with 100% sensitivity and 93.5% specificity. Conclusion TAT is an effective screening tool in identifying fever in children 1 to 4 years of age.

The Effect of Tiagabine on Spasticity in Children With Intractable Epilepsy: A Pilot Study

Preliminary pharmacologic evidence suggests that tiagabine, a new presynaptic gamma-aminobutyric acid-uptake inhibitor developed as an antiepileptic drug, may also relieve spasticity. This pilot study assessed the drugs efficacy in 14 children with congenital or acquired spastic quadriplegia and concomitant intractable epilepsy refractory to treatment with multiple antiepileptic drugs. The primary outcome variable was change in motor function; the secondary outcome was change in seizure frequency. Tiagabine was initiated at 0.1-0.2 mg/kg/day and then gradually titrated upward until seizures ceased, adverse effects supervened, or the maximum dose of 1.1 mg/kg/day was reached. When a modified Ashworth scale was used to assess motor function, a mean improvement of approximately 50% was observed. Common findings included improved tone, strength, coordination, range of motion, and relaxation of extremities, with less ataxia and wobbling. Mean reduction in seizure frequency was 50-74%. Randomized, double-blind controlled studies are needed to confirm the suggested efficacy of tiagabine in relieving chronic spasticity in children with neurodevelopmental disorders.

Parental Education on Asthma Severity in the Emergency Department and Primary Care Follow-up Rates

Asthma is the most prevalent chronic condition affecting children and a common chief complaint in emergency departments (EDs). We aimed to improve parents’ understanding of their child’s asthma severity on accessing our pediatric ED for an acute asthma exacerbation. A retrospective chart review was conducted to determine outpatient follow-up rates from our ED in 2010-2011. In an attempt to educate parents at ED discharge about their child’s asthma severity at presentation, we included a visual severity scale on their discharge instructions. Postdischarge telephone interviews were completed to determine postintervention follow-up rates. Asthma follow-up rates at 1 week improved from 20.8% to 50% after intervention. This difference was statistically significant after controlling for age and clinical asthma score with logistic regression (P < .0001). Offering predischarge education about a child’s initial asthma severity is a simple intervention that significantly improved follow-up rates for children seen in the ED for asthma exacerbation.

Quality improvement methods improve inhaled corticosteroid prescribing in the emergency department

Abstract Objective: Inhaled corticosteroids (ICS) are underutilized among persistent asthmatics. Because of low outpatient follow-up rates after Emergency Department (ED) visits, children are unlikely to be prescribed ICS by their primary care physician after an acute exacerbation. ED physicians have the opportunity to contribute to the delivery of preventive care in the acute care setting. Our objective was to evaluate if quality improvement (QI) methods could improve the rate of ICS initiation at ED discharge. Methods: Within the Pediatric ED (PED) at a tertiary children’s hospital, QI methods were used to encourage ICS prescribing at the time of ED discharge. Interventions focused on education at both the attending physician and resident level, process improvements designed to streamline prescribing, and directed provider feedback. This involved multiple plan-do-study-act cycles. Medical records of eligible patients were reviewed monthly to determine ICS prescribing rates. The effect of our interventions on prescribing rate was tracked over time using a run chart. Results: Following our interventions, the ICS initiation rate for children seen in and discharged home from the ED with an acute asthma exacerbation increased from a baseline median rate of 11.25% to a median rate of 79% representing a significant, non-random improvement. The ICS initiation rate has been sustained for 8 months over our goal rate of 75%. Conclusions: This study demonstrates that QI methods can be used to increase inhaled corticosteroid initiation rate at the time of ED discharge and, thus, improve the delivery of preventive asthma care in the acute care setting.

Parental Preference for Short- Versus Long-Course Corticosteroid Therapy in Children With Asthma Presenting to the Pediatric Emergency Department

Asthma is the most common chronic condition affecting children and a prominent chief complaint in pediatric emergency departments (ED). We aimed to determine parental preference between short- and long-term courses of oral corticosteroids for use in children with mild to moderate asthma presenting to our pediatric ED with acute asthma exacerbations. We surveyed parents of asthmatic children who presented to our pediatric ED from August 2011 to April 2012. Questions characterized each patient’s asthma severity, assessed parental preference among systemic steroid and inhaled medication delivery options for acute asthma management, and inquired about compliance, medication costs, and intention to follow up. The majority of our parents prefer the use of 1 to 2 days of steroids to 5 days for acute asthma exacerbations in the ED. Thus, dexamethasone is an attractive alternative to prednisone/prednisolone and should be considered in the management of acute asthma exacerbations in the ED.

Ipratropium Bromide for Acute Asthma Exacerbations in the Emergency Setting: A Literature Review of the Evidence

Since the 1970s, when inhaled anticholinergic agents were first introduced as adjunct therapies for the immediate treatment of pediatric asthma exacerbations, several trials have shown varying degrees of benefit from their use as bronchodilators in combination with inhaled short-acting &bgr;-adrenergic agonists and systemic corticosteroids. Although other anticholinergics exist, ipratropium bromide (IB) specifically has emerged as the overwhelming choice of pulmonologists and emergency physicians because of its limited systemic absorption from the lungs when given as an inhaled preparation. However, although the varying trials, predominantly in the emergency department setting, have typically shown a trend toward improved outcomes, none has set forth clear dosing protocol recommendations for use by practicing physicians. It is our goal in this review of the available literature on the use of IB, as an adjunct to inhaled short-acting &bgr;-adrenergic agonists, to summarize practical, evidence-based recommendations for use in the pediatric emergency department setting for acute asthma exacerbations. We also hope to better delineate the most effective dosing regimen in those patients who might benefit most from the addition of IB and to explore proposed additional benefits it may have as a modulator of cholinergic-induced effects from high-dose &bgr;-agonist therapy and viral triggers.

Pediatric emergency medicine fellowship research curriculum: a survey of fellowship directors.

Objective: To determine how pediatric emergency medicine (PEM) fellowship directors organize research training and to identify factors believed to be associated with successful research training. Methods: A 16-question survey study of PEM fellowship directors. Results: Of the 58 fellowship directors surveyed, 39 (67%) responded. Of 38 programs, PEM faculty from 20 (53%) served as research mentors for PEM fellows. The mean percentage of PEM faculty who had performed peer-review funded research was 26%. The mean number of trainee research months was 10.9 for 3 years. Of these research months, 93% were not protected (included clinical work hours). Only 5 programs provided some completely protected research months (months without any clinical work hours), and none of these were scheduled in blocks of greater than 3 consecutive months. Most (56%) of these research months were scheduled during the third year of training. The most likely explanations of the fellow successfully becoming research competent were eagerness to apply self and number of research months during training. Least likely explanations were faculty with peer-reviewed funded grants and blocks of research time. Thirty-five fellowship directors (90%) believed that upon completion of the training, their fellows would be research competent. Conclusions Besides the fellows eagerness to apply self, scheduling adequate time for research was reported as a highly important factor in achieving research competency among PEM fellows. Providing protected (no clinical responsibilities) research months to fellows and arranging more opportunities for PEM faculty to serve as research mentors may maintain or possibly improve the likelihood of PEM fellows to becoming research competent.

Effectiveness of a Breath-Actuated Nebulizer Device on Asthma Care in the Pediatric Emergency Department

The breath-actuated nebulizer (BAN) is a new respiratory device to deliver short-acting β-agonists to patients with asthma exacerbations. This pediatric convenience sample experimental study compares the BAN with conventional nebulizers and demonstrates that the BAN allows for shorter treatment times to achieve improved clinical asthma scores with less albuterol, shorter emergency department length of stay, and fewer hospitalizations.