Marc H. Gorelick

Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study

BACKGROUND CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was to identify children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary. METHODS We enrolled patients younger than 18 years presenting within 24 h of head trauma with Glasgow Coma Scale scores of 14-15 in 25 North American emergency departments. We derived and validated age-specific prediction rules for ciTBI (death from traumatic brain injury, neurosurgery, intubation >24 h, or hospital admission >or=2 nights). FINDINGS We enrolled and analysed 42 412 children (derivation and validation populations: 8502 and 2216 younger than 2 years, and 25 283 and 6411 aged 2 years and older). We obtained CT scans on 14 969 (35.3%); ciTBIs occurred in 376 (0.9%), and 60 (0.1%) underwent neurosurgery. In the validation population, the prediction rule for children younger than 2 years (normal mental status, no scalp haematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents) had a negative predictive value for ciTBI of 1176/1176 (100.0%, 95% CI 99.7-100 0) and sensitivity of 25/25 (100%, 86.3-100.0). 167 (24.1%) of 694 CT-imaged patients younger than 2 years were in this low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) had a negative predictive value of 3798/3800 (99.95%, 99.81-99.99) and sensitivity of 61/63 (96.8%, 89.0-99.6). 446 (20.1%) of 2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in validation populations. INTERPRETATION These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely be obviated. FUNDING The Emergency Medical Services for Children Programme of the Maternal and Child Health Bureau, and the Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Department of Health and Human Services.

PREVALENCE OF URINARY TRACT INFECTION IN FEBRILE YOUNG CHILDREN IN THE EMERGENCY DEPARTMENT

Objective. Establish prevalence rates of urinary tract infection (UTI) in febrile infants and young girls in an emergency department (ED) by demographics and clinical parameters. Methods. Cross-sectional prevalence survey of 2411 (83%) of all infants younger than 12 months and girls younger than 2 years of age presenting to the ED with a fever (≥38.5°C) who did not have a definite source for their fever and who were not on antibiotics or immunosuppressed. Otitis media, gastroenteritis, and upper respiratory infection were considered potential but not definite sources of fever. Results. Overall prevalence of UTI (growth of ≥104 CFU/mL of a urinary tract pathogen) was 3.3% (95% confidence interval [CI]: 2.6,4.0). Higher prevalences occurred in whites (10.7%; 95% CI: 7.1,14.3), girls (4.3%; 95% CI: 3.3,5.3), uncircumcised boys (8.0%; 95% CI: 1.9,14.1), and those who did not have another potential source for their fever (5.9%; 95% CI: 3.8,8.0), had a history of UTI (9.3%; 95% CI: 3.0,20.3), malodorous urine or hematuria (8.6%; 95% CI: 2.8,19.0), appeared “ill” (5.7%; 95% CI: 4.0,7.4), had abdominal or suprapubic tenderness on examination (13.2%; 95% CI: 3.7,30.7), or had fever ≥39°C (3.9%; 95% CI: 3.0,4.8). White girls had a 16.1% (95% CI: 10.6,21.6) prevalence of UTI. Conclusions. UTI is prevalent in young children, particularly white girls, without a definite source of fever. Specific clinical signs and symptoms of UTI are uncommon, and the presence of another potential source of fever such as upper respiratory infection or otitis media is not reliable in excluding UTI.

Pain Assessment for Pediatric Patients in the Emergency Department

OBJECTIVE. To examine the relationship between pediatric patient visit characteristics and pain score documentation in the emergency department (ED) and determine whether documentation of a pain score is associated with increased analgesic use. METHODS. A cross-sectional analysis was conducted of ED visits for pediatric patients from the National Hospital Ambulatory Medical Care Survey (1997–2000). Survey weighted regression first was used to assess the association between patient visit characteristics and pain score documentation. The regression then was repeated to determine the association between documentation of a pain score and analgesic use, adjusting for visit characteristics. RESULTS. A total of 24707 visits were included. Only 44.5% of visits had documented pain scores. In the regression analysis, younger age, self-pay, visits to pediatric facilities, and visits that were not designated as injury related were associated with decreased pain score documentation. Documentation of pain score was associated with increased odds of an analgesic prescription and opioid prescription. When no pain score was documented, the odds of receiving any analgesic was similar to visits with pain documented as mild. CONCLUSION. ED pain score documentation is suboptimal in the pediatric population. Infants and toddlers are at particular risk for not having a pain score documented. There is a significant association between pain score documentation and the use of any analgesic, particularly opioids. Improvements in pain documentation for acutely ill and injured children are needed to improve pain management.

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.

Quality of Primary Care and Subsequent Pediatric Emergency Department Utilization

OBJECTIVE. Our objective was to determine whether parent-reported, high-quality primary care was associated with decreased nonurgent pediatric emergency department utilization. METHODS. A retrospective analysis of prospectively collected data for a cohort of children from the 2000–2001 and 2001–2002 Medical Expenditure Panel Survey panels was performed. Baseline parent-reported quality of primary care with respect to family-centeredness, timeliness, and realized access (a measure of the childs ability to receive necessary care and referrals) was assessed by using composite scores from the Consumer Assessment of Healthcare Providers and Systems survey. The primary outcomes were the numbers of subsequent nonurgent and urgent emergency department visits per child. RESULTS. Of 8823 children included, 70.0% rated family-centeredness, 88.2% rated realized access, and 55.6% rated timeliness as high quality. After adjustment for demographic factors and health status, high-quality family-centeredness was associated with a 42% reduction in nonurgent emergency department visits for publicly insured children and a 49% reduction for children ≤2 years of age. Greater realized access was associated with a 44% reduction in nonurgent emergency department visits for children 3 to 11 years of age and a 56% reduction for children ≥12 years of age. Greater realized access was also associated with decreased nonurgent emergency department visits for publicly and privately insured children (37% and 35%, respectively). There was no significant association between timeliness and nonurgent emergency department utilization, nor was any quality-of-care domain associated with urgent emergency department utilization. CONCLUSIONS. Parent-reported, high-quality family-centeredness and a high level of realized access to primary care were associated with decreased subsequent nonurgent emergency department visits for children. Parent reports of health care quality in these domains provide important complementary information on health care quality.

Derivation of the DIVA score: a clinical prediction rule for the identification of children with difficult intravenous access.

Objective: To develop a clinical prediction rule that would be easy to apply and be useful for predicting success or failure of peripheral intravenous line insertion in children. Methods: This was a prospective cohort study of children aged 0 to 21 years undergoing peripheral intravenous placement by staff nurses in a pediatric emergency department. Information on candidate predictor variables was obtained before attempting intravenous placement, and the outcome was successful on first attempt. Backward stepwise logistic regression was used to identify factors independently predictive of success. Those factors remaining in the model were used in a set of linear scores. Receiver operating characteristic curves were constructed for each model, and the areas under the curve were calculated. Results: Six hundred fifteen subjects were enrolled. Success rate for intravenous insertion on first attempt was 75%. A 4-variable proportionally weighted rule (known as the difficult intravenous access [DIVA] score) was created (3 points for prematurity, 3 for younger than 1 year, 1 for 1-2 years of age, 2 for vein not palpable, and 2 for vein not visible). The area under the receiver operating characteristic curve was 0.67. Subjects with a DIVA score of 4 or more were more than 50% likely to have failed intravenous placement on first attempt. Conclusions: A clinical prediction rule that is easy to apply and is useful for predicting success or failure of peripheral intravenous insertion has been created. If externally validated, this DIVA score can be used to predict which children will have difficult intravenous access.

A Randomized Clinical Trial of Ibuprofen Versus Acetaminophen With Codeine for Acute Pediatric Arm Fracture Pain

STUDY OBJECTIVE We compare the treatment of pain in children with arm fractures by ibuprofen 10 mg/kg versus acetaminophen with codeine 1 mg/kg/dose (codeine component). METHODS This was a randomized, double-blind, clinical trial of children during the first 3 days after discharge from the emergency department (ED). The primary outcome was failure of the oral study medication, defined as use of the rescue medication. Pain medication use, pain scores, functional outcomes, adverse effects, and satisfaction were also assessed. RESULTS Three hundred thirty-six children were randomized to treatment, 169 to ibuprofen and 167 to acetaminophen with codeine; 244 patients were analyzed. Both groups used a median of 4 doses (interquartile range 2, 6.5). The proportion of treatment failures for ibuprofen (20.3%) was lower than for acetaminophen with codeine (31.0%), though not statistically significant (difference=10.7%; 95% confidence interval -0.2 to 21.6). The proportion of children who had any function (play, sleep, eating, school) affected by pain when pain was analyzed by day after injury was significantly lower for the ibuprofen group. Significantly more children receiving acetaminophen with codeine reported adverse effects and did not want to use it for future fractures. CONCLUSION Ibuprofen was at least as effective as acetaminophen with codeine for outpatient analgesia for children with arm fractures. There was no significant difference in analgesic failure or pain scores, but children receiving ibuprofen had better functional outcomes. Children receiving ibuprofen had significantly fewer adverse effects, and both children and parents were more satisfied with ibuprofen. Ibuprofen is preferable to acetaminophen with codeine for outpatient treatment of children with uncomplicated arm fractures.

Lachnospiraceae and Bacteroidales Alternative Fecal Indicators Reveal Chronic Human Sewage Contamination in an Urban Harbor

ABSTRACT The complexity of fecal microbial communities and overlap among human and other animal sources have made it difficult to identify source-specific fecal indicator bacteria. However, the advent of next-generation sequencing technologies now provides increased sequencing power to resolve microbial community composition within and among environments. These data can be mined for information on source-specific phylotypes and/or assemblages of phylotypes (i.e., microbial signatures). We report the development of a new genetic marker for human fecal contamination identified through microbial pyrotag sequence analysis of the V6 region of the 16S rRNA gene. Sequence analysis of 37 sewage samples and comparison with database sequences revealed a human-associated phylotype within the Lachnospiraceae family, which was closely related to the genus Blautia. This phylotype, termed Lachno2, was on average the second most abundant fecal bacterial phylotype in sewage influent samples from Milwaukee, WI. We developed a quantitative PCR (qPCR) assay for Lachno2 and used it along with the qPCR-based assays for human Bacteroidales (based on the HF183 genetic marker), total Bacteroidales spp., and enterococci and the conventional Escherichia coli and enterococci plate count assays to examine the prevalence of fecal and human fecal pollution in Milwaukees harbor. Both the conventional fecal indicators and the human-associated indicators revealed chronic fecal pollution in the harbor, with significant increases following heavy rain events and combined sewer overflows. The two human-associated genetic marker abundances were tightly correlated in the harbor, a strong indication they target the same source (i.e., human sewage). Human adenoviruses were routinely detected under all conditions in the harbor, and the probability of their occurrence increased by 154% for every 10-fold increase in the human indicator concentration. Both Lachno2 and human Bacteroidales increased specificity to detect sewage compared to general indicators, and the relationship to a human pathogen group suggests that the use of these alternative indicators will improve assessments for human health risks in urban waters.

Difficulty in obtaining peak expiratory flow measurements in children with acute asthma.

Objective To determine the frequency with which children ≥6 years with acute asthma can perform peak expiratory flow rate measurements (PEFR) in an emergency department (ED). Design/Methods Data were obtained from a prospective cohort study of children with acute asthma. All children (age 2–18 years old) treated in an urban pediatric ED for an acute exacerbation during randomly selected days over a 12-month period were prospectively evaluated. According to treatment protocols, PEFR was to be measured in all children age 6 years and older before therapy and after each treatment with inhaled bronchodilators. Registered respiratory therapists obtained PEFR and evaluated whether patients were able to perform the maneuver adequately. Results Four hundred and fifty-six children, 6 to 18 years old (median 10 years), were enrolled; 291 (64%) had PEFR measured at least once. Of those in whom PEFR was attempted at least once, only 190 (65%) were able to perform adequately. At the start of therapy, 54% (142/262) were able to perform PEFR. Of the 120 who were unable to perform initially, 76 had another attempt at the end of the ED treatment, and 55 (72%) were still unable to perform. A total of 149 patients had attempts at PEFR both at the start and end of treatment, of these, only 71 (48%) provided valid information on both attempts. Patients unable to perform PEFR were younger (mean ± SD = 8.7 ± 2.8 years) than those who were able to perform successfully (11.2 ± 3.2 years) and those with no attempts (10.0 ± 3.4 years). Children admitted to the hospital were more likely to be unable to perform PEFR (58/126 = 46%) than those discharged from the ED (43/330 = 13%, P < 0.0001). Conclusion Adequate PEFR measurements are difficult to obtain in children with acute asthma. Treatment and research protocols cannot rely exclusively on PEFR for evaluation of severity.

Association between Rainfall and Pediatric Emergency Department Visits for Acute Gastrointestinal Illness

Background Microbial water contamination after periods of heavy rainfall is well described, but its link to acute gastrointestinal illness (AGI) in children is not well known. Objectives We hypothesize an association between rainfall and pediatric emergency department (ED) visits for AGI that may represent an unrecognized, endemic burden of pediatric disease in a major U.S. metropolitan area served by municipal drinking water systems. Methods We conducted a retrospective time series analysis of visits to the Children’s Hospital of Wisconsin ED in Wauwatosa, Wisconsin. Daily visit totals of discharge International Classification of Diseases, 9th Revision codes of gastroenteritis or diarrhea were collected along with daily rainfall totals during the study period from 2002 to 2007. We used an autoregressive moving average model, adjusting for confounding variables such as sewage release events and season, to look for an association between daily visits and rainfall after a lag of 1–7 days. Results A total of 17,357 AGI visits were identified (mean daily total, 7.9; range, 0–56). Any rainfall 4 days prior was significantly associated with an 11% increase in AGI visits. Expected seasonal effects were also seen, with increased AGI visits in winter months. Conclusions We observed a significant association between rainfall and pediatric ED visits for AGI, suggesting a waterborne component of disease transmission in this population. The observed increase in ED visits for AGI occurred in the absence of any disease outbreaks reported to public health officials in our region, suggesting that rainfall-associated illness may be underestimated. Further study is warranted to better address this association.