Raymond D. Pitetti

Complementary and alternative medicine use in children.

Objective Adults frequently use complementary and alternative medicines (CAM). Few studies have reported how often CAM therapies are used to treat children. The purpose of this study is to describe the use of alternative therapies by children visiting an emergency department (ED) and to identify sociodemographic factors that may influence the decision to use such therapies. Design Survey of families using a self-administered questionnaire. Setting An urban, tertiary care pediatric emergency department. Participants Convenience sample of families presenting to the ED for acute care. Main outcome measure Use of CAM therapies to treat children. Secondary measures include the type of therapies used, types of medical problems the therapies were used for, reasons for using such therapies, use of such therapies by the child’s caretakers, and sociodemographic characteristics of the children and families. Results A review of 525 completed surveys identified 63 caretakers (12%) who acknowledged that they had used at least one form of CAM therapy to treat any of their children. Homeopathic and naturopathic remedies were the most common therapies used. Parents most often used CAM therapies to treat respiratory problems in their children and were most influenced by word-of-mouth. Children who were treated with CAM therapies were more likely to have a caretaker who used such therapies. Twelve (40%) of 30 families who reported using either an herbal or homeopathic remedy, also used a prescription or over-the-counter medication at the same time to treat their child. Thirty-nine of 55 families (70.9%) reported informing their child’s physician of their use of CAM therapies. Conclusion CAM therapies are frequently used to treat children. Most parents who use CAM therapies to treat their children use such therapies themselves. Large proportions of children who are taking herbal supplements are also taking prescription or over-the-counter medications concurrently.

When is a patient safe for discharge after procedural sedation? The timing of adverse effect events in 1,367 pediatric procedural sedations

STUDY OBJECTIVES The optimal timing of discharge from the emergency department (ED) after pediatric procedural sedation and analgesia has not been well studied. Because concern about delayed adverse effects commonly delays discharge after sedation, we attempted to establish the timing of adverse effects in our cohort of procedural sedations. METHODS We analyzed data from a prospectively generated database comprising consecutive sedation events throughout a 2-year period. We determined the timing of serious (eg, hypoxia, stridor, hypotension) and other adverse effects from final medication administration and calculated adverse effect risk ratios in relation to sedation characteristics. RESULTS In 1341 sedation events, there were 184 (13.7%) adverse effects, of which 159 (11.9%) were serious. The median age of children with and without adverse effects was similar (64 months in both groups). Most adverse effects occurred during the procedure (92%) rather than after the procedure (8%). Serious adverse effects occurred a median of 2 minutes after final medication dose (range -106 to +40 minutes). One hypoxic episode occurred each at 26, 30, and 40 minutes after final medication administration; all were repeated occurrences in children who had experienced previous hypoxia during the expected peak drug effect. CONCLUSION Adverse effects were common; however, serious adverse effects rarely occurred after 25 minutes from the final medication administration. Those that did occur this late were all preceded by a separate similar adverse effect during the expected peak drug effect, which suggests that when similar medication regimens are used, discharge from the ED may be safe at approximately 30 minutes after final sedation medication administration if no adverse effects have occurred.

A comparison of dog bite injuries in younger and older children treated in a pediatric emergency department.

Objective Dog bites account for a significant number of traumatic injuries in the pediatric population that often require medical treatment. Although agent, host, and environmental characteristics of dog bites have been well documented, no attempt has been made to compare these characteristics by patient age group. The purpose of this study is to determine if differences exist in agent, host, and environmental characteristics among younger (≤6 y) and older (>7 y) patients treated in a pediatric emergency department (ED) for dog bites. Findings from our study could be used to develop age-specific strategies for dog bite prevention. Theoretical Framework The epidemiologic triad of agent/host/environment formed the theoretical framework. Methods The study setting was the ED at Children’s Hospital of Pittsburgh. Patients were enrolled between 1999 and 2000 and were identified through a review of ED records (n = 386) of children sustaining dog bites. Records were abstracted with a researcher-designed and validated form for agent (eg, breed, number of biting dogs, owner, rabies status), host (eg, age, gender, number and location of bites, treatment), and environmental (eg, bite month and time, bite location, events leading to the bite, ZIP code) characteristics. Data were analyzed using descriptive and inferential statistical tests. Results Children younger than 6 years constituted 52.8% (n = 204) of the sample. As compared with older children, a higher proportion of younger children were bitten by their family dog (χ2 = 27.64, P = 0.001) whose rabies shots were up to date (χ2 = 12.08, P = 0.034). A higher proportion of younger children were bitten on the face (χ2 = 49.54, P = 0.000) and were bitten in their own homes (χ2 = 16.075, P = 0.013). Implications for Nursing Practice Young children frequently sustain dog bites from their family dog in their own homes. Injuries typically involve severe lacerations to the face. Prevention strategies for young children include close supervision of child–dog interactions.

Clinical evaluation of a quantitative real time polymerase chain reaction assay for diagnosis of primary Epstein-Barr virus infection in children.

Background. Epstein-Barr virus (EBV) infectious mononucleosis is often diagnosed based on characteristic clinical features and either a positive heterophil antibody test or serology, both of which can be unreliable in young children. Real time quantitative PCR assays that measure EBV DNA load in serum or plasma are highly sensitive in young children, but serum and plasma contain inhibitors of PCR which must be removed by DNA extraction techniques. A real time TaqMan PCR assay was designed and evaluated for simultaneously measuring EBV DNA load and validating the removal of PCR inhibitors from serum samples. Methods. A serum sample was available from patients classified serologically as primary EBV infection (n = 28), EBV-seronegative (n = 25) and EBV-seropositive (n = 26). Patients were classified as having EBV infectious mononucleosis if they had specified clinical findings and ≥10% atypical lymphocytes in peripheral blood or had a positive Monospot test result. DNA was purified by a spin column method and tested in PCR reactions with primers for EBV DNA polymerase gene and internal control targets. Amplification of the two PCR products was measured in real time with separate TaqMan DNA probes labeled with various fluorescent reporters. Results. The mean age of study patients was 9 years, 4 months. Twenty-one (75%) of the patients in the primary EBV infection group, one (4%) of the seronegatives and none of the seropositives had detectable EBV DNA. Within the primary infection group, those with detectable virus were more likely than those without detectable virus to have evidence of lymphadenopathy (14 of 16 vs. 1 of 5; P = 0.011), higher mean atypical (11.7 vs. 0.9%; P = 0.002) and absolute atypical (1.5 vs. 0.1 × 109/l; P = 0.004) lymphocyte count, higher mean absolute lymphocyte count (4.7 vs. 2.3 × 109/l; P = 0.026) and higher mean aspartate aminotransferase value (119.8 vs. 37.3 IU/l; P = 0.036). Ten patients, all in the primary infection group, had EBV infectious mononucleosis, and all had positive PCR results. No sample contained PCR inhibitors. Conclusions. A real time TaqMan PCR assay allows rapid identification of patients with primary EBV infection and those with EBV infectious mononucleosis.

Prehospital care and outcome of pediatric out-of-hospital cardiac arrest ☆

Cardiac arrest in children outside the hospital is associated with high mortality rates. Recent investigations have suggested that the use of advanced life support (ALS) measures by emergency medical services (EMS) personnel may decrease survival. These studies have used the pediatric Utstein style of defining ALS and basic life support (BLS) measures. The pediatric Utstein style defines BLS as “an attempt to restore effective ventilation and circulation” using noninvasive means to open the airway but specifically excludes the use of bag-valve-mask devices. Advanced life support is defined as the “addition of invasive maneuvers to restore effective ventilation and circulation.” The authors of the study described below believe that using this definition would categorize some patients into an ALS group who would otherwise be categorized as having received BLS (i.E., “bag-valve-mask only”). Objective: To compare survival rates among children receiving BLS or ALS following out-of-hospital cardiac arrest using amended definitions of prehospital life support measures. Specifically, the definition of BLS was expanded to include the use of bag-valve-mask devices only. Methods: This was a retrospective chart review in an urban, pediatric emergency department. Patients included all children presenting to the emergency department between January 1, 1986, and December 31, 1999, following out-of-hospital cardiac arrest. The main outcome measure was survival to hospital discharge. Results: Two hundred ten children were identified. Twenty-one patients were excluded from further analysis because of absent or incomplete medical records. One hundred eighty-nine patients were studied. Five children (2.6%) survived to discharge from the hospital. Of 189 children, 39 (20.6%) were provided BLS measures by prehospital personnel; 150 (79.4%) received ALS. There was no significant difference between groups in survival to hospital discharge. Patients who survived to hospital discharge were more likely to be in sinus rhythm upon arrival in the emergency department (p < 0.001) and to have received fewer doses of standard-dose epinephrine in the emergency department (p < 0.001). Conclusion: The use of ALS by prehospital personnel for children with out-of-hospital cardiac arrest did not improve survival to discharge from the hospital when compared with the use of BLS.

Telemedicine in Pediatric Transport: A Feasibility Study

Objective. Investigate the hypothesis that telemedicine, in the form of real-time audiovisual transmission, would permit accurate assessment of illness severity and allow improved triage for transport. Methods. A prospective study comparing assessments of patients examined conventionally (in person) and remotely by a telemedicine link. Fifteen patients (3 months to 14 years of age) admitted to our emergency department were evaluated as if for transport. Patients were evaluated simultaneously by a physically present pediatric emergency room physician and by a pediatric critical care physician linked to the examining room by a broadband audiovisual link. Each physician completed a patient assessment questionnaire independently. The sensitivity and specificity of the patient assessment by the audiovisually linked physician were calculated. Results. Sensitivity, ie, the ability of the remote, audiovisually connected telemedicine physician to detect abnormal findings, is 87.5%. Specificity, the ability of the remote physician to detect normal findings, is 93%. It is likely that sensitivity would be markedly improved with addition of an electronic stethoscope. Conclusion. This study demonstrates that pediatric patients may be assessed accurately with a broadcast-quality real-time audiovisual system. Such a system may have dramatic implications for providing pediatric specialty and subspecialty care in underserved areas.

Treatment of shigellosis with cefixime: two days vs. five days.

Background. Although the recommended standard course of therapy for shigellosis is 5 days of oral ampicillin or trimethoprim‐sulfamethoxazole therapy, successful outcome has been reported in adults treated with abbreviated courses of antibiotics. The purpose of this study was to compare short course (2‐day) vs. 5‐day therapy with cefixime for treatment of diarrheal disease caused by Shigella sonnei in children. Methods. This was a prospective, randomized, double blind, placebo‐controlled study. Patients were eligible if they were at least 6 months of age and presented to the Childrens Hospital of Pittsburgh during an outbreak of diarrhea caused by S. sonnei, with (1) a history of fever and diarrhea (at least three loose or watery stools per day), (2) bloody diarrhea or (3) diarrhea and known exposure to an individual with documented shigellosis. Patients were randomized to receive either 2 days of cefixime (8 mg/kg/day) given once daily followed by 3 days of placebo or 5 days of cefixime. Telephone follow‐up was performed on Days 3, 7 and 14 after enrollment. Follow‐up stool cultures were obtained on Day 7 to assess bacteriologic cure. There were standardized definitions for cure, improvement, failure and relapse. Results. Forty‐seven patients were enrolled. Eleven were eliminated from analysis because their stool cultures were not positive for S. sonnei. There were 36 evaluable patients, 21 in the 2‐day group and 15 in the 5‐day group. Patients ranged in age from 6 months to 17 years. Forty‐four percent of the subjects were male. Symptoms were improved or had resolved by Day 3 of therapy in all patients. There were 8 patients who experienced a clinical relapse: 5 of 21 (24%) patients in the 2‐day treatment group and 3 of 15 (20%) in the 5‐day group. There were 13 patients who experienced a bacteriologic failure (defined as the occurrence of a positive culture at the Day 7 follow‐up visit), 11 of 20 (55%) in the 2‐day group and 2 of 14 (14%) in the 5‐day group (P < 0.02). Conclusion. Two‐ and 5‐day treatment courses with cefixime for treatment of diarrheal disease caused by S. sonnei result in similar rates of clinical cure and clinical relapses; however, there was a higher rate of bacteriologic failure with shorter course therapy.

Race and Acute Abdominal Pain in a Pediatric Emergency Department

OBJECTIVE: To investigate the demographic and clinical factors of children who present to the pediatric emergency department (ED) with abdominal pain and their outcomes. METHODS: A review of the electronic medical record of patients 1 to 18 years old, who presented to the Children’s Hospital of Pittsburgh ED with a complaint of abdominal pain over the course of 2 years, was conducted. Demographic and clinical characteristics, as well as visit outcomes, were reviewed. Subjects were grouped by age, race, and gender. Results of evaluation, treatment, and clinical outcomes were compared between groups by using multivariate analysis and recursive partitioning. RESULTS: There were 9424 patient visits during the study period that met inclusion and exclusion criteria. Female gender comprised 61% of African American children compared with 52% of white children. Insurance was characterized as private for 75% of white and 37% of African American children. A diagnosis of appendicitis was present in 1.9% of African American children and 5.1% of white children. Older children were more likely to be admitted and have an operation associated with their ED visit. Appendicitis was uncommon in younger children. Constipation was commonly diagnosed. Multivariate analysis by diagnosis as well as recursive partitioning analysis did not reflect any racial differences in evaluation, treatment, or outcome. CONCLUSIONS: Constipation is the most common diagnosis in children presenting with abdominal pain. Our data demonstrate that no racial differences exist in the evaluation, treatment, and disposition of children with abdominal pain.

Emergency Department Evaluation of Ventricular Shunt Malfunction Is the Shunt Series Really Necessary

Objective: The malfunction of a ventricular shunt is one of the most common clinical problems encountered in pediatric neurosurgery. Standard emergency department (ED) evaluation of suspected shunt malfunction consists of plain radiographs of the skull, neck, chest, and abdomen (shunt series) to look for mechanical breaks, kinks, and disconnections in the shunt, and a cranial computed tomography (CT) scan to evaluate for signs of increased ventricular size. We hypothesized, however, that in the context of a cranial CT scan that did not demonstrate a shunt malfunction, obtaining the shunt series would not prove to be clinically useful. Methods: A retrospective chart review was conducted of all patients younger than 18 years with a history of a ventricular shunt who presented to an urban, tertiary pediatric ED between January 1, 2000, and September 30, 2004, for suspected shunt malfunction. Demographic and clinical characteristics of patients were recorded, as well as the results of shunt series and cranial CT scans. Shunt malfunction was defined as the performance of a shunt revision within 1 week of radiographic evaluation. Results: During the study period, 291 children with a ventricular shunt were evaluated in the ED 461 times for suspected shunt malfunction. The mean age of patients was 90.6 months (SD, 71.5 months); 163 (58.5%) were men, and 209 (71.8%) were white. Three hundred sixty patients (78.1%) had a shunt series performed during their ED evaluation, and 410 (88.9%) had a CT scan of the head. Seventy-one patients (15.4%) were diagnosed with shunt malfunction. Twenty-two had a normal cranial CT scan. Of these patients, 6 had an abnormal shunt series, and 14 had a normal shunt series. Conclusions: The routine use of the shunt series seems warranted in the evaluation of the child with suspected shunt malfunction as children with shunt malfunction may present with a normal cranial CT scan but an abnormal shunt series.

Evaluation of a new rapid antigen detection kit for group A beta-hemolytic streptococci.

Objective: To evaluate the use of a new rapid antigen-detection kit for group A beta-hemolytic streptococcus and compare results with previously published studies. Methods: Throat swabs were obtained prospectively from patients, aged one to 18 years, presenting to the emergency department, acute concerns clinic, and walk-in clinic of an urban tertiary care childrens hospital. Throat swabs were first inoculated on a 5% sheep blood agar plate and then used for the streptococcus A optical immunoassay (OIA) kit. Results of both the throat culture and the rapid antigen-detection test were then compared. Results: Two-hundred thirty-three patients were enrolled. Seventy-three patients had a positive culture and 63 patients had a positive OIA. Fifteen patients had a false negative result for the OIA kit and five patients had a false positive result Test sensitivity was 79.5%, specificity was 96.9%, positive predictive value was 92.1%, and negative predictive value was 91.2% Conclusion: Although previous studies have demonstrated OIA kit sensitivities as high as 98.9% and authors have, as a result, recommended that the performance of a backup throat culture for a negative OIA test is unnecessary, our results do not support this. A sensitivity of 79.5% is not sufficiently high to justify omission of a standard throat culture. Accordingly, all OIA tests that are negative should be confirmed by the performance of a throat culture.