Sharon R. Smith

Childhood Overweight Increases Hospital Admission Rates for Asthma

OBJECTIVES. Although childhood overweight has been associated with increased hospital lengths of stay for patients with asthma, the possible relationship between overweight and hospital admission for asthma has not been well studied. We hypothesized that overweight children who presented to the emergency department with asthma exacerbations were more likely to be admitted to the hospital than nonoverweight children. METHODS. A retrospective chart review was conducted of all children who were older than 2 years and presented to the emergency department with an asthma exacerbation in calendar year 2005. Children with chronic medical conditions other than asthma were excluded. Children were classified as nonoverweight (≤95% weight-for-age percentile) or overweight (>95% weight for age). RESULTS. During the study period, there were 884 visits to the emergency department for an asthma exacerbation by 813 children; 238 (27%) were admitted to the hospital, and 33 (4%) were admitted to the ICU. Overall, hospital admission was associated with higher clinical asthma score but not with age, gender, or poverty status (as quantified as home in zip-code areas designated as “impoverished”). Overweight children (n = 202 [23%]) were significantly older (8.5 ± 4.4 vs 7.3 ± 4.3 years) and more likely to live in an impoverished area (37% vs 28%). Presenting clinical asthma score and therapeutic interventions in the emergency department were similar for overweight and nonoverweight children; however, overweight children were significantly more likely to be admitted to the hospital. CONCLUSIONS. Overweight children who present to the emergency department with acute asthma exacerbations are significantly more likely to be admitted to the hospital than nonoverweight children. This identifies an important area in which childhood overweight has a significant impact on the health of children with asthma.

Recombinant human hyaluronidase-enabled subcutaneous pediatric rehydration.

OBJECTIVES: The Increased Flow Utilizing Subcutaneously-Enabled (INFUSE)-Pediatric Rehydration Study was designed to assess efficacy, safety, and clinical utility of recombinant human hyaluronidase (rHuPH20)-facilitated subcutaneous rehydration in children 2 months to 10 years of age. METHODS: Patients with mild/moderate dehydration requiring parenteral treatment in US emergency departments were eligible for this phase IV, multicenter, single-arm study. They received subcutaneous injection of 1 mL rHuPH20 (150 U), followed by subcutaneous infusion of 20 mL/kg isotonic fluid over the first hour. Subcutaneous rehydration was continued as needed for up to 72 hours. Rehydration was deemed successful if it was attributed by the investigator primarily to subcutaneous fluid infusion and the child was discharged without requiring an alternative method of rehydration. RESULTS: Efficacy was evaluated in 51 patients (mean age: 1.9 years; mean weight: 11.2 kg). Initial subcutaneous catheter placement was achieved with 1 attempt for 46/51 (90.2%) of patients. Rehydration was successful for 43/51 (84.3%) of patients. Five patients (9.8%) were hospitalized but deemed to be rehydrated primarily through subcutaneous therapy, for a total of 48/51 (94.1%) of patients. No treatment-related systemic adverse events were reported, but 1 serious adverse event occurred (cellulitis at infusion site). Investigators found the procedure easy to perform for 96% of patients (49/51 patients), and 90% of parents (43/48 parents) were satisfied or very satisfied. CONCLUSIONS: rHuPH20-facilitated subcutaneous hydration seems to be safe and effective for young children with mild/moderate dehydration. Subcutaneous access is achieved easily, and the procedure is well accepted by clinicians and parents.

ACUTE ASTHMA IN THE PEDIATRIC EMERGENCY DEPARTMENT

The management of children with acute asthma remains a difficult and challenging process. Although newer asthma medications are being developed, they are unlikely to have a large impact on the management of children with acute asthma. The leukotriene inhibitors are new anti-inflammatory agents for asthma and are beneficial for the treatment of patients with chronic asthma but have no therapeutic effect during the acute phase of an exacerbation. Older treatments, including the use of magnesium and heliox, have been revisited. Although some children with severe asthma may respond, these do not provide relief for most children with acute exacerbation. The new challenge for asthma care is finding ways to link children with their primary care providers so that regular asthma care can be established. The NHLBI recommends that children with asthma have regular visits with their primary care providers (e.g., four times a year). Regular care results in better adherence to medical and preventive management plans and improves the relationship between patients and physicians. Instituting an asthma action plan, which instructs families on when and how to begin therapy for an acute exacerbation, may prevent progression to a more severe condition.

Cost effectiveness of trauma quality assurance audit filters.

The American College of Surgeons Committee on Trauma (ACSCOT) has published recommended minimal audit filters for trauma quality assurance. In this study ten filters were assessed through variable sample sizes over a 1-year period for cost and efficiency. Each filtered case was screened by trauma nurse coordinators. The trauma director reviewed possible deviations from standard and presented cases at peer review conferences for consensus on problem identification. While several filters had reasonable yield, most filters had minimal or no yield. Ten de novo problems were identified at a cost of +1,000 per de novo problem. Six filters were modified based on common reasons for overfiltration, resulting in a substantial reduction in filtration rate without losing problem identification. We conclude that ACSCOT audit filters 1 (unexpected deaths), 4 (ICU LOS greater than twice the average), 5 (trauma surgeon response), and 9 (major surgery greater than 24 hours) have a reasonable yield. Filters 2, 3, 7, 8, 11, and 12 have limited value to an established suburban trauma center and are not cost effective. Modifications of these filters can reduce cost without obvious impact on effectiveness. Specific audit filters recommended for future study are presented.

Case report of metallic mercury injury.

Objective: Injury and poisoning from metallic mercury has become a rare event. Review of the literature and a case report of pediatric metallic mercury injury are presented. Design: A case report Setting: The Emergency Department at St. Louis Childrens Hospital. Patients or participants: A 15-year-oldboy Interventions: None Main outcome measures: None Results: The 15-year-old boy fell on a broken mercury thermometer. A subcutaneous abscess formed on his left forearm during the next five days. He had no signs or symptoms of mercury toxicity. His wound was debrided in the operating room and healed completely after several months. Conclusions: This case shows elemental mercury from a thermometer as a potential, if unusual, source of mercury toxicity

A Randomized Controlled Trial of Parental Asthma Coaching to Improve Outcomes Among Urban Minority Children

OBJECTIVES To investigate whether asthma coaching decreases emergency department (ED) visits and hospitalizations and increases outpatient asthma monitoring visits. DESIGN Randomized controlled trial. SETTING Urban tertiary care childrens hospital. PARTICIPANTS Primary caregivers (hereafter referred to as parents) of children aged 2 to 10 years with asthma who have Medicaid insurance coverage and are urban residents who were attending the ED for acute asthma care. INTERVENTION Eighteen months of participating in usual care (control group) vs receiving coaching focused on asthma home management, completion of periodic outpatient asthma monitoring visits, and development of a collaborative relationship with a primary care provider (intervention group). MAIN OUTCOME MEASURES The primary outcome was ED visits. Secondary outcomes were hospitalizations and asthma monitoring visits (nonacute visits focused on asthma care). Outcomes were measured during the year before and 2 years after enrollment. RESULTS We included 120 intervention parents and 121 control parents. More children of coached parents had at least 1 asthma monitoring visit after enrollment (relative risk [RR], 1.21; 95% confidence interval [CI], 1.04-1.41), but proportions with at least 4 asthma monitoring visits during 2 years were low (20.0% in the intervention group vs 9.9% in the control group). Similar proportions of children in both study groups had at least 1 ED visit (59.2% in the intervention group vs 62.8% in the control group; RR, 0.94; 95% CI, 0.77-1.15) and at least 1 hospitalization (24.2% in the intervention group vs 26.4% in the control group; 0.91; 0.59-1.41) after enrollment. An ED visit after enrollment was more likely if an ED visit had occurred before enrollment (RR, 1.46; 95% CI, 1.16-1.86; adjusted for study group), but risk was similar in both study groups when adjusted for previous ED visits (1.02; 0.82-1.27). CONCLUSION This parental asthma coaching intervention increased outpatient asthma monitoring visits (although infrequent) but did not decrease ED visits. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00149500.

Pilot study of oral montelukast added to standard therapy for acute asthma exacerbations in children aged 6 to 14 years.

Objective: We hypothesized that children with moderate acute asthma exacerbations receiving oral montelukast with standard therapy will have at least 12% greater forced expiratory volume in 1 second (FEV1) improvement in 3 hours than those receiving standard therapy alone. Methods: In this randomized, double-blind, placebo-controlled study, we enrolled emergency patients aged 6 to 14 years with moderate acute asthma exacerbations (peak expiratory flow rate, 40%-70% predicted). Subjects received montelukast 5 mg or placebo orally then standard therapy. We measured FEV1 before study medication administration and hourly for 3 hours. The primary outcome was FEV1% predicted change at 3 hours. Results: At the time of the planned interim analysis, we had enrolled 27 subjects; 23 (11 montelukast, 12 placebo) had a complete FEV1 data. Both groups had similar mean FEV1 increases at 3 hours (mean [SD]: montelukast = 16.8% [11.4%], placebo = 19.9% [12.1%]; 95% confidence interval for difference = −12.22% to 5.95%). Based on further analysis, we determined that enrollment of the planned sample was unlikely to significantly change the results. If our study hypothesis were true, the montelukast group mean FEV1 increase should be 32% or greater. The probabilities were low that the montelukast sample could be drawn from a normally distributed population with a mean of 32% and that subsequently enrolled montelukast subjects would have sufficient FEV1 improvements to attain a mean of greater than 32%. Conclusion: Based on these results, for children aged 6 to 14 years with moderate acute asthma exacerbations, oral montelukast (5 mg) added to standard therapy as in this design is unlikely to result in additional FEV1 improvements in 3 hours.

Recruitment into a Long‐Term Pediatric Asthma Study During Emergency Department Visits

Objective: Asthma is the most common chronic illness in childhood. Recruiting children and their parents into a research study in a busy urban emergency department (ED) is challenging. The purpose of this manuscript is to describe the recruitment process and the results of our recruitment in soliciting children and their parents to participate in an ED‐based asthma research study. Methods: The data for this manuscript came from a National Heart, Lung, and Blood Institute‐funded study: Study of Asthma Follow‐up from the Emergency Department (SAFE). SAFE evaluated an ED‐based intervention to link low‐income urban children with asthma to their primary care providers. Two persons were assigned specifically to enrolling, which was done from 0700 to 2300 hours Monday through Friday. Data for the analysis come from the web‐based database, the master log, and the hospitals patient database. A computerized randomization scheme chose 512 patients from all patients in the master log for more detailed demographic analyses. Results: Five hundred twenty‐seven subjects were enrolled between February 1999 and May 2001. There were 9188 children who presented for treatment of an acute asthma exacerbation during this interval. Chart reviews were conducted on a subset of patients presenting to the ED to ensure that the recruitment strategy did not bias the patients enrolled. Comparison of patients who were enrolled with those who were not enrolled indicated no differences by gender, race, insurance status, age, or socioeconomic status of neighborhood residence. Discussion: The high rate of enrollment was primarily due to the two dedicated enrollers. The enrollers quickly learned how to function within the ED and how to interact with both families and ED staff. Strategies identified by the enrollers as helpful in randomizing subjects included visits with the parents shortly after the physician had initiated treatment so that stability of the child had been achieved. Interacting with the child and showing concern for the comfort of both the child and parent during the ED stay were important as well. Conclusion: Recruiting subjects into long‐term follow‐up studies in the ED setting is a departure from traditional ED studies. The ED enrollment offers the distinct advantage of capturing subjects who are unlikely to present for care in other locations. We were able to successfully recruit low‐income urban parents of children with asthma for study of both short‐term and long‐term outcomes. The enrollment process successfully captured the subjects of interest without bias.

De novo mutations in CSNK2A1 are associated with neurodevelopmental abnormalities and dysmorphic features

Whole exome sequencing (WES) can be used to efficiently identify de novo genetic variants associated with genetically heterogeneous conditions including intellectual disabilities. We have performed WES for 4102 (1847 female; 2255 male) intellectual disability/developmental delay cases and we report five patients with a neurodevelopmental disorder associated with developmental delay, intellectual disability, behavioral problems, hypotonia, speech problems, microcephaly, pachygyria and dysmorphic features in whom we have identified de novo missense and canonical splice site mutations in CSNK2A1, the gene encoding CK2α, the catalytic subunit of protein kinase CK2, a ubiquitous serine/threonine kinase composed of two regulatory (β) and two catalytic (α and/or α′) subunits. Somatic mutations in CSNK2A1 have been implicated in various cancers; however, this is the first study to describe a human condition associated with germline mutations in any of the CK2 subunits.

Abdominal CT Does Not Improve Outcome for Children with Suspected Acute Appendicitis

Introduction Acute appendicitis in children is a clinical diagnosis, which often requires preoperative confirmation with either ultrasound (US) or computed tomography (CT) studies. CTs expose children to radiation, which may increase the lifetime risk of developing malignancy. US in the pediatric population with appropriate clinical follow up and serial exam may be an effective diagnostic modality for many children without incurring the risk of radiation. The objective of the study was to compare the rate of appendiceal rupture and negative appendectomies between children with and without abdominal CTs; and to evaluate the same outcomes for children with and without USs to determine if there were any associations between imaging modalities and outcomes. Methods We conducted a retrospective chart review including emergency department (ED) and inpatient records from 1/1/2009–2/31/2010 and included patients with suspected acute appendicitis. Results 1,493 children, aged less than one year to 20 years, were identified in the ED with suspected appendicitis. These patients presented with abdominal pain who had either a surgical consult or an abdominal imaging study to evaluate for appendicitis, or were transferred from an outside hospital or primary care physician office with the stated suspicion of acute appendicitis. Of these patients, 739 were sent home following evaluation in the ED and did not return within the subsequent two weeks and were therefore presumed not to have appendicitis. A total of 754 were admitted and form the study population, of which 20% received a CT, 53% US, and 8% received both. Of these 57%, 95% CI [53.5,60.5] had pathology-proven appendicitis. Appendicitis rates were similar for children with a CT (57%, 95% CI [49.6,64.4]) compared to those without (57%, 95% CI [52.9,61.0]). Children with perforation were similar between those with a CT (18%, 95% CI [12.3,23.7]) and those without (13%, 95% CI [10.3,15.7]). The proportion of children with a negative appendectomy was similar in both groups: CT (7%, 95% CI [2.1,11.9]), US (8%, 95% CI [4.7,11.3]) and neither (12%, 95% CI [5.9,18.1]). Conclusion In this uncontrolled study, the accuracy of preoperative diagnosis of appendicitis and the incidence of pathology-proven perforation appendix were similar for children with suspected acute appendicitis whether they had CT, US or neither imaging, in conjunction with surgical consult. The imaging modality of CT was not associated with better outcomes for children presenting to the ED with suspected appendicitis.