New Horizons in Emergency Department Management of Pediatric Sickle Cell Disease.

ABSTRACT: Sickle cell disease (SCD) is an important topic for emergency medicine audiences because complications of the disease account for a large proportion of hematologic emergencies that are seen in the emergency department each year. Early recognition and aggressive management of emergency complications of SCD can help to reduce the morbidity and mortality associated with this disease. Although the treatment recommendations for some complications of SCD are based on expert opinion, there has been advancement in the understanding of the pathogenesis of the disease and evidence regarding the treatment options available for managing acute complications. This continuing medical education article will provide a summary of the clinical manifestation and management of the most common acute complications of SCD: infection, vaso-occlusive episode, acute chest syndrome, splenic sequestration, stroke, and priapism.

Intranasal fentanyl and discharge from the emergency department among children with sickle cell disease and vaso-occlusive pain: A multicenter pediatric emergency medicine perspective.

Children with sickle cell disease (SCD) commonly experience vaso-occlusive pain episodes (VOE) due to sickling of erythrocytes, which often requires care in the emergency department. Our objective was to assess the use and impact of intranasal fentanyl for the treatment of children with SCD-VOE on discharge from the emergency department in a multicenter study. We conducted a cross-sectional study at 20 academic pediatric emergency departments in the United States and Canada. We used logistic regression to test bivariable and multivariable associations between the outcome of discharge from the emergency department and candidate variables theoretically associated with discharge. The study included 400 patients; 215 (54%) were female. The median age was 14.6 (interquartile range 9.8, 17.6) years. Nineteen percent (n = 75) received intranasal fentanyl in the emergency department. Children who received intranasal fentanyl had nearly nine-fold greater adjusted odds of discharge from the emergency department compared to those who did not (adjusted odds ratio 8.99, 95% CI 2.81-30.56, p < .001). The rapid onset of action and ease of delivery without intravenous access offered by intranasal fentanyl make it a feasible initial parenteral analgesic in the treatment of children with SCD presenting with VOE in the acute-care setting. Further study is needed to determine potential causality of the association between intranasal fentanyl and discharge from the emergency department observed in this multicenter study.

Return visit rates after an emergency department discharge for children with sickle cell pain episodes.

BACKGROUND: High return visit rates after hospitalization for people with sickle cell disease (SCD) have been previously established. Due to a lack of multicenter emergency department (ED) return visit rate data, the return visit rate following ED discharge for pediatric SCD pain treatment is currently unknown. PROCEDURE: A seven-site retrospective cohort study of discharged ED visits for pain by children with SCD was conducted using the Pediatric Emergency Care Applied Research Network Registry. Visits between January 2017 and November 2021 were identified using previously validated criteria. The primary outcome was the 14-day return visit rate, with 3- and 7-day rates also calculated. Modified Poisson regression was used to analyze associations for age, sex, initial hospitalization rate, and a visit during the COVID-19 pandemic with return visit rates. RESULTS: Of 2548 eligible ED visits, approximately 52% were patients less than 12 years old, 50% were female, and over 95% were non-Hispanic Black. The overall 14-day return visit rate was 29.1% (95% confidence interval [CI]: 27.4%-30.9%; site range 22.7%-31.7%); the 7- and 3-day return visit rates were 23.0% (95% CI: 21.3%-24.6%) and 16.7% (95% CI: 15.3%-18.2%), respectively. Younger children had slightly lower 14-day return visit rates (27.3% vs. 31.1%); there were no associations for site hospitalization rate, sex, and a visit occurring during the pandemic with 14-day returns. CONCLUSION: Nearly 30% of ED discharged visits after SCD pain treatment had a return visit within 14 days. Increased efforts are needed to identify causes for high ED return visit rates and ensure optimal ED and post-ED care.

A Qualitative Systematic Review of Pediatric Patient and Caregiver Perspectives on Pain Management for Vaso-Occlusive Episodes in the Emergency Department.

OBJECTIVES: The primary objective of this study is to describe the experiences of pediatric patients with sickle cell disease (SCD) and their caregivers who have presented to the emergency department (ED) for management of vaso-occlusive pain events. METHODS: We conducted a qualitative systematic review. The search protocol was developed to identify both published and unpublished literature that met inclusion/exclusion criteria. Included articles were primary hospital-based research with study populations that included (but were not limited to) pediatric patients aged 21 years or younger and qualitative or mixed-method analysis. RESULTS: Four themes were identified: (1) patients and caregivers perceive the ED as the last resort; (2) health care professionals in the ED lacked knowledge about SCD but rejected patients' and caregiver's attempts to share experience or advocate for their needs; (3) patients' accounts of pain are doubted because they do not always have "typical" signs of pain; and (4) caregivers identify racism as a reason for suboptimal care in the ED. CONCLUSIONS: There are multiple opportunities to improve management for vaso-occlusive pain events in the ED, including education of health care providers about SCD and complications, partnership between patients/caregivers and providers, and efforts to reduce the impact of systemic racism on health care delivery.

Diagnosis and Management of Pediatric Venous Thromboembolism: New Therapies on the Horizon.

ABSTRACT: The incidence of venous thromboembolism (VTE) is increasing in pediatric patients. Prompt recognition and evaluation of VTE in young patients could prevent significant morbidity or mortality. In contrast to VTE in adults, current treatment guidelines are largely based on expert opinion as limited randomized controlled trial data exist about the appropriate management in pediatric patients with traditional anticoagulants. However, recently approved direct-acting oral anticoagulants in adults are also being investigated in pediatric VTE and these data could inform future evidence-based treatment principles. Thus, healthcare providers must be well informed about the management of pediatric VTE and the data from these trials to date. This continuing medical education article will provide a summary of management of pediatric VTE with particular emphasis on emerging direct-acting oral anticoagulants.

A Multiyear Cross-sectional Study of Guideline Adherence for the Timeliness of Opioid Administration in Children With Sickle Cell Pain Crisis.

STUDY OBJECTIVE: The National Heart, Lung, and Blood Institute evidence-based guidelines for timeliness of opioid administration for sickle cell disease (SCD) pain crises recommend an initial opioid within 1 hour of arrival, with subsequent dosing every 30 minutes until pain is controlled. No multisite studies have evaluated guideline adherence, to our knowledge. Our objective was to determine guideline adherence across a multicenter network. METHODS: We conducted a multiyear cross-sectional analysis of children with SCD who presented between January 1, 2016, and December 31, 2018, to 7 emergency departments (EDs) within the Pediatric Emergency Care Applied Research Network. Visits for uncomplicated pain crisis were included, defined with an International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 code for SCD crisis and receipt of an opioid, excluding visits with other SCD complications or temperature exceeding 38.5°C (101.3°F). Times were extracted from the electronic record. Guideline adherence was assessed across sites and calendar years. RESULTS: A total of 4,578 visits were included. The median time to first opioid receipt was 62 minutes (interquartile range 42 to 93 minutes); between the first and second opioid receipt, 60 minutes (interquartile range 39 to 93 minutes). Overall, 48% of visits (95% confidence interval 47% to 50%) were guideline adherent for first opioid. Of 3,538 visits with a second opioid, 15% (95% confidence interval 14% to 16%) were guideline adherent. Site variation in adherence existed for time to first opioid (range 22% to 70%) and time between first and second opioid (range 2% to 36%; both P<.001). There was no change in timeliness to first dose or time between doses across years (P>.05 for both). CONCLUSION: Guideline adherence for timeliness of SCD treatment is poor, with half of visits adherent for time to first opioid and one seventh adherent for second dose. Dissemination and implementation research/quality improvement efforts are critical to improve care across EDs.

Normal saline bolus use in pediatric emergency departments is associated with poorer pain control in children with sickle cell anemia and vaso-occlusive pain.

Vaso-occlusive pain events (VOE) are the leading cause of emergency department (ED) visits in sickle cell anemia (SCA). This study assessed the variability in use of intravenous fluids (IVFs), and the association of normal saline bolus (NSB), on pain and other clinical outcomes in children with SCA, presenting to pediatric emergency departments (PED) with VOE. Four-hundred charts of children age 3-21 years with SCA/VOE receiving parenteral opioids at 20 high-volume PEDs were evaluated in a retrospective study. Data on type and amount of IVFs used were collected. Patients were divided into two groups: those who received NSB and those who did not. The association of NSB use on change in pain scores and admission rates was evaluated. Among 400 children studied, 261 (65%) received a NSB. Mean age was 13.8 ± 4.9 years; 46% were male; 92% had hemoglobin-SS. The IVFs (bolus and/or maintenance) were used in 84% of patients. Eight different types of IVFs were utilized and IVF volume administered varied widely. Mean triage pain scores were similar between groups, but improvement in pain scores from presentation-to-ED-disposition was smaller in the NSB group (2.2 vs 3.0, P = .03), while admission rates were higher (71% vs 59%, P = .01). Use of NSB remained associated with poorer final pain scores and worse change in pain scores in our multivariable model. In conclusion, wide variations in practice utilizing IVFs are common. NSB is given to >50% of children with SCA/VOE, but is associated with poorer pain control; a controlled prospective trial is needed to determine causality.

A Standardized Clinical Pathway to Decrease Hospital Admissions Among Febrile Children With Sickle Cell Disease.

BACKGROUND AND OBJECTIVE: Recurrent hospital admissions for patients with sickle cell disease (SCD) are costly and contribute to a low quality of life for patients. We implemented a clinical pathway to safely discharge SCD patients with fever who are evaluated in the emergency department (ED) of a large tertiary care center. METHODS: An interdisciplinary team of ED and hematology physicians, nurses, and an improvement advisor developed a clinical pathway that identified febrile SCD patients at low risk of serious bacterial infection based on historical, clinical, and laboratory criteria who could be discharged from the ED. Phone follow-up was planned through the use of an automated electronic notification that was sent to an established hematology follow-up pool at the time of ED discharge. We conducted two "fake front end" trials in the ED to receive feedback on our process before full implementation. A postpathway implementation quality improvement team monitored discharge rates, phone follow-up rates and adverse events. RESULTS: In the first 9 weeks postpathway implementation, 100 SCD patients were evaluated for fever; 84 (24%) met low-risk criteria and were discharged home. This reduction in admission rate has been maintained throughout the 3 years postimplementation. Successful phone follow-up was achieved in all discharged patients within 24 hours and no adverse events were identified. CONCLUSIONS: Low-risk febrile patients with SCD can be safely discharged from the ED. An automated notification system within the electronic medical record system can facilitate patient follow-up after ED discharge. Future quality improvement efforts aimed to further reduce admissions in this population should target patients with modifiable risk factors for serious bacterial infection.

Practice Variation in Emergency Department Management of Children With Sickle Cell Disease Who Present With Fever.

OBJECTIVES: Urgent medical evaluation is recommended for patients with sickle cell disease (SCD) and fever. Clear recommendations exist regarding certain aspects of treatment, but other areas lack evidence. We determined practice variation for children with SCD presenting with fever to the emergency department (ED). METHODS: Retrospective chart review of children ages 3 months to 21 years with SCD presenting to the ED with fever greater than or equal to 38.5°C in the ED or preceding 24 hours. Visits from 3 sickle cell centers were included. Outcomes included blood culture, complete blood count, antibiotic treatment, chest x-ray, urinalysis, electrolytes, and hospital disposition. Differences greater than 10% were considered clinically meaningful. RESULTS: The population included 14,454 visits, of which 4143 (29%) were febrile and met all inclusion criteria. A complete blood count and blood culture were obtained at 94% of visits, and antibiotics were given at 91%, with no differences among sites. Meaningful differences existed for disposition, with 52%, 43%, and 99% of patients admitted to the inpatient units at hospitals A, B, and C, respectively. Differences were seen in obtaining a urinalysis (33%, 17%, and 21%), electrolytes (2%, 50%, and 12%), and chest x-rays for patients 2 years and older (78%, 77%, 64%) for hospitals A, B, and C, respectively. CONCLUSIONS: Significant variation exists in the proportion of children who receive a urinalysis, electrolytes, chest x-ray, and, most importantly, admission to the hospital. These examples of practice variation represent potential opportunities to define best care practices for children with SCD presenting to the ED for fever.

A multicenter randomized controlled trial of intravenous magnesium for sickle cell pain crisis in children.

Magnesium, a vasodilator, anti-inflammatory, and pain reliever, could alter the pathophysiology of sickle cell pain crises. We hypothesized that intravenous magnesium would shorten length of stay, decrease opioid use, and improve health-related quality of life (HRQL) for pediatric patients hospitalized with sickle cell pain crises. The Magnesium for Children in Crisis (MAGiC) study was a randomized, double-blind, placebo-controlled trial of intravenous magnesium vs normal saline placebo conducted at 8 sites within the Pediatric Emergency Care Applied Research Network (PECARN). Children 4 to 21 years old with hemoglobin SS or Sß(0) thalassemia requiring hospitalization for pain were eligible. Children received 40 mg/kg of magnesium or placebo every 8 hours for up to 6 doses plus standard therapy. The primary outcome was length of stay in hours from the time of first study drug infusion, compared using a Van Elteren test. Secondary outcomes included opioid use and HRQL. Of 208 children enrolled, 204 received the study drug (101 magnesium, 103 placebo). Between-group demographics and prerandomization treatment were similar. The median interquartile range (IQR) length of stay was 56.0 (27.0-109.0) hours for magnesium vs 47.0 (24.0-99.0) hours for placebo (P = .24). Magnesium patients received 1.46 mg/kg morphine equivalents vs 1.28 mg/kg for placebo (P = .12). Changes in HRQL before discharge and 1 week after discharge were similar (P > .05 for all comparisons). The addition of intravenous magnesium did not shorten length of stay, reduce opioid use, or improve quality of life in children hospitalized for sickle cell pain crisis. This trial was registered at www.clinicaltrials.gov as #NCT01197417.

Determining the longitudinal validity and meaningful differences in HRQL of the PedsQL™ Sickle Cell Disease Module.

BACKGROUND: Detecting change in health status over time and ascertaining meaningful changes are critical elements when using health-related quality of life (HRQL) instruments to measure patient-centered outcomes. The PedsQL™ Sickle Cell Disease module, a disease specific HRQL instrument, has previously been shown to be valid and reliable. Our objectives were to determine the longitudinal validity of the PedsQL™ Sickle Cell Disease module and the change in HRQL that is meaningful to patients. METHODS: An ancillary study was conducted utilizing a multi-center prospective trial design. Children ages 4-21 years with sickle cell disease admitted to the hospital for an acute painful vaso-oclusive crisis were eligible. Children completed HRQL assessments at three time points (in the Emergency Department, one week post-discharge, and at return to baseline (One to three months post-discharge). The primary outcome was change in HRQL score. Both distribution (effect size, standard error of measurement (SEM)) and anchor (global change assessment) based methods were used to determine the longitudinal validity and meaningful change in HRQL. Changes in HRQL meaningful to patients were identified by anchoring the change scores to the patient's perception of global improvement in pain. RESULTS: Moderate effect sizes (0.20-0.80) were determined for all domains except the Communication I and Cognitive Fatigue domains. The value of 1 SEM varied from 3.8-14.6 across all domains. Over 50% of patients improved by at least 1 SEM in Total HRQL score. A HRQL change score of 7-10 in the pain domains represented minimal perceived improvement in HRQL and a HRQL change score of 18 or greater represented moderate to large improvement. CONCLUSIONS: The PedsQL™ Sickle Cell Disease Module is responsive to changes in HRQL in patients experiencing acute painful vaso-occlusive crises. The study data establish longitudinal validity and meaningful change parameters for the PedsQL™ Sickle Cell Disease Module. TRIAL REGISTRATION: ClinicalTrials.gov (study identifier: NCT01197417 ). Date of registration: 08/30/2010.

Implicit Bias in Pediatric Academic Medicine.

OBJECTIVE: Despite known benefits of diversity, certain racial/ethnic groups remain underrepresented in academic pediatrics. Little research exists regarding unconscious racial attitudes among pediatric faculty responsible for decisions on workforce recruitment and retention in academia. This study sought to describe levels of unconscious racial bias and perceived barriers to minority recruitment and retention among academic pediatric faculty leaders. METHODS: Authors measured unconscious racial bias in a sample of pediatric faculty attending diversity workshops conducted at local and national meetings in 2015. A paper version of the validated Implicit Association Test (IAT) measured unconscious racial bias. Subjects also reported perceptions about minority recruitment and retention. RESULTS: Of 68 eligible subjects approached, 58 (85%) consented and completed the survey with IAT. Of participants, 83% had leadership roles and 93% were involved in recruitment. Participants had slight pro-white/anti-black bias on the IAT (M = 0.28, SD = 0.49). There were similar IAT scores among participants in leadership roles (M = 0.33, SD = 0.47) and involved in recruitment (M = 0.28, SD = 0.43). Results did not differ when comparing participants in local workshops to the national workshop (n = 36, M = 0.29, SD = 0.40 and n = 22, M = 0.27, SD = 0.49 respectively; p = 0.88). Perceived barriers to minority recruitment and retention included lack of minority mentors, poor recruitment efforts, and lack of qualified candidates. CONCLUSIONS: Unconscious pro-white/anti-black racial bias was identified in this sample of academic pediatric faculty and leaders. Further research is needed to examine how unconscious bias impacts decisions in academic pediatric workforce recruitment. Addressing unconscious bias and perceived barriers to minority recruitment and retention represent opportunities to improve diversity efforts.

Medulloblastoma With Obstructive Hydrocephalus in a Young Infant.

Medulloblastoma is the most common posterior fossa tumor diagnosed in young infants. The presentation of posterior fossa tumors in neonates is highly variable. We report the case of a 2-month-old child who presented with poor feeding and lethargy and was noted to have a fixed downward gaze. Head computed tomography revealed a posterior fossa mass that was pathologically consistent with a medulloblastoma. This case demonstrates the uncommon presentation of posterior fossa tumors in young infants.

Association between Hospital Volume and Within-Hospital Intensive Care Unit Transfer for Sickle Cell Disease in Children's Hospitals.

OBJECTIVE: To assess the relationship between hospital volume and intensive care unit (ICU) transfer among hospitalized children with sickle cell disease (SCD). STUDY DESIGN: We conducted a retrospective cohort study of 83,477 SCD-related hospitalizations at children's hospitals (2009-2012) using the Pediatric Health Information System database. Hospital-level all-cause and SCD-specific volumes were dichotomized (low vs high). Outcomes were within-hospital ICU transfer (primary) and length of stay (LOS) total (secondary). Multivariable logistic/linear regressions assessed the association of hospital volumes with ICU transfer and LOS. RESULTS: Of 83,477 eligible hospitalizations, 1741 (2.1%) involving 1432 unique children were complicated by ICU transfer. High SCD-specific volume (OR 0.77, 95% CI 0.64-0.91) was associated with lower odds of ICU transfer while high all-cause hospital volume was not (OR 0.87, 95% CI 0.73-1.04). A statistically significant interaction was found between all-cause and SCD-specific volumes. When results were stratified according to all-cause volume, high SCD-specific volume was associated with lower odds of ICU transfer at low all-cause volume (OR 0.46, 95% CI 0.38-0.55). High hospital volumes, both all-cause (OR 0.94, 95% CI 0.92-0.97) and SCD-specific (OR 0.86, 95% CI 0.84-0.88), were associated with shorter LOS. CONCLUSIONS: Children's hospitals vary substantially in their transfer of children with SCD to the ICU according to hospital volumes. Understanding the practices used by different institutions may help explain the variability in ICU transfer among hospitals caring for children with SCD.

Use of Oral Contrast for Abdominal Computed Tomography in Children With Blunt Torso Trauma.

STUDY OBJECTIVE: We compare test characteristics of abdominal computed tomography (CT) with and without oral contrast for identifying intra-abdominal injuries. METHODS: This was a planned subanalysis of a prospective, multicenter study of children (<18 years) with blunt torso trauma. Children imaged in the emergency department with abdominal CT using intravenous contrast were eligible. Oral contrast use was based on the participating centers' guidelines and discretions. Clinical courses were followed to identify patients with intra-abdominal injuries. Abdominal CTs were considered positive for intra-abdominal injury if a specific intra-abdominal injury was identified and considered abnormal if any findings suggestive of intra-abdominal injury were identified on the CT. RESULTS: A total of 12,044 patients were enrolled, with 5,276 undergoing abdominal CT with intravenous contrast. Of the 4,987 CTs (95%) with documented use or nonuse of oral contrast, 1,010 (20%) were with and 3,977 (80%) were without oral contrast; 686 patients (14%) had intra-abdominal injuries, including 127 CTs (19%) with and 559 (81%) without oral contrast. The sensitivity in the detection of any intra-abdominal injury in the oral contrast versus no oral contrast groups was sensitivitycontrast 99.2% (95% confidence interval [CI] 95.7% to 100.0%) versus sensitivityno contrast 97.7% (95% CI 96.1% to 98.8%), difference 1.5% (95% CI -0.4% to 3.5%). The specificity of the oral contrast versus no oral contrast groups was specificitycontrast 84.7% (95% CI 82.2% to 87.0%) versus specificityno contrast 80.8% (95% CI 79.4% to 82.1%), difference 4.0% (95% CI 1.3% to 6.7%). CONCLUSION: Oral contrast is still used in a substantial portion of children undergoing abdominal CT after blunt torso trauma. With the exception of a slightly better specificity, test characteristics for detecting intra-abdominal injury were similar between CT with and without oral contrast.

Building a Physician-Scientist Pathway for Underrepresented Medical Students Through a Summer Research Experience.

PROBLEM: There is a need to increase the number of physician-scientists from underrepresented in medicine (URiM) groups. To engage URiM medical students, a committee of pediatric departmental leaders at the Children's Hospital of Philadelphia created the Summer Underrepresented in Medicine Medical Student Research program. This 8-week, onsite research and clinical experience takes place during the summer between students' first and second years of medical school. APPROACH: Applications were solicited between 2019-2023 through nationwide outreach to medical school deans and members of URiM student organizations. Accepted students were assigned a mentor to lead their research and clinical exposure. A curriculum highlighting aspects of academic medicine was developed. Students received a $3,000-$5,500 stipend for in-person participation. In 2020 and 2021, adjustments were made (e.g., virtual programming) to avoid interruptions during the COVID-19 pandemic. OUTCOMES: In the 2019-2023 application cycles, 298 students applied. Of 128 students who participated, 78 (61%) completed a postprogram survey. Students' survey feedback was positive. They indicated the program met expectations (mean rating = 1.3; scale: 1 = strongly agree to 5 = strongly disagree). Students reported they learned valuable information/skills (mean = 1.3) and that participation was worth time spent away from other responsibilities (mean = 1.3). The 2019 cohort (n = 12) achieved a 100% residency match rate. In addition, 4 (33%) of these students reported they are obtaining additional degrees or are performing research. After the program, many mentors continued to include students in their research projects. NEXT STEPS: Next steps include incorporating a standardized, scored rubric for selecting applicants; adding 3 lead mentors, an executive committee, and a faculty advisory board; establishing earlier pathway programming (e.g., at elementary and middle school levels); continuing to track/support alumni throughout their careers; and pursuing federal funding to expand the program.

Trends in blood transfusion among hospitalized children with sickle cell disease.

BACKGROUND: Blood transfusions represent a major therapeutic option in acute management of sickle cell disease (SCD). Few data exist documenting trends in transfusion among children with SCD, particularly during hospitalization. PROCEDURE: This was an analysis of cross-sectional data of hospital discharges within the Kid's Inpatient Database (years 1997, 2000, 2003, 2006, 2009). Hospitalizations for children (0-18 years) with a primary or secondary SCD-related diagnosis were examined. The primary outcome was blood transfusion. Trends in transfusion were assessed using weighted multivariate logistic regression in a merged dataset with year as the primary independent variable. Co-variables consisted of child and hospital characteristics. Multivariate logistic regression was conducted for 2009 data to assess child and hospital-level factors associated with transfusion. RESULTS: From 1997 to 2009, the percentage of SCD-related hospitalizations with transfusion increased from 14.2% to 28.8% (P < 0.0001). Among all SCD-related hospitalizations, the odds of transfusion increased over 20% for each successive study interval. Hospitalizations with vaso-occlusive pain crisis (OR 1.35, 95% CI 1.27-1.43) or acute chest syndrome/pneumonia (OR 1.24, 95% CI 1.13-1.35) as the primary diagnoses had the highest odds of transfusion for each consecutive study interval. Older age and male gender were associated with higher odds of transfusion. CONCLUSIONS: Blood transfusion is increasing over time among hospitalized children with SCD. Further study is warranted to identify indications contributing to the rise in transfusions and if transfusions in the inpatient setting have been used appropriately. Future studies should also assess the impact of rising trends on morbidity, mortality, and other health-related outcomes.

Identifying children at very low risk of clinically important blunt abdominal injuries.

STUDY OBJECTIVE: We derive a prediction rule to identify children at very low risk for intra-abdominal injuries undergoing acute intervention and for whom computed tomography (CT) could be obviated. METHODS: We prospectively enrolled children with blunt torso trauma in 20 emergency departments. We used binary recursive partitioning to create a prediction rule to identify children at very low risk of intra-abdominal injuries undergoing acute intervention (therapeutic laparotomy, angiographic embolization, blood transfusion for abdominal hemorrhage, or intravenous fluid for ≥2 nights for pancreatic/gastrointestinal injuries). We considered only historical and physical examination variables with acceptable interrater reliability. RESULTS: We enrolled 12,044 children with a median age of 11.1 years (interquartile range 5.8, 15.1 years). Of the 761 (6.3%) children with intra-abdominal injuries, 203 (26.7%) received acute interventions. The prediction rule consisted of (in descending order of importance) no evidence of abdominal wall trauma or seat belt sign, Glasgow Coma Scale score greater than 13, no abdominal tenderness, no evidence of thoracic wall trauma, no complaints of abdominal pain, no decreased breath sounds, and no vomiting. The rule had a negative predictive value of 5,028 of 5,034 (99.9%; 95% confidence interval [CI] 99.7% to 100%), sensitivity of 197 of 203 (97%; 95% CI 94% to 99%), specificity of 5,028 of 11,841 (42.5%; 95% CI 41.6% to 43.4%), and negative likelihood ratio of 0.07 (95% CI 0.03 to 0.15). CONCLUSION: A prediction rule consisting of 7 patient history and physical examination findings, and without laboratory or ultrasonographic information, identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention. These findings require external validation before implementation.

Emergency department epidemiology of pneumococcal bacteremia in children since the institution of widespread PCV7 vaccination.

BACKGROUND: The heptavalent pneumococcal conjugate vaccine (PCV7) has produced a shift in the epidemiology of invasive infections from Streptoccoccus pneumoniae. OBJECTIVE: Our aim was to determine the temporal changes in pneumococcal bacteremia (Streptococcus pneumoniae bacteremia [SPB]) in the emergency department (ED) since the introduction of PCV7. METHODS: This was a retrospective cohort study of children 0-18 years with SPB evaluated from 1998-2009 in a tertiary-care pediatric ED. The primary outcome was annual proportion of children with SPB from PCV7 serotypes (ie, 4, 6B, 9V, 14, 18C, 19F, and 23F) and nonvaccine serotypes (NVT). Rates of SPB (per 10,000 ED visits) were calculated. SPB was analyzed by time period: before October 2000 was considered "pre-PCV7," November 2000 to October 2003 was considered "peri-PCV7," and after November 2003 was "post-PCV7." Febrile young children (FYC) were defined as children age <36 months and fever without source. RESULTS: A total of 201 episodes of SPB occurred during the study, with a median age of 20.3 months (interquartile range 10.7-49.5 months; range 1.6-215.4 months); 56.7% were male and 69.7% were African American. SPB from PCV7 serotypes decreased more than fourfold, from 82.2% pre-PCV7 to 19.5% peri- and post-PCV7. Most SPB was from NVT serotype 19A (31.3%) peri- and post-PCV7. Annual rates of SPB were 4.01/10,000 ED visits pre-PCV7, decreasing to 2.10 peri-PCV7, and 1.75 post-PCV7. Among the 56 (27.8%) FYC with SPB, NVT were responsible for 11.5% of SPB pre-PCV7, and increased to 80.0% peri- and post-PCV7 (p < 0.001). CONCLUSIONS: Rates of SPB have decreased since the introduction of PCV7, yet SPB still occurs among children in the ED. NVT are increasing in prevalence, and SPB from PCV7-serotypes have decreased.