Reducing Abdominal Radiographs to Diagnose Constipation in the Pediatric Emergency Department.

OBJECTIVE: To determine the frequency of abdominal radiographs obtained in healthy children aged 6 months to 18 years to diagnose constipation in a pediatric emergency department, and evaluate the impact of quality improvement (QI) interventions on their use. STUDY DESIGN: QI study over 2.5 years at a large urban quaternary care children's hospital emergency department. Interventions consisted of educational presentations and individualized abdominal radiograph data reporting. The primary outcome measure was the percentage of abdominal radiographs performed on healthy patients discharged home with a diagnosis of constipation before and after QI interventions. RESULTS: The baseline total percentage of abdominal radiographs performed in otherwise healthy children discharged home with a diagnosis of constipation was 36% (October 2016 to January 2018). According to questionnaire results, ruling out obstruction was the most common reason for ordering an abdominal radiograph. After the QI interventions, the total percentage of abdominal radiograph decreased to 18% (April 2018 to March 2019). This 18% decrease was significant (P < .001) and sustained over a 12-month follow-up period. Throughout the study period, the average length of stay was 1.07 hours longer for children who had an abdominal radiograph. Clinically important return visits to the emergency department were uncommon during the postintervention phase (125/1830 [6.8%]), and not associated with whether or not an abdominal radiograph was performed at the initial visit. CONCLUSION: After these QI interventions, we noted a significant and sustained decrease in the percentage of abdominal radiographs obtained for otherwise healthy patients discharged home with a diagnosis of constipation.

Prognostic factors of early outcome and discharge status in patients undergoing surgical intervention following traumatic intracranial hemorrhage.

Over the past several decades, the rate of traumatic brain injury (TBI)-related emergency room visits in the United States has steadily increased, yet mortality in these patients has decreased. This improvement in outcome is largely due to advances in prehospital care, intensive care unit management, and the effectiveness of neurosurgical procedures, such as decompressive craniectomies. It is imperative to identify clinical factors predictive of patients who benefit from early mobilization of resources and operative treatment. Equally important is the identification of patients with good prognostic signs among patients receiving surgical intervention for TBI. We conducted a retrospective chart review of 181 patients requiring craniectomies and craniotomies for decompression or evacuation of an intracranial hemorrhage following TBI at a single level I trauma center between 2008-2010. Demographic features and perioperative clinical characteristics of these patients were examined in relation to favorable outcomes, defined as discharge to home or a rehabilitation facility, and unfavorable outcomes, defined as in-hospital mortality or discharge to step-down medical facilities. Younger age, greater Glasgow Coma Scale (GCS) score on admission, absence of preoperative coagulopathies, absence of hypernatremia, and absence of fever were all independent predictors of favorable outcome. Additionally, increased operative duration and increased length of hospital stay were identified as independent predictors of negative outcomes after surgery. This work supports some of the current prognostic models in the literature and identifies additional clinical variables with predictive value of early outcome and discharge status in patients undergoing surgical evacuation of traumatic intracranial hemorrhages.

Membrane-associated CD93 regulates leukocyte migration and C1q-hemolytic activity during murine peritonitis.

CD93 is emerging as a novel regulator of inflammation; however, its molecular function is unknown. CD93 exists as a membrane-associated glycoprotein on the surface of cells involved in the inflammatory cascade, including endothelial and myeloid cells. A soluble form (sCD93) is detectable in blood and is elevated with inflammation. In this study, we demonstrate heightened susceptibility to thioglycollate-induced peritonitis in CD93(-/-) mice. CD93(-/-) mice showed a 1.6-1.8-fold increase in leukocyte infiltration during thioglycollate-induced peritonitis between 3 and 24 h that returned to wild type levels by 96 h. Impaired vascular integrity in CD93(-/-) mice during peritonitis was demonstrated using fluorescence multiphoton intravital microscopy; however, no differences in cytokine or chemokine levels were detected with Luminex Multiplex or ELISA analysis. C1q-hemolytic activity in CD93(-/-) mice was decreased by 22% at time zero and by 46% 3 h after thioglycollate injection, suggesting a defect in the classical complement pathway. Leukocyte recruitment and C1q-hemolytic activity was restored to wild type levels when CD93 was expressed on either hematopoietic cells or nonhematopoietic cells in bone marrow chimeric mice. However, elevated levels of sCD93 in inflammatory fluid were observed only when CD93 was expressed on nonhematopoietic cells. Because cell-associated CD93 was sufficient to restore a normal inflammatory response, these data suggest that cell-associated CD93, and not sCD93, regulates leukocyte recruitment and complement activation during murine peritonitis.