Socioeconomic differences in antibiotic use for common infections in pediatric urgent-care centers-A quasi-experimental study.

OBJECTIVE: To investigate differences in the rate of firstline antibiotic prescribing for common pediatric infections in relation to different socioeconomic statuses and the impact of an antimicrobial stewardship program (ASP) in pediatric urgent-care clinics (PUCs). DESIGN: Quasi-experimental. SETTING: Three PUCs within a Midwestern pediatric academic center. PATIENTS AND PARTICIPANTS: Patients aged >60 days and <18 years with acute otitis media, group A streptococcal pharyngitis, community-acquired pneumonia, urinary tract infection, or skin and soft-tissue infections who received systemic antibiotics between July 2017 and December 2020. We excluded patients who were transferred, admitted, or had a concomitant diagnosis requiring systemic antibiotics. INTERVENTION: We used national guidelines to determine the appropriateness of antibiotic choice in 2 periods: prior to (July 2017-July 2018) and following ASP implementation (August 2018-December 2020). We used multivariable regression analysis to determine the odds ratios of appropriate firstline agent by age, sex, race and ethnicity, language, and insurance type. RESULTS: The study included 34,603 encounters. Prior to ASP implementation in August 2018, female patients, Black non-Hispanic children, those >2 years of age, and those who self-paid had higher odds of receiving recommended firstline antibiotics for all diagnoses compared to male patients, children of other races and ethnicities, other ages, and other insurance types, respectively. Although improvements in prescribing occurred after implementation of our ASP, the difference within the socioeconomic subsets persisted. CONCLUSIONS: We observed socioeconomic differences in firstline antibiotic prescribing for common pediatric infections in the PUCs setting despite implementation of an ASP. Antimicrobial stewardship leaders should consider drivers of these differences when developing improvement initiatives.

Ankle Injuries in the Pediatric Emergency Department.

Ankle injuries are a common reason for presentation to the pediatric emergency department. An understanding of the anatomy of the ankle joint, the mechanism of injury, and a thorough history and physical examination can help narrow the differential diagnosis. This article will discuss the management of common ankle injuries, including ankle sprains, dislocations, and pediatric fractures, including transitional triplane and Tillaux fractures. A brief review of the literature regarding radiographic evaluation of the ankle and various ankle rules is also discussed.

Emergency Department Utilization Among Assault-Injured Youth: Implications for Youth Violence Screening.

OBJECTIVE: Assault is a common cause of youth emergency department (ED) visits. Little is known about prior ED utilization patterns among assault-injured youth. This study's objectives were to determine whether, and how, prior ED visit history distinguishes assault-injured youth from unintentionally injured youth. METHODS: A 5-year retrospective, case-control study was conducted using a hospital billing database. Youth ages 13 to 24 years presenting to the ED of an urban level 1 trauma center in 2011 with an E-code of physical assault- or weapon-related injuries were compared 1:1 to randomly assigned, age- and sex-matched controls with an E-code corresponding to unintentional injury. Bivariate, t test, Wilcoxon rank sum tests, and conditional logistic regression were performed to determine how previous ED visits distinguished assault-injured youth from unintentionally injured youth. RESULTS: In 2011, 964 patients presented with assault-related injuries. Over the previous 5 years, assault-injured youth had a median of 1 prior ED visit (interquartile range, 0-3); unintentionally injured youth had a median of zero prior ED visits (interquartile range, 0-2). Assault-injured youth had significantly higher median numbers of previous psychiatric and assault-related ED visits when compared to unintentionally injured youth. A youth with 1 previous psychiatric ED visit had a 4-fold increased odds (adjusted odds ratio [AOR], 4.05; 95% confidence interval, 2.41-6.83) of having a 2011 assault-related ED visit compared to unintentionally injured youth. CONCLUSIONS: Assault-injured youth are more likely to have had prior ED use particularly for psychiatric illnesses and assault-related injury. Targeted youth violence screening may be appropriate for such patients.

A survey of resident attitudes and behaviors regarding youth violence prevention in the acute care setting.

BACKGROUND: Surgery, emergency medicine (EM), and pediatric resident physicians play an integral role in treating youth violence patients. We assessed these residents' behaviors, attitudes, and perceived barriers to youth violence prevention (YVP) in the acute care setting. METHODS: A cross-sectional survey of EM, surgery, and pediatric residents at one large medical institution was conducted using a theory-based self-administered paper questionnaire. Data were analyzed using descriptive statistics and Fisher's exact tests to examine differences between resident specialties. RESULTS: Of 73 residents, 55 completed the questionnaire, composed of 23 EM (42%), 18 pediatrics (33%), and 14 surgery (25%) residents, with a response rate of 75%. Fifteen percent (n = 8) of the respondents received YVP training during residency. The majority (n = 49, 91%.) of the respondents reported consistently collecting a history of events leading to violent injury. A smaller percentage of residents reported consistent assessment of retaliation risk (n = 11, 20%), referral to social work (n = 37, 69%), and screening for substance abuse (n = 37, 69%) and mental health (n = 35, 65%). Surgery residents were more likely than pediatric and EM residents to refer to social work (100% vs. 72% and 45%, p < 0.01) and screen for substance abuse (93% vs. 78% and 45%, p = 0.01). While the majority of residents agreed that youth violence is preventable (n = 50, 91%) and physicians should play a role in prevention (n = 47, 85%), there was less agreement that YVP should be a resident task (n = 38, 69%). Less than half of residents (n = 26, 47%) felt competent discussing safety risks and plans. Residents cited lack of time and training as the top two barriers for conducting risk assessments and referring to support services. CONCLUSION: While EM, surgery, and pediatric residents agree that YVP is essential and should involve physicians, many do not perceive this as part of their responsibilities, and they do not feel competent in this role.

Effect of Propofol on Acid Reflux Measured with the Bravo pH Monitoring System.

Background/Aim. The aim of this study was to determine the effect of propofol on acid reflux as measured with the Bravo pH monitoring system. Methods. 48-hour pH tracings of 88 children were retrospectively evaluated after placement of the Bravo capsule under propofol. Comparisons between day 1 and day 2, as well as 6-hour corresponding segments from day 1 and day 2, were made. Results. The number of reflux episodes was significantly increased during the first six-hour period on day one as compared to day 2 (P = 0.006). The fraction of time the pH was <4 was also increased during this period, though it did not reach statistical significance. When comparing full 24-hour periods, there was no difference noted in either the number of reflux episodes or the fraction of time pH < 4 between day one and day two. Conclusion. Our data suggest an increase in gastroesophageal reflux during the postanesthesia period. This could be a direct effect of propofol, or related to other factors. Regardless of the cause, monitoring of pH for the first 6 hours following propofol administration may not be reliable when assessing these patients. Monitoring pH over a prolonged 48-hour time period can overcome this obstacle.

Caregiver expectations of clinicians during the asthma diagnostic process in young children: thematic analysis of focus groups.

OBJECTIVE: Asthma is difficult to diagnose in young children, and the subjective experience of caregivers varies. Clinicians' ability to meet caregiver expectations during the diagnostic process improves the caregiver-clinician relationship, and effectiveness of disease management strategies. METHODS: We performed thematic analysis of seven focus groups (FGs) with 38 caregivers of children 1-6 years old diagnosed with asthma in the preceding 12 months. Caregivers were classified as satisfied or dissatisfied with clinicians during the asthma diagnostic process. Differential themes in these two groups identified caregiver expectations that determined satisfaction with the diagnostic process. RESULTS: Caregiver expectations during the asthma diagnostic process included (1) provision of a diagnostic strategy, (2) acknowledgment of caregiver advocacy, (3) addressing caregiver's beliefs about treatment with asthma medications before a diagnosis was confirmed, and (4) discussing asthma specialist involvement in the diagnosis. Higher perceived severity of a child's illness made caregiver expectations more difficult to meet. CONCLUSIONS: We conclude that clinicians considering an asthma diagnosis in young children must include a diagnostic strategy that is congruent with the caregiver's beliefs about the underlying illness, use of medication, and asthma specialist involvement. Perceived illness severity must also be accounted for when designing a diagnostic strategy.