Utility of common bile duct measurement in the diagnosis of cholecystitis and choledocholithiasis in children.

BACKGROUND: Ultrasound is an integral part of evaluating for acute cholecystitis and choledocholithiasis in pediatric patients. Finding the common bile duct (CBD), a structure which is normally <4 mm in children, can be very challenging. OBJECTIVE: The primary objective of this study was to determine the prevalence of isolated sonographic CBD dilation in pediatric patients with acute cholecystitis and/or choledocholithiasis without laboratory abnormalities or pathologic findings on radiology based biliary ultrasound, apart from cholelithiasis. METHODS: We conducted a retrospective chart review of patients ≤21-years-old, at a single free-standing tertiary care children's hospital, who received a biliary ultrasound in the radiology department (RADUS) from September 2005 to February 2020. We identified patients who had a diagnosis of acute cholecystitis and/or choledocholithiasis on RADUS. Based on prior studies, a positive ultrasound was defined as having gallbladder wall thickening (GWT), pericholecystic fluid (PCF), or sonographic Murphy's sign (SMS). The final diagnosis was confirmed using the gold standard, cholecystectomy pathology diagnosis for patients with cholecystitis and endoscopic retrograde cholangiopancreatography (ERCP) diagnosis for patients with choledocholithiasis. Ultrasound data and contemporaneous laboratory values were collected. RESULTS: 180 patients met inclusion criteria. For the study population, 97 (53.9%) had a positive ultrasound, 127 patients (70.6%) had a dilated CBD, and 170 (94.4%) had at least one abnormal laboratory finding. Within the study population there were 76 patients (42.3%) with acute cholecystitis, 55 patients (30.5%) with choledocholithiasis, and 49 patients (27.2%) with acute cholecystitis and choledocholithiasis. Of the 127 patients with a dilated CBD, 80 (62.9%) had a normal ultrasound, apart from cholelithiasis. In this group of 80, 78 patients (97.5%) had at least one abnormal laboratory finding. Thus, for the entire study population, isolated CBD dilation without a positive ultrasound or laboratory abnormalities occurred in 2 patients (1.1%). Of note, these 2 patients had an ultrasound diagnosis of choledocholithiasis. CONCLUSION: The prevalence of isolated sonographic CBD dilation in pediatric patients with cholecystitis and/or choledocholithiasis was 1.1%. Thus, biliary ultrasound without CBD measurement is unlikely to result in missed cholecystitis and/or choledocholithiasis if the biliary ultrasound does not demonstrate GWT, PCF, SMS, or choledocholithiasis, and the patient has normal laboratory values.

Violent Injury as a Predictor of Subsequent Assault-Related Emergency Department Visits Among Adolescents.

PURPOSE: To measure the risk of a subsequent assault-related emergency department (ED) visit in assault injured adolescents as compared to those who initially presented for non-assault related injuries. METHODS: This was a historical cohort study of youth (ages 10-18 years) seen at two pediatric EDs between 2016 and 2019. Participants were included if their visit had an International Classification of Diseases-10 code for assaultive injury or accidental injury (motor vehicle collisions (MVC) and sports injuries). We calculated the rate of a subsequent ED visit for an assault-related injury, and then used survival analysis to compare time to subsequent ED visit with an assault-related injury between study and comparison groups. RESULTS: A total of 6125 adolescents met inclusion criteria (Assault: n = 2782, 45.4%; MVC: n = 1834, 29.9%; Sports n = 1509, 24.6%). The overall rate per 100 person years of a subsequent assault-related ED visit was 5.6 (n = 344). Patients who initially presented with an assault-related injury had an increased adjusted relative risk (aRR) of return for a subsequent ED visit for an assault-related injury when compared to MVC patients (aRR 17.6 [95% CI: 9.6, 32.2]). Kaplan-Meier time to event analysis found that patients in the assault injury group have a higher probability of a subsequent ED visit for an assault-related injury compared to patients in the MVC injury group (adjusted hazard ratio (aHR): 17.7 [95% CI: 9.67, 32.42]). DISCUSSION: Adolescents injured by assault are more likely to return to the ED for a subsequent assault-related injury compared to adolescents who initially present with non-assault-related injuries.

Experiencing Bullying Is Associated With Firearm Access, Weapon Carriage, Depression, Marijuana Use, and Justice Involvement in Adolescents.

OBJECTIVES: The aims of this study were to assess whether bullying experience among youths is associated with firearm access and to evaluate assault perpetration risk factors between bullied and nonbullied adolescents. METHODS: This was a secondary analysis of a cross-sectional survey designed to measure self-reported social determinants of health and behavioral health risks among adolescents (13-21 years) in a pediatric emergency department between July 2017 and August 2019. Participants were included in this subanalysis if they responded to a survey item that assessed bullying. Multivariable logistic regression was used to measure the association of firearm access, weapon carriage, and assault perpetration factors (violence, mental health, substance abuse, and justice involvement) with bullying after adjustment for sex, race/ethnicity, and insurance status. RESULTS: Of the 369 participants meeting inclusion criteria, 147 adolescents (40.5%) reported experiencing bullying. Bullied teenagers had higher odds of a gun in the home (adjusted odds ratio [aOR], 3.0; 95% confidence interval [CI], 1.2-7.8]), weapon carriage (aOR, 5.6; 95% CI, 1.6-18.8), witnessing an assault (aOR, 3.0; 95% CI, 1.6-5.6), negative experience with law enforcement (aOR, 4.5; 95% CI, 2.2-9.2), mental health diagnosis (aOR, 3.9; 95% CI, 2.3-6.7), and marijuana use (aOR, 2.7; 95% CI, 1.1-7.0]). CONCLUSIONS: More than 1 in 3 adolescents presenting to the emergency department report having ever experienced bullying. Bullied teenagers have a higher likelihood of firearm access, weapon carriage, and violent injury perpetration risk factors compared with nonbullied youths. Further studies are needed to understand the relationship between bullying and assault perpetration.

Improving Care at Emergency Department Discharge for Pediatric Patients with Anaphylaxis Using a Quality Improvement Framework.

Introduction: Anaphylaxis is a potentially fatal systemic reaction that requires prompt recognition and targeted treatment. Despite international consensus and national guidelines, there is often incomplete care for pediatric patients discharged from the emergency department (ED) with a diagnosis of anaphylaxis. Our institution experienced wide variability in discharge planning for patients with anaphylaxis. The goal of our study was to improve care at ED discharge for pediatric patients with anaphylaxis using a quality improvement framework. The specific aims were to increase the frequency of patients diagnosed with anaphylaxis who receive an anaphylaxis action plan at ED discharge from 0% to 60% and to increase referrals to an allergy clinic from a baseline of 61%-80% between October 2020 and April 2021. Methods: Targeted interventions included revisions to the electronic health record system, forging interdisciplinary partnerships and emphasizing provider education. Outcome measures were the proportion of patients receiving an anaphylaxis action plan and an allergy clinic follow-up. The balancing measure was the ED length of stay. Results: The study showed an increase in anaphylaxis action plans from 0% to 34%. Allergy clinic referral rates improved from 61% to 82% within the same period. The average length of stay of 347 minutes remained unchanged. Conclusions: Revising the discharge instructions to include an anaphylaxis action plan and reinforcing provider behaviors with educational interventions led to an overall improvement in discharge care for patients with anaphylaxis. Future work will focus on electronic health record changes to continue progress in additional clinical settings.

Pediatric Blunt Abdominal Trauma and Point-of-Care Ultrasound.

ABSTRACT: Blunt abdominal trauma (BAT) accounts for most trauma in children. Although the focused assessment with sonography in trauma (FAST) is considered standard of care in the evaluation of adults with traumatic injuries, there is limited evidence to support its use as an isolated evaluation tool for intra-abdominal injury as a result of BAT in children. Although a positive FAST examination could obviate the need for a computed tomography scan before OR evaluation in a hemodynamically unstable patient, a negative FAST examination cannot exclude intra-abdominal injury as a result of BAT in isolation. In this article, we review the evaluation of BAT in children, describe the evaluation for free intraperitoneal fluid and pericardial fluid using the FAST examination, and discuss the limitations of the FAST examination in pediatric patients.

AIDS Presenting in an Adolescent Male With Persistent Conjunctivitis and Eye Pain.

An adolescent male with persistent conjunctivitis and an episcleral nodule presented with new-onset focal seizures and headaches. The patient was found to have cotton wool spots and papilledema on retinal examination. He was ultimately diagnosed with HIV retinopathy and AIDS. Ocular manifestations are rare presenting symptoms of AIDS among adolescents in the United States. Ocular disease in pediatric HIV/AIDS patients is most often caused by opportunistic infections. HIV retinopathy, the most common cause of blindness in patients with HIV, is usually a late disease manifestation. It is important for providers caring for adolescents to be aware of the potential ocular manifestations of HIV/AIDS. Teenagers are less likely to be aware of their HIV status and less likely to be tested for HIV, despite high risk exposures, and therefore, universal and routine HIV screening is recommended for all patients.