Preliminary validation of a structural magnetic resonance imaging metric for tracking dementia-related neurodegeneration and future decline.

Alzheimer's disease (AD) is a progressive neurodegenerative disease characterized by cognitive decline and atrophy in the medial temporal lobe (MTL) and subsequent brain regions. Structural magnetic resonance imaging (sMRI) has been widely used in research and clinical care for diagnosis and monitoring AD progression. However, atrophy patterns are complex and vary by patient. To address this issue, researchers have made efforts to develop more concise metrics that can summarize AD-specific atrophy. Many of these methods can be difficult to interpret clinically, hampering adoption. In this study, we introduce a novel index which we call an "AD-NeuroScore," that uses a modified Euclidean-inspired distance function to calculate differences between regional brain volumes associated with cognitive decline. The index is adjusted for intracranial volume (ICV), age, sex, and scanner model. We validated AD-NeuroScore using 929 older adults from the Alzheimer's Disease Neuroimaging Initiative (ADNI) study, with a mean age of 72.7 years (SD = 6.3; 55.1-91.5) and cognitively normal (CN), mild cognitive impairment (MCI), or AD diagnoses. Our validation results showed that AD-NeuroScore was significantly associated with diagnosis and disease severity scores (measured by MMSE, CDR-SB, and ADAS-11) at baseline. Furthermore, baseline AD-NeuroScore was associated with both changes in diagnosis and disease severity scores at all time points with available data. The performance of AD-NeuroScore was equivalent or superior to adjusted hippocampal volume (AHV), a widely used metric in AD research. Further, AD-NeuroScore typically performed as well as or sometimes better when compared to other existing sMRI-based metrics. In conclusion, we have introduced a new metric, AD-NeuroScore, which shows promising results in detecting AD, benchmarking disease severity, and predicting disease progression. AD-NeuroScore differentiates itself from other metrics by being clinically practical and interpretable.

Experience with the use of propofol for radiologic imaging in infants younger than 6 months of age.

BACKGROUND: There is an increased risk associated with procedural sedation of infants younger than 6 months of age. The use of propofol for radiologic imaging of this age group is not well studied. OBJECTIVE: We hypothesize that adverse events are higher in the infant population receiving propofol for radiologic imaging. MATERIALS AND METHODS: A retrospective chart review was undertaken of 304 infants younger than 6 months old who received propofol for procedural sedation from October 2012 to February 2015. Patient demographics, propofol dosing, sedation-related adverse events and interventions were collected. Serious adverse events were defined as laryngospasm, aspiration, the need for admission, cardiac arrest or death. RESULTS: Procedural sedation for radiologic imaging was successful in 301/304 (99%) of infants using propofol. Of these 304 patients, 130 (42.8%) patients were female, and 240 of the 304 (79%) were between 3 and 6 months of age. The majority of patients (172/304 [56.6%]) were American Society of Anesthesiologists-Physical Status Class II. There were 57 sedation-related, minor adverse events in 39 out of 304 (12.8%) patients. Thirteen of the 304 (4.3%) patients had 14 serious adverse events, with airway obstruction the most common. Eighty interventions were required in 56/304 (18.4%) patients. The most common interventions were continuous positive airway pressure (CPAP) in 25/304 patients (8.2%) and jaw thrust in 15/304 (4.9%). The median induction propofol dose was 4.7 mg/kg. A need for an increase in the propofol infusion rate during the procedure was noted in 162/304 (53.3%) infants. No significant predictors of sedation-related adverse events were detected. CONCLUSION: Propofol can be used for radiologic imaging of infants younger than 6 months of age with a high success rate. Practitioners should be mindful of significantly higher dosing requirements and a higher incidence of airway events, which can be easily identified and managed by a team of experienced sedation providers.

Return to the emergency department after ventricular shunt evaluation.

OBJECT Patients with CSF shunts are medically complex and frequently present to the emergency department (ED) with suspected shunt malfunction. After adequate evaluation in the ED and proper disposition, some patients return to the ED within a short period of time. In this study, the authors examined the reasons for ED revisits within 7 days of the index ED visit to discern possible preventable returns. METHODS There were 3080 index ED visits made by patients with shunted hydrocephalus between 2010 and 2013. Index ED visits preceded by another ED visit or neurosurgical procedure within 60 days were excluded. Index ED visits for reasons unrelated to shunt function and those that led directly to admissions and shunt revision surgeries were also excluded. The remaining 1509 ED visits were eligible for analysis in this study. Final dispositions from the index ED visit included home (1176 cases), admission to the neurosurgery service for observation (134 cases), and admission to other services (199 cases). Subsequent events within 7 days, including ED revisits, hospital admissions, and shunt-related surgery were recorded, and reasons for the ED revisits were categorized based on whether the visit was related to shunt function concerns. Clinical and socioeconomic factors were analyzed for their association with ED revisits by using statistical methods. RESULTS Of the 1176 patients discharged home from the ED after shunt function evaluation, 101 (8.6%) returned to the ED within 7 days. Of the 134 patients admitted to the neurosurgery service for observation only, 8 (6.0%) returned to the ED within 7 days of discharge. Of the 199 patients admitted to hospital services other than neurosurgery, 13 (6.5%) returned to the ED within 7 days of discharge. The reasons for ED revisits vary (total of 122 visits combining the 3 groups), but at least 60% of the revisits were clearly unrelated to shunt function. A younger age, daytime arrival to the ED, and living within the metropolitan area were identified as risk factors for ED revisits. CONCLUSIONS Children with CSF shunts are medically complex and use ED services often. After an index ED visit at which shunt function was deemed to be the chief concern, the purpose of the subsequent return to the ED within 7 days was often for complaints unrelated to shunt function. Caution is warranted when attempting to classify these complex patients as having potential preventable return-to-system events.

Association of Respiratory Picornaviruses With High Acuity and Severe Illness in a Pediatric Health Care System.

OBJECTIVES: We aimed to determine the illness severity associated with respiratory picornaviruses (rhinovirus/enterovirus). METHODS: Electronic medical records of pediatric emergency department (PED) visits were reviewed. The percent positive of respiratory pathogens, tested by using viral polymerase chain reaction panel, was determined for the July 2012 to June 2013 period. Logistic regression was used to determine the association of picornaviruses, respiratory syncytial virus (RSV), and influenza with ICU admission during the 2012-2013 academic year. Medical records of visits leading to ICU admission with picornaviruses were reviewed. RESULTS: During 2012-2013, picornaviruses were more commonly identified (22.6%) among admitted patients than influenza (6.4%) or RSV (15.1%). Picornaviruses and RSV were associated with ICU admission (picornaviruses: adjusted odds ratio [aOR], 1.99 [95% confidence interval (CI): 1.68-2.36]; RSV: aOR, 1.49 [95% CI: 1.20-1.85]) while influenza was not (aOR, 0.93 [95% CI: 0.66-1.29]). Of visits resulting in ICU admission, 79% were from patients with previous high-risk medical conditions, of which asthma or a history of wheezing was the most common (43%). CONCLUSIONS: Picornaviruses can be associated with severe disease in children, especially those with underlying medical conditions. During times of high picornavirus activity, hospitals should target infection control measures to limit the spread of picornaviruses and protect the vulnerable patients. Future research into targeted therapies for picornaviruses and vaccines is needed.

Syncope in the Pediatric Emergency Department - Can We Predict Cardiac Disease Based on History Alone?

BACKGROUND: The American Heart Association recommends a "meticulous history" when evaluating patients with an initial episode of syncope. However, little is known about which historical features are most helpful in identifying children with undiagnosed cardiac syncope. OBJECTIVES: Our objectives were 1) to describe the cardiac disease burden in Emergency Department (ED) syncope presentations, and 2) to identify which historical features are associated with a cardiac diagnosis. METHODS: Using syncope presentations in our ED between May 1, 2009 and February 28, 2013, we 1) performed a cross-sectional study describing the burden of cardiac syncope, and 2) determined the sensitivity and specificity of four historical features identifying cardiac syncope. RESULTS: Of 3445 patients, 44.5% were male presenting at 11.5 ± 4.5 years of age. Of patients with a cardiac diagnosis (68, ~2%), only 3 (0.09%) were noted to have a previously undiagnosed cardiac cause of syncope: 2 with supraventricular tachycardia and 1 with myocarditis. Among the three cases and 100 randomly selected controls, the respective sensitivity and specificity of the historical features were 67% and 100% for syncope with exercise, 100% and 98% for syncope preceded by palpitations, and 67% and 70% for syncope without prodrome. The presence of at least two features yielded a sensitivity of 100% and specificity of 100%. CONCLUSIONS: Our study, which represents the largest published series of pediatric syncope presenting to the ED, confirms that newly diagnosed cardiac causes of syncope are rare. Using a few specific historical features on initial interview can help guide further work-up more precisely.

Understanding variations in pediatric asthma care processes in the emergency department using visual analytics.

Health care delivery processes consist of complex activity sequences spanning organizational, spatial, and temporal boundaries. Care is human-directed so these processes can have wide variations in cost, quality, and outcome making systemic care process analysis, conformance testing, and improvement challenging. We designed and developed an interactive visual analytic process exploration and discovery tool and used it to explore clinical data from 5784 pediatric asthma emergency department patients.

Cloud-based Predictive Modeling System and its Application to Asthma Readmission Prediction.

The predictive modeling process is time consuming and requires clinical researchers to handle complex electronic health record (EHR) data in restricted computational environments. To address this problem, we implemented a cloud-based predictive modeling system via a hybrid setup combining a secure private server with the Amazon Web Services (AWS) Elastic MapReduce platform. EHR data is preprocessed on a private server and the resulting de-identified event sequences are hosted on AWS. Based on user-specified modeling configurations, an on-demand web service launches a cluster of Elastic Compute 2 (EC2) instances on AWS to perform feature selection and classification algorithms in a distributed fashion. Afterwards, the secure private server aggregates results and displays them via interactive visualization. We tested the system on a pediatric asthma readmission task on a de-identified EHR dataset of 2,967 patients. We conduct a larger scale experiment on the CMS Linkable 2008-2010 Medicare Data Entrepreneurs' Synthetic Public Use File dataset of 2 million patients, which achieves over 25-fold speedup compared to sequential execution.

Adult patients in the pediatric emergency department: presentation and disposition.

BACKGROUND: Pediatric emergency departments (PEDs) are intended to care for acutely ill and injured children. Adult patients sometimes present to these facilities as well. Some of these are young adults still under the care of pediatric specialists, but older adults and those not under the care of specialists may seek care and may challenge pediatric care providers. Understanding the spectrum of adult illness encountered in the PED may help ensure optimum care for this patient population. OBJECTIVE: This study aimed to describe the presentations of adult patients in 2 high-volume PEDs of a pediatric health care system. METHODS: This is a retrospective review of electronic medical record to identify all visits for patients 21 years or older between 2008 and 2010. Patient demographics, reason for visit, diagnosis, and treatment details were identified. RESULTS: The combined PEDs recorded 417,799 total visits with 1097 patients 21 years or older; 188 of these were still followed by pediatric specialists. For the 907 remaining, the mean age was 36.5.years (range, 21-88 years); 73% were female. Fifty-one percent of the patients were triaged into the highest acuity levels. Fifty-seven percent of the patients were transferred to adult facilities for definitive care. There were no deaths among these patients at either PED, but 2 patients did require intubation and 1 received a period of chest compressions. Reason for presenting to the PED included on-site visitor (45%), mistakenly presented to children's hospital (34%), and hospital employee (21%). The most common presenting complaints were neurologic conditions, trauma/acute injuries, and chest pain. CONCLUSIONS: Adult patients in PEDs are rare but have relatively high acuity and often require transfer. Pediatric emergency department clinicians should have adequate, ongoing training to capably assess and stabilize adult patients across a spectrum of illness presentation.

Return to system within 30 days of pediatric neurosurgery.

OBJECT: Quality assessment measures have not been well developed for pediatric neurosurgical patients. This report documents the authors' experience in extracting information from an administrative database to establish the rate of return to system within 30 days of pediatric neurosurgical procedures. METHODS: Demographic, socioeconomic, and clinical characteristics were prospectively collected in administrative, business, and operating room databases. The primary end point was an unexpected return to the hospital system within 30 days from the date of a pediatric neurosurgical procedure. Statistical methods were used to identify clinical and demographic factors associated with the primary end point. RESULTS: There were 1358 pediatric neurosurgical procedures performed in the Children's Healthcare of Atlanta operating rooms in 2012, with 37.4% of these surgeries being preceded by admissions through the emergency department. Medicare or Medicaid was the payor for 54.9% of surgeries, and 37.6% of surgeries were shunt related. There were 148 unexpected returns to the system within 30 days after surgery, and in 109 of these cases, the patient had a presenting complaint that was attributable to the index surgery (related returns). The most common complaints were headache, nausea, vomiting, or seizure after shunt revision or cranial procedures (n = 62). The next most common reason for re-presentation was for wound concerns (n = 30). Thirty-seven of the 109 related returns resulted in a reoperation. The monthly rate of related returns was 8.1% ± 2.5% over the 12-month study period. When using related returns as the dependent variable, the authors found that patients who underwent a shunt-related surgery were both more likely to unexpectedly return to the system (OR 1.86, p = 0.008) and to require surgery upon readmission (OR 3.28, p = 0.004). Because an extended hospitalization shortened the window of time for readmission after surgery, extended length of stay was protective against return to system within 30 days of surgery. Importantly, if related and unrelated returns were analyzed together as the dependent variable (n = 148), no independent clinical and demographic risk factor could be identified. CONCLUSIONS: Quality assessment measures need to be clearly and carefully defined, as the definition itself will impact the analytical results. Clinicians must play a leading role in the development of these measures to ensure their clinical meaningfulness.

How well do General EMS 911 dispatch protocols predict ED resource utilization for pediatric patients?

INTRODUCTION: The use of Emergency Medical Services (EMS) for low-acuity pediatric problems is well documented. Attempts have been made to curb potentially unnecessary transports, including using EMS dispatch protocols, shown to predict acuity and needs of adults. However, there are limited data about this in children. The primary objective of this study is to determine the pediatric emergency department (PED) resource utilization (surrogate of acuity level) for pediatric patients categorized as "low-acuity" by initial EMS protocols. METHODS: Records of all pediatric patients classified as "low acuity" and transported to a PED in winter and summer of 2010 were reviewed. Details of the PED visit were recorded. Patients were categorized and compared based on chief complaint group. Resource utilization was defined as requiring any prescription medications, labs, procedures, consults, admission or transfer. "Under-triage" was defined as a "low-acuity" EMS transport subsequently requiring emergent interventions. RESULTS: Of the 876 eligible cases, 801 were included; 392/801 had no resource utilization while 409 of 801 had resource utilization. Most (737/801) were discharged to home; however, 64/801 were admitted, including 1 of 801 requiring emergent intervention (under-triage rate 0.12%). Gastroenterology and trauma groups had a significant increase in resource utilization, while infectious disease and ear-nose-throat groups had decreased resource utilization. DISCUSSION: While this EMS system did not well predict overall resource utilization, it safely identified most low-acuity patients, with a low under-triage rate. This study identifies subgroups of patients that could be managed without emergent transport and can be used to further refine current protocols or establish secondary triage systems.

Pulmonary embolism in the pediatric emergency department.

OBJECTIVE: To describe patients who present to the pediatric emergency department (PED) and are subsequently diagnosed with pulmonary embolism (PE). METHODS: Electronic medical records from 2003 to 2011 of a tertiary care pediatric health care system was retrospectively reviewed to identify patients <21 years who had a final International Classification of Diseases, Ninth Revision diagnosis of PE. Patient demographics, and hospital course were recorded. Adult validated clinical decision rules Wells criteria and Pulmonary Embolism Rule-out Criteria (PERC) were retrospectively applied. PERC identified 8 clinical criteria for adult patients using logistic regression modeling to exclude PE without additional diagnostic evaluation. If all criteria are met, further evaluation is not indicated. RESULTS: Of 1 185 794 PED visits, 105 patients had an ultimate diagnosis of PE. Twenty-five met study criteria, and all were admitted. Forty percent of these patients had PE diagnosed in the PED. The most common risk factors were BMI ≥25 (50%, 10 of 20), oral contraceptive use (38% 5 of 13 female patients), and history of previous thrombus without PE (28%, 7 of 25). When the PERC rule was applied retrospectively, 84% of patients could not be ruled out, indicating additional evaluation for PE was needed. CONCLUSIONS: Pulmonary embolism is rare in children but does occur. This study emphasizes risk factors among children that should raise the suspicion of PE. Additional studies are needed to further evaluate risk factors and signs and symptoms of PE to develop pediatric specific clinical decision rules to provide reliable and reproducible means of determining pretest probability of PE.

Acute neck infections in children: who is likely to undergo surgical drainage?

BACKGROUND: Superficial neck infections including lymphadenitis and abscesses are commonly encountered in pediatric emergency departments (PEDs). It is often unclear which patients are likely to develop an abscess that necessitates surgical drainage. In evaluating these patients, computed tomography (CT) and ultrasound are often used to identify/confirm abscess formation. The criteria for determining the need for imaging studies are not well defined. DESIGN/METHODS: All visits to the study PED were examined in 2009 to 2010. Visits with the diagnosis of cervical lymphadenitis or abscess were identified. Records were retrospectively reviewed to determine the duration of symptoms, fever, previous antibiotic therapy, prior PED visit, size of neck swelling, fluctuance on physical examination, white blood cell count, and results of CT and/or ultrasound obtained in the PED. Data were analyzed to determine which of these characteristics were more likely to be associated with an abscess that was operatively drained. RESULTS: A total of 768 patients were evaluated for neck infections. One hundred twelve (14%) of these pediatric patients underwent abscess drainage in the operating room. Two hundred eighty-nine patients underwent a neck CT and/or ultrasound, of which 119 were positive for abscess. Factors associated with surgical drainage included fluctuance (odds ratio [OR], 18.92; 95% confidence interval [CI], 3.66-31.37), previous emergency department visit (OR, 2.79; 95% CI, 1.34-5.84), and age less than 4 years (OR, 3.01; 95% CI, 1.15-9.87). A recursive partitioning model stratified patients' risk for going to the operating room. Patients without fluctuance and with no prior emergency department visit, along with no prior antibiotic use, have less than 4% chance of having an abscess that necessitates surgical drainage. CONCLUSIONS: Pediatric patients who are more likely to have a neck infection that necessitates surgical drainage can be stratified based on clinical characteristics. This knowledge may allow physicians to better predict the resource needs including hospital admission and emergent imaging for neck infection.

The use of ondansetron for nausea and vomiting after head injury and its effect on return rates from the pediatric ED.

BACKGROUND: The use of ondansetron in children with vomiting after a head injury has not been well studied. Concern about masking serious injury is a potential barrier to its use. OBJECTIVE: The aim of this study was to evaluate the use of ondansetron in children with head injury and symptoms of vomiting in the pediatric emergency department (PED) and its effect on return rates and masking of more serious injuries. DESIGN/METHODS: Visits to 2 PEDs from 2003 to 2010 with a diagnosis of head injury were evaluated retrospectively. Patients discharged home after a head computed tomography (CT) are the primary cohort for the study. A logistic regression model was used to analyze ondansetron's effects on the likelihood of return to the PED within 72 hours for persistent symptoms. A secondary analysis was performed on patients with a diagnoses of head injury who did not receive a head CT and were discharged. RESULTS: A total of 6311 patients had a diagnosis of head injury, had a head CT performed, and were discharged from the PED. The use of ondansetron increased significantly from 3.7% in 2003 to 22% in 2010 (P < .001). After controlling for demographic/acuity differences, receiving ondansetron in the PED was associated with a lower likelihood of returning within 72 hours (0.49, 95% confidence interval [0.26-0.92]). In patients with head injury who did not have a head CT performed and were sent home, the use of ondansetron in the PED was not associated with an increased risk of missed diagnoses. CONCLUSION: Ondansetron use in children with a CT scan who are dispositioned home is relatively safe, does not appear to mask any significant conditions, and significantly reduces return visits to the PED.

Management of afebrile neonates with skin and soft tissue infections in the pediatric emergency department.

OBJECTIVE: To describe the management of afebrile neonatal skin and soft tissue infections (SSTIs) in the pediatric emergency department (PED). METHODS: This is a retrospective cohort study of all patients aged 0 to 28 days seen in the PED for SSTIs from 2004 to 2010. The SSTIs were identified from the International Classification of Diseases, Ninth Revision codes of pustulosis, cellulitis, and abscess. Records were reviewed to determine the absence of fever; anatomical location; cultures of blood, urine, and cerebrospinal fluid; antibiotic usage; and return visits. Data were analyzed to compare admitted versus discharged patients with SSTI subtypes. RESULTS: Of the 136 neonates identified, 104 met inclusion criteria. Afebrile SSTIs included 8 pustulosis, 45 cellulitis, and 51 abscesses. Blood cultures were obtained in 13% of pustulosis, 96% of cellulitis, and 69% of abscesses. No serious bacterial infection was noted. Three blood cultures grew contaminants. Parenteral antibiotics for neonates with pustulosis, cellulitis, and abscesses were given in 13%, 87%, and 59%, respectively. Admission rates for neonates with pustulosis, cellulitis, and abscesses were 13%, 84%, and 55%, respectively. Cases of cellulitis were more likely to have blood cultures drawn (odds ratio [OR], 13.7; 95% confidence interval [CI], 3.03-62.3), receive intravenous antibiotics (OR, 5.87; 95% CI, 2.16-15.0), and be admitted to the hospital (OR, 5.62; 95% CI, 2.16-14.6) as compared with the other SSTI subtypes. CONCLUSIONS: None of the neonates who had cultures drawn had serious bacterial infection. The SSTI subtype correlated with the extent of evaluation and dispositions. The findings of this study will help with management strategies for afebrile neonates with SSTIs in the PED.

Effects of a system-wide fracture care program to enhance access and follow-up for orthopedics.

OBJECTIVES: Fractures of the extremities are commonly encountered in pediatric emergency departments (PEDs) nationwide. These fractures can lead to bone malformation and deformities if not managed properly. There are multiple barriers to obtaining necessary outpatient follow-up for fracture care, which leads to increased return to the PED for management. Because of these barriers, a "Fracture Care Program" was implemented at the study hospital's network. This study aimed to determine implementation of a Fracture Care Program would lead to reduced PED utilization. METHODS: All visits to the study PEDs were examined from January 1 to August 30, 2010. At PED discharge, patients were given a Fracture Care Program handout, which outlined step-by-step instructions for identifying and scheduling an appointment with a local orthopedic surgeon as an outpatient. A telephone hotline number was also provided where they could speak with a representative of the orthopedics department for assistance in obtaining follow-up. Detailed records were reviewed to determine whether these instructions were associated with lower rates of return. RESULTS: A total of 2120 patients met inclusion criteria. Of these, 1233 (58%) received the Fracture Care discharge instructions. After controlling for differences in payor status and demographic differences, patients who received instructions were less likely to return to the PED (odds ratio, 0.616; 95% confidence interval, 0.40-0.95) within 30 days for orthopedic care than patients who did not receive the instructions. CONCLUSIONS: This systematic coordination of services of a large tertiary care pediatric health care system, local pediatric orthopedic surgery private practices, academic practices, and hospital-affiliated practices improved overall access for families related to orthopedic follow-up care. This model may also aid in helping to improve follow-up in other pediatric subspecialties.

Ondansetron use in the pediatric emergency room for diagnoses other than acute gastroenteritis.

BACKGROUND: Ondansetron is widely used in the pediatric emergency department (PED) for vomiting and acute gastroenteritis (GE). Little is known about the spectrum of its use in diagnoses other than acute GE. OBJECTIVE: The objective of this study was to evaluate the spectrum of diagnoses for which ondansetron is used in the PED. METHODS: Medical records from 2 tertiary care PEDs from January 2006 to December 2008 were retrospectively reviewed. Patients 3 months to 18 years of age given ondansetron in the PED were identified. Patients without a primary discharge diagnosis (based on International Classification of Diseases, Ninth Revision code) of vomiting or GE were defined as non-GE. Patient age, initial triage level (1 = lowest acuity, 5 = highest), route of administration (enteral vs parenteral), primary diagnosis, disposition, and prescription for ondansetron at discharge were recorded; GE and non-GE patients were compared based on age and triage acuity. RESULTS: There were 32,971 patients who received ondansetron in the PED; 12,620 (38%) were non-GE patients. Non-GE patients were older (8.3 vs 4.3 years, P < 0.001) and of higher average initial triage level (2.95 vs 2.33, P < 0.001) compared with GE patients. Within non-GE patients, 79% received ondansetron enterally, 71% were discharged, and 37% of those discharged received an ondansetron prescription. The most common primary diagnoses for non-GE discharged patients were fever (15%), abdominal pain/tenderness (13%), head injury/concussion (7%), pharyngitis (6%), viral infection (6%), migraine variants (5%), and otitis media (5%). The most common diagnoses of patients admitted were appendicitis (11%), asthma (6%), pneumonia (4%), and diabetes (4%). CONCLUSIONS: Although ondansetron is a widely accepted treatment for GE in children, this study identifies a broader spectrum of primary diagnoses for which ondansetron is being used.

Trends in computed tomography utilization in the pediatric emergency department.

OBJECTIVE: The purpose of this study was to determine the overall trend of computed tomography (CT) utilization in the pediatric emergency department (PED) from 2003 to 2010 and to determine trends categorized by common chief complaints. METHODS: Electronic chart records at 2 tertiary care PEDs within a large pediatric health care system were reviewed from January 2003 through December 2010. The annual CT utilization rate, by anatomic location, was determined. Annual CT utilization rates were compared with alternative imaging trends for visits with chief complaints of head injury, seizure, and abdominal pain. Analysis was performed with linear regression. RESULTS: There was no change in overall CT utilization from 2003 to 2010 (ß 0.25, 95% confidence interval [CI] [-1.61 to 2.73]) or within anatomic subgroups. Head CT utilization for the chief complaints of seizure (ß -0.97, 95% CI [-1.44 to -0.90]) and head injury (ß -0.93, 95% CI [-1.71 to -0.73]) showed significant declines. Although there was no change in the abdominal CT utilization rate for abdominal pain, abdominal ultrasound utilization for abdominal pain significantly increased (ß 0.89, 95% CI [0.25-0.79]). CONCLUSIONS: Our data showed no overall increase in CT utilization through 2010. In areas where alternative non-radiation-based modalities were options, there were decreased CT trends and increased use of potential alternative non-radiation-based modalities. This is the first large PED cohort study to show a decrease in CT utilization in recent years in a regional pediatric referral center and may correlate with increased awareness of radiation risk in children.

A clinical decision tool for predicting patient care characteristics: patients returning within 72 hours in the emergency department.

The primary purpose of this study was to develop a clinical tool capable of identifying discriminatory characteristics that can predict patients who will return within 72 hours to the Pediatric emergency department (PED). We studied 66,861 patients who were discharged from the EDs during the period from May 1 2009 to December 31 2009. We used a classification model to predict return visits based on factors extracted from patient demographic information, chief complaint, diagnosis, treatment, and hospital real-time ED statistics census. We began with a large pool of potentially important factors, and used particle swarm optimization techniques for feature selection coupled with an optimization-based discriminant analysis model (DAMIP) to identify a classification rule with relatively small subsets of discriminatory factors that can be used to predict - with 80% accuracy or greater - return within 72 hours. The analysis involves using a subset of the patient cohort for training and establishment of the predictive rule, and blind predicting the return of the remaining patients. Good candidate factors for revisit prediction are obtained where the accuracy of cross validation and blind prediction are over 80%. Among the predictive rules, the most frequent discriminatory factors identified include diagnosis (> 97%), patient complaint (>97%), and provider type (> 57%). There are significant differences in the readmission characteristics among different acuity levels. For Level 1 patients, critical readmission factors include patient complaint (>57%), time when the patient arrived until he/she got an ED bed (> 64%), and type/number of providers (>50%). For Level 4/5 patients, physician diagnosis (100%), patient complaint (99%), disposition type when patient arrives and leaves the ED (>30%), and if patient has lab test (>33%) appear to be significant. The model was demonstrated to be consistent and predictive across multiple PED sites.The resulting tool could enable ED staff and administrators to use patient specific values for each of a small number of discriminatory factors, and in return receive a prediction as to whether the patient will return to the ED within 72 hours. Our prediction accuracy can be as high as over 85%. This provides an opportunity for improving care and offering additional care or guidance to reduce ED readmission.

Use of troponin as a screen for chest pain in the pediatric emergency department.

Troponin levels are commonly employed in the assessment of adults presenting with chest pain or concern for coronary ischemia. However, the utility of troponin measurements in children is not well defined. The purpose of this study was to review the use and clinical yield of serum troponin assay in a large pediatric emergency department (ED). We identified all patients <22 years of age, not previously known to have cardiac disease, who presented with chest pain and whose troponin levels were evaluated in our pediatric ED during a 7-year period. Test results were correlated to patient factors, such as chief complaint, cardiac history, diagnostic workup, and discharge diagnoses. Of the 212 study patients who presented with chest pain, troponin levels were increased (≥ 0.1 ng/ml) in 37 (17%) subjects. The disposition for these 37 subjects included transfer to adult facility (n = 6), admission to our pediatric inpatient service (n = 27), and discharge to home from the ED (n = 10). Only one subject had an acute myocardial infarction. For those with increased troponin level, 18 of 37 (48%) cases were attributed to a primary cardiac diagnosis with the most common discharge diagnosis of myocarditis or pericarditis. In the pediatric ED setting, selective use of troponin assay may be a useful test in the management of patients with chest pain. Most cases of increased troponin level related to chest pain represent myocarditis, often mild and self-resolving. Given the low likelihood that acute coronary syndrome is the etiology of chest pain, immediate transfer to an adult facility for the majority of patients with increase of troponin does not appear warranted.

Development of a screening tool for pediatric sexual assault may reduce emergency-department visits.

OBJECTIVE: To define the characteristics of a novel screening tool used to identify which prepubertal children should potentially receive an initial evaluation for alleged sexual assault in a nonemergent setting. METHODS: Electronic medical records were retrospectively reviewed from 2007 to 2008. Visits with a chief complaint or diagnosis of alleged sexual assault for patients aged 12 years or younger were identified. Complete records, those with no evaluation before pediatric emergency-department arrival, and those with child advocacy center follow-up were included. Records were reviewed to answer the following: (1) Did the incident occur in the past 72 hours, and was there oral or genital to genital/anal contact? (2) Was genital or rectal pain, bleeding, discharge, or injury present? (3) Was there concern for the child's safety? (4) Was an unrelated emergency medical condition present? An affirmative response to any of the questions was considered a positive screen (warranting immediate evaluation); all others were considered negative screens. Those who had positive physical examination findings of anogenital trauma or infection, a change in custody, or an emergency medical condition were defined as high risk (having a positive outcome). RESULTS: A total of 163 cases met study criteria; 90 of 163 (55%) patients had positive screens and 73 of 163 (45%) had negative screens. No patients with negative screens were classified as high risk. The screening tool has sensitivity of 100% (95% confidence interval: 93.5-100.0). CONCLUSIONS: This screening tool may be effective for determining which children do not require emergency-department evaluation for alleged sexual assault.