Advances in point-of-care ultrasound in pediatric emergency medicine.

PURPOSE OF REVIEW: Point-of-care ultrasound (POCUS) has become an integral part of emergency medicine practice. Research evaluating POCUS in the care of pediatric patients has improved the understanding of its potential role in clinical care. RECENT FINDINGS: Recent work has investigated the ability of pediatric emergency medicine (PEM) physicians to perform a wide array of diagnostic and procedural applications in POCUS ultrasound. Studies have demonstrated that PEM providers are able to identify an array of diseases, including intussusception, pyloric stenosis and appendicitis. Novel applications of ultrasound, such as a cardiac evaluation in the acutely ill patient or identification of skull fractures in the assessment of a patient with head injury, have shown excellent promise in recent studies. These novel applications have the potential to reshape pediatric diagnostic algorithms. SUMMARY: Key applications in PEM have been investigated in the recent publications. Further exploration of the ability to integrate ultrasound into routine practice will require larger-scale studies and continued growth of education in the field. The use of ultrasound in clinical practice has the potential to improve safety and efficiency of care in the pediatric emergency department.

Regulation of angiogenesis and choroidal neovascularization by members of microRNA-23~27~24 clusters.

MicroRNAs (miRNAs) modulate complex physiological and pathological processes by repressing expression of multiple components of cellular regulatory networks. Here we demonstrate that miRNAs encoded by the miR-23∼27∼24 gene clusters are enriched in endothelial cells and highly vascularized tissues. Inhibition of miR-23 and miR-27 function by locked nucleic acid-modified anti-miRNAs represses angiogenesis in vitro and postnatal retinal vascular development in vivo. Moreover, miR-23 and miR-27 are required for pathological angiogenesis in a laser-induced choroidal neovascularization mouse model. MiR-23 and miR-27 enhance angiogenesis by promoting angiogenic signaling through targeting Sprouty2 and Sema6A proteins, which exert antiangiogenic activity. Manipulating miR-23/27 levels may have important therapeutic implications in neovascular age-related macular degeneration and other vascular disorders.

Bedside hip ultrasonography in the pediatric emergency department: a tool to guide management in patients presenting with limp.

We present a case of a 3-year-old girl brought to the emergency department for evaluation of limp after falling off the monkey bars 1 day prior. X-rays of the entire left lower extremity were normal with no evidence of fracture, dislocation, or effusion. Point-of-care ultrasound of the left hip demonstrated a hip effusion, which prompted further imaging, ultimately revealing an occult fracture of the left proximal femoral metaphysis. This case demonstrates the ability of point-of-care ultrasound to guide the management of patients presenting to the pediatric emergency department with musculoskeletal complaints.

Unscheduled return visits to the emergency department: the impact of language.

BACKGROUND: Return visits to the emergency department (ED) resulting in admission are an important marker of quality of care. Patients and families with limited English proficiency (LEP) are at risk for suboptimal care related to imprecise communication. OBJECTIVE: The objective of this study was to compare the rate of return visits resulting in admission in LEP patients to the rate in the English-speaking patients. METHODS: We assembled a retrospective cohort of patients cared for in a pediatric, tertiary ED. Eligible patients included those who were discharged on the first encounter, and those who returned and were admitted to the hospital within 72 hours of ED discharge were identified. A logistic regression was performed comparing the rate of return visits resulting in admission in the LEP and non-LEP populations adjusting for emergency severity index and time of day at ED visit. RESULTS: A total of 119,782 patients were discharged from the ED during a 32-month study period. Of these patients, 11.7% (14,053) identified a language other than English as their primary language. The rate of return visits resulting in admission was 1.2% (1279/105,729) among English speakers and 1.6% (220/14,053) in the LEP population. Patients with LEP were more likely to return to the ED for admission (odds ratio, 1.30; 95% confidence interval, 1.12-1.50; P < 0.001) The increased risk of a return visit for LEP patients remained significant after controlling for age, emergency severity index, and time of day (adjusted odds ratio, 1.43; 95% confidence interval, 1.23-1.66; P < 0.001). CONCLUSION: Patients with LEP are at higher risk of return visit for admission.

Development and evaluation of a program for the use of ultrasound for central venous catheter placement in a pediatric emergency department.

BACKGROUND: A growing body of literature supports the use of ultrasound (US) to assist central venous catheter (CVC) placement, and in many settings, this has become the standard of care. However, this remains a relatively new and uncommonly performed procedure for pediatric emergency medicine physicians. OBJECTIVES: This study aims to describe the change over time in percentage of CVC procedures performed with US assistance per 10,000 patient visits in a pediatric emergency department. METHODS: We describe the development of an emergency US program in a pediatric emergency department and investigate how US use for CVC placement in internal jugular and femoral veins changed from July 2007, when US became available, until December 2011. Data related to CVC procedures were obtained from a procedure database maintained for quality assurance purposes. RESULTS: The percentage of CVC procedures performed with US assistance increased significantly over time (P < 0.001). CONCLUSIONS: The development of an emergency US program was associated with significantly increased physician use of US for CVC placement.

Bedside ultrasonography in the pediatric emergency department: the focused assessment with sonography in trauma examination uncovers an occult intra-abdominal tumor.

We present a case of a 3-year-old male with history of minor trauma, who was brought in by ambulance from the playground where he had an acute mental status change and was noted to be hypotensive on initial evaluation. History and examination did not indicate a clear etiology of his symptoms. Point-of-care emergency ultrasonography revealed free fluid in the abdomen and expedited the care of the child's unexpected intra-abdominal hemorrhage from an occult abdominal tumor. This case demonstrates the ability of practitioners to expedite and focus care with the use of rapid assessment with ultrasonography in the pediatric emergency department.

Mild traumatic brain injury in the pediatric population: the role of the pediatrician in routine follow-up.

BACKGROUND: Traumatic brain injury is common in children. Fortunately, most patients suffer mild traumatic brain injury (MTBI). Appropriate guidelines for follow-up care are not well established. We sought to determine practice experience and preferences of general pediatricians related to follow-up care of MTBI. METHODS: Members of the American Academy of Pediatrics Council of Community Pediatrics and general pediatricians in the Pennsylvania Chapter of the American Academy of Pediatrics participated in a web-based survey regarding practice setting, level of comfort caring for patients with MTBI, and referral patterns for such patients. RESULTS: A total of 298 pediatricians responded. An urban or suburban practice setting was reported by 83.3% with a wide distribution in practice experience (0-10 years 40.5%, 11-20 years 24.5%, >21 years 35%). Most respondents (54.5%) had cared for at least 2 to 5 patients with MTBI in the past 6 months but only 8% had seen >10 patients. Fifty-nine percent had not participated in continuing medical education activities related to MTBI and 62.2% did not use neurocognitive tests. The majority (89%) thought that they were the appropriate provider for follow-up; this declined to 61.2% for patients with loss of consciousness and only 5.4% if patients had persistent symptoms. Neurologists (75%) were the consultant of choice for referral. Increased practice experience was associated with an increased comfort in determining return to play status. CONCLUSION: In this survey, pediatricians thought that they were the most appropriate clinicians to follow-up patients with MTBI. However, most accepted this responsibility without the benefit of specific continuing medical education or using neurocognitive tests. Ensuring the availability of appropriate resources for pediatricians to care for these patients is important.

Medical students' exposure to bloodborne pathogens in the operating room: 15 years later.

We compared the rates of exposure to blood in the operating room among third-year medical students during 2005-2006 with the rates reported in a study completed at the same institution during 1990-1991. The number of medical students exposed to blood decreased from 66 (68%) of 97 students during 1990-1991 to 8 (11%) of 75 students during 2005-2006 (P<.001).

Ultrasound assistance for central venous catheter placement in a pediatric emergency department improves placement success rates.

OBJECTIVES: The use of ultrasound (US) has been shown to improve success rates and reduce complications of central venous catheter (CVC) placement in adult emergency department (ED) patients. The authors sought to determine if US assistance for CVC placement is associated with an increased success rate in pediatric ED patients. METHODS: This was a retrospective cohort study of CVC placement in a pediatric ED from January 2003 to October 2011. Data were extracted from a procedure log created to record details entered by physicians at the time of CVC placement, including indication, location, complications, and information regarding use of US. All femoral vein and internal jugular vein CVC placement attempts performed by, assisted with, or directly supervised by pediatric emergency physicians (EPs) were included. Characteristics of procedures performed with and without US assistance were compared, controlling for patient and physician factors. The primary outcome was the success rate of CVC placement. RESULTS: There were 168 patients undergoing CVC placement attempts. The proportion of successful placement attempts was significantly higher when using US assistance (96 of 98) compared to those without (55 of 70; 98% vs. 79%, odds ratio [OR] = 13.1, 95% confidence interval [CI] = 2.9 to 59.4). When controlling for patient- and physician-specific factors, success rates remained significantly higher. CONCLUSIONS: Ultrasound assistance was associated with greater likelihood of success in CVC placement in a pediatric ED.

Pediatric emergency medicine fellow training in ultrasound: consensus educational guidelines.

The importance of point-of-care emergency ultrasound (EUS) to the practice of emergency medicine (EM) is well established, and mounting research continues to demonstrate how EUS can benefit pediatric emergency department (ED) patients. As members of the EM community, pediatric EM (PEM) physicians should understand the potential value of EUS and seek opportunities to incorporate EUS into their daily practice. Currently, EUS education and training is at an early developmental stage for PEM fellows and varies greatly between programs. The goal of this article is to provide consensus education guidelines and to describe a sample curriculum that can be used by PEM fellowship programs when developing or revising their US training curricula. The authors recognize that programs may be at different stages of EUS development and will consequently need to tailor curricula to individual institutional needs and capabilities. This guideline was developed through a collaborative process between EUS educators and members of the American Academy of Pediatrics Section of EM Fellowship Directors Subcommittee. The guideline includes the following topics: important considerations regarding EUS in PEM, PEM US program framework, PEM US curriculum, PEM US education program, and competency assessment.

Dietary arginine supplementation attenuates renal damage after relief of unilateral ureteral obstruction in rats.

BACKGROUND: Progression of renal injury after relief of unilateral ureteral obstruction (UUO) has been demonstrated. Nitric oxide (NO) may be an effective intervention due to its vasodilatory, antifibrotic, and anti-apoptotic effects. Herein, we used dietary L-arginine (ARG) supplementation in a UUO relief model. METHODS: This study comprised group 1, control (no treatment). All other rats were subject to 3-day UUO, which was then relieved, and the rats maintained for 7 additional days. Group 2, no additional treatment; group 3, L-ARG; group 4, L-NAME, NO synthase inhibitor; group 5, ARG and L-NAME. Urinary NO(2/3) was quantified. GFR and ERPF were measured at day 10. Interstitial fibrosis and fibroblast expression, macrophage infiltration, tubular apoptosis, and proliferation, NOS expression, and the levels of tissue TGF-beta were evaluated. RESULTS: Urinary NO(2/3) was significantly increased by ARG treatment and decreased by L-NAME. GFR and ERPF measured 7 days following relief were not significantly different in the previously obstructed kidneys (POK) of groups 2 and 3. L-NAME significantly reduced GFR and ERPF in the POK. ARG significantly reduced apoptosis, macrophage infiltration, and fibroblast expression in the POK. L-NAME exacerbated the effects on apoptosis and fibroblasts. Fibrosis was minimal in groups 1 through 3, but was significantly increased by L-NAME. ARG did not affect renal NOS expression and tissue TGF-beta1 levels. CONCLUSION: Dietary ARG supplementation during UUO relief did not improve ERPF or GFR. However, renal damage, including fibrosis, apoptosis, and macrophage infiltration was significantly improved by ARG treatment. This suggests that increasing NO availability could be beneficial in the setting of UUO relief.