How good is our diagnostic intuition? Clinician prediction of bacteremia in critically ill children.

BACKGROUND: Clinical intuition and nonanalytic reasoning play a major role in clinical hypothesis generation; however, clinicians' intuition about whether a critically ill child is bacteremic has not been explored. We endeavored to assess pediatric critical care clinicians' ability to predict bacteremia and to evaluate what affected the accuracy of those predictions. METHODS: We conducted a retrospective review of clinicians' responses to a sepsis screening tool ("Early Sepsis Detection Tool" or "ESDT") over 6 months. The ESDT was completed during the initial evaluation of a possible sepsis episode. If a culture was ordered, they were asked to predict if the culture would be positive or negative. Culture results were compared to predictions for each episode as well as vital signs and laboratory data from the preceding 24 h. RESULTS: From January to July 2017, 266 ESDTs were completed. Of the 135 blood culture episodes, 15% of cultures were positive. Clinicians correctly predicted patients with bacteremia in 82% of cases, but the positive predictive value was just 28% as there was a tendency to overestimate the presence of bacteremia. The negative predictive value was 96%. The presence of bandemia, thrombocytopenia, and abnormal CRP were associated with increased likelihood of correct positive prediction. CONCLUSIONS: Clinicians are accurate in predicting critically ill children whose blood cultures, obtained for symptoms of sepsis, will be negative. Clinicians frequently overestimate the presence of bacteremia. The combination of evidence-based practice guidelines and bedside judgment should be leveraged to optimize diagnosis of bacteremia.

Critical care resource use, cost, and mortality associated with firearm-related injuries in US children's hospitals.

BACKGROUND/PURPOSE: To assess trends and resource use attributable to firearm-related injuries in US pediatric intensive care units (PICUs). METHODS: Retrospective data from Pediatric Health Information Systems (PHIS) database from 2004 to 2017. RESULTS: Of 5,984,938 admissions to 28 children's hospitals, 3707 were for firearm injuries. A total of 1088 of 3707 hospitalizations (29.9%) required PICU admission. Median PICU length of stay was 2 days (IQR, 1-6 days), and the median cost for PICU patients was $37,569.31 (IQR, $19,243.83-$77,856.32). Use of mechanical ventilation (674/1088 admissions [61.9%]), surgical procedures (744/1088 admissions [68.3%]), blood transfusions (429/1088 admissions [39.9%]), and intracranial pressure monitoring devices (30/1088 admissions [2.8%]) increased in PICU patients. Computed tomography showed an overall increase (197/287 [68.6%] to 138/177 [78%], P = .037) from 2004 to 2007 to 2016-2017. Mortality among PICU patients (140/1058 [13.23%]) attributable to firearm-related injuries increased insignificantly (34/285 (11.93%] to 25/172 [14.53%], P = .746). CONCLUSIONS: Using PHIS data, we found a significant increase in median cost per hospitalization and an increase in critical care resource use, including the frequency of invasive mechanical ventilatory assistance, neuromonitoring, operations performed, and transfusion of blood products. Further research is needed to continue to characterize the burden of pediatric critical firearm injury. TYPE OF STUDY: Retrospective cohort study. LEVEL OF EVIDENCE: Level III.

Human papillomavirus vaccination: the policy debate over the prevention of cervical cancer--a commentary.

The human papillomavirus (HPV) family causes a variety of benign, premalignant, and malignant lesions in men and women. HPV types 16 and 18 are responsible for causing 70% of all cases of cervical cancer each year. Recently, a vaccine that can prevent cervical cancer by protecting women from infection with the most common types of HPV has been made available. Following Food and Drug Administration approval and endorsement by the Centers for Disease Control and Prevention, it is the right and the duty of the state legislatures to implement vaccination programs. This vaccine, a vaccine for a sexually transmitted disease, has stirred a fierce debate. Religion and sexuality have dominated the discussion, and political calculations are inherent to the process; nonetheless, epidemiological analyses are also essential to the decision to mandate the HPV vaccine. HPV vaccine program implementation processes are at many stages in many states, and programs vary widely. Some provide information to families, whereas others allot a range of funding for voluntary vaccination. Virginia is, thus far, the only state to have enacted a mandate. This article discusses the various programs in place, the proposed legislation, and the debate surrounding the political process.