Impact of steroids on the immune profiles of children with asthma living in the inner-city.

Background: Inner-city asthma is associated with high morbidity and systemic steroid use. Chronic steroid use impacts immune function; however, there is a lack of data with regard to the extent of immunosuppression in patients with asthma and who are receiving frequent systemic steroids. Objective: To identify the impact of frequent systemic steroid bursts on the immune function of children with asthma who live in the inner city. Methods: Children ages 3-18 years with asthma were divided into study (≥2 systemic steroid bursts/year) and control groups (0-1 systemic steroid bursts/year). Lymphocyte subsets; mitogen proliferation assay; total immunoglobulin G (IgG) value, and pneumococcal and diphtheria/tetanus IgG values were evaluated. Results: Ninety-one participants were enrolled (study group [n = 42] and control group [n = 49]). There was no difference in adequate pneumococcal IgG value, diphtheria/tetanus IgG value, mitogen proliferation assays, lymphocyte subsets, and IgG values between the two groups. Children who received ≥2 steroid bursts/year had a significantly lower median pneumococcal IgG serotype 7F value. Most of the immune laboratory results were normal except for the pneumococcal IgG value. Most of the participants (n/N = 72/91 [79%]) had an inadequate pneumococcal IgG level (<7/14 serotypes ≥1.3 µg/mL). The participants with inadequate pneumococcal IgG level and who received a pneumococcal polysaccharide vaccine 23 (PPSV23) boost had a robust response. There was no significant difference in infection, steroid exposure, asthma severity, or morbidities between those with adequate versus inadequate pneumococcal IgG values. Conclusion: Children with asthma who live in the inner city and receive ≥2 steroid bursts/year do not have a significantly different immune profile from those who receive ≤1 steroid bursts/year do not have a significantly different immune profile from those who do not. Although appropriately vaccinated, most participants had an inadequate pneumococcal IgG level, regardless of steroid exposure and asthma severity. These children may benefit from PPSV23.

Peri-Intubation Arrest in High Risk vs. Standard Risk Pediatric Trauma Patients Undergoing Endotracheal Intubation.

BACKGROUND: While the anatomically difficult airway has been studied in pediatric trauma patients, physiologic risk factors are poorly understood. Our objective was to evaluate if previously published high risk physiologic criteria for difficult airway in medical patients is associated with adverse outcomes in pediatric trauma patients. METHODS: This was a retrospective chart review of patients ≤18 years with traumatic injuries who underwent endotracheal intubation (EI) in a pediatric emergency department (PED) between 2016 and 2021. High risk criteria evaluated included 1) hypotension, 2) concern for cardiac dysfunction, 3) persistent hypoxemia, 4) severe metabolic acidosis (pH < 7.1), 5) post-return of spontaneous circulation. Our primary outcome was peri-intubation cardiac arrest, defined as cardiac arrest within 10  minutes of EI. Secondary outcomes included in-hospital cardiac arrest and mortality and first pass EI success. RESULTS: One third (n = 32; 36.4%) of the 88 patients analyzed had at least one high risk criteria. When compared to the standard risk group, those in the high risk group had a higher incidence of peri-intubation arrest (28.1% vs. 0%, difference: 28.1%, 95% CI: 10.1-46.2), PED/in-hospital arrest (43.8% vs. 3.4%, difference: 38.4%, 95% CI: 17.8-59.0) and in-hospital mortality (33.4% vs. 3.6%, difference: 29.8%, 95% CI: 8.4-46.9). Having multiple high risk criteria progressively increased the odds of post-intubation PED/in-hospital cardiac arrest (1 risk factor: OR = 6.7, 95% CI: 1.5-30.2; 2 risk factors: OR = 12.5, 95% CI: 2.3-70.0; ≥ 3 risk factors: OR = 56.1, 95% CI: 6.0-523.8). CONCLUSIONS: The presence of high risk physiologic criteria is associated with increased incidence of peri-intubation, in-hospital arrest, and death in pediatric trauma patients. Children with multiple risk factors are at an incremental risk of cardiac arrest.

Resource Utilization for Pediatric Patients Discharged After Interhospital Transfer.

BACKGROUND: Transfers to a pediatric emergency department (ED) with subsequent discharge home should be optimized. Transfers to a pediatric ED (PED) from community and academic general EDs are compared with a focus upon subsequent resource utilization with the PED to identify patterns of resource and education needs within general EDs. METHODS: Patients younger than 21 years transferred to a PED from general EDs over a 1-year period and discharged home were retrospectively reviewed. The referring institutions were categorized as academic or community. Demographic and clinical variables reflecting PED care were abstracted and referrals from the academic and community institutions were compared. RESULTS: Among 5675 interfacility transfers, 1603 (28.2%) were discharged home from the PED. Most patients were transferred from a community ED (n = 1081, 67.4%). Laboratory testing, ancillary studies, and medication administration did not differ between patients transferred from an academic or community ED. Patients from a community ED were more likely to have a procedure performed (44% vs 39%, P = 0.04). Patients from a community ED were also more likely to have high resource utilization in the PED (61% vs 55%, P = 0.03). DISCUSSION: Most children transferred to a PED from a general ED required few resources in the PED before discharge home. The pattern of care delivered in the PED differed by the designation of the transferring ED providing insight into the differential educational and resource needs of general EDs in caring for pediatric patients.

Kidney Echogenicity and Vesicoureteral Reflux in Children with Febrile Urinary Tract Infection.

OBJECTIVE: To evaluate increased kidney echogenicity as a predictor of vesicoureteral reflux (VUR) in young children with first febrile urinary tract infection (UTI). STUDY DESIGN: We performed a single center retrospective study of hospitalized children with first febrile UTI diagnosed in accordance with the American Academy of Pediatrics guidelines. All patients had kidney bladder ultrasound (KBUS) and voiding cystourethrography. Variables analyzed using χ2 test or Mann-Whitney U test as appropriate. Multivariable logistic regression analysis was performed for the abnormal KBUS findings and OR and 95% CI were calculated. RESULTS: Our cohort included 415 children (830 kidney units) with median age of 5 months (1 month to 5 years) and 80% were female. One hundred thirty-two (31.8%) patients had abnormal KBUS, including increased echogenicity in 45 patients. Overall, 42.2% of patients with increased echogenicity had VUR vs 23.3% with normal ultrasound (P = .013) and 31.1% of patients with increased echogenicity had high-grade III-V VUR vs 8.1% with normal ultrasound (P = .001). In total, 24.3% of kidneys with increased echogenicity had VUR vs 20% with normal ultrasound (P = .246) and 20% of kidneys with increased echogenicity had high-grade III-V VUR vs 9.9%with normal ultrasound (P = .005). CONCLUSIONS: These data support adding increased kidney echogenicity to the list of other KBUS findings that are helpful in decision making about a need for voiding cystourethrography in young children with first febrile UTI.

Bicycle handlebar injuries - a systematic review of pediatric chest and abdominal injuries.

OBJECTIVE: The severity of handlebar injuries can be overlooked due to subtle signs and wide range of associated internal injuries. Our objective was to describe thoracoabdominal injuries due to bicycle handlebars and their outcomes in children. METHODS: Articles that reported thoracoabdominal injuries were identified from database conception to March 3, 2019 using PubMed, EMBASE, Cochrane Library, CINHAHL Complete, Web of Science and Scopus. A systematic review of studies of thoracoabdominal handlebar injuries in children ≤21 years on human-powered bicycles in English was performed. Information on demographics, clinical features, injuries, interventions and outcomes was noted. RESULTS: A total of 138 articles were identified from 1952 to 2019. There were 1072 children (males, 85.1%) and 1255 thoracoabdominal injuries. Mean age was 9.7 ± 3.3 years old. Common clinical features included abdominal pain and guarding, vomiting, fever and a handlebar imprint. The liver was the most frequently injured organ. Surgery was performed in 338 children with a mean age of 10.0 ± 3.3 years. Twenty-seven children (2.5%) were discharged and returned due to worsening symptoms, of whom 23 (85.2%) required surgery. Thirty-one children (2.9%) transferred to a higher level of care due to injury severity. Two deaths were reported. CONCLUSION: Bicycle handlebars can cause significant thoracoabdominal injuries. Presence of abdominal pain, vomiting, fever or a circular imprint on the chest or abdomen should prompt further workup. Future studies on diagnostic modalities and best practices are needed to lower the chance of missed injuries.

Contemporary feeding practices in postoperative patients with Congenital Heart Disease.

BACKGROUND: We aimed to assess the current nutritional practices in postoperative patients with Congenital Heart Disease. METHODS: Cross-sectional electronic survey was sent to members of The Pediatric Cardiac Intensive Care Society. MEASUREMENTS AND MAIN RESULTS: In Total, 52 members of the Pediatric Cardiac Intensive Care Society responded to the survey consisting of 14% paediatric intensivist, 53% paediatric cardiac intensivist, and 33% nurse/nurse practitioner with a median of 10 years of experience. There was an even distribution between intensivist (55%) and dietitian or nutritionist (45%) in nutrition management. Ninety-eight percent of respondents report that they would feed patients on inotropic or vasoactive support. Only 27% of respondents reported using indirect calorimetry in calculating resting energy expenditure which is the current gold standard. Academic hospitals compared to non-academic hospital were most likely to report feeding patients within 24 hours postoperative (p = 0.014). Having a feeding protocol was associated with feeding within 24 hours postoperative (p = 0.014) and associated with >50% goal intake by 48 hours postoperative (p = 0.025). CONCLUSIONS: Substantial variation in feeding practice still exists despite the American Society for Parenteral and Enteral Nutrition guidelines from 2017. Report of institutional established feeding protocol was associated with increased early feeding and reaching goal feeds by 48 hours postoperative. Very few centres reported use of indirect calorimetry in postoperative paediatric cardiac intensive care patients and many respondents lacked knowledge about applications in this population. Additional work to determine optimal feeding pathways and assessment of caloric needs in this population is needed.

Does Postmortem Imaging Provide Additional Findings After Unexpected Deaths in Infants and Children?

METHODS: We performed a retrospective study of unexpected deaths in children 2 years or younger between 2008 and 2018. Children with known traumatic deaths and those transferred after a cardiopulmonary arrest at an outside institution were excluded. We collected patient demographics, physical examination findings, and type of PMI performed along with their results. RESULTS: We analyzed 150 deaths with majority (128; 85.3%) being infants. No PMI was performed in 20 children (13.3%). An autopsy was not performed in 22 children (14.6%). A skeletal survey and an autopsy were performed only in 72.6% (93/128) infants. PMI provided additional findings in 51 infants (34%) and 13 children (59.1%) aged 13 to 24 months. PMI identified abuse in 11 children with a negative physical examination result, 3 of whom had a negative autopsy. CONCLUSIONS: The American Academy of Pediatrics recommendations of performance of a skeletal survey and an autopsy were not adhered to after all infant deaths. PMI is useful in identification of additional findings in children 2 years or younger, especially those concerning for physical abuse in infants with a negative physical examination.

Bladder Stimulation for Clean Catch Urine Collection: Improved Parent and Provider Satisfaction.

OBJECTIVES: Previous studies have demonstrated the efficacy of fluid intake with suprapubic and lumbar paravertebral massage for clean catch urine (CCU) collection in infants. We investigated the acceptability and feasibility of integrating this bladder stimulation technique (BST) into routine care in the pediatric emergency department (PED). METHODS: This was a prospective cohort study. Infants less than 6 months of age requiring a urinalysis and urine culture as part of their PED visit were recruited. All PED nurses and technicians received a standardized training outlining the BST using a video module and print materials. Success rates, bacterial contamination, parental perception of patient distress, and parent and provider satisfaction with the BST for CCU collection were compared with urethral catheterization. RESULTS: A total of 124 patients were recruited. The BST was successful in 38% (47/124) with a median time to void of 73 seconds (interquartile range: 19, 151). The BST was more likely to be successful in infants less than 90 days (53%; 95% confidence interval, 0.075-0.046; P = 0.005). A urinary tract infection was diagnosed in 4% of patients, with no significant differences between BST (1/47; 2%) and catheterization (4/59; 7%; P = 0.65). Patients experienced less discomfort during the BST compared with catheterization (mean numeric rating scale score, 2/10 vs 6/10; P < 0.001), and the BST was viewed positively by both parents and providers. Compared with catheterization, parents were significantly more satisfied with the BST (BST, 98%; catheterization, 58%; P < 0.001) and were more likely to consent to the BST in the future (BST, 98%; catheterization, 69%; P < 0.001). Most providers reported that the BST was well tolerated by participants (46/47; 98%), and providers felt that the BST improved parental satisfaction with the clinical encounter (46/47; 98%). CONCLUSION: The BST for CCU collection is a well-tolerated and well-received approach that can easily be implemented into clinical practice with minimal training.

Toys and Toy Accessories Strike Back: Pediatric Injuries From Plush Toys, Toy Figurines, and Doll and Toy Accessories.

OBJECTIVE: The aim of the study was to examine age-associated injury trends and severe injury proportions for plush toys, toy figurines, and doll and toy accessories. We hypothesized that the proportion of severe injuries would be highest in the younger than 3-year and 3- to 5-year age groups. METHODS: We analyzed injury patterns from plush toys, toy figurines, and doll and toy accessories for ages of 0 to 18 years from 2010 to 2018 using the Consumer Product Safety Commission National Electronic Injury Surveillance System. Exclusion criteria included unspecified toy categories, adult or pet involvement, or unspecified disposition. National estimates were calculated with National Electronic Injury Surveillance System sample weights. Outcome of interest was severe injury proportions per age and toy category. Severe injury was defined as life- or limb-threatening injuries or injuries requiring admission. χ2 test was used to analyze the distribution of categorical variables. RESULTS: We analyzed 1360 injuries. The majority occurred in female (n = 771, 56.7%) and ages of 3 to 5 years (n = 580, 42.7%). Annual injury frequency remained stable. One fifth of injuries were severe (n = 321, 23.6%), with a national estimate of 9304.7. The majority of both total (n = 778, 57.2%) and severe injuries (n = 182, 56.7%) resulted from toy figurines. Life-threatening injury secondary to foreign body aspiration or ingestion with a risk for asphyxiation was the most common severe injury. Severe injuries were significantly more common in the younger than 3-year group (odds ratio, 3.59; 95% confidence interval, 2.40-5.36) and 3- to 5-year age group (odds ratio, 2.97; 95% confidence interval, 2.01-4.39) than the older than 5-year age group. CONCLUSIONS: Injury frequency remained stable. The greatest proportion of injuries were in ages up to 5 years, with most injuries occurring in the 3- to 5-year age category, and a significant proportion of injuries were severe.

Emergency Department Utilization and Serious Bacterial Infection Rates in Children With Renal Transplants.

OBJECTIVES: Emergency department (ED) visits by children with solid organ transplants have increased significantly. Our objectives were to describe the common complaints, diagnosis, types, and rates of serious bacterial infection (SBI) in children with renal transplant (RT) who present to the hospital. METHODS: We conducted a retrospective study from 2012 to 2016 of RT children up to 18 years who presented to the ED or were directly admitted. We excluded patients who presented for a procedure. We collected demographics, transplant type, immunosuppressive data, chief complaints, diagnostic testing with results, interventions performed, and final diagnosis. RESULTS: We analyzed 131 visits in 29 patients during the study period. Most common chief complaints were infectious (34.4%) and gastrointestinal (26%). Infection was proven in 42.0% of visits with only 3.1% being organ rejection. Serious bacterial infection was diagnosed in 34 visits (26.0%) with urinary tract infection (UTI) being the most common (20.6%). Of the 33 visits for fever, SBI occurred in 16 (48.5%) patients with the most common SBI being UTI 10 (30.3%). Bacteremia occurred in 1 patient and hypotension in 4 patients. Antibiotic administration was the most common intervention performed (78; 59.5%). Significant interventions were uncommon (2 patients). Logistic regression revealed no factors to be associated with SBI. CONCLUSIONS: Our cohort of children with RT presented most commonly with infections to the hospital with UTI being the most common SBI. Bacteremia and significant interventions were rare. Future studies are needed to identify subgroups of low-risk pediatric RT patients who can possibly be safely discharged home from the ED.

Extracorporeal membrane oxygenation outcomes in children with Williams syndrome: a review of the ELSO registry.

INTRODUCTION: Williams syndrome (WS) results from a microdeletion that usually involves the elastin gene, leading to generalized arteriopathy. Cardiovascular anomalies are seen in 80% of WS patients, including supravalvular aortic stenosis (SVAS), pulmonary artery stenosis (PAS), and pulmonary stenosis (PS). Sudden death associated with procedural sedation and in the perioperative period in WS children have been reported. This study aims to describe extracorporeal membrane oxygenation (ECMO) use in WS children, identify risk factors for hospital mortality of WS patients, and compare outcomes between WS children and non-WS children with SVAS, PAS, and PS. METHODS: Children 0-18 years-old in the Extracorporeal Life Support Organization (ELSO) Registry with a primary or secondary diagnosis of WS, SVAS, PAS, or PAS were included. RESULTS: Included were 50 WS children and 1222 non-WS children with similar cardiac diagnoses. ECMO use increased over time in both groups (p = 0.93), with most cases occurring in the current era. WS children were younger (p = 0.004), weighed less (p = 0.048), had a pulmonary indication for ECMO (50% vs 10%, p < 0.001), and were placed more on high frequency ventilation (p < 0.001) than non-WS patients. Despite reporting a respiratory indication, most (84%) WS patients were placed on VA-ECMO. There were no significant differences between the two groups in terms of pre-ECMO cardiac arrest, ECMO duration, or reason for ECMO discontinuation. Both groups had a mortality rate of 48% (p = 1.00). No risk factors for WS mortality were identified.

Estimation of national stress index using socioeconomic antecedents - a case of MIMIC model.

Developed economies are at the forefront of facing the brunt of non-communicable diseases (NCD). The majority of the health expenditures are routed in managing obesity and mental disorder-related patients, and there is a fall in the productivity of the distressed and NCD prone labour. Several indicators of stress are used in literature to assess its implications. However, empirically no database has maintained the longitudinal data of national stress level. This study focused on constructing the socioeconomic antecedent of non-communicable stress which is leading to several NCDs. For this Multiple Indicator and Multiple Causes (MIMIC) model is utilized for 151 countries between 2008 and 2018. The results show that macroeconomic conditions, trade, and environmental quality follow fundamentals in explaining stress. While, national stress index is a significant source of smoking and mental disorder prevalence.

Antipsychiatric Medication Errors in Children Boarded in a Pediatric Emergency Department.

OBJECTIVES: Mental health visits to the pediatric emergency department (PED) have increased significantly. Our objective was to describe medication errors in children with mental health illness who were boarded in a PED for more than 6 hours. METHODS: We conducted a retrospective study from 2014 to 2015 of children 6 to 18 years with psychiatric complaints and a length of stay of more than 6 hours. Admitted patients and those not on home medications were excluded. We collected demographics, number, types, and doses of antipsychiatric medications and errors. RESULTS: A total of 676 patients (53.1% males) with a median age of 14 (interquartile range, 12, 15) years were included. The median length of stay was 11.7 (interquartile range, 8.5, 20.5) hours. A total of 974 medication errors occurred in 491 (72.7%) patients. Omission errors were noted in 376 patients (76.6%), commission in 44 patients (9.0%), and both in 71 patients (14.4%). Among commission errors, 8 (18.1%) were serious and 8 (18.1%) were significant. One third of patients (30.5%) had 1 medication error, 23.9% had 2, 11.7% had 3, and 5% had 4.Medication errors were most commonly noted in antidepressant and antipsychotic classes. One third (35.8%) of errors involved 2 medication classes. Being on 3 (odds ratio, 1.8; 95% confidence interval, 1.09-2.9) or 4 or more (odds ratio, 2.81; 95% confidence interval, 1.54-5.34) antipsychiatric medications was significantly associated with a prescription error. CONCLUSION: There is a high incidence of medication errors, particularly those of omission, among antipsychiatric prescriptions in children boarded in the PED. A refinement of current medication reconciliation and integration of psychiatric medication databases between the PED and pharmacies are urgently needed to reduce these errors.

Analgesia Use in Children with Acute Long Bone Fractures in the Pediatric Emergency Department.

BACKGROUND: Practice variation exists in pain management of children with long bone fractures (LBFs). OBJECTIVE: The objectives of this study were to describe current pain management in children with LBFs and the factors associated with the undertreatment of pain. METHODS: We retrospectively studied children (aged 0-18 years) with a diagnosis of LBF in a pediatric emergency department (PED) from November 2015 through August 2016. Demographic characteristics and quality measures were noted. We determined the impact of PED crowding using the National Emergency Department Overcrowding Scale. RESULTS: A total of 905 patients (63% male, 48% African American) were enrolled. Median age was 6 years (interquartile range [IQR] 7 years), 72% had upper extremity injuries, falls were the most common mechanism (74%), and the majority were discharged (77%). Median time to pain score was 6 min (IQR 14 min). Seventy-two percent received analgesia with a median time to order of 63 min and medication receipt of 87 min. Ibuprofen was the analgesia prescribed most commonly. There were no identified factors associated with oligoanalgesia. Nonuse of narcotics was associated with African-American race, public insurance, single fractures, and arrival via private vehicle. Ambulance arrivals, lower extremity fractures, and disaster mode were associated with receiving analgesia within 60 min. CONCLUSIONS: In our study, 28% of children with LBFs did not receive pain medications, especially during normal PED volumes. Additional studies are required to explore triage as a venue for analgesia delivery for LBFs.

Management of Childhood Migraine by Headache Specialist vs Non-Headache Specialists.

OBJECTIVE: This study aims to compare the management practices of a headache specialist with non-headache specialists in the treatment of children with migraine. The use of appropriate rescue medications and prophylactic agents, application of neuroimaging, and short-term outcomes are compared in children treated by the two groups of physicians. METHODS: A retrospective cohort study was conducted by utilizing the electronic medical records of children 3-18 years of age with migraine, who were evaluated at a tertiary care children's hospital from 2016 to 2018. RESULTS: Of the 849 patients who met the study criteria, 469 children were classified as having chronic migraine or high-frequency episodic migraine and were followed-up on at least 1 occasion by the neurologists. Imaging was obtained in 66.5% of all children with migraine. The headache specialist used 5-HT agonists ("triptans") for migraine management in 56.7% (76/135) of cases compared to non-headache specialists who prescribed them in 28.7% (96/334) of cases (P < .001). Of the children with chronic migraine, the headache specialist evaluated 135 patients while the non-headache specialists treated 334 children. Non-headache specialists prescribed prophylaxis in the form of natural supplements more frequently (63.8% of cases) compared to the headache specialist (38.5% of children) (P < .001). Moreover, prophylaxis with prescription drugs was utilized more often by headache specialist (66.7%) than non-headache specialists (37.4%) (P < .001). CONCLUSIONS: Imaging appears to be commonly recommended by both headache specialists and non-headache specialists in children with migraine. The headache specialist was more likely to use triptans as rescue medications for pediatric migraine. Outcomes in the short-term were not statistically different whether children were being managed by the headache specialist or the non-headache specialists.

Procedural sedation in children with autism spectrum disorders in the emergency department.

BACKGROUND AND OBJECTIVES: Children with autism spectrum disorder (ASD) present more frequently to the emergency department (ED) than children with normal development, and frequently have injuries requiring procedural sedation. Our objective was to describe sedation practice and outcomes in children with ASD in the ED. METHODS: We performed a retrospective chart review of children with ASD who underwent sedation at two tertiary care EDs between January 2009-December 2016. Data were collected on children 1-18 years of age with ASD who were sedated in the ED. RESULTS: There were 6020 ED visits by children with ASD, 126 (2.1%) of whom received sedation. The most frequent indications for sedation were laceration repair (24.6%), incision and drainage (17.5%), diagnostic imaging (14.3%), and physical examination (11.9%). The most common sedatives used were ketamine (50.8%) and midazolam (50.8%). Ketamine was most commonly given intravenously (71.9%), while midazolam was usually given intranasally (71.9%). Procedures could not be completed in 4 (3.2%) patients, and adverse events were noted in 23 (18.3%) patients. Only four (3.2%) patients required supplemental oxygenation, and one received positive pressure ventilation. CONCLUSIONS: Children with autism in the ED commonly received sedation; one in four of which were for non-painful diagnostic procedures or physical examination. Over one-third received sedation via a non-parenteral route for intended minimal sedation. Sedative medication dosing and observed adverse events were similar to those reported previously in children without ASD. Emergency providers must be prepared to meet the unique sedation needs of children with ASD.

Delayed Admissions to the Pediatric Intensive Care Unit: Progression of Disease or Errors in Emergency Department Management.

OBJECTIVES: Few studies have evaluated impact of emergency department (ED) management on delayed transfers to the pediatric intensive care unit (PICU). Our study objectives were to describe patient characteristics of PICU transfers less than or equal to 12 hours of admission and determine the reason for transfer. METHODS: We conducted a retrospective chart review of patients transferred to PICU less than or equal to 12 hours of admission. We extracted patient demographics, emergency severity index category, ED, floor and PICU length of stay (LOS), and PICU "significant" interventions. Charts were reviewed independently by the study principal investigator and a PICU attending who classified transfers as secondary to progression of disease or error in ED management. Furthermore, errors were classified as diagnostic, management, or disposition errors. RESULTS: A total of 164 patients met inclusion criteria. Most were male (86/164, 52.4%), with emergency severity index category 2 (116/164, 70.7%) and respiratory diagnosis (98/164, 59.8%). Most transfers (136/164, 82.9%) resulted from progression of illness. No significant interventions were performed in 48.8% (80/164) of patients. Of 164 transfers, 28 (17.1%) resulted from ED error, and half of these were management errors. Compared with disease progression, the ED error group had a significantly shorter median floor LOS {3.45 [interquartile range (IQR): 2.15, 7.56] vs 6.58 (IQR: 3.70, 9.20); P = 0.005}, more PICU interventions [1.5 (IQR: 0, 4) vs 0 (IQR: 0, 2); P = 0.006], and longer PICU LOS [2.50 (IQR: 1.09, 4.25) vs 1.36 (IQR: 0.80, 2.50); P = 0.013]. CONCLUSIONS: Most PICU transfers less than or equal to 12 hours after admission result from illness progression. Half of these do not require significant interventions. The PICU transfers after ED management error had significantly shorter floor LOS, longer PICU LOS, and more interventions.

Utility of Neuroimaging in Children Presenting to a Pediatric Emergency Department With Ataxia.

OBJECTIVES: The aim of this study was to evaluate the utility of neuroimaging in children who present to the pediatric emergency department with acute-/subacute-onset ataxia. Neuroimaging is performed in many children with ataxia to rule out serious intracranial pathology. There is, however, limited evidence to support such practice. METHODS: This was a retrospective review of electronic medical records of children who presented to the emergency department with ataxia between 2007 and 2013. Patient demographics, historical features, physical examination findings, laboratory results, and neuroimaging results were collected. Neuroimaging studies that were classified as abnormal by a neuroradiologist were further reviewed and classified by the study neurologist as clinically significant or not. RESULTS: The records of 141 subjects were analyzed. The most common causes of ataxia were infectious/postinfectious (36.2%) and ingestion (15.6%). Neuroimaging was performed in 104 children (73.8%). Neuroimaging was abnormal in 63 children (60.6%). However, these abnormalities were clinically significant in only 14 children (13.5%). Focal neurological findings were noted in 12 of 14 children (85.7%) with clinically significant neuroimaging. CONCLUSIONS: Clinically significant neuroimaging was noted in a minority of children who presented with acute/subacute ataxia. The majority of patients with clinically significant neuroimaging had focal neurological findings on examination. Neuroimaging may not be required in all children presenting to the ED with acute ataxia, but further large-scale studies are needed to validate these findings and identify a subset of patients with ataxia in whom imaging can be deferred.

Changes in Bi-ventricular Function After Hematopoietic Stem Cell Transplant as Assessed by Speckle Tracking Echocardiography.

Hematopoietic stem cell transplant (HSCT) is a therapeutic option for patients with sickle cell disease (SCD) and severe acquired aplastic anemia (SAA). HSCT may have beneficial effects on ventricular function in damaged myocardium. We hypothesized improvement in ventricular performance and pulmonary hypertension following HSCT with strain echocardiography in SCD and SAA. Echocardiographic strain and other standard functional data were obtained via retrospective cohort analysis of patients (n = 23) with SCD and SAA who underwent HSCT and were followed at a single center between 2000 and 2014. Left ventricular global longitudinal strain was below normal at baseline, and decreased significantly (from - 16.6 to - 11.1, P = 0.05) from pre-HSCT to the initial post-HSCT echocardiogram at 109 (SD ± 83) days. At 351 (SD ± 115) days, longitudinal strain improved significantly from initial decline (from - 11.1 to - 17.5, P = 0.009) but was comparable to baseline (P = 0.43). Other measurements of bi-ventricular function did not change significantly. Tricuspid regurgitation velocities as surrogates for pulmonary hypertension improved in the subset of patients with baseline elevated values although data points were limited. Abnormal myocardial systolic function was detected at baseline with strain imaging. HSCT was associated with initial worsening longitudinal strain values, followed by improvement to baseline levels by 1 year. Insufficient data exist on whether pulmonary hypertension improves after HSCT.

Optimal dosing of intravenous ketamine for procedural sedation in children in the ED-a randomized controlled trial.

OBJECTIVE: The objective of the study is to compare need for redosing, sedation efficacy, duration, and adverse events between 3 commonly administered doses of parenteral ketamine in the emergency department (ED). METHODS: We conducted a prospective, double-blind, randomized controlled trial on a convenience sample of children 3 to 18years who received intravenous ketamine for procedural sedation. Children from each age group (3-6, 7-12, and 13-18years) were assigned in equal numbers to 3 dosing groups (1, 1.5, and 2mg/kg) using random permuted blocks. The primary outcome measure was need for ketamine redosing to ensure adequate sedation. Secondary outcome measures were sedation efficacy, sedation duration, and sedation-related adverse events. RESULTS: A total of 171 children were enrolled of whom 125 (1mg/kg, 50; 1.5mg/kg, 35; 2mg/kg, 40) received the randomized dose and were analyzed. The need for ketamine redosing was higher in the 1mg/kg group (8/50; 16.0% vs 1/35; 2.9% vs 2/40; 5.0%). There was no significant difference in the median Ramsay sedation scores (5.5 [interquartile range {IQR}, 4-6] vs 6 [IQR, 4-6] vs 6 [IQR, 5-6]), FACES-R score (0 [IQR, 0-4] vs 0 [IQR, 0-0] vs 0 [IQR, 0-0]), sedation duration in minutes (23 [IQR, 19-38] vs 24.5 [IQR, 17.5-34.5] vs 23 [IQR, 19-29]), and adverse events (10.0% vs 14.3% vs 10.0%) between the 3 dosing groups. Physician satisfaction was lower in the 1mg/kg group (79.6% vs 94.1% vs 97.3%). CONCLUSIONS: Adequate sedation was achieved with all 3 doses of ketamine. Higher doses did not increase the risk of adverse events or prolong sedation. Ketamine administered at 1.5 or 2.0mg/kg intravenous required less redosing and resulted in greater physician satisfaction.