Leukocytosis and C-Reactive Protein Levels as Indicators of Infection in Children With Diabetic Ketoacidosis.

BACKGROUND: Diabetic ketoacidosis (DKA) is one of the serious complications of type 1 diabetes mellitus and may be aggravated by infection. Diagnosing an infection in a patient with DKA is often complicated because of the overlap of symptoms and the presence of leukocytosis in both conditions. Reliable indicators for the diagnosis of bacterial infection in DKA may reduce unnecessary use of antibiotics and enable closer monitoring of patients at risk. METHODS: This is a retrospective study. The study cohort included 180 children and adolescents with type 1 diabetes mellitus who were admitted to the Pediatric Emergency Department at Shaare Zedek Medical Center and had blood test results. We compared white blood cell count, C-reactive protein (CRP) levels, blood glucose levels, pH, the degree of acidosis, and the incidence of infection in patients with and without DKA. RESULTS: The incidence of probable bacterial infection in the entire cohort was 13.9%: 15.7% in the DKA group and 7.5% in the non-DKA group ( P = 0.65). The incidence of leukocytosis was significantly higher in patients with DKA ( P = 0.0003), although this was not related to bacterial infection. The CRP levels were higher in the DKA group with infection than without infection, and this was statistically significant ( P = 0.008). CONCLUSIONS: Our findings suggest that leukocytosis in DKA is not a reliable indicator of concomitant bacterial infection. In contrast, CRP levels were not related to the DKA or degree of acidosis and were significantly higher in patients with infection within the DKA group, and are therefore a more reliable indicator of concomitant infection in these patients.

Antibiotics for Clinical Dysentery in the Pediatric Emergency Department.

BACKGROUND: Clinical dysentery causes hundreds of thousands of deaths annually worldwide. However, current recommendations reserve antibiotics for those either clinically sick or with highly suspected cases of shigellosis. This treatment stems from rising antibiotic resistance. Children diagnosed with clinical dysentery in the pediatric emergency department (PED) are regarded more cautiously. OBJECTIVES: To explore the use of antibiotics in children diagnosed with clinical dysentery in the PED. METHODS: A retrospective case study of children with clinical dysentery at a single PED during the years 2015 and 2018. Demographics as well as clinical findings were compared to culture results and antibiotic treatment. RESULTS: The study included 281 children who were diagnosed with clinical dysentery during the study period; 234 (83%) were treated with antibiotics. However, cultures were positive in only 162 cases (58%). Only 32% were Shigella spp. Younger age, fever, and leukocytosis were related to antibiotic treatment. CONCLUSIONS: The diagnosis of clinical dysentery is misgiven commonly in the PED leading to widespread use of antibiotics when not indicated. This treatment may impact antibiotic resistance patterns. Further studies and interventions are necessary to create clear guidelines in the PED setting.

Management of intraorbital infections in the pediatric emergency department.

Intraorbital infections may lead to severe complications, necessitating rapid diagnosis and intervention. The decision process regarding the need for emergent imaging and possible surgical intervention is unclear in the literature. This retrospective cohort study included two major pediatric emergency departments in Israel between 2010 and 2020. Patients arriving at the emergency department with an admission diagnosis of intraorbital infection and at least one high-risk symptom for orbital involvement were included in the study. The main outcome measures were the computerized tomography (CT) timing and results, whether the case was managed surgically or conservatively and whether the patient returned to the same hospital with significant complications. Ninety-five patients were included; 70 underwent a CT scan in the first 24 h, and of those 21 were managed surgically; 16 were treated based on clinical findings alone, with no imaging performed. When comparing groups based on management, we found no significant differences based on presenting symptoms, duration of complaints, or severity of CT findings. However, having three or more high-risk presenting symptoms was associated with a greater likelihood of surgical intervention (multivariate logistic regression p = 0.069, odds ratio 1.73, 95% confidence interval 0.96-3.11; one-way ANOVA and Fisher's exact test p < 0.05). CONCLUSION: The decision to treat intraorbital infections at our institutions appears to be based on clinical impression of disease severity rather than radiologic findings. This suggests a need for further interdisciplinary studies to clarify optimal management. WHAT IS KNOWN: • Orbital c ellulitis is associated with significant potential complications, necessitating rapid diagnosis and treatment. • Present literature provides insufficiently clear guidance on emergency department management. WHAT IS NEW: • Consideration of all relevant factors (clinical features, laboratory findings, timing of imaging, and conservative vs. surgical management) in a single retrospective cohort. • Our findings suggest that decision-making in practice may be guided by clinical impression rather than imaging.

Comparing blood culture contamination rates by different sampling methods in a paediatric emergency department.

AIM: Blood culture contamination (BCC) can cause unnecessary hospitalisations and inappropriate use of antibiotics. The aim of this study was to find risk factors associated with BCCs in children and to compare contamination rates between open and closed blood culture collection systems. METHODS: Data were prospectively collected regarding blood cultures obtained in the paediatric emergency department from February 26, 2020, to September 30, 2020, based on the method of drawing blood reported by the obtaining physician. A comparison between contaminated and non-contaminated blood cultures was performed. We also compared the composition of the contaminations in the study period to the same period in 2019. RESULTS: A total of 512 blood cultures were included, 33 (6.4%) of which were contaminated. The only parameter that was associated with an increased rate of contamination by 2.34 fold (95% CI 1.1-4.99, P = 0.028) was obtaining blood through an 'open' system, using a syringe connected to a needle in order to draw blood from an open ended needle. The proportion of contaminations originating from oral flora decreased in the study period by 44.7% as compared to the same period in the previous year (13% vs. 23.5%, P = 0.056). CONCLUSIONS: 'Open system' method, which is commonly used in paediatric emergency departments for blood culture obtainment, was associated with an increase in BCC. Adherence to blood cultures obtainment guidelines, even at the price of two different blood tests, is important in order to reduce BCC rates in children.

SARS-CoV-2 antibodies started to decline just four months after COVID-19 infection in a paediatric population.

AIM: We evaluated the prevalence of paediatric severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections using antibody testing and characterised antibody titres by time from exposure. METHODS: This was a single-centre, prospective, cross-sectional cohort study. Patients under 18 years old were eligible to participate if they attended the paediatric emergency department at the tertiary Shaare Zedek Medical Center, Jerusalem, Israel, from 18 October 2020 to 12 January 2021 and required blood tests or intravenous access. SARS-CoV-2 seropositivity and antibody levels were tested by a dual-assay model. RESULTS: The study comprised 1138 patients (56% male) with a mean age of 4.4 years (interquartile range 1.3-11.3). Anti-SARS-CoV-2 antibodies were found in 10% of the patients. Seropositivity increased with age and 41% of seropositive patients had no known exposure. Children under 6 years of age had higher initial antibody levels than older children, followed by a steeper decline. The seropositivity rate did not vary during the study, despite schools re-opening. The findings suggest that children's immunity may start falling 4 months after the initial infection. CONCLUSION: Immunity started falling after just 4 months, and re-opening schools did not affect infection rates. These findings could aid decisions about vaccinating paediatric populations and school closures.

Pediatric Ocular Injury Due to Hand Sanitizer Exposure: An Emerging Hazard.

OBJECTIVES: The objective of this study was to describe the incidence and severity of ocular exposure to alcohol-based hand rub (ABHR) in children presenting to a tertiary medical center during the severe acute respiratory syndrome coronavirus 2 pandemic. METHODS: A retrospective single-center observational study conducted from February 21, 2020, to October 11, 2020. Subjects 10 years or younger who presented with ABHR-induced ocular injury were included. The same period from 2019 was studied and a comparison was performed between the 2 years. Outcome measures included the number of subjects with ocular injury due to ABHR, extent of ocular epithelial defects, length of hospitalization and time to resolution. RESULTS: A total of 9 patients presented to the Pediatric Emergency Department after sustaining ocular chemical injuries from ABHR during this period. Treatment included immediate irrigation followed by topical antibiotics, steroids, and lubrication. Six children were discharged and followed as outpatients with no reported adverse ocular sequelae. Three patients exhibited epithelial defects involving 85% to 100% of the cornea, 30% to 75% of the conjunctiva and required inpatient treatment ranging from 4 to 11 days. All patients experienced a complete resolution of the ocular epithelial defects after 12 to 19 days. No long-term irreversible damage was observed and visual acuity returned to normal in all patients. CONCLUSIONS: The utilization of ABHR during the severe acute respiratory syndrome coronavirus 2 pandemic resulted in childhood ocular injury. Prompt treatment led to good visual outcomes. These products should be regarded as potentially toxic and stored out of the reach of young children.

Jerusalem's CoVID-19 Experience-The Effect of Ethnicity on Disease Prevalence and Adherence to Testing.

BACKGROUND: The management of the SARS-CoV-2 pandemic depends amongst other factors on disease prevalence in the general population. The gap between the true rate of infection and the detected rate of infection may vary, especially between sub-groups of the population. Identifying subpopulations with high rates of undetected infection can guide authorities to direct resource distribution in order to improve health equity. METHODS: A cross-sectional epidemiological survey was conducted between April and July 2021 in the Pediatric Emergency Department of the Shaare Zedek Medical Center, Jerusalem, Israel. We compared three categories: unconfirmed disease (UD), positive serology test result with no history of positive PCR; confirmed disease (CD), history of a positive PCR test result, regardless of serology test result; and no disease (ND), negative serology and no history of PCR. These categories were applied to local prevailing subpopulations: ultra-orthodox Jews (UO), National Religious Jews (NRJ), secular Jews (SJ), and Muslim Arabs (MA). RESULTS: Comparing the different subpopulations groups, MAs and UOs had the greatest rate of confirmed or unconfirmed disease. MA had the highest rate of UD and UO had the highest rate of CD. UD significantly correlated with ethnicity, with a low prevalence in NRJ and SJ. UD was also associated with larger family size and housing density defined as family size per number of rooms. CONCLUSION: This study highlights the effect of ethnicity on disease burden. These findings should serve to heighten awareness to disease burden in weaker populations and direct a suitable prevention program to each subpopulation's needs. Early awareness and possible intervention may lower morbidity and mortality.

Trends in Health Quality-Related Publications Over the Past Three Decades: Systematic Review.

BACKGROUND: Quality assessment in health care is a process of planned activities with the ultimate goal of achieving a continuous improvement of medical care through the evaluation of structure, process, and outcome measures. Physicians and health care specialists involved with quality issues are faced with an enormous and nearly always increasing amount of literature to read and integrate. Nevertheless, the novelty and quality of these articles (in terms of evidence-based medicine) has not been systematically assessed and described. OBJECTIVE: The objective of this study was to test the hypothesis that the number of high-evidence journal articles (according to the pyramid of evidence), such as randomized control trials, systematic reviews, and ultimately, practice guidelines, increases over time, relative to lower-evidence journal articles, such as editorials, reviews, and letters to the editors. METHODS: We used PubMed database to retrieve relevant articles published during the 31-year period between January 1, 1989, and December 31, 2021. The search was conducted in April 2022. We used the keywords "quality care," "quality management," "quality indicators," and "quality improvement" and limited the search fields to title and abstract in order to limit our search results to articles nearly exclusively related to health care quality. RESULTS: During this 31-year evaluation period, there was a significant cubic increase in the total number of publications, reviews, clinical trials (peaking in 2017, with a sharp decline until 2021), controlled trials (peaking in 2016, with a sharp drop until 2021), randomized controlled trials (peaking in 2017, with a sharp drop until 2021), systematic reviews (nearly nonexistent in the 1980s through 1990s to a peak of 222 in 2021), and meta-analyses (from nearly none in the 1980s through 1990s to a peak of approximately 40 per year in 2020). There was a linear increase in practice guidelines from none during 1989-1991 to approximately 25 per year during 2019-2021, including a cubic increase in editorials, peaking in 2021 at 125 per year, and in letters to the editor, peaking at 50-78 per year in the last 4 years (ie, 2018-2021). CONCLUSIONS: Over the past 31 years, the field of quality in health care has seen a significant yearly increase of published original studies with a relative stagnation since 2015. We suggest that contributors to this dynamic field of research should focus on producing more evidence-based publications and guidelines.

Removal of external auditory canal foreign bodies in the pediatric emergency department - A retrospective comparison study.

INTRODUCTION: The removal of foreign bodies from the external auditory canal (EAC) is a common cause of referral to the pediatric emergency department (PED). The attempt at removal of foreign bodies can lead to complications ranging from mild canal injuries and through severe inner ear damage. The removal requires knowledge and expertise. Ear, Nose and Throat (ENT) physicians are considered the most qualified to remove these foreign bodies. The decision of when the ENTs need to be involved is debated. METHODS: A retrospective analytical comparison study was conducted. The study included all children admitted to the PED for EAC foreign body removal, between the years 2009-2019. RESULTS: A total of 333 children were included in the study. The mean age was 6.53 years. Success rate of the procedure on the first attempt performed by pediatricians was 82.4% and when performed by ENT physicians the success rate was 96.1%. However, when those with a previous attempt of removal were removed from the study the success rates of PED physicians were 93.9% and of ENT physicians were 96.8%. CONCLUSION: This single center study shows that with correct case evaluation, the PED physician can and should succeed in EAC FB removal with minimal complications and comparable to ENT performance. If a first attempt failed, an ENT consult is warranted.

"Feed and Swaddle" method of Infants Undergoing Head CT for minor head injury in the pediatric emergency department - A comparative case review.

INTRODUCTION: Brain imaging for suspected significant head injuries in pediatric emergency departments is an important and time-sensitive procedure. The use of sedation to successfully complete imaging can be limited due to young age and other injury related factors. Using a non-pharmacological method using feeding and swaddling can be used. This may obviate the need for sedation but can be time consuming. METHODS: A retrospective study of all children undergoing brain imaging for head injury during the years 2016-2021. Use of sedation, time to completion and imaging findings were compared. RESULTS: Of 281 children requiring brain imaging, 268 (95.4%) were completed using the feed and swaddle method. Time to imaging completion was similar between sedation and feed and swaddle groups (85.5 min vs. 86 min). Abnormal findings on imaging were found in 186 (69.4%) in the feed and swaddle group and in 10 (77%) of the sedation group. No adverse events were seen in the sedation group. CONCLUSION: Using the feed and swaddle method can help lower the need for sedation in the under 1 year age group with a successful and timely completion of brain imaging.

The effect of C-reactive protein on chest X-ray interpretation: A decision-making experiment among pediatricians.

INTRODUCTION: Clinical decision-making is complex and requires the integration of multiple sources of information. Physicians tend to over-rely on objective measures, despite the lack of supportive evidence in many cases. We sought to test if pediatricians over-rely on C-reactive protein (CRP) results when managing a child with suspected pneumonia. METHODS: A nationwide decision-making experiment was conducted among 337 pediatricians in Israel. Each participant was presented with two detailed vignettes of a child with suspected pneumonia, each with a chest X-ray (CXR) taken from a real-life case of viral pneumonia. Participants were randomly assigned to one of three groups: Controls-where no lab tests were provided, and two intervention groups where the vignettes also noted a high or a low CRP value, in varying orders. Between-participant and within-participant analyses were conducted to study the effect of CRP on CXR interpretation. The three groups were presented with identical medical history, vital signs, findings on physical examination, blood count, and CXR. RESULTS: Three-hundred and one pediatricians (89.3% of those approached) completed the study. Pediatricians were 60%-90% more likely to diagnose viral pneumonia as bacterial when presented with high CRP levels versus low CRP levels, despite the identical clinical data and CXR (62% vs. 39% and 58% vs. 31% of physicians; p = .002). Accordingly, they were 60%-90% more likely to prescribe antibiotics in these cases (86% vs. 53% and 78% vs. 41% of physicians; p < .001). CONCLUSIONS: CRP by itself may modify the way in which pediatricians interpret a CXR, leading to the overprescription of antibiotics.