Documented Penicillin Allergies on Antibiotic Selection at Pediatric Emergency Department Visits.

BACKGROUND: Penicillin or amoxicillin are the recommended treatments for the most common pediatric bacterial illnesses. Allergies to penicillin are commonly reported among children but rarely true. We evaluated the impact of reported penicillin allergies on broad-spectrum antibiotic use overall and for the treatment of common respiratory infections among treat-and-release pediatric emergency department (ED) visits. METHODS: Retrospective cohort study of pediatric patients receiving antibiotics during a treat-and-release visit at a large, pediatric ED in the northeast from 2014 to 2016. Study exposure was a reported allergy to penicillin in the electronic medical record. Study outcomes were the selection of broad-spectrum antibiotics and alternative (second-line) antibiotic therapy for the treatment of acute otitis media (AOM) and group A streptococcus (GAS) pharyngitis. We used unadjusted and adjusted generalized estimating equation models to analyze the impact of reported penicillin allergies on the selection of broad-spectrum antibiotics. We used unadjusted and adjusted logistic regression models to determine the probability of children with a documented penicillin allergy receiving alternative antibiotic treatments for AOM and GAS. RESULTS: Among 12,987 pediatric patients, 810 (6.2%) had a documented penicillin allergy. Penicillin allergies increased the odds of children receiving a broad spectrum versus narrow spectrum antibiotic (adjusted odds ratio, 13.55; 95% confidence interval (CI), 11.34-16.18). In our adjusted logistic regression model, the probability of children with a documented penicillin allergy receiving alternative antibiotic treatment for AOM was 0.97 (95% CI, 0.94-0.99) and for GAS was 0.97 (95% CI, 0.92-0.99). CONCLUSIONS: Antibiotic stewardship efforts in pediatric EDs may consider the delabeling of penicillin allergies particularly among children receiving antibiotics for an acute respiratory infection as a target for intervention.

Violence prevention emergency tool (VPET) screening of youth in the pediatric ED.

Background Violence is an increasingly common and significant problem for youth worldwide. Youth who rely on treatment at urban EDs are more likely to die as the result of violence than any other disease/condition for which they seek care. The first step in helping youth that are at risk, is identifying them. We developed a 7-item screening tool called VPET. The purpose of this study is to validate the VPET screening tool in identifying high-risk youth. Methods and findings We prospectively enrolled a convenience sample of children during the index ED visit who were called 3 months and 6 months after this visit. 269 youth (33%) completed 3-month follow up (44.2% male); 240 youth (29.4%) completed 6-month follow up (45% male); 84.0% reported some level of violence exposure after 3-months and 84.2% (n = 240) reported some level of violence exposure after 6-months. Predictive validity was assessed by Spearman's correlation between VPET score and follow-up score at 3-months and 6-months post-enrollment; logistic regression to calculate odds ratios between positive VPET item responses and positive follow-up score; ROC curve analysis. VPET score had internal consistency, as tested by Cronbach's alpha (α = 0.642). Children who were male, non-white, and had been hurt at home or school reported the highest VPET scores. Conclusion VPET has sufficiently strong psychometric function and performs well as a screening tool to predict future violence exposure for youth ages 8-17. Five questions on the VPET screening tool are independently predictive of violence reported at 6 months and four questions at 3 months.

Prevalence of Cyberbullying in Patients Presenting to the Pediatric Emergency Department.

OBJECTIVES: Mental health (MH) complaints are increasingly responsible for visits to pediatric emergency departments (PEDs). Bullying is associated with MH problems. Most adolescents use social media and many experience problems with cyberbullying (CB). This study determines prevalence of CB in MH and non-MH adolescents in a PED, describes technology use in these groups, and measures influence of CB on presentation to the PED and on thoughts/acts of self-harm. METHODS: A prospective survey was administered to a convenience sample of 149 patients aged 11 to 17 years in a PED. Data were analyzed using descriptive and comparative statistical methods. RESULTS: Cyberbullying was significantly more common in MH than in the non-MH patients (17% vs 3%, P = 0.007). More MH patients reported that bullying led to the current PED visit than that in the non-MH group (25% vs 10%, P = 0.02), and they were significantly more likely to report that CB led to self-harm (22% vs 4%, P = 0.003). Mental health participants who spent more than 3 hours on the Internet report higher levels of bullying than non-MH patients (38% vs 6%, P < 0.001). CONCLUSIONS: Prevalence of bullying in MH patients presenting to a PED is significantly greater than controls, and CB caused more MH patients to have acts or thoughts of self-harm. Bullying is a risk factor for self-harm and suicide in patients with MH problems. Future studies should evaluate CB as part of suicide screening tools for emergency MH patients.

CARES: improving the care and disposition of psychiatric patients in the pediatric emergency department.

OBJECTIVES: Pediatric psychiatric emergencies are a nationwide crisis and have contributed to an increase in behavioral health emergency department (ED) visits. A collaborative response to this crisis was the creation of the Child & Adolescent Rapid Emergency Stabilization (CARES) program. The objective of this study is to determine how the CARES unit influenced length of stay (LOS) and costs for psychiatric patients in the pediatric ED. METHODS: A retrospective review of ED patients was conducted. Children presenting 1 year before CARES, October 13, 2006, to October 13, 2007 (pre-CARES), were compared with 1 year after, October 15, 2007, to October 15, 2008 (post-CARES). The study population includes all patients presenting to the ED with psychiatric illnesses. The primary outcome is mean LOS in hours. Supplemental analyses of total charges, payments, and costs were performed. RESULTS: There were 1719 visits before and 1867 visits after CARES, with 1190 and 1273 unique patient visits, respectively. Children in both groups had similar age, gender, and ethnicity. Pre-CARES had a mean LOS of 19.7 hours (SD, 32.6), whereas post-CARES had 10.8 hours (SD, 19.9) (P < 0.0001). Evaluating only unique visits, the difference remained highly significant. Post-CARES, compared with pre-CARES, the average charge per patient decreased by $905 (P < 0.0001), average payment decreased by $111 (P < 0.06), and average total cost decreased by $569 or 38.7% (P < 0.0001). The total cost savings the year after CARES opened was $1,019,168.55.

Overexpression of p49/STRAP alters cellular cytoskeletal structure and gross anatomy in mice.

BACKGROUND: The protein p49/STRAP (SRFBP1) is a transcription cofactor of serum response factor (SRF) which regulates cytoskeletal and muscle-specific genes. RESULTS: Two conserved domains were found in the p49/STRAP protein. The SRF-binding domain was at its N-terminus and was highly conserved among mammalian species, xenopus and zebrafish. A BUD22 domain was found at its C-terminus in three sequence databases. The BUD22 domain was conserved among mammalian p49/STRAP proteins, and yeast cellular morphogenesis proteins, which is involved in ribosome biogenesis that affects growth rate and cell size. The endogenous p49/SRAP protein was localized mainly in the nucleus but also widely distributed in the cytoplasm, and was in close proximity to the actin. Transfected GFP-p49/STRAP protein co-localized with nucleolin within the nucleolus. Overexpression of p49/STRAP reduced actin content in cultured cells and resulted in smaller cell size versus control cells. Increased expression of p49/STRAP in transgenic mice resulted in newborns with malformations, which included asymmetric abdominal and thoracic cavities, and substantial changes in cardiac morphology. p49/STRAP altered the expression of certain muscle-specific genes, including that of the SRF gene, which is a key regulator of cardiac genes at the developmental, structural and maintenance level and has two SRE binding sites. CONCLUSIONS: Since p49/STRAP is a co-factor of SRF, our data suggest that p49/STRAP likely regulates cell size and morphology through SRF target genes. The function of its BUD22 domain warrants further investigation. The observed increase in p49/STRAP expression during cellular aging may contribute to observed morphological changes in senescence.

Restless legs syndrome, periodic limb movements of sleep, and subclinical cardiovascular disease.

Restless legs syndrome (RLS) and periodic limb movements of sleep (PLMS) have been variably implicated in risk for cardiovascular disease (CVD), but there is lack of consensus on these relationships. We sought to assess subclinical CVD measures and RLS/PLMS in a large cohort to further evaluate these associations. The Emory Center for Health Discovery and Well Being cohort is composed of employed adults, with subclinical CVD measures including endothelial function (flow-mediated vasodilation), microvascular function (reactive hyperemia index, RHI), arterial stiffness (pulse wave velocity and augmentation index), and carotid intima-media thickness (cIMT). Participants were grouped based on presence (N = 50) or absence (N = 376) of RLS and subclinical CVD measures compared between groups. A subset of participants (n = 40) underwent ambulatory monitoring for PLMS and obstructive sleep apnea. PLMS association with subclinical CVD measures was assessed. RLS status was significantly associated with flow-mediated dilation in univariate analyses but not after controlling for potential confounders; RLS was not associated with other subclinical CVD measures. PLMS were significantly correlated with the RHI, augmentation index, and cIMT in univariate analyses; only the association between PLMS and cIMT remained significant (p = 0.04) after controlling for RLS status, age, apnea-hypopnea index, hyperlipidemia, and hypertension. The observed association between higher PLMS and greater cIMT suggests that PLMS may be a marker of subclinical CVD. Further work is needed to determine the relationship between PLMS and CVD risk. Supplementary Information: The online version contains supplementary material available at 10.1007/s41105-023-00497-7.

Aggregate Clinical and Biomarker-Based Model Predicts Adverse Outcomes in Patients With Coronary Artery Disease.

Despite guideline-based therapy, patients with coronary artery disease (CAD) are at widely variable risk for cardiovascular events. This variability demands a more individualized risk assessment. Herein, we evaluate the prognostic value of 6 biomarkers: high-sensitivity C-reactive protein, heat shock protein-70, fibrin degradation products, soluble urokinase plasminogen activator receptor, high-sensitivity troponin I, and B-type natriuretic peptide. We then develop a multi-biomarker-based cardiovascular event prediction model for patients with stable CAD. In total, 3,115 subjects with stable CAD who underwent cardiac catheterization at Emory (mean age 62.8 years, 17% Black, 35% female, 57% obstructive CAD, 31% diabetes mellitus) were randomized into a training cohort to identify biomarker cutoff values and a validation cohort for prediction assessment. Main outcomes included (1) all-cause death and (2) a composite of cardiovascular death and nonfatal myocardial infarction (MI) within 5 years. Elevation of each biomarker level was associated with higher event rates in the training cohort. A biomarker risk score was created using optimal cutoffs, ranging from 0 to 6 for each biomarker exceeding its cutoff. In the validation cohort, each unit increase in the biomarker risk score was independently associated with all-cause death (hazard ratio 1.62, 95% confidence interval [CI] 1.45 to 1.80) and cardiovascular death/MI (hazard ratio 1.52, 95% CI 1.35 to 1.71). A biomarker risk prediction model for cardiovascular death/MI improved the c-statistic (∆ 6.4%, 95% CI 3.9 to 8.8) and net reclassification index by 31.1% (95% CI 24 to 37), compared with clinical risk factors alone. Integrating multiple biomarkers with clinical variables refines cardiovascular risk assessment in patients with CAD.

Circulating progenitor cells and outcomes in patients with coronary artery disease.

BACKGROUND: Low quantities of circulating progenitor cells (CPCs), specifically CD34+ populations, reflect impairment of intrinsic regenerative capacity. This study investigates the relationship between subsets of CPCs and adverse outcomes. METHODS: 1366 individuals undergoing angiography for evaluation of coronary artery disease (CAD) were enrolled into the Emory Cardiovascular Biobank. Flow cytometry identified CPCs as CD45med blood mononuclear cells expressing the CD34 epitope, with further enumeration of hematopoietic CPCs as CD133+/CXCR4+ cells and endothelial CPCs as vascular endothelial growth factor receptor-2 (VEGFR2+) cells. Adjusted Cox or Fine and Gray's sub-distribution hazard regression models analyzed the relationship between CPCs and 1) all-cause death and 2) a composite of cardiovascular death and non-fatal myocardial infarction (MI). RESULTS: Over a median 3.1-year follow-up period (IQR 1.3-4.9), there were 221 (16.6%) all-cause deaths and 172 (12.9%) cardiovascular deaths/MIs. Hematopoietic CPCs were highly correlated, and the CD34+/CXCR4+ subset was the best independent predictor. Lower counts (≤median) of CD34+/CXCR4+ and CD34+/VEGFR2+ cells independently predicted all-cause mortality (HR 1.46 [95% CI 1.06-2.01], p = 0.02 and 1.59 [95% CI 1.15-2.18], p = 0.004) and cardiovascular death/MI (HR 1.50 [95% CI 1.04-2.17], p = 0.03 and 1.47 [95% CI 1.01-2.03], p = 0.04). A combination of low CD34+/CXCR4+ and CD34+/VEGFR2+ CPCs predicted all-cause death (HR 2.1, 95% CI 1.4-3.0; p = 0.0002) and cardiovascular death/MI (HR 2.0, 95% CI 1.3-3.2; p = 0.002) compared to those with both lineages above the cut-offs. CONCLUSIONS: Lower levels of hematopoietic and endothelial CPCs indicate diminished endogenous regenerative capacity and independently correlate with greater mortality and cardiovascular risk in patients with CAD.

A multicenter evaluation of pediatric emergency department injury visits during the COVID-19 pandemic.

BACKGROUND: Injuries, the leading cause of death in children 1-17 years old, are often preventable. Injury patterns are impacted by changes in the child's environment, shifts in supervision, and caregiver stressors. The objective of this study was to evaluate the incidence and proportion of injuries, mechanisms, and severity seen in Pediatric Emergency Departments (PEDs) during the COVID-19 pandemic. METHODS: This multicenter, cross-sectional study from January 2019 through December 2020 examined visits to 40 PEDs for children < 18 years old. Injury was defined by at least one International Classification of Disease-10th revision (ICD-10) code for bodily injury (S00-T78). The main study outcomes were total and proportion of PED injury-related visits compared to all visits in March through December 2020 and to the same months in 2019. Weekly injury visits as a percentage of total PED visits were calculated for all weeks between January 2019 and December 2020. RESULTS: The study included 741,418 PED visits for injuries pre-COVID-19 pandemic (2019) and during the COVID-19 pandemic (2020). Overall PED visits from all causes decreased 27.4% in March to December 2020 compared to the same time frame in 2019; however, the proportion of injury-related PED visits in 2020 increased by 37.7%. In 2020, injured children were younger (median age 6.31 years vs 7.31 in 2019), more commonly White (54% vs 50%, p < 0.001), non-Hispanic (72% vs 69%, p < 0.001) and had private insurance (35% vs 32%, p < 0.001). Injury hospitalizations increased 2.2% (p < 0.001) and deaths increased 0.03% (p < 0.001) in 2020 compared to 2019. Mean injury severity score increased (2.2 to 2.4, p < 0.001) between 2019 and 2020. Injuries declined for struck by/against (- 4.9%) and overexertion (- 1.2%) mechanisms. Injuries proportionally increased for pedal cycles (2.8%), cut/pierce (1.5%), motor vehicle occupant (0.9%), other transportation (0.6%), fire/burn (0.5%) and firearms (0.3%) compared to all injuries in 2020 versus 2019. CONCLUSIONS: The proportion of PED injury-related visits in March through December 2020 increased compared to the same months in 2019. Racial and payor differences were noted. Mechanisms of injury seen in the PED during 2020 changed compared to 2019, and this can inform injury prevention initiatives.

The feasibility of screening for violence in the pediatric emergency department.

BACKGROUND: Youth violence is a significant public health concern. The objective of this study was to evaluate the feasibility of violence screening tools in a pediatric emergency department (PED). METHODS: Children between eight and 17 years presenting to the PED were prospectively enrolled. Two questionnaires were administered: Violence Prevention Emergency Tool (VPET) and Violence Exposure Scale for Children (VEX). RESULTS: One hundred children were enrolled: mean age was 12.9 years (SD 2.8), 42% girls, 48% Hispanic, and 13% African-American. Mean time to complete VPET was 9.0 minutes and VEX 4.9 minutes. Ease of understanding between VPET and VEX were 74% vs 92% (interviewer) and 74% vs 93%, (subjects) both P < 0.05. The number of repeated items was significantly less for VEX compared to VPET, 1% vs 6% (P < 0.01). CONCLUSION: It may be feasible to screen for exposure to violence in the PED. VEX is a more feasible screening tool compared to VPET.

Differential Sex-Specific Effects of Angiotensin-Converting Enzyme Inhibition and Angiotensin Receptor Blocker Therapy on Arterial Function in Hypertension: CALIBREX Trial.

BACKGROUND: Increased arterial stiffness is associated with adverse cardiovascular outcomes. We studied the sex-specific impact of angiotensin antagonists on vascular function in hypertension with the hypothesis that their effects on arterial stiffness may be variable in men and women. METHODS: In 141 hypertensive participants with mild cognitive impairment (age 65.9±7.7, 57% female), candesartan (up to 32 mg, n=77) or lisinopril (up to 40 mg, n=64) were administered to achieve blood pressure <140/90 mm Hg. Pulse wave velocity, central pulse pressure, and central augmentation index were measured using applanation tonometry (SphygmoCor, Australia). Multivariate linear regression and mixed model analyses were performed using intention-to-treat and per protocol analyses for those completing the study. RESULTS: Blood pressure reduction was similar among candesartan and lisinopril groups. Compared with candesartan, lisinopril therapy resulted in lower pulse wave velocity (0.5±0.8 versus -0.7±0.4 m/s, respectively; P=0.003) and central pulse pressure (-1±3 versus -7±4 mm Hg; P=0.03) after 1 year. There was a significant interaction by sex whereby the improvements in pulse wave velocity and central pulse pressure with lisinopril compared with candesartan were only observed in women. In contrast, there was greater improvement in augmentation index with candesartan compared with lisinopril (-4±7% versus -1.5±8%; P=0.05), with no sex differences. CONCLUSIONS: Despite equipotent antihypertensive effects, lisinopril was more effective than candesartan at lowering arterial stiffness in women. In contrast, candesartan was more effective than lisinopril in improving pulse wave reflections in both sexes. These findings demonstrate differential sex-specific effects of renin-angiotensin system antagonists on arterial function in hypertension that may contribute to long-term cardiovascular and neurocognitive outcomes in this population.

Assessing the Effect of Electronic Medical Record Note Template on Firearm Access Screening in High-Risk Children.

BACKGROUND: Children who survive a suicide attempt are at greater risk of later dying by suicide. Firearm screening and provision of lethal means restriction counseling may improve the safety of this high-risk cohort. Our objective was to determine firearm screening rates among children hospitalized after suicide attempts. We also assessed the effects of templating firearm screening questions into the psychiatric consultation note. METHODS: This retrospective pre- and postintervention study identified children <19 years old admitted after a suicide attempt from January 1, 2016 to March 1, 2020. In mid-2017, the psychiatry consult note incorporated a previously available optional firearm screening tool as an embedded field (intervention). The intervention effect on proportion of children at high risk screened for firearm access was assessed by interrupted time series analysis. RESULTS: Of 26 088 total admissions, 357 met inclusion criteria. The majority were teenagers (15 years old, interquartile range 14 to 16), 275 were female (77%), and 167 were White (47%). Overall, 286 (80%) of patients had firearm access screening documentation. Of the 71 (20%) without screening, 21 (30%) were discharged from the hospital; 50 (70%) were transferred to psychiatric facilities. There was no significant difference in screening rates after the intervention (Intervention shift P = .74, slope P = .85). CONCLUSIONS: Many children were not screened for firearm access after a suicide attempt requiring hospitalization despite the screening tool integration. Multidisciplinary quality improvement efforts are needed to ensure that this critical risk reduction intervention is implemented for all patients after a suicide attempt.

Impact of Connecticut's graduated driver licensing system on teenage motor vehicle crash rates.

BACKGROUND: In response to high rates of teen motor vehicle crashes (MVCs) many states have enacted graduated driver licensing (GDL) systems. GDL delays full licensure and allows beginners to obtain experience under lower risk conditions. The purpose of this study is to evaluate the impact over the past 10 years to determine its effect on teen MVCs. METHODS: Connecticut MVC data from 1999 to 2008 were analyzed. Percent change (1999 vs. 2008) in MVC rates per 10,000 registered drivers was calculated by age, gender, during the night restriction (11:00 pm and 5:00 am), and MVCs with passengers. Linear regression analysis estimated the decrease of MVC rates each year. RESULTS: The MVC rate decreased by 40% for 16-year-old and 30% for 17-year-old drivers. In comparison, rates among 18-year-old, 19-year-old, 25- to 29-year-old, and 30- to 59-year-old drivers were reduced by 16%, 7%, 8%, and 11%, respectively. The MVC rate for 20- to 24-year-old drivers increased by 1%. During nighttime restricted driving times, MVC rates decreased by 54% among 16-year-old and 49% among 17-year-old drivers. The MVC rate with passengers decreased by 65% for 16-year-old and 53% for 17-year-old drivers. In comparison, rates of nighttime and with passenger MVCs among older drivers were significantly less. CONCLUSIONS: Implementation of Connecticut's GDL system has resulted in significant reductions in MVC rates among novice drivers. This analysis provides a method for other states to examine the impact of their GDL system.

The practice of lethal means restriction counseling in US emergency departments to reduce suicide risk: a systematic review of the literature.

BACKGROUND: Suicide is a leading cause of death in the US. Lethal means restriction (LMR), which encourages limiting access and reducing the lethality of particular methods of suicide, has been identified as a viable prevention strategy. For this approach to be successful, adequate education about risks and means must be communicated to families and individuals at risk for suicide. This systematic review aims to identify LMR methods most commonly communicated by healthcare providers in the emergency department, and barriers to the delivery of such counseling. METHODS: The protocol for this systematic review is registered with PROSPERO (CRD42018076734). Included studies were identified through searching four databases (PubMed, Scopus, PsycInfo, and EBSCO). Studies were selected and coded independently by two researchers using the PICOS framework. Included studies examined LMR counseling delivered in the ED regardless of patient age, sex or race/ethnicity. RESULTS: A total of 1282 studies were screened; 9 met the inclusion criteria. Included studies were published from 1998 to 2020. Study participants were majority female, and safe firearm storage was the most common form of LMR counseling provided. Eight studies included counseling on multiple forms of lethal means, [e.g., alcohol, medication, and firearm storage] and one study focused solely on safe firearm storage. Two studies reported barriers limiting healthcare providers' delivery of LMR counseling, including lack of specialized skills and skepticism regarding the effectiveness of LMR counseling. CONCLUSION: There is limited published evidence that identifies the most effective methods and target populations for LMR counseling. Given the growing literature that provides evidence of gender differences in suicide modality (e.g., guns, medications, suffocation), LMR counseling should be multifaceted, to address common means of suicide in both men and women. Despite evidence that the majority of suicide attempts and half of completed suicides do not involve firearms, results showed that LMR counseling is frequently focused on promoting the safe storage of firearms. This highlights the need to include counseling focused on a variety of lethal means to reduce risk of suicide completion. Prospective studies should also aim to identify the most efficacious methods of delivering LMR counseling in the clinical settings.

Using trauma registry data to guide injury prevention program activities.

BACKGROUND: Injury prevention programs should be based on objective injury data. This study demonstrates how local injury data can be used to help guide injury prevention programs. METHODS: We reviewed trauma registry data (2004-2006) from a Level I pediatric trauma center. Data included demographic information, anatomic location of injury, mechanism of injury, safety device utilization, Injury Severity Score (ISS), and temporal and geographic variables. The Injury Prevention Priority Score for each mechanism of injury was calculated. RESULTS: There were 1,874 trauma patients. Most admissions were among white males, aged 11 years to 15 years (mean, 7.9 years ± 5.2 years). Most admissions occurred during summertime and on weekend evenings. Blunt injuries (92%) and fractures (56%) predominated (mean ISS, 5.9). A severe ISS >15 was highest among 11 year to 15 year and lowest among patients older than 15 years (p < 0.01). Falls, cut, or pierce, ATV, and off-road motorcycle ranked highest in the Injury Prevention Priority Score. Of the 134 motor vehicle occupants, 52% (n = 70) were restrained in car seats/seat belts. Only 15% of bicyclists, 24% of motorcyclists, and 58% of ATV riders wore helmets. CONCLUSION: A significant percentage of injured children and adolescents were not using proven effective injury prevention devices at the time of their injury. These data identified areas for further study and will help guide community injury prevention programs at our institution.

Rapid urine drug screens: diphenhydramine and methadone cross-reactivity.

BACKGROUND: Rapid urine screens to detect drugs of abuse are often used in pediatric emergency departments (PEDs). A positive result may lead to further clinical testing, social evaluation, and increased stress/inconvenience. A PED patient with suspected diphenhydramine (DPH) ingestion had a positive methadone result on the rapid urine drug screen, One Step Multi-Drug, Multi-Line Screen Test Device (ACON Laboratories, San Diego, Calif). There was no history of methadone exposure so the patient was admitted while confirmatory testing was performed. Gas chromatography/mass spectroscopy testing of the urine failed to confirm the presence of methadone. We present this unreported false-positive methadone result and evaluation of the kit for cross-reactivity of DPH and methadone. METHODS: The same One Step urine drug screen was tested at an independent laboratory for cross-reactivity between methadone and DPH including the DPH metabolites. Drug-free urine was fortified with DPH, nordiphenhydramine, or dinordiphenhydramine at 0, 10, 25, 50, and 100 µg/mL for each analyte. One hundred microliters of the solutions were added to each of the 4 wells on test cassettes. Urine was allowed to migrate according to manufacturer instructions. Each cassette was interpreted by 2 analysts to ensure consistent interpretation and accurate data recording. RESULTS: In vitro laboratory testing results showed cross-reactivity between methadone and DPH but not for nordiphenhydramine or dinordiphenhydramine. CONCLUSIONS: Rapid urine drug screens using immunoassays based on the principle of competitive binding may show false-positive methadone results for patients who have ingested DPH. Product information for urine drug screens may not include all cross-reacting agents and should be used with caution when interpreting drug screen results in PED patients.

Lights, camera, action spotlight on trauma video review: an underutilized means of quality improvement and education.

BACKGROUND: Trauma video review (TVR) is an effective method of quality improvement and education. The objective of this study was to determine TVR practices in the United States and use of TVR for quality improvement and education. METHODS: Adult and pediatric trauma centers identified by the American College of Surgeons (n = 102) and the National Association of Children's Hospitals and Related Institutions (n = 24) were surveyed by telephone. Surveys included questions regarding program demographics, residency information, and past/present TVR practices. RESULTS: One hundred eight trauma centers (86%) were contacted, and 99% (107/108) completed surveys. Of the surveyed centers, 34% never used TVR; 37% previously used TVR and had discontinued at the time of the survey, with most reporting legal/privacy concerns; 20% were currently using TVR; and 9% were planning to use TVR in the future. Nineteen percent (14/73) of general trauma centers are using or planning to use TVR compared with 50% (17/34) of pediatric centers (P = 0.001). One hundred percent of current TVR programs report that TVR improves the trauma resuscitation process.Most pediatric emergency medicine (87%), emergency medicine (89%), and surgery (97%) trainees participate in trauma resuscitation at trauma centers. Fifty-two percent of centers using TVR report trainee attendance at TVR process/conference; 38% specifically use TVR for resident education. CONCLUSIONS: All current TVR programs report that it improves their trauma processes. More pediatric trauma centers report planning future TVR programs, but the implication of such plans remains unclear. Opportunities exist for expanded use of TVR for resident education.

Machine learning for suicide risk prediction in children and adolescents with electronic health records.

Accurate prediction of suicide risk among children and adolescents within an actionable time frame is an important but challenging task. Very few studies have comprehensively considered the clinical risk factors available to produce quantifiable risk scores for estimation of short- and long-term suicide risk for pediatric population. In this paper, we built machine learning models for predicting suicidal behavior among children and adolescents based on their longitudinal clinical records, and determining short- and long-term risk factors. This retrospective study used deidentified structured electronic health records (EHR) from the Connecticut Children's Medical Center covering the period from 1 October 2011 to 30 September 2016. Clinical records of 41,721 young patients (10-18 years old) were included for analysis. Candidate predictors included demographics, diagnosis, laboratory tests, and medications. Different prediction windows ranging from 0 to 365 days were adopted. For each prediction window, candidate predictors were first screened by univariate statistical tests, and then a predictive model was built via a sequential forward feature selection procedure. We grouped the selected predictors and estimated their contributions to risk prediction at different prediction window lengths. The developed predictive models predicted suicidal behavior across all prediction windows with AUCs varying from 0.81 to 0.86. For all prediction windows, the models detected 53-62% of suicide-positive subjects with 90% specificity. The models performed better with shorter prediction windows and predictor importance varied across prediction windows, illustrating short- and long-term risks. Our findings demonstrated that routinely collected EHRs can be used to create accurate predictive models for suicide risk among children and adolescents.

Analysis of Care Coordination Needs for Families of Children with Special Health Care Needs.

OBJECTIVES: To identify the diverse services required by families of children with special health care needs (CSHCN) and identify the specific care coordination (CC) efforts associated with the most common types of observed diagnoses. Requested services were categorized into specific sectors, and CC efforts were quantified by observed diagnoses and defined sectors. METHODS: CC service data were extracted and analyzed from patient encounters over 4 years (2009-2013) in a department database. This included descriptive information about referrals and linkages to medical, dental, and behavioral health providers and to state, private, and community agencies. Diagnostic classifications and CC sectors were defined to enable categorization. RESULTS: A total of 2682 CSHCN records were reviewed. The majority (59%) required services/resources in 1 to 2 sectors, 24% required services/resources in 3 to 5 sectors, and 17% required services/resources in 6 or more sectors. Including informational service, the most frequently required sectors across the study population were education, financial, medical/dental, social connections, and advocacy. Children diagnosed with autism spectrum disorder had the highest needs across all sectors. CONCLUSION: Most CSHCN and their families use a substantial amount of CC time and effort to secure services from diverse sectors. High-quality and efficient CC requires an understanding of the specific needs of these CSHCN and their families and how to link them to a diverse array of services and resources.

Circulating Progenitor Cells in Patients With Coronary Artery Disease and Renal Insufficiency.

Patients with coronary artery disease and renal insufficiency (RI) (estimated glomerular filtration rate <60 ml/min/1.73 m2) are at an increased risk of cardiovascular events. The contribution of regenerative capacity, measured as circulating progenitor cell (CPC) counts, to this increased risk is unclear. CPCs were enumerated as cluster of differentiation (CD) 45med+ mononuclear cells expressing CD34+, CD133+, CXCR4+ (chemokine [C-X-C motif] receptor 4), and VEGF2R+ (vascular endothelial growth factor receptor 2) epitopes in 1,281 subjects with coronary artery disease (35% with RI). Patients with RI and low (median) were at a similar risk as those without RI.