Evaluation of Quantitative Pupillometry in Acute Postinjury Pediatric Concussion.

BACKGROUND: Although millions of children sustain concussions each year, a rapid and objective test for concussion has remained elusive. The aim of this study was to investigate quantitative pupillometry in pediatric patients in the acute, postinjury setting. METHODS: This was a prospective case-control study of concussed patients presenting to the emergency department within 72 hours of injury. Pupillary measurements were gathered using NeurOptics' PLR 3000; evaluation included a symptom checklist and neurocognitive assessment. Data were analyzed using descriptive statistics and regression models. RESULTS: A total of 126 participants were enrolled. One significant difference in pupillometry between concussed and control participants was found: left minimum pupil diameter in 12- to 18 year-olds (P = 0.02). Models demonstrating odds of a concussion revealed significant associations for time to 75% recovery (T75) of the left pupil in five- to 11-year-olds and average dilation velocity of the left pupil in 12- to 18-year-olds (P = 0.03 and 0.02 respectively). Models predicting symptom improvement showed one significant association: percent change of the right pupil in five-to-11-year-olds (P = 0.02). Models predicting neurocognitive improvement in 12- to 18-year-olds demonstrated significant association in T75 in the left pupil for visual memory, visual motor processing speed, and reaction time (P = 0.002, P = 0.04, P = 0.04). CONCLUSIONS: The limited statistically significant associations found in this study suggest that pupillometry may not be useful in pediatrics in the acute postinjury setting for either the diagnosis of concussion or to stratify risk for prolonged recovery.

9-1-1 Activations from Ambulatory Care Centers: A Sicker Pediatric Population.

BACKGROUND: Pediatric patients transferred by Emergency Medical Services (EMS) from urgent care (UC) and office-based physician practices to the emergency department (ED) following activation of the 9-1-1 EMS system are an under-studied population with scarce literature regarding outcomes for these children. The objectives of this study were to describe this population, explore EMS level-of-care transport decisions, and examine ED outcomes. METHODS: This was a retrospective review of patients zero to <15 years of age transported by EMS from UC and office-based physician practices to the ED of two pediatric receiving centers from January 2017 through December 2019. Variables included reason for transfer, level of transport, EMS interventions and medications, ED medications/labs/imaging ordered in the first hour, ED procedures, ED disposition, and demographics. Data were analyzed with descriptive statistics, X test, point biserial correlation, two-sample z test, Mann-Whitney U test, and 2-way ANOVA. RESULTS: A total of 450 EMS transports were included in this study: 382 Advanced Life Support (ALS) runs and 68 Basic Life Support (BLS) runs. The median patient age was 2.66 years, 60.9% were male, and 60.7% had private insurance. Overall, 48.9% of patients were transported from an office-based physician practice and 25.1% were transported from UC. Almost one-half (48.7%) of ALS patients received an EMS intervention or medication, as did 4.41% of BLS patients. Respiratory distress was the most common reason for transport (46.9%). Supplemental oxygen was the most common EMS intervention and albuterol was the most administered EMS medication. There was no significant association between level of transport and ED disposition (P = .23). The in-patient admission rate for transported patients was significantly higher than the general ED admission rate (P <.001). CONCLUSION: This study demonstrates that pediatric patients transferred via EMS after activation of the 9-1-1 system from UC and medical offices are more acutely ill than the general pediatric ED population and are likely sicker than the general pediatric EMS population. Paramedics appear to be making appropriate level-of-care transport decisions.

Weighty Matters: A Real-World Comparison of the Handtevy and Broselow Methods of Prehospital Weight Estimation.

INTRODUCTION: The majority of pediatric medications are dosed according to weight and therefore accurate weight assessment is essential. However, this can be difficult in the unpredictable and peripatetic prehospital care setting, and medication errors are common. The Handtevy method and the Broselow tape are two systems designed to guide Emergency Medical Services (EMS) providers in both pediatric patient weight estimation and medication dosing. The accuracy of the Handtevy method of weight estimation as practiced in the field by EMS has not been previously examined. STUDY OBJECTIVE: The primary objective of this study was to examine the field performance of the Handtevy method and the Broselow tape with respect to prehospital patient weight estimation. METHODS: This was a retrospective chart review of trauma and non-trauma patients transported by EMS to the emergency department (ED) of a quaternary care children's hospital from January 1, 2021 through June 30, 2021. Demographic data, ED visit information, prehospital weight estimation, and medication dosing were collected and analyzed. Scale-based weight from the ED was used as the standard for comparison. RESULTS: A total of 509 patients <13 years of age were included in this study. The EMS providers using the Broselow method estimated patient weight to within +/-10% of ED scale weight in 51.3% of patients. When using the Handtevy method, the EMS providers estimated patient weight to within +/-10% of ED scale weight in 43.7% of patients. When comparing the Handtevy versus Broselow method of prehospital weight estimation, there was no significant association between method and categorized weight discrepancy (over, under, or accurate estimates - defined as within 10% of ED scale weight; P = .25) or percent weight discrepancy (P = .75). On average, prehospital weight estimation was 6.33% lower than ED weight with use of the Handtevy method and 6.94% lower with use of the Broselow method. CONCLUSION: This study demonstrated no statistically significant difference between the use of the Handtevy or Broselow methods with respect to prehospital weight estimation. While further research is necessary, these results suggest similar field performance of the Broselow and Handtevy methods.

SARS-CoV-2 Serology Testing in an Asymptomatic, At-Risk Population: Methods, Results, Pitfalls.

The primary aim of this study was to determine the seroprevalence of SARS-CoV-2 antibodies in a population of pediatric healthcare workers (HCWs). This study was conducted 14 May-13 July 2020. Study participants included pediatric HCWs at a pediatric hospital with either direct patient contact or close proximity to patient-care areas. SARS-CoV-2 antibodies were assessed via the Wytcote Superbio SARS-CoV-2 IgM/IgG Antibody Fast Detection Kit and the Abbott Architect SARS-CoV-2 IgG assay. Participants underwent RT-PCR testing upon entry to the study and following rapid IgM+/IgG+ results; respiratory panel PCR (RP-PCR) was performed following IgM+ results. A total of 57 of 289 (19.7%) of participants demonstrated positive serology as assessed by the Wytcote rapid kit (12 on Day 1 and 45 throughout the study). However, only one of these participants demonstrated IgG+ serology via the Abbott assay. Two participants tested SARS-CoV-2+ via RT-PCR testing. One individual was adenovirus+ and enterovirus/rhinovirus+. In our study population, we observed a seroprevalence of SARS-CoV-2 antibodies of 0.35%. The lack of concordance between antibody tests suggests that the Wytcote rapid test kit may not be of use as a screening tool. However, the feasibility of the overall process indicates that a similar methodology may have potential for future epidemiologic surveillance.

Rapid antibody testing for SARS-CoV-2 vaccine response in pediatric healthcare workers.

BACKGROUND: The durability of the immune response to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination remains unknown. The objective of this study was to evaluate a rapid SARS-CoV-2 IgM/IgG antibody detection kit as a qualitative screen for the humoral response to vaccination. METHODS: Study participants (n = 125) included pediatric healthcare workers (HCWs) who had received two doses of BNT162b2 or mRNA-1273. Participants were tested on study entry (March 12, 2021 to April 9, 2021). The mean number of days post second dose was 22 (range 17-36). Participants were tested for IgM/IgG antibodies to the SARS-CoV-2 spike protein with the RightSign COVID-19 IgG/IgM Rapid Test Cassette. ELISA/competitive inhibition ELISA (CI-ELISA) were subsequently run to assess for the neutralization effect and SARS-CoV-2 anti-nucleocapsid IgM/IgG antibodies. RESULTS: Overall, 98.4% of participants were IgG-positive and 0.8% were IgM-positive on rapid RightSign testing. Of those with IgG-positive results, 100% were anti-spike protein IgG-positive on CI-ELISA; none of those who tested IgG-negative via the rapid test were IgG-positive on CI-ELISA. All HCWs who tested RightSign positive demonstrated neutralizing capability on CI-ELISA. Overall, 1.6% demonstrated anti-nucleocapsid IgM antibodies and 5.6% demonstrated anti-nucleocapsid IgG antibodies. CONCLUSIONS: The strong agreement between the rapid RightSign IgG results and confirmatory CI-ELISA testing suggests that this test may be used to assess for positive, and neutralizing, antibody responses to SARS-CoV-2 mRNA vaccination.

Features associated with surgically significant abscesses on computed tomography evaluation of the neck in pediatric patients.

BACKGROUND: Neck-related chief complaints are common in the pediatric Emergency Department (ED), and although the incidence of pathology such as retropharyngeal abscesses is rare, the ability to rule out abscesses requiring surgical/procedural intervention is essential. However, there are no clear clinical guidelines regarding work-up and diagnosis in this population, possibly contributing to an excess use of potentially harmful and costly computed tomography (CT) imaging. OBJECTIVE: In this study we sought to identify historical, physical exam, and laboratory findings associated with surgically significant neck abscesses to better delineate CT neck imaging criteria. METHODS: We conducted a retrospective chart review of all patients ≤18 years presenting to a pediatric ED between 2013 and 2017 who underwent CT neck imaging. Surgically significant abscesses (SSAs) were defined as abscesses ≥2 cm, retropharyngeal abscesses (RPA), parapharyngeal abscesses (PPA), or peritonsillar abscesses (PTA). Historical factors, physical exam findings, laboratory results, demographics, and CT results were analyzed using univariate statistical analysis and regression models. RESULTS: A total of 718 patients received neck CTs and 153 SSAs were identified. In children younger than 6 years, factors associated with statistically significant increased odds of an SSA were reported throat pain (OR 1.18; 95% CI 1.05, 1.33), fussiness (OR 1.18; 1.01, 1.39), lethargy (OR 1.43; 1.07, 1.91), tonsillar enlargement (OR 1.17; 1.02, 1.34), C-reactive protein (CRP) > 10 (OR 1.22; 1.07, 1.40), and an ED visit within the preceding week (OR 1.18; 1.04, 1.33). In children older than 6 years, the factors associated with statistically significant increased odds of an SSA included current antibiotic use (OR 1.12; 1.02, 1.22) and a CRP >10 (OR 1.14; 1.03, 1.26). CONCLUSION: Some historical, physical exam, and laboratory findings are associated with SSAs, and while not definitive in isolation, may be beneficial additions to routine SSA assessment, as a supplement to clinical judgement regarding CT and observation decisions. This may potentially allow for the identification of patients requiring CT versus those who may not, and thus the opportunity to safely reduce the use of CT imaging in select patients.

Provider Antibody Serology Study of Virus in the Emergency Room (PASSOVER) Study: Special Population COVID-19 Seroprevalence.

INTRODUCTION: Limited data on the seroprevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) among healthcare workers (HCW) are publicly available. In this study we sought to determine the seroprevalence of SARS-CoV-2 in a population of HCWs in a pediatric emergency department (ED). METHODS: We conducted this observational cohort study from April 14-May 13, 2020 in a pediatric ED in Orange County, CA. Asymptomatic HCW ≥18 years of age were included in the study. Blood samples were obtained by fingerstick at the start of each shift. The inter-sampling interval was ≤96 hours. The primary outcome was positive seroprevalence of SARS-CoV-2 as determined with an antibody fast detection kit (Colloidal Gold, Superbio, Timisoara, Romania) for the SARS-CoV-2 immunoglobulin M/immunoglobulin G (IgM/IgG) antibody. RESULTS: A total of 143 HCWs participated in the study. Overall SARS-CoV-2 seroprevalence was 10.5% (n = 15). Positive seroprevalence was classified as IgG only (4.9%), IgM+IgG (3.5%), or IgM only (2.1%). SARS-CoV-2 was detected by reverse transcription polymerase chain reaction RT-PCR in 0.7% of the overall study population (n = 1). Samples obtained on Day 1 indicated seropositivity in 4.2% of the study population (n = 6). Subsequent seroconversion occurred in 6.3% of participants (n = 9). The rate of seroconversion was linear with a rate of approximately one new case every two days, starting at Day 9 of the study. CONCLUSION: We observed a linear rate of seroconversion to SARS-CoV-2-positive status among asymptomatic HCWs who underwent daily symptom surveys and temperature screens in an environment with universal source control. Rapid antibody testing may be useful for screening for SARS-CoV-2 seropositivity in high-risk populations, such as HCWs in the ED.

Predictors for COVID-19-related new-onset maladaptive behaviours in children presenting to a paediatric emergency department.

BACKGROUND AND OBJECTIVE: The goal of the present study was to determine the incidence of new onset maladaptive behaviours in paediatric emergency department (PED) patients during the COVID-19 pandemic and to examine whether child and parent anxiety and parental health status were predictors for the new-onset of maladaptive behaviours. METHODS: Participants included child-parent dyads seen in a PED following the state's issuance of mandatory stay-at-home orders on 19 March 2020. A total of 351 children age 0-25 years and 335 parents enrolled in the study. Parents provided baseline demographic data and completed standardised surveys that assessed aspects of parental and child anxiety and parental health, as well as child new-onset maladaptive behaviours. Children ≥8 years of age completed surveys that assessed child anxiety. FINDINGS: Parents reported the new onset of maladaptive behaviours in children during the pandemic with frequencies up to 43%. Bivariate analysis identified predictors such as child anxiety (t(96) = -2.04, P = 0.044) as well as parental variables such as state anxiety (t(190) = -4.91, P < 0.001) and parental sensitivity to anxiety (t(243) = -3.19, P = 0.002). A logistic regression model identified parent mental health and COVID-19 anxiety as predictors of new onset maladaptive behaviours in children (X2 (6) = 42.514, P < 0.001). Specifically, every unit change in parental anxiety of COVID-19 was associated with a unit increase in maladaptive behaviours in children. CONCLUSIONS: We identified distinct parent and child-related factors that predicted new onset child maladaptive behaviours during the COVID-19 pandemic. The identification of such predictors may help clinicians to prevent maladaptive responses to the pandemic quarantine.