Opportunities for Early Identification: Implementing Universal Depression Screening with a Pathway to Suicide Risk Screening in a Pediatric Health Care System.

OBJECTIVES: To describe the implementation process and assess results of a large-scale universal depression screening program with pathways to suicide risk screening in a pediatric integrated delivery network. STUDY DESIGN: This retrospective study analyzes depression and suicide risk screening data for 95 613 patients ages 12-17 years. RESULTS: Of the 95 613 adolescent patients who were screened for depression, 2.4% (2266) screened positive for risk for moderate-severe depression (>10 Patient Health Questionnaire; 9-item version) and 4.1% (3942) endorsed elevated suicide risk (≥1 Columbia Suicide Severity Rating Scale). Overall, 51% of screened patients who present with a primary psychiatric concern screened positive for elevated risk of suicide (2132). Two percent of screened patients who presented with a primary medical concern screened positive for elevated risk of suicide. Nearly one-half (45.9%) of all elevated suicide risk screenings were from patients with a primary medical concern. CONCLUSIONS: A large-scale universal depression screening program with a pathway to identify elevated suicide risk was implemented in a pediatric health care system using the Patient Health Questionnaire and the Columbia Suicide Severity Rating Scale. This screening program identified youth with moderate-severe depression and elevated risk for suicide with and without presenting psychiatric concerns across service settings.

The utility of unenhanced computed tomography in appendicitis in children.

To evaluate the utility of unenhanced helical computed tomography (UHCT) in appendicitis in children, we performed a retrospective study of 112 consecutive patients. The radiologist's interpretation of the UHCT was compared with disease status using appendix pathology findings as the gold standard for diagnosis. The performance characteristics of UHCT were as follows: sensitivity 87.5% (95% CI: 75.8-94.8%), specificity 93.7% (95% CI: 85.4%-98.0%), positive predictive value 91.3% (95% CI: 83.2%-99.4%), negative predictive value 90.8% (95% CI: 83.7%-97.8%), overall diagnostic accuracy 90.9% (95% CI: 85.7-96.3%). Positive and negative likelihood ratios were 13.8 (95% CI: 5.3-35.8) and 0.13 (95% CI: 0.06-0.28), respectively. UHCT seems to be a very useful diagnostic test for the evaluation of childhood appendicitis when interpreted by experienced radiologists. The diagnostic accuracy of UHCT found in this study is comparable to that reported for contrast-enhanced CT as well as graded compression ultrasound in appendicitis in children.

Acute disseminated encephalomyelitis in childhood: epidemiologic, clinical and laboratory features.

BACKGROUND: Acute disseminated encephalomyelitis (ADEM) is a central nervous system demyelinating disease that usually follows an apparently benign infection in otherwise healthy young persons. The epidemiology, infectious antecedents and pathogenesis of ADEM are poorly characterized, and some ADEM patients are subsequently diagnosed with multiple sclerosis (MS). METHODS: We retrospectively (1991-1998) and prospectively (1998-2000) studied all persons aged < 20 years diagnosed with ADEM from the 3 principal pediatric hospitals in San Diego County, CA, during 1991-2000. Acute neurologic abnormalities and imaging evidence of demyelination were required for study inclusion. Epidemiologic variables, risk factors, clinical course, laboratory and radiographic findings, neuropathology and treatment data were analyzed. Interleukin (IL)-12, interferon-gamma (IFN-gamma) and IL-10 were assayed in blinded manner on cerebrospinal fluid (CSF) obtained prospectively from a subset of ADEM cases and compared with CSF from patients with enteroviral (EV) meningoencephalitis confirmed by polymerase chain reaction (PCR) and controls without pleocytosis. RESULTS: Data were analyzed on 42 children and adolescents diagnosed with ADEM during 1991-2000, and CSF IL-12, IFN-gamma and IL-10 levels were compared among ADEM (n = 14), EV meningoencephalitis (n = 14) and controls without pleocytosis (n = 28). Overall incidence of ADEM was 0.4/100,000/year; incidence quadrupled during 1998-2000 compared with earlier years. No gender, age stratum, ethnic group or geographic area was disproportionately affected. A total of 4 (9.5%) patients initially diagnosed with ADEM were subsequently diagnosed with MS after multiple episodes of demyelination. Although most children eventually recovered, 2 died, including 1 of the 3 ultimately diagnosed with MS. Magnetic resonance imaging was required for diagnosis among 74% of patients; computerized tomography findings were usually normal. Patients with EV had significantly higher mean CSF IFN-gamma (P = 0.005) and IL-10 (P = 0.05) than patients with ADEM and controls without CSF pleocytosis. CSF from ADEM patients had CSF cytokine values statistically similar to those of 3 patients subsequently diagnosed with MS. CONCLUSIONS: ADEM is a potentially severe demyelinating disorder likely to be increasingly diagnosed as more magnetic resonance imaging studies are performed on patients with acute encephalopathy. Further characterization of the central nervous system inflammatory response will be needed to understand ADEM pathogenesis, to improve diagnostic and treatment strategies and to distinguish ADEM from MS.

Clinical performance of an in-line, ex vivo point-of-care monitor: a multicenter study.

BACKGROUND: The management of critically ill infants and neonates includes frequent determination of arterial blood gas, electrolyte, and hematocrit values. An objective of attached point-of-care patient monitoring is to provide clinically relevant data without the adverse consequences associated with serial phlebotomy. METHODS: We prospectively determined the mean difference (and SD of the difference) from laboratory methods of an in-line, ex vivo monitor, the VIA LVM Blood Gas and Chemistry Monitoring System (VIA LVM Monitor; Metracor Technologies, Inc.), in 100 critically ill neonates and infants at seven children's hospitals. In doing so, we examined monitor stability with continuous use. In vivo patient test results from laboratory benchtop analyzers were compared with those from the VIA LVM Monitor on paired samples. In a separate in vitro comparison, benchtop analyzer and monitor test results were compared on whole-blood split samples. RESULTS: A total of 1414 concurrent, paired-sample measurements were obtained. The mean differences (SD of differences) from laboratory methods and r values for the combined data for the VIA LVM Monitor from the seven sites were 0.001 (0.026) and 0.97 for pH, 0.7 (3.6) mmHg and 0.94 for PCO(2), 4.2 (9.6) mmHg and 0.98 for PO(2), 0.0 (2.9) mmol/L and 0.87 for sodium, 0.1 (0.2) mmol/L and 0.96 for potassium, and 0.3% (2.9%) and 0.90 for hematocrit. Performance results were similar among the study sites with increasing time of monitor use and between in vivo paired-sample and in vitro split-sample test results. CONCLUSION: The VIA LVM Monitor can be used to assess critically ill neonates and infants.

Pediatric acute hemorrhagic leukoencephalitis: report of a surviving patient and review.

Acute hemorrhagic leukoencephalitis (AHLE) is a rare, fulminant CNS demyelinating condition usually diagnosed at autopsy. We report the clinical, laboratory, radiographic, and pathologic features of the first nonfatal case of pediatric AHLE confirmed by brain biopsy. Pathologic diagnosis of this condition may be critical to exclude more-common processes and to expedite the decision to administer high-dose corticosteroid therapy, which is potentially lifesaving.