Staged imaging pathway for the evaluation of pediatric appendicitis.

PURPOSE: Despite significant radiation exposure involved with computed tomography (CT) in evaluation of pediatric appendicitis, its use is still widespread. The goal of this study was to assess the effect of a staged imaging pathway for appendicitis to significantly decrease CT use while maintaining diagnostic accuracy. METHODS: Chart review was performed for patients evaluated for appendicitis over a 12-month period prior to and after pathway implementation. RESULTS: There was a significant decrease in CT use as initial imaging after implementation of the pathway; 87.1-13.4 % for evaluations positive for appendicitis (decrease 84.6 %, p < 0.0001) and 82.6-9.2 % for evaluations negative for appendicitis (decrease 88.9 %, p < 0.0001). Use of CT during any point in the evaluation decreased from 91.7 to 25.1 % (decrease 72.6 %, p < 0.0001). The negative appendectomy rate was similar; 5.4 % prior, 4.9 % post (p = 0.955). The missed appendicitis rate did not statistically change; 1.1 % prior, 3.7 % post (p = 0.523). The perforation rate was not statistically altered; 6.5 % prior; 9.8 % post (p = 0.421). 350 less patients underwent CT during the year following the pathway. CONCLUSIONS: The staged imaging pathway resulted in a marked decrease in children exposed to CT without compromising diagnostic accuracy.

Cerebral sinovenous thrombosis in a toddler with iron deficiency anemia.

Cerebral sinovenous thrombosis (CSVT) is an increasingly recognized cause of neurological morbidity and mortality within the pediatric population. Unlike its manifestation in the adult population, CSVT in children has a broad and often multifactorial cause. Our case describes an 18-month-old young boy presenting to the emergency department twice during a 48-hour period with vomiting and lethargy. The child was found to have a sagittal sinus venous thrombosis caused by severe dietary iron deficiency anemia. Severe iron deficiency anemia has been linked to CSVT formation in several recent case reports.

Pediatric emergency medicine physicians' current practices and beliefs regarding mental health screening.

BACKGROUND: Only 20% of children with mental health issues are identified and receiving appropriate treatment nationally. The emergency department (ED) may represent a significant opportunity to provide selective pediatric mental health screening to an at-risk population. OBJECTIVE: To describe the current standard of care and perceived limitations among pediatric emergency medicine (PEM) physicians regarding mental health screening. METHODS: A 23-question survey on screening practices for pediatric mental illness (PMI) was sent to PEM physician participants identified through the American Academy of Pediatrics Section on Emergency Medicine mailing list. RESULTS: Of the 576 physicians meeting our inclusion criteria, 384 (67%) surveys were returned. Eighty-six percent of respondents indicated screening for PMI in 10% or less of their eligible patients. Overall, 43% of respondents indicated screening only if the chief complaint was psychiatric in nature. The remaining 217 physicians most commonly screened for depression (83%), suicidality (76%), and substance abuse (67%). Only 9% of physicians stated that they used evidence-based medicine in determining their screening practices. Women physicians (odds ratio, 1.94; 95% confident interval, 1.08-3.47) and those using evidence-based medicine (odds ratio, 3.88; 95% confidence interval, 1.92-7.85) were more likely to conduct screening. Significant limitations to screening identified by respondents include the following: time limitations (93%), absence of a validated screening tool (62%), limited resources (46%), and lack of training (44%). Eighty-eight percent of physicians believe that a validated and standardized screening tool would improve their ability to identify PMI. CONCLUSIONS: Routine PMI screening is conducted infrequently by most PEM physicians. Improved physician education/training and the development of a validated ED-specific mental health screening tool would assist PEM physicians in the early detection of PMI.