Risk Factors for Ankle Fractures in Asian Adolescents Seen in a Pediatric Emergency Department.

OBJECTIVES: Pediatric ankle injuries remain one of the most common presenting complaints to the pediatric emergency department (PED). In this study, we aimed to describe risk factors associated with simple ankle fractures and ankle fractures that require surgery, among adolescents presenting to the PED with ankle injuries. METHODS: We analyzed a retrospective cohort study of adolescents 12 to 16 years old who presented to our PED with an acute ankle injury and received an ankle radiograph from November 1, 2016, to October 31, 2017. Demographic, anthropometric variables, physical examination findings including those of the Ottawa Ankle Rules were obtained. We recorded any surgical interventions required, as well as follow-up and to return to physical activity. RESULTS: Five hundred fifty-six cases of adolescent ankle injuries were reviewed, of which 109 adolescents had ankle fractures, whereas 19 had ankle fractures requiring surgery. Sports-related injuries remained the most common cause of ankle fractures. Age (adjusted odds ratio [aOR], 0.69; 95% confidence interval [CI], 0.56-0.83; P < 0.001), male sex (aOR, 2.12; 95% CI, 1.34-3.35; P < 0.001), clinical findings of tenderness over the lateral malleolus (aOR, 3.13; 95% CI, 1.74-5.64; P < 0.001) or medial malleolus (aOR, 3.55; 95% CI, 2.18-5.78; P < 0.001), and inability to walk (aOR, 3.09; 95% CI, 1.95-4.91; P < 0.001) were significant independent risk factors for ankle fractures.Patients with a weight more than 90th centile for age were at greater risk of ankle fractures requiring surgery (aOR, 2.64; 95% CI, 1.05-6.64; P = 0.04). CONCLUSIONS: We found that younger age, male sex, and clinical findings in the Ottawa Ankle Rules correlated well with predicting ankle fractures and are well suited for application in the Southeast Asian population. Weight greater than the 90th percentile for age was a significant risk factor for ankle fractures requiring surgery.

Differences in radiation dose for computed tomography of the brain among pediatric patients at the emergency departments: an observational study.

BACKGROUND: Computed tomography (CT) is associated with a risk of cancer development. Strategies to reduce radiation doses vary between centers. We compared radiation doses of CT brain studies between pediatric and general emergency departments (EDs), and determine the proportion studies performed within the reference levels recommended by the International Commission on Radiological Protection (ICRP). METHODS: A retrospective review was carried out in a healthcare network consisting of one pediatric ED and three general hospital EDs. Pediatric patients less than 16 years old with CT brain studies performed between 1 January 2015 and 31 December 2018 were included. Information on demographic, diagnosis, volume-averaged computed-tomography dose index and dose length product (DLP) were collected. Effective dose was then calculated from DLP using conversion factors, termed k-coefficients which were derived using a 16 cm head CT dose phantom. RESULTS: Four hundred and seventy-nine CT brain studies were performed - 379 (79.1%) at the pediatric ED. Seizure (149, 31.1%), head injury (147, 30.7%) and altered mental status (44, 9.2%) were the top three ED diagnoses. The median effective dose estimates were higher in general than pediatric EDs, particularly for those aged > 3 to ≤6 years old [1.57 mSv (IQR 1.42-1.79) versus 1.93 mSv (IQR 1.51-2.28), p = 0.047], > 6 to ≤10 years old [1.43 mSv (IQR 1.27-1.67) versus 1.94 mSv (IQR 1.61-2.59), p = 0.002) and > 10 years old (1.68 mSv (IQR 1.32-1.72) versus 2.03 mSv (IQR 1.58-2.88), p < 0.001). Overall, 233 (48.6%) and 13 (2.7%) studies were within the reference levels recommended by ICRP 60 and 103 respectively. CONCLUSIONS: Radiation doses for CT brain studies were significantly higher at general EDs and less than half of the studies were within the reference levels recommended by ICRP. The development of diagnostic reference levels (DRLs) as a benchmark and clinical justification for performing CT studies can help reduce the radiation risks in the pediatric population.

Differences in intubation outcomes for pediatric patients between pediatric and general Emergency Departments.

BACKGROUND: Intubation is a life-saving intervention at the Emergency Department (ED). However, general and pediatric EDs may vary in their preparedness to manage children with airway emergencies. AIMS: We aimed to compare rates of first-pass intubation and adverse tracheal intubation-associated events between general and pediatric EDs. METHODS: A retrospective review of medical records was conducted at a pediatric ED and three general EDs from January 1, 2015, to December 31, 2018. Information about the intubation process involving pediatric patients (less than 16 years old), as well as eventual outcomes of first-pass intubation and adverse tracheal intubation-associated events were collected and analyzed. RESULTS: There were 180 pediatric intubations, of which 115 (63.9%) were performed in pediatric ED. The median age was 2 years old (interquartile range 0-6). Intubation was most commonly performed for patients with cardiac arrest (88, 48.9%). Direct laryngoscopy was used in 178 (98.9%) cases and uncuffed tube was used in 135 (75.0%) cases. Apneic oxygenation was performed in 26 (14.4%) cases-all in pediatric ED. Intubation was predominantly performed by senior clinicians (162, 90.0%). Overall, intubation was performed successfully in 175 (97.2%) cases, with a first-pass intubation rate of 82.2% which was similar between pediatric (96, 83.5%) and general EDs (52, 80%) (Odds ratio [OR] 1.26, 95% confidence interval [CI] 0.58 to 2.76, p = .558). There were 68 adverse tracheal intubation-associated events with right mainstem intubation being the most common (23, 12.8%). Pediatric EDs (44, 38.3%) had a higher rate of adverse tracheal intubation-associated events than general EDs (15, 23.1%) (OR 2.07, 95% CI 1.04 to 4.11; p = .037). CONCLUSIONS: Differences exist in intubation outcomes between pediatric and general EDs. Quality improvement efforts should focus on standardizing intubation practices across both pediatric and general EDs.

Novel Coronavirus 2019 Transmission Risk in Educational Settings.

Transmission risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in schools is unknown. Our investigations, especially in preschools, could not detect SARS-CoV-2 transmission despite screening of symptomatic and asymptomatic children. The data suggest that children are not the primary drivers of SARS-CoV-2 transmission in schools and could help inform exit strategies for lifting of lockdowns.

Personal level exposure and hazard potential of particulate matter during haze and non-haze periods in Singapore.

Severe haze episodes originating from biomass burning are common in Southeast Asia. However, there is a paucity of data on the personal exposure and characteristics of Particulate Matter (PM) present in ambient air during haze and non-haze periods. Aims of this study were to monitor 24 h ambulatory exposure to PM among school children in Singapore; characterize haze and non-haze PM for their physicochemical properties, cytotoxicity and inflammatory potential, using bronchial epithelial cell culture model (BEAS-2B). Forty-six children had ambulatory PM exposure monitored using portable Aethalometer and their hourly activity recorded. The mean (±SE) PM exposure on a typical school day was 3343 (±174.4) ng/m3/min. Higher PM exposure was observed during haze periods and during commuting to and from the school. Characterization of PM collected showed a drastic increase in the proportion of ultrafine particle (UFP) in haze PM. These PM fraction showed higher level of sulphur, potassium and trace metals in comparison to those collected during non-haze periods. Dose dependent increases in abiotic reactive oxygen species generation, activation of NF-κB and cytotoxicity were observed for both haze and non-haze PM. Generally, haze PM induced significantly higher release of IL-6, IL-8 and TNFα by BEAS-2B cells in comparison to non-haze PM. In summary, this study provides experimental evidence for higher PM exposure during haze period which has the potential to elicit oxidative stress and pro-inflammatory cytokine release from airway epithelial cells.