Care of Children with Supraventricular Tachycardia in the Emergency Department.

Prior studies have characterized children with supraventricular tachycardia (SVT) in inpatient settings, however there is a paucity of data regarding pediatric SVT in the Emergency Department (ED) setting. We sought to describe pediatric ED visits for SVT and assess whether variability exists in care. We performed a cross-sectional study of ED visits for SVT among children < 18 years old from 2010 to 2017 at 33 pediatric hospitals. Visits were included if made for a primary International Disease Classification Ninth or Tenth Revision diagnosis code for SVT and intravenous (IV) adenosine was given on the initial or 2nd hospital day. We evaluated factors associated with hospital admission using multivariate logistic regression and described variability in frequency of rate of hospitalization, second-line IV antiarrhythmic medication usage, and diagnostic testing across sites. We included 2329 ED visits made by 1738 children and the median patient age was 6.3 years (IQR 1.5-11.9). There were 2 deaths (0.1% of visits). Marked variability existed between centers in rates of admission to the hospital (range 17-85%) and ICU (range 4-60%). Factors associated with admission included: younger age, male sex and presence of comorbid conditions. A second IV antiarrhythmic agent was used in 17% of visits (range 4-41% across hospitals). There was variability in rates of diagnostic testing between centers [chest x-ray (range 10-47%), complete blood count (range 10-72%), electrolytes (range 22-86%), echocardiography (range 3-68%)]. Management of SVT is variable across pediatric hospitals, suggesting an opportunity for standardization in care.

Risk of Serious Infections Associated with Biologic Agents in Juvenile Idiopathic Arthritis: A Systematic Review and Meta-Analyses.

OBJECTIVE: To assess whether treatment with biologic response modifying agents during clinical trial study periods increases the risk of serious infections in children with juvenile idiopathic arthritis (JIA). STUDY DESIGN: A systematic literature review using Medline, Embase, Cochrane library, and the clinical trial registry was performed up to July 2017. Random effects meta-analyses were used to compare rates of serious infections in children with JIA given biologic agents compared with controls, and the pooled relative risk calculated. Subanalyses were performed for different biologic agent classes. RESULTS: In total, 19 trials accounting for 21 individual studies were included (11 for tumor necrosis factor-alpha inhibitors [n = 814 patients], 3 for interleukin-6 inhibitors [n = 318], 6 for interleukin-1 inhibitors [n = 353], and 1 for selective T-lymphocyte costimulation modulators [n = 122]). Patients (68% female) had a mean age of 10.8 years. Seventeen serious infections were reported among 810 children receiving biologic agents and 15 among 797 controls. The most frequent infections were bronchopulmonary and varicella. No statistically significant difference in risk of serious infections was found between children receiving biologic agents compared with control groups (pooled relative risk = 1.13; 95% CI [0.63, 2.03]) during the trial study periods. The risk remained nonsignificant when evaluating the different classes of biologic agents separately. However, the analyses were underpowered to detect differences in the risk of serious infections overall or differences between classes of biologic agents. CONCLUSIONS: In this systematic review and meta-analyses, serious infections were uncommon and not significantly increased among patients with JIA receiving biologic agents compared with controls. However, the analyses were underpowered and study periods were relatively short. Ongoing careful monitoring for serious infections remains necessary for all patients with JIA, and particularly those receiving biologic agents.

Quality Improvement Effort to Reduce Cranial CTs for Children With Minor Blunt Head Trauma.

OBJECTIVE: Blunt head trauma is a common injury in children, although it rarely requires surgical intervention. Cranial computed tomography (CT) is the reference standard for the diagnosis of traumatic brain injury but has been associated with increased lifetime malignancy risk. We implemented a multifaceted quality improvement initiative to decrease the use of cranial CT for children with minor head injuries. METHODS: We designed and implemented a quality improvement effort that included an evidence-based guideline as well as individual feedback for children aged 0 to 21 years who present to the emergency department (ED) for evaluation of minor blunt head trauma. Our primary outcome was cranial CT rate, and our balancing measure was any return to the ED within 72 hours that required hospitalization. We used statistical process control methodology to measure cranial CT rates over time. RESULTS: We included 6851 ED visits of which 4242 (62%) occurred in the post-guideline implementation period. From a baseline CT rate of 21%, we observed an absolute reduction of 6% in cranial CT rate (95% confidence interval 3% to 9%) after initial guideline implementation and an additional absolute reduction of 6% (95% confidence interval 4% to 8%) after initiation of individual provider feedback. No children discharged from the ED required admission within 72 hours of initial evaluation. CONCLUSIONS: An ED quality improvement effort that included an evidence-based guideline as well as individual provider feedback was associated with a reduction in cranial CT rates without an increase in missed significant head injuries.