External Validation of the UTICalc with and Without Race for Pediatric Urinary Tract Infection.

OBJECTIVE: To validate externally the UTICalc, a popular clinical decision support tool used to determine the risk of urinary tract infections (UTIs) in febrile children, and compare its performance with and without the inclusion of race and at differing risk thresholds. METHODS: We performed a retrospective, singlecenter case-control study of febrile children (2-24 months) in an emergency department. Cases with culture-confirmed UTI were matched 1:1 to controls. We compared the performance of the original model which included race (version 1.0) to a revised model which did not consider race (version 3.0). We evaluated model performance at risk thresholds between 2% and 5%. RESULTS: We included 185 cases and 197 controls (median age 8.4 months; IQR, 4.4-13.0 months; 60.5% girls). When using UTICalc version 1.0, the model area under the receiver operator characteristic curve (AUROC) was 73.4% (95% CI 68.4%-78.5%), which was similar to the version 3.0 model (73.8%; 95% CI 68.7%-78.8%). When using a 2% risk threshold, the version 3.0 model demonstrated a sensitivity of 96.7% and a specificity of 25.0%, with declines in sensitivity and gains in specificity at higher risk thresholds. Version 1.0 of the UTICalc had 12 false negatives, of whom 10 were Black (83%); whereas version 3.0 had 6 false negatives, of whom 2 were Black (33%). CONCLUSIONS: Versions of the UTICalc with and without race had similar performance to each other with a slight decline from the original derivation sample. The removal of race did not adversely affect the accuracy of the UTICalc.

Hospitalization and evaluation of brief resolved unexplained events (BRUEs) from a statewide sample.

OBJECTIVE: The 2016 clinical practice guideline (CPG) replacing apparent life-threatening event (ALTE) with brief resolved unexplained event (BRUE) was associated with a reduction in hospitalizations and clinical testing among children with this condition in pediatric hospitals. However, as only a minority of acute-care encounters occur in dedicated pediatric centers, the overall effect of this CPG on children with ALTE/BRUE remains unknown. The purpose of this study is to examine changes in the diagnosis and management of BRUE in a statewide sample of non-pediatric hospitals following publication of the CPG. METHODS: This is a retrospective study of encounters of infants (<1 year) presenting to 178 non-pediatric Illinois Emergency Departments (EDs) between 2013 and 2019 with an International Classification of Disease (ICD) 9th and 10th revision billing code of ALTE or BRUE (799.82, ICD-9; R68.13, ICD-10). Our primary outcomes were counts of ALTE/BRUE and the percent of patients with ALTE/BRUE admitted and/or transferred to another facility. Our secondary outcome was clinical testing. We used interrupted time-series analysis for our primary outcome and chi-square testing for secondary outcomes. Results were stratified into academic and community EDs. RESULTS: This study included 4639 ED encounters for infants with BRUE that presented to academic EDs (2229; 48.0%) or community EDs (2410; 52.0%). At academic EDs, ALTE/BRUE diagnoses were increasing by 2.3 per quarter prior to the CPG publication and decreased by 0.5 per quarter after the CPG publication, representing a change in slope of -2.8 per quarter (p < 0.01). The percent of ALTE/BRUE patients admitted/transferred was decreasing by 0.1% per quarter in the pre-intervention period and decreased by 0.3% per quarter in the post-intervention period, representing a change in slope of 0.7% (p = 0.03). At community EDs, ALTE/BRUE diagnoses were increasing by 2.9 per quarter prior to the CPG publication and increased by 1.4 per quarter after the CPG publication, a non-significant change in slope. The percent of ALTE/BRUE patients admitted/transferred was decreasing by 1.6% in the pre-intervention period and decreased by 0.9% in the post-intervention period, a non-significant change in slope. At academic EDs, there was no significant change in clinical testing. At community EDs, a lower proportion of patients in the post-intervention period had chest radiographs, blood cultures, metabolic panels, blood counts, and urine testing, while a higher proportion had pertussis testing and respiratory pathogen testing. CONCLUSIONS: Counts of BRUE diagnoses and the overall proportion of children admitted or transferred showed a consistent decrease at academic EDs but had a nonsignificant change in trend at community EDs following the CPG publication in 2016. There was no significant change in clinical testing at academic EDs while community EDs had a significant decrease in some testing and an increase in other types of testing. Our findings suggest the need for greater implementation efforts in non-pediatric settings, specifically community EDs, where pediatric patients with BRUE present infrequently in order to optimize care for these children.

Guillain-Barré syndrome hyponatremia: is it SIADH or pseudohyponatremia?

Approximately 5% of hospitalized patients with Guillain-Barré syndrome (GBS) experience SIADH; but pseudohyponatremia has also been reported in patients treated with IVIG. We present a case of a 51-year-old male with GBS who developed acute hyponatremia the day after initiation of IVIG; his sodium levels began to improve within 24 h of completion of IVIG. Differentiating between pseudohyponatremia caused by the IVIG treatment and SIADH caused by GBS was the key to successfully treating this patient. This case exemplifies the importance of pursuing further studies to determine the exact cause of hyponatremia in GBS in order to prevent further neurologic damage to the patient.

Modified single patch: are we still worried about subaortic stenosis?

BACKGROUND: When the modified single-patch technique for atrioventricular septal defect (AVSD) repair was introduced by Dr Benson Wilcox, there was concern that these patients might be at risk for late subaortic stenosis and left ventricular outflow tract obstruction (LVOTO). This review evaluated our modified single-patch population for LVOTO in the postoperative period. METHODS: Between January 2000 and 2013, 77 infants underwent AVSD repair with a modified single-patch technique. Median age was 4.2 months, and median weight was 5 kg. Eight patients had a prior repair of coarctation of the aorta via left thoracotomy in the newborn period. RESULTS: The median hospital stay was 10 days. No patient required a pacemaker. The mean and median follow-up times were 4.6 and 3.7 years, respectively. Only 2 patients (2.5%) required reoperation for LVOTO; both had prior repair of coarctation of the aorta (2 of 8 vs 0 of 69, p = 0.01). A discrete fibrous subaortic membrane developed in the first patient that required resection at 3 and 7 years after repair. The other patient had LVOTO from accessory chordae of the left atrioventricular valve and required mitral valve replacement 5 months after repair. One early death occurred at 4 months postoperatively due to liver failure related to hyperalimentation. CONCLUSIONS: At intermediate term follow-up, LVOTO does not appear to be a significant postoperative issue after modified single-patch repair of AVSD. Coarctation of the aorta was the most significant predictor of late LVOTO after repair of AVSD with the modified single-patch technique.