Incidence of Bacteremia and Serious Bacterial Infections in Hyperpyrexic Infants Offered Universal Pneumococcal Conjugate Vaccine 13 and Haemophilus influenzae B Immunization.

BACKGROUND: High fevers, especially in young children, often alarm clinicians and prompt extensive evaluation based on perceptions of increased risk of serious bacterial infection (SBI), and even brain damage or seizure disorders. OBJECTIVE: The aim of this study was to determine the prevalence of SBI in infants aged 3-36 months with fever ≥40.5°C in a population of infants offered universal pneumococcal conjugate vaccine 13 and Haemophilus influenzae B immunization. METHODS: This study is a retrospective review of all infants aged 3-36 months with temperature ≥40.5°C presenting to a tertiary care pediatric emergency department over a 30-month period in an era of universal pneumococcal conjugate 13 and H. influenzae B immunization. RESULTS: SBI was recorded in 54 (21.8%) of 247 study infants, most commonly pneumonia 30 patients (12.1%) and urinary tract infection 16 patients (6.5%). Two patients had positive blood cultures, yielding a bacteremia rate of 0.8%. Patients with SBI had a significantly higher WBC count (P < 0.0001) and C-reactive protein levels (P < 0.0001), and were significantly more likely to be hospitalized (P < 0.0001). DISCUSSION: Although SBI was common (21.8%) in our cohort of hyperpyrexic infants universally offered vaccination with pneumococcal conjugate 13 and H. influenzae B vaccines, bacteremia was a rare finding (0.8%).

Patients with Altered Mental Status May Benefit from Medical Toxicology Consultation.

BACKGROUND: Presentation of intoxicated patients to hospitals is frequent, varied, and increasing. Medical toxicology expertise could lead to important changes in diagnosis and treatment, especially in patients presenting with altered mental status. OBJECTIVES: To describe and analyze clinical scenarios during a 1-year period after the establishment of a medical toxicology consultation service (MTCS). METHODS: Cases of 10 patients with altered mental status at presentation were evaluated. Medical toxicology consultation suggested major and significant changes in diagnosis and management. RESULTS: Of 973 toxicology consultations performed during the study period, bedside consultation was provided for 413 (42%) patients. Of these 413, 88 (21%) presented with some level of altered mental status. We described 10 patients in whom medical toxicology consultation brought about major and significant changes in diagnosis and management. CONCLUSIONS: Benefits may be derived from medical toxicology consultations, especially in patients with altered mental status. Medical toxicology specialists are well positioned to provide high value and expedited patient care.

Acute intoxication caused by three common synthetic cannabinoids: The experience of a large, urban, tertiary care hospital.

BACKGROUND: Synthetic cannabinoids (SC) are chemical substances, which activate cannabinoid receptors in a similar fashion to tetrahydrocannabinol, but with increased efficacy, and are used as illicit recreational drugs. OBJECTIVE: Our objective was to characterize the clinical manifestations and management of three specific, common SC exposures in a cohort of patients presenting to the emergency department of our institution. METHODS: Retrospective case series of patients admitted to an urban tertiary care center between August 1, 2018 and December 31, 2021, with confirmed SC use and positive urinary immunoassay testing for AB-FUBINACA, 4F-MDMB-BUTINACA and ACHMINACA. RESULTS: 58 patients met inclusion criteria during the 3-year study period; median age was 35 years, 60% were male, 31% patients were exposed to >1 substance, and 31% needed hospital addition. The most common physical signs were cardiovascular (54%) and neuropsychiatric (45%). Severe outcomes included coma and seizures, necessitating intubation in 4 patients, and acute renal injury in 7 patients. CONCLUSION: SC are potentially harmful drugs of abuse which can lead to life-threatening complications. Acute care personnel should be aware of the broad range of signs and symptoms of SC use. Testing with short turn around times is available to assess SC use.

Outcomes of children presenting to the emergency department with fever and bulging fontanelle.

BACKGROUND: In infants aged 3-18 months presenting with a bulging fontanelle and fever it is often necessary to exclude central nervous system infection by performing a lumbar puncture. Several studies have shown that well-appearing infants with normal clinical, laboratory and imaging studies have a benign (non-bacterial) disease. At our institution, we often observe such infants and withhold lumbar puncture. OBJECTIVE: To determine the clinical characteristics and outcomes of well-appearing, febrile infants with a bulging fontanelle, whether they did or did not undergo lumbar puncture. DESIGN: A retrospective chart review of the medical records of all febrile infants with a bulging fontanelle seen between March 2018 and March 2020 at Dana Children's Hospital. The following data were extracted: age of the patient, gender, previous medical history, general appearance, vomiting, appetite, fever, blood test results and CSF results (when taken), final diagnosis, disposition status, and whether or not the patient returned to our ER. Stats: Descriptive statistics were used to describe the study population. RESULTS: The study group included 40 children, 22 males, and 18 females. Their age ranged from 3 to 13 months. Only 8 of the patients in the study group were admitted and 32 were discharged. Only 13 (32.5%) had an LP performed, three of which had elevated levels of WBC in the CSF, two of them had a positive culture. None of the patients who were discharged returned to the ED. CONCLUSIONS: Our study, combined with previous works, supports the assumption that management of well-appearing infants with normal medical history who present with fever and bulging fontanelle could be done without a lumbar puncture. Larger and prospective studies are needed to support this observation.

C-Reactive Protein and the Outcome of a Pediatric Emergency Department 7 Days Revisit.

BACKGROUND: Pediatric emergency department (PED) return visits represent an important quality of care metric and constitute a patient-centered outcome. C-reactive protein (CRP) is an inflammatory biomarker that is commonly used as screening tool in the PED. In this study, we assessed the clinical outcomes of children whose levels of CRP are 150 mg/L or higher at the initial PED visit and if such levels could be useful in predicting outcomes at a second PED visit. METHODS: A historical cohort study of all patients who visited the PED between July 2007 and June 2017 and had a CRP value of 150 mg/L or greater in the setting of a febrile illness. Data of patients with a return visit to the PED within 7 days were assessed for an association between laboratory values, diagnosis and clinical outcome. RESULTS: One hundred thirty-six index visits were included in this study. One hundred fifteen (84.6%) of the revisits were discharged after their second visit, and 21 (15.4%) were admitted to the inpatient unit. Admitted patients did not differ from patients who were discharged home in diagnosis and CRP levels, but a difference in white blood cell and absolute neutrophil counts was observed. CONCLUSIONS: The intensity of the inflammatory response, as expressed by the high concentrations of CRP in children, does not seem to predict the outcome at a repeat PED visit within 7 days.

Bradycardia Without Hypertension: Is It a Common Clinical Presentation of Ventriculoperitoneal Shunt Malfunction in Pediatric Patients?

BACKGROUND: Mechanical shunting of cerebrospinal fluid is an effective treatment for hydrocephalus. Some studies suggest that bradycardia without hypertension may also be observed in ventriculoperitoneal (VP) shunt malfunction; however, in our experience, this is not a common presenting sign. OBJECTIVE: The aim of this study was to evaluate whether bradycardia without hypertension was a common sign in patients presenting to the pediatric emergency department (ED) with a VP shunt malfunction. METHODS: A retrospective observational study, from May 2006 to April 2015, which included a random sample of children admitted to the ED with clinical features suggestive of possible VP shunt malfunction. Control patients were defined as those who arrived at our ED with suspected VP shunt malfunction that was later ruled out on further workup. RESULTS: A total of 65 patients were included in this study. A significantly greater number of patients with a confirmed shunt pathology presented with vomiting (P = 0.01) and lethargy/apathy (P = 0.01). In the control group, a significantly greater number of patients presented with fever (P = 0.004) and seizures (P = 0.02). The number of patients presenting with bradycardia was not significantly different between the shunt pathology and control groups (P > 0.05). CONCLUSIONS: Bradycardia is not a common presentation in patients with VP shunt malfunction. Bradycardia is often recognized as a significant sign; however, it is one of the last presenting signs. Educating patients about the early signs must be considered as part of the treatment for VP shunt malfunction.

The importance of skull impact site for minor mechanism head injury requiring neurosurgical intervention.

PURPOSE: The most frequent impact sites for head injury patients who require surgical intervention are the temporo-parietal regions. However, most recent guidelines for indication of neuroimaging for head injury sparsely address the impact site as a risk factor. Our purpose was to determine the association between the site of impact in a minor mechanism pediatric head injury and neurosurgical intervention. METHOD: A retrospective cohort study of head injury patients seen between 2000 and 2016 in a large trauma center was carried out. We looked at all children ages 0-18 years who underwent neurosurgical intervention for head traumas. A major mechanism was defined as a fall of >1 m, being struck by a fast-flying object, or a motor collision involving an estimated speed of >40 kph. All other mechanisms were classified as minor. RESULTS: Out of 533 patients, we excluded patients with non-accidental trauma, patients with a relevant chronic illness, patients with a major mechanism of injury, and patients with missing important data, leaving 43 as the study group. Of the 43 patients with a minor mechanism, none had a site of impact that was outside the temporo-parietal region. CONCLUSION: We studied one of the largest cohorts of pediatric patients undergoing neurosurgical intervention for a head injury. In our cohort, none of the children who sustained a minor mechanism of injury suffered a site of impact in the occipital or frontal bone regions outside the temple region. These data suggest that injury location should be considered in assessing the need for neuroimaging in minor mechanism head trauma patients.

Pediatric Electric Bicycle Injuries: The Experience of a Large Urban Tertiary Care Pediatric Hospital.

BACKGROUND: Electric bicycles (E-bikes) are one of a wide range of light electric vehicles that provide convenient local transportation and attractive recreational opportunities. The aim of this study was to report E-bike-related injuries in children presenting to a trauma center. METHODS: Retrospective observational study, from December 2014 to November 2015, which included all pediatrics patients admitted to the emergency department with an injury related to E-bike use, was performed. RESULTS: A total of 97 E-bike injuries presented to the emergency department during this period. Mean age of E-bikers was 13.7 years (range, 7.5-16 years). Injuries to the head and the upper and the lower extremities were the most common. Thirteen patients (15%) were admitted, and 4 underwent surgery. CONCLUSIONS: Children are mainly injured as riders when using E-bikes. There is a need for regulation regarding the use of E-bikes to enhance the safety of both bikers and other road and pavement users.

Comparison Between Small and Large Bowel Intussusception in Children: The Experience of a Large Tertiary Care Pediatric Hospital.

BACKGROUND: Intussusception is the most common cause of intestinal obstruction in young children, and delayed diagnosis may lead to serious sequelae. The objective of this study was to determine the prevalence of ileoileal intussusception and to document and compare clinical outcomes with ileocolic intussusception. METHODS: A retrospective cohort study of children with an abdominal ultrasound that diagnosed intussusception. Clinical data and diagnostic studies were retrieved, to compare ileoileal with ileocolic intussusception. RESULTS: A total of 488 patients were evaluated with an abdominal ultrasound on suspicion of intussusception; 54 (11%) had ileoileal intussusception and 30 (6%) ileocolic intussusception. The significant features distinguishing the 2 conditions were fever, more common in patients with ileoileal intussusception, and an abdominal mass, which was papable more commonly in ileocolic intussusception. None of the ileoileal intussusception patients required surgical intervention, and all were discharged without complication. CONCLUSIONS: With recent advances in abdominal ultrasound, the diagnosis of ileoileal intussusception has become easier than before. Patients presenting with small bowel intussusception may not need any immediate intervention. The presence of fever supports the diagnosis of ileoileal intussusception.

Childhood Drowning: Review of Patients Presenting to the Emergency Departments of 2 Large Tertiary Care Pediatric Hospitals Near and Distant From the Sea Coast.

OBJECTIVE: Drowning is a leading cause of death among infants and toddlers. Unique physiological and behavioral factors contribute to high mortality rates. Drowning incidents predominantly occur during warmer months and holidays. The aim of this study was to describe the characteristics of pediatric drowning victims who attended 2 different emergency departments (EDs), 1 near and 1 distant from the sea coast, to recognize risk factors, complications, causes of death, and the educational needs of families and caregivers. METHODS: Retrospective cohort analysis of incident history, clinical presentation, treatments, and outcomes of drowning victims was performed. Data were analyzed both by age group and proximity of institution to the sea coast. RESULTS: From 2005 to 2015, 70 drowning patients presented to the 2 institutions; there was no difference in incident history or outcomes based on proximity to the sea coast. Fifty-six percent of patients were younger than 6 years, the majority drowning in pools. More of the older children drowned in the sea (48% vs 23%). Half of all patients were treated and followed in the ED or ward, and the other half were treated in the pediatric intensive care unit; 12 suffered severe complications, including 5 diagnosed with brain death. Cardiopulmonary resuscitation was performed in 80% of the fatal group and 23% of the nonfatal group (P = 0.006). Seven children who experienced a cardiac arrest with hypothermia were treated before arrival in the ED, and 5 had ongoing cardiac arrest upon arrival in the ED (these were the 5 suffering brain death). DISCUSSION: Most of patients younger than 6 years drowned in swimming pools, suggesting that parents are perhaps less vigilant in these circumstances, even though they may remain in close proximity. Active adult supervision entails attention, proximity, and continuity. Educational efforts should be aimed at reminding parents of this, especially in the summer months.

Outpatient Management of Headache after Pediatric Emergency Department Visit: Are we Missing Anything?

BACKGROUND: Headache is a common complaint in children at a pediatric emergency department (PED). The primary objective of this analysis is to describe the outcome of patients presenting with headache to the PED and discharged with neurology follow up. The secondary objective is to describe the diagnostic evaluation children with headache underwent in the PED and to evaluate headache characteristics which are more likely associated with serious, life-threatening conditions. METHODS: A retrospective chart review of children who were discharged from the PED after evaluation for headache, with a scheduled urgent neurology outpatient clinic follow up at the same institution, over a 3.5-year period. RESULTS: During the study period, we identified 300 children whose admitting diagnosis was headache and they were discharged from the PED with a scheduled follow up. None of these patients had papilledema on fundoscopy performed by an ophthalmologist during the PED visit. Following neurology outpatient clinic visit, 62 (21%) were referred to perform brain magnetic resonance imaging. None of the patients had a diagnosis of brain tumor or any anatomic abnormality that could increase intracranial pressure. CONCLUSIONS: No immediate life-threatening cases presented to the follow up neurology clinic for evaluation. A scheduled urgent neurology outpatient clinic follow up in any child with headache who is discharged from the PED, offers a safety net, even when the physical examination including fundoscopy is normal.

Levocarnitine for the Treatment of Valproic Acid-Induced Hyperammonemic Encephalopathy in Children: The Experience of a Large, Tertiary Care Pediatric Hospital and a Poison Center.

BACKGROUND: Although rare, symptomatic hyperammonemia is sometimes associated with valproic acid (VPA), especially in children. L-carnitine (levocarnitine), sometimes classified as an essential amino acid, is vital to mitochondrial utilization of fatty acids and can be helpful in treating this condition. The data supporting this, however, are limited. STUDY QUESTION: The aim of the study was to illustrate the role of L-carnitine in the treatment of patients with VPA-induced hyperammonemic encephalopathy (VPE) at 2 different institutions. METHODS: Medical records of affected patients were reviewed; data collected included exposure history, clinical manifestations, physical examination, and laboratory values. RESULTS: There were 13 cases of VPE; 12 were associated with therapeutic dosing and 1 with an overdose. The maximum ammonia concentration was 557 µmol/L, and blood concentrations of VPA ranged from 68 to 600 µg/mL (therapeutic range 50-100 µg/mL). In all cases, liver function tests were normal or only mildly increased. In this study, 12 patients received a daily dose of L-carnitine 100 mg/kg, and 1 received 200 mg/kg (intravenous infusion over 30 minutes) divided every 8 hours until clinical improvement. All patients made a full recovery. None developed adverse effects or reactions, and no cases of toxicity were reported. CONCLUSION: Our series suggests that intravenous L-carnitine, at a dose of 100 mg·kg·d in 3 divided doses each over 30 minutes until clinical improvement occurs, is a safe and effective treatment in the management of VPE in children.

Are We Over-Treating Insect Bite Related Periorbital Cellulitis in Children? The Experience of a Large, Tertiary Care Pediatric Hospital.

INTRODUCTION: Preseptal (periorbital) and orbital cellulitis are potentially catastrophic infections near the eye. Preseptal cellulitis is far more common, and although classically reported to be associated with dacrocystitis, sinusitis/upper respiratory infection, trauma/surgery, or infection from contiguous areas, it can also be associated with insect bites. The objective of this study was to determine the prevalence of insect bite-associated preseptal cellulitis and to compare clinical findings and outcomes of these patients with those having other causes for the condition. METHODS: Retrospective chart review of children with a final discharge diagnosis of periorbital cellulitis from January 2009 to December 2014 at a tertiary care children' hospital. RESULTS: 213 children were diagnosed with preseptal cellulitis during the 5-year study period, of whom 60 (28%) were associated with insect bites. Patients in the noninsect bite group more commonly had fever at presentation (P < 0.001), with increased white blood cell and C reactive protein values (both P < 0.001). No patient with insect bite-associated preseptal cellulitis presented with fever, and none underwent radiographic testing or computerized tomography; their mean age was also lower (P < 0.001) and length of stay was significantly shorter. CONCLUSIONS: This study suggests that children with preseptal cellulitis associated with insect bites could be candidates for oral antibiotic therapy with outpatient follow-up by.

Predictors for hospital admission of asymptomatic to moderately symptomatic children after drowning.

Drowning is a leading cause of injury-related death worldwide, but there are limited data on the management and disposition of asymptomatic and mildly symptomatic adults and children following a drowning event. Some authors have recommended admission for all drowning victims due to the possibility of respiratory and clinical deterioration in a seemingly well patient. In order to identify predictors for admission and to establish a unified approach for management, we retrospectively collected all children ≤ 16 years old presented following a drowning event to the pediatric ED over a period of 12 years. The children were divided into two groups, those who were discharged home from the ED and those who were admitted. Seventy-one surviving and non-intubated children were asymptomatic to moderately symptomatic, and they comprised the study group. Crepitations on lung auscultation, oxygen desaturation, and respiratory distress were significantly higher in the admitted group (n = 26) compared with the discharged group (n = 45) (P < 0.05). Respiratory distress and lung crepitations were independent predictors for admission. Eventually, 30% of the hospitalized patients required oxygen therapy, but there were no cases that deteriorated and required invasive ventilation. No readmissions occurred in the group of children who were discharged from the ED.Conclusion: Children who after six hours show no respiratory distress and have normal oxygen saturation and normal auscultation can be safely discharged home. Respiratory distress and lung crepitations should both warrant the physician to consider admission of asymptomatic to moderately symptomatic children following a drowning event. An algorithm to assist patient management is proposed. What is Known: •There are few data in the literature regarding the management and disposition of asymptomatic to moderately symptomatic children after drowning. What is New: •We found that respiratory distress and lung crepitations are independent predictors for admission. An algorithm to assist patient management is proposed.

Acute disseminated encephalomyelitis in children - clinical and MRI decision making in the emergency department.

BACKGROUND: Acute disseminated encephalomyelitis (ADEM) is an uncommon, treatable, primarily pediatric, immune-mediated disease. Diagnosis of ADEM requires two essential elements: typical clinical presentation and magnetic resonance imaging (MRI) findings. The aim of this study was to evaluate how clinical findings in the initial emergency department (ED) presentation influenced the timing of MRI. METHODS: A retrospective chart review was conducted of children diagnosed with ADEM, over a 12-year period, in a tertiary care pediatric center. Clinical presentation at ED admission was recorded and patients who underwent an MRI as part of their ED evaluation (early MRI) with those who had MRI performed during ward hospitalization (late MRI) were compared. RESULTS: 30 patients were diagnosed with ADEM during the study period. Encephalopathy and polyfocal neurological signs were described in 80% and 50% of patients ED charts, respectively. Seven patients underwent early MRI and polyfocal neurological signs were more common in this group (p = 0.006). Fever was more common in the late MRI group (p = 0.02). Following diagnosis, all patients were treated with immune-modulation therapy, improved clinically, and were discharged. CONCLUSION: 20% of ADEM patients were not encephalopathic at ED presentation. Polyfocal neurological signs and absence of fever at ED presentation were related to earlier MRI utilization and thus earlier diagnosis and treatment. Familiarity with the ADEM constellation of signs, and a high index of suspicion, may help the ED clinician in early diagnosis and treatment of this rare disease.

Fever as a Presenting Symptom in Children Evaluated for Ileocolic Intussusception: The Experience of a Large Tertiary Care Pediatric Hospital.

BACKGROUND: Intussusception is the most common cause of intestinal obstruction in young children, and delayed diagnosis may lead to bowel perforation. The objective of this study was to determine the prevalence of fever in patients with ileocolic intussusception and to determine its utility as a predictive symptom. METHODS: This was a 3-year retrospective study, at a tertiary care center, of children aged 1 month to 6 years, presenting with possible intussusception. Charts were reviewed for clinical signs and symptoms at presentation, and all diagnostic studies were retrieved. A pediatric radiologist reviewed all ultrasounds. RESULTS: A total of 488 ultrasounds were performed on suspicion of intussusception. In 30 patients with confirmed ileocolic intussusception, mean age was 27 months and all were successfully reduced by air enema. Of 118 patients with fever, 2 had confirmed intussusception, 1 with pneumonia and 1 with acute otitis media, compared with 116 febrile patients with negative ultrasounds (P < 0.05). CONCLUSIONS: Traditional teaching is that intussusception presents as intermittent colicky abdominal pain, red currant jelly stool, vomiting, and a palpable abdominal mass, but it is important to remember that this classic triad is a very late finding and this condition should be recognized before the development of these findings. The concurrence of fever can help to rule out the possibility of intussusception and prompt the health care professional to search diligently for alternative infectious etiologies but cannot eliminate the possibility, especially when other findings suggestive of intussusception are present.

Accidental Rivaroxaban Intoxication in a Boy: Some Lessons in Managing New Oral Anticoagulants in Children.

Novel oral anticoagulants offer equivalent or improved therapeutic profiles compared with warfarin, with less risk of bleeding, no interactions with food, and no need for routine laboratory monitoring. Caution must be exercised in using these drugs in certain patient populations, for example, renal insufficiency, those receiving additional antithrombotic therapy, those with questionable compliance, children, and those with a high risk of gastrointestinal bleeding. One of the novel oral anticoagulants, rivaroxaban, is a direct Factor Xa inhibitor, used to reduce risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, deep vein thrombosis, and pulmonary embolism. We report a child who presented abnormal coagulation tests after unintended ingestion of 4 tablets of rivaroxaban. The patient was treated with fresh frozen plasma as well as admitted to intensive care and improved several hours later. We discuss his presentation and review of the literature on this topic.

Lactose Breath Test in Children: Relationship Between Symptoms During the Test and Test Results.

BACKGROUND: Lactose malabsorption affects 70% of the world population. The hydrogen breath test (HBT) is used clinically to test for this condition. The aim of our study was to describe the relationship between symptoms experienced before and during the HBT and test results. METHODS: We included children who underwent the HBT in the pediatric gastroenterology unit at Dana-Dwek Children's Hospital during a 6-month period. Previous symptoms and those experienced before and after the HBT were assessed using a questionnaire and a validated pain scale. RESULTS: Ninety-five children were included in the study, and 66.3% had a positive HBT. Diarrhea and flatulence during the test were significantly more frequent in the group with a positive HBT compared to those with a negative test (31.7% vs. 9.4%, P = 0.016 and 69.8% vs. 40.6%, P = 0.006, respectively). The frequency of abdominal pain and bloating was similar. CONCLUSIONS: Diarrhea and flatulence during the HBT are the most specific symptoms of lactose intolerance. Abdominal pain should not be automatically attributed to lactose intolerance even in the presence of lactose malabsorption. Coupling the HBT with a real-time questionnaire facilitates interpretation of results and subsequent recommendations.

Treatment of pediatric black widow spider envenomation: A national poison center's experience.

BACKGROUND: Black widow species (Latrodectus species) envenomation can produce a syndrome characterized by painful muscle rigidity and autonomic disturbances. Symptoms tend to be more severe in young children and adults. We describe black widow spider exposures and treatment in the pediatric age group, and investigate reasons for not using antivenom in severe cases. METHODS: All black widow exposures reported to the Rocky Mountain Poison Center between January 1, 2012, and December 31, 2015, were reviewed. Demographic data were recorded. Patients were divided into 2 groups. Group 1: contact through families from their place of residence, public schools and/or cases where patients were not referred to healthcare facilities. Group 2: patient contact through healthcare facilities. RESULTS: 93 patients were included. Forty (43%) calls were in Group 1 and 53 (57%) in Group 2. Symptoms were evident in all victims; 43 (46.2%) were grade 1, 16 (17.2%) grade 2 and 34 (36.5%) grade 3, but only 14 patients (41.1%) of this group received antivenom. Antivenom use was associated with improvement of symptoms within minutes, and all treated patients were discharged within hours, without an analgesic requirement or any complications. Reasons for not receiving antivenom included: skin test positive (2/20), strong history of asthma or allergies (2/20), physician preference (2/20), non-availability of the antivenom at the health care facility (14/20). CONCLUSION: In our study, most symptomatic black widow envenomations were minor. Relatively few patients received antivenom, but antivenom use was associated with shorter symptom duration among moderate and major outcome groups.

Japanese scoring systems to predict resistance to intravenous immunoglobulin in Kawasaki disease were unreliable for Caucasian Israeli children.

AIM: This study assessed the validity of using established Japanese risk scoring methods to predict intravenous immunoglobulin (IVIG) resistance to Kawasaki disease in Israeli children. METHODS: We reviewed the medical records of 282 patients (70% male) with Kawasaki disease from six Israeli medical centres between 2004 and 2013. Their mean age was 2.5 years. The risk scores were calculated using the Kobayashi, Sano and Egami scoring methods and analysed to determine whether a higher risk score predicted IVIG resistance in this population. Factors that predicted a lack of response to the initial IVIG dose were identified. RESULTS: We found that 18% did not respond to the first IVIG dose. The three scoring methods were unable to reliably predict IVIG resistance, with sensitivities of 23%-32% and specificities of 67%-87%. Calculating a predictive score that was specific for this population was also unsuccessful. The factors that predicted a lacked of response to the first IVIG dose included low albumin, elevated total bilirubin and ethnicity. CONCLUSION: The established risk scoring methods created for Japanese populations with Kawasaki disease were not suitable for predicting IVIG resistance in Caucasian Israeli children, and we were unable to create a specific scoring method that was able to do this.