A clinical prediction tool to predict urinary tract infection in pediatric febrile patients younger than 2 years old: a retrospective analysis of a fever registry

Objective@#Urinary tract infection (UTI) is a significant issue in young febrile patients due to potential long-term complications. Early detection of UTI is crucial in pediatric emergency departments (PEDs). We developed a tool to predict UTIs in children. @*Methods@#Clinical data of patients <24 months of age with a fever and UTI or viral infection were extracted from the fever registry collected in two PEDs. Stepwise multivariate logistic regression was performed to establish predictors of identified eligible clinical variables for the derivation of the prediction model. @*Results@#A total of 1,351 patients were included in the analysis, 643 patients from A hospital (derivation set) and 708 patients from B hospital (validation set). In the derivation set, there were more girls and a lower incidence of a past history of UTI, older age, less fever without source, and more family members with upper respiratory symptoms in the viral infection group. The stepwise regression analysis identified sex (uncircumcised male), age (≤12 months), a past history of UTI, and family members with upper respiratory symptoms as significant variables. @*Conclusion@#Young febrile patients in the PED were more likely to have UTIs if they were uncircumcised boys, were younger than 12 months of age, had a past history of UTIs, or did not have families with respiratory infections. This clinical prediction model may help determine whether to perform urinalysis in the PED.

Unplanned Revisit to Pediatric Emergency Department: Patients' Characteristics and Relationship with Overcrowding

PURPOSE: Revisit to the pediatric emergency department (ED) in the short-term period may be due to inadequate evaluation during the previous visit, which may indicate a problem with quality in emergency care. The aims of this study are to analyze the characteristics of patients who revisited the pediatric ED within 48 hours after discharge and to evaluate the relation between overcrowding and revisit rates. METHODS: Retrospectively, we reviewed the charts of patients who returned within 48 hours after visiting a PED during a one-year period between June 1st, 2011 and December 31st, 2011. We determined the rate of return visits and review the characteristics of patients, emergency severity index (ESI) level at visits, cause of revisit, diagnosis, and crowding degree of the pediatric ED at the patient's first visit. RESULTS: A total of 16,688 patients visited the pediatric ED and 13,716 patients were discharged from the PED during the period. Of these discharged patients, 534 patients revisited inevitably within 48 hours. The most common cause of revisit was relapse or worsened symptoms (70.0%). There was no significant difference in sex, severity of patient, and crowding degree of the pediatric ED at the first visit, however, patients who revisited were younger than those who did not (p=0.005). The ESI level at the return visit was significantly higher irrespective of admission after revisit (p<0.001). In diagnosis grouping, patients with gastrointestinal diseases, respiratory diseases, and neoplastic diseases showed a higher rate of revisit. CONCLUSION: Approximately 4% of our pediatric ED visits were for children returning within 48 hours. Patients who revisited were younger and patients with gastrointestinal diseases, neoplastic diseases, and respiratory diseases were more likely to revisit. Careful explanation of the possibility of worsened symptoms is necessary for these patients.

The Comparisons of the Management and Pain Control for Appendicitis between Adults and Children in the Emergency Department

PURPOSE: Appendicitis is one of the most common causes of acute abdominal pain presenting to the emergency department (ED). Emergency physicians are responsible for correct diagnosis and management of pain associated with appendicitis before surgery. We analyzed the comparison of management and pain control for appendicitis between adults and children in the ED. METHODS: This study was a retrospective case control study, conducted in two EDs of a teaching hospital from 2011 to 2012. Patients who were diagnosed as appendicitis based on the radiologic modality were enrolled. We analyzed the clinical characteristics of the patients, who were adults and children diagnosed with appendicitis, respectively. We also analyzed the predictors of pain control for the appendicitis patients by multiple logistic regression. RESULTS: A total of 2,130 patients were enrolled during a two-year period. The median age of the patients was 33 years (IQR 19~47) and 22.8% of patients were under 18 years of age; 54.6% were men. Ultrasonography was performed on 10.8% of patients and computed tomography (CT) on 89.4%. Significant difference in overall pain management was observed between children and adults (adult 29.5% vs children 20.6%, p=0.001). Adult patients younger than 65 years old, male, and those who underwent CT scan received more analgesics than others. Significant difference of the type of analgesics was observed between adults patients and pediatric patients. The use of analgesics did not affect the outcome, such as complication, unplanned revisit. CONCLUSION: Both adults and children with acute appendicitis still did not receive enough pain medication in the ED, even after being diagnosed.

Abdominal Radiography for the Evaluation of Acute Fecal Impaction in Children in Pediatric Emergency Department: Comparison of Three Scoring Methods

PURPOSE: The aim of this study is to evaluate suitable tools for an approach to acute fecal impaction by comparison of the Leech, Barr and Blethyn scoring methods in pediatric emergency department (PED). METHODS: Children with diagnosis of fecal impaction were included in this study at PED of Seoul National University Hospital. Of them, 50 children were randomly selected and their radiographs were independently scored on two occasions at two weeks intervals using three scoring methods by nine emergency physicians and one radiologist. Inter-observer and intra-observer agreement were assessed by calculating intra-class correlation coefficient (ICC). Likert scale was used to assess the easiness and effectiveness of Leech, Barr and Blethyn scoring methods. RESULTS: (I) Inter-observer agreement: The ICC values of the Leech, Barr and Blethyn were 0.861, 0.887, and 0.821 at first trial and 0.889, 0.891, and 0.827 at second trial, respectively (p0.8) were 5, 6 and 2 in Leech, Barr and Blethyn, respectively. (III) Easiness and effectiveness: The mean Likert scale of the Leech, Barr and Blethyn in easiness was 4.4, 1.4, and 3.9 and in effectiveness, 3.9, 2.9, and 3.2, respectively; it showed significant differences for both attributes (p<0.001, p=0.03, respectively). In post-hoc test, the Leech was assumed to be easier and more effective than Barr (p<0.001). However, no significant differences in easiness and effectiveness were observed between Leech and Blethyn (p=0.37, p=0.14, respectively). CONCLUSION: The Leech, Barr and Blethyn have all good inter-observer agreement. The Leech has been found to carry better intra-observer agreement than the other two, and may be one of the easiest and most effective tools for the evaluation of acute fecal impaction in children in PED.

External Validation of Prehospital Stroke Screen Scales for EMT: One Center Study

PURPOSE: We evaluated the validity of Cincinnati Prehospital Stroke Scale (CPSS) and the Los Angeles Prehospital Stroke Screen (LAPSS) as prehospital stroke assessment tools for EMT-basics in Korea. METHODS: Patients (age> or =15 years) transported to a regional emergency center by 119 ambulances with one of 4 chiefs (altered mental status, weakness, dizziness, and syncope) were prospectively enrolled in the study during a 12-months period. Independent hospital EMT-basics in the emergency department triaged and recorded the LAPSS and the CPSS finding. On the basis of the final diagnosis by a neurologist, the sensitivity and specificity of the two methods were evaluated for all kinds of stroke and acute stroke within six hours of symptom onset. RESULTS: The study collected data for 653 patients. 47.2% of patients were male, with an average age of 62.2+/-15.3 years old. Their chief complaints were altered mental status (55.4%), weakness (9.3%), dizziness (16.7%), and syncope (18.5%). Of 89 stroke patients, 51.7% were diagnosed with ischemic stroke, 32.6% with hemorrhagic stroke, 15.7% with transient ischemic attack, and 6.9% with acute stroke. For all strokes, sensitivity and specificity of the LAPSS were 21.3% and 95.7%, and those of the CPSS were 44.9% and 80.7%, respectively. For acute stroke, sensitivity and specificity of the LAPSS were 22.2% and 94.6%, and those of the CPSS were 48.9% and 79.1%. CONCLUSION: US prehospital stroke assessment tools had low sensitivity in the hands of Korean EMT-basics in one regional emergency medical center. For improving prehospital diagnosis of stroke in Korean EMS, we should recommend the development of additional assessment tools.