Predicting Delayed Shock in Multisystem Inflammatory Disease in Children: A Multicenter Analysis From the New York City Tri-State Region.

OBJECTIVES: Patients with multisystem inflammatory disease in children (MIS-C) are at risk of developing shock. Our objectives were to determine independent predictors associated with development of delayed shock (≥3 hours from emergency department [ED] arrival) in patients with MIS-C and to derive a model predicting those at low risk for delayed shock. METHODS: We conducted a retrospective cross-sectional study of 22 pediatric EDs in the New York City tri-state area. We included patients meeting World Health Organization criteria for MIS-C and presented April 1 to June 30, 2020. Our main outcomes were to determine the association between clinical and laboratory factors to the development of delayed shock and to derive a laboratory-based prediction model based on identified independent predictors. RESULTS: Of 248 children with MIS-C, 87 (35%) had shock and 58 (66%) had delayed shock. A C-reactive protein (CRP) level greater than 20 mg/dL (adjusted odds ratio [aOR], 5.3; 95% confidence interval [CI], 2.4-12.1), lymphocyte percent less than 11% (aOR, 3.8; 95% CI, 1.7-8.6), and platelet count less than 220,000/uL (aOR, 4.2; 95% CI, 1.8-9.8) were independently associated with delayed shock. A prediction model including a CRP level less than 6 mg/dL, lymphocyte percent more than 20%, and platelet count more than 260,000/uL, categorized patients with MIS-C at low risk of developing delayed shock (sensitivity 93% [95% CI, 66-100], specificity 38% [95% CI, 22-55]). CONCLUSIONS: Serum CRP, lymphocyte percent, and platelet count differentiated children at higher and lower risk for developing delayed shock. Use of these data can stratify the risk of progression to shock in patients with MIS-C, providing situational awareness and helping guide their level of care.

Vaping-Associated Lung Injury During COVID-19 Multisystem Inflammatory Syndrome Outbreak.

BACKGROUND: E-cigarette or vaping product use-associated lung injury (EVALI) is a complex inflammatory syndrome predominantly seen in adolescents and young adults. The clinical and laboratory profile can easily mimic infectious and noninfectious conditions. The exclusion of these conditions is essential to establish the diagnosis. Recently, the novel coronavirus disease 2019 (COVID-19) pandemic introduced the multisystem inflammatory syndrome in children (MIS-C). MIS-C knowledge is evolving. The current criteria to establish the diagnosis are not specific and have overlapping features with EVALI, making the accurate diagnosis a clinical challenge during continued COVID-19 transmission within the community. CASE REPORT: Three young adults evaluated at our emergency department for prolonged fever and gastrointestinal and respiratory symptoms were initially assessed for possible MIS-C due to epidemiologic links to COVID-19 and were eventually diagnosed with EVALI. The clinical, laboratory, and radiologic characteristics of both entities are explored, as well as the appropriate medical management. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Physician awareness of overlapping and differentiating EVALI and MIS-C features is essential to direct appropriate diagnostic evaluation and medical management of adolescents and young adults presenting with systemic inflammatory response during the unfolding pandemic of COVID-19.

The Practice of Obtaining a Chest X-Ray in Pediatric Patients Presenting With Their First Episode of Wheezing in the Emergency Department: A Survey of Attending Physicians.

BACKGROUND: Routine use of chest X-ray (CXR) in pediatric patients presenting with their first episode of wheezing was recommended by many authors. Although recent studies conclude that a CXR is not routinely indicated in these children, there continues to be reports of overuse. OBJECTIVE: To examine the attitudes of practicing physicians in ordering CXRs in pediatric patients presenting with their first episode of wheezing to an emergency department (ED) and the factors that influence this practice by surveying ED physicians. METHODS: A survey targeting pediatric emergency medicine (PEM) and general emergency medicine attending physicians was distributed electronically to the nearly 3000 members of the PEM Brown listserve and the Pediatric Section of American College of Emergency Physicians listserve. The 14-item survey included closed ended and free text questions to assess the respondent's demographic characteristics, their belief and current practice of obtaining a CXR in pediatric patients presenting with their first episode of wheezing. Data were analyzed using descriptive statistics and χ test. RESULTS: Of the 537 attending physicians who participated, their primary residency training was: 42% pediatrics, 54% emergency medicine, and 4% other. Seventy-two percent of participating physicians supervise residents, 54% were board-eligible or -certified in PEM. Thirty percent (95% confidence interval [CI], 26-34) of participants indicated that they would always obtain a CXR in pediatric patients presenting with their first episode of wheezing. Eighty-one percent (95% CI, 75-87) of those who always obtain a CXR believe that it is the standard of care. Of the 376 physicians who do not always obtain a CXR, 18% (95% CI, 15-23) always obtain a CXR under certain age (2 weeks to 12 years, median of 1 year). Physicians who report a primary residency in pediatrics, who supervise residents, who were board-eligible or -certified in PEM, and who were practicing for greater than 5 years were less likely to obtain a CXR (P < 0.001, P < 0.001, P < 0.001, P = 0.001). CONCLUSIONS: In our study, a significant number of practicing ED physicians routinely obtain a CXR in children with their first episode of wheezing presenting to the ED. The factors influencing this practice are primary residency training, fellowship training, resident supervision, and years of independent practice. This identifies a target audience that would benefit from education to decrease the overuse of CXRs in children with wheezing.

Listeria and enterococcal infections in neonates 28 days of age and younger: is empiric parenteral ampicillin still indicated?

INTRODUCTION: Empiric parenteral ampicillin has traditionally been used to treat listeria and enterococcal serious bacterial infections (SBI) in neonates 28 days of age or younger. Anecdotal experience suggests that these infections are rare. Existing data suggest an increasing resistance to ampicillin. Guidelines advocating the routine use of empiric ampicillin may need to be revisited. OBJECTIVE: This study aimed to describe the epidemiology and ampicillin sensitivity of listeria and enterococcal infections in neonates 28 days of age and younger who presented to 2 pediatric emergency departments (ED) in Michigan. METHODS: We conducted a 2-center, retrospective chart review (2006-2010) of neonates 28 days of age or younger who were evaluated for SBI in the ED. We abstracted and compared relevant demographic, historical and physical details, laboratory test results, and antibiotic sensitivity patterns to ampicillin from the eligible patient records. RESULTS: We identified SBI in 6% (72/1192) of neonates 28 days of age or younger who were evaluated for SBI, of which 0.08% (1/1192) neonates had enterococcal bacteremia and 0.08% (1/1192) neonates had listeria bacteremia. A total of 1.4% (15/1192) of patients had enterococcal urinary tract infection (UTI). Urinalysis is less helpful as a screening tool for enterococcal UTI when compared with Escherichia coli UTI (P < 0.001). Seventy-three percent (11/15) of urine isolates had an increase of minimal inhibitory concentrations, which indicate gradual development of resistance to ampicillin. CONCLUSIONS: Listeria is an uncommon cause of neonatal SBI in febrile neonates who presented to the ED. Empiric use of ampicillin may need to be reconsidered if national data confirm very low listeria and enterococcal prevalence and high ampicillin resistance patterns.

The Practice of Obtaining a Chest Radiograph in Pediatric Patients Presenting With Their First Episode of Wheezing: A Survey of Resident Physicians.

A chest radiograph (CXR) is not routinely indicated in children presenting with their first episode of wheezing; however, it continues to be overused. A survey was distributed electronically to determine what trainees are taught and their current practice of obtaining a CXR in children presenting with their first episode of wheezing and the factors that influence this practice. Of the 1513 trainees who completed surveys, 35.3% (535/1513) reported that they were taught that pediatric patients presenting with their first episode of wheezing should be evaluated with a CXR. In all, 22.01% (333/1513) indicated that they would always obtain a CXR in these patients, and 13.75% (208/1513) would always obtain a CXR under a certain age (4 weeks to 12 years, median of 2 years). Our study identifies a target audience that would benefit from education to decrease the overuse of CXRs in children.

A Case Series of SARS-CoV-2 RT-PCR-Positive Hospitalized Infants 60 Days of Age or Younger From 2 New York City Pediatric Emergency Departments.

The emergence of novel coronavirus disease-2019 poses an unprecedented challenge to pediatricians. While the majority of children experience mild disease, initial case reports on young infants are conflicting. We present a case series of 8 hospitalized infants 60 days of age or younger with coronavirus disease-2019. A quarter of these patients had coinfections (viral or bacterial). None of these infants had severe disease. Continued vigilance in testing this vulnerable group of infants is warranted.

Parental Coronavirus Disease 2019 Testing of Hospitalized Children: Rethinking Infection Control in a Pandemic.

BACKGROUND: Novel coronavirus disease 2019 (COVID-19) poses a challenge to infection control within hospital systems. Asymptomatic children and their caretakers carry the risk of silently spreading infection in pediatric emergency departments and hospital units. Our current knowledge is evolving, and infection control measures are frequently changing depending on new emerging data. METHODS: We conducted a point-prevalence study to assess SARS-CoV-2 Real-Time Polymerase Chain Reaction (SARS-CoV-2 RT-PCR) results of hospitalized children, their asymptomatic caretakers, and caretaker-child test concordance at a major community hospital in New York City. We screened Children and caretakers with temperature measurements and the presence of COVID-19 symptoms before pediatric emergency department evaluation. Children requiring hospitalization and their caretakers had nasopharyngeal swabs for SARS-CoV-2 RT-PCR. The paired results are used to identify the infection control level at the appropriate pediatric unit. RESULTS: Forty consecutive asymptomatic caretaker-child pairs had SARS-CoV-2 RT-PCR testing between May 28th to June 22nd, 2020. The rate of asymptomatic COVID-19 was 2.5% in hospitalized children and 7.5% in caretakers. The caretaker-child SARS-CoV-2 RT-PCR test concordance was evident in 95% of the cohort. CONCLUSION: This cohort had a low asymptomatic SARS-CoV-2 PCR positive rate in children and their caretakers with a high concordance rate of paired test results. It suggests that children's SARS-CoV-2 PCR test result will likely correspond to their accompanying caretaker at healthcare facilities where admission screening is performed.

The 2015 Academic College of Emergency Experts in Indias INDO-US Joint Working Group White Paper on Establishing an Academic Department and Training Pediatric Emergency Medicine Specialists in India.

The concept of pediatric emergency medicine (PEM) is virtually nonexistent in India. Suboptimally organized prehospital services substantially hinder the evaluation, management, and subsequent transport of the acutely ill and/or injured child to an appropriate facility. Furthermore, the management of the ill child at the hospital level is often provided by overburdened providers who, by virtue of their training, lack experience in the skills required to effectively manage pediatric emergencies. Finally, the care of the traumatized child often requires the involvement of providers trained in different specialities, which further impedes timely access to appropriate care. The recent recognition of Doctor of Medicine in Emergency Medicine as an approved discipline of study as per the Indian Medical Council Act provides an unprecedented opportunity to introduce PEM as a formal academic program in India. PEM has to be developed as a 3 year superspeciality course after completion of MD Diplomate of National Board (DNB) Pediatrics or MD DNB in EM. The National Board of Examinations that accredits and administers postgraduate and postdoctoral programs in India also needs to develop an academic program DNB in PEM. The goals of such a program would be to impart theoretical knowledge, training in the appropriate skills and procedures, development of communication and counseling techniques, and research. In this paper, the Joint Working Group of the Academic College of Emergency Experts in India (JWG ACEE India) gives its recommendations for starting 3 year DM DNB in PEM, including the curriculum, infrastructure, staffing, and training in India. This is an attempt to provide an uniform framework and a set of guiding principles to start PEM as a structured superspeciality to enhance emergency care for Indian children.

The 2015 Academic College of Emergency Experts in India's INDO-US Joint Working Group White Paper on Establishing an Academic Department and Training Pediatric Emergency Medicine Specialists in India.

The concept of pediatric emergency medicine (PEM) is virtually nonexistent in India. Suboptimally, organized prehospital services substantially hinder the evaluation, management, and subsequent transport of the acutely ill and/or injured child to an appropriate facility. Furthermore, the management of the ill child at the hospital level is often provided by overburdened providers who, by virtue of their training, lack experience in the skills required to effectively manage pediatric emergencies. Finally, the care of the traumatized child often requires the involvement of providers trained in different specialities, which further impedes timely access to appropriate care. The recent recognition of Doctor of Medicine (MD) in Emergency Medicine (EM) as an approved discipline of study as per the Indian Medical Council Act provides an unprecedented opportunity to introduce PEM as a formal academic program in India. PEM has to be developed as a 3-year superspeciality course (in PEM) after completion of MD/Diplomate of National Board (DNB) Pediatrics or MD/DNB in EM. The National Board of Examinations (NBE) that accredits and administers postgraduate and postdoctoral programs in India also needs to develop an academic program - DNB in PEM. The goals of such a program would be to impart theoretical knowledge, training in the appropriate skills and procedures, development of communication and counseling techniques, and research. In this paper, the Joint Working Group of the Academic College of Emergency Experts in India (JWG-ACEE-India) gives its recommendations for starting 3-year DM/DNB in PEM, including the curriculum, infrastructure, staffing, and training in India. This is an attempt to provide an uniform framework and a set of guiding principles to start PEM as a structured superspeciality to enhance emergency care for Indian children.

Cerebral venous sinus thrombosis with ophthalmic manifestations in 18-year-olds on oral contraceptives.

Cerebral venous sinus thrombosis (CVST) is a rare and potentially life-threatening cause of stroke. In the past few decades, the incidence and patient demographics have changed because of many factors, including the widespread use of oral contraceptives, improved detection of prothrombotic conditions, and advancement of imaging technology. The presentation of CVST is varied and can include ocular signs and symptoms. We present 2 cases of oral contraceptive-induced CVST in 18-year-old women, whose main presenting findings were ophthalmologic.