A smoking cessation intervention for low-income smokers in the ED.

BACKGROUND: There is a high prevalence of smoking among caregivers who bring their children to the pediatric emergency department (PED) and even higher rates of tobacco smoke exposure (TSE) and related morbidity among their children. The PED visit presents an opportunity to intervene with caregivers, but it is unknown whether they are more likely to quit if their child has a TSE-related illness. We sought to examine a PED-based smoking cessation intervention and compare outcomes based on children's TSE-related illness. METHODS: A single-arm, prospective trial, with baseline, 3, and 6 month assessments was used in this study. Caregivers whose child had either a TSE-related (n=100) or non-TSE-related illness (n=100) were given a brief intervention consisting of counseling, referral to the Quitline, and free nicotine replacement therapy. RESULTS: Participants were 91.5% female, 50.5% African American, 100% Medicaid recipients, 30.8 years old, child age mean of 5.5 years, 90% highly nicotine dependent, and 60.3% and 75.8% allowed smoking in the home and car, respectively. At follow-up (65% retention), 80% reported quit attempts at 3 months and 89% between 3 and 6 months. There were significant decreases in number of cigarettes smoked, time to first cigarette, and smoking in the home and car. Quit rates were 12.2% at 3 months, 14.6% at 6 months, and 7.3% at both time points (50% biochemically confirmed). There were no significant differences in outcomes based on children's illness. CONCLUSIONS: A brief PED-based smoking cessation intervention resulted in quit attempts and successful quits. However, the presence of a TSE-related illness did not result in different cessation outcomes.

Factors associated with participation in research conducted in a pediatric emergency department.

OBJECTIVE: To examine the association of demographic and study characteristics in eligible subjects who agree to participate compared with those who did not participate in clinical research studies in a pediatric emergency department (PED). METHODS: Information for all families approached for participation in PED-based clinical research studies during a 6-year period was recorded in an electronic database. This included demographic factors, decision to participate, primary reason for not participating, and study characteristics. Forty studies were included in this analysis. Differences in participation rate among demographic and study characteristics were examined. Multivariable logistic regression was used to predict the likelihood of participation. RESULTS: Participation rates were similar with respect to sex (50.1% in male vs 49.9% in female), whereas families with younger children were more likely to participate (mean age, 8.5 years vs 10.2 years among nonparticipants P < 0.001). White patients were more likely to participate than African American patients (54.7% vs 45.6% in African Americans, P < 0.001). The presence of compensation, brief time requirement, and older children was negatively associated with participation for moderate to very invasive studies. However, for noninvasive and mildly invasive studies, the presence of compensation and the time required were not associated with participation. CONCLUSIONS: Study characteristics including invasiveness, time required of patients, and whether compensation is offered, along with demographic factors, influence participation in clinical studies conducted in the PED. When designing a research study in the PED, these, along with novel approaches to including all races and ethnicities in PED research, should be considered.

Can Computerized Neuropsychological Testing in the Emergency Department Predict Recovery for Young Athletes With Concussions?

OBJECTIVE: The objective of this study was to determine if computerized neurocognitive testing (Immediate Post-Concussion Assessment and Cognitive Testing [ImPACT]) in the emergency department (ED) can be used as a prognostic tool to detect young athletes at risk of having protracted concussive symptoms. METHODS: This was a prospective cohort study of athletes aged 11 to 18 years who presented to an ED less than 24 hours after sustaining a sports-related concussion. ImPACT was administered in the ED, and performance was categorized as "poor" if the athlete had 3 (of 4) or greater low domain scores. Participants completed the Post-Concussion Symptom Scale (PCSS) in the ED and by phone at 1 and 2 weeks after injury. Athletes were symptomatic if their PCSS score was more than 6 in males and more than 8 in females. RESULTS: One hundred nine patients were enrolled; 60% and 36% remained symptomatic at 1 and 2 weeks after injury, respectively. "Poor" ImPACT performance was not particularly useful in predicting athletes with protracted symptoms (at 1 week: positive predictive value, 70.8%; negative predictive value, 43.5%; at 2 weeks: positive predictive value, 47.8%; negative predictive value, 68.9%). In bivariate analysis, a higher ED PCSS score was associated with protracted symptoms (at 1 week: odds ratio, 1.1 [confidence interval, 1.0-1.1]; at 2 weeks: odds ratio, 1.0 [confidence interval, 1.0-1.1]). CONCLUSIONS: Computerized neurocognitive testing in the ED has limited usefulness in predicting protracted symptoms. Total acute symptom burden may be a useful prognostic tool in the ED evaluation of concussed young athletes, yet further research is necessary.

Variation in suicide occurrence by day and during major American holidays.

BACKGROUND: Due to temporal variations in completed suicides, it has been suggested that impulsivity and environmental factors may influence suicide. STUDY OBJECTIVE: Our intent was to determine if particular days of the week, seasons, or holidays were associated with increased attempted and completed suicides by poisoning. METHODS: All calls recorded in the National Poison Database System coded as "suspected suicide" from 2006 through 2010 were included. Exposures were evaluated by day, season, and holidays, and compared to control dates. RESULTS: There were 1,065,067 exposures (63% female) related to suicide attempts, with completions in 0.4% of cases. Sundays and Mondays for adults, and Mondays and Tuesdays for age < 19 years were the most common. Spring and fall had higher numbers of exposures than summer and winter. New Year's Day had a higher number of exposures, whereas Independence Day, Thanksgiving, and Christmas had fewer exposures. CONCLUSIONS: The beginning of the week, spring and fall, and New Year's Day were associated with higher numbers of ingestions with suicidal intent. This has implications for clinicians advising potential victims and providing emergency care for these patients.

The contribution of housing renovation to children's blood lead levels: a cohort study.

BACKGROUND: Routine renovation of older housing is a risk factor for childhood lead poisoning, but the contribution to children's blood lead levels is poorly defined for children with lower exposure levels. METHODS: We examined a prospective cohort of 276 children followed from 6 to 24 months of age. We conducted surveys of renovation activities and residential lead hazards and obtained blood lead level (B-Pb) every six months. We analyzed B-Pb in a repeated measures design using a mixed effects linear model. RESULTS: Parent reported interior renovation ranged from 11 to 25% of housing units at the four, 6-month periods. In multivariable analysis, children whose housing underwent interior renovation had a 12% higher mean B-Pb by two years of age compared with children whose housing units were not renovated (p < 0.01). The time between renovation and the child blood lead sample was associated with higher B-Pb (p-value for trend <0.01); compared to children in non-renovated housing, children whose housing units underwent renovation in the prior month had a 17% higher mean B-Pb at two years of age, whereas children whose housing renovation occurred in the prior 2-6 months had an 8% higher mean B-Pb. We also found an association between higher paint lead loading, measured using an X-ray fluorescence (XRF) based paint lead index, and child B-Pb (p = 0.02); for every 10 mg/cm2 increase in paint lead loading index there was a 7.5% higher mean childhood B-Pb. CONCLUSIONS: In an analysis of data collected before the recent changes to Environmental Protection Agency's Lead, Renovation, Repair and Painting Rule, routine interior housing renovation was associated with a modest increase in children's B-Pb. These results are important for the provision of clinical advice, for housing and public health professionals, and for policymakers.

Maternal somatic symptoms, psychosocial correlates, and subsequent pediatric emergency department use.

BACKGROUND: Somatization is associated with increased health care use in adults. Whether mothers with somatic symptoms use more health care resources for their children has not been investigated. OBJECTIVE: This study aimed to explore the association of maternal somatic symptoms and emergency department (ED) use. DESIGN/METHODS: Mothers from a cohort of 319 mother-child dyads were screened for somatic symptoms using the Patient Health Questionnaire 15. Dyads were followed up for 3 years after the initial ED visit to record ED use. The outcome variable was ED use (lower ED use, 0-3 visits, higher ED use, 4+ visits). The primary independent variable was somatization, with a dichotomous variable analyzing the Patient Health Questionnaire 15 symptom count of less than 7 symptoms (lower somatization) and 7 or more symptoms (higher somatization [HISOM]). Secondary independent variables included demographic data, maternal major depression, and maternal difficulty in taking care of the child or themselves. Statistical analysis included bivariate and multivariate analyses. RESULTS: Mothers with HISOM symptoms did not demonstrate an increased use of the ED in bivariate analysis. Higher somatization mothers did show an increased (1) endorsement of maternal major depression symptoms and (2) maternal perception of difficulty in taking care of the child and themselves. When adjusted for these and other covariates, HISOM mothers were more likely to be in the higher ED use group (1.83; 95% confidence interval, 0.99-3.38) P = 0.055). CONCLUSIONS: Mothers with higher somatic symptom loads were more likely to screen positive for depression and to report difficulty caring for their child and for themselves. A trend toward higher use of the pediatric ED warrants further study.

Inability of S100B to predict postconcussion syndrome in children who present to the emergency department with mild traumatic brain injury: a brief report.

OBJECTIVE: This study aimed to explore the ability of the serum marker S100B to predict the development and severity of postconcussion syndrome (PCS) at 3 months in children after mild traumatic brain injury (mTBI). METHODS: This is a retrospective analysis of a prospective observational study conducted in a pediatric emergency department (ED). Children were eligible for the study if they were between the ages 5 and 18 years, presented within 6 hours of injury, met the case definition of mTBI from American Congress of Rehabilitation Medicine, had a Glasgow Coma Scale score of greater than 13, consented to have blood drawn for S100B levels, and completed the 3-month telephone follow-up. At the follow-up, the Rivermead Postconcussion Questionnaire was conducted to determine the development and severity of PCS. RESULTS: A total of 76 children were included in this cohort. The children had a mean (SD) age of 14.0 (3.1) years, 60.5% were male, and 89.5% had a Glasgow Coma Scale of 15. Twenty-eight (36.8%) developed PCS. For the children who developed PCS, the mean (SD) S100B level was 0.092 (0.376) µg/L. For children who did not develop PCS (n = 48), the mean (SD) S100B level was 0.022 (0.031) µg/L. The analyses did not support an association between initial S100B levels measured in the ED and development of PCS or severity of PCS symptoms. CONCLUSIONS: In this small sample, S100B, measured immediately after injury in the ED, did not seem to predict those children with mTBI who will go on to develop PCS.

The growing impact of pediatric pharmaceutical poisoning.

OBJECTIVE: To understand which medications, under which circumstances, are responsible for the noted increase in pediatric medication poisonings, resource use, and morbidity. STUDY DESIGN: Patient records from 2001-2008 were obtained from the National Poison Data System of the American Association of Poison Control Centers for children aged ≤5 years evaluated in a health care facility following exposure to a potentially toxic dose of a pharmaceutical agent. Pharmaceutical agents were classified as over-the-counter or prescription and by functional category. Exposures were classified as child self-ingested the medication or as therapeutic error. For the 8-year period, emergency visits, admissions, significant injuries, and trends in these events were calculated for each substance category. RESULTS: We evaluated 453 559 children for ingestion of a single pharmaceutical product. Child self-exposure was responsible for 95% of visits. Child self-exposure to prescription products dominated the health care impact with 248 023 of the visits (55%), 41 847 admissions (76%), and 18 191 significant injuries (71%). The greatest resource use and morbidity followed self-ingestion of prescription products, particularly opioids, sedative-hypnotics, and cardiovascular agents. CONCLUSIONS: Prevention efforts have proved to be inadequate in the face of rising availability of prescription medications, particularly more dangerous medications.

The acceptability of mental health screening in a pediatric emergency department.

OBJECTIVES: The purposes of the study were (1) to assess the acceptability of mental health screening in the pediatric emergency department (ED) for children and their parents; (2) to measure providers' perceptions on whether screening has an impact on patient care; and (3) to determine the impact of screening status on acceptability. METHODS: A validated pediatric mental health screening instrument was administered to 384 parent-child dyads. A 6-item satisfaction questionnaire was administered by a trained research coordinator to assess parent-child reactions to the screen. Emergency department providers rated how difficult the screening made it for them to care for the patient. Research staff reported the difficulty of conducting screening during the ED visit and the amount of time parents/children spent completing the screen. RESULTS: Most parents (82%) and children (75%) felt the screening was acceptable. Parent reports of pediatric mental health problems were not associated with lower acceptability scores. The number of mental health problems reported by a child was associated with an increased likelihood that the screening made the child upset (P = 0.02). Parents who reported pediatric mental health problems were more likely to find the screening helpful (odds ratio,1.84 [95% confidence interval, 1.15-2.93]), with black parents more likely to report that the screen was helpful (odds ratio, 2.5 [95% confidence interval, 1.43-4.33]). Nearly all doctors (99%) and nurses (97%) reported that the screening did not make it difficult for them to care for the patient. CONCLUSIONS: Overall, mental health screening appears to be acceptable in the pediatric ED.

Association of prenatal and childhood blood lead concentrations with criminal arrests in early adulthood.

BACKGROUND: Childhood lead exposure is a purported risk factor for antisocial behavior, but prior studies either relied on indirect measures of exposure or did not follow participants into adulthood to examine the relationship between lead exposure and criminal activity in young adults. The objective of this study was to determine if prenatal and childhood blood lead concentrations are associated with arrests for criminal offenses. METHODS AND FINDINGS: Pregnant women were recruited from four prenatal clinics in Cincinnati, Ohio if they resided in areas of the city with a high concentration of older, lead-contaminated housing. We studied 250 individuals, 19 to 24 y of age, out of 376 children who were recruited at birth between 1979 and 1984. Prenatal maternal blood lead concentrations were measured during the first or early second trimester of pregnancy. Childhood blood lead concentrations were measured on a quarterly and biannual basis through 6.5 y. Study participants were examined at an inner-city pediatric clinic and the Cincinnati Children's Hospital Medical Center in Cincinnati, Ohio. Total arrests and arrests for offenses involving violence were collected from official Hamilton County, Ohio criminal justice records. Main outcomes were the covariate-adjusted rate ratios (RR) for total arrests and arrests for violent crimes associated with each 5 microg/dl (0.24 micromol/l) increase in blood lead concentration. Adjusted total arrest rates were greater for each 5 microg/dl (0.24 micromol/l) increase in blood lead concentration: RR = 1.40 (95% confidence interval [CI] 1.07-1.85) for prenatal blood lead, 1.07 (95% CI 0.88-1.29) for average childhood blood lead, and 1.27 (95% CI 1.03-1.57) for 6-year blood lead. Adjusted arrest rates for violent crimes were also greater for each 5 microg/dl increase in blood lead: RR = 1.34 (95% CI 0.88-2.03) for prenatal blood lead, 1.30 (95% CI 1.03-1.64) for average childhood blood lead, and 1.48 (95% CI 1.15-1.89) for 6-year blood lead. CONCLUSIONS: Prenatal and postnatal blood lead concentrations are associated with higher rates of total arrests and/or arrests for offenses involving violence. This is the first prospective study to demonstrate an association between developmental exposure to lead and adult criminal behavior.

Pediatric emergency department overcrowding and impact on patient flow outcomes.

BACKGROUND: Understanding the impact of overcrowding in pediatric emergency departments (PEDs) on quality of care is a growing concern. Boarding admitted patients in the PED and increasing emergency department (ED) visits are two potentially significant factors affecting quality of care. OBJECTIVES: The objective was to describe the impact ED boarding time and daily census have on the timeliness of care in a PED. METHODS: Pediatric ED boarding time and daily census were determined each day from July 2003 to July 2007. Outcome measures included mean length of stay (LOS), time to triage, time to physician, and patient elopement during a 24-hour period. RESULTS: For every 50 patients seen above the average daily volume of 250, LOS increased 14.8 minutes, time to triage increased 6.6 minutes, time to physician increased 18.2 minutes, and number of patient elopements increased by three. For each increment of 24 hours to total ED boarding time, LOS increased 7.6 minutes, time to triage increased 0.6 minutes, time to physician increased 3 minutes, and number of patient elopements increased by 0.6 patients. CONCLUSIONS: ED boarding time and ED daily census show independent associations with increasing overall LOS, time to triage, time to physician, and number of patient elopements in a PED.

Mental health problems in children and caregivers in the emergency department setting.

INTRODUCTION: Although mental health problems are increasing in the primary care sector, the prevalence of mental health problems in families presenting for nonpsychiatric complaints in the emergency department (ED) setting is generally unknown. As such, we set out to assess the frequency of mental health concerns and associated risk factors in children presenting for care in a pediatric ED. METHODS: A total of 411 mother-child dyads were randomly selected during a 2-year period from the less acute area of a large pediatric ED. Mothers were interviewed for child mental health concerns using structured diagnostic instruments. Mothers were also interviewed for their own mental health symptoms. Risk factor analysis for the outcome of a pediatric mental health concern was performed using bivariate and multivariate techniques. RESULTS: Of all children, 45% met criteria for a mental health concern, with 23% of all children meeting criteria for two or more mental health concerns; 21% of mothers screened positive for a mental health problem themselves. Once adjusted, children whose mothers' screened positive for a mental illness were more likely to have a mental health concern themselves. CONCLUSION: There is a large burden of mental health concerns in children and their mothers presenting to the ED for medical care. Efficiently and accurately identifying mental illness in children presenting to a pediatric ED is the first step in the intervention process for a population that might otherwise slip through the system.

Studying the Safety and Performance of Rapid Sequence Intubation: Data Collection Method Matters.

OBJECTIVE: We sought to describe and compare chart and video review as data collection sources for the study of emergency department (ED) rapid sequence intubation (RSI). METHODS: This retrospective cohort study compares the availability and content of key RSI outcome and process data from two sources: chart and video data from 12 months of pediatric ED RSI. Key outcomes included adverse effects (oxyhemoglobin desaturation, physiologic changes, inadequate paralysis, vomiting), process components (number of laryngoscopy attempts, end-tidal CO2 detection), and timing data (duration of preoxygenation and laryngoscopy attempts). RESULTS: We reviewed 566 documents from 114 cases with video data. Video review detected higher rates of adverse effects (67%) than did chart review (46%, p < 0.0001), identifying almost twice the rate of desaturation noted in the chart (34% vs. 18%, p = 0.0002). The performance and timing of key RSI processes were significantly more reliably available via video review (timing and duration of preoxygenation, as well as timing, duration, and number of laryngoscopy attempts, all p < 0.05). Video review identified 221 laryngoscopy attempts, whereas chart review only identified 187. CONCLUSIONS: When compared with video review for retrospective study of RSI in a pediatric ED, chart review significantly underestimated adverse effects, inconsistently contained data on important RSI process elements, rarely provided time data, and often conflicted with observations made on video review. Interpretation of and design of future studies of RSI should take into consideration the quality of the data source.

Are internal medicine residency programs adequately preparing physicians to care for the baby boomers? A national survey from the Association of Directors of Geriatric Academic Programs Status of Geriatrics Workforce Study.

Patients aged 65 and older account for 39% of ambulatory visits to internal medicine physicians. This article describes the progress made in training internal medicine residents to care for older Americans. Program directors in internal medicine residency programs accredited by the Accreditation Council for Graduate Medical Education were surveyed in the spring of 2005. Findings from this survey were compared with those from a similar 2002 survey to determine whether any changes had occurred. A 60% response rate was achieved (n=235). In these 3-year residency training programs, 20 programs (9%) required less than 2 weeks of clinical instruction that was specifically structured to teach geriatric care principles, 48 (21%) at least 2 weeks but less than 4 weeks, 144 (62%) at least 4 weeks but less than 6 weeks, and 21 (9%) required 6 or more weeks. As in 2002, internal medicine residency programs continue to depend on nursing home facilities, geriatric preceptors in nongeriatric clinical ambulatory settings, and outpatient geriatric assessment centers for their geriatrics training. Training was most often offered in a block format. The mean number of physician faculty per residency program dedicated to teaching geriatric medicine was 3.5 full-time equivalents (FTEs) (range 0-50), compared with a mean of 2.2 FTE faculty in 2002 (P

Religion, spirituality, and depressive symptoms in patients with HIV/AIDS.

BACKGROUND: Depression has been linked to immune function and mortality in patients with chronic illnesses. Factors such as poorer spiritual well-being has been linked to increased risk for depression and other mood disorders in patients with HIV. OBJECTIVE: We sought to determine how specific dimensions of religion, spirituality, and other factors relate to depressive symptoms in a contemporary, multi-center cohort of patients with HIV/AIDS. DESIGN: Patients were recruited from 4 medical centers in 3 cities in 2002 to 2003, and trained interviewers administered the questionnaires. The level of depressive symptoms was measured with the 10-item Center for Epidemiologic Studies Depression (CESD-10) Scale. Independent variables included socio-demographics, clinical information, 8 dimensions of health status and concerns, symptoms, social support, risk attitudes, self-esteem, spirituality, religious affiliation, religiosity, and religious coping. We examined the bivariate and multivariable associations of religiosity, spirituality, and depressive symptoms. MEASUREMENTS AND MAIN RESULTS: We collected data from 450 subjects. Their mean (SD) age was 43.8 (8.4) years; 387 (86.0%) were male; 204 (45.3%) were white; and their mean CD4 count was 420.5 (301.0). Two hundred forty-one (53.6%) fit the criteria for significant depressive symptoms (CESD-10 score > or = 10). In multivariable analyses, having greater health worries, less comfort with how one contracted HIV, more HIV-related symptoms, less social support, and lower spiritual well-being was associated with significant depressive symptoms (P<.05). CONCLUSION: A majority of patients with HIV reported having significant depressive symptoms. Poorer health status and perceptions, less social support, and lower spiritual well-being were related to significant depressive symptoms, while personal religiosity and having a religious affiliation was not associated when controlling for other factors. Helping to address the spiritual needs of patients in the medical or community setting may be one way to decrease depressive symptoms in patients with HIV/AIDS.

Implementing duty-hour restrictions without diminishing patient care or education: can it be done?

PURPOSE: To implement and evaluate a new ward team call system that would meet the Accreditation Council on Graduate Medical Education's (ACGME) duty-hour requirements without compromising patient care or detracting from resident education. METHOD: The new system was implemented in the internal medicine residency program at the University Hospital at the University of Cincinnati Medical Center. In 2003-04, residents and faculty were surveyed about their experiences with the new and old ward systems relative to duty-hour requirements, patient care, and resident education. Responses were given on a five-point scale (5 = strongly agree, 1 = strongly disagree). Data were compiled and compared using a two-sample t-test. RESULTS: Faculty believed the new system improved compliance with the duty-hour requirements (mean = 4.3, 95% confidence interval [CI]: 4.1-4.6), although were neutral regarding patient care (mean = 3.5, 95% CI: 3.2-3.8) and education (mean = 3.3, 95% CI: 2.9-3.6). Residents were more neutral regarding ACGME requirements (mean = 3.5, 95% CI: 3.3-3.7) and patient care (mean = 3.2, 95% CI 3.0-3.3). Residents reported a slightly negative impact on education (mean = 2.8, 95% CI: 2.5-3.0). In response to an exclusive question, residents reported that the new system did not reduce fatigue (mean = 2.7, 95% CI: 2.6-3.0). CONCLUSIONS: Respondents perceived that this ward call system met ACGME requirements and maintained quality patient care but may have sacrificed some traditional resident education tenets.

A national survey of family medicine residency education in geriatric medicine: comparing findings in 2004 to 2001.

BACKGROUND AND OBJECTIVES: We compared findings from this 2004 survey with our 2001 survey to determine progress in family medicine residency programs' efforts to better train residents to care for America's aging population. METHODS: A survey was mailed and made available on-line to all 470 family medicine residency directors in the United States. RESULTS: The response rate was 71%. Ninety-six percent of family medicine residencies have a required geriatrics curriculum, compared to 92% in 2001. There was a significant increase in the number of required lecture hours in geriatrics in 2004 as compared to 2001. Since 2001, the median number of MD geriatrics faculty per program has nearly doubled from .5 full-time equivalent (FTE) to .9 FTE. Conflicting time demands with other curricula was ranked as the most significant barrier to geriatrics education in both 2004 and 2001. However, in 2001, the attitude of residents was listed as a significant barrier by 32.1% of the program directors as compared to just 3.6% in 2004. CONCLUSIONS: Family medicine educators are continuing to improve the training of residents to provide state-of-the-art care for the aging population. Faculty must take advantage of this period of experimentation in residency education to identify best practices for geriatrics education.

Prediction of Persistent Postconcussion Symptoms in Youth Using a Neuroimaging Decision Rule.

OBJECTIVE: To evaluate the ability of risk strata generated by a neuroimaging rule, developed to assess risk of clinically important traumatic brain injury (ciTBI), to predict postconcussive symptoms in youth with an acute mild traumatic brain injury. METHODS: We performed a prospective cohort study of youth aged 5 to 17 years presenting to an emergency department (ED) within 24 hours of mild traumatic brain injury. Risk strata (very low, intermediate, and at risk) of ciTBI were determined in ED by criteria set forth by the neuroimaging rule. Postconcussive symptoms were assessed using the Health and Behavior Inventory (HBI) in the ED and at 1, 2, and 4 weeks after injury. General linear models were used to examine the relationship between the HBI score at 1 week and risk strata. Repeated measures analysis was used to measure change in HBI over time. RESULTS: Of the 120 participants, 46 were categorized by the Pediatric Emergency Care Applied Research Network (PECARN) rule as very low risk, 39 as intermediate risk, and 35 as at risk for ciTBI. Adjusted mean HBI scores (95% confidence intervals) at 1 week were 18.0 (13.9, 22.2) for at risk, 13.8 (9.9, 17.6) for intermediate risk, and 17.1 (13.4, 20.8) for very low risk. Risk strata were not significantly associated with the adjusted HBI score at 1 week (P = .17). While adjusted HBI scores declined significantly over time (P < .0001), the trajectories of the HBI score over time did not differ significantly by risk strata (P = .68). CONCLUSIONS: Risk of ciTBI as determined by factors within a neuroimaging rule alone is insufficient to predict children with persistent postconcussive symptoms.

Utility of Pediatric Appendicitis Score in Female Adolescent Patients.

OBJECTIVES: Acute appendicitis is common in the pediatric population and is difficult to diagnose in adolescent females. The validated Pediatric Appendicitis Score (PAS) has unclear utility in female adolescents. The purpose of this study is to determine the sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of the PAS for female adolescents compared to all other patients. METHODS: This study examined a retrospective observational cohort of patients ages 3 to 21 years in a pediatric emergency department with prospectively assigned PAS from an existing database. We compared the sensitivity, specificity, PPV, and NPV of the PAS for acute appendicitis among female adolescent patients (13 to 21 years) and all other patients. RESULTS: Of the 1,228 patients enrolled, 901 (73.4%) had a complete PAS. Among the 901 patients, 249 (27.6%) had pathology-proven appendicitis, 494 (54.8%) were female, and 272 (30.2%) were adolescent females. At a cutoff of ≥8, the PAS showed a specificity of 89% for adolescent females and 78% for all other patients (p < 0.001), although the specificities did not differ at a cutoff of ≥7. At both cutoffs, the PPVs were poor in both groups. At a cutoff of ≥3, the PAS showed similar sensitivities in both groups. At a cutoff of <3, the NPVs did not significantly differ between groups. CONCLUSION: At a cutoff of ≥8 (although not ≥7), the PAS demonstrated a higher specificity among female adolescents compared to all other patients. The PPV for both cutoffs in both groups were poor. At a cutoff of ≥3, sensitivities were equivalent. The NPV for a cutoff of <3 was acceptable but similar in both groups. While sensitivities were similar to previously reported, specificities in both groups were lower. This highlights the need for further investigation of the PAS's performance in specific subpopulations.

Risk Stratification to Decrease Unnecessary Diagnostic Imaging for Acute Appendicitis.

BACKGROUND: There has been an increase in the use of imaging modalities to diagnose appendicitis despite evidence that can help identify children at especially high or low risk of appendicitis who may not benefit. We hypothesized that the passive diffusion of a standardized care pathway (including diagnostic imaging recommendations) would improve the diagnostic workup of appendicitis by safely decreasing the use of unnecessary imaging when compared with historical controls and that an electronic, real-time decision support tool would decrease unnecessary imaging. METHODS: We used an interrupted time series trial to compare proportions of patients who underwent diagnostic imaging (computed tomography [CT] and ultrasound) between 3 time periods: baseline historical controls, after passive diffusion of a diagnostic workup clinical pathway, and after introduction of an electronic medical record-embedded clinical decision support tool that provides point-of-care imaging recommendations (active intervention). RESULTS: The moderate- and high-risk groups showed lower proportions of CT in the passive and active intervention time periods compared with the historical control group. Proportions of patients undergoing ultrasound in all 3 risk groups showed an increase from the historical baseline. Time series analysis confirmed that time trends within any individual time period were not significant; thus, incidental secular trends over time did not appear to explain the decreased use of CT. CONCLUSIONS: Passive and active decision support tools minimized unnecessary CT imaging; long-term effects remain an important area of study.