Suicide attempt management among Turkish and American adolescents: A comparison of two pediatric emergency departments.

Background/aim: Suicide is one of the leading causes of death among adolescents. This study aimed to compare the characteristics and short-term outcomes of Turkish and American adolescents with suicide attempts and determine the differences in management and resource utilization between two pediatric emergency departments; one in Türkiye and one in the United States of America. Materials and methods: Adolescents who presented to the emergency departments with a chief complaint of suicide attempt between October 2017 and September 2018 were eligible for including in the study. Characteristics and other information of 217 (131 American and 86 Turkish) suicide attempter adolescents were retrieved from medical records. Outcome was defined as re-admission to the emergency department for another suicide attempt within 3 months of the index visit. Results: Overall, 78% of adolescents were female. Abuse history (physical/sexual) was more common among American adolescents (p = 0.005), whereas uncontrolled psychiatric diseases were more evident in Turkish cases (p < 0.001). Social worker assessment and hospitalization rates were significantly lower, with shorter mean duration of follow-up in the emergency department among Turkish compared to American adolescents (respectively, p < 0.001, p < 0.001 and p = 0.002). Repeated suicide attempts within three months were significantly higher in the Turkish group compared to the American one (29% vs. 8%, p < 0.001). Receiving a social worker assessment, hospitalization and longer observation in emergency department reduced the incidence of repeated suicide attempts (respectively, p < 0.001, p = 0.003 and p = 0.012). Conclusion: Turkish adolescents had shorter observation time in the emergency department, received fewer assessment by social workers and were less likely to be hospitalized. These may have contributed to the higher rate of repeat suicide attempts following discharge from the emergency department. Adequate resources are needed to help decrease the burden of suicide among Turkish adolescents.

Association of Pyuria with Uropathogens in Young Children.

OBJECTIVE: To examine the association between uropathogens and pyuria in children <24 months of age. STUDY DESIGN: A retrospective study of children <24 months of age evaluated in the emergency department for suspected urinary tract infection (UTI) with paired urinalysis and urine culture during a 6-year period. Bagged urine specimens or urine culture growing mixed/multiple urogenital organisms were excluded. Analysis was limited to children with positive urine culture as defined by the American Academy of Pediatrics clinical practice guideline culture thresholds. RESULTS: Of 30 462 children, 1916 had microscopic urinalysis and positive urine culture. Urine was obtained by transurethral in-and-out catheterization in 98.3% of cases. Pyuria (≥5 white blood cells per high-powered field) and positive leukocyte esterase (small or more) on the urine dipstick were present in 1690 (88.2%) and 1692 (88.3%) of the children respectively. Children with non-Escherichia coli species were less likely to exhibit microscopic pyuria than children with E coli (OR 0.24, 95% CI 0.17-0.34) with more pronounced effect on Enterococcus and Klebsiella (OR 0.08, 95% CI 0.03-0.18 and OR 0.18, 95% CI 0.11-0.27 respectively). Similarly, positive leukocyte esterase was less frequently seen in non-E coli uropathogens compared with E coli. CONCLUSIONS: Pyuria and leukocyte esterase are not sensitive markers to identify non-E coli UTI in young children. More sensitive screening biomarkers are needed to identify UTI with these uropathogens.

Pain Reduction Emergency Protocol: A Prospective Study Evaluating Impact of a Nurse-initiated Protocol on Pain Management and Parental Satisfaction.

OBJECTIVES: Pain control remains suboptimal in pediatric emergency departments (EDs). Only 60% of pediatric patients requiring pain medications receive them in the ED, with an average time of administration being 90 minutes after arrival. Although pain protocols (PP) have been proposed and evaluated in children with long-bone fractures, data on PP utility for general pediatric patients with acute pain are limited. Our objective is to introduce a nursing-initiated PP with medication algorithms for use in triage, measure the improvement in management of severe pain on arrival to the ED and determine the effect on parental satisfaction. METHODS: Prospective prestudy and poststudy conducted from June to October 2017. Patients aged 3 to 17 years presenting to a large tertiary pediatric ED with acute pain were eligible. Preprotocol demographics, clinical data, and pain interventions were obtained over a 6-week period. A convenience sample of parents completed a satisfaction survey rating their experience with ED pain management during this time. In the 4-week intervention phase, the PP was introduced to our ED nurses. Postintervention data were collected in the same fashion as the preintervention phase. Analysis was done using independent sample t test and χ2 models. RESULTS: There were 1590 patients evaluated: preprotocol (n = 816), postprotocol (n = 774). Approximately 10% more patients with severe pain received pain medication in the post-PP sample compared with pre-PP (85.6% and 75.9% respectively). Parental satisfaction was higher in patients who received analgesic medications within 90 minutes of arrival to the ED (P = 0.007). CONCLUSIONS: The introduction of a PP in the ED setting improved the treatment of pain. There was a significant increase in patients with severe pain receiving analgesic medications. Additionally, parents were more satisfied if their children received pain medication in a more timely fashion. Pediatric EDs should consider introducing PPs to improve appropriate and timely administration of pain medication in triage.

The Evaluation of Trauma Care: The Comparison of 2 High-Level Pediatric Emergency Departments in the United States and Turkey.

OBJECTIVE: The purpose of the study is to compare the outcomes of pediatric trauma patients with motor vehicle crashes (MVCs) and motor vehicle versus pedestrian crashes (MPCs) at a level 1 pediatric trauma center in the United States and a pediatric trauma center in Turkey. METHODS: The medical records of all pediatric MVC and MPC subjects presenting to the emergency departments (EDs) of a level 3 hospital in Turkey (Izmir Tepecik Training and Research Hospital [ITTRH]) and a level 1 pediatric trauma center in the United States (Children's Medical Center Dallas [CMCD]) over a 1-year period were reviewed. Data that were collected include patient demographics, prehospital report (mechanism of injury, mode of transportation), injury severity score (ISS), abbreviated injury scale score, Glasgow Coma Scale score, ED length of stay, ED interventions, ED and hospital disposition, and mortality. Patients with moderate (ISS, 5-15) and severe (ISS, >15) trauma scores were included in the study. RESULTS: One hundred six patient charts from the ITTRH and 125 patient charts from the CMCD with moderate and severe ISS due to MVCs and MPCs were reviewed. Most of the patients were pedestrians (86%) in the ITTRH group and passengers (60%) in the CMCD group. The percentage of patients transferred by ambulance (ground or air) to the CMCD and the ITTRH was 97.9% and 85%, respectively. Fifteen percent of ITTRH patients and 2.1% of CMCD patients arrived by private vehicle. Emergency department arrival ISS and Glasgow Coma Scale were similar between the 2 hospitals (P > 0.05). The overall mortality rate in the study population was 8.8% (11/125) at the CMCD and 4.7% (5/106) at the ITTRH. (P = 0.223). Blood product utilization was significantly higher in the CMCD group compared with the ITTRH group (P = 0.005). The use of hypertonic saline/mannitol/hyperventilation in patients with significant head trauma and increased intracranial pressure was higher in the ITTRH group (P = 0.000). CONCLUSIONS: This is the first study that compared pediatric trauma care and outcome at a level 1 pediatric trauma center in the United States and a pediatric hospital in Turkey. Our findings highlight the opportunities to improve pediatric trauma care in Turkey. Specifically, there is a need for national trauma registries, enhanced trauma education, and standardized trauma patient care protocols. In addition, efforts should be directed toward improving prehospital care through better integration within the health care system and physician participation in educating prehospital providers. Data and organized trauma care will be instrumental in system-wide improvement and developing appropriate injury-prevention strategies.

Straight to the Operating Room: An Emergent Surgery Track for Acute Testicular Torsion Transfers.

OBJECTIVE: To assess the effect of implementing an emergency surgery track for testicular torsion transfers. We hypothesized that transferring children from other facilities diagnosed with torsion straight to the operating room (STOR) would decrease ischemia time, lower costs, and reduce testicular loss. STUDY DESIGN: Demographics, arrival to incision time, hospital cost in dollars, and testicular outcome (determined by testicular ultrasound) at follow-up were retrospectively compared in all patients transferred to our tertiary care children's hospital with a diagnosis of testicular torsion from 2012 to 2016. Clinical data for STOR and non-STOR patients were compared by Wilcoxon rank-sum, 2-tailed t test, or Fisher exact test as appropriate. RESULTS: Sixty-eight patients met inclusion criteria: 35 STOR and 33 non-STOR. Children taken STOR had a shorter median arrival to incision time (STOR: 54 minutes vs non-STOR: 94 minutes, P < .0001) and lower median total hospital costs (STOR: $3882 vs non-STOR: $4419, P < .0001). However, only 46.8% of STOR patients and 48.4% of non-STOR patients achieved surgery within 6 hours of symptom onset. Testicular salvage rates in STOR and non-STOR patients were not significantly different (STOR: 68.4% vs non-STOR: 36.8%, P = .1), but follow-up was poor. CONCLUSIONS: STOR decreased arrival to incision time and hospital cost but did not affect testicular loss. The bulk of ischemia time in torsion transfers occurred before arrival at our tertiary care center. Further interventions addressing delays in diagnosis and transfer are needed to truly improve testicular salvage rates in these patients.

Abusive Injuries Are Worse Than Vehicular Injuries: Should We Refocus Prevention?

OBJECTIVES: The objective of this study was to compare the injury severity and outcome of motor vehicle and nonaccidental traumatic injuries and examine trends in mortality rates over time. METHODS: We reviewed data from 2005 to 2013 from a level 1 pediatric trauma center including demographics, injury severity, and outcomes. Primary outcomes of interest were mortality rates and hospital length of stay. RESULTS: Injury severity scores were significantly worse for nonaccidental traumas (NATs) (P < 0.001) compared with motor vehicle collisions and motor pedestrian collisions. Nonaccidental traumas were also found to have significantly longer length of stay and higher fatality rates (P < 0.001). Significant differences were also found for the types of injuries sustained for head, extremity, trunk, and other injuries (P < 0.001), and for internal injuries (P < 0.01. Admission rates also dropped for both motor vehicle collisions and motor pedestrian collisions across the 9-year period (P < 0.001) but remained stable for NATs. CONCLUSION: In this study population, more severe injuries, higher mortality rates, and longer hospital stays were observed in pediatric NAT compared with those sustained through vehicular means. Furthermore, we observed statistically significant declines in motor vehicle-related injuries compared with NAT.

Transscrotal Near Infrared Spectroscopy as a Diagnostic Test for Testis Torsion in Pediatric Acute Scrotum: A Prospective Comparison to Gold Standard Diagnostic Test Study.

PURPOSE: A rapid test for testicular torsion in children may obviate the delay for testicular ultrasound. In this study we assessed testicular tissue percent oxygen saturation (%StO2) measured by transscrotal near infrared spectroscopy as a diagnostic test for pediatric testicular torsion. MATERIALS AND METHODS: This was a prospective comparison to a gold standard diagnostic test study that evaluated near infrared spectroscopy %StO2 readings to diagnose testicular torsion. The gold standard for torsion diagnosis was standard clinical care. From 2013 to 2015 males with acute scrotum for more than 1 month and who were less than 18 years old were recruited. Near infrared spectroscopy %StO2 readings were obtained for affected and unaffected testes. Near infrared spectroscopy Δ%StO2 was calculated as unaffected minus affected reading. The utility of near infrared spectroscopy Δ%StO2 to diagnose testis torsion was described with ROC curves. RESULTS: Of 154 eligible patients 121 had near infrared spectroscopy readings. Median near infrared spectroscopy Δ%StO2 in the 36 patients with torsion was 2.0 (IQR -4.2 to 9.8) vs -1.7 (IQR -8.7 to 2.0) in the 85 without torsion (p=0.004). AUC for near infrared spectroscopy as a diagnostic test was 0.66 (95% CI 0.55-0.78). Near infrared spectroscopy Δ%StO2 of 20 or greater had a positive predictive value of 100% and a sensitivity of 22.2%. Tanner stage 3-5 cases without scrotal edema or with pain for 12 hours or less had an AUC of 0.91 (95% CI 0.86-1.0) and 0.80 (95% CI 0.62-0.99), respectively. CONCLUSIONS: In all children near infrared spectroscopy readings had limited utility in diagnosing torsion. However, in Tanner 3-5 cases without scrotal edema or with pain 12 hours or less, near infrared spectroscopy discriminated well between torsion and nontorsion.

A Prospective Evaluation of the Accuracy of Weight Estimation Using the Broselow Tape in Overweight and Obese Pediatric Patients in the Emergency Department.

OBJECTIVES: The aims of the study were to examine the predictive accuracy of Broselow tape (BT) weight estimation and body mass index-based weight categorization in overweight and obese pediatric patients and to develop an adjustment factor that improves the BT weight estimate in overweight and obese pediatric patients. METHODS: A prospective observational study was conducted. We enrolled noncritical pediatric patients presenting to a tertiary care pediatric emergency department with nonurgent complaints. Patients had their weights, heights, abdominal circumferences, and actual BT measurements documented by research staff. RESULTS: One hundred seventy-eight patients aged 2 to 18 years were enrolled. Using the Centers for Disease Control and Prevention's definition of body mass index classification, 71 patients (39.89%) had normal BMI, 43 patients (24.16%) were overweight, and 64 patients (35.96%) were obese. The accuracy of the BT-estimated weight range, compared with the actual weight, is 40.5% in our study population. When stratified by BMI classification, the accuracy proportions were the following: 71.8% for normal, 41.9% for overweight, and 4.7% for obese patients. The adjustment formula ([0.014 × waistline in cm + 0.3] × BT weight) improved overall weight estimation from 40.5% to 65.2%. The greatest improvement was noted in obese children, where the BT accuracy improved from 4.7% to 59.4%. CONCLUSIONS: The growing pediatric obesity epidemic has challenged the BT's ability to accurately estimate the weights in overweight and obese pediatric patients. Our study demonstrated inverse relationship between the accuracy of BT and body weight. An adjustment factor significantly improved BT accuracy in obese children.

Diagnosing Testicular Torsion before Urological Consultation and Imaging: Validation of the TWIST Score.

PURPOSE: The TWIST (Testicular Workup for Ischemia and Suspected Torsion) score uses urological history and physical examination to assess risk of testis torsion. Parameters include testis swelling (2 points), hard testis (2), absent cremasteric reflex (1), nausea/vomiting (1) and high riding testis (1). While TWIST has been validated when scored by urologists, its diagnostic accuracy among nonurological providers is unknown. We assessed the usefulness of the TWIST score when determined by nonurological nonphysician providers, mirroring emergency room evaluation of acute scrotal pain. MATERIALS AND METHODS: Children with unilateral acute scrotum were prospectively enrolled in a National Institutes of Health clinical trial. After undergoing basic history and physical examination training, emergency medical technicians calculated TWIST score and determined Tanner stage per pictorial diagram. Clinical torsion was confirmed by surgical exploration. All data were captured into REDCap™ and ROC curves were used to evaluate the diagnostic usefulness of TWIST. RESULTS: Of 128 patients (mean age 11.3 years) 44 (13.0 years) had torsion. TWIST score cutoff values of 0 and 6 derived from ROC analysis identified 31 high, 57 intermediate and 40 low risk cases (positive predictive value 93.5%, negative predictive value 100%). CONCLUSIONS: TWIST score assessed by nonurologists, such as emergency medical technicians, is accurate. Low risk patients do not require ultrasound to rule out torsion. High risk patients can proceed directly to surgery, with more than 50% avoiding ultrasound. In the future emergency medical technicians and/or emergency room triage personnel may be able to calculate TWIST score to guide radiological evaluation and immediate surgical intervention at initial assessment long before urological consultation.

Addition of a biomarker panel to a clinical score to identify patients at low risk for appendicitis.

BACKGROUND: The diagnosis of pediatric acute appendicitis can be difficult. Although scoring systems such as the Pediatric Appendicitis Score (PAS) are helpful, they lack adequate sensitivity and specificity as standalone diagnostics. When used for risk stratification, they often result in large percentages of moderate-risk patients requiring further diagnostic evaluation. METHODS: We applied a biomarker panel (the APPY1 Test) that has high sensitivity and negative predictive value (NPV) to patients with PAS in the moderate-risk range (3-7) and reclassified those patients with a negative result to the low-risk group. We compared the specificity, sensitivity, and NPV of the original and reclassified low-risk groups at several different PAS low-risk cutoffs. RESULTS: The application of a negative biomarker panel to a group of patients with a moderate risk for appendicitis (PAS, 3-7) resulted in 4 times more patients (586 vs 145) being safely classified as low risk. Reclassification increased the overall specificity or the proportion of patients without appendicitis who were correctly identified as low risk, from 10.3% to 42.0%. The high NPV (97.2%) in the original group was preserved (97.6%) in the reclassified low-risk group, as was the sensitivity (original 99.1% vs reclassified 96.9%). CONCLUSION: The addition of negative biomarker test results to patients with a moderate risk of appendicitis based on the PAS can safely reclassify many to a low-risk group. This may allow clinicians to provide more conservative management in children with suspected appendicitis and decrease unnecessary resource utilization.

Prospective validation of a biomarker panel to identify pediatric ED patients with abdominal pain who are at low risk for acute appendicitis.

OBJECTIVES: The objective of the study is to prospectively validate the diagnostic accuracy of a biomarker panel consisting of white blood cell, C-reactive protein, and myeloid-related protein 8/14 levels in identifying pediatric patients with abdominal pain who are at low risk for appendicitis. METHODS: This prospective observational study enrolled subjects aged 2 to 20 years presenting to 29 US emergency departments with abdominal pain suggesting possible acute appendicitis. Blood samples were analyzed for white blood cell, C-reactive protein, and myeloid-related protein 8/14 levels from which the composite biomarker panel results were calculated, then correlated with the final diagnosis either positive or negative for acute appendicitis. RESULTS: A total of 2201 patients were enrolled, with 1887 completing all aspects of the study. Prevalence of appendicitis in this cohort was 25.3%. The biomarker panel exhibited a sensitivity of 97.1% (95% confidence interval [CI], 95.1%-98.2%), negative predictive value of 97.4% (95% CI, 95.8%-98.5%), negative likelihood ratio of 0.08 (95% CI, 0.05-0.13), with a specificity of 37.9% (95% CI, 35.4%-40.4%) for appendicitis. The panel correctly identified 534 (37.8%) of 1410 patients who did not have appendicitis with 14 false negatives (2.9%). Overall, 23.7% (132/557) of computed tomographic (CT) scans were done for patients with negative biomarker panel results, including 31.2% (131/420) of patients who had CT but did not have appendicitis. CONCLUSION: This biomarker panel exhibited high sensitivity and negative predictive value for acute appendicitis in this large prospective cohort. This panel may be useful in identifying pediatric patients who are at low risk for appendicitis and might be followed clinically, potentially reducing the dependence on CT in the evaluation for acute appendicitis.

Pediatric Outcomes of Emergency Medical Services Non-Transport Before and During the COVID-19 Pandemic.

Introduction: Pediatric patients account for 6-10% of emergency medical services (EMS) activations in the United States. Approximately 30% of these children are not transported to an emergency department (ED). Adult data in the literature reports higher hospitalization and complications following non-transport. Few studies discuss epidemiology and characteristics of pediatric non-transport; however, data on outcome is limited. Our primary aim was to determine outcomes of non-transported children within our urban EMS system before and during the COVID-19 pandemic. Our secondary objective was to explore reasons for non-transport. Methods: This was a prospective, descriptive pilot study. We compared EMS data for September 2019 (pre-COVID-19) to September 2020 (pandemic). Included were children aged 0-17 years who activated EMS and did not receive transport to the primary hospital for the EMS capture area. We defined outcomes as repeat EMS activation, ED visits, and hospital admissions, all within 72 hours. Data was obtained via electronic capture. We used descriptive statistics to analyze our data, chi square for categorical data, stepwise logistic regression, and univariate logistic regression to test for association of covariates with non-transport. Results: There were 1,089 pediatric EMS activations in September 2019 and 780 in September 2020. Non-transport occurred in 633 (58%) in September 2019 and 412 (53%) in September 2020. Emergency medical services was reactivated within 72 hours in the following: 9/633 (1.4%) in 2019; and 5/412 (1.2%) in 2020 (P = 0.77). Visits to the ED occurred in 57/633 (9%) in 2019 and 42/412 (10%) in 2020 (P = 0.53). Hospital admissions occurred in 10/633 (1.5%) in 2019 and 4/412 (0.97%) in 2020 (P = 0.19). One non-transported patient was admitted to the intensive care unit in September 2020 (<1%) and survived. Hispanic ethnicity, age >12 years, and fever were associated with repeat EMS activation. The most common reason for non-transport in both study periods was that the parent felt an ambulance was not necessary (47%). Conclusion: In our system, non-transport of pediatric patients occurred in >50% of EMS activations with no significant adverse outcome. Age >12 years, fever, and Hispanic ethnicity were more common in repeated EMS activations. The most common reason for non-transport was parents feeling it was not necessary. Future studies are needed to develop reliable EMS guidelines for pediatric non-transport.

Does a prehospital Glasgow Coma Scale score predict pediatric outcomes?

BACKGROUND: Although the Glasgow Coma Scale (GCS) score is widely used by medical professionals to evaluate and predict neurological outcomes, studies using the prehospital (P) GCS score to predict neurological outcomes in children are few. OBJECTIVE: The objective of this study was to determine the agreement between the P GCS score and the emergency department (ED) GCS score, and the association between P GCS score and outcomes at hospital discharge in pediatric patients 5 to 18 years of age. METHODS: Medical record review of children 5 to 18 years old with traumatic brain injury (TBI) was conducted. Children with documented P and ED GCS scores were eligible for enrollment. The hospital records of each enrolled child were reviewed, and the Glasgow outcome score and the disability rating scale scores were calculated. Agreement between the P and ED GCS scores was calculated using χ (κ statistic). RESULTS: One hundred eighty-five subjects were included. There was strong agreement between P and ED GCS scores (κ = +0.69; confidence interval, 0.57-0.81). The Glasgow outcome score category improved with improving GCS category. The median disability rating scale score was also similar for P and ED GCS scores and was higher with decreasing GCS. CONCLUSIONS: Our data showed strong agreement between P and ED GCS scores. Also, there was strong association between P GCS scores and short-term outcomes in children with TBI. The results support the use of GCS in prehospital transport destination guidelines for children with TBI.

REDUCE-PCP study: radiographs in the emergency department utilization criteria evaluation-pediatric chest pain.

BACKGROUND: Many emergency physicians order chest x-rays (CXRs) for pediatric patients who present with a chief complaint of chest pain despite a paucity of research to support this testing, which exposes patients to radiation, cost, and delays. OBJECTIVES: This study aimed to begin development of a decision making tool that will allow emergency physicians to selectively obtain CXR films in pediatric patients presenting with chest pain. METHODS: We performed a retrospective cohort study of 400 consecutive pediatric patients with a chief complaint of chest pain and reviewed charts to determine how many received a CXR and which clinical characteristics were present in all patients. Chest radiograph findings were graded for significance as follows: (1) no or minor clinical significance: normal result in the CXR film without effect on the immediate evaluation of a patient; (2) moderate clinical significance: only impact on plan for follow-up; and (3) major clinical significance: result in the CXR film directly affects immediate management. We then evaluated each chart for historical or examination findings that might identify criteria associated with positive radiographic findings to propose a set of criteria that could lead to the development of a decision rule that allows a reduced utilization while having a high sensitivity for clinically significant positive findings on CXR film. RESULTS: Of the 400 pediatric patients reviewed, 63.5% (n = 254) received a CXR in the emergency department (ED). Of those receiving a CXR, only 8.26% (n = 21) had a finding that affected either ED management or follow-up planning. The criteria that would have identified all patients with positive results in the CXR films were abnormal vital signs, shortness of breath, palpitations, presence of comorbidities, abnormal or unilateral breath sounds, history of trauma, murmur, or cough. CONCLUSIONS: This pilot study demonstrates the potential for a decision rule to eliminate both cost and radiation exposure by using defined criteria to determine the need for a CXR in pediatric ED patients. We identified 8 simple criteria that would have identified all children who benefited from a CXR in this study. The next phase of this study will prospectively evaluate the utility of each of the criteria as part of a draft decision rule.

Pyuria and Urine Concentration for Identifying Urinary Tract Infection in Young Children.

OBJECTIVES: Accuracy of pyuria for urinary tract infection (UTI) varies with urine concentration. Our objective of this study was to determine the optimal white blood cell (WBC) cutoff for UTI in young children at different urine concentrations as measured by urine specific gravity. METHODS: Retrospective cross-sectional study of children <24 months of age evaluated in the emergency department for suspected UTI with paired urinalysis and urine culture during a 6-year period. The primary outcome was positive urine culture result as described in the American Academy of Pediatrics clinical practice guideline culture thresholds. Test characteristics for microscopic pyuria cut points and positive leukocyte esterase (LE) were calculated across 3 urine specific gravity groups: low <1.011, moderate 1.011 to 1.020, and high >1.020. RESULTS: Of the total 24 171 patients analyzed, urine culture result was positive in 2003 (8.3%). Urine was obtained by transurethral in-and-out catheterization in 97.9%. Optimal WBC cutoffs per high-power field (HPF) were 3 (positive likelihood ratio [LR+] 10.5; negative likelihood ratio [LR-] 0.12) at low, 6 (LR+ 12; LR- 0.14) at moderate, and 8 (LR+ 11.1; LR- 0.35) at high urine concentrations. Likelihood ratios for small positive LE from low to high urine concentrations (LR+ 25.2, LR- 0.12; LR+ 33.1, LR- 0.15; LR+ 37.6, LR- 0.41) remained excellent. CONCLUSIONS: Optimal pyuria cut point in predicting positive urine culture results changes with urine concentration in young children. Pyuria thresholds of 3 WBCs per HPF at low urine concentrations whereas 8 WBCs per HPF at high urine concentrations have optimal predictive value for UTI. Positive LE is a strong predictor of UTI regardless of urine concentration.

Dallas MegaShelter Medical Operations Response to Hurricane Harvey.

On August 25, 2017, Hurricane Harvey made landfall near Corpus Christi, Texas. The ensuing unprecedented flooding throughout the Texas coastal region affected millions of individuals.1 The statewide response in Texas included the sheltering of thousands of individuals at considerable distances from their homes. The Dallas area established large-scale general population sheltering as the number of evacuees to the area began to amass. Historically, the Dallas area is one familiar with "mega-sheltering," beginning with the response to Hurricane Katrina in 2005.2 Through continued efforts and development, the Dallas area had been readying a plan for the largest general population shelter in Texas. (Disaster Med Public Health Preparedness. 2019;13:33-37).

Prospective Evaluation of Predictors of Testis Atrophy After Surgery for Testis Torsion in Children.

OBJECTIVE: To prospectively correlate pain duration, red scrotal skin, ultrasound appearance of testis, and intraoperative testis color to future testis atrophy after acute testicular torsion. METHODS: Patients 2 months-18 years old with unilateral acute scrotum were consecutively enrolled in a National Institutes of Health transcutaneous near-infrared spectroscopy study, with a subgroup analysis of the true torsion group. Presence or absence of red scrotal skin, pain duration, testicular heterogeneity on preoperative ultrasound, and intraoperative testis color based on a novel visual chart 5 minutes after detorsion were recorded. All testes underwent orchiopexy regardless of appearance. Percent volume difference between normal and torsed testicles on follow-up ultrasound was compared between patients with and without risk factors. RESULTS: Thirty of 56 patients who had surgical detorsion underwent scrotal ultrasound at a mean of 117 days after surgery. A color of black or hemorrhagic 5 minutes after detorsion, pain duration >12 hours, and heterogeneous parenchyma on preoperative ultrasound were associated with significant testis volume loss in follow-up compared with normal testis. All patients with a black or hemorrhagic testis had >80% volume loss. Erythematous scrotal skin was not significantly associated with smaller affected testis volume in follow-up. CONCLUSION: Based on the high atrophy rate, orchiectomy can be considered for testes that are black or hemorrhagic 5 minutes after detorsion. Pain duration >12 hours and parenchymal heterogeneity on preoperative ultrasound were also associated with testis atrophy. Red scrotal skin was not a reliable predictor of atrophy and should not delay exploration.

Fatal injuries of US citizens abroad.

BACKGROUND: US citizens are increasingly traveling, working, and studying abroad as well as retiring abroad. The objective of this study was to describe the type and scope of injury deaths among US citizens abroad and to compare injury death proportions by region to those in the United States. METHODS: A cross-sectional design using reports of US citizen deaths abroad for 1998, 2000, and 2002 on file at the US State Department was employed. The main outcome measures were the frequencies of injury deaths and proportional mortality ratios (PMRs) comparing deaths abroad to deaths in the United States. RESULTS: Two thousand eleven injury deaths were reported in the 3 years, comprising 13% of all deaths. The overall age-adjusted PMR for injury fatalities abroad compared to the United States was 1.6 (95% confidence interval 1.6-1.7). The highest age-adjusted PMRs for motor vehicle crashes were found in Africa (2.7) and Southeast Asia (1.6). The proportion of drowning deaths was elevated in all regions abroad. CONCLUSIONS: Injuries occur at a higher proportion abroad than in the United States. Motor vehicle crash and drowning fatalities are of particular concern. Improved data quality and surveillance of deaths would help government agencies create more evidence-based country advisories.

Recommendations for water safety and drowning prevention for travelers.

Drowning is a serious worldwide, mostly preventable injury problem, particularly among international travelers. In 2000, approximately 449,000 people have drowned worldwide, and the exact number of travelers is not precisely known. Although comprehensive infectious disease information has been available to international travelers for many years, advice on injury risk and prevention, more specifically on drowning prevention, has received little attention. The goals of this review were to develop research-based drowning prevention and water-safety recommendations for travelers and to identify research needs for future recommendations. A group of injury-prevention and travel-medicine experts conducted several rounds of voting and ranking of the strength and evidence of drowning-prevention recommendations. Each of the thirty-two recommendations created have also been categorized using the Committee to Advise on Tropical Medicine and Travel scale and have been framed in the context of preevent, event, and postevent categories commonly used in injury-control theory and Haddon's Matrix. These recommendations were developed for use by travel-medicine professionals or others who prepare individuals for travel. Several of the identified interventions to prevent drownings lack conclusive scientific evidence of their effectiveness and warrant further studies to better understand their true effectiveness. Furthermore, funding for the studies of intervention effectiveness and the implications of these interventions for international travelers are essential, yet insufficient.