Characterizing Acute Pulmonary Embolism Cases Diagnosed at an Emergency Department Revisit Using a Statewide Clinical Registry.

STUDY OBJECTIVE: To assess the rate and characteristics of acute pulmonary embolism (PE) cases diagnosed in the emergency department (ED) following an ED discharge visit within 10 days. METHODS: This is a retrospective analysis of 40 EDs in a statewide clinical registry from 2017 to 2022. We identified adult patients with acute PEs diagnosed in the ED. We assessed PE cases wherein a prior ED visit for the same patient resulting in discharge had taken place within 10 days without interval hospitalization. We then characterized the overall rate of revisit PE cases per overall acute PE cases and per 10,000 ED discharges. We also reported on subgroups of revisit cases where the preceding visit resulted in diagnosis of COVID-19, other cardiopulmonary conditions, and cardiopulmonary symptom codes (eg, chest pain, unspecified). RESULTS: Of 24,525 acute PEs, 1,202 (4.9%, 95% confidence interval [CI] 4.6% to 5.2%) had an ED discharge within the preceding 10 days (2.0 per 10,000 ED discharges, 95% CI 1.9 to 2.1). Two hundred thirty-three (19.4%) were originally discharged with a COVID-19 diagnosis, 107 (8.9%) were originally discharged with another cardiopulmonary condition, and 201 (16.7%) were cases discharged with a nonspecific cardiopulmonary symptom code. Discharges with diagnoses of COVID-19, pneumonia, and pleural effusion had higher rates of revisits with acute PE. CONCLUSION: In this retrospective analysis, about 1 in 20 acute PEs and 2 in 10,000 ED discharges were associated with an ED revisit for acute PE. Some cases may represent potential diagnostic opportunities, whereas others may be progression of disease, risk factors for PE, or unrelated.

Epidemiology of Bacteremia in Febrile Infants Aged 60 Days and Younger.

STUDY OBJECTIVE: To describe the current epidemiology of bacteremia in febrile infants 60 days of age and younger in the Pediatric Emergency Care Applied Research Network (PECARN). METHODS: We conducted a planned secondary analysis of a prospective observational study of febrile infants 60 days of age and younger presenting to any of 26 PECARN emergency departments (2008 to 2013) who had blood cultures obtained. We excluded infants with significant comorbidities or critically ill appearance. The primary outcome was prevalence of bacteremia. RESULTS: Of 7,335 screened infants, 4,778 (65.1%) had blood cultures and were enrolled. Of these patients, 84 had bacteremia (1.8%; 95% confidence interval [CI] 1.4% to 2.2%). The prevalence of bacteremia in infants aged 28 days or younger (47/1,515) was 3.1% (95% CI 2.3% to 4.1%); in infants aged 29 to 60 days (37/3,246), 1.1% (95% CI 0.8% to 1.6%). Prevalence differed by week of age for infants 28 days of age and younger (0 to 7 days: 4/156, 2.6%; 8 to 14 days: 19/356, 5.3%; 15 to 21 days: 15/449, 3.3%; and 22 to 28 days: 9/554, 1.6%). The most common pathogens were Escherichia coli (39.3%; 95% CI 29.5% to 50.0%) and group B streptococcus (23.8%; 95% CI 16.0% to 33.9%). Bacterial meningitis occurred in 19 of 1,515 infants 28 days of age and younger (1.3%; 95% CI 0.8% to 2.0%) and 5 of 3,246 infants aged 29 to 60 days (0.2%; 95% CI 0.1% to 0.4%). Of 84 infants with bacteremia, 36 (42.9%; 95% CI 32.8% to 53.5%) had urinary tract infections (E coli 83%); 11 (13.1%; 95% CI 7.5% to 21.9%) had bacterial meningitis. CONCLUSION: The prevalence of bacteremia and meningitis among febrile infants 28 days of age and younger is high and exceeds that observed in infants aged 29 to 60 days. E coli and group B streptococcus are the most common bacterial pathogens.

Incident Reporting to Improve Patient Safety: The Effects of Process Variance on Pediatric Patient Safety in the Emergency Department.

OBJECTIVE: Medical errors threaten patient safety, especially in the pediatric emergency department (ED) where overcrowding, multiple handoffs, and workflow interruptions are common. Errors related to process variance involve situations that are not consistent with standard ED operations or routine patient care. SETTING/PARTICIPANTS: We performed a planned subanalysis of the Pediatric Emergency Care Applied Research Network incident reporting data classified as process variance events. Confidential deidentified incident reports (IRs) were collected and classified by 2 independent investigators. Events categorized as process variance were then subtyped for severity and contributing factors. Data were analyzed using descriptive statistics. OUTCOME MEASURES: The study intention was to describe and measure reported medical errors related to process variance in 17 EDs in the Pediatric Emergency Care Applied Research Network from 2007 to 2008. RESULTS: Between July 2007 and June 2008, 2906 eligible reports were reviewed. Process variance events were identified in 15.4% (447/2906). The majority were related to patient flow (35.4%), handoff communication (17.2%), and patient identification errors (15.9%). Most staff involved included nurses (47.9%) and physicians (28%); trainees were infrequently reported. The majority of events did not result in harm (65.7%); 17.9% (80/447) of cases were classified as unsafe conditions but did not reach the patient. Temporary harm requiring further treatment or hospitalization was reported in 5.6% (25/447). No events resulted in permanent harm, near death, or death. Contributing factors included human factors (92.1%), in particular handoff communication, interpersonal skills, and compliance with established procedures, and system-level errors (18.1%), including unclear or unavailable policies and inadequate staffing levels. CONCLUSIONS: Although process variance events accounted for approximately 1 in 6 reported safety events, very few led to patient harm. Because human and system-level factors contributed to most of these events, our data provide an insight into potential areas for further investigation and improvements to mitigate errors in the ED setting.

Radiologic Safety Events Within a Pediatric Emergency Medicine Network.

OBJECTIVES: The aim of this study was to describe the epidemiology of radiologic safety events using an analysis of deidentified incident reports (IRs) collected within a large multicenter pediatric emergency medicine network. METHODS: This study is a report of a planned subanalysis of IRs that were classified as radiologic events. The parent study was performed in the PECARN (Pediatric Emergency Care Applied Research Network). Incident reports involving radiology were classified into subtypes: delay in test, delay in results, misread or changed reading, wrong patient, wrong site, or other. The severity of radiology-related incidents was characterized. Contributing factors were identified and classified as environmental, equipment, human (employee), information technology systems, parent or guardian, or systems based. RESULTS: Two hundred three (7.0%) of the 2906 IRs submitted during the study period involved radiology. Eighteen of the hospitals submitted at least 1 IR and 15 of these hospitals reported at least 1 radiologic event. The most common type of radiologic event was misread/changed reading, which accounted for over half of all IRs (50.3%). Human factors were the most frequent contributing factor identified and accounted for 67.6% of all factors. The severity of events ranged from unsafe conditions to events with temporary harm that required hospitalization. CONCLUSIONS: We described the epidemiology of radiology-related IRs from a large multicenter pediatric emergency research network. The study identified specific themes regarding types of radiologic errors, including the systems issues and the contributing factors associated with those errors. Results from this analysis may help identify effective intervention strategies to ameliorate the frequency of radiology-related safety events in the emergency department setting.

Laboratory Errors in a Pediatric Emergency Department Network: An Analysis of Incident Reports.

OBJECTIVES: To describe the types and severity of reported laboratory errors in pediatric emergency departments. METHODS: Retrospective review of incident reports classified as laboratory errors from July 2007 to June 2008 within the Pediatric Emergency Care Applied Research Network. Laboratory testing errors recorded included: delayed results or lost specimen, unlabeled specimens, wrong patient, failure to label specimen correctly, and other. The severity of laboratory-related incidents was characterized using the National Coordinating Council for Medication Error Reporting and Prevention severity classification system. Contributing factors were classified as environmental, equipment, human (employee), information technology systems, parent or guardian, or systems-based. RESULTS: A total of 335 (42.2%) laboratory reports were related to events in the preanalytic phase. Involved staff personnel were identified in 345 of the reports (43.5%). Nurses were identified in 179 (22.6%) and physicians in 38 (4.8%). The majority of laboratory errors [408 (51.5%)] were not associated with harm; 138 (17.4%) patients were harmed by the error; 136 (98.6%) patients were temporarily harmed and required treatment, and 1 (0.7%) patient was hospitalized or had their hospitalization prolonged with the event. Human factors 657 (82.8%) were the most common contributing factor. CONCLUSIONS: Laboratory errors are a common cause of safety events in the pediatric ED. Most events are preanalytic and involve problems with specimens that are improperly collected, mislabeled, or lost. Although most events were not associated with harm, there is potential for significant injury.

Intramuscular midazolam versus intravenous lorazepam for the prehospital treatment of status epilepticus in the pediatric population.

OBJECTIVE: To examine the effectiveness of intramuscular (IM) midazolam versus intravenous (IV) lorazepam for the treatment of pediatric patients with status epilepticus (SE) in the prehospital care setting. METHODS: This multicenter clinical trial randomized patients diagnosed with SE to receive either IM midazolam or IV lorazepam administered by paramedics in the prehospital care setting. Included in this secondary analysis were only patients younger than 18 years of age. Evaluated were the associations of the treatment group (IM vs. IV) with the primary outcome, defined as seizure cessation prior to emergency department (ED) arrival, and with patient characteristics, time to important events, and adverse events. Descriptive statistics and 99% confidence intervals (CIs) were used for the analysis. RESULTS: Of 893 primary study subjects, 120 met criteria for this study (60 in each treatment group). There were no differences in important baseline characteristics or seizure etiologies between groups. The primary outcome was met in 41 (68.3%) and 43 (71.7%) of subjects in the IM and IV groups, respectively (risk difference [RD] -3.3%, 99% CI -24.9% to 18.2%). Similar results were noted for those younger than 11 years (RD -1.3%, 99% CI -25.7% to 23.1%). Time from initiating the treatment protocol was shorter for children who received IM midazolam, mainly due to the shorter time to administer the active treatment. Safety profiles were similar. SIGNIFICANCE: IM midazolam can be rapidly administered and appears to be safe and effective for the management of children with SE treated in the prehospital setting. The results must be interpreted in the context of the secondary analysis design and sample size of the study.

Reported medication events in a paediatric emergency research network: sharing to improve patient safety.

OBJECTIVE: Medication errors are an important cause of preventable morbidity, especially in children in emergency department (ED) settings. Internal use of voluntary incident reporting (IR) is common within hospitals, with little external reporting or sharing of this information across institutions. We describe the analysis of paediatric medication events (ME) reported in 18 EDs in a paediatric research network in 2007-2008. METHODS: Confidential, deidentified incident reports (IRs) were collected, and MEs were independently categorised by two investigators. Discordant responses were resolved by consensus. RESULTS: MEs (597) accounted for 19% of all IRs, with reporting rates varying 25-fold across sites. Anti-infective agents were the most commonly reported, followed by analgesics, intravenous fluids and respiratory medicines. Of the 597 MEs, 94% were medication errors and 6% adverse reactions; further analyses are reported for medication errors. Incorrect medication doses were related to incorrect weight (20%), duplicate doses (21%), and miscalculation (22%). Look-alike/sound-alike MEs were 36% of incorrect medications. Human factors contributed in 85% of reports: failure to follow established procedures (41%), calculation (13%) or judgment (12%) errors, and communication failures (20%). Outcomes were: no deaths or permanent disability, 13% patient harm, 47% reached patient (no harm), 30% near miss or unsafe conditions, and 9% unknown. CONCLUSIONS: ME reporting by the system revealed valuable data across sites on medication categories and potential human factors. Harm was infrequently reported. Our analyses identify trends and latent systems issues, suggesting areas for future interventions to reduce paediatric ED medication errors.

Creating an infrastructure for safety event reporting and analysis in a multicenter pediatric emergency department network.

OBJECTIVE: Hospital incident reporting is widely used but has had limited effectiveness for improving patient safety nationally. We describe the process of establishing a multi-institutional safety event reporting system. METHODS: A descriptive study in The Pediatric Emergency Care Applied Research Network of 22 hospital emergency departments was performed. An extensive legal analysis addressed investigators' concerns about sharing confidential incident reports (IRs): (1) the ability to identify sites and (2) potential loss of peer review statute protection. Of the 22 Pediatric Emergency Care Applied Research Network sites, 19 received institutional approval to submit deidentified IRs to the data center. Incident reports were randomly assigned to independent review; discordance was resolved by consensus. Incident reports were categorized by type, subtype, severity, staff involved, and contributing factors. RESULTS: A total of 3,106 IRs were submitted by 18 sites in the first year. Reporting rates ranged more than 50-fold from 0.12 to 6.13 per 1000 patients. Data were sufficient to determine type of error (90% of IRs), severity (79%), staff involved (82%), and contributing factors (82%). However, contributing factors were clearly identified in only 44% of IRs and required extrapolation by investigators in 38%. The most common incidents were related to laboratory specimens (25.5%), medication administration (19.3%), and process variance, such as delays in care (14.4%). CONCLUSIONS: Incident reporting provides qualitative data concerning safety events. Perceived legal barriers to sharing confidential data can be addressed. Large variability in reporting rates and low rates of providing contributing factors suggest a need for standardization and improvement of safety event reporting.

Children with and without developmental disabilities: sedation medication requirements and adverse events related to sedation.

OBJECTIVE: Our objective was to prospectively compare sedation medication requirements and adverse events related to sedation in children with and without developmental disabilities. METHODS: We conducted a prospective, observational, age-matched, 1:2 case-control study of children (3-10 years) sedated for brain magnetic resonance imaging at a tertiary-care children's hospital. Developmental assessment was performed using the Vineland Adaptive Behavioral Scale and by a pediatric neurologist. Patients were sedated according to institutional sedation protocol. Patient demographics, type and dose of sedation medications, depth of sedation, and adverse events were collected. We defined hypoxia as oxygen saturation 90% or less for 30 seconds or longer and requiring airway maneuvers. RESULTS: Seventy children were designated as cases (DD) and 140 as controls (DN). DD had a significantly lower mean Vineland Adaptive Behavioral Scale score than did DN (DD: 62.34 ± 9.70, DN: 103.0 ± 13.71; P < 0.001). A combination of pentobarbital and fentanyl (DD: 32/70 [45.7%], DN: 60/140 [42.9%]) and combination of pentobarbital and midazolam (DD: 28/70 [40%], DN: 43/140 [30.7%]) were the most common sedatives used in both groups. There was no difference in the mean dose of pentobarbital (DD:4.68 ± 1.63 mg/kg, DN:4.67 ± 1.69 mg/kg; P = 0.9), fentanyl (DD: 0.61 ± 0.65 µg/kg, DN: 0.64 ± 0.65 µg/kg; P = 0.7), and midazolam (DD: 0.15 ± 0.17 mg/kg, DN: 0.11 ± 0.14 mg/kg; P = 0.1). There was no difference in the overall adverse events (DD: 30%, DN: 32.9%; P = 0.7) as well as hypoxia (DD: 10%; DN: 9.3%, P = 0.9). CONCLUSIONS: When compared with DN children, DD children do not require a higher dose of sedatives and do not have a higher incidence of adverse events.

Effect of a rapid assessment program on total length of stay in a pediatric emergency department.

OBJECTIVES: Wait times and length of stay (LOS) measure efficiency of care in pediatric emergency departments (PEDs). Our hospital introduced a rapid assessment program (RAP) wherein patients will be seen by a physician within 29 minutes of arrival to the PED. Our primary objective was to evaluate the impact of this RAP on total LOS and compare it with the pre-RAP period. The secondary objective was to compare door-to-physician times and admission frequencies. METHODS: We conducted an observational study of randomly selected visits before (in 2004) and after (in 2005) RAP in a PED. Data were acquired retrospectively from charts. We compared total LOS (time from arrival at triage to discharge), boarding time (time from the decision to admit to transfer to inpatient bed), door-to-physician time (arrival at triage to first evaluation by physician), and admission frequencies. RESULTS: Data from 990 visits (in 2004) and 1010 visits (in 2005) indicated similar age, sex, seasonal distribution, and weekday distribution. The total median LOS decreased by 37 minutes with RAP (103 [interquartile range {IQR}, 57-187] minutes in 2005 vs 140 [IQR, 78-234] minutes in 2004, P < 0.001) but only among lower triage categories. Median door-to-physician time decreased by 20 minutes with RAP (15 [IQR, 7-29] minutes in 2005 vs 35 [IQR, 18-72] minutes in 2004, P < 0.001) among lower triage categories. The LOS was reduced both in admitted and discharged patients with no difference in the boarding times or admission frequencies. CONCLUSIONS: In our PED, a RAP reduced the total LOS of patients with lower acuity of illness.

"Family plan"--multiple-patient visits from the same family to an inner-city pediatric emergency department.

OBJECTIVES: The issue of multiple family members presenting to the emergency department (ED) for care during a single visit is unique to pediatric EDs (PEDs). The epidemiology of such multiple-patient visits (MPVs) has not been well characterized. The aims of this study were to describe patient characteristics, Emergency Severity Index (ESI) triage categories, length of stay, ED disposition, and payer characteristics of such MPV and to compare these characteristics to that of the overall ED visits (OEVs). METHODS: We conducted a retrospective chart review of MPVs to an inner-city PED from June to December 2006. We collected patient demographics, ESI triage categories, ED disposition, length of stay, and payer characteristics. Descriptive methods and comparative methods were used to summarize the sample characteristics and compare group differences, respectively. RESULTS: Multiple-patient visit constituted 2.2% (1166/52,491) of the total ED visits with a total of 2511 patients. The majority (88%; 1025/1166) of such visits were with 2 patients in a family. Ninety-one percent (2285/2511) of patients presented for medical complaints. Compared with the OEV, MPV belonged significantly more to ESI triage category 5 (51.2% vs 28.6%) and less to ESI triage category 3 (10.0% vs 24.6%; χ(2) = 775.4; P < 0.01). A significantly higher percentage of MPV patients belonged to Medicaid Health Maintenance Organization compared with the OEV patients (72.4% vs 47.6%; P < 0.01). Only 3.3% of MPV patients required hospital admission. CONCLUSIONS: In our inner-city PED, most of the MPVs are for medical complaints, belong to a lower acuity, and have a low hospital admission rate.

Awareness and utilization of emergency medical services by limited English proficient caregivers of pediatric patients.

BACKGROUND: Previous studies have shown that limited-English-proficient (LEP) patients are less likely to utilize health care services. Objective. To assess the knowledge and perceived barriers to utilization of emergency medical services (EMS) by LEP caregivers of children served by an urban EMS system. METHODS: We prospectively surveyed a convenience sample of caregivers of children presenting to the emergency department (ED) from January to December 2008. Caregivers were identified as LEP using their response to the U.S. Census question ;;How well do you speak English?'' Caregivers were assigned to one of three cohorts: 1) LEP Spanish- and Arabic-speaking caregivers (n = 50), 2) proficient-in-English (PE) Spanish- and Arabic-speaking caregivers (n = 50), and (3) native English-speaking (NES) caregivers (n = 100). We collected data on EMS awareness and perceived barriers to EMS utilization using a written survey administered in the caregivers' preferred language (English, Spanish, or Arabic). We used descriptive methods to summarize sample characteristics and comparative methods (chi-square test, analysis of variance [ANOVA], and t-test) to compare group differences. RESULTS: There were no differences in the patient age groups, triage categories, caregiver age, and payer status among the three groups. The LEP caregivers were less aware of EMS (93% NES vs. 94% PE vs. 60% LEP; p < 0.01) and had called EMS significantly fewer times when compared with the NES and PE groups (16% LEP vs. 58% NES vs. 48% PE; p < 0.01). Fourteen percent of the LEP caregivers were unaware of the telephone number to call for EMS. Concerns about inability to communicate with the operator and cost were cited by the LEP caregivers as the main barriers to EMS utilization. CONCLUSIONS: Caregivers with limited English proficiency are less aware of and are less likely to utilize EMS for their children. Barriers to utilization include concerns of cost and communication with the operator.

The Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics: miniMAGIC.

OBJECTIVES: Vascular access device decision-making for pediatric patients remains a complex, highly variable process. To date, evidence-based criteria to inform these choices do not exist. The objective of the Michigan Appropriateness Guide for Intravenous Catheters in pediatrics (miniMAGIC) was to provide guidance on device selection, device characteristics, and insertion technique for clinicians, balancing and contextualizing evidence with current practice through a multidisciplinary panel of experts. METHODS: The RAND Corporation and University of California, Los Angeles Appropriateness Method was used to develop miniMAGIC, which included the following sequential phases: definition of scope and key terms, information synthesis and literature review, expert multidisciplinary panel selection and engagement, case scenario development, and appropriateness ratings by an expert panel via 2 rounds. RESULTS: The appropriateness of the selection, characteristics, and insertion technique of intravenous catheters commonly used in pediatric health care across age populations (neonates, infants, children, and adolescents), settings, diagnoses, clinical indications, insertion locations, and vessel visualization devices and techniques was defined. Core concepts including vessel preservation, insertion and postinsertion harm minimization (eg, infection, thrombosis), undisrupted treatment provision, and inclusion of patient preferences were emphasized. CONCLUSIONS: In this study, we provide evidence-based criteria for intravenous catheter selection (from umbilical catheters to totally implanted venous devices) in pediatric patients across a range of clinical indications. miniMAGIC also highlights core vascular access practices in need of collaborative research and innovation.

Caregiver adherence to follow-up after an emergency department visit for common pediatric illnesses: Impact on future ED use.

BACKGROUND: Access to primary care is often a problem for children living in urban areas and the rate of emergency department (ED) use can be high. For acute childhood illnesses, primary care follow-up is often recommended to prevent subsequent ED visits. METHODS: We conducted an observational study of 455 children with common childhood illnesses, between 6 weeks and 8 years of age, presenting to 1 of 3 EDs, and discharged to the community. ED physicians recommended that the child visit their primary care physician within 1 to 4 days of discharge (ie, "short-term" follow-up). Caregivers were surveyed during the ED index visit and after discharge to assess primary care follow-up adherence. We collected data on child and caregiver characteristics, type and severity of illness at the ED index visit, and ED return visits in the 2-month period after the ED index visit. RESULTS: A total of 45.3% of caregivers adhered to short-term primary care follow-up. Short-term follow-up adherence was associated with greater ED use for the same illness over the subsequent 2 months (odds ratio = 2.97; 95% confidence interval, 1.31-6.72). Subsequent ED use was greatest for children with short-term primary care follow-up and: (1) prior ED use, (2) single caregivers, (3) mild severity illnesses at the ED index visit, or (4) younger children. ED use after the initial visit did not vary by type of illness or site. CONCLUSIONS: There was no evidence that primary care follow-up soon after an ED visit was associated with a lower rate of subsequent ED use for common pediatric illnesses.

Sedation medication received and adverse events related to sedation for brain MRI in children with and without developmental disabilities.

BACKGROUND: There are few studies on sedation medication requirements and sedation related adverse events in developmentally disabled children. OBJECTIVES: The objectives of our study were to compare sedation medication received and sedation related adverse events for brain magnetic resonance imaging (MRI) between children with and without developmental disabilities. We hypothesized that developmentally disabled children would require increased doses of sedative medications and will have increased frequency of adverse events when compared with normal children. METHODS: We conducted a retrospective chart review on children 1-18 years, who required sedation for an elective brain MRI. Children were excluded if they required sedation for diagnostic imaging other than brain MRI, belonged to ASA category >3, or required general anesthesia. Data on developmental status, demographics and details of sedation medications received along with adverse events were collected. RESULTS: About 53.5% (260/486) of the patients were classified as developmentally disabled. Pentobarbital and fentanyl were the two most common medications used for sedation in children with and without developmental disability. There was no difference in the mean dosages of pentobarbital (3.02 mg x kg(-1) vs 3.06 mg x kg(-1); P = 0.2) and fentanyl (1.01 mcg x kg(-1) vs 1.02 mcg x kg(-1); P = 0.81) in the two groups. There was a threefold increased incidence of hypoxia noted in children with developmental disability (11.9% vs 4.9%; P < 0.01). Presence of developmental disability alone was significantly associated with sedation related hypoxia (OR = 3.2, 95% CI: 1.8, 6.94; P < 0.01). CONCLUSIONS: Children with developmental disabilities have similar requirements for sedation medications but are three times more likely to experience hypoxia when compared with normal children.

A 16-year-old boy with acute urinary retention.

Urinary retention can be described as the inability to void volitionally despite an adequate volume of urine in the bladder. It is a common complaint in adults, especially among elderly males with benign prostatic hyperplasia. Children, in contrast, are more likely to have voluntary retention of urine due to urethral irritation or dysuria. Gently massaging the suprapubic region while the child is in a warm bath often relieves the retention in these cases. Other patients described as lazy voiders can present with acute urinary retention. These patients are typically young girls who are embarrassed to void at school. Retraining or timed voiding is often successful managing lazy voiders. However, these benign disorders should only be diagnosed after anatomical or organic causes for their symptoms have been considered and ruled out.

Boerhaave syndrome--unusual cause of chest pain.

Spontaneous esophageal rupture (Boerhaave syndrome) is uncommon in children. Delayed or missed diagnosis can lead to poor outcomes in terms of morbidity and mortality. To highlight the importance of early recognition and management of spontaneous esophageal rupture in children, we report a case of a 16-year-old boy who presented in the emergency department with acute chest pain after episodes of vomiting.

The Yale Observation Scale Score and the Risk of Serious Bacterial Infections in Febrile Infants.

OBJECTIVES: To assess the performance of the Yale Observation Scale (YOS) score and unstructured clinician suspicion to identify febrile infants ≤60 days of age with and without serious bacterial infections (SBIs). METHODS: We performed a planned secondary analysis of a prospective cohort of non-critically ill, febrile, full-term infants ≤60 days of age presenting to 1 of 26 participating emergency departments in the Pediatric Emergency Care Applied Research Network. We defined SBIs as urinary tract infections, bacteremia, or bacterial meningitis, with the latter 2 considered invasive bacterial infections. Emergency department clinicians applied the YOS (range: 6-30; normal score: ≤10) and estimated the risk of SBI using unstructured clinician suspicion (<1%, 1%-5%, 6%-10%, 11%-50%, or >50%). RESULTS: Of the 4591 eligible infants, 444 (9.7%) had SBIs and 97 (2.1%) had invasive bacterial infections. Of the 4058 infants with YOS scores of ≤10, 388 (9.6%) had SBIs (sensitivity: 51/439 [11.6%]; 95% confidence interval [CI]: 8.8%-15.0%; negative predictive value: 3670/4058 [90.4%]; 95% CI: 89.5%-91.3%) and 72 (1.8%) had invasive bacterial infections (sensitivity 23/95 [24.2%], 95% CI: 16.0%-34.1%; negative predictive value: 3983/4055 [98.2%], 95% CI: 97.8%-98.6%). Of the infants with clinician suspicion of <1%, 106 had SBIs (6.4%) and 16 (1.0%) had invasive bacterial infections. CONCLUSIONS: In this large prospective cohort of febrile infants ≤60 days of age, neither the YOS score nor unstructured clinician suspicion reliably identified those with invasive bacterial infections. More accurate clinical and laboratory predictors are needed to risk stratify febrile infants.

Healthy children with invasive community-acquired methicillin-resistant Staphylococcus aureus infections.

Reports of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections in the pediatric community have exploded during the past decade. These infections typically result in mild skin and soft tissue infections that can be managed simply with oral antimicrobials. Recently, there have been reports of invasive CA-MRSA infecting children without risk factors, with isolated cases of life-threatening disease. We report 2 atypical cases of invasive CA-MRSA infecting previously healthy children.