Predictors of a drainable suppurative adenitis among children presenting with cervical adenopathy.

OBJECTIVES: We sought to identify predictors for a drainable suppurative adenitis [DSA] among patients presenting with acute cervical lymphadenitis. METHODS: A retrospective cross sectional study of all patients admitted to an urban pediatric tertiary care emergency department over a 15 year period. Otherwise healthy patients who underwent imaging for an evaluation of cervical lymphadenitis were included. Cases were identified using a text-search module followed by manual review. We excluded immunocompromised patients and those with lymphadenopathy felt to be not directly infected (i.e. reactive) or that was not acute (symptom duration >28 days). Data collected included: age, gender, duration of symptoms, highest recorded temperature, physical exam findings, laboratory and imaging results, and surgical findings. A DSA was defined as >1.5 cm in diameter on imaging. We performed binary logistic regression to determine independent clinical predictors of a DSA. RESULTS: Three hundred sixty-one patients met inclusion criteria. Three hundred six patients (85%) had a CT scan, 55 (15%) had an ultrasound and 33 (9%) had both. DSA was identified in 71 (20%) patients. Clinical features independently associated with a DSA included absence of clinical pharyngitis, WBC >15,000/mm3, age ≤3 years, anterior cervical chain location, largest palpable diameter on exam >3 cm and prior antibiotic treatment of >24 h. The presence of fever, skin erythema, or fluctuance on examination, was not found to be predictive of DSA. CONCLUSIONS: We identified independent predictors of DSA among children presenting with cervical adenitis. Risk can be stratified into risk groups based on these clinical features.

No longer a "nursemaid's" elbow: mechanisms, caregivers, and prevention.

OBJECTIVES: We sought to identify specific mechanisms leading to radial head subluxation, as well as correlation with different caregivers, as a potential platform for education and injury prevention. METHODS: A retrospective cohort study of all patients admitted to an urban pediatric tertiary care emergency department with radial head subluxation from 1995 to 2009 was performed. Cases were identified using a text-search module followed by a manual chart review. We excluded patients with fractures, osteopenia, and neuromuscular conditions. Data collected included age, gender, arm involved, position of the arm at presentation, mechanism of injury, caregivers involved, imaging, and type of reduction. Multivariate logistic regression analysis was used to determine predictors for different mechanisms. RESULTS: There were 3170 cases of radial head subluxation identified. The median age was 2.1 years (interquartile range, 1.5-2.8 years), and 59% were female (95% confidence interval [CI], 57%-60%). There were 2011 patients (63%) presenting with a traction mechanism, 547 (17%) with a nontraction traumatic mechanism, and 612 (19%) with an unknown or undocumented mechanism.Within the traction group, we identified several potentially preventable mechanisms including lifting the child by the arms (28.3%), "wrestling" (12.3%), swinging child by the arms (9.2%), and placing the child into and out of a seat (4.3%). Male caregivers were more likely to be involved when a child is swung by the arms (odds ratio [OR], 3.2; 95% CI, 1.6-6.2), lifted (OR, 1.9; 95% CI, 1.4-2.7), or "wrestled" with (OR, 6.4; 95% CI, 3.3-12.0). Mechanisms common for female caregivers included the child pulling away from parent (OR, 2.3; CI, 1.54 3.4), tripping (2.0; CI, 1.3-3.0), and getting dressed (OR, 2.1; CI, 1.1-4.4). CONCLUSIONS: Radial head subluxation mechanisms can be classified into subcategories, which may be caregiver and even patient gender specific. Provider awareness regarding these mechanisms may help target education and prevention.

Acute periorbital infections: who needs emergent imaging?

OBJECTIVES: Computed tomography (CT) is used often in the evaluation of orbital infections to identify children who are most likely to benefit from surgical intervention. Our objective was to identify predictors for intraorbital or intracranial abscess among children who present with signs or symptoms of periorbital infection. These predictors could be used to better target patients for emergent CT. METHODS: This was a retrospective cohort study of all patients admitted to an urban pediatric tertiary care emergency department between 1995 and 2008. We included otherwise healthy patients with suspected acute clinical periorbital or orbital cellulitis without a history of craniofacial surgery, trauma, or external source of infection. Immunocompromised patients and patients with noninfectious causes of periorbital swelling were excluded. Variables analyzed included age, duration of symptoms, highest recorded temperature, previous antibiotic therapy, physical examination findings, laboratory results, and interpretation of imaging. CT scans of the orbit were reread by a neuroradiologist. RESULTS: Nine hundred eighteen patients were included; 298 underwent a CT scan, and of those, 111 were shown to have an abscess. Although proptosis, pain with external ocular movement, and ophthalmoplegia were associated with presence of an abscess, 56 (50.5%) patients with abscess did not experience these symptoms. Other variables associated with the presence of an abscess in multivariate analysis were a peripheral blood neutrophil count greater than 10,000/microL, absence of infectious conjunctivitis, periorbital edema, age greater than 3 years, and previous antibiotic therapy (P < .05 for all). Our recursive partitioning model identified all high-risk (44%) patients as well as a low-risk (0.4%-2%) group (Rsq = 0.27). CONCLUSIONS: We confirmed that patients with proptosis and/or pain or limitation of extraocular movements are at high risk for intraorbital abscess, yet many do not have these predictors. Other features can identify patients who do not have such obvious predictors but do have significant risk of disease. A recursive partitioning model is presented.