Implementing Point-of-Care Ultrasound for Acute Scrotal Pain in the Pediatric Emergency Department: Screening Testicular Torsion and Patient Flow Analysis.

OBJECTIVES: Testicular torsion (TT) is a pediatric surgical emergency that requires prompt treatment. This study investigated the feasibility of point-of-care ultrasound (POCUS) for diagnosing TT in the pediatric emergency department (ED). METHODS: We retrospectively reviewed the medical records of patients, aged 18 years or younger, who visited a university-affiliated hospital pediatric ED with acute scrotal pain without trauma history and underwent diagnostic ultrasounds between January 2010 and October 2022. RESULTS: This study included 731 patients (median age: 9 years), Of these, 315 (43%) were in the POCUS-performed group: 188 in the POCUS-only group, and 127 in the POCUS-and-RADUS group. The other 416 patients (56.9%) were in the RADUS-only group. In total, 45 patients (6.2%) were diagnosed with TT (19 in the POCUS-performed group and 26 in the RADUS-only group). The sensitivity, specificity, and positive and negative predictive values of POCUS for diagnosing TT were 94.7%, 92.9%, 46.2%, and 99.6%, respectively. The median time to perform POCUS was shorter than RADUS (23 versus 61 minutes, P < .001). The POCUS-performed group had a shorter ED length of stay than the RADUS-only group (93 versus 170 minutes, P < .001). Among the patients diagnosed with TT, performing POCUS first did not significantly delay the ED process, including time to operation (250 versus 205 minutes, P = .142). CONCLUSIONS: For patients with acute scrotal pain, evaluation performed by pediatric emergency physicians using POCUS performs well in screening TT, and can decrease length of stay in the ED.

Safety and efficacy of pediatric sedation protocol for diagnostic examination in a pediatric emergency room: A retrospective study.

Pediatric patients undergoing diagnostic tests in the pediatric emergency room are frequently sedated. Although efforts are made to prevent adverse events, no sedation protocol has specified the optimal regimen, dosage, and interval of medication to prevent adverse events. This study analyzed the safety and efficacy of sequential pediatric sedation protocols for pediatric patients undergoing diagnostic tests in the pediatric emergency room of a single tertiary medical center. The medical records of patients aged < 18 years who visited the pediatric emergency room of Seoul Asan Medical Center between January and December 2019 for diagnostic testing were retrospectively reviewed. Sedation protocols consisted of 50 mg/kg and 25 mg/kg chloral hydrate, 0.1 mg/kg and 0.1 mg/kg midazolam, and 1 mg/kg and 0.5 to 1 mg/kg ketamine, administered sequentially at intervals of 30, 20, 10, 10, and 10 minutes, respectively. Patients were assessed prior to sedation, and adverse events were investigated. Of the 289 included patients, 20 (6.9%) experienced adverse events, none serious, and nine (3.1%) failed to reach the depth of sedation required to complete the test. The regimen (P = .622) and dosage (P = .777) of the sedatives were unrelated to the occurrence of adverse events when sedation was performed according to protocol. The sedation protocol used in these patients, consisting of sequential administration of minimum dosages, achieved a sufficient depth of sedation with relatively few adverse events, indicating that this protocol can be used safely and effectively for painless sedation in pediatric patients undergoing diagnostic testing.

The Association Between Media-Based Exposure to Nonsuicidal Self-Injury and Emergency Department Visits for Self-Harm.

OBJECTIVE: This study aimed to evaluate the association between media-based exposure to nonsuicidal self-injury (NSSI) and emergency department (ED) visits due to self-harm in Korea, specifically before and after the initial broadcast of the song Barcode, which has an explicit focus on NSSI. METHOD: We used the national emergency department information system to obtain data related to ED visits due to self-harm between January 1, 2014, and December 31, 2018. Using interrupted time series regression analysis, we assessed the monthly ED visits due to self-harm before and after the media-based exposure to NSSI on March 30, 2018. In addition, self-harm methods were assessed. RESULTS: A total of 35,928,834 visits to ED were identified, of which 115,647 were due to self-harm. ED visits due to self-harm showed a significant step increase in the 10- to 14-year-old (ß = 0.883, p = .001), 15- to 19-year-old (ß = 2.941, p < .001), 20- to 24-year-old (ß = 1.997, p = 0.002), and 25- to 29-year-old (ß = 1.438, p = .029) age groups, before and after the media-based exposure to NSSI. The most pronounced increase was observed in male participants aged 20 to 24 years (ß = 1.790, p = .012) and female participants aged 15 to 19 years (ß = 5.158, p < .001). Self-harm by cutting has increased significantly in participants aged 10 to 29 years, and self-harm by poisoning has also increased significantly in participants aged 10 to 19 and 25 to 29 years. CONCLUSION: ED visits due to self-harm increased significantly, especially in adolescents and young adults, following the exposure to NSSI. Responsible media reporting on NSSI and appropriate guidelines would help prevent a further increase in self-harm. DIVERSITY & INCLUSION STATEMENT: We worked to ensure sex and gender balance in the recruitment of human participants. We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants. The author list of this paper includes contributors from the location and/or community where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work.

Decreased Incidence of Pediatric Intussusception during COVID-19.

Coronavirus disease 2019 (COVID-19) changed the epidemiology of various diseases. The present study retrospectively investigates the epidemiologic and clinical changes in pediatric intussusception for ages ≤ 7 years before (February 2019-January 2020) and after (February 2020-January 2021) the COVID-19 outbreak in a single pediatric emergency department of a university-affiliated tertiary hospital. The incidence of communicable diseases-defined as infectious diseases with the potential for human-to-human transmission via all methods, non-communicable diseases, and intussusception were decreased following the COVID-19 outbreak (15,932 to 3880 (24.4%), 12,994 to 8050 (62.0%), and 87 to 27 (31.0%), respectively). The incidence of intussusception correlated significantly with the change in incidence of communicable diseases (Poisson log-linear regression, odds ratio = 2.15, 95% CI = 1.08-4.26, and p = 0.029). Compared with the pre-pandemic period, patients of the pandemic period showed higher proportions of pathologic leading point (PLP) and hospitalization (14.8% vs. 2.3% and 18.5% vs. 4.6%, respectively), lower base excesses (-4.8 mmol/L vs. -3.6 mmol/L), and higher lactate concentrations (1.7 mmol/L vs. 1.5 mmol/L). The incidence of pediatric intussusception decreased after the COVID-19 pandemic. This reduced incidence may be related to the reduced incidence of communicable diseases. However, the proportions of more severe diseases and PLPs were higher after the COVID-19 pandemic.

Feasibility of Point-of-Care Ultrasound for Diagnosing Hypertrophic Pyloric Stenosis in the Emergency Department.

OBJECTIVES: This study aimed to investigate the feasibility of point-of-care ultrasound (POCUS) for diagnosing hypertrophic pyloric stenosis (HPS) in the emergency department (ED). METHODS: A retrospective study was conducted in infants aged younger than 90 days who were brought to the ED due to vomiting between January 2015 and December 2019. Of these, infants who were clinically suspected of having HPS and underwent ultrasound were included and categorized into 3 groups: POCUS only, POCUS followed by radiologist-performed ultrasound (RADUS), and RADUS only. All confirmative diagnoses of HPS were made by RADUS. The diagnostic performance of POCUS was analyzed, and the ED patient flow was compared between the POCUS-performed (POCUS only or POCUS followed by RADUS) and RADUS-only groups. RESULTS: Overall, 171 patients with a median age of 34 days were included. Of these, 79 patients (46.2%) underwent POCUS only, and none had HPS; 50 patients (29.2%) underwent POCUS followed by RADUS; and 42 patients (24.5%) underwent RADUS only. Overall, 41 patients (24.0%) were diagnosed with HPS, and POCUS showed a sensitivity of 96.6% and specificity of 94.0%. In the total cohort, length of stay in the ED (EDLOS) was shorter in the POCUS-performed group than in the RADUS-only group (2.6 vs 3.8 hours, P = 0.015). Among non-HPS patients, time to disposition (1.8 vs 2.7 hours, P = 0.005) and EDLOS (2.0 vs 3.0 hours, P = 0.004) were shorter in the POCUS-performed group than in the RADUS-only group. Performing POCUS followed by RADUS did not significantly delay the treatment among HPS patients. CONCLUSIONS: Point-of-care ultrasound is accurate and useful for diagnosing HPS and improved the ED patient flow by reducing EDLOS and door-to-disposition time in non-HPS patients.

Innovative Culture and Firm Performance of Medical Device Companies: Mediating Effects of Investment in Education and Training.

This research explored the mediating effect of investment in education and training relating to the innovative culture and organizational performance of medical device companies. We used the Human Capital Corporate Panel data provided by the Korea Vocational Competency Development Institute. In the industrial classification system of panel data, the industries related to medical devices were extracted and conclusively analyzed for 8629 workers and 368 companies. The independent and dependent variables were innovative culture and corporation performance, respectively. Investment in training and education was a mediating variable between the independent and dependent variables. Quantitative data were analyzed using SPSS software. A higher level of organizational satisfaction emerged in an innovative culture. Innovative culture positively affected organizational satisfaction. Further, investment in education and training to promote an innovative culture positively affected organizational satisfaction. Medical device companies should improve their performance by creating an innovative culture.

Pediatric Sedation in the Emergency Department: Trends from a Nationwide Population-based Study in Korea, 2007-2018.

BACKGROUND: Pediatric sedation in the emergency department (ED) is widely performed in Korea; thus exploring the trends of its use is necessary. This study aimed to investigate the characteristics of patients and sedatives use in the ED and verify their changes over recent years. METHODS: A nationwide population-based retrospective study was conducted including pediatric patients aged ≤ 15 years who received sedative medication in the ED and were discharged during 2007-2018, using the Korean Health Insurance Review and Assessment Service database. Patient characteristics (age, sex, level of ED, and diagnosis) and type of sedative used were analyzed. RESULTS: Sedation was performed in total 468,221 visits during 2007-2018 (399,320 visits, at least 3.8% of overall ED visits during 2009-2018). Among these, 71.0% were children aged 1-3 years and 93.5% were sedated to support diagnosis of injury. An increase in total sedation was observed in patients aged 4-6 years during the study period (from 13.8% to 21.8%). A gradual decrease in the use of chloral hydrate (CH) compared with an increase in ketamine use was observed (CH, from 70.6% to 28.6%; ketamine, from 23.8% to 60.7%). Therefore, ketamine was the most used sedative since 2014. The most frequently used sedatives over the study period differed according to age groups (CH in <1 year and 1-3 years; ketamine in 4-6 years and 7-10 years; and midazolam in 11-15 years). CONCLUSIONS: The characteristics of patients related to sedatives use in the ED have changed over time. These changes should be considered in the development of future Korean guidelines regarding pediatric sedation in the ED.

Clinical utility of procalcitonin in febrile infants younger than 3 months of age visiting a pediatric emergency room: a retrospective single-center study.

BACKGROUND: Fever in infants under 90 days of age is highly likely to be caused by a severe bacterial infection (SBI) and it accounts for a large number of patients visiting the pediatric emergency room. In order to predict the bacterial infection and reduce unnecessary treatment, the classic classification system is based on white blood cell (WBC) count, urinalysis, and x-ray, and it is modified and applied at each center by incorporating recently studied biomarkers such as c-reactive protein (CRP) or procalcitonin (PCT). This study analyzed the usefulness of PCT in predicting SBI when applied along with the existing classification system, including CRP, among infants less than 90 days old who visited with a fever at a single institution pediatric emergency center. METHODS: We retrospectively reviewed the medical records of patients younger than 3 months of age who presented with fever at the Seoul Asan Medical Center pediatric emergency room between July 2017 and October 2018. RESULTS: A total of 317 patients were analyzed, and 61 were diagnosed with SBI, among which urinary tract infection (UTI) accounted for the largest proportion (55/61, 90.2%). There were differences in WBC, neutrophil proportion, CRP, and PCT between the SBI group and the non-SBI group, and the AUC values of WBC, CRP, and PCT were 0.651, 0.804, and 0.746, respectively. When using the cut-off values of CRP and PCTs as 2.0 mg/dL and 0.3 ng/mL, respectively, the sensitivity and specificity for SBI were 49.2/89.5, and 54.1/87.5, respectively. WBC, CRP, and PCT were statistically significant for predicting SBI in multivariate analysis (odds ratios 1.066, 1.377, and 1.291, respectively). When the subjects were classified using the existing classification criteria, WBC and CRP, the positive predictive value (PPV) and negative predictive value (NPV) were 29.3 and 88.7%, respectively, and when PCT was added, the PPV and NPV were 30.7 and 92%, respectively, both increased. CONCLUSION: PCT is useful for predicting SBI in children aged 3 months or less who visit the emergency room with a fever. It is useful as a single biomarker, and when used in conjunction with classic biomarkers, its diagnostic accuracy is further increased.

Initial Characteristics and Clinical Severity of Hemophagocytic Lymphohistiocytosis in Pediatric Patients Admitted in the Emergency Department.

OBJECTIVES: The diagnosis and management of children with hemophagocytic lymphohistiocytosis (HLH) admitted in the emergency department (ED) are challenging. The present study aimed at describing the initial characteristics of pediatric patients with HLH upon admission in the ED. Moreover, the clinical severity of the condition was assessed. METHODS: We performed a retrospective study of patients who visited the pediatric ED and were newly diagnosed with HLH during hospitalization between February 2012 and January 2017. The patients were classified in the clinically unstable group if at least 1 of the following conditions was observed upon admission in the ED: hypoxia requiring oxygen supplementation, hypotension requiring inotropic support, coagulopathy with prothrombin time (international normalized ratio, ≥1.5), and seizures or altered consciousness. RESULTS: We enrolled 31 pediatric patients with HLH, with a median age of 6.53 years (interquartile range, 1.35-13.24 years). Abdominal discomfort along with fever (74.2%) was the most common presenting symptom in patients admitted in the ED. Based on the HLH-2004 diagnostic criteria, fever (96.8%), hyperferritinemia (96.8%), splenomegaly (74.2%), hypertriglyceridemia and/or hypofibrinogenemia (67.7%), and bicytopenia (41.9%) were observed in the patients. However, only 8 patients (25.8%) met the criteria. Nineteen patients (61.3%) were included in the clinically unstable group. This group had lower albumin (2.3 vs 3.3 g/dL, P = 0.002) and fibrinogen levels and higher ferritin level and neutrophil count than the clinically stable group. Meanwhile, the number of clinical findings that met the diagnostic criteria was not different between the 2 groups. Lower albumin level was a significant risk factor in the clinically unstable group (odds ratio, 0.040; P = 0.004). CONCLUSIONS: Pediatric patients with HLH often have clinically unstable conditions upon admission in the ED. However, only few patients meet the HLH-2004 diagnostic criteria. Lower albumin level may be useful in assessing clinically unstable patients and preparing for possible deterioration.

Characteristics and Trends of Suicide Attempt or Non-suicidal Self-injury in Children and Adolescents Visiting Emergency Department.

BACKGROUND: Non-suicidal self-injury (NSSI) and suicidality are common reasons for child and adolescent psychiatric emergencies. We aimed to investigate the incidence of pediatric emergency department (PED) utilization for psychiatric problems in children and adolescents and to identify demographic and clinical characteristics of youths who visited the PED for suicide attempt (SA) and/or NSSI. METHODS: The medical records of children and adolescents who visited the PED for psychiatric problems from January 2015 to November 2019 were reviewed retrospectively. Demographic and clinical variables including psychiatric disorders were collected. We compared the characteristics of youths who presented to the PED for SA and/or NSSI with those of youths without SA or NSSI. Student's t-test, χ² test, and multivariate logistic regression were used for statistical analysis. RESULTS: During 59 months of observation, 194 youths visited the PED and the number of total PED visits was 336. Among them, 46 youths (23.7%) visited the PED for SA and/or NSSI at least once, and the number of visits was 91 (27.1% of PED visits). Youths with SA and/or NSSI were older (P = 0.001) and more likely to be a girl (P = 0.005) and to report parental absence (P = 0.023). Bipolar and related disorders (P = 0.032) and depressive disorders (P = 0.004) were more common in youths with SA and/or NSSI, while schizophrenia spectrum and other psychotic disorders (P = 0.030) and somatic symptom and related disorders (P = 0.007) were more common in those without SA and NSSI. After adjusting for age, sex, and parental marital status, bipolar and related disorders (odds ratio [OR], 6.72), depressive disorders (OR, 9.59), and somatic symptom and related disorders (OR, 0.12) were significantly associated with SA and/or NSSI. Youths with SA and/or NSSI also stayed longer in the PED (P = 0.007). CONCLUSION: SA and NSSI are one of the main reasons for child and adolescent admittance to psychiatric services in the PED and are associated with psychiatric comorbidities. An appropriate risk assessment for suicidality and self-injury and proper management and referral to mental health services at the PED are of the utmost importance.

Quality of Life in Older Adults with Benign Prostatic Hyperplasia.

The purpose of this study is to identify factors that affect health-related quality of life (HRQOL) of older patients with Benign Prostatic Hyperplasia (BPH) and suggest ways to improve the same. Through this, we will improve the self-management practice of patients and promote the treatment of BPH in older patients. The 2015 Korea Health Panel Survey data were used in this study. A total of 422 BPH patients aged 65 or older were included. Logistic regression analysis was conducted to identify factors affecting the HRQOL of older patients with BPH. General characteristics of factors affecting older patients with BPH included income level and type of insurance. In addition, among medical-related characteristics and health behavior factors, subjective health status, unmet medical care needs, moderate physical activity, sitting time, and drinking influenced the HRQOL. Therefore, in order to improve the HRQOL of adult patients with BPH, it is necessary to improve medical accessibility by strengthening primary care. In addition, it is necessary to increase the amount of activity in daily life through healthcare medical devices.

Lactic acid level as an outcome predictor in pediatric patients with intussusception in the emergency department.

BACKGROUND: Intussusception decreases blood flow to the bowel, and tissue hypoperfusion results in increased lactic acid levels. We aimed to determine whether lactic acid levels are associated with pediatric intussusception outcomes. METHODS: The electronic medical records of our emergency department pediatric patients diagnosed with intussusception, between January 2015 and October 2018, were reviewed. An outcome was considered poor when intussusception recurred within 48 h of reduction or when surgical reduction was required due to air enema failure. RESULTS: A total of 249 patients were included in the study, including 39 who experienced intussusception recurrence and 11 who required surgical reductions; hence, 50 patients were included in the poor outcome group. The poor and good outcome groups showed significant differences in their respective blood gas analyses for pH (7.39 vs. 7.41, P = .001), lactic acid (1.70 vs. 1.30 mmol/L, P < .001), and bicarbonate (20.70 vs. 21.80 mmol/L, P = .036). Multivariable logistic regression analyses showed that pH and lactic acid levels were the two factors significantly associated with poor outcomes. When the lactic acid level cutoff values were ≥ 1.5, ≥2.0, ≥2.5, and ≥ 3.0 mmol/L, the positive predictive values for poor outcomes were 30.0, 34.6, 50.0, and 88.9%, respectively. CONCLUSION: Lactic acid levels affect outcomes in pediatric patients with intussusception; higher lactic acid levels are associated with higher positive predictive values for poor outcomes.

Point-of-care ultrasound may be useful for detecting pediatric intussusception at an early stage.

BACKGROUND: This study aimed to verify the usefulness of point-of-care ultrasound (POCUS) performed by pediatric emergency physicians for detecting intussusception at an early stage. METHODS: This retrospective study included 1-month- to 6-year-old children with clinically suspected intussusception, who underwent POCUS in the pediatric emergency department between December 2016 and February 2018. The criteria for performing POCUS were set to broader standards: presenting any one of intermittent abdominal pain/irritability or bloody stool, or ≥ 2 symptoms among nonspecific abdominal pain/irritability, abdominal mass/distension, vomiting, or lethargy. POCUS results were interpreted and categorized as "negative" or "suspicious," and a radiologist performed confirmatory ultrasound in "suspicious" cases. RESULTS: We analyzed 575 POCUS scans from 549 patients (mean age, 25.5 months). Among the 92 "suspicious" cases (16.0%), 70 (12.2%) were confirmed to have intussusception. POCUS showed 100% sensitivity, 95.6% specificity, and 97.8% accuracy. Patients with confirmed intussusception were mainly diagnosed in the early stages, with a mean symptom duration of 11.7 h, and most patients (97.1%) were treated successfully via air enema reduction. Compared to the non-intussusception group, the intussusception group had more intermittent abdominal pain (P < 0.001), but less vomiting (P = 0.001); the other clinical features showed no intergroup differences. CONCLUSION: POCUS performed using the criteria set to broader standards by pediatric emergency physicians may be useful for detecting intussusception at an early stage, which may present with obscure clinical symptoms.

Clinical Implications of Ketosis in Children with Benign Convulsions with Mild Gastroenteritis.

BACKGROUND AND PURPOSE: The pathophysiologic mechanisms underlying benign convulsions with mild gastroenteritis (CwG) in children remain unclear. We investigated the incidence of ketosis in CwG and whether this is related to seizures. METHODS: This retrospective study included children aged from 6 months to 6 years who visited our emergency department and were diagnosed as CwG between June 2015 and December 2018. The clinical and laboratory data were analyzed for these cases. Ketosis and severe ketosis were defined as blood ß-hydroxybutyrate levels of ≥0.6 and ≥4.5 mmol/L, respectively. RESULTS: We enrolled 42 pediatric CwG patients aged 21.0±11.5 months (mean±SD) whose blood ß-hydroxybutyrate level was 3.65±1.51 mmol/L. Ketosis was observed in 95.2% of these children, while 35.7% had severe ketosis. Compared to the non-severe-ketosis group (n=27), the severe-ketosis group (n=15) demonstrated significantly lower blood glucose levels (68.8 vs. 82.6 mg/dL, p=0.020) and sodium levels (134.2 vs. 135.6 mEq/L, p=0.018), and included a larger proportion of low-body-weight children (defined as adjusted weight <50th percentile for age and sex) (53.3% vs. 18.5%, p=0.019). However, the incidence of repetitive seizures (two or more during an illness period) did not differ between these groups. Moreover, severe ketosis was not associated with the risk of seizure recurrence in the emergency department. CONCLUSIONS: Children with CwG are in a state of considerable ketosis. Severe ketosis in CwG may be associated with low blood glucose and sodium levels but does not reduce seizure recurrence.

Point-of-Care Ultrasound Could Streamline the Emergency Department Workflow of Clinically Nonspecific Intussusception.

OBJECTIVES: The aim of this study was to evaluate whether point-of-care ultrasound (POCUS) for intussusception screening streamlines the workflow of clinically nonspecific intussusception (CNI), an intussusception presenting with only 1 manifestation of the classic triad, and/or vomiting. METHODS: We reviewed 274 consecutive children with intussusception, aged 6 years or younger, who visited a tertiary care hospital emergency department between May 2012 and April 2016. This period was dichotomized by May 2014 (the "PRE" and "POST" groups), starting point of implementation of the POCUS protocol for intussusception screening. All children with CNI who had positive results on or forwent POCUS underwent radiologist-performed ultrasound (US). We measured and compared emergency department length of stay (EDLOS), the sum of door-to-reduction and observation times, and the frequency of POCUS and positive US results between the 2 groups. RESULTS: Of 160 children with CNI, 93 visited the emergency department since May 2014. The POST group showed a shorter median EDLOS (856 vs 630 minutes, P < 0.001), door-to-reduction time (137 vs 111 minutes, P = 0.002), and observation time (700 vs 532 minutes, P < 0.001). The POST group had a higher frequency of POCUS (12% vs 60%, P < 0.001) with positive US results (33% vs 59%, P < 0.001). The PRE group had a higher frequency of severe bowel edema (16% vs 1%, P < 0.001). No significant differences were found in the severity, recurrence, admission, and surgery. One child had a false-negative result on POCUS. CONCLUSIONS: Point-of-care ultrasound could streamline the workflow of CNI via decrease in EDLOS and unnecessary referrals for US.

Implications of Increased Weight Status for the Occurrence of Fall-Induced Intracranial Hemorrhage in Children Aged 4 Years or Younger.

OBJECTIVES: The aim of this study was to investigate the association between increased weight status (IWS), a weight for age/sex at greater than the 95th percentile, and fall-induced intracranial hemorrhage (ICH) in children aged 4 years or younger. METHODS: In 7072 children aged 4 years or younger with head injury who visited a tertiary care hospital emergency department in Korea from 2013 through 2015, the presence of fall-induced ICH was reviewed. The association between IWS and ICH was investigated by multivariable logistic regression. We retrospectively validated the Pediatric Emergency Care Applied Research Network rule alone and in combination with IWS for predicting ICH. RESULTS: Of 7072 children, 547 (7.7%) underwent computed tomography, of whom 451 (6.4%) were enrolled. Of these, 41 (9.1%; estimated event rate, 0.6%) had ICHs, and 26 (5.8%) had IWS. Increased weight status was more common in the children with ICH (P = 0.023). The association between IWS and ICH remained significant after adjustment (odds ratio, 5.24; 95% confidence interval [CI], 1.49-18.46; P = 0.010). The validation of the rule in combination with IWS showed no significant increases in a sensitivity (92.7% [95% CI, 80.1%-98.5%] to 95.7% [95% CI, 83.5%-99.4%]) and negative predictive value (98.2% [95% CI, 94.7%-99.4%] to 98.8% [95% CI, 95.4%-99.8%]). CONCLUSIONS: Increased weight status is associated with fall-induced ICH in children aged 4 years or younger. Information on weight status could be potentially helpful in predicting ICH in young children with fall-induced head injury.

High Concentration of C-Reactive Protein Is Associated With Serious Bacterial Infection in Previously Healthy Children Aged 3 to 36 Months With Fever and Extreme Leukocytosis.

OBJECTIVES: The aim of the study was to investigate the diagnostic efficacy of C-reactive protein (CRP) in predicting serious bacterial infection (SBI) in febrile children aged 3 to 36 months with extreme leukocytosis (EL), defined as a peripheral white blood cell count of 25,000 to 49,999/mm. METHODS: The presence of SBI was reviewed in previously healthy children aged 3 to 36 months with a fever of 39°C or higher and EL, who visited a tertiary care hospital emergency department between September 2010 and August 2015. We measured cutoff values of CRP with corresponding likelihood ratios (LRs) and posttest probabilities (PPs). RESULTS: Of 9989 febrile children, 4252 (42.6%) underwent assays for white blood cell and CRP. Of 233 (5.5%) children with EL, 133 (3.1%) were enrolled, of whom 43 (32.3%; 95% confidence interval [CI], 25.0%-40.7%) had SBI, including 33 pyelonephritis, 5 deep abscesses, 3 lobar pneumonia, and 2 soft tissue infections. With the cutoff of 7.8 mg/dL, the sensitivity of CRP in predicting SBI was 81.4% (95% CI, 67.4%-90.3%); the specificity, 80.0% (95% CI, 70.6%-87.0%); the positive predictive value, 66.0% (95% CI, 52.6%-77.3%); the negative predictive value, 90.0% (95% CI, 81.5%-94.9%); the positive LR, 4.1; and the PP, 66.0% (95% CI, 55.6%-75.0%). A CRP concentration of 16.1 mg/dL or higher yielded an LR of 11.2 and a PP of 84.2% (95% CI, 62.1%-94.5%). A CRP concentration of lower than 3.4 mg/dL yielded an LR of 0.05 and a PP of 2.4% (95% CI, 0.3%-14.6%). CONCLUSIONS: High concentration of CRP is strongly associated with the presence of SBI in febrile children with EL.

Requirement for Head Magnetic Resonance Imaging in Children Who Present to the Emergency Department With Acute Nontraumatic Visual Disturbance.

OBJECTIVES: This study aimed to investigate the clinical features and head magnetic resonance imaging (MRI) findings in children who presented to the emergency department with acute nontraumatic visual disturbance and to study related clinical factors for discovering positive lesions on head MRI. METHODS: We performed a retrospective study of 1-month to 15-year-old children who underwent head MRI as an evaluation for acute nontraumatic visual disturbance as a chief complaint in our pediatric emergency department between March 2010 and March 2015. The symptoms of visual disturbance were blurred vision, diplopia, loss of vision, and visual hallucination. Head MRI findings were considered positive when lesions could explain the symptoms. RESULTS: We identified 39 patients (25 with blurred vision, 9 with diplopia, 3 with loss of vision, and 2 with visual hallucination) with a mean age of 8.35 ± 4.06 years. Positive head MRI findings were identified in 13 patients (33.3%). Brain tumors were most common (53.8%), followed by optic nerve inflammations (23.1%), congenital brain lesions (15.4%), and hypertensive encephalopathy (7.7%). Compared with the negative head MRI group, the positive head MRI group showed significantly less transient visual disturbance (duration <1 hour to complete recovery) (P = 0.001), more limited eye movement (P = 0.003), and more pupillary abnormalities (P = 0.030). CONCLUSIONS: We suggest performing urgent head MRI in children with acute nontraumatic visual disturbance if the symptoms last longer than 1 hour without complete recovery and are accompanied by limited eye movement or pupillary abnormality.

Development of screening tool for child abuse in the korean emergency department: Using modified Delphi study.

Mandatory reporting rate of suspected child abuse by health care provider is relatively low in South Korea. The purpose of the study was to develop a screening tool for child abuse and evaluate the feasibility of using this screening tool in emergency department (ED) of South Korea. Injured children younger than 14 years old in the ED were enrolled as subjects to use this screening tool. Candidate items for screening tool were decided after reviewing relevant previous studies by researchers. Using the modified Delphi method, it was judged that the consensus for items of screening tool was achieved in 2 rounds, and the final item of the screening tool was decided through the discussion in the final round. The registry including the developed screening tool was applied to 6 EDs over 10 weeks. Variables of the registry were retrospectively analyzed. A child abuse screening tool called Finding Instrument for Non-accidental Deeds (FIND) was developed. It included 8 questions. One item (suspected signs in physical examination) had 100% agreement; 3 items (inconsistency with development, inconsistent history by caregivers, and incompatible injury mechanism) had 86.7% agreement; and 4 items (delayed visit, inappropriate relationship, poor hygiene, and head or long bone injury in young infants) had 80% agreement. During the period of registry enrollment, the rate of screening with FIND was 72.9% (n = 2815). 36 (1.3%) cases had 1 or more "positive" responses among 8 items. Two (0.07%) cases were reported to the Child Protection Agency. An ED based screening tool for child abuse consisting of 8 questions for injured children younger than 14 years old was developed. The use of screening tools in Korean ED is expected to increase the reporting rate of child abuse. However, further study is necessary to investigate the accuracy of this screening tool using a national child abuse registry.