Factors Associated With Improved Pediatric Resuscitative Care in General Emergency Departments.

OBJECTIVES: To describe the quality of pediatric resuscitative care in general emergency departments (GEDs) and to determine hospital-level factors associated with higher quality. METHODS: Prospective observational study of resuscitative care provided to 3 in situ simulated patients (infant seizure, infant sepsis, and child cardiac arrest) by interprofessional GED teams. A composite quality score (CQS) was measured and the association of this score with modifiable and nonmodifiable hospital-level factors was explored. RESULTS: A median CQS of 62.8 of 100 (interquartile range 50.5-71.1) was noted for 287 resuscitation teams from 175 emergency departments. In the unadjusted analyses, a higher score was associated with the modifiable factor of an affiliation with a pediatric academic medical center (PAMC) and the nonmodifiable factors of higher pediatric volume and location in the Northeast and Midwest. In the adjusted analyses, a higher CQS was associated with modifiable factors of an affiliation with a PAMC and the designation of both a nurse and physician pediatric emergency care coordinator, and nonmodifiable factors of higher pediatric volume and location in the Northeast and Midwest. A weak correlation was noted between quality and pediatric readiness scores. CONCLUSIONS: A low quality of pediatric resuscitative care, measured using simulation, was noted across a cohort of GEDs. Hospital factors associated with higher quality included: an affiliation with a PAMC, designation of a pediatric emergency care coordinator, higher pediatric volume, and geographic location. A weak correlation was noted between quality and pediatric readiness scores.

Neuroimaging Rates for Closed Head Trauma in a Community Hospital.

OBJECTIVES: We aimed to characterize the utility of neuroimaging for head trauma in a suburban community hospital and determine whether imaging practices conform to most recent pediatric guidelines. METHODS: The electronic medical record was surveyed for computed tomographic and magnetic resonance imaging head scans on patients aged 1 to 18 years who were evaluated for trauma. The query included the following: date, sex, type of scan (computed tomography or magnetic resonance imaging), age, patient location, reason for scan, Glasgow Coma Scale (GCS) score (if entered), result, and text from physician's notes. RESULTS: A total of 2679 patients were identified. Within this cohort was a maximum of 29 surgical patients, of whom 8 required a surgical procedure but not neurosurgery among the 592 patients who had a GCS score of 14-15 entered, 2 were confirmed/possible neurosurgical patients, giving a neurosurgical rate of 0.34%. When the GCS 3-13 patient group was analyzed, the relative risk of requiring neurosurgery climbed to 52. Using an established algorithm for pediatric head trauma imaging would have reduced the number of scanned patients to 533. The individual cost of identifying the 29 surgical patients in our population exceeded $31,000. CONCLUSIONS: Our rate of serious lesions in GCS 14-15 patients was identical to a larger prospective study in urban teaching hospitals. Using their previously described algorithm might have reduced the number of patients scanned by more than 70% and saved close to $750,000 for the study period.

CYP2D6*36 gene arrangements within the cyp2d6 locus: association of CYP2D6*36 with poor metabolizer status.

Unexplained cases of CYP2D6 genotype/phenotype discordance continue to be discovered. In previous studies, several African Americans with a poor metabolizer phenotype carried the reduced function CYP2D6*10 allele in combination with a nonfunctional allele. We pursued the possibility that these alleles harbor either a known sequence variation (i.e., CYP2D6*36 carrying a gene conversion in exon 9 along the CYP2D6*10-defining 100C>T single-nucleotide polymorphism) or novel sequences variation(s). Discordant cases were evaluated by long-range polymerase chain reaction (PCR) to test for gene rearrangement events, and a 6.6-kilobase pair PCR product encompassing the CYP2D6 gene was cloned and entirely sequenced. Thereafter, allele frequencies were determined in different study populations comprising whites, African Americans, and Asians. Analyses covering the CYP2D7 to 2D6 gene region established that CYP2D6*36 did not only exist as a gene duplication (CYP2D6*36x2) or in tandem with *10 (CYP2D6*36+*10), as previously reported, but also by itself. This "single" CYP2D6*36 allele was found in nine African Americans and one Asian, but was absent in the whites tested. Ultimately, the presence of CYP2D6*36 resolved genotype/phenotype discordance in three cases. We also discovered an exon 9 conversion-positive CYP2D6*4 gene in a duplication arrangement (CYP2D6*4Nx2) and a CYP2D6*4 allele lacking 100C>T (CYP2D6*4M) in two white subjects. The discovery of an allele that carries only one CYP2D6*36 gene copy provides unequivocal evidence that both CYP2D6*36 and *36x2 are associated with a poor metabolizer phenotype. Given a combined frequency of between 0.5 and 3% in African Americans and Asians, genotyping for CYP2D6*36 should improve the accuracy of genotype-based phenotype prediction in these populations.

Trichophyton rubrum tinea capitis in a young child.

While the primary etiologic agent of tinea capitis in the United States has varied over the past century, the last several decades have been marked by a predominance of infection with Trichophyton tonsurans. Related anthropophilic organisms commonly isolated in other dermatophytoses are infrequently observed in tinea capitis. We report the unusual occurrence of tinea capitis in a young boy infected with Trichophyton rubrum.

Percutaneous lidocaine administration via a new iontophoresis system in children: tolerability and absence of systemic bioavailability.

OBJECTIVE: Rapid achievement of dermal anesthesia in pediatric practice without discomfort is both desirable and difficult. The Northstar Iontophoretic Drug Delivery System (IDDS) is designed to achieve this objective in 10 minutes using a current of 1.78 mA, compared with the 40 to 60 minutes required for traditional percutaneous methods (eg, eutectic mixture of local anesthetics or EMLA cream). For evaluating the tolerance of this IDDS in pediatrics, 12 healthy children (5-15 years, 4 girls and 8 boys, 10 white, weight 19-79 kg) were evaluated. METHODS: An open-label trial with random applications of IDDS containing lidocaine (100 mg of 10%) and epinephrine (1.05 mg of 1:10,000) to 3 of the 4 possible sites (back, chest, dorsum of hand, and antecubital fossa) was conducted. Three successive applications (time = 0, 3 hours and 3.5 hours) were performed in each subject, with repeated blood sampling (n = 12 over 10 hours) for assessment of plasma lidocaine concentrations. Skin evaluation (by Draize scoring) at both anode and cathode sites was performed at 10 and 24 hours. RESULTS: Few of the subjects (0%-28%) experienced any dermal abnormalities at 10 hours. These findings were maintained at the 24-hour follow-up evaluation with the vast majority of subjects (92%-100%) having no evidence of erythema or edema irrespective of application site. Erythema associated with the anode seemed to be more prominent when the study device was applied to either the chest or the back as compared with the antecubital fossa or dorsum of the hand. No subjects complained of pain/discomfort associated with IDDS delivery. Plasma lidocaine levels in all subjects were below 10 ng/mL at all time points. CONCLUSIONS: The IDDS seems not to deliver a significant, systemic dose of lidocaine and to be well tolerated and potentially suitable for clinical use in pediatric subjects.