Serious bacterial infections in young children with fever without source after discharge from emergency department: A National Health Insurance database cohort study.

BACKGROUND: Well-appearing febrile young children discharged from the emergency department (ED) after medical assessment are still at risk for serious bacterial infections (SBI). The incidence of SBI and the effectiveness of laboratory tests in the pneumococcal conjugate vaccine era remain unknown. METHODS: We conducted a study using Taiwan's National Health Insurance claims data from 2004 to 2014. Children aged 2-24 months discharged from the ED with a diagnosis compatible with fever without source (FWS) were enrolled. RESULTS: The study identified 431,884 children from the ED with FWS. 13.53% of the children had revisits, 8.62% needed hospitalization and 1.57% developed SBI. Younger children had a higher SBI rate, but a lower revisit rate. The revisit rate was 12.22% for children aged 2-6 months, 13.61% for children aged 7-12 months and 13.77% for children aged 13-24 months (p < 0.0001). The SBI rate was 4.44% for children aged 2-6 months, 1.85% for children aged 2-6 months and 0.96% for children aged 13-24 months (p < 0.0001). Children with hemogram tests, compared to those without, had a higher revisit rate (16.30% vs. 13.15%, p < 0.0001), and a higher SBI rate in the children aged 13-24 months (1.30% vs. 0.92%, p < 0.0001); furthermore, children with urinalysis had a significantly higher revisit rate (14.42% vs. 13.24%, p < 0.0001) and higher SBI rate (2.10% vs. 1.40%, p < 0.0001). CONCLUSION: Children with FWS aged 2-24 months who were discharged from ED after blood test and urinalysis were still at risk for SBI, especially those aged 2-6 months.

Treatment of Kawasaki Disease: A Network Meta-Analysis of Four Dosage Regimens of Aspirin Combined With Recommended Intravenous Immunoglobulin.

Aspirin was once believed to reduce the mortality of Kawasaki disease (KD) due to its effect on the thrombotic occlusion of coronary arteries. However, conflicting evidence has been found regarding aspirin treatment and its benefit in patients with acute KD. We compared the efficacy of different aspirin doses in acute KD. A literature search of PubMed, EMBASE, and Cochrane databases was conducted to identify studies comparing different doses of aspirin for acute KD. The primary outcome of interest was coronary artery lesions (CAL). We used random-effects network meta-analysis. Six retrospective studies, including 1944 patients receiving aspirin in doses of 0, 3-5, 30-50, or 80-100 mg/kg/day, were selected. The risks of CAL were not significantly different for the various doses of aspirin compared to the placebo: odds ratio (OR) was 1.10 [95% confidence interval (CI): 0.70-1.71] for patients with aspirin 3-5 mg/kg/day; OR = 1.23 (95% CI: 0.67-2.26) for aspirin 30-50 mg/kg/day, and OR = 1.59 (95% CI: 0.74, 3.421) for 80-100 mg/kg/day. The P-score ranged from 0.76 for placebo to 0.19 for aspirin 80-100 mg/kg/day. The different doses of aspirin exhibited no significant difference with regard to the efficacy of CAL or with the secondary outcomes of intravenous immunoglobulin resistance or hospital stays for acute KD. Therefore, we found that treatment without any aspirin is not inferior to other doses of aspirin and can also slightly reduce the risk of CAL.

Point-of-Care Ultrasound May Reduce Misdiagnosis of Pediatric Intussusception.

Aim: Intussusception, the most common abdominal emergency in early childhood, is frequently misdiagnosed at initial presentation. The effect of using point-of-care ultrasonography (POCUS) by emergency medicine physicians on pediatric intussusception misdiagnosis rate remains unclear. Here, we summarize outcomes and misdiagnoses before and after training junior and senior physicians on using POCUS for diagnosing intussusception and compared their performance levels. Materials and Methods: This observational cohort analysis included patients with suspected intussusception who visited a pediatric emergency department (ED) between January 2017 and December 2019. All enrolled patients were evaluated by junior (<10-year experience) or senior attending physicians. Misdiagnosis was defined as a finding of negative air reduction or confirmation of diagnosis on ED revisit or admission. The misdiagnosis rates and outcomes before and after POCUS training for intussusception diagnosis were evaluated and performance of the junior and senior physicians was compared. Results: Of the 167 enrolled patients, 130 were confirmed to have intussusception by air reduction. Misdiagnosis rate was significantly lower in the post-training patient group after training than in the pre-training patient group (43.7 vs. 12.7%, P < 0.001). After training, fewer misdiagnoses were made by the junior (59.1 vs. 25.9%, P = 0.003) and senior (31.7 vs. 0%, P < 0.001) physicians. In the post-training patient group, the door-to-reduction time and rate of ultrasonography consultation with an expert also decreased significantly (118.2 ± 124.5 vs. 198 ± 250.2 min, P = 0.006). Abdominal pain (80.9%) was the most common symptom of intussusception, followed by vomiting (58.3%), fever (17.8%), bloody stool (15.4%), and diarrhea (14.2%). Even after training, the presenting symptoms of intussusception often leading junior physicians to misdiagnosis were diarrhea and fever. Conclusions: A brief POCUS training leads to decreased misdiagnosis rates in both the senior and junior physicians. Junior physicians should increase their awareness regarding diarrhea and fever being the presenting symptoms of intussusception, particularly in early childhood. Combining clinical judgment and POCUS results forms the core principle of the evaluation of children with intussusception.

Risk factors for child maltreatment by the utilization of medical service and socioeconomic environment in Taiwan.

Child maltreatment is complicated by cultural, welfare, and socioeconomic factors. However, the relationship between child maltreatment and socioeconomic factors has not been completely understood. We investigated risk factors for child abuse and neglect in Taiwan.The data in our study was obtained from Taiwan National Statistics at county level from 2004 to 2015. We included 4 areas (eastern, western, southern, northern) involving 20 cities and counties. The trends of child maltreatment rate based on different years and different areas were surveyed. In addition, panel data analysis was used to analyze the links between child maltreatment rate and socioeconomic factors.An increasing trend of child maltreatment rate in Taiwan was observed. During the past decade, child maltreatment rate increased from 14.5 in 2004 to 23.4 cases per 10000 children in 2014. The peak, which was 43 cases per 10000 children, occurred in 2012. Significant geographical differences were observed, and the highest child maltreatment rate was seen in eastern Taiwan. Panel data analysis revealed a lag effect of the unemployment rate on child maltreatment rate at the county level: the child maltreatment rate increased by 7 percent, while the prior unemployment rate increased by one percent. In addition, the medical personnel density was related to the child maltreatment rate within the county.Previous unemployment rate had a lag impact on child maltreatment occurrence. Unemployment rate has not only a direct impact on the economy but also sequential effects on child maltreatment.

Epidemiology and clinical analysis of critical patients with child maltreatment admitted to the intensive care units.

Children with abuse who are admitted to the intensive care unit (ICU) may have high mortality and morbidity and commonly require critical care immediately. It is important to understand the epidemiology and clinical characteristics of these critical cases of child maltreatment.We retrospectively evaluated the data for 355 children with maltreatments admitted to the ICU between 2001 and 2015. Clinical factors were analyzed and compared between the abuse and the neglect groups, including age, gender, season of admission, identifying settings, injury severity score (ISS), etiologies, length of stay (LOS) in the ICU, clinical outcomes, and mortality. In addition, neurologic assessments were conducted with the Pediatric Cerebral Performance Category (PCPC) scale.The most common type of child maltreatments was neglect (n = 259), followed by physical abuse (n = 96). The mean age of the abuse group was less than that of the neglect group (P < .05). Infants accounted for the majority of the abuse group, and the most common etiology of abuse was injury of the central nervous system (CNS). In the neglect group, most were of the preschool age and the most common etiologies of abuse were injury of the CNS and musculoskeletal system (P < .001). The mortality rate in the ICU was 9.86%. The ISS was significantly associated with mortality in both the 2 groups (both P < .05), whereas the LOS in the ICU and injuries of the CNS, musculoskeletal system, and respiratory system were all associated with mortality in the neglect group (all P < .05). The PCPC scale showed poor prognosis in the abuse group as compared to the neglect group (P < .01).In the ICU, children in the abuse group had younger age, higher ISS, and worse neurologic outcome than those in the neglect group. The ISS was a predictor for mortality in the abuse and neglect groups but the LOS in the ICUs, injuries of the CNS, musculoskeletal system, and respiratory system were indicators for mortality in the neglect group. Most importantly, identifying the epidemiological information may provide further strategies to reduce the harm, lower the medical costs, and improve clinical care quality and outcomes in children with abuse.

Child protection medical service demonstration centers in approaching child abuse and neglect in Taiwan.

Child abuse includes all forms of physical and emotional ill treatment, sexual abuse, neglect, and exploitation that results in actual or potential harm to the child's health, development, or dignity. In Taiwan, the Child Protection Medical Service Demonstration Center (CPMSDC) was established to protect children from abuse and neglect. We further analyzed and compared the trends and clinical characteristics of cases reported by CPMSDC to evaluate the function of CPMSDC in approaching child abuse and neglect in Taiwan. We prospectively recorded children with reported child abuse and neglect in a CPMSDC in a tertiary medical center from 2014 to 2015. Furthermore, we analyzed and compared age, gender, scene, identifying settings, time of visits, injury type, injury severity, hospital admission, hospitalization duration, and outcomes based on the different types of abuse and the different settings in which the abuse or neglect were identified. Of 361 child abuse cases (mean age 4.8 ±â€Š5.36 years), the incidence was highest in 1- to 6-year-old children (n = 198, 54.85%). Physical abuse and neglect were predominant in males, while sexual abuse was predominant in females (P < 0.001). Neglect was most common (n = 279, 75.85%), followed by physical (n = 56, 15.51%) and sexual abuse (n = 26, 7.2%). The most common identifying setting was the emergency department (n = 320, 88.64%), with neglect being most commonly reported. Head, neck, and facial injuries were more common in physically abused children than in neglected and sexual abused children (P < 0.005), leading to longer hospitalization (P = 0.042) and a higher Injury Severity Score (P = 0.043). There were more skin injuries in neglect (P < 0.001). The mortality rate was 2.49% (n = 9). The CPMSDC could enhance the ability, alertness, and inclination of professionals to identify suspected cases of child abuse, and to increase the rate of registry. Cases of physical abuse had a higher Injury Severity Score, longer duration of hospitalization, and more injuries of head, face, and neck compared with other types of abuse. The reported rate of neglect was highly elevated after the CPMSDC established during the study period. Recognition of neglect is not easy, but the consequent injury, especially asphyxia, may lead to mortality.

Risk of Tuberculosis in Children with Juvenile Idiopathic Arthritis: A Nationwide Population-Based Study in Taiwan.

OBJECTIVE: We aimed to determine the risk of tuberculosis in children with juvenile idiopathic arthritis (JIA) in Taiwan. METHODS: We used the Taiwan National Health Insurance Research Database (NHIRD) to conduct a nested case-control study. We identified a JIA cohort and matched each JIA child with non-JIA children for comparison. Methotrexate (MTX), tumor necrosis factor (TNF) inhibitor administration, and new tuberculosis cases were determined during our study period. To compare tuberculosis (TB) risk among our study groups, Cox proportional regression models were used to determine adjusted hazard ratios (aHRs). RESULTS: We identified 1495 children with JIA and 11592 non-JIA children. Majority (68.7%) children with JIA had not received MTX or TNF inhibitors; 23.9% used MTX without TNF inhibitors, and 7.4% received TNF inhibitors, irrespective of MTX administration. In total, 43 children developed tuberculosis. The overall tuberculosis infection rate for children with JIA was two times higher than that for non-JIA children. Compared with non-JIA children, children with JIA who used MTX without TNF inhibitors revealed a significantly increased of tuberculosis infection rate (aHR = 4.67; 95% CI: 1.65-13.17; P = 0.004). Children with JIA who either received TNF inhibitors or never used MTX and TNF inhibitors revealed a tuberculosis infection rate comparable to that of non-JIA children. CONCLUSIONS: Analysis of nationwide data of Taiwan suggested that children with JIA were at higher risk of tuberculosis compared with those without JIA.

Clinical features of adult and pediatric anaphylaxis in Taiwan.

BACKGROUND: Most epidemiologic studies of anaphylaxis have been on Western populations, leaving the clinical and demographic pattern of this acute allergic condition in Asia unclear. OBJECTIVE: To investigate the clinical characteristics of patients with anaphylaxis in Chang Gung Memorial Hospital, the largest medical center in Taiwan. METHODS: We conducted a retrospective analysis of 201 patients who visited the emergency department or were admitted to the hospital for anaphylaxis from 2000 to 2010. We analyzed the causes, clinical presentation, and management, and also compared adult and pediatric cases. RESULTS: The average patient age was 43.3 years. Mortality from anaphylaxis was 0.5% (1/201). The annual number of cases presenting with anaphylaxis increased throughout the decade we studied. Seven types of etiology were identified: medication (53%), contrast medium (24%), idiopathic condition (8%), food (5%), blood transfusion (4%), insect sting (3%), and others (3%). Skin and respiratory presentations are more common in children than in adults (skin presentation, 81% vs. 51%, p = 0.002); respiratory presentation, 74% vs. 49%, p = 0.011), and cardiovascular presentation is more frequent in adults than in children (83% vs. 61%, p = 0.006). Clinical presentations with angioedema, gastro-intestinal and neurological system involvement, and management were not significantly different between adults and children. CONCLUSIONS: We conclude that anaphylaxis in Taiwan appears to be increasing, just as in the West, but shows a different clinical picture; medication rather than food was the most common cause of anaphylaxis in our population. Moreover, food-induced anaphylaxis in children is not so prevalent in Taiwan.