Seronegative autoimmune hepatitis in children : A real diagnostic challenge.

BACKGROUND AND AIM: Classical autoimmune hepatitis (AIH) is characterized by the presence of conventional autoantibodies (anti-smooth muscle, antinuclear and anti-liver-kidney-microsomal antibodies). The absence of such autoantibodies in some patients does not preclude AIH diagnosis or the need for its treatment. This group of patients was termed seronegative AIH. Whether non-conventional autoantibodies can identify this group of patients is still elusive. We aimed to study the prevalence of seronegativity of conventional autoantibodies and the occurrence of non-conventional autoantibodies in children with AIH. METHODS: In this study, 55 children with AIH were investigated for non-conventional autoantibodies (anti-neutrophil cytoplasmic antibodies, antibodies to soluble liver antigen, anti-tissue transglutaminase and antiplatelet antibodies). All the patients received immunosuppressive therapy and were assessed for treatment response. RESULTS: Of the patients 44 had classical AIH (type 1, 70.09%, type 2, 9.09%) and 20% were seronegative. The four studied non-conventional autoantibodies occurred in four patients, one for each. All non-conventional autoantibodies were exclusively associated with type 1 AIH. The clinical profile, ultrasonographic findings, liver biochemistry and histopathological findings were comparable in the classical and seronegative AIH. The majority of patients with classical (72.7%) and seronegative (54.5%) AIH were treatment responders. CONCLUSION: Seronegative AIH represents a substantial percentage of pediatric patients diagnosed with AIH. They were even negative for non-conventional autoantibodies. Furthermore, apart from autoantibodies, seronegative AIH is almost indistinguishable from the classical AIH and the majority of patients were treatment responders. This favorable response to immunosuppression deserves sustainable efforts for considering such a diagnosis and start therapy to halt disease progression is worthwhile.

Effects of Patient Characteristics on Diagnostic Performance of Self-Collected Samples for SARS-CoV-2 Testing.

We evaluated the performance of self-collected anterior nasal swab (ANS) and saliva samples compared with healthcare worker-collected nasopharyngeal swab specimens used to test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We used the same PCR diagnostic panel to test all self-collected and healthcare worker-collected samples from participants at a public hospital in Atlanta, Georgia, USA. Among 1,076 participants, 51.9% were men, 57.1% were >50 years of age, 81.2% were Black (non-Hispanic), and 74.9% reported >1 chronic medical condition. In total, 8.0% tested positive for SARS-CoV-2. Compared with nasopharyngeal swab samples, ANS samples had a sensitivity of 59% and saliva samples a sensitivity of 68%. Among participants tested 3-7 days after symptom onset, ANS samples had a sensitivity of 80% and saliva samples a sensitivity of 85%. Sensitivity varied by specimen type and patient characteristics. These findings can help physicians interpret PCR results for SARS-CoV-2.

Management of Minor Traumatic Brain Injury in an ED Observation Unit.

INTRODUCTION: Traumatic intracranial hemorrhages (TIH) have traditionally been managed in the intensive care unit (ICU) setting with neurosurgery consultation and repeat head CT (HCT) for each patient. Recent publications indicate patients with small TIH and normal neurological examinations who are not on anticoagulation do not require ICU-level care, repeat HCT, or neurosurgical consultation. It has been suggested that these patients can be safely discharged home after a short period of observation in emergency department observation units (EDOU) provided their symptoms do not progress. METHODS: This study is a retrospective cross-sectional evaluation of an EDOU protocol for minor traumatic brain injury (mTBI). It was conducted at a Level I trauma center. The protocol was developed by emergency medicine, neurosurgery and trauma surgery and modeled after the Brain Injury Guidelines (BIG). All patients were managed by attendings in the ED with discretionary neurosurgery and trauma surgery consultations. Patients were eligible for the mTBI protocol if they met BIG 1 or BIG 2 criteria (no intoxication, no anticoagulation, normal neurological examination, no or non-displaced skull fracture, subdural or intraparenchymal hematoma up to 7 millimeters, trace to localized subarachnoid hemorrhage), and had no other injuries or medical co-morbidities requiring admission. Protocol in the EDOU included routine neurological checks, symptom management, and repeat HCT for progression of symptoms. The EDOU group was compared with historical controls admitted with primary diagnosis of TIH over the 12 months prior to the initiation of the mTBI protocols. Primary outcome was reduction in EDOU length of stay (LOS) as compared to inpatient LOS. Secondary outcomes included rates of neurosurgical consultation, repeat HCT, conversion to inpatient admission, and need for emergent neurosurgical intervention. RESULTS: There were 169 patients placed on the mTBI protocol between September 1, 2016 and August 31, 2019. The control group consisted of 53 inpatients. Median LOS (interquartile range [IQR]) for EDOU patients was 24.8 (IQR: 18.8 - 29.9) hours compared with a median LOS for the comparison group of 60.2 (IQR: 45.1 - 85.0) hours (P < .001). In the EDOU group 47 (27.8%) patients got a repeat HCT compared with 40 (75.5%) inpatients, and 106 (62.7%) had a neurosurgical consultation compared with 53 (100%) inpatients. Subdural hematoma was the most common type of hemorrhage. It was found in 60 (35.5%) patients, and subarachnoid hemorrhage was found in 56 cases (33.1%). Eleven patients had multicompartment hemorrhage of various classifications. Twelve (7.1%) patients required hospital admission from the EDOU. None of the EDOU patients required emergent neurosurgical intervention. CONCLUSION: Patients with minor TIH can be managed in an EDOU using an mTBI protocol and discretionary neurosurgical consults and repeat HCT. This is associated with a significant reduction in length of stay.

Atypical Presentation of Cervical Carcinoma With Cerebral Metastasis.

BACKGROUND: Cervical cancer is a leading cause of morbidity and mortality in women, but cerebral metastasis from cervical carcinoma is a rare event with a reported incidence of 0.57%. CASE REPORT: We describe a case of brain metastasis from primary cervical adenocarcinoma with several distinct features. This case illustrates uncommon presenting neurologic symptoms, a rare combination of histopathologic features, and atypical findings on radiographic evaluation. CONCLUSION: Clinicians must maintain a high index of suspicion for cerebral metastasis to make an accurate diagnosis and initiate appropriate management of advanced cervical cancer.

Increase in moped injuries requiring emergency care.

BACKGROUND: There has been a marked increased in moped use over the past few years. In addition, there has been an increase in moped-related injuries presenting to the emergency department (ED). The objective of this study is to characterize moped-related injuries presenting to US EDs and obtain national estimates of moped injury incidence over time. METHODS: Data regarding moped injuries were queried from the National Electronic Injury Surveillance System from calendar year 2007 to 2015. Data included diagnosis, body part injured, ED disposition, and patient demographics. RESULTS: There were an estimated 114 729 moped-related injuries treated in US EDs from 2007 to 2015 (95% confidence interval, 102 156-127 302). In addition, there was an increase in the number of moped injuries annually (B = 762.1, P < .01). The average number of moped injuries yearly was 12 748. The mean age was 34 years. Patients between ages 19 and 38 years represented 42% of the study population. Men (74%) and whites (55%) accounted for most of the injured population. Most injuries were stabilized in the ED and discharged home (85%). Approximately 9% of injuries were admitted to the hospital, and fractures constituted 59% of all diagnoses admitted to the hospital. Contusions (27%) and fractures (24%) accounted for most diagnoses. The most common body part injured was the head (16%). CONCLUSIONS: Moped injuries have increased since 2007 and mopeds are associated with severe injuries. Education and reexamination of current moped laws may decrease the number and severity of moped-related injuries.

Safety and Efficacy of Ureteral Stent Placement at the Bedside Using Local Anesthesia.

PURPOSE: Ureteral stent placement for decompressing renal units obstructed by calculi is safe and can be potentially lifesaving in the prompt resolution of the sequelae of renal obstruction, infection and an obstructing stone. At many institutions there can be prolonged delay in getting patients to the operating room for stent placement. We hypothesized that it is safe and efficacious to attempt ureteral stent placement using local anesthesia at the bedside without live fluoroscopic guidance. MATERIALS AND METHODS: Patients presenting with symptomatic, obstructing ureteral calculi were given the option of bedside ureteral stent placement. Viscous lidocaine was placed into the urethra before flexible cystoscopic examination. A 260 cm Glidewire® was used as initial access with only 1 attempt at passage. All stent placements were confirmed with immediate post-procedure radiograph. Prospectively collected data were retrospectively analyzed for all patients who underwent attempted bedside ureteral stent placement. RESULTS: A total of 42 patients underwent attempted bedside stent placement under local anesthesia without fluoroscopic guidance. Mean stone size was 8.3 mm and 71% of stones were in the proximal ureter. Ureteral stent placement was pursued in 14% of patients for infection and in 59% for intractable pain. Ureteral stent placement was successful in 30 patients (71%). Statistical analysis did not reveal any significant predictors of successful stent placement in this cohort of patients. CONCLUSIONS: In our cohort bedside ureteral stent placement was well tolerated, safe and efficacious, thus expediting upper tract decompression in the setting of obstructed renal units in more than 70% of patients.

Characteristics of United States Emergency Department Visits for Traumatic Amputations in the Elderly Adult from 2010 to 2013.

BACKGROUND: Elderly adults (65 years of age and older) are of particular concern for traumatic amputations due to age-related changes in vision and coordination, making them more susceptible to injury. OBJECTIVES: The objective of this study is to describe the epidemiology of traumatic amputations in the elderly adults treated in United States emergency departments (ED). DESIGN: A retrospective analysis using data from the National Electronic Injury Surveillance System from 2010 to 2013. PARTICIPANTS: People aged 65 years and older treated in U.S. hospital EDs for traumatic amputations from 2010 to 2013. RESULTS: There were 15,611 elderly patients treated for amputations from 2010 to 2013, averaging 3,902 amputations per year in the United States. The frequency of amputations declined with increasing age. The mean age was 74 years old. Males represented 84% of the cohort. The majority of the injuries that were recorded took place at home (71%). The most common associated consumer products were saws, lawnmowers, and doors. Saws accounted for approximately 45% of amputations. In females, doors were the most common consumer product associated with amputations. Approximately 45% of amputations were complete amputations. The most common digit to be amputated was the thumb (24%). Approximately 72% of the cases in the cohort were treated and released from the ED. CONCLUSION: Traumatic amputations in elderly adults were frequently due to saws and lawnmowers. An increase in injury prevention efforts in this patient population is warranted.

Improving Quality of Emergency Care Through Integration of Mental Health.

The goal of this study was to better integrate emergency medical and psychiatric care at a large urban public hospital, identify impact on quality improvement metrics, and reduce healthcare cost. A psychiatric fast track service was implemented as a quality improvement initiative. Data on disposition from the emergency department from January 2011 to May 2012 for patients impacted by the pilot were analyzed. 4329 patients from January 2011 to August 2011 (pre-intervention) were compared with 4867 patients from September 2011 to May 2012 (intervention). There was a trend of decline on overall quality metrics of time to triage and time from disposition to discharge. The trend analysis of the psychiatric length of stay and use of restraints showed significant reductions. Integrated emergency care models are evidence-based approach to ensuring that patients with mental health needs receive proper and efficient treatment. Results suggest that this may also improve overall emergency department's throughput.

Tricycle Injuries Presenting to US Emergency Departments, 2012-2013.

OBJECTIVE: To investigate the characteristics of tricycle-related injuries in children presenting to US emergency departments (EDs). METHODS: Data regarding tricycle injuries in children younger than 18 years of age were obtained from the National Electronic Injury Surveillance System for calendar years 2012 and 2013. Data included body regions injured, ED disposition, and demographics. RESULTS: There were an estimated 9340 tricycle-related injuries treated in US EDs from 2012 to 2013. The average age was 3 years. Children 2 years of age had the highest frequency of injuries. Boys accounted for 63.6% of all injuries. Children 1 to 2 years of age represented 51.9% of all injuries. Lacerations were the most common type of injury. Internal organ damage was the most common type of injury in 3- and 5-year-olds. Contusions were the most common type of injury in 1- and 7-year-olds. The head was the most commonly injured region of the body and the most common region to endure internal damage. The elbows were the most commonly fractured body part. The upper extremity was more frequently fractured than the lower extremity. Approximately 2.4% of all injured children were admitted to the hospital. CONCLUSIONS: The upper extremity of children, particularly the elbow, was more frequently fractured than the lower extremity. The head was the most common body part to endure internal damage. By elucidating the characteristics of tricycle-related injuries, preventive measures can be implemented to decrease the incidence of tricycle-related injuries and ED visits.

Choice of motorcycle helmet makes a difference: a prospective observational study.

BACKGROUND: Although many states mandate that motorcyclists wear helmets, their laws do not indicate which type of helmet should be used. In addition, there are no prospective studies in the literature evaluating patterns of injuries as they relate to helmet type. The hypothesis in this study was that full-face helmets (FFHs) reduce craniofacial injuries associated with motorcycle collisions when compared with other helmet types. METHODS: A prospective observational study was conducted at a Level I trauma center to evaluate the efficacy of helmet types relative to craniofacial injuries. Data included patient demographics, helmet types, injuries, and outcomes. The incidences of facial fractures, skull fractures, and traumatic brain injuries (TBIs) were compared in patients wearing FFHs versus other helmet types (OH) during motorcycle crashes. RESULTS: From 2011 to 2012, 151 patients of motorcycle crashes (135 males, 16 female; mean age, 38.4 years; range, 19-74 years) whose helmet types were identified by health care providers were entered into the study. The distribution of helmets was 84 FFH and 67 OH (39 half and 28 modular). Facial fractures were present in 7% of the patients wearing FFH (95% confidence interval, 0.015-0.125) versus 27% (95% confidence interval, 0.164-0.376) of those wearing OH (p = 0.004). In addition skull fractures were present in 1% of the patients wearing FFH versus 8% in those wearing OH (p < 0.05). While there was a trend for patients wearing FFH to have a lower incidence of TBI (13% vs. 25% in those wearing OH), this was not statistically significant (p = 0.053). There were no differences in Injury Severity Score (ISS), length of stay, or mortality between the two groups. CONCLUSION: Victims of motorcycle crashes who are wearing FFH have a significant reduction in facial and skull fractures when compared with those wearing OH. Further studies will be needed to assess whether FFH will significantly decrease the incidence of TBI. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Design and implementation of an interdisciplinary pediatric mock code for undergraduate and graduate nursing students.

Higher patient acuity and shortage of healthcare professionals have led to an expansion in the role and responsibilities for nurses, and ultimately, nursing students. Nursing faculty are challenged to develop strategies based on core competencies to obtain optimal practice within this complex system. Use of patient simulators is an effective strategy as it allows for deliberate practice of skills and standardized exposure to limited scenarios. The rarity of pediatric codes and opportunities for students to interact in teams led faculty to develop an interdisciplinary pediatric mock code simulation. Senior baccalaureate students function as members of a pediatric code team with emergency nurse practitioner students as code team leaders. Student preparation included Web-based information and an interactive class on code skills and team communication during a sentinel event. The scenario incorporated team roles and family-centered care. The debriefing session reinforced the evidence and reviewed quality improvement and safety through error identification and patient consequences. A total of 43 BSN students and 12 emergency nurse practitioner students participated. The simulation was rated very highly for realism, enjoyment, concept clarification in debriefing, increasing knowledge base, ability to function in the clinical setting, and increasing confidence in caring for a critically ill infant.

The use of simulation and a modified TeamSTEPPS curriculum for medical and nursing student team training.

INTRODUCTION: We describe our adaptation of the team strategies and tools to enhance performance and patient safety (TeamSTEPPS) for use as an educational intervention for medical and nursing students. We hypothesized that participation in a team training program using the modified TeamSTEPPS program would positively affect knowledge and attitudes toward teamwork skills and their ability to recognize the presence and quality of team skills. METHODS: Two hundred thirteen students participated in a 4-hour team training program that included a lecture followed by small group team training exercises. Nurse/physician pairs facilitated student team activities. Knowledge and attitudes were assessed before and after the educational intervention. Recognition of team skills was assessed using videos. RESULTS: Statistically significant differences were found with participant knowledge (P<0.001) and attitude (P=0.004). Students were able to identify the presence and quality of team skills in the video vignettes. Overwhelmingly, the students recognized team skills much better in the success video than in the opportunity video (P<0.001), and they rated the success video much higher than the opportunity video (P<0.001) with regards to the quality of team skills. CONCLUSIONS: We successfully adapted TeamSTEPPS for use with our medical and nursing students, educated facilitators, and implemented the course. Our students improved their knowledge of vital team and communication skills, attitudes toward working as teams, and were able to identify effective team skills.

Comparison of laboratory values obtained by phlebotomy versus saline lock devices.

OBJECTIVES: To assess the utility of a peripheral saline lock device (SLD) as an alternative to a second venipuncture for obtaining selected blood samples. METHODS: This prospective study used a comparative design and was conducted in an urban emergency department (ED). Adult patients with an existing SLD in place who required serial phlebotomy were eligible for inclusion in the study. Each subject had blood samples obtained by venipuncture (control) with a Vacutainer adapter according to standard protocols. Within 5 minutes of obtaining the control samples, a sample was obtained from the patients' SLDs; a tourniquet was applied proximal to the intravenous line, a 5-mL waste portion was obtained, and a Vacutainer adapter was placed to draw specimens for testing. Each of the paired samples was analyzed for hematocrit, electrolytes, and cardiac enzymes. The Bland-Altman method was used to analyze the concordance between each pair of measurements. Paired t-tests for each of the eight laboratory tests were used to assess whether the values were statistically different from each other. The 95% limits of agreement around the mean differences were calculated. Differences between SLD aspirates and venipuncture aspirates also were compared with the federal regulatory standards that ensure reliable and accurate laboratory testing. RESULTS: Eighty-one patients were eligible for the study; in 73 (90.1%; 95% confidence interval [CI] = 81.5% to 95.6%) of the patients, the SLD could be aspirated for testing. The paired t-tests indicated that there were no statistically significant differences between the mean values of the two methods of testing. Of the 584 paired values analyzed, 35 (6.0%; 95% CI = 4.3% to 8.2%) exceeded the Bland-Altman limits of agreement, and 43 (7.4%; 95% CI = 5.4% to 9.8%) fell outside the acceptable range determined by the federal regulation of clinical laboratories. Of those values that exceeded the acceptable Bland-Altman limits of agreement, none would have resulted in clinical intervention. CONCLUSIONS: Aspirating blood via an SLD is an acceptable method of obtaining serial laboratory values in a group of stable, consenting adult ED patients.