Predictors of ventriculoperitoneal shunt pathology.

BACKGROUND: Diagnosis of ventriculoperitoneal (VP) shunt pathology remains a dilemma in patients with nonspecific constitutional signs and symptoms. Eosinophilia has been described in association with shunt infection and malfunction. Our purpose was to further define the relationship of eosinophilia and shunt pathology and to determine other predictors of VP shunt infection and malfunction. METHODS: Records of all patients admitted with a suspected VP shunt infection or malfunction were reviewed. The following data were abstracted: age; reason for and age at initial shunt placement; number of revisions; date of last revision; history of fever or vomiting; ventricular fluid cell count; differential and culture; complete blood count and differential; need for shunt revision or replacement; and use of antibiotics. After exclusion of patients admitted for initial shunt placement, the remainder were divided into three groups: those with shunt infection; those with shunt malfunction; and those without documented infection or malfunction. RESULTS: Of 12 patients with shunt infection and 69 with shunt malfunction, 2 and 11, respectively, had eosinophilia defined as > or =5%. The presence of eosinophilia had a 96% positive predictive value for shunt pathology and raised the pretest probability of pathology from 84% to a post test probability of 96%. The combination of fever history and ventricular fluid neutrophils >10% had a 99% specificity for shunt infection, had a 93 and 95% positive and negative predictive value, respectively, and raised the pretest probability of infection from 12% to a posttest probability of 92%. CONCLUSIONS: In patients suspected of having a VP shunt malfunction, the presence of > or =5% eosinophils in the ventricular fluid indicates shunt pathology. The combination of fever and ventricular fluid neutrophils > 10% is predictive of shunt infection.

The potential for errors in children with special health care needs.

Children with special health care needs (CSHCN) are at risk for suboptimal treatment when presenting for emergent care to unfamiliar health care providers. Errors in their management may stem from failure to recognize occult conditions, lack of familiarity with rare or complex medical problems, or lack of prior knowledge of baseline physical findings. An emergency information form (EIF) that contains patient-specific information on essential diagnostic and therapeutic interventions may provide a ready personal reference for the emergent care of CSHCN. Coupled with the use of medical identification jewelry and an electronic transmission system, an EIF has the potential to eliminate management errors in the care of these patients.

The objective structured clinical examination: a step in the direction of competency-based evaluation.

BACKGROUND: The Accreditation Council for Graduate Medical Education is embarking on the major task of a paradigm shift in graduate education in the direction of competency-based medical education and evaluation of outcomes. The Objective Structured Clinical Examination (OSCE), a measure of clinical competence that focuses on outcomes via observable behaviors, is gaining national recognition. OBJECTIVE: To review the pediatric literature relevant to the OSCE. METHOD: A MEDLINE search from the date of the original report of the OSCE (1975) to the present was performed. All English-language studies regarding the use of the OSCE in pediatric education published in the United States and Great Britain were reviewed. MAIN OUTCOME MEASURES: Reliability and validity of the OSCE were examined. Use of standardized pediatric patients was discussed. RESULTS: A greater number of stations and similarity between tasks at different stations increased the reliability of the OSCE. A greater number of stations increased sampling of material and content validity. Correlation between the OSCE and precertification examinations ranged between 0.59 and 0.71, with P< or =.01. Correlation between the OSCE and monthly clinical evaluations was much lower (0.39-0.57), but still statistically significant at P< or =.05. Gaps between expected and actual performance were documented. Overall, the experience of being a standardized patient was viewed as positive by children and their parents. CONCLUSIONS: With appropriate attention to design, acceptable reliability and validity can be achieved for the OSCE. Significant correlations between the OSCE and precertification examinations as well as monthly clinical evaluations were found, the former being stronger than the latter. We conclude that the combination of the OSCE, standardized board examinations, and direct observation in the clinical setting has the potential to become the "gold standard" for measuring physician competence.

Acceptance of family member presence during pediatric resuscitations in the emergency department: effects of personal experience.

OBJECTIVE: Opinions remain polarized on allowing family member presence during pediatric resuscitations (FMP). Reluctance to adopt FMP may stem from preconceived notions on this practice. This study evaluates the effect of prior experience with FMP and on its acceptance by emergency department personnel (EDP). METHODS: EDP from three different EDs were surveyed concerning FMP. Study facilities included an urban teaching community ED with routine FMP (R-ED), a suburban community ED with occasional FMP (O-ED) and an urban university pediatric ED with virtually no FMP (N-ED) during pediatric resuscitations. Survey information included hospital of practice, position in ED, years in practice, opinions on FMP and personal experience with FMP for five clinical scenarios: laceration repair (LAC), intravenous access (IV), lumbar puncture (LP), endotracheal intubation (ETI), cardiopulmonary resuscitation (CPR), and critical resuscitation (CR). Statistical analysis was through chi square and regression analysis. RESULTS: Eighty-five emergency department personnel participated in the survey, 57 (67%) nurses, 22 (25%) physicians, 4 technicians (5%), and 2 nurses aids (2%). There was a significant correlation between a favorable opinion concerning family member presence during LP, ETI, CPR and CR and the type of Emergency Department in which the individual practiced (P<0.002). Regression analysis demonstrated a similar relation between personal experience with LAC, IV, ETI, CR, and CPR and a favorable opinion on FMP during that activity (P<0.03). CONCLUSION: Opinions on FMP are strongly influenced by experience with this practice. Emergency department personnel with prior exposure to family member presence during resuscitations favor this activity. Biases by EDP lacking experience with FMP may limit its introduction into unfamiliar institutions.

Home schooled children: a pediatric perspective.

To explore the attitudes and self-assessed knowledge of pediatricians regarding home schooling and determine whether practices provide preventive services typically rendered by the school system, we surveyed pediatricians in Wisconsin and Maryland (high versus low rates of home schooling, respectively). Of the 598 (53%) responding, only 18% supported home schooling. They judged home-schooled children to perform at an average (58%) or below average (12%) level on standardized tests and regarded them to be less mature than their peers (51%). These opinions differ from studies published in the educational literature. Many practitioners do not perform routine vision (18%) or hearing (83%) screens or monitor for overdue immunizations (71%). As pediatricians and child advocates, we need to become more knowledgeable about home schooling and provide preventive services for these children.

Family member knowledge of children's medical problems: the need for universal application of an emergency data set.

OBJECTIVE: Advances in medical care have led to a growing population of special needs children who are at risk for suboptimal care when they present to a physician with no previous knowledge of their medical history. This risk may be amplified in the emergency department setting when time-sensitive interventions must be initiated without immediate access to consultants or past records. Our purpose in this study was to evaluate caretakers' knowledge of their children's chronic medical problems and their ability to relate this knowledge to unfamiliar health care providers. METHODS: Caretaker/child pairs presenting for specialty visits were surveyed. Questions focused on knowledge of the child's illness, medicine regime, and how to contact the specialist. Chart review confirmed responses of caretakers and provided sociodemographic information. Descriptive statistics and chi2 were used in data analysis. RESULTS: Of the 49 caretakers interviewed, 85% were parents, 53% were African-American, and 43% were Caucasian. One-half of the group received medical assistance. The mean age of the children was 55 months. Responses showed that 53% of caretakers were unable to provide their children's specific diagnoses. Of these, one half could provide a lay diagnosis whereas the remaining one half could only identify the organ system involved or that there was a problem. For children on medications, 29% of caretakers could not provide an accurate list. Name of the subspecialist and phone number of the subspecialty clinic was unknown by 25% of caretakers. No child wore medical identification jewelry. CONCLUSIONS: Caretakers are not always able to accurately relay vital information on their child's essential medical needs, a problem that may be compounded in emergency situations. The use of some form of independent identification and information set is needed to assure proper treatment of children with special health care needs encountering an unfamiliar health care provider.

Subcutaneous lidocaine does not affect the success rate of intravenous access in children less than 24 months of age.

OBJECTIVE: To determine whether subcutaneous lidocaine (SQL), when used to decrease the pain of IV catheter insertion, adversely affects IV access in children < 24 months of age. METHODS: A historically controlled comparison of IV access successes with and without SQL in children < 2 years of age was performed in a 30,000-annual-visit community hospital ED. On-site data collected at the time of IV placement included: patient age, weight, hydration status, number of attempts, and location of attempts. All patients had IV attempts made by the same emergency physician. RESULTS: A total of 110 children, mean age 9.6 +/- 6.9 months, were included in the study analysis. Of the 110, 70 had an IV catheter placed with no pretreatment, while 40 had SQL pretreatment. The average number of attempts for all patients was 1.36 +/- 0.73, with 83 (75%) performed successfully in 1 attempt and 101 (91%) within 2 attempts. The mean numbers of attempts were similar for the control and SQL groups: 1.34 vs 1.40, respectively (p = 0.68), as were the proportions successful in 1 attempt (77% vs 73%; p = 0.58) and within 2 attempts (91% vs 90%; p = 0.84). CONCLUSION: SQL use prior to an IV attempt in children < 2 years of age does not impact vascular access. A secondary finding was that vascular access with and without SQL in infants and small children generally can be accomplished in 1 attempt.

Lidocaine for lumbar punctures. A help not a hindrance.

OBJECTIVE: To determine whether premedication for lumbar puncture (LP) with lidocaine hinders collection of cerebrospinal fluid (CSF) through either increased number of attempts or increased incidence of traumatic punctures. DESIGN: A randomized controlled trial. SETTING: The pediatric emergency department of an innercity teaching hospital. PATIENTS: A convenience sample of 100 children, younger than 3 years, who required an LP as part of their diagnostic workup. INTERVENTION: Patients were randomized to receive either lidocaine or no local anesthetic before undergoing an LP. MAIN OUTCOME MEASURES: Comparison of the number of attempts needed to obtain CSF and the number of traumatic LPs between the lidocaine-treated and no local anesthetic groups. RESULTS: The 51 patients randomized to receive lidocaine did not differ markedly in age from the 49 patients randomized to receive no local anesthetic. Ease of obtaining CSF, as measured by number of attempts, did not differ with 59% of the patients in each group requiring 1 attempt. Defining a traumatic LP as more than 1000 x 10(6)/L red blood cells in the CSF showed notably more traumatic LPs in the lidocaine-treated group. Defining a traumatic LP as one with more than 10,000 x 10(6)/L red blood cells in the CSF showed no significant difference in the number of traumatic LPs whether or not the patient was premedicated with lidocaine. The level of experience of the physician performing the LP did not affect the outcome. CONCLUSIONS: Premedication with lidocaine for an LP does not binder the ease of obtaining CSF. The clinical relevance of a greater number of traumatic LPs in the lidocaine-treated group is questionable because this finding is negated when traumatic is defined as more than 10,000 x 10(6)/L CSF red blood cells. Based on these results, we advocate premedication with a local anesthetic when an LP is performed in the pediatric emergency department.

Family member presence during pediatric emergency department procedures.

OBJECTIVE: Exclusion of family members (FM) during pediatric procedures in the emergency department (ED) is an accepted practice. This study questions the validity of such a practice. SUBJECTS: FM of ED pediatric patients undergoing procedures and ED staff performing procedures. SITES: ED of a tertiary care university-affiliated community hospital and the pediatric ED of a university hospital. METHODS: Post-procedure surveys were obtained from FM remaining with their child during an ED procedure and from the ED personnel performing the procedures. FM activity during the procedure was also recorded. RESULTS: Ninety-six children (average age 20 months) underwent a total of 127 procedures. ED procedures included: vascular access 91, lumbar puncture 23, urethral catheterization 9, nasogastric tube placement 1, rapid sequence intubation 1, fluid resuscitation from shock 1, and removal of foreign body from eye 1. Three children were critically ill during performance of procedures. ED staff answered 98 surveys concerning the performance of the 127 procedures. FM ACTIVITIES INCLUDED: Stood at bedside 35 (31%), soothed child 21 (19%), and helped restrain child 55 (55%). In 55 (57%) cases the FM was the only adult present with the ED staff member performing the procedure(s). FM MEMBER OPINIONS OF PRESENCE DURING PROCEDURES WERE: Good idea 101 (91%), bad idea 6 (5%), and did not care 4 (4%). ED staff opinions were: good idea 92 (93%), bad idea 2 (2%), and did not care 4 (5%). FM presence made four (5%) members of the ED staff nervous. CONCLUSION: FM presence during ED procedures is a practice favored by both parents and ED staff at our institutions. This practice should not be limited to minimally invasive procedures in stable patients but should be considered for procedures such as lumbar punctures and intubations even in critically ill patients.

Cerebrospinal fluid analysis in systemically ill children without central nervous system disease.

OBJECTIVE: Experience led us to question the applicability of standards for normal cerebrospinal fluid (CSF), originally developed in healthy children, to children with systemic illness but without central nervous system (CNS) infection. The purpose of this study was to test our hypothesis that systemically ill children, in the absence of CNS infection, have an elevated CSF white blood cell count and a greater percentage of neutrophils than accepted norms. METHODS: We enrolled 345 patients in the following diagnostic categories: infants 1 month of age or younger with possible sepsis (n = 95), patients older than 1 month of age with possible sepsis (n = 155), patients with a focus of infection in close proximity to the CNS (n = 51), and patients presenting with seizures and fevers (n = 45). Sociodemographic data and results of CSF examination were abstracted from the medical records. Statistical analysis systems were used for data processing. RESULTS: The CSF white blood cell count did not significantly differ from standards except for a lower mean count in the group presenting with seizures. The percent of CSF neutrophils was significantly greater than standards, however, for those patients older than 1 month of age with possible sepsis, those with a focus of infection in close proximity to the CNS, and those presenting with seizures. Data analysis by quantiles shows only 25% to 50% of patients, in each of the diagnostic categories, meeting the current definition of normal CSF neutrophil count. CONCLUSIONS: Our results show that a mean of at least 5% neutrophils may be present in the CSF with a diagnosis of fever without a source, a focus of infection in close proximity to the CNS, or a seizure with fever in the absence of CNS infection. These data support tailoring treatment based on clinical assessment rather than what is considered an abnormal CSF neutrophil count by current standards.

Follow-up: who does it and how do they do it?

Follow-up appointments and phone contact after discharge are important components of the emergency department (ED) encounter. We surveyed ED directors at hospitals with accredited pediatric residency programs to determine mechanisms for follow-up 1) to chart progression of illness (POI), 2) for positive laboratory or x-ray results, and 3) for specific illness such as child abuse, burns, and complex wounds. One hundred thirty-five of 207 program directors responded (65%). To follow POI, 54% of EDs use the ED itself, and 59% send patients to community physicians. Of those that use community physicians, 24% do not notify the physician to expect a follow-up visit, and 27% do not send a copy of the ED chart to a physician's office. To follow POI, 20% of EDs have no formal mechanism for telephone follow-up. Sixteen percent keep no record of phone contact. For follow-up of positive laboratory tests or x-rays, results are better; only 4 and 5%, respectively, do not keep records of phone contact. Eleven percent of EDs have no mechanism for follow-up of child abuse. Mechanisms for follow-up of children seen in the ED are variable. We have identified deficiencies in the following areas: 1) lack of communication with the physician to provide follow-up, 2) lack of documentation regarding subsequent patient contacts for POI and positive test results, and 3) lack of resources to follow victims of child abuse. These deficiencies have potential implications regarding optimal patient outcome.

Hand-held metal detector identification of ingested foreign bodies.

The study purpose was to determine the ability of hand-held metal detectors (HHMDs) to identify the presence of ingested metallic foreign bodies (MFBs). Twenty-three children presenting to the emergency department with a complaint of MFBs ingested were enrolled. Sixteen of 23 patients had radiographically proven foreign bodies. The MFBs comprised coins (n = 11), a button battery (n = 1), a medallion (n = 1), a token (n = 1), a needle (n = 1), and a marble (leaded glass) (n = 1). The HHMD correctly detected 15 of 16 radiographically positive MFBs (93%) and correctly excluded a potential MFB in six of six radiographically negative cases. The only foreign body not detected was an ingested needle. One radiograph was equivocal. Radiographic localization of the ingested objects was as follows: esophagus, n = 4; stomach, n = 9; and intestines, n = 3. The HHMD correctly localized all detected MFBs. The HHMD had a sensitivity of 94%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 86%. HHMDs are effective screening devices for possible ingested MFBs. Positive studies localized to the stomach and lower gastrointestinal tract do not require confirmatory radiographic studies.

Subcutaneous fat necrosis of the newborn: link to maternal use of cocaine during pregnancy.

Cocaine has received much attention in the literature for its effects on the mother/infant pair when used during pregnancy. We describe a neonate who presents with wide-spread subcutaneous fat necrosis (SCFN), an as-yet-unreported finding that appears to be related to maternal use of cocaine during pregnancy.