A Novel Risk Score to Guide the Evaluation of Acute Hematogenous Osteomyelitis in Children.

OBJECTIVES: To identify independent predictors of and derive a risk score for acute hematogenous osteomyelitis (AHO) in children. METHODS: We conducted a retrospective matched case-control study of children >90 days to <18 years of age undergoing evaluation for a suspected musculoskeletal (MSK) infection from 2017 to 2019 at 23 pediatric emergency departments (EDs) affiliated with the Pediatric Emergency Medicine Collaborative Research Committee. Cases were identified by diagnosis codes and confirmed by chart review to meet accepted diagnostic criteria for AHO. Controls included patients who underwent laboratory and imaging tests to evaluate for a suspected MSK infection and received an alternate final diagnosis. RESULTS: We identified 1135 cases of AHO matched to 2270 controls. Multivariable logistic regression identified 10 clinical and laboratory factors independently associated with AHO. We derived a 4-point risk score for AHO using (1) duration of illness >3 days, (2) history of fever or highest ED temperature ≥38°C, (3) C-reactive protein >2.0 mg/dL, and (4) erythrocyte sedimentation rate >25 mm per hour (area under the curve: 0.892, 95% confidence interval [CI]: 0.881 to 0.901). Choosing to pursue definitive diagnostics for AHO when 3 or more factors are present maximizes diagnostic accuracy at 84% (95% CI: 82% to 85%), whereas children with 0 factors present are highly unlikely to have AHO (sensitivity: 0.99, 95% CI: 0.98 to 1.00). CONCLUSIONS: We identified 10 predictors for AHO in children undergoing evaluation for a suspected MSK infection in the pediatric ED and derived a novel 4-point risk score to guide clinical decision-making.

Patient Characteristics Associated with Hospital Admission or Antiarrhythmic Medication Changes After Emergency Department Evaluation of Supraventricular Tachycardia.

BACKGROUND: Supraventricular tachycardia (SVT) is a relatively frequent diagnosis in the pediatric emergency department (ED). However, there are no consensus guidelines for ED disposition, and there are limited data on ED outcomes. Better understanding of those who are admitted or have antiarrhythmic medication changes may avoid potentially unnecessary transfers or admissions. Our objective was to identify patient factors associated with discharge from the emergency department without medication initiation or modification after management of SVT in the pediatric ED. DESIGN/METHODS: A retrospective review of children aged 0-18 years seen in the emergency department for SVT was conducted using electronic medical record data over a ten-year period at a single academic tertiary children's hospital. Patients with congenital cardiac disease or prior cardiac surgeries were excluded. Multivariable logistic regression analysis was used to determine association between patient factors of interest and the primary outcome of admission and secondary outcome of change to antiarrhythmic medications. RESULTS: We analyzed 197 patients encounters. The mean age was 7 years. Of these 104 (52.8%) were admitted to the hospital or discharged with antiarrhythmic medication changes. This primary outcome was associated with younger age (aOR 0.77, 95% CI 0.67-0.86), history of pre-excitation (aOR 5.82, 95% CI 2.01-18.8), intercurrent illness (aOR 3.75, 95% CI 1.27-12.1), number of adenosine doses prior to arrival (aOR 5.45, 95% CI 1.55-22.3), and in-person cardiology consultation (aOR 6.42, 95% CI 2.43-19.4). CONCLUSIONS: Nearly half of children treated in a pediatric ED for SVT are discharged without changes in medications. We identified patient factors associated with hospital admission or antiarrhythmic medication changes. These factors represent high value care and can be assessed when considering transfer from a referring facility. Risk stratification using these patient characteristics may reduce potentially avoidable transfers and admissions.

Risk-stratification in febrile infants 29 to 60 days old: a cost-effectiveness analysis.

BACKGROUND: Multiple clinical prediction rules have been published to risk-stratify febrile infants ≤60 days of age for serious bacterial infections (SBI), which is present in 8-13% of infants. We evaluate the cost-effectiveness of strategies to identify infants with SBI in the emergency department. METHODS: We developed a Markov decision model to estimate outcomes in well-appearing, febrile term infants, using the following strategies: Boston, Rochester, Philadelphia, Modified Philadelphia, Pediatric Emergency Care Applied Research Network (PECARN), Step-by-Step, Aronson, and clinical suspicion. Infants were categorized as low risk or not low risk using each strategy. Simulated cohorts were followed for 1 year from a healthcare perspective. Our primary model focused on bacteremia, with secondary models for urinary tract infection and bacterial meningitis. One-way, structural, and probabilistic sensitivity analyses were performed. The main outcomes were SBI correctly diagnosed and incremental cost per quality-adjusted life-year (QALY) gained. RESULTS: In the bacteremia model, the PECARN strategy was the least expensive strategy ($3671, 0.779 QALYs). The Boston strategy was the most cost-effective strategy and cost $9799/QALY gained. All other strategies were less effective and more costly. Despite low initial costs, clinical suspicion was among the most expensive and least effective strategies. Results were sensitive to the specificity of selected strategies. In probabilistic sensitivity analyses, the Boston strategy was most likely to be favored at a willingness-to-pay threshold of $100,000/QALY. In the urinary tract infection model, PECARN was preferred compared to other strategies and the Boston strategy was preferred in the bacterial meningitis model. CONCLUSIONS: The Boston clinical prediction rule offers an economically reasonable strategy compared to alternatives for identification of SBI.

Acute and chronic ethanol administration: A potential model of behavioral sensitization using wheel-running in male CD1 mice.

RATIONALE: We define behavioral sensitization as an augmented response to subsequent dosing after chronic intermittent administration of a drug. However, the biphasic effects of ethanol (EtOH), first stimulatory followed by depressive, make animal models of behavioral sensitization rare. OBJECTIVES: This study aimed to determine a dose of EtOH that did not depress wheel-running (WR) in CD1 mice and then to develop a model of EtOH-induced behavioral sensitization. METHODS: For the first part of this study, male CD1 mice (n = 24, 6/group) were administered either phosphate buffer saline (PBS), 0.5 g/kg, 1 g/kg, or 2 g/kg EtOH at a volume of 3 ml/kg, intraperitoneally (IP). Mice were divided into equal groups and received the weight-based dose once daily on Days 1, 2, 3, 4, and 5. All mice received a challenge dose of 0.5 g/kg on Day 10. In both parts of the study, mice were habituated to the running wheel for 5 min prior to dosing and wheel running was measured for 10 min after each dose. RESULTS: The acute dose-response of EtOH effects on wheel running determined a significant difference between doses in wheel running (p < 0.05), with a post-hoc analysis establishing that 0.5 g/kg EtOH resulted in significantly more WR compared to 2 g/kg EtOH (p < 0.05). The chronic study demonstrated a significant main effect of Day (1 vs. 5 vs. Challenge, p < 0.001) and an interaction between Day and Treatment, with post-hoc analysis determining the effect to be between PBS and EtOH WR on Day 5 (p < 0.05). In addition, Bonferroni post-hoc analysis determined no differences between Days in the PBS condition, but a significant difference in the EtOH condition between Day 1 and Day 5 (p < 0.001) and that difference from Day 1 persisted when comparing to the Challenge Day (p < 0.01). CONCLUSION: After chronic, intermittent, low dose administration of EtOH, male mice showed an increase in activity as measured by wheel running. Therefore, we laid the groundwork for a potentially useful rodent model for EtOH-induced behavioral sensitization.

Association of Bacteremia with Vaccination Status in Children Aged 2 to 36 Months.

OBJECTIVE: To determine the association between bacteremia and vaccination status in children aged 2-36 months presenting to a pediatric emergency department. STUDY DESIGN: Retrospective cohort study of children aged 2-36 months with blood cultures obtained in the pediatric emergency department between January 2013 and December 2017. The exposure of interest was immunization status, defined as number of Haemophilus influenzae type B (Hib) and Streptococcus pneumoniae vaccinations, and the main outcome positive blood culture. Subjects with high-risk medical conditions were excluded. RESULTS: Of 5534 encounters, 4742 met inclusion criteria. The incidence of bacteremia was 1.5%. The incidence of contaminated blood culture was 5.0%. The relative risk of bacteremia was 0.79 (95% CI 0.39-1.59) for unvaccinated and 1.20 (95% CI 0.52-2.75) for undervaccinated children relative to those who had received age-appropriate vaccines. Five children were found to have S pneumoniae bacteremia and 1 child had Hib bacteremia; all of these subjects had at least 3 sets of vaccinations. No vaccine preventable pathogens were isolated from blood cultures of unvaccinated children. We found no S pneumoniae or Hib in children 2-6 months of age who were not fully vaccinated due to age (95% CI 0-0.13%) and the contamination rate in this group was high compared with children 7-36 months (6.6% vs 3.7%). CONCLUSIONS: Bacteremia in young children is an uncommon event. Contaminated blood cultures were more common than pathogens. Bacteremia from S pneumoniae or Hib is uncommon and, in this cohort, was independent of vaccine status.

Invasive Bacterial Infections in Afebrile Infants Diagnosed With Acute Otitis Media.

OBJECTIVES: To determine the prevalence of invasive bacterial infections (IBIs) and adverse events in afebrile infants with acute otitis media (AOM). METHODS: We conducted a 33-site cross-sectional study of afebrile infants ≤90 days of age with AOM seen in emergency departments from 2007 to 2017. Eligible infants were identified using emergency department diagnosis codes and confirmed by chart review. IBIs (bacteremia and meningitis) were determined by the growth of pathogenic bacteria in blood or cerebrospinal fluid (CSF) culture. Adverse events were defined as substantial complications resulting from or potentially associated with AOM. We used generalized linear mixed-effects models to identify factors associated with IBI diagnostic testing, controlling for site-level clustering effect. RESULTS: Of 5270 infants screened, 1637 met study criteria. None of the 278 (0%; 95% confidence interval [CI]: 0%-1.4%) infants with blood cultures had bacteremia; 0 of 102 (0%; 95% CI: 0%-3.6%) with CSF cultures had bacterial meningitis; 2 of 645 (0.3%; 95% CI: 0.1%-1.1%) infants with 30-day follow-up had adverse events, including lymphadenitis (1) and culture-negative sepsis (1). Diagnostic testing for IBI varied across sites and by age; overall, 278 (17.0%) had blood cultures, and 102 (6.2%) had CSF cultures obtained. Compared with infants 0 to 28 days old, older infants were less likely to have blood cultures (P < .001) or CSF cultures (P < .001) obtained. CONCLUSION: Afebrile infants with clinician-diagnosed AOM have a low prevalence of IBIs and adverse events; therefore, outpatient management without diagnostic testing may be reasonable.

Pediatric Appendicitis: Association of Chief Complaint With Missed Appendicitis.

OBJECTIVES: We evaluated the association between the emergency department (ED) triage chief complaint and rate of missed appendicitis in children. METHODS: We performed a retrospective chart review of patients who presented to a pediatric ED and were diagnosed with appendicitis over 5 years (July 1, 2009 to June 30, 2014). We reviewed the medical record for any additional ED visits in the 7 days preceding the diagnosis of appendicitis. Triage chief complaints were classified as "suggestive of appendicitis" (abdominal pain, right lower quadrant pain, or rule out appendicitis) or "nonspecific" (fever, vomiting, dehydration, etc). We evaluated the association between triage chief complaint and missed diagnosis of appendicitis. RESULTS: We reviewed 1680 patients with appendicitis. In 67 (4%) cases, patients had at least 1 additional ED visit during the week preceding the diagnosis of appendicitis. When comparing those diagnosed with appendicitis at their initial ED visit to those diagnosed after multiple visits, we found no difference in age (9.9 vs 10.1 years, P = 0.665), sex (55.7% vs 49.3% male, P = 0.291), white blood cell count (14.4 vs 12.3 × 103/L, P = 0.115), or presence of fever (19.9% vs 19.4%, P = 0.920). Of patients with a triage chief complaint that was suggestive of appendicitis, 3.8% were missed on their initial ED visit versus 8.8% of those with a nonspecific triage chief complaint (odds ratio, 2.46; 95% confidence interval, 1.1-5.6). CONCLUSIONS: A triage chief complaint less suggestive of appendicitis was associated with a higher rate of missed appendicitis in a pediatric ED. Our findings further confirm the potential impact of anchoring bias by a triage chief complaint when attempting to diagnose appendicitis.

Isolated Increased Intracranial Pressure and Unilateral Papilledema in an Infant With Traumatic Brain Injury and Nondepressed Basilar Skull Fracture.

Traumatic brain injury is one of the most common pediatric injuries; totaling more than 500,000 emergency department visits per year. When the injury involves a skull fracture, sinus venous thrombosis and the risk of resultant increased intracranial pressure (ICP) are a concern. We describe a previously healthy 11-month-old female infant with nondepressed skull fracture who developed increased ICP in the absence of intracranial changes on imaging. Funduscopic examination revealed unilateral papilledema, and opening pressure on lumbar puncture was elevated at 35 cm of H2O. Computed tomography scan demonstrated a nondepressed occipital bone fracture. However, further imaging, including magnetic resonance imaging with angiogram/venogram, did not reveal any intracranial abnormalities. In particular, there was no evidence of sinus venous thrombosis. Given her presentation and signs of increased ICP, she was started on acetazolamide and improved dramatically. A thorough literature search was completed but yielded no information on infants with increased ICP after nondepressed skull fracture in the absence of radiographic findings to suggest a cause for the increase in pressure. Trauma alone can lead to increased ICP secondary to several processes, although this is expected in moderate to severe head trauma. Our case demonstrates that increased ICP can be present in infants with mild traumatic brain injury in the absence of intracranial pathology. This should be considered in patients who present with persistent vomiting that is refractory to antiemetics.

Seasonal, Weather, and Temporal Factors in the Prediction of Admission to a Pediatric Trauma Center.

BACKGROUND: Our objective is to identify seasonal and weather trends associated with pediatric trauma admissions. METHODS: We reviewed all trauma activations leading to admission in patients ≤18 years admitted to a regional pediatric trauma center from January 1, 2000, to December 31, 2015. We reviewed climatologic measures of the mean temperature, mean visibility, and precipitation for each admission in the 6 h prior to each presentation in addition to time of arrival, weekday/weekend presentation, and season. We used a negative binomial regression model with multivariable analysis to estimate associations between weather and rate of trauma admissions. Results were presented as incidence rate ratios (IRR) with 95% confidence intervals (CI). RESULTS: In total, 3856 encounters [2539 males (65.8%), mean age 10.2 years ± SD 5.1 years] were included. Results from multivariable analysis (IRR, 95% CI) suggested an association of admissions with rain (0.82, 0.75-0.90) and overnight hours (23:51-05:50; 0.69, 0.58-0.82) as compared to morning (05:51-11:50). The IRR of trauma increased during the afternoon (11:51-17:50; 4.05, 3.57-4.61), night periods (17:51-23:50; 5.59, 4.94-6.33), and weekends (1.24, 1.15-1.32), and with every 1 °C increase in temperature (1.04, 1.03-1.04). After accounting for other variables, season was not found to be independently predictive of trauma admission. CONCLUSION: Trauma admissions had a higher rate during afternoon, evening hours, and weekends. The presence of rain lowered the rate of pediatric trauma admission. Each degree increase in temperature increased the rate of trauma admissions by 4%. The findings provide information from the perspective of emergency preparedness, resource utilization, and staffing to pediatric trauma centers.

Weather and Temporal Factors Associated with Use of Emergency Medical Services.

Background: Fluctuations in emergency medical services (EMS) responses can have a substantial impact on the ability of agencies to meet resource needs within an EMS system. We aimed to identify weather characteristics as potentially predictable factors associated with EMS responses. Methods: We reviewed hourly counts of scene responses documented by 24 EMS agencies in Western Pennsylvania from January 1, 2014 to December 31, 2017 and compared rates of responses to weather characteristics. Responses to counties nonadjacent to the studied weather reporting station and interfacility/scheduled transports were excluded. We identified the mean temperature, meters visibility, dew point, wind speed, total millimeters of precipitation, and presence of rain or snow in 6-hour windows prior to dispatch, in addition to temporal factors of time of day and weekend vs. weekday. Analysis was performed using multivariable linear regression of a negative binomial distribution, reporting incidence rate ratios (IRR) with 95% confidence intervals (CI). Secondary analyses were performed for transports to the hospital and cases involving transports for traumatic complaints and pediatric patients (age <18 years). Results: We included 529,058 responses (54.8% female, mean age 57.2 ± SD 24.7 years). In our multivariable model, responses were associated with (IRR, 95% CI) rain (1.10, 1.08-1.11) snow (1.07, 1.05-1.09), and both rain and snow (1.15, 1.11-1.19). A lower incidence of responses occurred on weekends (0.84, 0.83-0.85) and at night (0.62, 0.61-0.62). Increasing temperature in 5 °C increments was associated with an increase in responses across seasons with an effect that varied between 1.16 (1.15-1.17) in winter to 1.31 (1.28-1.33) in summer. Windy weather was associated with increased responses from light breeze (1.10, 1.09-1.11) to fresh breeze or greater (1.23, 1.16-1.30). Transports occurred in a similar pattern to responses. Trauma transports (n = 64,235) occurred more during weekends (1.04, 1.02-1.06). Pediatric transports (n = 21,880) were not significantly associated with precipitation or season. Conclusion: EMS responses increased with rising temperature and following rain and snow. These findings may assist in planning by EMS agencies and emergency departments to identify periods of greatest resource utilization.

Pediatric Referrals to an Emergency Department From Urgent Care Centers.

OBJECTIVE: The aims of this study were to describe pediatric emergency department (ED) referrals from urgent care centers and to determine the percentage of referrals considered essential and serious. METHODS: A prospective study was conducted between April 2013 and April 2015 on patients younger than 21 years referred directly to an ED in central Pennsylvania from surrounding urgent care centers. Referrals were considered essential or serious based on investigations/procedures performed or medications/consultations received in the ED. RESULTS: Analysis was performed on 455 patient encounters (mean age, 8.7 y), with 347 (76%) considered essential and 40 (9%) considered serious. The most common chief complaints were abdominal pain (83 encounters), extremity injury (76), fever (39), cough/cold (29), and head/neck injury (29). Thirty-three percent of the patients received laboratory diagnostic investigations (74% serum, 56% urine), and 52% received radiologic investigations (67% x-ray, 17% computed tomography scan, 13% ultrasound, 11% magnetic resonance imaging). Forty-four percent of the patients received a procedure, with the most common being intravenous (IV) placement (66%); reduction, casting, or splinting of extremity fracture/dislocation (18%); and laceration repair (14%). The most common medications administered were IV fluids (33%), oral analgesics (30%), and IV analgesics (26%). Eighty-three percent of the patients were discharged home, 12% were hospitalized, and 4% had emergent surgical intervention. The most common primary diagnoses were closed extremity fracture (60 encounters), gastroenteritis (42), brain concussion (28), upper respiratory infection (24), and nonsurgical, unspecified abdominal pain (24). CONCLUSIONS: Many ED referrals directed from urgent care centers in our sample were considered essential, and few were considered serious. Urgent care centers should develop educational and preparedness strategies based on the epidemiology of emergencies that may occur.

Low Compliance of Urgent Care Centers in the United States With Recommendations for Office-Based Disaster Preparedness.

OBJECTIVES: The aim of the study was to determine the compliance of urgent care centers in the United States with published recommendations for office-based disaster preparedness. METHODS: An electronic questionnaire was distributed to urgent care center administrators as identified by the American Academy of Urgent Care Medicine directory. RESULTS: One hundred twenty-two questionnaires of the 872 distributed were available for analysis (14% usable response rate). Twenty-seven percent of centers have an established disaster plan for events that involve their establishment and surrounding community; 49% practice the plan at least once a year, 19% less frequent than once a year, and 32% never practice. Forty-seven percent of centers are familiar with designated emergency shelters and community evacuation plans. Seventeen percent of centers function as part of a surveillance system to provide early detection of any biologic/chemical/nuclear agents. Twenty-two percent of centers take part in local community and hospital disaster planning, exercises, and drills through emergency medical services and public health systems. Five percent of centers aid schools, child care centers, camps, and other child congregate facilities in disaster planning. Twenty-eight percent of centers have an assembled emergency/disaster kit, containing such items as water, first aid supplies, radios, flashlights, batteries, heavy-duty gloves, food, and sanitation supplies. CONCLUSIONS: Areas for improvement in urgent care center disaster preparedness were identified, such as developing an office disaster plan that is practiced at least yearly, becoming familiar with designated emergency shelters and community evacuation plans, providing surveillance to detect potential acts of terrorism, assisting community organizations (hospitals, schools, child care centers, etc) in disaster planning, and assembling office emergency/disaster kits.

Pediatric Care Provided at Urgent Care Centers in the United States: Compliance With Recommendations for Emergency Preparedness.

OBJECTIVES: To describe the compliance of urgent care centers in the United States with pediatric care recommendations for emergency preparedness as set forth by the American Academy of Pediatrics. METHODS: An electronic questionnaire was distributed to urgent care center administrators as identified by the American Academy of Urgent Care Medicine directory. RESULTS: A total of 122 questionnaires of the 872 distributed were available for analysis (14% usable response rate). The most common diagnoses reported for pediatric patients included otitis media (72%), upper respiratory illness (69%), strep pharyngitis (61%), bronchiolitis (30%), and extremity sprain/strain (28%). Seventy-one percent of centers have contacted community emergency medical services (EMS) to transport a critically ill or injured child to their local emergency department in the past year. Sixty-two percent of centers reported having an established written protocol with community EMS and 54% with their local emergency department or hospital. Centers reported the availability of the following essential medications and equipment: oxygen source (75%), nebulized/inhaled ß-agonist (95%), intravenous epinephrine (88%), oxygen masks/nasal cannula (89%), bag-valve-mask resuscitator (81%), suctioning device (60%), and automated external defibrillator (80%). Centers reported the presence of the following written emergency plans: respiratory distress (40%), seizures (67%), dehydration/shock (69%), head injury (59%), neck injury (67%), significant fracture (69%), and blunt chest or abdominal injury (81%). Forty-seven percent of centers conduct formal reviews of emergent or difficult cases in a quality improvement format. CONCLUSIONS: Areas for improvement in urgent care center preparedness were identified, such as increasing the availability of essential medications and equipment, establishing transfer and transport agreements with local hospitals and community EMS, and ensuring a structured quality improvement program.

Compliance of camps in the United States with guidelines for health and safety practices.

OBJECTIVE: To determine the compliance of US camps with guidelines for health and safety practices as set forth by the American Academy of Pediatrics and the US Department of Homeland Security. METHODS: An electronic questionnaire was distributed to US camps during the summer of 2012 as identified by 3 online summer camp directories. RESULTS: Analysis was performed on 433 completed questionnaires. Fourteen percent of camps were considered medically related. Ninety-three percent of camps have established relationships with community emergency medical services, 34% with local orthodontists, and 37% with local mental health professionals. Camps reported the immediate availability of the following: automated external defibrillators (75%), respiratory rescue inhalers (44%), epinephrine autoinjectors (64%), cervical spine collars (62%), and backboard with restraints (76%). Camps reported the presence of the following written health policies: dehydration (91%), asthma and anaphylaxis (88%), head injuries (90%), seizures (78%), cardiac arrest (76%), and drowning (73%). Although 93% of camps have a disaster response plan, 15% never practice the plan. Sixty-eight percent of camps are familiar with community evacuation plans, and 67% have access to vehicles for transport. Camps reported the presence of the following written disaster policies: fire (96%), tornadoes (68%), arrival of suspicious individuals (84%), hostage situations (18%). CONCLUSIONS: Areas for improvement in the compliance of US camps with specific recommendations for health and safety practices were identified, such as medically preparing campers before their attendance, developing relationships with community health providers, increasing the immediate availability of several emergency medications and equipment, and developing policies and protocols for medical and disaster emergencies.