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.

Pediatric Blast Trauma: A Systematic Review and Meta-Analysis of Factors Associated with Mortality and Description of Injury Profiles.

INTRODUCTION: Blast polytrauma is among the most serious mechanisms of injury confronted by medical providers. There are currently no specific studies or guidelines that define risk factors for mortality in the context of pediatric blast injuries or describe pediatric blast injury profiles. OBJECTIVE: The objectives of this study were to evaluate risk factors for pediatric mortality and to describe differences in injury profiles between explosions related to terrorism versus unrelated to terrorism within the pediatric population. METHODS: A PRISMA systematic review and meta-analysis was performed where articles published from the years 2000-2021 were extracted from PubMed. Mortality and injury profile data were extracted from articles that met inclusion criteria. A bivariant unadjusted odds ratio (OR) analysis was performed to establish protective and harmful factors associated with mortality and to describe the injury profiles of blasts related to terrorism. Statistical significance was established at P < .05. RESULTS: Thirty-eight articles were included and described a total of 222,638 unique injuries. Factors associated with increased mortality included if the explosion was related to terrorism (OR = 32.73; 95% CI, 28.80-37.21; P < .05) and if the explosion involved high-grade explosives utilized in the Global War on Terror ([GWOT] OR = 1.28; 95% CI, 1.04-1.44; P < .05). Factors associated with decreased mortality included if the patient was resuscitated in a North Atlantic Treaty Organization (NATO)-affiliated combat trauma hospital (OR = 0.48; 95% CI, 0.37-0.62; P < .05); if the explosive was fireworks (OR = 3.20×10-5; 95% CI, 2.00×10-6-5.16×10-4; P < .05); and if the explosion occurred in the United States (OR = 2.40×10-5; 95% CI, 1.51×10-6-3.87×10-4; P < .05). On average, victims of explosions related to terrorism were 10.30 years old (SD = 2.73) with 68.96% (SD = 17.58%) of victims reported as male. Comparison of victims of explosions related to terrorism revealed a higher incidence of thoracoabdominal trauma (30.2% versus 8.6%), similar incidence of craniocerebral trauma (39.5% versus 43.1%), and lower incidence of extremity trauma (31.8% versus 48.3%) compared to victims of explosions unrelated to terrorism. CONCLUSION: Explosions related to terrorism are associated with increased mortality and unique injury profiles compared to explosions unrelated to terrorism in the pediatric population. Such findings are important for optimizing disaster medical education of pediatric providers in preparation for and management of acute sequelae of blast injuries-terror-related and otherwise.

Concussion Referral and Practice Patterns by Pediatric Emergency Medicine Providers.

OBJECTIVES: Concussion is a commonly encountered diagnosis for pediatric emergency medicine (PEM) providers, yet little is known regarding referral patterns to specialists. Our goal was to assess PEM providers' referral patterns and current usage of standardized evaluation tools. METHODS: This study was conducted as cross-sectional survey of PEM providers recruited from the American Academy of Pediatrics Section on Emergency Medicine Listserv. Surveys were distributed at 3 time points between December 1, 2020, and February 28, 2021, and included multiple choice, Likert scale, and free text questions. Descriptive statistics and bivariate analyses were used to describe the sample and compare responses between those with variable experience and confidence in concussion management. RESULTS: In total, 162 of 491 Listserv members (33.0%) completed the survey. The factors most often reported to assist in referral decisions were history of severe (92.6%) or multiple (90.7%) prior concussions, prolonged symptom duration (89.5%), and severity of current symptoms (84.6%). Most providers reported having large experience (63.0%) and confidence (54.9%) in managing concussion. Standardized symptom scales (8.0%), vestibular (11.7%) and balance assessments (13.0%), and prognostic tools (6.8%) were infrequently used. Most (64.2%) providers felt specialty referral was important. More than 80% reported high likelihood to use an accurate risk stratification tool to facilitate referral. CONCLUSIONS: Although most PEM providers reported significant experience and confidence in managing pediatric concussion, standardized assessment tools were infrequently used. Most were likely to use a risk stratification tool to assist in specialty referral. Future studies should assess the ability of targeted referral strategies to improve recovery for concussed youth.

Rest-Based Concussion Management of Pediatric Emergency Medicine Providers.

OBJECTIVES: This study aimed to survey pediatric emergency medicine (PEM) providers on their management of 2 hypothetical acute concussion scenarios. We hypothesized that most providers would recommend a management strategy based on cognitive and physical rest. METHODS: Fifty-nine percent (46/78) of PEM providers that were surveyed completed the study. The survey consisted of 2 clinical scenarios-a female patient with a mild concussion and a male patient with a moderate concussion. Practitioners were asked questions regarding how they would hypothetically manage these patients in terms of recommendations for returning to school and returning to sports. RESULTS: Eighty-six percent of providers recommended moderate time off from school for the moderate concussion scenario compared with 67% of providers in the mild concussion scenario (P = 0.008). In regard to return to sports, all providers recommended moderate time off in both scenarios, including 78% of providers who recommended clearance by a physician in the moderate concussion scenario. CONCLUSIONS: In both of our hypothetical concussion scenarios, including a very mild head injury, most PEM providers surveyed recommended a management strategy that included a moderate degree of a delay of return to school and sports. Given recent evidence suggesting that prolonged rest does not reduce the risk of prolonged concussion symptoms, recommendations of periods of cognitive rest, particularly absences from school, should be approached cautiously. Future studies should examine why providers are recommending rest-based treatment strategies and the potential benefits of active rehabilitation.

Effect of Cognitive and Physical Rest on Persistent Postconcussive Symptoms following a Pediatric Head Injury.

OBJECTIVE: To evaluate the effect of cognitive and physical rest on persistent postconcussive symptoms in a pediatric population. STUDY DESIGN: A prospective cohort study of 5- to 18-year-olds diagnosed with an acute concussion in a tertiary care pediatric emergency department was conducted from December 2016 to May 2019. Participants (n = 119) were followed over 1 month to track days off from school and sports and the development of persistent postconcussive symptoms (residual concussion symptoms beyond 1 month). Participants were dichotomized into minimal (≤2) and moderate (>2) rest, based on days off from school and sports after a concussion. Univariate and multivariable logistic regression analyses were completed to examine associations with persistent postconcussive symptoms. RESULTS: Of the participants in our study, 24% had persistent postconcussive symptoms. Adolescent age, history of prolonged concussion recovery, and headache at presentation were associated with higher odds of persistent postconcussive symptoms in univariate analyses. In a multivariable logistic regression model, only adolescent age was associated with increased odds of persistent postconcussive symptoms. Compared with the minimal cognitive rest group, moderate cognitive rest did not decrease the odds of persistent postconcussive symptoms (aOR, 1.15; 95% CI, 0.44-2.99). Compared with the minimal physical rest group, moderate physical rest also did not decrease the odds of persistent postconcussive symptoms (aOR, 3.17; 95% CI, 0.35-28.78). CONCLUSIONS: Emerging evidence supports early return to light activity for recovery of acute pediatric concussion. Our study adds to this management approach as we did not find that rest from school and sports resulted in a decreased odds of persistent postconcussive symptoms.

Pediatric Patient Compliance With Recommendations for Acute Concussion Management.

Emerging evidence supports an active approach for acute pediatric concussion management. The current practices of pediatric emergency providers following acute concussions has not been well studied. We prospectively enrolled 134 pediatric patients with an acute concussion. Providers completed a real-time survey to assess their recommendations for time off from school and sports. Seven to 10 days post-injury, patient compliance with provider recommendations was assessed. Forty-seven (35.1%) providers recommended moderate time off from school. In this cohort (n = 44), 14 (31.8%) patients took more than 2 days off from school. When minimal rest was prescribed (n = 80), 26 (32.5%) patients took more than 2 days off from school, P = .94. One third of our pediatric emergency providers are still recommending moderate time off from school. Regardless of physician prescriptions, patients took a similar amount of time off from school. Our study questions the influence of physician recommendations on management of acute pediatric concussions.

Point-of-Care Ultrasound Evaluation of Severe Renal Trauma in an Adolescent.

Traumatic renal injuries are more common in pediatrics because of the relatively larger size of the kidneys in the pediatric patient. Although computerized tomography remains the criterion standard for the initial evaluation of blunt renal trauma, there is evidence that renal ultrasound may serve a role in postinjury surveillance. Here, we present a case in which point-of-care ultrasound was used to image severe blunt renal trauma in a 17-year-old adolescent boy. In this case, point-of-care ultrasound identified severely distorted renal parenchyma after a grade 5 renal laceration was identified on computerized tomography scan.

Pediatric Patient With Altered Mental Status and Hypoxemia: Case Report.

Childhood cases of myxedema coma are extremely rare. We report a case of a 5-year-old girl transferred to a tertiary care pediatric emergency department with hypoxemia and altered mental status and diagnosed with severe hypothyroidism and myxedema coma in the setting of acute influenza infection. Although it is rare, myxedema coma must remain in the differential diagnosis for altered mental status and organ dysfunction in the pediatric population.

History of Somatization Is Associated with Prolonged Recovery from Concussion.

OBJECTIVE: To determine the association between a history of somatization and prolonged concussion symptoms, including sex differences in recovery. STUDY DESIGN: A prospective cohort study of 10- to 18-year-olds with an acute concussion was conducted from July 2014 to April 2015 at a tertiary care pediatric emergency department. One hundred twenty subjects completed the validated Children's Somatization Inventory (CSI) for pre-injury somatization assessment and Postconcussion Symptoms Scale (PCSS) at diagnosis. PCSS was re-assessed by phone at 2 and 4 weeks. CSI was assessed in quartiles with a generalized estimating equation model to determine relationship of CSI to PCSS over time. RESULTS: The median age of our study participants was 13.8 years (IQR 11.5, 15.8), 60% male, with separate analyses for each sex. Our model showed a positive interaction between total CSI score, PCSS and time from concussion for females P < .01, and a statistical trend for males, P = .058. Females in the highest quartile of somatization had higher PCSS than the other 3 CSI quartiles at each time point (B -26.7 to -41.1, P values <.015). CONCLUSIONS: Patients with higher pre-injury somatization had higher concussion symptom scores over time. Females in the highest somatization quartile had prolonged concussion recovery with persistently high symptom scores at 4 weeks. Somatization may contribute to sex differences in recovery, and assessment at the time of concussion may help guide management and target therapy.

Metabolic manifestations of polycystic ovary syndrome in nonobese adolescents: retinol-binding protein 4 and ectopic fat deposition.

OBJECTIVE: To determine whether nonobese adolescents with polycystic ovary syndrome (PCOS) have higher levels of retinol-binding protein 4 (RBP4) and ectopic fat than controls and whether RBP4 and ectopic fat correlate with comorbidities of metabolic disease. DESIGN: Cross-sectional case-control study. SETTING: Pediatric clinical research center based in a quaternary care medical center. PATIENT(S): Twenty-four nonobese adolescents between the ages of 13 and 21 years, 13 with PCOS and 11 controls. INTERVENTION(S): Measurement of RBP4, insulin resistance, lipids, and body composition. MAIN OUTCOME MEASURE(S): Retinol-binding protein 4, reproductive and adrenal hormones, insulin resistance, intrahepatic and intramyocellular lipid levels, and visceral adipose tissue. RESULT(S): Adolescents with PCOS had higher intrahepatic lipid content and a statistical trend for higher RBP4 compared with controls. Retinol-binding protein 4 correlated with body fat, triglycerides, insulin resistance, and androgens but not intrahepatic lipid content; however, when adjusted for body fat, the correlation between RBP4 and triglycerides weakened to a statistical trend and was no longer statistically significant for the other measures. CONCLUSION(S): This small preliminary study of nonobese adolescent girls suggests that RBP4 may be involved in the dyslipidemia associated with PCOS and that there may be an independent relationship between RBP4 and triglycerides but not between RBP4 and insulin resistance. Although intrahepatic lipid content was higher in PCOS, it did not correlate with RBP4, triglycerides, or insulin resistance.

Cohort study of molecular identification and typing of Mycobacterium abscessus, Mycobacterium massiliense, and Mycobacterium bolletii.

Mycobacterium abscessus is the most common cause of rapidly growing mycobacterial chronic lung disease. Recently, two new M. abscessus-related species, M. massiliense and M. bolletii, have been described. Health care-associated outbreaks have recently been investigated by the use of molecular identification and typing tools; however, very little is known about the natural epidemiology and pathogenicity of M. massiliense or M. bolletii outside of outbreak situations. The differentiation of these two species from M. abscessus is difficult and relies on the sequencing of one or more housekeeping genes. We performed extensive molecular identification and typing of 42 clinical isolates of M. abscessus, M. massiliense, and M. bolletii from patients monitored at the NIH between 1999 and 2007. The corresponding clinical data were also examined. Partial sequencing of rpoB, hsp65, and secA led to the unambiguous identification of 26 M. abscessus isolates, 7 M. massiliense isolates, and 2 M. bolletii isolates. The identification results for seven other isolates were ambiguous and warranted further sequencing and an integrated phylogenetic analysis. Strain relatedness was assessed by repetitive-sequence-based PCR (rep-PCR) and pulsed-field gel electrophoresis (PFGE), which showed the characteristic clonal groups for each species. Five isolates with ambiguous species identities as M. abscessus-M. massiliense by rpoB, hsp65, and secA sequencing clustered as a distinct group by rep-PCR and PFGE together with the M. massiliense type strain. Overall, the clinical manifestations of disease caused by each species were similar. In summary, a multilocus sequencing approach (not just rpoB partial sequencing) is required for division of M. abscessus and closely related species. Molecular typing complements sequence-based identification and provides information on prevalent clones with possible relevant clinical aspects.