Epidemiology of brief resolved unexplained events and impact of clinical practice guidelines in general and pediatric emergency departments.

OBJECTIVES: The aim of this study was to describe the incidence of brief resolved unexplained events (BRUEs) and compare the impact of a national clinical practice guideline (CPG) on admission and diagnostic testing practices between general and pediatric emergency departments (EDs). METHODS: Using the Nationwide Emergency Department Sample for 2012-2019, we conducted a cross-sectional study of children <1 year of age with an International Classification of Diseases diagnostic code for BRUE. Population incidence rate was estimated using Centers for Disease Control and Prevention birth data. ED incidence rate was estimated for all ED encounters. We used interrupted time series to evaluate the associated impact of the CPG publication on the outcomes of ED disposition (discharge, admission, and transfer) and electrocardiogram (ECG) use. RESULTS: Of 133,972 encounters for BRUE, 80.0% occurred in general EDs. BRUE population incidence was 4.28 per 1000 live births and the annual incidence remained stable (p = 0.19). BRUE ED incidence was 5.06 per 1000 infant ED encounters (p = 0.14). The impact of the BRUE CPG on admission rates was limited to pediatric EDs (level shift -23.3%, p = 0.002). Transfers from general EDs did not change with the CPG (level shift 2.2%, p = 0.17). After the CPG was published, ECGs increased by 13.7% in pediatric EDs (p = 0.005) but did not change in general EDs (level shift -0.2%, p = 0.82). CONCLUSIONS: BRUEs remain a common pediatric problem at a population level and in EDs. Although a disproportionate number of infants present to general EDs, there is differential uptake of the CPG recommendations between pediatric and general EDs. These findings may support quality improvement opportunities aimed at improving care for these infants and decreasing unnecessary hospital admissions or transfers.

Diagnostic testing for evaluation of brief resolved unexplained events.

BACKGROUND: Since the publication of the American Academy of Pediatrics (AAP) clinical practice guideline for brief resolved unexplained events (BRUEs), a few small, single-center studies have suggested low yield of diagnostic testing in infants presenting with such an event. We conducted this large retrospective multicenter study to determine the role of diagnostic testing in leading to a confirmatory diagnosis in BRUE patients. METHODS: Secondary analysis from a large multicenter cohort derived from 15 hospitals participating in the BRUE Quality Improvement and Research Collaborative. The study subjects were infants < 1 year of age presenting with a BRUE to the emergency departments (EDs) of these hospitals between October 1, 2015, and September 30, 2018. Potential BRUE cases were identified using a validated algorithm that relies on administrative data. Chart review was conducted to confirm study inclusion/exclusion, AAP risk criteria, final diagnosis, and contribution of test results. Findings were stratified by ED or hospital discharge and AAP risk criteria. For each patient, we identified whether any diagnostic test contributed to the final diagnosis. We distinguished true (contributory) results from false-positive results. RESULTS: Of 2036 patients meeting study criteria, 63.2% were hospitalized, 87.1% qualified as AAP higher risk, and 45.3% received an explanatory diagnosis. Overall, a laboratory test, imaging, or an ancillary test supported the final diagnosis in 3.2% (65/2036, 95% confidence interval [CI] 2.7%-4.4%) of patients. Out of 5163 diagnostic tests overall, 1.1% (33/2897, 95% CI 0.8%-1.5%) laboratory tests and 1.5% (33/2266, 95% CI 1.0%-1.9%) of imaging and ancillary studies contributed to a diagnosis. Although 861 electrocardiograms were performed, no new cardiac diagnoses were identified during the index visit. CONCLUSIONS: Diagnostic testing to explain BRUE including for those with AAP higher risk criteria is low yield and rarely contributes to an explanation. Future research is needed to evaluate the role of testing in more specific, at-risk populations.

Diagnostic testing for and detection of physical abuse in infants with brief resolved unexplained events.

BACKGROUND: A Brief Resolved Unexplained Event (BRUE) can be a sign of occult physical abuse. OBJECTIVES: To identify rates of diagnostic testing able to detect physical abuse (head imaging, skeletal survey, and liver transaminases) at BRUE presentation. The secondary objective was to estimate the rate of physical abuse diagnosed at initial BRUE presentation through 1 year of age. PARTICIPANTS AND SETTING: Infants who presented with a BRUE at one of 15 academic or community hospitals were followed from initial BRUE presentation until 1 year of age for BRUE recurrence or revisits. METHODS: This study was part of the BRUE Research and Quality Improvement Network, a multicenter retrospective cohort examining infants with BRUE. Generalized estimating equations assessed associations with performance of diagnostic testing (adjusted odds ratio (aOR)). RESULTS: Of the 2036 infants presenting with a BRUE, 6.2 % underwent head imaging, 7.0 % skeletal survey, and 12.1 % liver transaminases. Infants were more likely to undergo skeletal survey if there were physical examination findings concerning for trauma (aOR 8.23, 95 % CI [1.92, 35.24], p < 0.005) or concerning social history (aOR 1.89, 95 % CI [1.13, 3.16], p = 0.015). There were 7 (0.3 %) infants diagnosed with physical abuse: one at BRUE presentation, one <3 days after BRUE presentation, and five >30 days after BRUE presentation. CONCLUSION: There were low rates of diagnostic testing and physical abuse identified in infants presenting with BRUE. Further study including standardized testing protocols is warranted to identify physical abuse in infants presenting with a BRUE.

Concussion severity and functional outcome using biomarkers in children and youth involved in organized sports, recreational activities and non-sport related incidents.

This prospective multicenter study evaluated differences in concussion severity and functional outcome using glial and neuronal biomarkers glial Fibrillary Acidic (GFAP) and Ubiquitin C-terminal Hydrolase (UCH-L1) in children and youth involved in non-sport related trauma, organized sports, and recreational activities. Children and youth presenting to three Level 1 trauma centersfollowing blunt head trauma with a GCS 15 with a verified diagnosis of a concussion were enrolled within 6 hours of injury. Traumatic intracranial lesions on CT scan and functional outcome within 3 months of injury were evaluated. 131 children and youth with concussion were enrolled, 81 in the no sports group, 22 in the organized sports group and 28 in the recreational activities group. Median GFAP levels were 0.18, 0.07, and 0.39 ng/mL in the respective groups (p = 0.014). Median UCH-L1 levels were 0.18, 0.27, and 0.32 ng/mL respectively (p = 0.025). A CT scan of the head was performed in 110 (84%) patients. CT was positive in 5 (7%), 4 (27%), and 5 (20%) patients, respectively. The AUC for GFAP for detecting +CT was 0.84 (95%CI 0.75-0.93) and for UCH-L1 was 0.82 (95%CI 0.71-0.94). In those without CT lesions, elevations in UCH-L1 were significantly associated with unfavorable 3-month outcome. Concussions in the 3 groups were of similar severity and functional outcome. GFAP and UCH-L1 were both associated with severity of concussion and intracranial lesions, with the most elevated concentrations in recreational activities .

Incidence of Postoperative Cerebral Aneurysm Clip Slippage: Review of a Consecutive Case Series of 115 Clipped Aneurysms.

OBJECTIVE: Although delayed postoperative clip slippage has been reported in previous case reports and case series, its true incidence with high rate of follow-up imaging has not been reported. We attempted to determine the incidence of clip slippage in a cohort of consecutive aneurysm clippings. METHODS: We performed a retrospective review of a prospectively maintained database of 115 consecutive saccular aneurysm clippings at a single institution. Postoperative imaging was reviewed for clip slippage within 24 hours and at 3-12 months. Eighty-six aneurysms (75.8%) were exclusively clipped with Sugitaclip (Mizuho Medical, Tokyo, Japan) Titanium II clips, 16 aneurysms were exclusively clipped with Yasargil (Aesculap, Center Valley, PA) titanium clips (13.9%), 5 aneurysms were only clipped with Sugita aneurysm clips (4.3%), and 3 aneurysms were only clipped with Peter Lazic (Peter Lazic Microsurgical Innovations, Tuttlingen, Germany) clips (2.6%). RESULTS: In this cohort, 94.7% of clipped aneurysms had follow-up imaging within 24 hours, and 51.3% had delayed follow-up imaging within 3-12 months. We identified 3 cases of clip slippage in 115 consecutive aneurysm clippings, resulting in an incidence of 2.6%. The average cumulative closing force of clips per aneurysm across the study was 2.32 N, and the median number of clips placed was 1. Two of the 3 cases of clip slippage had a closing force <2.32 N and only placement of a single clip. CONCLUSIONS: Because our series showed a 2.6% incidence of clip slippage, clipped aneurysms should be monitored with early and delayed vascular follow-up imaging. Lower cumulative clip closing force, single clip placement, and oversized clip blade length may be risk factors for postoperative aneurysmal clip slippage.

Explanatory Diagnoses Following Hospitalization for a Brief Resolved Unexplained Event.

BACKGROUND AND OBJECTIVES: Most young infants presenting to the emergency department (ED) with a brief resolved unexplained event (BRUE) are hospitalized. We sought to determine the rate of explanatory diagnosis after hospitalization for a BRUE. METHODS: This was a multicenter retrospective cohort study of infants hospitalized with a BRUE after an ED visit between October 1, 2015, and September 30, 2018. We included infants without an explanatory diagnosis at admission. We determined the proportion of patients with an explanatory diagnosis at the time of hospital discharge and whether diagnostic testing, consultation, or observed events occurring during hospitalization were associated with identification of an explanatory diagnosis. RESULTS: Among 980 infants hospitalized after an ED visit for a BRUE without an explanatory diagnosis at admission, 363 (37.0%) had an explanatory diagnosis identified during hospitalization. In 805 (82.1%) infants, diagnostic testing, specialty consultations, and observed events did not contribute to an explanatory diagnosis, and, in 175 (17.9%) infants, they contributed to the explanatory diagnosis (7.0%, 10.0%, and 7.0%, respectively). A total of 15 infants had a serious diagnosis (4.1% of explanatory diagnoses; 1.5% of all infants hospitalized with a BRUE), the most common being seizure and infantile spasms, occurring in 4 patients. CONCLUSIONS: Most infants hospitalized with a BRUE did not receive an explanation during the hospitalization, and a majority of diagnoses were benign or self-limited conditions. More research is needed to identify which infants with a BRUE are most likely to benefit from hospitalization for determining the etiology of the event.

Accuracy of Diagnostic Codes for Identifying Brief Resolved Unexplained Events.

OBJECTIVES: To evaluate International Classification of Diseases, 10th Revision (ICD-10) coding strategies for the identification of patients with a brief resolved unexplained event (BRUE). METHODS: Multicenter retrospective cohort study, including patients aged <1 year with an emergency department (ED) visit between October 1, 2015, and September 30, 2018, and an ICD-10 code for the following: (1) BRUE; (2) characteristics of BRUE; (3) serious underlying diagnoses presenting as a BRUE; and (4) nonserious diagnoses presenting as a BRUE. Sixteen algorithms were developed by using various combinations of these 4 groups of ICD-10 codes. Manual chart review was used to assess the performance of these ICD-10 algorithms for the identification of (1) patients presenting to an ED who met the American Academy of Pediatrics clinical definition for a BRUE and (2) the subset of these patients discharged from the ED or hospital without an explanation for the BRUE. RESULTS: Of 4512 records reviewed, 1646 (36.5%) of these patients met the American Academy of Pediatrics criteria for BRUE on ED presentation, 1016 (61.7%) were hospitalized, and 959 (58.3%) had no explanation on discharge. Among ED discharges, the BRUE ICD-10 code alone was optimal for case ascertainment (sensitivity: 89.8% to 92.8%; positive predictive value: 51.7% to 72.0%). For hospitalized patients, ICD-10 codes related to the clinical characteristics of BRUE are preferred (specificity 93.2%, positive predictive value 32.7% to 46.3%). CONCLUSIONS: The BRUE ICD-10 code and/or the diagnostic codes for the characteristics of BRUE are recommended, but the choice between approaches depends on the investigative purpose and the specific BRUE population and setting of interest.

Risk Factors and Outcomes After a Brief Resolved Unexplained Event: A Multicenter Study.

BACKGROUND: The accuracy of the risk criteria for brief resolved unexplained events (BRUEs) from the American Academy of Pediatrics (AAP) is unknown. We sought to evaluate if AAP risk criteria and event characteristics predict BRUE outcomes. METHODS: This retrospective cohort included infants <1 year of age evaluated in the emergency departments (EDs) of 15 pediatric and community hospitals for a BRUE between October 1, 2015, and September 30, 2018. A multivariable regression model was used to evaluate the association of AAP risk factors and event characteristics with risk for event recurrence, revisits, and serious diagnoses explaining the BRUE. RESULTS: Of 2036 patients presenting with a BRUE, 87% had at least 1 AAP higher-risk factor. Revisits occurred in 6.9% of ED and 10.7% of hospital discharges. A serious diagnosis was made in 4.0% (82) of cases; 45% (37) of these diagnoses were identified after the index visit. The most common serious diagnoses included seizures (1.1% [23]) and airway abnormalities (0.64% [13]). Risk is increased for a serious underlying diagnosis for patients discharged from the ED with a history of a similar event, an event duration >1 minute, an abnormal medical history, and an altered responsiveness (P < .05). AAP risk criteria for all outcomes had a negative predictive value of 90% and a positive predictive value of 23%. CONCLUSIONS: AAP BRUE risk criteria are used to accurately identify patients at low risk for event recurrence, readmission, and a serious underlying diagnosis; however, their use results in the inaccurate identification of many patients as higher risk. This is likely because many AAP risk factors, such as age, are not associated with these outcomes.

Evaluating glial and neuronal blood biomarkers GFAP and UCH-L1 as gradients of brain injury in concussive, subconcussive and non-concussive trauma: a prospective cohort study.

OBJECTIVES: To evaluate the ability of glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase (UCH-L1) to detect concussion in children and adult trauma patients with a normal mental status and assess biomarker concentrations over time as gradients of injury in concussive and non-concussive head and body trauma. DESIGN: Large prospective cohort study. SETTING: Three level I trauma centres in the USA. PARTICIPANTS: Paediatric and adult trauma patients of all ages, with and without head trauma, presenting with a normal mental status (Glasgow Coma Scale score of 15) within 4 hours of injury. Rigorous screening for concussive symptoms was conducted. Of 3462 trauma patients screened, 751 were enrolled and 712 had biomarker data. Repeated blood sampling was conducted at 4, 8, 12, 16, 24, 36, 48, 60, 72, 84, 96, 108, 120, 132, 144, 156, 168 and 180 hours postinjury in adults. MAIN OUTCOMES: Detection of concussion and gradients of injury in children versus adults by comparing three groups of patients: (1) those with concussion; (2) those with head trauma without overt signs of concussion (non-concussive head trauma controls) and (3) those with peripheral (body) trauma without head trauma or concussion (non-concussive body trauma controls). RESULTS: A total of 1904 samples from 712 trauma patients were analysed. Within 4 hours of injury, there were incremental increases in levels of both GFAP and UCH-L1 from non-concussive body trauma (lowest), to mild elevations in non-concussive head trauma, to highest levels in patients with concussion. In concussion patients, GFAP concentrations were significantly higher compared with body trauma controls (p<0.001) and with head trauma controls (p<0.001) in both children and adults, after controlling for multiple comparisons. However, for UCH-L1, there were no significant differences between concussion patients and head trauma controls (p=0.894) and between body trauma and head trauma controls in children. The AUC for initial GFAP levels to detect concussion was 0.80 (0.73-0.87) in children and 0.76 (0.71-0.80) in adults. This differed significantly from UCH-L1 with AUCs of 0.62 (0.53-0.72) in children and 0.69 (0.64-0.74) in adults. CONCLUSIONS: In a cohort of trauma patients with normal mental status, GFAP outperformed UCH-L1 in detecting concussion in both children and adults. Blood levels of GFAP and UCH-L1 showed incremental elevations across three injury groups: from non-concussive body trauma, to non-concussive head trauma, to concussion. However, UCH-L1 was expressed at much higher levels than GFAP in those with non-concussive trauma, particularly in children. Elevations in both biomarkers in patients with non-concussive head trauma may be reflective of a subconcussive brain injury. This will require further study.

Appendicitis: Role of MRI.

The diagnosis of pediatric appendicitis can be difficult, with a substantial proportion misdiagnosed based on clinical features and laboratory tests alone. Accordingly, advanced imaging with ultrasound (US), computed tomography (CT), and/or magnetic resonance imaging has become routine for most children undergoing diagnostic evaluation for appendicitis. There is increasing interest in the use of US as the primary imaging modality and reserving CT as a secondary diagnostic modality in equivocal cases. Magnetic resonance imaging, using a rapid protocol, without contrast or sedation, has been found to be highly sensitive and specific in the evaluation of children with acute right lower quadrant pain in a number of studies. Because magnetic resonance imaging has the advantage over CT of not using contrast or ionizing radiation, it may replace CT in many instances, whether after US as part of a stepwise imaging algorithm or as a primary imaging modality. Accessibility and cost, however, limit its more widespread use currently.

Association and Clinical Outcomes of Marijuana in Patients with Intracerebral Hemorrhage.

OBJECTIVE: An epidemiological relationship between intracerebral hemorrhage (ICH) and marijuana use is not known. Data about the impact of marijuana on ICH patient's outcomes remain scarce. METHODS: The Nationwide Inpatient Sample was investigated from 2004 to 2011 to identify cohorts with marijuana (N = 2,496,165) and nonmarijuana (N = 116,163,454) usage. Patients with a primary diagnosis of ICH were identified using International Classification of Diseases, Ninth Edition, Clinical Modification codes. Univariable analysis was used to compare demographics and risk factors for ICH, and to study patient outcomes in ICH patients with or without marijuana use. Binary logistic regression analyses were used to study marijuana as independent predictor of ICH and to assess its effect on patient outcomes. RESULTS: The prevalence of ICH was greater in the marijuana cohort (relative risk: 1.11, confidence interval [CI]: 1.07-1.16). However, marijuana use (odds ratio [OR]: 1.063; CI: .963-1.173) was not an independent predictor of ICH after adjusting for other illicit drug use and ICH risk factors. For in-hospital outcomes, marijuana users had fewer adverse discharge dispositions (OR .78; CI: .72-.86), reduced length of hospitalization (OR .54; CI: .48-.61), and lower hospitalization cost (OR .72; CI: .64-.81) but higher in-hospital mortality (OR 1.26; CI: 1.12-1.41). CONCLUSIONS: Marijuana users are more likely to be admitted with ICH, however, marijuana is not an independent risk factor for ICH. Although marijuana has paradoxical effect on ICH related outcomes, higher mortality rates in marijuana users offset any potential protective effect among ICH patients.

Economic Analysis of Diagnostic Imaging in Pediatric Patients With Suspected Appendicitis.

OBJECTIVE: The use of computed tomography (CT) and ultrasound (US) in patients with acute abdominal pain has substantial variation across pediatric emergency departments (EDs). This study compares the cost of diagnosing and treating suspected appendicitis across a multicenter network of children's hospitals. METHODS: This study is a secondary analysis using deidentified data of a prospective, observational study of patients with suspected appendicitis at nine pediatric EDs. The study included patients 3 to 18 years old who presented to the ED with acute abdominal pain of <96 hours' duration. RESULTS: Our data set contained 2,300 cases across nine sites. There was an appendicitis rate of 31.8% and perforation rate of 25.7%. Sites correctly diagnosed appendicitis in over 95% of cases. The negative appendicitis rate ranged from 2.5% to 4.7% while the missed appendicitis rate ranged from 0.3% to 1.1% with no significant differences in these rates across site. Across sites, we found a strong positive correlation (0.95) between CT rate and total cost per case and a strong negative correlation (-0.71) between US rate and cost. The cost per case at US sites was 5.2% ($367) less than at CT sites (p < 0.001). Similarly, costs per case at mixed sites were 3.4% ($244) less than at CT sites (p < 0.001). Comparing costs among CT sites or among US sites, the cost per case generally increased as the images per case increased among both CT sites and US sites, but the costs were universally higher at CT sites. CONCLUSIONS: Our results provide support for US as the primary imaging modality for appendicitis. Sites that preferentially utilized US had lower costs per case than sites that primarily used CT. Imaging rates across sites varied due to practice patterns and resulted in a significant cost consequence without higher rates for negative appendectomies or missed appendicitis cases.

Subarachnoid Hemorrhage and Readmissions: National Rates, Causes, Risk Factors, and Outcomes in 16,001 Hospitalized Patients.

INTRODUCTION: The acute complications of aneurysmal subarachnoid hemorrhage (aSAH) often lead to readmissions, which are linked to hospital reimbursement. The national rates, causes, risk factors, and outcomes associated with 30-day and 90-day readmission after aSAH have not previously been reported. METHODS: The Nationwide Readmissions Database was queried from January to September 2013 for all patients (age ≥18 years) with a diagnosis of aSAH. Data points included demographics, comorbidities, complications, and discharge outcomes. Causes and risk factors for 30-day and 90-day readmission were identified in univariate and multivariable analysis. RESULTS: In 12,777 patients discharged alive after hospitalization for aSAH, 962 (7.5%) were readmitted within 30 days and 2153 (16.7%) within 90 days. Common causes of readmission included stroke, hydrocephalus, septicemia, and headache. At 30-day and 90-day readmission, 39.7% and 51.2% of patients with diagnosis of hydrocephalus underwent ventriculoperitoneal shunt placement, respectively. In multivariable analysis, cannabis use and diabetes were predictors of both 30-day and 90-day readmission and older patients were uniquely susceptible to 30-day readmissions. Risk factors for 90-day readmission included Medicare insurance, hypothyroidism, initial discharge to skilled nursing facility, and several index complications including bowel obstruction, gastrostomy, acute lung injury, and cerebral edema. Average cost and length of stay were calculated at 30-day ($16.647, 7.1 days) and 90-day readmission ($17,926, 6.7 days). Mortality was 2.8% within 30 days and 3.8% within 90 days. CONCLUSIONS: Many readmissions occur outside the 30-day follow-up period in patients subarachnoid hemorrhage and possess unique risk factors, which may help identify high-risk patients.

Time From Emergency Department Evaluation to Operation and Appendiceal Perforation.

BACKGROUND AND OBJECTIVES: In patients with appendicitis, the risk of perforation increases with time from onset of symptoms. We sought to determine if time from emergency department (ED) physician evaluation until operative intervention is independently associated with appendiceal perforation (AP) in children. METHODS: We conducted a planned secondary analysis of children aged 3 to 18 years with appendicitis enrolled in a prospective, multicenter, cross-sectional study of patients with abdominal pain (<96 hours). Time of initial physical examination and time of operation were recorded. The presence of AP was determined using operative reports. We analyzed whether duration of time from initial ED physician evaluation to operation impacted the odds of AP using multivariable logistic regression, adjusting for traditionally suggested risk factors that increase the risk of perforation. We also modeled the odds of perforation in a subpopulation of patients without perforation on computed tomography. RESULTS: Of 955 children with appendicitis, 25.9% (n = 247) had AP. The median time from ED physician evaluation to operation was 7.2 hours (interquartile range: 4.8-8.5). Adjusting for variables associated with perforation, duration of time (≤ 24 hours) between initial ED evaluation and operation did not significantly increase the odds of AP (odds ratio = 1.0, 95% confidence interval, 0.96-1.05), even among children without perforation on initial computed tomography (odds ratio = 0.95, 95% confidence interval, 0.89-1.02). CONCLUSIONS: Although duration of abdominal pain is associated with AP, short time delays from ED evaluation to operation did not independently increase the odds of perforation.

Gastrointestinal Bowel Obstruction in Acute Ischemic Stroke: Incidence, Risk Factors, and Outcomes in a U.S. Nationwide Analysis of 3,998,667 Hospitalizations.

OBJECTIVE: The prognosis from acute ischemic stroke (AIS) is worsened by poststroke medical complications. The incidence, risk factors, and outcomes of gastrointestinal bowel obstruction (GIBO) in AIS are not known. METHODS: We queried the Nationwide Inpatient Sample (2002-2011) to identify all patients with a primary diagnosis of AIS and subsets with and without a secondary diagnosis of GIBO without hernia. Multivariable analysis was utilized to identify risk factors for GIBO in AIS patients and the association between GIBO, in-hospital complications, and outcomes. RESULTS: We identified 16,987 patients with GIBO (.43%) among 3,988,667 AIS hospitalizations and 4.2% of these patients underwent surgery. In multivariable analysis, patients with 75+ years of age were two times as likely to suffer GIBO compared to younger patients (P < .0001). African Americans were 42% more likely to have GIBO compared to Whites (P < .0001). Stroke patients with pre-existing comorbidities (coagulopathy, cancer, blood loss anemia, and fluid/electrolyte disorder) were more likely to experience GIBO (all P < .0001). AIS patients with GIBO were 184% and 39% times more likely to face moderate-to-severe disability and in-hospital death, respectively (P < .0001). GIBO occurrence increased length of stay and total costs by an average of 9.7 days and $22,342 (P < .0001). CONCLUSION: GIBO is a rare but burdensome complication of AIS, associated with complications, disability, and mortality. The risk factors identified in this study aim to encourage the monitoring of patients at highest risk for GIBO. The predominant form of stroke-related GIBO is nonmechanical obstruction, although the causative relationship remains unknown.

Hyponatremia in Guillain-Barré Syndrome.

OBJECTIVES: To evaluate incidence, risk factors, and in-hospital outcomes associated with hyponatremia in patients hospitalized for Guillain-Barré Syndrome (GBS). METHODS: We identified adult patients with GBS in the Nationwide Inpatient Sample (2002-2011). Univariate and multivariable analyses were used. RESULTS: Among 54,778 patients hospitalized for GBS, the incidence of hyponatremia was 11.8% (compared with 4.0% in non-GBS patients) and increased from 6.9% in 2002 to 13.5% in 2011 (P < 0.0001). Risk factors associated with hyponatremia in multivariable analysis included advanced age, deficiency anemia, alcohol abuse, hypertension, and intravenous immunoglobulin (all P < 0.0001). Hyponatremia was associated with prolonged length of stay (16.07 vs. 10.41, days), increased costs (54,001 vs. 34,125, $USD), and mortality (20.5% vs. 11.6%) (all P < 0.0001). In multivariable analysis, hyponatremia was independently associated with adverse discharge disposition (odds ratio: 2.07, 95% confidence interval, 1.91-2.25, P < 0.0001). CONCLUSIONS: Hyponatremia is prevalent in GBS and is detrimental to patient-centered outcomes and health care costs. Sodium levels should be carefully monitored in high-risk patients.

Neuronal Biomarker Ubiquitin C-Terminal Hydrolase Detects Traumatic Intracranial Lesions on Computed Tomography in Children and Youth with Mild Traumatic Brain Injury.

This study examined the performance of serum ubiquitin C-terminal hydrolase (UCH-L1) in detecting traumatic intracranial lesions on computed tomography (CT) scan (+CT) in children and youth with mild and moderate TBI (mmTBI) and assessed its performance in trauma control patients without head trauma. This prospective cohort study enrolled children and youth presenting to three level 1 trauma centers after blunt head trauma and a Glasgow Coma Scale (GCS) score of 9-15 as well as trauma control patients with GCS 15 that did not have blunt head trauma. The primary outcome measure was the presence of intracranial lesions on initial CT scan. Blood samples were obtained in all patients within 6 h of injury and measured by enzyme-linked immunosorbent assay ELISA for UCH-L1 (ng/mL). A total of 256 children and youth were enrolled in the study and had serum samples drawn within 6 h of injury for analysis; 196 had blunt head trauma and 60 were trauma controls. CT scan of the head was performed in 151 patients and traumatic intracranial lesions on CT scan were evident in 17 (11%), all of whom had a GCS of 13-15. The area under the receiver operating characteristic curve (AUC) for UCH-L1 in detecting children and youth with traumatic intracranial lesions on CT was 0.83 (95% confidence interval [CI], 0.73-0.93). In those presenting with a GCS of 15, the AUC for detecting lesions was 0.83 (95% CI, 0.72-0.94). Similarly, in children under 5 years of age, the AUC was 0.79 (95% CI, 0.59-1.00). Performance for detecting intracranial lesions at a UCH-L1 cut-off level of 0.18 ng/mL yielded a sensitivity of 100%, a specificity of 47%, and a negative predictive value of 100%. UCH-L1 showed good performance in infants and toddlers younger than 5 years and performed well in children and youth with a GCS score of 15. Before clinical application, further study in larger cohort of children and youth with mild TBI is warranted.

Traumatic subdural hematoma: Is there a weekend effect?

OBJECTIVE: Traumatic subdural hematoma (TSDH) is a surgical emergency. The effect of weekend admission on surgery and in-hospital outcomes in TSDH is not known. METHODS: We queried the Nationwide Inpatient Sample from 2002 to 2011 and used ICD-9-CM codes to identify all non-elective admissions with a primary diagnosis of TSDH. We did a subgroup analysis of patients who underwent surgical evacuation. Predictor variables included several patient and hospital characteristics. Outcome variables included length of stay, total hospitalization cost, in-hospital complications, adverse discharge disposition, and in-hospital mortality. We used multivariable analysis to determine if weekend admission was independently associated with increased likelihood of poor outcomes. RESULTS: Out of a total of 404,212 TSDH admissions, 24.8% received surgical intervention. Patients admitted on weekends were less likely to undergo surgical intervention (odds ratio [OR]: 0.85). In the surgical cohort, weekend admissions consisted of more patients with prolonged loss of consciousness (24+h) without return to baseline (7.0% vs. 4.8%). In all TSDH patients and in sub-group of surgical cohort, weekend admission was associated with an increased likelihood of in-hospital complication (OR: 1.06 and 1.12), prolonged length of stay (OR: 1.08 and 1.17), increased total hospital costs (OR: 1.04 and 1.11), adverse discharge (OR: 1.08 and 1.18), and in-hospital mortality (OR: 1.04 and 1.11). All p-values were less than 0.01. CONCLUSION: Our study demonstrates that patients admitted on weekends had similar mortality despite higher severity with no clinically significant weekend effect for tSDH.

A Clinical Score to Predict Appendicitis in Older Male Children.

OBJECTIVE: To develop a clinical score to predict appendicitis among older, male children who present to the emergency department with suspected appendicitis. METHODS: Patients with suspected appendicitis were prospectively enrolled at 9 pediatric emergency departments. A total of 2625 patients enrolled; a subset of 961 male patients, age 8-18 were analyzed in this secondary analysis. Outcomes were determined using pathology, operative reports, and follow-up calls. Clinical and laboratory predictors with <10% missing data and kappa > 0.4 were entered into a multivariable model. Resultant ß-coefficients were used to develop a clinical score. Test performance was assessed by calculating the sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratios. RESULTS: The mean age was 12.2 years; 49.9% (480) had appendicitis, 22.3% (107) had perforation, and the negative appendectomy rate was 3%. In patients with and without appendicitis, overall imaging rates were 68.6% (329) and 84.4% (406), respectively. Variables retained in the model included maximum tenderness in the right lower quadrant, pain with walking/coughing or hopping, and the absolute neutrophil count. A score ≥8.1 had a sensitivity of 25% (95% confidence interval [CI], 20%-29%), specificity of 98% (95% CI, 96%-99%), and positive predictive value of 93% (95% CI, 86%-97%) for ruling in appendicitis. CONCLUSIONS: We developed an accurate scoring system for predicting appendicitis in older boys. If validated, the score might allow clinicians to manage a proportion of male patients without diagnostic imaging.