Magnetic Resonance Imaging Availability Reduces Computed Tomography Use for Pediatric Appendicitis Diagnosis.

OBJECTIVES: To determine if introducing magnetic resonance imaging (MRI) as an imaging option for children with suspected appendicitis and an inconclusive ultrasound reduces computed tomography (CT) use. METHODS: This is a retrospective cohort study of patients aged 5 to 18 years who presented to a pediatric emergency department (ED) with suspected appendicitis. Rates of CT use 1 year before and 1 year after MRI availability are compared. Secondary outcomes include missed and negative appendectomies, imaging charges, time to antibiotics and surgery, time to radiology read, ED length of stay, and test characteristics of MRI and CT. RESULTS: Of the 981 patients screened, 499 patients met inclusion criteria. There was an absolute reduction of CT use of 25% from 38% in year 1 to 13% in year 2 (95% confidence interval, 18% to 33%). Advanced imaging charges were $371 higher in year 2 (MRI) than year 1 (CT), and median time to radiologist reads was longer in MRIs than CTs (129 versus 62 minutes; difference 53 minutes, 95% confidence interval, 23 to 74 minutes). All other secondary outcomes, including ED length of stay and test characteristics, were statistically similar. CONCLUSIONS: Introducing MRI for as an imaging option for children with suspected appendicitis and an inconclusive ultrasound markedly reduced CT use, but did result in a small increase in imaging charges and time to preliminary radiology read.

Reduction in Head Computed Tomography Ordering in Pediatric Emergency Patients: Effect of National Publication and Local Availability of Urgent Neurology Appointments.

OBJECTIVE: The objective of this study was to evaluate the effect of the Pediatric Emergency Care Applied Research Network (PECARN) blunt head trauma guidelines and implementation of urgent neurology follow-up (UNF) appointments on an observed decline in head computed tomography (CT) use for pediatric emergency department (PED) patients presenting with headache, seizure, and trauma. METHODS: Patients ages 0 to 18 years presenting to and discharged from an urban tertiary care PED with chief complaint of trauma, headache, and seizure between 2007 and 2013 were retrospectively included. The total number of head CTs obtained in the trauma, headache, and seizure groups was compared before and after the publication of the PECARN guidelines in 2009 and the implementation of urgent UNF within a week from PED discharge in 2011, respectively. RESULTS: Between 2007 and 2013, 24,434 encounters were identified with 2762 head CTs performed. Analysis demonstrated a decline in pediatric head CTs for trauma (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.8-2.2) after the publication of the PECARN study on blunt head trauma, for headache (OR, 1.4; 95% CI, 1.1-1.8) and seizure (OR, 1.9; 95% CI, 1.4-2.6) with UNF. However, cross comparison (headache and seizure with PECARN and trauma with UNF) also demonstrated similar significant declines. CONCLUSIONS: The decline in head CTs observed at our institution demonstrated a strong linear relationship, yet cannot be solely attributed to the PECARN blunt head trauma study or the implementation of UNF.

Nebulized budesonide added to standard pediatric emergency department treatment of acute asthma: a randomized, double-blind trial.

OBJECTIVES: The goal was to determine if adding inhaled budesonide to standard asthma therapy improves outcomes of pediatric patients presenting to the emergency department (ED) with acute asthma. METHODS: The authors conducted a randomized, double-blind, placebo-controlled trial in a tertiary care, urban pediatric ED. Patients 2 to 18 years of age with moderate to severe acute asthma were randomized to receive either a single 2-mg dose of budesonide inhalation suspension (BUD) or normal sterile saline (NSS) placebo, added to albuterol, ipratropium bromide (IB), and systemic corticosteroids (SCS). The primary outcome was the difference in median asthma scores between treatment groups at 2 hours. Secondary outcomes included differences in vital signs and hospitalization rates. RESULTS: A total of 180 patients were enrolled. Treatment groups had similar baseline demographics, asthma scores, and vital signs. A total of 169 patients (88 BUD, 81 NSS) were assessed for the primary outcome. No significant difference was found between groups in the change in median asthma score at 2 hours (BUD -3, NSS -3, p = 0.64). Vital signs at 2 hours were also similar between groups. Fifty-six children (62%) were admitted to the hospital in the BUD group and 55 (62%) in the NSS group (difference 0%, 95% confidence interval [CI] = -14% to 14%). Neither multivariate adjustment nor planned subgroup analysis by inhaled corticosteroids (ICS) use prior to the ED significantly altered the results. CONCLUSIONS: For children 2 to 18 years of age treated in the ED for acute asthma, a single 2-mg dose of budesonide added to standard therapy did not improve asthma severity scores or other short-term ED-based outcomes.