Publications by authors named "Amy D Thompson"

30 Publications

  • Page 1 of 1

Predictors of Invasive Herpes Simplex Virus Infection in Young Infants.

Pediatrics 2021 Sep;148(3)

Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.

Objectives: To identify independent predictors of and derive a risk score for invasive herpes simplex virus (HSV) infection.

Methods: In this 23-center nested case-control study, we matched 149 infants with HSV to 1340 controls; all were ≤60 days old and had cerebrospinal fluid obtained within 24 hours of presentation or had HSV detected. The primary and secondary outcomes were invasive (disseminated or central nervous system) or any HSV infection, respectively.

Results: Of all infants included, 90 (60.4%) had invasive and 59 (39.6%) had skin, eyes, and mouth disease. Predictors independently associated with invasive HSV included younger age (adjusted odds ratio [aOR]: 9.1 [95% confidence interval (CI): 3.4-24.5] <14 and 6.4 [95% CI: 2.3 to 17.8] 14-28 days, respectively, compared with >28 days), prematurity (aOR: 2.3, 95% CI: 1.1 to 5.1), seizure at home (aOR: 6.1, 95% CI: 2.3 to 16.4), ill appearance (aOR: 4.2, 95% CI: 2.0 to 8.4), abnormal triage temperature (aOR: 2.9, 95% CI: 1.6 to 5.3), vesicular rash (aOR: 54.8, (95% CI: 16.6 to 180.9), thrombocytopenia (aOR: 4.4, 95% CI: 1.6 to 12.4), and cerebrospinal fluid pleocytosis (aOR: 3.5, 95% CI: 1.2 to 10.0). These variables were transformed to derive the HSV risk score (point range 0-17). Infants with invasive HSV had a higher median score (6, interquartile range: 4-8) than those without invasive HSV (3, interquartile range: 1.5-4), with an area under the curve for invasive HSV disease of 0.85 (95% CI: 0.80-0.91). When using a cut-point of ≥3, the HSV risk score had a sensitivity of 95.6% (95% CI: 84.9% to 99.5%), specificity of 40.1% (95% CI: 36.8% to 43.6%), and positive likelihood ratio 1.60 (95% CI: 1.5 to 1.7) and negative likelihood ratio 0.11 (95% CI: 0.03 to 0.43).

Conclusions: A novel HSV risk score identified infants at extremely low risk for invasive HSV who may not require routine testing or empirical treatment.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/peds.2021-050052DOI Listing
September 2021

Electrocardiogram as a Lyme Disease Screening Test.

J Pediatr 2021 Jul 12. Epub 2021 Jul 12.

Division of Emergency Medicine, Boston Children's Hospital, Boston, MA.

Objective: To examine the association between electrocardiographic (ECG) evidence of carditis at the time of Lyme disease evaluation and a diagnosis of Lyme disease.

Study Design: We performed an 8-center prospective cohort study of children undergoing emergency department evaluation for Lyme disease limited to those who had an ECG obtained by their treating clinicians. The study cardiologist reviewed all ECGs flagged as abnormal by the study sites to assess for ECG evidence of carditis. We defined Lyme disease as the presence of an erythema migrans lesion or a positive 2-tier Lyme disease serology. We used logistic regression to measure the association between Lyme disease and atrioventricular (AV) block or any ECG evidence of carditis.

Results: Of the 546 children who had an ECG obtained, 214 (39%) had Lyme disease. Overall, 42 children had ECG evidence of carditis, of whom 24 had AV block (20 first-degree). Of the patients with ECG evidence of carditis, only 21 (50%) had any cardiac symptoms. The presence of AV block (OR 4.7, 95% CI 1.8-12.1) and any ECG evidence of carditis (OR 2.3, 95% CI 1.2-4.3) were both associated with diagnosis of Lyme disease.

Conclusions: ECG evidence of carditis, especially AV block, was associated with a diagnosis of Lyme disease. ECG evidence of carditis can be used as a diagnostic biomarker for Lyme disease to guide initial management while awaiting Lyme disease test results.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpeds.2021.07.010DOI Listing
July 2021

Neonatal Mastitis and Concurrent Serious Bacterial Infection.

Pediatrics 2021 Jul 29;148(1). Epub 2021 Jun 29.

Department of Pediatrics and Emergency Medicine, School of Medicine, University of California, Davis, Sacramento, California.

Objectives: Describe the clinical presentation, prevalence, and outcomes of concurrent serious bacterial infection (SBI) among infants with mastitis.

Methods: Within the Pediatric Emergency Medicine Collaborative Research Committee, 28 sites reviewed records of infants aged ≤90 days with mastitis who were seen in the emergency department between January 1, 2008, and December 31, 2017. Demographic, clinical, laboratory, treatment, and outcome data were summarized.

Results: Among 657 infants (median age 21 days), 641 (98%) were well appearing, 138 (21%) had history of fever at home or in the emergency department, and 63 (10%) had reported fussiness or poor feeding. Blood, urine, and cerebrospinal fluid cultures were collected in 581 (88%), 274 (42%), and 216 (33%) infants, respectively. Pathogens grew in 0.3% (95% confidence interval [CI] 0.04-1.2) of blood, 1.1% (95% CI 0.2-3.2) of urine, and 0.4% (95% CI 0.01-2.5) of cerebrospinal fluid cultures. Cultures from the site of infection were obtained in 335 (51%) infants, with 77% (95% CI 72-81) growing a pathogen, most commonly methicillin-resistant (54%), followed by methicillin-susceptible (29%), and unspecified (8%). A total of 591 (90%) infants were admitted to the hospital, with 22 (3.7%) admitted to an ICU. Overall, 10 (1.5% [95% CI 0.7-2.8]) had sepsis or shock, and 2 (0.3% [95% CI 0.04-1.1]) had severe cellulitis or necrotizing soft tissue infection. None received vasopressors or endotracheal intubation. There were no deaths.

Conclusions: In this multicenter cohort, mild localized disease was typical of neonatal mastitis. SBI and adverse outcomes were rare. Evaluation for SBI is likely unnecessary in most afebrile, well-appearing infants with mastitis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/peds.2021-051322DOI Listing
July 2021

Validation of Septic Knee Monoarthritis Prediction Rule in a Lyme Disease Endemic Area.

Pediatr Emerg Care 2021 May 13. Epub 2021 May 13.

From the *Brown University, Providence, RI †Division of Pediatric Emergency Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA ‡Division of Pediatric Emergency Medicine, Children's Hospital of Wisconsin, Milwaukee, WI §Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA ∥Departments of Pediatrics and Emergency Medicine, Hasbro Children's Hospital, Providence, RI ¶Division of Emergency Medicine, Nemours/A.I. duPont Hospital for Children, Wilmington, DE #Department of Emergency Medicine, Children's Minnesota, Minneapolis, MN **Division of Emergency Medicine, Boston Children's Hospital, Boston, MA.

Objective: In Lyme disease endemic areas, Lyme and septic arthritis often present similarly. A published septic knee arthritis clinical prediction rule includes 2 high-risk predictors: absolute neutrophil count of 10,000 cells/mm or greater and erythrocyte sedimentation rate of 40 mm/h or greater. The objective of the study was to externally validate this prediction rule in a multicenter prospective cohort.

Methods: We enrolled a prospective cohort of children with knee monoarthritis undergoing evaluation for Lyme disease at 1 of 8 Pedi Lyme Net emergency departments located in endemic areas. We defined a case of septic arthritis with a positive synovial fluid culture or a synovial fluid white blood cell count of 50,000 or greater per high powered field with a positive blood culture and Lyme arthritis with a positive or equivocal C6 EIA, followed by a positive supplemental immunoblot. Other children were classified as having inflammatory arthritis. We report the performance of the septic arthritis clinical prediction rule in our study population.

Results: Of the 543 eligible children, 13 had septic arthritis (2.4%), 234 Lyme arthritis (43.1%), and 296 inflammatory arthritis (54.5%). Of the 457 children (84.2%) with available laboratory predictors, all children with septic arthritis were classified as high risk (sensitivity, 100%; 95% confidence interval [CI], 62.8%-100%; specificity, 68.1%; 95% CI, 63.6-73.3; negative predictive value, 278/278 [100%]; 95% CI, 98.6%-100%). Of the 303 low-risk children, 52 (17.2%) underwent diagnostic arthrocentesis.

Conclusions: The septic knee arthritis clinical prediction rule accurately distinguished between septic and Lyme arthritis in an endemic area. Clinical application may reduce unnecessary invasive diagnostic procedures.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/PEC.0000000000002455DOI Listing
May 2021

Research environment and resources to support pediatric emergency medicine fellow research.

AEM Educ Train 2021 Jul 9;5(3):e10585. Epub 2021 Mar 9.

Section of Emergency Medicine Children's Hospital Colorado Aurora Colorado USA.

Background: There is a need for pediatric emergency medicine (PEM) researchers, but the current state of PEM fellow research training is not well described. We sought to (1) describe resources and gaps in PEM fellowship research training and (2) assess agreement between fellow and program director (PD) perceptions of these in fellow research experience.

Methods: Surveys were distributed electronically to U.S. PEM fellows and PDs from March to April 2020. Fellows and PDs were queried on program research infrastructure and current gaps in fellow research experience. For programs that had at least one fellow and PD response, each fellow response was compared to their PD's corresponding response (reference standard). For each binary survey item, we determined the percent of responses with agreement between the fellow and PD.

Results: Of 79 fellowship programs, 70 (89%) were represented with at least one response, including responses from 59 PDs (75%) and 218 fellows (39% of all fellows, representing 80% of programs). Fellows and PDs identified mentorship and faculty engagement as the most important needs for successful fellowship research; for every one fellow there was a median of 0.8 potential faculty mentors in the division. Twenty percent of fellows were not satisfied with mentorship opportunities. There was no association between fellow career research intent (high, defined as ≥20% dedicated time, or low) with current year of training (p = 0.88), program size (p = 0.67), and area of research focus (p = 0.40). Fellows were often unaware of research being performed by division faculty.

Conclusion: PEM fellows were not consistently aware of resources available to support research training. To better support PEM fellows' research training, many programs may need to expand mentorship and increase fellows' awareness of local and external resources and opportunities.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/aet2.10585DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8171771PMC
July 2021

Treatment of suspected sepsis and septic shock in children with chronic disease seen in the pediatric emergency department.

Am J Emerg Med 2021 06 22;44:56-61. Epub 2021 Jan 22.

Division of Emergency Medicine, Department of Pediatrics, Nemours, Alfred I. Dupont Hospital for Children. 1600 Rockland Road, Wilmington, DE 19803, United States of America. Electronic address:

Background: Research demonstrates that timely recognition and treatment of sepsis can significantly improve pediatric patient outcomes, especially regarding time to intravenous fluid (IVF) and antibiotic administration. Further research suggests that underlying chronic disease in a septic pediatric patient puts them at higher risk for poor outcomes.

Objective: To compare treatment time for suspected sepsis and septic shock in pediatric patients with chronic disease versus those without chronic disease seen in the Pediatric Emergency Department (PED).

Methods: We reviewed patient data from a pediatric sepsis outcomes dataset collected at two tertiary care pediatric hospital sites from January 2017-December 2018. Patients were stratified into two groups: those with and without chronic disease, defined as any patient with at least one of eight chronic health conditions.

Inclusion Criteria: patients seen in the PED ultimately diagnosed with sepsis or septic shock, patient age 0 to 20 years and time zero for identification of sepsis in the PED.

Exclusion Criteria: time zero unavailable, inability to determine time of first IVF or antibiotic administration or patient death within the PED. Primary analysis included comparison of time zero to first IVF and antibiotic administration between each group.

Results: 312 patients met inclusion criteria. 169 individuals had chronic disease and 143 did not. Median time to antibiotics in those with chronic disease was 41.9 min versus 43.0 min in patients without chronic disease (p = 0.181). Time to first IVF in those with chronic disease was 22.0 min versus 12.0 min in those without (p = 0.010). Those with an indwelling line/catheter (n = 40) received IVF slower than those without (n = 272), with no significant difference in time to antibiotic administration by indwelling catheter status (p = 0.063). There were no significant differences in the mode of identification of suspected sepsis or septic shock between those with versus without chronic disease (p = 0.27).

Conclusions: Study findings suggest pediatric patients with chronic disease with suspected sepsis or septic shock in the PED have a slower time to IVF administration but equivocal use of sepsis recognition tools compared to patients without chronic disease.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajem.2021.01.026DOI Listing
June 2021

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

Pediatrics 2021 01 7;147(1). Epub 2020 Dec 7.

Department of Pediatrics, University of Florida, Jacksonville, Jacksonville, Florida.

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 ( < .001) or CSF cultures ( < .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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/peds.2020-1571DOI Listing
January 2021

Pediatric Lyme Disease Biobank, United States, 2015-2020.

Emerg Infect Dis 2020 12;26(12):3099-3101

In 2015, we founded Pedi Lyme Net, a pediatric Lyme disease research network comprising 8 emergency departments in the United States. Of 2,497 children evaluated at 1 of these sites for Lyme disease, 515 (20.6%) were infected. This network is a unique resource for evaluating new approaches for diagnosing Lyme disease in children.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3201/eid2612.200920DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7706969PMC
December 2020

Exhaled end-tidal carbon dioxide as a predictor of lactate and pediatric sepsis.

Am J Emerg Med 2020 12 1;38(12):2620-2624. Epub 2020 Aug 1.

Division of Emergency Medicine, Department of Pediatrics, Nemours Alfred I. duPont Hospital For Children, Wilmington, DE, United States of America.

Objective: The objective of this study was to investigate the relationship between exhaled end-tidal carbon dioxide (ETCO) and serum lactate via nasal capnography and to assess the ability of ETCO to predict disease severity in children with suspected sepsis in a pediatric emergency department.

Methods: This prospective study included patients (≥ 30 days to ≤21 years of age) who presented with suspected sepsis to a tertiary pediatric emergency department. Pearson correlation coefficient was generated to measure the linear relationship between ETCO and lactate. Receiver operating characteristic curves (ROC) were generated to assess the performance of ETCO to predict a lactate ≥2 mmol/L and severe disease. Severe disease was defined as severe sepsis and septic shock.

Results: From November 1, 2018 to March 31, 2020, 105 emergency department patients underwent evaluation for suspected sepsis. Sixty-nine patients met the inclusion criteria for the study. There was an inverse relationship between ETCO and lactate with a correlation coefficient of -0.34 (p = .005). Severe disease had lower ETCO (32 ± 6 mmHg, p < .001) and higher lactate (3.3 ± 1.7 mmol/L, p < .001). The area under the curve (AUC) for ETCO to predict severe disease was 0.75 (95% CI 0.63, 0.86). An ETCO cut off point of 30 mmHg correlated with a sensitivity of 93% and specificity of 32%.

Conclusions: We observed a significant inverse relationship between ETCO2 and lactate in children presenting with suspected sepsis. A lower ETCO2 was predictive of severe disease.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajem.2020.07.075DOI Listing
December 2020

Performance of the Modified Boston and Philadelphia Criteria for Invasive Bacterial Infections.

Pediatrics 2020 04 23;145(4). Epub 2020 Mar 23.

Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts.

Background: The ability of the decades-old Boston and Philadelphia criteria to accurately identify infants at low risk for serious bacterial infections has not been recently reevaluated.

Methods: We assembled a multicenter cohort of infants 29 to 60 days of age who had cerebrospinal fluid (CSF) and blood cultures obtained. We report the performance of the modified Boston criteria (peripheral white blood cell count [WBC] ≥20 000 cells per mm, CSF WBC ≥10 cells per mm, and urinalysis with >10 WBC per high-power field or positive urine dip result) and modified Philadelphia criteria (peripheral WBC ≥15 000 cells per mm, CSF WBC ≥8 cells per mm, positive CSF Gram-stain result, and urinalysis with >10 WBC per high-power field or positive urine dip result) for the identification of invasive bacterial infections (IBIs). We defined IBI as bacterial meningitis (growth of pathogenic bacteria from CSF culture) or bacteremia (growth from blood culture).

Results: We applied the modified Boston criteria to 8344 infants and the modified Philadelphia criteria to 8131 infants. The modified Boston criteria identified 133 of the 212 infants with IBI (sensitivity 62.7% [95% confidence interval (CI) 55.9% to 69.3%] and specificity 59.2% [95% CI 58.1% to 60.2%]), and the modified Philadelphia criteria identified 157 of the 219 infants with IBI (sensitivity 71.7% [95% CI 65.2% to 77.6%] and specificity 46.1% [95% CI 45.0% to 47.2%]). The modified Boston and Philadelphia criteria misclassified 17 of 53 (32.1%) and 13 of 56 (23.3%) infants with bacterial meningitis, respectively.

Conclusions: The modified Boston and Philadelphia criteria misclassified a substantial number of infants 29 to 60 days old with IBI, including those with bacterial meningitis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/peds.2019-3538DOI Listing
April 2020

The Champagne Tap: Time to Pop the Cork?

Acad Emerg Med 2020 11 20;27(11):1194-1198. Epub 2020 Apr 20.

From, Division of Emergency Medicine, Boston Children's Hospital, Boston, MA.

Background: A "champagne tap" is a lumbar puncture with no cerebrospinal fluid (CSF) red blood cells (RBCs). Clinicians disagree whether the absence of CSF white blood cells (WBCs) is also required.

Aims: As supervising providers frequently reward trainees after a champagne tap, we investigated how varying the definition impacted the frequency of trainee accolades.

Materials & Methods: We performed a secondary analysis of a retrospective cross-sectional study of infants ≤60 days of age who had a CSF culture performed in the emergency department (ED) at one of 20 centers participating in a Pediatric Emergency Medicine Collaborative Research Committee (PEM CRC) endorsed study. Our primary outcomes were a champagne tap defined by either a CSF RBC count of 0 cells/mm regardless of CSF WBC count or both CSF RBC and WBC counts of 0 cells/mm .

Results: Of the 23,618 eligible encounters, 20,358 (86.2%) had both a CSF RBC and WBC count obtained. Overall, 3,147 (13.3%) had a CSF RBC count of 0 cells/mm and 377 (1.6%) had both CSF WBC and RBC counts of 0 cells/mm (relative rate 8.35, 95% confidence interval 7.51 to 9.27).

Conclusions: In infants, a lumbar puncture with a CSF RBC count of 0 cells/mm regardless of the CSF WBC count occurred eight-times more frequently than one with both CSF WBC and RBC counts of 0 cells/mm . A broader champagne tap definition would allow more frequent recognition of procedural success, with the potential to foster a supportive community during medical training, potentially protecting against burnout.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/acem.13966DOI Listing
November 2020

Potential selection bias when subjects were excluded because of missing values.

Am J Emerg Med 2020 03 20;38(3):681-682. Epub 2019 Dec 20.

Nemours Alfred I. duPont Hospital for Children, Attn: Emergency Medicine, 1600 Rockland Rd., Wilmington, DE 19803, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajem.2019.12.001DOI Listing
March 2020

Is lactic acidosis predictive of outcomes in pediatric diabetic ketoacidosis?

Am J Emerg Med 2020 02 24;38(2):329-332. Epub 2019 Oct 24.

Division of Emergency Medicine, Department of Pediatrics, Nemours Alfred I. duPont Hospital for Children, Wilmington, DE, USA.

Objectives: The objective of this study was to investigate the significance and prevalence of lactic acidosis in pediatric diabetic ketoacidosis (DKA) presenting to the emergency department.

Methods: A retrospective cohort study of children (age ≤ 21 years) presenting to a tertiary care emergency department in DKA from December 1, 2015 to December 1, 2018. Patients needed to have DKA requiring admission to the pediatric intensive care unit and have had a lactate level collected while in the emergency department to be included.

Results: 92 patients resulting in 113 encounters had DKA and a lactate level collected in the emergency department. The mean lactate level was 3.5 mmol/L (±SD 2.1). 72 (63.7%) encounters had lactic acidosis (p < 0.001). There was no significant association between the presence of lactic acidosis and pediatric intensive care unit length of stay (p = 0.321), hospital length of stay (p = 0.426), morbidity (p = 0.552) and mortality (p = 1.000). Initial glucose levels were significantly higher in the patients presenting with lactic acidosis (p = 0.001).

Conclusions: Lactic acidosis is a common finding in pediatric DKA patients presenting to the emergency department. Serum lactate alone should not be used as an outcome predictor in pediatric DKA.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajem.2019.158449DOI Listing
February 2020

A Call to Restore Your Calling: Self-Care of the Emergency Physician in the Face of Life-Changing Stress-Part 3 of 6: Physician Illness and Impairment.

Pediatr Emerg Care 2019 Aug;35(8):585-588

Employee Assistance Program, Nemours Alfred I. duPont Hospital for Children, Wilmington, DE.

Physicians suffer from most medical conditions at the same rate as their lay peers. However, physicians' self-care is often sacrificed for patient care. This third article in our series examines physician and trainee illness and impairment. Presenteeism, physician impairment, and substance use disorder (SUD) are defined. We call attention to the potential for harm of dated cultural norms, which often fuel physicians' neglect of their own health and development of ill-advised coping skills.Although any medical condition may become a functional impairment, the primary cause of physician impairment is SUD. Alcohol and prescription opioids top the list of substances used in excess by physicians. Although SUD is less prevalent in residency, we focus on the rise of marijuana and alcohol use in emergency medicine trainees. A nonpunitive model for the prevention and treatment of SUD in residency is described.Physicians are ethically and legally mandated to report any concern for impairment to either a state physician health program or a state medical board. However, recognizing physician SUD is challenging. We describe its clinical presentation, voluntary and mandated treatment tracks, provisions for protecting reporters from civil liability, prognosis for return to practice, and prevention efforts. We underscore the need to model healthy coping strategies and assist trainees in adopting them.In closing, we offer our colleagues and trainees today's to-do list for beginning the journey of reclaiming your health. We also provide resources focused on the practical support of ill and/or impaired physicians.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/PEC.0000000000001896DOI Listing
August 2019

A Call to Restore Your Calling: Self-Care of the Emergency Physician in the Face of Life-Changing Stress-Part 3 of 6: Physician Illness and Impairment.

Pediatr Emerg Care 2019 Aug;35(8):585-588

Employee Assistance Program, Nemours Alfred I. duPont Hospital for Children, Wilmington, DE.

Physicians suffer from most medical conditions at the same rate as their lay peers. However, physicians' self-care is often sacrificed for patient care. This third article in our series examines physician and trainee illness and impairment. Presenteeism, physician impairment, and substance use disorder (SUD) are defined. We call attention to the potential for harm of dated cultural norms, which often fuel physicians' neglect of their own health and development of ill-advised coping skills.Although any medical condition may become a functional impairment, the primary cause of physician impairment is SUD. Alcohol and prescription opioids top the list of substances used in excess by physicians. Although SUD is less prevalent in residency, we focus on the rise of marijuana and alcohol use in emergency medicine trainees. A nonpunitive model for the prevention and treatment of SUD in residency is described.Physicians are ethically and legally mandated to report any concern for impairment to either a state physician health program or a state medical board. However, recognizing physician SUD is challenging. We describe its clinical presentation, voluntary and mandated treatment tracks, provisions for protecting reporters from civil liability, prognosis for return to practice, and prevention efforts. We underscore the need to model healthy coping strategies and assist trainees in adopting them.In closing, we offer our colleagues and trainees today's to-do list for beginning the journey of reclaiming your health. We also provide resources focused on the practical support of ill and/or impaired physicians.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/PEC.0000000000001896DOI Listing
August 2019

Utility of applying white blood cell cutoffs to non-diagnostic MRI and ultrasound studies for suspected pediatric appendicitis.

Am J Emerg Med 2019 09 18;37(9):1723-1728. Epub 2018 Dec 18.

Division of Emergency Medicine, Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA. Electronic address:

Background: Non-contrast magnetic resonance imaging (MRI) and ultrasound studies in pediatric patients with suspected appendicitis are often non-diagnostic. The primary objective of this investigation was to determine if combining these non-diagnostic imaging results with white blood cell (WBC) cutoffs improves their negative predictive values (NPVs).

Methods: A retrospective chart review was conducted including patients ≤18 years old with suspected appendicitis who had MRI performed with or without a preceding ultrasound study in a pediatric emergency department. Imaging results were sorted into 2 diagnostic and 5 non-diagnostic categories. NPVs were calculated for the non-diagnostic MRI and ultrasound categories with and without combining them with WBC cutoffs of <10.0 and <7.5 × 10/L.

Results: Of the 612 patients with MRI studies included, 402 had ultrasound studies performed. MRI with incomplete visualization of a normal appendix without secondary signs of appendicitis had an NPV of 97.9% that changed to 98.1% and 98.2% when combined with WBC cutoffs of <10.0 and <7.5, respectively. Ultrasound studies with incomplete visualization of a normal appendix without secondary signs had an NPV of 85.3% that improved to 94.8% and 96.5% when combined with WBC cutoffs of <10.0 and <7.5, respectively.

Conclusions: In pediatric patients with suspected appendicitis, MRI studies with incomplete visualization of a normal appendix without secondary signs have a high NPV that does not significantly change with the use of these WBC cutoffs. In contrast, combining WBC cutoffs with ultrasound studies with the same interpretation identifies low-risk groups.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajem.2018.12.029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8043663PMC
September 2019

Application of the Bacterial Meningitis Score for Infants Aged 0 to 60 Days.

J Pediatric Infect Dis Soc 2019 Dec;8(6):559-562

Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Massachusetts.

In 4292 infants aged ≤60 days with cerebrospinal fluid (CSF) pleocytosis, the bacterial meningitis score had excellent sensitivity (121 of 121 [100.0%] [95% confidence interval, 96.5%-100.0%]) but low specificity (66 of 4171 [1.6%] [95% confidence interval, 1.3%-2.0%]) and therefore should not be applied clinically to infants in this age group.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/jpids/piy126DOI Listing
December 2019

Herpes Simplex Virus Infection in Infants Undergoing Meningitis Evaluation.

Pediatrics 2018 02 3;141(2). Epub 2018 Jan 3.

Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts.

Background: Although neonatal herpes simplex virus (HSV) is a potentially devastating infection requiring prompt evaluation and treatment, large-scale assessments of the frequency in potentially infected infants have not been performed.

Methods: We performed a retrospective cross-sectional study of infants ≤60 days old who had cerebrospinal fluid culture testing performed in 1 of 23 participating North American emergency departments. HSV infection was defined by a positive HSV polymerase chain reaction or viral culture. The primary outcome was the proportion of encounters in which HSV infection was identified. Secondary outcomes included frequency of central nervous system (CNS) and disseminated HSV, and HSV testing and treatment patterns.

Results: Of 26 533 eligible encounters, 112 infants had HSV identified (0.42%, 95% confidence interval [CI]: 0.35%-0.51%). Of these, 90 (80.4%) occurred in weeks 1 to 4, 10 (8.9%) in weeks 5 to 6, and 12 (10.7%) in weeks 7 to 9. The median age of HSV-infected infants was 14 days (interquartile range: 9-24 days). HSV infection was more common in 0 to 28-day-old infants compared with 29- to 60-day-old infants (odds ratio 3.9; 95% CI: 2.4-6.2). Sixty-eight (0.26%, 95% CI: 0.21%-0.33%) had CNS or disseminated HSV. The proportion of infants tested for HSV (35%; range 14%-72%) and to whom acyclovir was administered (23%; range 4%-53%) varied widely across sites.

Conclusions: An HSV infection was uncommon in young infants evaluated for CNS infection, particularly in the second month of life. Evidence-based approaches to the evaluation for HSV in young infants are needed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/peds.2017-1688DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5810597PMC
February 2018

Multicenter Observational Study of the Use of Nebulized Hypertonic Saline to Treat Children Hospitalized for Bronchiolitis From 2008 to 2014.

Hosp Pediatr 2017 Jul 31. Epub 2017 Jul 31.

Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; and.

Objectives: Among children hospitalized for bronchiolitis, we examined temporal trends in the use of hypertonic saline (HTS) and the characteristics associated with receiving this treatment.

Methods: We conducted a secondary analysis of data from 2 large, multicenter prospective cohort studies that included young children hospitalized with bronchiolitis during 5 winter seasons (2008-2014). Our outcome was receipt of HTS any time during the preadmission visit or hospitalization. For comparison with the observed trends in HTS use, we conducted a PubMed literature review of studies evaluating HTS use for bronchiolitis. We classified publications according to their assessment of HTS efficacy (positive, negative, or neutral).

Results: Among 2709 hospitalized children, 241 (8.9%) received HTS. There was marked variability in HTS use by site (0%-91%), with use more common among children admitted to the ICU than those treated on the ward (31% vs 15%). Over the study period, administration of HTS increased from 2% during the 2008-2009 season to 27% during the 2011-2012 season, but then it decreased to 11% during the 2013-2014 season. Before 2010, the number of PubMed HTS publications ranged from 0 to 3 articles per year, with all classified as either positive or neutral. The number of positive publications increased in 2010 ( = 5), whereas negative publications peaked in 2014 ( = 4).

Conclusions: Use of HTS in children hospitalized with bronchiolitis increased during the 2008 to 2012 winter seasons and then declined. These findings paralleled trends in the HTS literature, with positive articles encouraging HTS use in early years followed by a growing number of neutral and negative articles after 2012.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/hpeds.2017-0002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5525378PMC
July 2017

Impact of Enteroviral Polymerase Chain Reaction Testing on Length of Stay for Infants 60 Days Old or Younger.

J Pediatr 2017 10 10;189:169-174.e2. Epub 2017 Jul 10.

Division of Emergency Medicine, Boston Children's Hospital, Boston, MA. Electronic address:

Objective: To determine the impact of a cerebrospinal fluid enterovirus polymerase chain reaction (PCR) test performance on hospital length of stay (LOS) in a large multicenter cohort of infants undergoing evaluation for central nervous system infection.

Study Design: We performed a planned secondary analysis of a retrospective cohort of hospitalized infants ≤60 days of age who had a cerebrospinal fluid culture obtained at 1 of 18 participating centers (2005-2013). After adjustment for patient age and study year as well as clustering by hospital center, we compared LOS for infants who had an enterovirus PCR test performed vs not performed and among those tested, for infants with a positive vs negative test result.

Results: Of 19 953 hospitalized infants, 4444 (22.3%) had an enterovirus PCR test performed and 945 (21.3% of tested infants) had positive test results. Hospital LOS was similar for infants who had an enterovirus PCR test performed compared with infants who did not (incident rate ratio 0.98 hours; 95% CI 0.89-1.06). However, infants PCR positive for enterovirus had a 38% shorter LOS than infants PCR negative for enterovirus (incident rate ratio 0.62 hours; 95% CI 0.57-0.68). No infant with a positive enterovirus PCR test had bacterial meningitis (0%; 95% CI 0-0.4).

Conclusions: Although enterovirus PCR testing was not associated with a reduction in LOS, infants with a positive enterovirus PCR test had a one-third shorter LOS compared with infants with a negative enterovirus PCR test. Focused enterovirus PCR test use could increase the impact on LOS for infants undergoing cerebrospinal fluid evaluation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpeds.2017.06.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5870831PMC
October 2017

Correction of Cerebrospinal Fluid Protein in Infants With Traumatic Lumbar Punctures.

Pediatr Infect Dis J 2017 Oct;36(10):1006-1008

From the *Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts; †Sections of Pediatric Emergency Medicine and Pediatric Infectious Diseases, Baylor College of Medicine, Houston, Texas; ‡Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; §Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota; ¶Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut; ‖Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; **Division of Pediatric Emergency Medicine, Hospital for Sick Children, Toronto, Ontario, Canada; ††Department of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, Michigan; ‡‡Section of Pediatric Emergency Medicine, Children's Hospital Colorado, Aurora, Colorado; §§Division of Pediatric Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama; and ¶¶Departments of Pediatrics and Emergency Medicine, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware.

In our multicenter cohort of infants ≤60 days of age, we identified 2646 infants with a traumatic lumbar puncture, of which 31 (1.2%) had bacterial meningitis. For every 1000 cerebrospinal fluid red blood cells/mm, cerebrospinal (cerebrospinal fluid) protein increased 1.1 mg/dL (95% confidence interval: 1.0-1.2 mg/dL).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/INF.0000000000001634DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5607637PMC
October 2017

Nasal Airway Microbiota Profile and Severe Bronchiolitis in Infants: A Case-control Study.

Pediatr Infect Dis J 2017 Nov;36(11):1044-1051

From the *Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; †Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; ‡Department of Medicine, Boston Children's Hospital, Boston, Massachusetts; §Alkek Center for Metagenomics and Microbiome Research, Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas; ¶Department of Molecular Virology and Microbiology, and Pediatrics, Baylor College of Medicine, Houston, Texas; ‖Department of Pediatrics, University of Louisville, Louisville, Kentucky; and **Alfred I. duPont Hospital for Children, Wilmington, Delaware.

Background: Little is known about the relationship of airway microbiota with bronchiolitis in infants. We aimed to identify nasal airway microbiota profiles and to determine their association with the likelihood of bronchiolitis in infants.

Methods: A case-control study was conducted. As a part of a multicenter prospective study, we collected nasal airway samples from 40 infants hospitalized with bronchiolitis. We concurrently enrolled 110 age-matched healthy controls. By applying 16S ribosomal RNA gene sequencing and an unbiased clustering approach to these 150 nasal samples, we identified microbiota profiles and determined the association of microbiota profiles with likelihood of bronchiolitis.

Results: Overall, the median age was 3 months and 56% were male. Unbiased clustering of airway microbiota identified 4 distinct profiles: Moraxella-dominant profile (37%), Corynebacterium/Dolosigranulum-dominant profile (27%), Staphylococcus-dominant profile (15%) and mixed profile (20%). Proportion of bronchiolitis was lowest in infants with Moraxella-dominant profile (14%) and highest in those with Staphylococcus-dominant profile (57%), corresponding to an odds ratio of 7.80 (95% confidence interval, 2.64-24.9; P < 0.001). In the multivariable model, the association between Staphylococcus-dominant profile and greater likelihood of bronchiolitis persisted (odds ratio for comparison with Moraxella-dominant profile, 5.16; 95% confidence interval, 1.26-22.9; P = 0.03). By contrast, Corynebacterium/Dolosigranulum-dominant profile group had low proportion of infants with bronchiolitis (17%); the likelihood of bronchiolitis in this group did not significantly differ from those with Moraxella-dominant profile in both unadjusted and adjusted analyses.

Conclusions: In this case-control study, we identified 4 distinct nasal airway microbiota profiles in infants. Moraxella-dominant and Corynebacterium/Dolosigranulum-dominant profiles were associated with low likelihood of bronchiolitis, while Staphylococcus-dominant profile was associated with high likelihood of bronchiolitis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/INF.0000000000001500DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5479744PMC
November 2017

The Impact of High-Profile Sexual Abuse Cases in the Media on a Pediatric Emergency Department.

J Child Sex Abus 2016 Aug-Sep;25(6):627-35

b Department of Pediatrics , Nemours/Division of Emergency Services, Alfred I duPont Hospital for Children , Wilmington , Delaware , USA.

High-profile media cases of sexual abuse may encourage disclosures of abuse from victims of unrelated assaults and also influence parental concerns, leading to increased emergency department visits. In the region of the study authors' institution, there are two recent high-profile sexual abuse cases with media coverage: Earl Bradley, a Delaware pediatrician, and Jerry Sandusky, a Pennsylvania college football coach. This is a retrospective cohort study of children evaluated for sexual abuse at a pediatric emergency department. Patients were classified as either presenting during a media period or non-media period. The media periods were one-month periods immediately following breaking news reports, when the cases were highly publicized in the media. The non-media periods were the 12-month periods directly preceding the first reports. The median number of emergency department visits per month during a non-media period was 9 visits (interquartile range 6-10). There were 11 visits in the month following the Sandusky case and 13 visits following the Bradley case. There was no statistical difference in number of emergency department visits for sexual abuse between the periods (p = .09). These finding have implications regarding use of resources in pediatric EDs after high-profile sexual abuse cases.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1080/10538712.2016.1187697DOI Listing
April 2017

The Fecal Microbiota Profile and Bronchiolitis in Infants.

Pediatrics 2016 07;138(1)

Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts;

Background: Little is known about the association of gut microbiota, a potentially modifiable factor, with bronchiolitis in infants. We aimed to determine the association of fecal microbiota with bronchiolitis in infants.

Methods: We conducted a case-control study. As a part of multicenter prospective study, we collected stool samples from 40 infants hospitalized with bronchiolitis. We concurrently enrolled 115 age-matched healthy controls. By applying 16S rRNA gene sequencing and an unbiased clustering approach to these 155 fecal samples, we identified microbiota profiles and determined the association of microbiota profiles with likelihood of bronchiolitis.

Results: Overall, the median age was 3 months, 55% were male, and 54% were non-Hispanic white. Unbiased clustering of fecal microbiota identified 4 distinct profiles: Escherichia-dominant profile (30%), Bifidobacterium-dominant profile (21%), Enterobacter/Veillonella-dominant profile (22%), and Bacteroides-dominant profile (28%). The proportion of bronchiolitis was lowest in infants with the Enterobacter/Veillonella-dominant profile (15%) and highest in the Bacteroides-dominant profile (44%), corresponding to an odds ratio of 4.59 (95% confidence interval, 1.58-15.5; P = .008). In the multivariable model, the significant association between the Bacteroides-dominant profile and a greater likelihood of bronchiolitis persisted (odds ratio for comparison with the Enterobacter/Veillonella-dominant profile, 4.24; 95% confidence interval, 1.56-12.0; P = .005). In contrast, the likelihood of bronchiolitis in infants with the Escherichia-dominant or Bifidobacterium-dominant profile was not significantly different compared with those with the Enterobacter/Veillonella-dominant profile.

Conclusions: In this case-control study, we identified 4 distinct fecal microbiota profiles in infants. The Bacteroides-dominant profile was associated with a higher likelihood of bronchiolitis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/peds.2016-0218DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4925084PMC
July 2016

Enteroviral testing and length of hospital stay for children evaluated for lyme meningitis.

J Emerg Med 2013 Jun 12;44(6):1196-200. Epub 2013 Apr 12.

Division of Emergency Medicine, Boston Children's Hospital, Boston, MA 02115, USA.

Background: In Lyme disease-endemic areas, many children with aseptic meningitis are hospitalized while awaiting Lyme serology results. Although Lyme serology takes several days, an enteroviral polymerase chain reaction (EV PCR) test takes only a few hours to return results.

Objective: Our aim was to measure the impact of EV PCR testing on duration of stay for children evaluated for Lyme meningitis.

Methods: A retrospective cohort study was performed with children evaluated for Lyme meningitis at 3 Emergency Departments located in Lyme disease-endemic areas. We defined Lyme meningitis using the Centers for Disease Control and Prevention criteria (either positive Lyme serology test result or an erythema migrans rash). The duration of stay was compared by EV PCR test result (positive, negative, and not obtained).

Results: There were 423 study patients identified, 117 (28%) of whom had Lyme meningitis and 209 (49%) had an EV PCR test performed. Median length of stay varied by the EV PCR test status: children with a positive EV PCR test (n = 103; 28 h; interquartile range 17-48 h), those with a negative EV PCR test (n = 106; 72 h; interquartile range 48-120 h), and those who did not have an EV PCR test obtained (n = 214; 48 h; interquartile range 24-96 h; p ≤ 0.001).

Conclusions: Rapid EV PCR testing could assist clinical decision making by Emergency Physicians, avoiding potentially unnecessary hospitalization and parenteral antibiotics for children at low risk of Lyme meningitis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jemermed.2012.11.096DOI Listing
June 2013

Electrocardiograph Abnormalities in Children With Lyme Meningitis.

J Pediatric Infect Dis Soc 2012 Dec 16;1(4):293-8. Epub 2012 Aug 16.

Department of Pediatrics, University of Cincinnati College of Medicine, and Divisions of Infectious Diseases Hospital Medicine, Cincinnati Children's Hospital Medical Center, Ohio

Objective: The objective of the study was to estimate the prevalence of and identify risk factors for electrocardiographic (ECG) changes in children presenting with Lyme meningitis.

Design: This was a cross-sectional study.

Setting: The study was set in three large urban pediatric tertiary care centers.

Participants: Children who were diagnosed with Lyme meningitis and underwent ECG testing were included.

Outcome Measure: The presence of an ECG abnormality associated with early-disseminated Lyme infection was the outcome measure.

Results: Multivariable logistic regression was used to identify factors independently associated with ECG abnormalities. ECG testing was performed in 103 (66%) of 157 children with Lyme meningitis. The median age of these children was 10.8 years; 68% were male. ECG abnormalities, identified in 34 (33%) subjects, included one or more of the following: atrioventricular block (n = 16; 16%), ST-T wave changes (n = 14; 14%), and prolongation of the corrected QT interval (n = 11; 11%). In multivariate analysis, age ≥13 years and fever for ≥5 days were independently associated with ECG abnormalities. The probability of ECG abnormalities was greater than 50% in those with fever for ≥5 days or age ≥13 years, and if a subject fulfilled both criteria, the probability of ECG abnormalities was 83% (95% confidence interval: 50%-96%).

Conclusions: Electrocardiographic abnormalities occur commonly in children with Lyme meningitis. While older children with prolonged fever were most likely to have such abnormalities, the clinical consequences of asymptomatic ECG abnormalities in children with Lyme meningitis are not known.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/jpids/pis078DOI Listing
December 2012

Treatment complications in children with lyme meningitis.

Pediatr Infect Dis J 2012 Oct;31(10):1032-5

Division of Emergency Medicine, Department of Pediatrics, Nemours, Alfred I. duPont Hospital for Children, Jefferson Medical College, Wilmington, DE, USA.

Background: The rate and type of treatment complications in children treated for Lyme meningitis have not been described.

Methods: We performed a retrospective cohort study of children with Lyme meningitis who presented to 1 of 3 emergency departments located in Lyme disease endemic areas between 1997 and 2010. We defined a case of Lyme meningitis as a child with cerebrospinal fluid pleocytosis and either positive Lyme serology or an erythema migrans rash. We identified prescribed treatment and reasons for all return visits. Our primary outcome was the presence of any treatment complication within 30 days of diagnosis.

Results: We identified 157 patients with Lyme meningitis with a median age of 10 years (interquartile range: 7-13 years). Of the 149 children with Lyme meningitis and available follow-up records, 39 (26%) had 1 or more complications, and 21 (14%) required a change in prescribed antibiotic therapy. The median time for developing the first complication was 11 days (interquartile range: 9-14 days). Ten percent of the patients had an adverse drug reaction. Of the 144 children who had a peripherally inserted central catheter placed, 25 (17%) had at least 1 peripherally inserted central catheter-associated complication: 14 (10%) had a mechanical problem, 11 (8%) had an infectious complication and 1 (1%) had a venous thromboembolism.

Conclusions: As current Lyme meningitis treatment regimens have substantial associated morbidity, future research should investigate the efficacy of alternate regimens.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/INF.0b013e31825eb3c7DOI Listing
October 2012

Validation of a clinical prediction rule to distinguish Lyme meningitis from aseptic meningitis.

Pediatrics 2012 Jan 19;129(1):e46-53. Epub 2011 Dec 19.

Division of Emergency Medicine, Children's Hospital and Harvard Medical School, Boston 300 Longwood Ave, Boston, MA 02115, USA.

Objectives: The "Rule of 7's," a Lyme meningitis clinical prediction rule, classifies children at low risk for Lyme meningitis when each of the following 3 criteria are met: <7 days of headache, <70% cerebrospinal fluid (CSF) mononuclear cells, and absence of seventh or other cranial nerve palsy. The goal of this study was to test the performance of the Rule of 7's in a multicenter cohort of children with CSF pleocytosis.

Methods: We performed a retrospective cohort study of children evaluated at 1 of 3 emergency departments located in Lyme disease-endemic areas with CSF pleocytosis and Lyme serology obtained. Lyme meningitis was defined using the Centers for Disease Control and Prevention criteria (either positive Lyme serology test result or an erythema migrans [EM] rash). We calculated the performance of the Rule of 7's in our overall study population and in children without physician-documented EM.

Results: We identified 423 children, of whom 117 (28% [95% confidence interval (CI): 24%-32%]) had Lyme meningitis, 306 (72% [95% CI: 68%-76%]) had aseptic meningitis, and 0 (95% CI: 0%-1%) had bacterial meningitis. Of the 130 classified as low risk, 5 had Lyme meningitis (sensitivity, 112 of 117 [96% (95% CI: 90%-99%)]; specificity, 125 of 302 [41% (95% CI: 36%-47%)]). In the 390 children without EM, 3 of the 127 low-risk patients had Lyme meningitis (2% [95% CI: 0%-7%]).

Conclusions: Patients classified as low risk by using the Rule of 7's were unlikely to have Lyme meningitis and could be managed as outpatients while awaiting results of Lyme serology tests.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/peds.2011-1215DOI Listing
January 2012

Integrating spatial epidemiology into a decision model for evaluation of facial palsy in children.

Arch Pediatr Adolesc Med 2011 Jan;165(1):61-7

Division of Emergency Medicine, Children's Hospital Boston, Boston, MA 02115, USA.

Objective: To develop a novel diagnostic algorithm for Lyme disease among children with facial palsy by integrating public health surveillance data with traditional clinical predictors.

Design: Retrospective cohort study.

Setting: Children's Hospital Boston emergency department, 1995-2007.

Patients: Two hundred sixty-four children (aged <20 years) with peripheral facial palsy who were evaluated for Lyme disease.

Main Outcome Measures: Multivariate regression was used to identify independent clinical and epidemiologic predictors of Lyme disease facial palsy.

Results: Lyme diagnosis was positive in 65% of children from high-risk counties in Massachusetts during Lyme disease season compared with 5% of those without both geographic and seasonal risk factors. Among patients with both seasonal and geographic risk factors, 80% with 1 clinical risk factor (fever or headache) and 100% with 2 clinical factors had Lyme disease. Factors independently associated with Lyme disease facial palsy were development from June to November (odds ratio, 25.4; 95% confidence interval, 8.3-113.4), residence in a county where the most recent 3-year average Lyme disease incidence exceeded 4 cases per 100,000 (18.4; 6.5-68.5), fever (3.9; 1.5-11.0), and headache (2.7; 1.3-5.8). Clinical experts correctly treated 68 of 94 patients (72%) with Lyme disease facial palsy, but a tool incorporating geographic and seasonal risk identified all 94 cases.

Conclusions: Most physicians intuitively integrate geographic information into Lyme disease management, but we demonstrate quantitatively how formal use of geographically based incidence in a clinical algorithm improves diagnostic accuracy. These findings demonstrate potential for improved outcomes from investments in health information technology that foster bidirectional communication between public health and clinical settings.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/archpediatrics.2010.250DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3644029PMC
January 2011

Clinical predictors of Lyme disease among children with a peripheral facial palsy at an emergency department in a Lyme disease-endemic area.

Pediatrics 2008 Nov 17;122(5):e1080-5. Epub 2008 Oct 17.

Division of Emergency Medicine, Children's Hospital Boston, Boston, Massachusetts 02115, USA.

Introduction: Although Lyme disease can cause peripheral facial palsy in Lyme disease-endemic areas, diagnostic predictors in children have not been described.

Objective: Our goal was to determine clinical predictors of Lyme disease as the etiology of peripheral facial palsy in children presenting to an emergency department in a Lyme disease-endemic area.

Methods: We reviewed all available electronic medical charts of children
Results: We identified 313 patients with peripheral facial palsy evaluated for Lyme disease. The mean age was 10.7 years, and 52% were male. Of these, 106 (34%) had Lyme disease facial palsy. After adjusting for year of study, the following were independently associated with Lyme disease facial palsy: onset of symptoms during peak Lyme disease season (June to October), absence of previous herpetic lesions, presence of fever, and history of headache. In the subset of patients without meningitis, both onset of symptoms during Lyme disease season and presence of headache remained significant independent predictors.

Conclusions: Lyme disease is a frequent cause of facial palsy in children living in an endemic region. Serologic testing and empiric antibiotics should be strongly considered, especially when children present during peak Lyme disease season or with a headache.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/peds.2008-1273DOI Listing
November 2008
-->