Publications by authors named "Garth D Meckler"

32 Publications

Prevalence of Bacterial Meningitis Among Febrile Infants Aged 29-60 Days With Positive Urinalysis Results: A Systematic Review and Meta-analysis.

JAMA Netw Open 2021 May 3;4(5):e214544. Epub 2021 May 3.

Division of Pediatric Emergency Medicine, Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.

Importance: Fever in the first months of life remains one of the most common pediatric problems. Urinary tract infections are the most frequent serious bacterial infections in this population. All published guidelines and quality initiatives for febrile young infants recommend lumbar puncture (LP) and cerebrospinal fluid (CSF) testing on the basis of a positive urinalysis result to exclude bacterial meningitis as a cause. For well infants older than 28 days with an abnormal urinalysis result, LP remains controversial.

Objective: To assess the prevalence of bacterial meningitis among febrile infants 29 to 60 days of age with a positive urinalysis result to evaluate whether LP is routinely required.

Data Sources: MEDLINE and Embase were searched for articles published from January 1, 2000, to July 25, 2018, with deliberate limitation to recent studies. Before analysis, the search was repeated (October 6, 2019) to ensure that new studies were included.

Study Selection: Studies that reported on healthy, full-term, well-appearing febrile infants 29 to 60 days of age for whom patient-level data could be ascertained for urinalysis results and meningitis status were included.

Data Extraction And Synthesis: Data were extracted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and used the Newcastle-Ottawa Scale to assess bias. Pooled prevalences and odds ratios (ORs) were estimated using random-effect models.

Main Outcomes And Measures: The primary outcome was the prevalence of culture-proven bacterial meningitis among infants with positive urinalysis results. The secondary outcome was the prevalence of bacterial meningitis, defined by CSF testing or suggestive history at clinical follow-up.

Results: The parent search yielded 3227 records; 48 studies were included (17 distinct data sets of 25 374 infants). The prevalence of culture-proven meningitis was 0.44% (95% CI, 0.25%-0.78%) among 2703 infants with positive urinalysis results compared with 0.50% (95% CI, 0.33%-0.76%) among 10 032 infants with negative urinalysis results (OR, 0.74; 95% CI, 0.39-1.38). The prevalence of bacterial meningitis was 0.25% (95% CI, 0.14%-0.45%) among 4737 infants with meningitis status ascertained by CSF testing or clinical follow-up and 0.28% (95% CI, 0.21%-0.36%) among 20 637 infants with positive and negative urinalysis results (OR, 0.89; 95% CI, 0.48-1.68).

Conclusions And Relevance: In this systematic review and meta-analysis, the prevalence of bacterial meningitis in well-appearing febrile infants 29 to 60 days of age with positive urinalysis results ranged from 0.25% to 0.44% and was not higher than that in infants with negative urinalysis results. These results suggest that for these infants, the decision to use LP should not be guided by urinalysis results alone.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.4544DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8116985PMC
May 2021

Predicting Adverse Outcomes for Shiga Toxin-Producing Escherichia coli Infections in Emergency Departments.

J Pediatr 2021 May 5;232:200-206.e4. Epub 2021 Jan 5.

Department of Pediatrics, Joseph M. Sanzari Women and Children's Hospital, Hackensack University Medical Center, Hackensack, NJ.

Objective: To assess the performance of a hemolytic uremic syndrome (HUS) severity score among children with Shiga toxin-producing Escherichia coli (STEC) infections and HUS by stratifying them according to their risk of adverse events. The score has not been previously evaluated in a North American acute care setting.

Study Design: We reviewed medical records of children <18 years old infected with STEC and treated in 1 of 38 participating emergency departments in North America between 2011 and 2015. The HUS severity score (hemoglobin [g/dL] plus 2-times serum creatinine [mg/dL]) was calculated using first available laboratory results. Children with scores >13 were designated as high-risk. We assessed score performance to predict severe adverse events (ie, dialysis, neurologic complication, respiratory failure, and death) using discrimination and net benefit (ie, threshold probability), with subgroup analyses by age and day-of-illness.

Results: A total of 167 children had HUS, of whom 92.8% (155/167) had relevant data to calculate the score; 60.6% (94/155) experienced a severe adverse event. Discrimination was acceptable overall (area under the curve 0.71, 95% CI 0.63-0.79) and better among children <5 years old (area under the curve 0.77, 95% CI 0.68-0.87). For children <5 years, greatest net benefit was achieved for a threshold probability >26%.

Conclusions: The HUS severity score was able to discriminate between high- and low-risk children <5 years old with STEC-associated HUS at a statistically acceptable level; however, it did not appear to provide clinical benefit at a meaningful risk threshold.
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http://dx.doi.org/10.1016/j.jpeds.2020.12.077DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8084908PMC
May 2021

Assessing appropriateness of pediatric emergency department visits: is it even possible?

CJEM 2020 09;22(5):661-664

University of British Columbia, Division of Emergency Medicine, Department of Pediatrics, BC Children's Hospital Vancouver, BC.

Objectives: Numerous studies reported on the frequency of, and factors associated with inappropriate or unnecessary emergency department (ED) visits using clinician judgment as the gold standard of appropriateness. This study evaluated the reliability of clinician judgment for assessing appropriateness of pediatric ED visit.

Methods: We conducted a retrospective cohort study comparing 3 clinicians' determination of ED visit appropriateness with and without guidance from a three-question structured algorithm. We used a cohort of scheduled ED return visits deemed appropriate by the index treating clinician between May 1, 2012, and April 30, 2013. We measured the level of agreement among three clinician investigators with and without use of the structured algorithm.

Results: A total of 207 scheduled ED return visits were reviewed by the primary clinician reviewer who agreed with the index treating clinician for 79/207 visits (38.2%). Among a random subset of 90 return visits reviewed by all three clinicians, agreement was 67% with a Fleiss' Kappa of 0.30 (0.17-0.44). Using a three-question algorithm based on objective criteria, agreement with the index treating provider increased to 115/207 (55.6%).

Conclusions: Although an important contributor to pediatric ED overcrowding, unnecessary or inappropriate visits are difficult to identify. We demonstrated poor reliability of clinician judgment to determine appropriateness of ED return visits, likely due to variability in clinical decision-making and risk-tolerance, social and systems factors impacting access and use of health care. We recommend that future studies evaluating the appropriateness of ED use standardized, objective criteria rather than clinician judgment alone.
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http://dx.doi.org/10.1017/cem.2019.473DOI Listing
September 2020

Effectiveness of Emergency Department Treatment of Pediatric Headache and Relation to Rebound Headache.

Pediatr Emerg Care 2020 Dec;36(12):e720-e725

Department of Pediatrics, Pediatric Emergency Medicine, University of British Columbia, BC Children's Hospital, Vancouver, Canada.

Objective: This study aimed to assess the association between the degree of headache relief obtained in the pediatric emergency department (PED) with abortive treatment and unscheduled return visits to the PED for a recurrent or persistent headache within 72 hours.

Methods: This was a retrospective observational study with 369 patients, all younger than 18 years, who presented to the PED with a primary complaint of either a headache or migraine. Patient and visit details were collected from the medical chart, along with presenting and discharge pain score. Percent pain reduction at discharge was determined through the following calculation: (Presenting Pain Score - Discharge Pain Score)/Presenting Pain Score. Associations were assessed using multivariable logistic regression.

Results: No significant association was found between the percent pain reduction and return to the PED (P = 0.49). Mean presenting pain score at the index visit was statistically higher for those who ended up returning to the PED versus those who did not (8.1 vs 7.4; P = 0.02). A trend toward increase in return visits was seen among patients who had a headache duration greater than 3 days (odds ratio, 1.99) and patients who experienced less than 50% pain reduction in the PED (odds ratio, 1.77).

Conclusions: Complete resolution in the PED may not be necessary, given the lack of association between the degree of pain relief and revisit rates. Perhaps, the goal should be to achieve at least 50% pain reduction before discharge.
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http://dx.doi.org/10.1097/PEC.0000000000002027DOI Listing
December 2020

Predicting Hemolytic Uremic Syndrome and Renal Replacement Therapy in Shiga Toxin-producing Escherichia coli-infected Children.

Clin Infect Dis 2020 04;70(8):1643-1651

University of Pennsylvania Perelman School of Medicine, Children's Hospital of Philadelphia.

Background: Shiga toxin-producing Escherichia coli (STEC) infections are leading causes of pediatric acute renal failure. Identifying hemolytic uremic syndrome (HUS) risk factors is needed to guide care.

Methods: We conducted a multicenter, historical cohort study to identify features associated with development of HUS (primary outcome) and need for renal replacement therapy (RRT) (secondary outcome) in STEC-infected children without HUS at initial presentation. Children aged <18 years who submitted STEC-positive specimens between January 2011 and December 2015 at a participating study institution were eligible.

Results: Of 927 STEC-infected children, 41 (4.4%) had HUS at presentation; of the remaining 886, 126 (14.2%) developed HUS. Predictors (all shown as odds ratio [OR] with 95% confidence interval [CI]) of HUS included younger age (0.77 [.69-.85] per year), leukocyte count ≥13.0 × 103/μL (2.54 [1.42-4.54]), higher hematocrit (1.83 [1.21-2.77] per 5% increase) and serum creatinine (10.82 [1.49-78.69] per 1 mg/dL increase), platelet count <250 × 103/μL (1.92 [1.02-3.60]), lower serum sodium (1.12 [1.02-1.23 per 1 mmol/L decrease), and intravenous fluid administration initiated ≥4 days following diarrhea onset (2.50 [1.14-5.46]). A longer interval from diarrhea onset to index visit was associated with reduced HUS risk (OR, 0.70 [95% CI, .54-.90]). RRT predictors (all shown as OR [95% CI]) included female sex (2.27 [1.14-4.50]), younger age (0.83 [.74-.92] per year), lower serum sodium (1.15 [1.04-1.27] per mmol/L decrease), higher leukocyte count ≥13.0 × 103/μL (2.35 [1.17-4.72]) and creatinine (7.75 [1.20-50.16] per 1 mg/dL increase) concentrations, and initial intravenous fluid administration ≥4 days following diarrhea onset (2.71 [1.18-6.21]).

Conclusions: The complex nature of STEC infection renders predicting its course a challenge. Risk factors we identified highlight the importance of avoiding dehydration and performing close clinical and laboratory monitoring.
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http://dx.doi.org/10.1093/cid/ciz432DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7931832PMC
April 2020

Management practice-related and modifiable factors associated with paediatric emergency return visits.

Paediatr Child Health 2019 Feb 7;24(1):e1-e7. Epub 2018 Apr 7.

Department of    Pediatrics, BC Children's Hospital Research Institute, University of   British Columbia, Vancouver, British Columbia.

Objectives: We explored practice-related factors associated with preventable unscheduled return visits to an emergency department (RTED).

Methods: We conducted a retrospective cohort study, using standardized review of health records. We included all visits with at least one RTED within 7 days of the index visit. Cases were reviewed by investigators and clinicians to identify: 1) the proportion of unscheduled RTED, 2) the proportion deemed clinically unnecessary and 3) the contribution of clinical practice pattern and system factors.

Results: There were 2809 (7.3%) index visits associated with at least one RTED. Of these, 1983 (70.6%) were unscheduled, 784 (39.5%) were considered clinically unnecessary and 739 out of 784 medically unnecessary RTEDs (94.3%) were attributed to a mismatch between parental expectations and natural progression of disease that did not require Emergency Department (ED) reassessment or interventions. Eighty per cent of reviewed written discharge instructions lacked any anticipatory guidance around symptom range and duration and 21.2% contained instructions to return to the ED for signs and symptoms which do not require ED care. An administrative or system challenge was noted as the reason for the unnecessary and unscheduled RTED in 17.5%. In 3.4% of cases, nonemergency consultants were responsible for the disposition decision and discharge process.

Conclusions: Unscheduled unnecessary return visits to our ED contribute to a significant proportion of our annual volume. Providing discharge instructions that help families distinguish expected range and duration of symptoms from signs requiring ED care was identified as a potential strategy to impact the frequency of unscheduled RTED.
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http://dx.doi.org/10.1093/pch/pxy039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6376311PMC
February 2019

Opioid Prescribing Practices for Pediatric Headache.

J Pediatr 2019 01 28;204:240-244.e2. Epub 2018 Sep 28.

Center for Policy Research-Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, OR.

Objectives: To characterize the frequency of opioid prescribing for pediatric headache in both ambulatory and emergency department (ED) settings, including prescribing rates by provider type.

Study Design: A retrospective cohort study of Washington State Medicaid beneficiaries, aged 7-17 years, with an ambulatory care or ED visit for headache between January 1, 2012, and September 30, 2015. The primary outcome was any opioid prescribed within 1 day of the visit.

Results: A total of 51 720 visits were included, 83% outpatient and 17% ED. There was a predominance of female (63.2%) and adolescent (59.4%) patients, and 30.5% of encounters involved a pediatrician. An opioid was prescribed in 3.9% of ED and 1.0% of ambulatory care visits (P < .001). Pediatricians were less likely to prescribe opioids in both ED (-2.70 percentage point; 95% CI, -3.53 to -1.88) and ambulatory settings (-0.31 percentage point; 95% CI, -0.54 to -0.08; P < .001).

Conclusions: Opioid prescribing rates for pediatric headache were low, but significant variation was observed by setting and provider specialty. We identified opioid prescribing by nonpediatricians as a potential target for quality improvement efforts.
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http://dx.doi.org/10.1016/j.jpeds.2018.08.078DOI Listing
January 2019

System outcomes associated with a pediatric emergency department clinical decision unit.

CJEM 2019 03 15;21(2):195-198. Epub 2018 Apr 15.

*Department of Pediatrics,University of British Columbia,BC Children's Hospital Research Institute,Vancouver,BC.

Objectives: Our objectives were to describe disposition decisions and emergency department return (EDR) rates following a clinical decision unit (CDU) stay; and to determine changes to short stay (<48 hour) hospitalization rates after CDU implementation.

Methods: We conducted a retrospective cohort study of pediatric emergency department (PED) visits with a CDU stay from January 1 to December 31, 2015. Health records data were extracted onto standardized online forms, then used to determine disposition and 7-day EDR rates. Two trained investigators blindly reviewed EDR visits to determine if they were related to the index CDU stay. We compared short stay inpatient admission rates (i.e., hospital length of stay <48 hours) in 2013 and 2015, before and after CDU implementation.

Results: Of 1696 index CDU stays, 1503 (89%) were discharged, and 139 discharged patients (9.2%) had ≥1 clinically-related EDR. Median (IQR) CDU length of stay (LOS) was 4.4 hours (2.7-7.8) and total PED LOS (including CDU) was 7.8 hours (5.4-12.0). Asthma represented 31% of cases. Short stay hospitalization rate decreased from 3.62% in 2013 to 3.23% in 2015 (difference=0.39%; 95% CI=0.15-0.63; p=0.001).

Conclusions: Most CDU patients were discharged, but 9% had a clinically-related ED revisit. CDU implementation was associated with a small but significant reduction in short stay hospitalization.
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http://dx.doi.org/10.1017/cem.2018.57DOI Listing
March 2019

Low-Dose Propofol for Pediatric Migraine: A Prospective, Randomized Controlled Trial.

J Emerg Med 2018 05 15;54(5):600-606. Epub 2018 Feb 15.

Department of Pediatrics, Pediatric Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada; British Columbia Children's Hospital, Vancouver, British Columbia, Canada.

Background: Migraine headaches are a common reason for pediatric emergency department (ED) visits. Small studies suggest the potential efficacy of sub-anesthetic doses of propofol for migraine with a favorable side effect profile and potentially decreased length of stay (LOS).

Objective: The objective of this study was to compare the efficacy of low-dose propofol (LDP) to standard therapy (ST) in pediatric migraine treatment.

Methods: We conducted a prospective, pragmatic randomized controlled trial from April 2014 through June 2016 in the ED at two pediatric hospitals. Patients aged 7-19 years were eligible if they were diagnosed with migraine by the emergency physician and had a presenting visual analog pain score (VAS) of 6-10. Primary outcome was the percent of pain reduction. Secondary outcomes were ED LOS, 24-h rebound headache, return visits to the ED, and adverse reactions.

Results: Seventy-four patients were enrolled, but 8 were excluded, leaving 66 patients in the final analysis (36 ST, 30 LDP). Pain reduction was 59% for ST and 51% for LDP (p = 0.34) with 72.2% vs. 73.3% achieving a VAS ≤ 4 with initial therapy (p = 0.92). There was a nonsignificant trend toward shorter median LOS from drug administration to final disposition favoring propofol (79 min vs. 111 min; p = 0.09). Rebound headache was significantly more common in the ST vs. LDP group (66.7% vs. 25.0%; p = 0.01).

Conclusions: LDP did not achieve better pain reduction than ST, however, LDP was associated with significantly fewer rebound headaches and a nonsignificant trend toward shorter median LOS from drug administration to disposition.
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http://dx.doi.org/10.1016/j.jemermed.2018.01.003DOI Listing
May 2018

Topiramate for pediatric migraine prevention.

Can Fam Physician 2017 Jul;63(7):529-531

I have several teenagers in my clinic with migraine headache and some of them have frequent episodes that cause considerable interference with daily activity. I would like to offer them prophylactic therapy to reduce the frequency of their migraine episodes. Is topiramate an effective and safe option for adolescents? Both Health Canada and the US Food and Drug Administration have approved the use of topiramate for migraine prevention in adults; however, only the US Food and Drug Administration has approved topiramate for migraine prophylaxis in adolescents 12 to 17 years of age. Although several studies support its effectiveness in preventing migraine, most of these studies are small; and a recent large multicentre, randomized placebo-controlled trial was stopped early when no benefit was shown over placebo. Adverse effects of topiramate are mild and typically resolve over time. The recommended dosage is 2 mg/kg per day, up to an adult dose of 100 mg/d.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5507226PMC
July 2017

Return visits to the pediatric emergency department: A multicentre retrospective cohort study.

CJEM 2018 07 19;20(4):578-585. Epub 2017 Jun 19.

*Department of Pediatrics,University of British Columbia,British Columbia Children's Hospital,Vancouver,BC.

Objective: Return visits to the emergency department (RTED) for the same clinical complaint occur in 2.7% to 8.1% of children presenting to pediatric emergency departments (PEDs). Most studies examining RTEDs have focused solely on PEDs and do not capture children returning to other local emergency departments (EDs). Our objective was to measure the frequency and characterize the directional pattern of RTED to any of 18 EDs serving a large geographic area for children initially evaluated at a PED.

Methods: We conducted a retrospective cohort study of all visits to a referral centre PED between August 2012 and August 2013. We compared demographic variables between children with and without an RTED, measures of flow and disposition outcomes between the initial (index) visit and RTED, and between RTED to the original PED versus to other EDs in the community.

Results: Among all PED visits, 7.6% had an RTED within 7 days, of which 13% were to a facility other than the original PED. Children with an RTED had higher acuity and longer length of stay on their index visit. They were also more likely to be admitted on a subsequent visit than the overall PED population. RTED to the original PED had a longer waiting time (WT), length of stay, and more frequently resulted in hospitalization than RTED to a general ED.

Conclusions: A significant proportion of RTED occur at a site other than where the original ED visit occurred. Examining RTED to and from only PEDs underestimates its burden on emergency health services.
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http://dx.doi.org/10.1017/cem.2017.40DOI Listing
July 2018

Pediatric Disaster Triage: Multiple Simulation Curriculum Improves Prehospital Care Providers' Assessment Skills.

Prehosp Emerg Care 2017 Mar-Apr;21(2):201-208. Epub 2016 Oct 17.

Objective: Paramedics and emergency medical technicians (EMTs) triage pediatric disaster victims infrequently. The objective of this study was to measure the effect of a multiple-patient, multiple-simulation curriculum on accuracy of pediatric disaster triage (PDT).

Methods: Paramedics, paramedic students, and EMTs from three sites were enrolled. Triage accuracy was measured three times (Time 0, Time 1 [two weeks later], and Time 2 [6 months later]) during a disaster simulation, in which high and low fidelity manikins and actors portrayed 10 victims. Accuracy was determined by participant triage decision concordance with predetermined expected triage level (RED [Immediate], YELLOW [Delayed], GREEN [Ambulatory], BLACK [Deceased]) for each victim. Between Time 0 and Time 1, participants completed an interactive online module, and after each simulation there was an individual debriefing. Associations between participant level of training, years of experience, and enrollment site were determined, as were instances of the most dangerous mistriage, when RED and YELLOW victims were triaged BLACK.

Results: The study enrolled 331 participants, and the analysis included 261 (78.9%) participants who completed the study, 123 from the Connecticut site, 83 from Rhode Island, and 55 from Massachusetts. Triage accuracy improved significantly from Time 0 to Time 1, after the educational interventions (first simulation with debriefing, and an interactive online module), with a median 10% overall improvement (p < 0.001). Subgroup analyses showed between Time 0 and Time 1, paramedics and paramedic students improved more than EMTs (p = 0.002). Analysis of triage accuracy showed greatest improvement in overall accuracy for YELLOW triage patients (Time 0 50% accurate, Time1 100%), followed by RED patients (Time 0 80%, Time 1 100%). There was no significant difference in accuracy between Time 1 and Time 2 (p = 0.073).

Conclusion: This study shows that the multiple-victim, multiple-simulation curriculum yields a durable 10% improvement in simulated triage accuracy. Future iterations of the curriculum can target greater improvements in EMT triage accuracy.
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http://dx.doi.org/10.1080/10903127.2016.1235239DOI Listing
June 2017

Inpatient Pediatric Migraine Treatment: Does Choice of Abortive Therapy Affect Length of Stay?

J Pediatr 2016 12 12;179:211-215. Epub 2016 Sep 12.

Department of Pediatrics, Pediatric Emergency Medicine, University of British Columbia BC Children's Hospital, Vancouver, British Columbia, Canada.

Objective: To describe the inpatient management of pediatric migraine and the association between specific medications and hospital length of stay (LOS).

Study Design: Historical cohort study review of patients age <19 years of age admitted to a single tertiary care children's hospital between 2010 and 2015 for treatment of migraine headache.

Results: The cohort consisted of 58 encounters with an average patient age of 14.3 years (SD 3.2 years) with a female predominance (62%). The mean number of inpatient medications received by patients was 3 (range 1-7), with dopamine antagonists and dihydroergotamine used most commonly (67% and 59% of encounters, respectively). The average LOS was 56 hours (95% CI 48.2-63.2) and did not vary by medication received, although patients who received an opioid had a significantly longer LOS (79.2 vs 47.9 hours respectively; P < .001).

Conclusions: Children admitted to the hospital for treatment of migraine headache frequently require a large number of medications over an average hospital LOS of more than 2 days without apparent differences based on medication received other than prolonged stays for subjects who received opioids.
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http://dx.doi.org/10.1016/j.jpeds.2016.08.050DOI Listing
December 2016

Relative Effectiveness of Dopamine Antagonists for Pediatric Migraine in the Emergency Department.

Pediatr Emerg Care 2018 Mar;34(3):165-168

Objective: Migraine headaches are common in the pediatric emergency department. The mainstay of abortive treatment consists of nonsteroidal anti-inflammatories and dopamine antagonists. The objective of this study was to compare the effectiveness of 3 commonly used dopamine antagonists to abort pediatric migraine.

Methods: This was a retrospective cohort study of all patients who presented to the pediatric emergency department at a tertiary care pediatric hospital between January 2010 and December 2013. Patients were treated for a migraine headache with a combination of ketorolac and one of the following dopamine antagonists: prochlorperazine, metoclopramide, or promethazine. The primary outcome was treatment failure and receiving non-evidence-based treatment defined by the need for opioids. Secondary outcomes included pain score reduction and return visit within 48 hours.

Results: There were 57 patients during this period with 67 visits that met inclusion criteria: 27 (40.3%) visits in which patients were treated with prochlorperazine, 23 (34.3%) visits in which patients were treated with metoclopramide, and 17 (25.4%) visits in which patients were treated with promethazine. Across visits, the mean age was 14.5 years, and 63% were women. Opioids were given for treatment failure in 8.7% of visits in which patients received prochlorperazine, 25% in which patients received metoclopramide, and 42.8% in which patients received promethazine. Patients treated with promethazine had significantly higher odds of needing opioids and experiencing less than 50% reduction in pain score compared with prochlorperazine after adjusting for patient characteristics.

Conclusions: This study suggests variable efficacy among 3 commonly used dopamine antagonists for pediatric migraine headache. Promethazine seems least effective and results in higher use of opioids compared with other available dopamine antagonists.
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http://dx.doi.org/10.1097/PEC.0000000000000718DOI Listing
March 2018

Time on the scene and interventions are associated with improved survival in pediatric out-of-hospital cardiac arrest.

Resuscitation 2015 Sep 19;94:1-7. Epub 2015 Jun 19.

Department of Critical Care and Neuroscience and Mental Health Research Program, The Hospital for Sick Children, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, Faculty of Medicine and Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada. Electronic address:

Background: Survival is less than 10% for pediatric patients following out-of-hospital cardiac arrest. It is not known if more time on the scene of the cardiac arrest and advanced life support interventions by emergency services personnel are associated with improved survival.

Aim: This study was performed to determine which times on the scene and which prehospital interventions were associated with improved survival.

Methods: We studied patients aged 3 days to 19 years old with out-of-hospital cardiac arrest, using the Resuscitation Outcomes Consortium cardiac arrest database from 11 North American regions, from 2005 to 2012. We evaluated survival to hospital discharge according to on-scene times (<10, 10 to 35 and >35 min).

Results: Data were available for 2244 patients (1017 infants, 594 children and 633 adolescents). Infants had the lowest rate of survival (3.7%) compared to children (9.8%) and adolescents (16.3%). Survival improved over the 7 year study period especially among adolescents. Survival was highest in the 10 to 35 min on-scene time group (10.2%) compared to the >35 min. group (6.9%) and the <10 min. group (5.3%, p=0.01). Intravenous or intra-osseous access attempts and fluid administration were associated with improved survival, whereas advanced airway attempts were not associated with survival and resuscitation drugs were associated with worse survival.

Conclusions: In this observational study, a scene time of 10 to 35 min was associated with the highest survival, especially among adolescents. Access for fluid resuscitation was associated with increased survival but advanced airway and resuscitation drugs were not.
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http://dx.doi.org/10.1016/j.resuscitation.2015.06.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4540668PMC
September 2015

Intranasal sumatriptan for migraine in children.

Can Fam Physician 2015 May;61(5):435-7

Question: I am seeing more and more children and adolescents with headaches that can be defined as migraine headache. I have read about intranasal sumatriptan as an abortive therapy. Is this an effective treatment?

Answer: Acute migraine headache among children and adolescents is common and treatment is challenging. Intranasal sumatriptan is a safe and mostly effective option for children and adolescents. Currently the recommended dose is 20 mg for children who weigh more than 40 kg and 10 mg for children who weigh between 20 and 39 kg. Larger trials should be conducted to overcome the limitations of small sample sizes, potential low plasma concentration, and placebo effects witnessed in studies to date.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4430059PMC
May 2015

Test characteristics of quick brain MRI for shunt evaluation in children: an alternative modality to avoid radiation.

J Neurosurg Pediatr 2015 Apr 30;15(4):420-6. Epub 2015 Jan 30.

Division of Pediatric Emergency Medicine.

Object: Quick brain magnetic resonance imaging (QB-MRI) is a rapid, radiation-free technique to detect life-threatening CSF shunt malfunction. QB-MRI has not been widely studied or adopted. The primary objective of this study was to evaluate the test characteristics of QB-MRI for detecting shunt malfunction. Test characteristics of brain computed tomography (CT) and QB-MRI were then compared. Secondary objectives included comparison of time to study completion and use of sedatives for both modalities, as well as comparison of time to study completion for QB-MRI before and after implementation of a Pediatric Emergency Department (PED) shunt clinical pathway.

Methods: A retrospective chart review was performed at 2 tertiary care hospital PEDs. The authors reviewed the charts of children who underwent QB-MRI or CT for suspected shunt malfunction between July 2008 and June 2012. They also reviewed the patients' neuroradiology reports and classified ventricular size as positive (enlarged) or negative (normal, smaller, or unchanged). Shunt malfunction was defined by surgical revision within 30 days.

Results: Nine hundred ninety-seven PED visits (involving 724 QB-MRIs and 273 CTs) were included. Surgical revision was performed in 235 cases (23.6%). For QB-MRI, sensitivity was 58.5% (95% CI 51.1%-65.6%) and specificity was 93.3% (90.8%-95.3%). For CT, sensitivity was 53.2% (95% CI 38.1%-67.9%) and specificity was 95.6% (92%-97.9%). The mean time to completion of QB-MRI was 115 minutes versus 83 minutes for CT (difference 32 minutes, 95% CI, 22-42 minutes, p < 0.001). The mean time from presentation to completion of QB-MRI prior to application of the CSF shunt pathway was 132 minutes versus 112 minutes after application of the CSF shunt pathway (difference 20 minutes, 95% CI 5-35 minutes, p = 0.01). Anxiolytic medications were used in 3.7% of CT studies and 4.4% of QB-MRI studies (p = 0.74).

Conclusions: QB-MRI and CT have similar test characteristics for detecting CSF shunt malfunction in children and similar requirements for sedation. The longer interval from order placement to imaging completion for QB-MRI is arguably justified by reduction of radiation exposure in this population subject to frequent brain imaging.
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http://dx.doi.org/10.3171/2014.9.PEDS14207DOI Listing
April 2015

Understanding safety in prehospital emergency medical services for children.

Prehosp Emerg Care 2014 Jul-Sep;18(3):350-8. Epub 2014 Mar 26.

Objective: For over a decade, the field of medicine has recognized the importance of studying and designing strategies to prevent safety issues in hospitals and clinics. However, there has been less focus on understanding safety in prehospital emergency medical services (EMS), particularly in regard to children. Roughly 27.7 million (or 27%) of the annual emergency department visits are by children under the age of 19, and about 2 million of these children reach the hospital via EMS. This paper adds to our qualitative understanding of the nature and contributors to safety events in the prehospital emergency care of children.

Methods: We conducted four 8- to 12-person focus groups among paid and volunteer EMS providers to understand 1) patient safety issues that occur in the prehospital care of children, and 2) factors that contribute to these safety issues (e.g., patient, family, systems, environmental, or individual provider factors). Focus groups were conducted in rural and urban settings. Interview transcripts were coded for overarching themes.

Results: Key factors and themes identified in the analysis were grouped into categories using an ecological approach that distinguishes between systems, team, child and family, and individual provider level contributors. At the systems level, focus group participants cited challenges such as lack of appropriately sized equipment or standardized pediatric medication dosages, insufficient human resources, limited pediatric training and experience, and aspects of emergency medical services culture. EMS team level factors centered on communication with other EMS providers (both prehospital and hospital). Family and child factors included communication barriers and challenging clinical situations or scene characteristics. Finally, focus group participants highlighted a range of provider level factors, including heightened levels of anxiety, insufficient experience and training with children, and errors in assessment and decision making.

Conclusions: The findings of our study suggest that, just as in hospital medicine, factors at the systems, team, child/family, and individual provider level system contribute to errors in prehospital emergency care. These factors may be modifiable through interventions and systems improvements. Future studies are needed to ascertain the generalizability of these findings and further refine the underlying mechanisms.
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http://dx.doi.org/10.3109/10903127.2013.869640DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4062591PMC
March 2015

Pediatric migraine: abortive management in the emergency department.

Headache 2014 Feb 29;54(2):235-45. Epub 2013 Oct 29.

Department of Emergency Medicine/Pediatrics, Oregon Health & Science University, Portland, OR, USA.

Studies suggest that headache accounts for approximately 1% of pediatric emergency department (ED) visits. ED physicians must distinguish between primary headaches, such as a tension or migraine, and secondary headaches caused by systemic disease including neoplasm, infection, or intracranial hemorrhage. A recent study found that 40% of children presenting to the ED with headache were diagnosed with a primary headache, and 75% of these were migraine. Once the diagnosis of migraine has been made, the ED physician is faced with the challenge of determining appropriate abortive treatment. This review summarizes the most recent literature on pediatric migraine with an emphasis on diagnosis and abortive treatment in the ED.
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http://dx.doi.org/10.1111/head.12253DOI Listing
February 2014

Diagnostic testing and treatment of pediatric headache in the emergency department.

J Pediatr 2013 Dec 20;163(6):1634-7. Epub 2013 Aug 20.

Department of Pediatrics, Oregon Health and Science University, Portland, OR. Electronic address:

Objective: To describe the variability in diagnostic testing and treatment of headaches in children presenting to the emergency department (ED) with use of a nationally representative sample.

Study Design: This was a retrospective cohort study using the National Hospital Ambulatory Medical Care Survey during 2005-2009. To assess the use of evidence-based treatment, we analyzed all patients <18 years old in 2 groups: (1) primary discharge diagnosis of headache and (2) discharge diagnosis of migraine.

Results: Four hundred forty-eight sampled ED visits from 2005-2009 represented a national estimate of 1.7 million visits with a discharge diagnosis of headache. A total of 95 visits represented a national estimate of 340 000 visits with a discharge diagnosis of migraine. Median age was 13.1 years and 60% were female with a primary diagnosis of headache. In this group, neuroimaging was performed in 37% of patients and 39% underwent blood tests. Nonsteroidal anti-inflammatory drugs and opioids were most commonly used for treatment. For children with a discharge diagnosis of migraine, approximately 40% of patients received non-evidence-based treatment, most commonly with opioid medications, and >20% of patients underwent computed tomography scanning.

Conclusions: There is significant variability in the evaluation and treatment of pediatric headache in the ED. Despite evidence-based clinical guidelines for migraine headache, a large number of children continue to receive opioids and ionizing radiation in the ED.
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http://dx.doi.org/10.1016/j.jpeds.2013.07.006DOI Listing
December 2013

Bedside optic nerve sheath diameter ultrasound for the evaluation of suspected pediatric ventriculoperitoneal shunt failure in the emergency department.

Childs Nerv Syst 2013 Dec 1;29(12):2275-80. Epub 2013 Jun 1.

Department of Emergency Medicine, University of California, San Franisco, 505 Parnassus Avenue, Room M24, San Francisco, CA, 94143-0203, USA,

Objective: To determine the feasibility and test characteristics of optic nerve sheath diameter (ONSD) measured by ocular ultrasound as a screening tool for ventriculoperitoneal shunt (VPS) failure.

Methods: Prospective observational study using a convenience sample of children 6 months to 18 years of age, presenting to an academic pediatric emergency department for evaluation of possible VPS failure between September 2008 and March 2009. ONSD was measured by anterior transbulbar and lateral transbulbar techniques. Mean ONSD was compared between subjects with and without shunt failure, as determined by neurosurgical decision to operate.

Results: A total of 39 encounters were completed, including 20 VPS failures. The mean ONSD was 4.5 ± 0.9 and 5.0 ± 0.6 mm among encounters with and without shunt failure (p = 0.03), respectively. The mean ONSD was not statistically different when obtained by the anterior transbulbar vs. the lateral transbulbar approach (4.8 ± 1.0 vs. 4.7 ± 0.8 mm, p = 0.12). ONSD ultrasound had a sensitivity of 61.1 % (95 % CI 35.7-82.7) and specificity of 22.2 % (95 % CI 6.4-47.6 %) for detecting shunt failure in this sample.

Conclusions: ONSD ultrasound does not appear to be a useful primary screening tool in emergency department evaluation of VPS failure. There was no difference between the anterior transbulbar approach and the lateral transbulbar approach. Children with VPS in our sample have larger ONSD measurements than in previously reported studies.
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http://dx.doi.org/10.1007/s00381-013-2172-yDOI Listing
December 2013

Low-dose propofol for the abortive treatment of pediatric migraine in the emergency department.

Pediatr Emerg Care 2012 Dec;28(12):1293-6

Department of Pediatrics, Department of Neurology, Oregon Health and Science University, Portland, OR 97239, USA.

Objective: Limited progress has been made in the past decade for abortive treatment of migraine headache in the pediatric emergency department (PED). Propofol, a general anesthetic, has been reported to be effective in the treatment of refractory headaches in adults at subanesthetic doses but never in the pediatric population. The goal of this study was to review our institution's experience with subanesthetic doses of propofol for the abortive treatment of pediatric migraine and compare propofol with standard abortive therapy in the PED.

Methods: Retrospective review of all patients discharged from the Oregon Health and Science University PED with a diagnosis of migraine headache from January 2010 to July 2011. Patients treated with subanesthetic doses of propofol were compared with matched controls who received standard abortive migraine therapy, defined as the combined use of a nonsteroidal anti-inflammatory medication, diphenhydramine, and prochlorperazine. Outcome variables of interest included reduction of pain as measured on a self-reported visual analog scale and length of stay after administration of initial abortive medication.

Results: Patients who received subanesthetic doses of propofol achieved significantly greater reduction in pain scores (80.1% vs 61.1%; P < 0.05) compared with matched controls as well as shorter stay (122 minutes vs 203 minutes; P = 0.2) after treatment. No adverse effects (hypotension, respiratory depression, or hypoxia) were recorded in either group.

Conclusions: Propofol seems to be effective for the abortive treatment of pediatric migraine headache in the PED. Further prospective trials are warranted to either support or refute these initial findings.
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http://dx.doi.org/10.1097/PEC.0b013e3182768a6bDOI Listing
December 2012

Pediatric educational needs assessment for urban and rural emergency medical technicians.

Pediatr Emerg Care 2011 Dec;27(12):1130-5

Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Portland, OR 97239, USA.

Objective: The objective of the study was to identify past experiences, present needs, barriers, and desired methods of training for urban and rural emergency medical technicians.

Methods: This 62-question pilot-tested written survey was administered at the 2008 Oregon EMS and 2009 EMS for Children conferences. Respondents were compared with registration lists and the state emergency medical services (EMS) database to assess for nonresponder bias. Agencies more than 10 miles from a population of 40,000 were defined as rural.

Results: Two hundred nineteen (70%) of 313 EMS personnel returned the surveys. Respondents were 3% first responders, 27% emergency medical technician basics, 20% intermediates, and 47% paramedics. Sixty-eight percent were rural, and 32% were urban. Sixty-eight percent reported fewer than 10% pediatric transports. Overall, respondents rated their comfort caring for pediatric patients as 3.1 on a 5-point Likert scale (95% confidence interval, 3.1-3.2). Seventy-two percent reported a mean rating of less than "comfortable" (4 on the scale) across 17 topics in pediatric care, which did not differ by certification level. Seven percent reported no pediatric training in the last 2 years, and 76% desired more. The "quality of available trainings" was ranked as the most important barrier to training; 26% of rural versus 7% of urban EMS personnel ranked distance as the most significant barrier (P < 0.01). Fifty-one percent identified highly realistic simulations as the method that helped them learn best. In the past 2 years, 19% had trained on a highly realistic pediatric simulator. One to 3 hours was the preferred duration for trainings.

Conclusions: Except for distance as a barrier, there were no significant differences between urban and rural responses. Both urban and rural providers desire resources, in particular, highly realistic simulation, to address the infrequency of pediatric transports and limited training.
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http://dx.doi.org/10.1097/PEC.0b013e31823a3e73DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3237926PMC
December 2011

Treatment of acute otitis media in children.

N Engl J Med 2011 05;364(18):1775-6; author reply 1777-8

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http://dx.doi.org/10.1056/NEJMc1102207DOI Listing
May 2011

A proposal to limit otoscopy to reduce unnecessary use of antibiotics: a call for research.

Expert Rev Anti Infect Ther 2011 Feb;9(2):177-81

Department of Emergency Medicine, Oregon Health and Science University, CDW-EM, 3181 SouthWest Sam Jackson Park Road, Portland, OR 97239, USA.

Acute otitis media (AOM) is the most common bacterial infection in childhood, accounting for more than 10 million prescriptions written in the USA alone. Otoscopy is the only method to diagnose AOM, is difficult to perform in young children and has been found to be inaccurate. Otoscopy has certain risks, the most common of which are child discomfort, trauma to the external ear canal and parental anxiety. Current guidelines emphasize the importance of making an accurate diagnosis of AOM, which includes the presence of fever, otalgia or both. We propose a new strategy to limit the use of otoscopy to circumstances in which the pretest probability of AOM is high. We suggest indications for mandatory otoscopy and a flow chart outlining a proposal for limiting otoscopy in the management of AOM. Clinical research evaluating the rational use of otoscopy is encouraged to evaluate outcomes and acceptance of this proposal. Limiting otoscopy to clinical conditions in which the likelihood of AOM is high may reduce unnecessary pain and anxiety associated with the procedure, reduce rates of misdiagnosis and support the more judicious use of antibiotics.
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http://dx.doi.org/10.1586/eri.10.175DOI Listing
February 2011

Wounds.

Pediatr Rev 2010 Aug;31(8):326-34; quiz 334

Section of Pediatric Emergency Medicine, Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, USA.

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http://dx.doi.org/10.1542/pir.31-8-326DOI Listing
August 2010

Halo scalp ring with purulent drainage in a newborn.

Pediatr Emerg Care 2010 Jan;26(1):46-7

Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.

We present the case of a 2-week-old male infant who repeatedly presented to the pediatric emergency department for fussiness and drainage from a head wound. The infant had an ultimate diagnosis of halo scalp ring, a rare dermatologic condition that is treated conservatively. This condition shares characteristics with infectious processes and must be differentiated from more serious illness to minimize unnecessary and expensive medical treatment.
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http://dx.doi.org/10.1097/PEC.0b013e3181cd14c7DOI Listing
January 2010

To intubate or not to intubate? Transporting infants on prostaglandin E1.

Pediatrics 2009 Jan 8;123(1):e25-30. Epub 2008 Dec 8.

Department of Transport and Emergency Medicine, Children's Hospital, Los Angeles, California, USA.

Objectives: The purpose of this work was to describe the pretransport and transport management of infants receiving prostaglandin E(1) infusion for congenital heart disease and to compare transport complications among unintubated and electively intubated infants.

Methods: We conducted a retrospective chart review of 202 infants receiving prostaglandin E(1) during transport to our facility from 2000 to 2005. Prostaglandin E(1) adverse effects were described as likely or possible and transport complications as major or minor (requiring no intervention). Logistic regression was used to identify risk factors for major transport complications, and subgroup analysis compared risks among unintubated and prophylactically intubated infants.

Results: Sixty-four percent of infants were intubated before transport: 34% emergently before prostaglandin E(1), 14% for prostaglandin E(1)-related adverse effects, and 11% prophylactically. Likely prostaglandin E(1) adverse effects were noted in 38% of infants, including 18% with apnea. Major complications occurred during 42% of all of the transports, including 7 (10%) of 73 unintubated infants and 14 (61%) of 23 prophylactically intubated infants. After controlling for multiple factors, elective intubation was a significant predictor of major transport complications.

Conclusions: Despite high rates of prostaglandin E(1) adverse effects, elective intubation of infants for transport significantly increased the odds of a major transport complication. The risks of prophylactic intubation before the transport of otherwise stable infants on prostaglandin E(1) must be weighed carefully against possible benefits.
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http://dx.doi.org/10.1542/peds.2008-0641DOI Listing
January 2009