Publications by authors named "Joanna S Cohen"

26 Publications

  • Page 1 of 1

Frequency of Opioid Prescription Filling After Discharge from the Pediatric Emergency Department.

J Emerg Med 2022 06 29;62(6):775-782. Epub 2022 Mar 29.

Division of Pediatric Emergency Medicine, Children's National Hospital, Washington, DC; George Washington University School of Medicine, Washington, DC.

Background: Little is known about prescription filling of pain medicine for children. In adult populations, race and insurance type are associated with differences in opioid prescription fill rate. We hypothesize that known disparities in pain management for children are exacerbated by the differential rates of opioid prescription filling between patients based on age and race.

Objective: To determine if there are demographic or clinical factors associated with differences in opioid prescription fill rates after discharge from the pediatric emergency department (ED).

Methods: This was a retrospective cross-sectional study of all patients younger than 19 years discharged with an opioid prescription from either of two pediatric EDs in 2018. We performed multivariable logistic regression to measure associations between prescription filling and demographic and clinical factors.

Results: There were 287 patient visits in which opioids were prescribed. Forty percent of prescriptions were filled. The majority of patients were male (53%), black (69%), and had public insurance (55%). There were no significant associations between prescription filling and age, insurance status, or race/ethnicity. Patients with sickle cell disease were more likely to fill prescriptions (odds ratio 3.87, 95% confidence interval 2.33-6.43) and patients without an identified primary care provider were less likely to fill prescriptions (odds ratio 0.16, 95% confidence interval 0.03-0.84).

Conclusion: Less than half of opioid prescriptions prescribed at discharge from a pediatric emergency department are filled. Patient age, insurance status, and race/ethnicity are not associated with opioid prescription filling. Patients with sickle cell disease and those with a primary care provider are more likely to fill their opioid prescriptions.
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http://dx.doi.org/10.1016/j.jemermed.2022.01.002DOI Listing
June 2022

Variability in advanced imaging of pediatric neck infections in US emergency departments.

Am J Emerg Med 2022 Mar 10;53:140-143. Epub 2022 Jan 10.

Division of Emergency Medicine, Children's National Health System, Washington, D.C, United States of America; Department of Pediatrics and Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, D.C, United States of America.

Objectives: To describe the use of computed tomography (CT) and ultrasound (US) imaging for the evaluation of neck infections in pediatric patients in United States emergency departments (EDs).

Methods: This is a cross-sectional analysis, using the National Emergency Department Sample database, of pediatric patients evaluated for common neck infections between 2012 and 2018. We used bivariable analysis to assess for differences in US and CT use by ED type. We performed multivariable logistic regression to adjust for potential confounding factors including patient characteristics (sex, age, insurance status, discharge diagnosis) and ED characteristics (metropolitan statistical area, pediatric center). Results are reported as odds ratios and adjusted odds ratios with 95% confidence intervals.

Results: There were 19,363 ED visits for pediatric neck infections in the database over the study period, representing 84,439 national visits. Of those imaged, 80.8% were imaged with CT and 19.2% were imaged with US. Pediatric patients evaluated in general EDs as compared to pediatric EDs (aOR 5.32, 95% CI 3.06, 9.24) and patients with a diagnosis of peritonsillar abscess (aOR 2.11, 95% CI 1.34, 3.33) and retropharyngeal abscess (aOR 6.12, 95% CI 2.14, 17.53) were more likely to be imaged with CT scan.

Conclusions: Children with neck infections evaluated in general EDs are significantly more likely to undergo CT scans when compared to those evaluated in pediatric EDs. To reduce exposure to radiation in children, we propose the dissemination of US-first protocols in general EDs for the evaluation of pediatric neck infections.
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http://dx.doi.org/10.1016/j.ajem.2022.01.001DOI Listing
March 2022

Validation of "Personal Protective Equipment Conservation Strategies Tool" to Predict Consumption of N95s, Facemasks, and Gowns During Pandemic-Related Shortages.

Comput Inform Nurs 2022 Jan;40(1):28-34

Author Affiliations: Department of Engineering Management and Systems Engineering, The George Washington University (Ms Rickard); and Emergency Medicine and Trauma Center (Drs Cohen and Ong, Mr Dwyer, and Ms Perritt) and Emergency Medicine Section of Data Analytics (Drs Chamberlain and McKinley), Children's National Hospital, Washington, DC; and Department of Emergency Medicine, University of California San Francisco (Dr Ong).

We sought to prospectively validate a model to predict the consumption of personal protective equipment in a pediatric emergency department during the COVID-19 pandemic. We developed the Personal Protective Equipment Conservation Strategies Tool, a Monte Carlo simulation model with input parameters defined by members of our emergency department personal protective equipment task force. Inputs include different conservation strategies that reflect dynamic reuse policies. Over the course of 4 consecutive weeks in April and May 2020, we used the model to predict the consumption of N95 respirators, facemasks, and gowns in our emergency department based on values for each input parameter. At the end of each week, we calculated the percent difference between actual consumption and predicted consumption based on model outputs. Actual consumption of personal protective equipment was within 20% of model predictions for each of the 4 consecutive weeks for N95s (range, -16.3% to 16.1%) and facemasks (range, -7.6% to 13.1%), using "maximum conservation" and "high conservation" strategies, respectively. Actual consumption of gowns was 11.8% less than predicted consumption for Week 1, gown resupply data were unavailable on Weeks 2-4. The Personal Protective Equipment Conservation Strategies Tool was prospectively validated for "maximum conservation" and "high conservation" models, with actual consumption within 20% of model predictions.
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http://dx.doi.org/10.1097/CIN.0000000000000831DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8745942PMC
January 2022

Factors associated with clinical severity in emergency department patients presenting with symptomatic SARS-CoV-2 infection.

J Am Coll Emerg Physicians Open 2021 Aug 29;2(4):e12453. Epub 2021 Jun 29.

School of Medicine and Health Sciences Department of Emergency Medicine, The George Washington University Washington District of Columbia USA.

Objective: To measure the association of race, ethnicity, comorbidities, and insurance status with need for hospitalization of symptomatic emergency department patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

Methods: This study is a cohort study of symptomatic patients presenting to a single emergency department (ED) with laboratory-confirmed SARS-CoV-2 infection from March 7-August 9, 2020. We collected patient-level information regarding demographics, insurance status, comorbidities, level of care, and mortality using a structured chart review. We compared characteristics of patients categorized by (1) home discharge, (2) general hospital ward admission, and (3) intensive care unit (ICU) admission or death within 30 days of the index visit. Univariate and multivariable logistic regression analyses were performed to report odds ratios (OR) and 95% confidence intervals (95% CI) between hospital admission versus ED discharge home and between ICU care versus general hospital ward admission.

Results: In total, 994 patients who presented to the ED with symptoms were included in the analysis with 551 (55.4%) patients discharged home, 314 (31.6%) patients admitted to the general hospital ward, and 129 (13.0%) admitted to the ICU or dying. Patients requiring admission were more likely to be Black or to have public insurance (Medicaid and/or Medicare). Patients who were admitted to the ICU or dying were more likely aged ≥ 65 years or male. In multivariable logistic regression, old age, public insurance, diabetes, hypertension, obesity, heart failure, and hyperlipidemia were independent predictors of hospital admission. When comparing those who needed ICU care versus general hospital ward admission in univariate logistic regression, patients with Medicaid (OR 2.4, 95% CI 1.2-4.6), Medicare (OR 4.2, 95% CI 2.1-8.4), Medicaid and Medicare (OR 4.3, 95% CI 2.4-7.7), history of chronic obstructive pulmonary disease (OR 2.2, 95% CI 1.2-4.2), hypertension (OR 1.7, 95% CI 1.1-2.7), and heart failure (OR 2.6, 95% CI 1.4-4.7) were more likely to be admitted into the ICU or die; Black (OR 1.1, 95% CI 0.4-2.9) and Hispanic/Latino (OR 1.0, 95% CI 0.6-1.8) patients were less likely to be admitted into the ICU; however, the associations were not statistically significant. In multivariable logistic regression, old age, male sex, public insurance, and heart failure were independent predictors of ICU care/death.

Conclusion: Comorbidities and public insurance are predictors of more severe illness for patients with SARS-CoV-2. This study suggests that the disparities in severity seen in COVID-19 among Black patients may be attributable, in part, to low socioeconomic status and chronic health conditions.
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http://dx.doi.org/10.1002/emp2.12453DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8240469PMC
August 2021

Triple threat: New presentation with diabetic ketoacidosis, COVID-19, and cardiac arrhythmias.

Am J Emerg Med 2021 11 19;49:437.e5-437.e8. Epub 2021 Apr 19.

Children's National Hospital, Washington, DC, United States; George Washington University School of Medicine and Health Sciences, United States. Electronic address:

Patients with diabetes have increased susceptibility to infection with Severe acute respiratory syndrome-coronavirus 2 and increased morbidity and mortality from Coronavirus disease 2019 (COVID-19) infection. Mortality from COVID-19 is sometimes caused by cardiac arrhythmias. Electrolyte disturbances in patients with diabetic ketoacidosis (DKA) can increase the risk of cardiac arrhythmias. Despite these correlations, little has been reported about the co-incidence of these three conditions: COVID-19, DKA and cardiac arrhythmias. In this case report we describe two children with COVID-19, new-onset DKA and cardiac arrhythmias. These cases emphasize the importance of close cardiac and electrolyte monitoring in patients with COVID-19 infection.
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http://dx.doi.org/10.1016/j.ajem.2021.04.045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8053600PMC
November 2021

Firearms Injuries Involving Young Children in the United States During the COVID-19 Pandemic.

Pediatrics 2021 07 13;148(1). Epub 2021 Apr 13.

Division of Emergency Medicine, Children's National Health System, Washington, District of Columbia

Objectives: Increased rates of firearm ownership, school closures, and a suspected decrease in supervision during the coronavirus disease 2019 (COVID-19) pandemic place young children at increased risk of firearm injuries. We measured trends in firearm injuries in children and inflicted by children discharging a firearm during the pandemic and correlated these changes with a rise in firearm acquisition.

Methods: In this cross-sectional study with an interrupted time series analysis, we used multiyear data from the Gun Violence Archive. We compared trends in (1) firearm injuries in children younger than 12 years old and (2) firearm injuries inflicted by children younger than 12 years old during the pre-COVID-19 period (March to August in the years 2016-2019) and during the first 6 months of the COVID-19 pandemic (March 2020 to August 2020). Linear regression models were developed to evaluate the relationship between firearm injuries and new firearm acquisitions.

Results: There was an increased risk of (1) firearm injuries in young children (relative risk = 1.90; 95% confidence interval 1.58 to 2.29) and (2) firearm injuries inflicted by young children (relative risk = 1.43; 95% confidence interval 1.14 to 1.80) during the first 6 months of the COVID-19 pandemic as compared to the pre-COVID-19 study period. These increased incidents correlate with an increase in new firearm ownership ( < .03).

Conclusions: There has been a surge in firearm injuries in young children and inflicted by young children during the first 6 months of the COVID-19 pandemic. There is an urgent and critical need for enactment of interventions aimed at preventing firearm injuries and deaths involving children.
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http://dx.doi.org/10.1542/peds.2020-042697DOI Listing
July 2021

Epinephrine autoinjector prescription filling after pediatric emergency department discharge.

Allergy Asthma Proc 2021 03;42(2):142-146

From the Division of Emergency Medicine, Children's National Medical Center, Washington, D.C.

There are known racial and socioeconomic disparities in the use of epinephrine autoinjectors (EAI) for anaphylaxis. To measure the rates of EAI prescription filling and identify patient demographic factors associated with filling rates among patients discharged from the pediatric emergency department. This was a retrospective observational cohort study of all patients discharged from a pediatric emergency department who received an outpatient prescription for an EAI between January 1, 2018, and October 31, 2019. The rates of prescription filling were calculated, and multivariable logistic regression was performed to identify sociodemographic factors associated with prescription filling. Of 717 patients included in the analysis, 54.8% (95% confidence interval {CI}, 51.1%-58.5%) filled their prescription. There were no significant associations between EAI fill rates and patient age or sex. In bivariable analysis, non-Hispanic white patients were more likely to fill EAI prescriptions compared with non-Hispanic Black patients (odds ratio [OR] 1.89 [95% CI, 1.11-3.20]), and patients with in-state Medicaid were significantly less likely to fill EAI prescriptions compared with those patients with private insurance (OR 0.69 [95% CI, 0.48-0.98]). However, after multivariable adjustment, there was no significant difference in filling by age, insurance status, or race or ethnicity. Only approximately half the patients had their EAI prescriptions filled after discharge. Filling rates did not vary by sociodemographic characteristics.
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http://dx.doi.org/10.2500/aap.2021.42.200099DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8133020PMC
March 2021

Implementing Paper Documentation During an Influenza Surge in a Pediatric Emergency Department.

Pediatr Emerg Care 2021 Feb;37(2):126-130

From the Department of Pediatrics and Emergency Medicine, Children's National Health System.

Objective: We hypothesized that a paper documentation and discharge bundle can expedite patient care during an influenza-related surge.

Methods: Retrospective cohort study of low-acuity patients younger than 21 years surging into a pediatric emergency department between January and March 2018 with influenza-like illness. Patient visits documented using a paper bundle were compared with those documented in the electronic medical record on the same date of visit. The primary outcome of interest was time from physician evaluation to discharge for patient visits documented using the paper bundle compared with those documented in the electronic medical record. Secondary outcome was difference in return visits within 72 hours. We identified patient and visit level factors associated with emergency department length of stay.

Results: A total of 1591 patient visits were included, 1187 documented in the electronic health record and 404 documented using the paper bundle. Patient visits documented using the paper bundle had a 21% shortened median time from physician evaluation to discharge (41 minutes; interquartile range, 27-62.8 minutes) as compared with patient visits documented in the electronic health record (52 minutes; interquartile range, 35-61 minutes; P < 0.001). There was no difference in return visits (odds ratio, 0.7; 95% confidence interval, 0.2, 2.2).

Conclusions: Implementation of paper charting during an influenza-related surge was associated with shorter physician to discharge times when compared with patient visits documented in the electronic health record. A paper bundle may improve patient throughput and decrease emergency department overcrowding during influenza or coronavirus disease-related surge.
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http://dx.doi.org/10.1097/PEC.0000000000002334DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7850558PMC
February 2021

Results of Testing Children for Severe Acute Respiratory Syndrome Coronavirus-2 Through a Community-based Testing Site.

J Pediatr 2021 04 22;231:157-161.e1. Epub 2020 Dec 22.

Children's National Hospital, Washington, DC; Department of Pediatrics, George Washington University, Washington, DC; Division of Laboratory Medicine and Pathology, Children's National Hospital, Washington, DC.

Objective: To describe the demographics, clinical features, and test results of children referred from their primary provider for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in the community setting.

Study Design: Retrospective cross-sectional study of children ≤22 years of age who were tested for SARS-CoV-2 at a community-based specimen collection site in Washington, DC, affiliated with a large children's hospital between March 21 and May 16, 2020.

Results: Of the 1445 patients tested at the specimen collection site for SARS-CoV-2 virus, 408 (28.2%) had a positive polymerase chain reaction test. The daily positivity rate increased over the study period, from 5.4% during the first week to a peak of 47.4% (P < .001). Patients with fever (aOR, 1.7; 95% CI, 1.3-2.3) or cough (aOR, 1.4; 95% CI, 1.1-1.9) and those with known contact with someone with confirmed SARS-CoV-2 infection (aOR, 1.6; 95% CI, 1.0-2.4.) were more likely have a positive test, but these features were not highly discriminating.

Conclusions: In this cohort of mildly symptomatic or well children and adolescents referred to a community drive-through/walk-up SARS-CoV-2 testing site because of risk of exposure or clinical illness, 1 in 4 patients had a positive test. Children and young adults represent a considerable burden of SARS-CoV-2 infection. Assessment of their role in transmission is essential to implementing appropriate control measures.
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http://dx.doi.org/10.1016/j.jpeds.2020.12.030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7831849PMC
April 2021

Patient and Visit Characteristics of Pediatric Patients With High-frequency Low-acuity Emergency Department Visits.

Pediatr Emerg Care 2022 Jan;38(1):e417-e421

From the Division of Emergency Medicine, Children's National Health System.

Introduction: Pediatric patients account for a disproportionate number of low-acuity emergency department (ED) visits. The aim of this study is to describe pediatric patient and visit characteristics for high-frequency users for low-acuity visits.

Methods: This was a retrospective cohort study of children presenting to a tertiary care pediatric ED and an affiliated community ED, over a 2-year period, with at least 10 low-acuity visits. Twenty patients with the highest number of visits were classified as "superusers." We analyzed patient data from the larger sample of high-frequency users and visit specific data from superuser visits. IBM SPSS Statistics 25 (SPSS Inc., Chicago, IL) was used to perform descriptive statistics and to summarize demographic and visit specific variables.

Results: We identified 181 high-frequency users with a mean number of visits of 14.3 ± 4.3 and a subpopulation of 20 superusers accounting for 434 visits. The majority of high-frequency users (89%) identified as African American and had public insurance (96.1%). Many patients received primary care affiliated with the home institution. In the first year of the study, 50.3% of high-frequency users were infants younger than 1 year at the index visit and 47.4% of superusers were infants at the index visit.Superuser visits were evenly distributed among seasons and the majority of visits occurred during the weekdays (70.7%). The majority of visits were for medical complaints (86.6%) and almost half (47.6%) resulted in some testing (24.9%) or treatment (30.6%); however, only 1.4% resulted in hospital admission.

Conclusions: In our sample, most high-frequency low-acuity ED patients were infants, African American and have public insurance. Many are seen during clinic hours and are paneled at affiliated clinics. Among superusers, the majority of the visits did not require any testing, intervention, or treatment.
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http://dx.doi.org/10.1097/PEC.0000000000002312DOI Listing
January 2022

Barriers to Firearm Injury Research.

Am J Prev Med 2020 06 5;58(6):825-831. Epub 2020 Mar 5.

Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia; Departments of Pediatrics and Emergency Medicine, George Washington University Hospital, Washington, District of Columbia.

Introduction: Firearm injuries and motor vehicle injuries are 2 leading causes of fatal injury in the U.S., each accounting for approximately 35,000 deaths annually. Research on firearm injuries is under-represented compared with research on motor vehicle collisions. This study seeks to identify perceived barriers to firearm injury research versus motor vehicle injury research.

Methods: This was a mixed-methods survey of corresponding authors of a minimum of 1 study, archived in PubMed, related to firearm injury or motor vehicle injury between 2014 and 2018. Analyses were performed in 2019. Electronic surveys included both closed- and open-ended questions to assess barriers to research. Bivariable and multivariable logistic regression was performed to identify differences in perceptions to barriers between the 2 groups. Qualitative analysis of free-text responses was performed through inductive derivation of themes.

Results: Surveys were distributed to 113 firearm injury researchers (42% response rate) and 241 motor vehicle injury researchers (31.5% response rate). After adjustment, firearm injury researchers were less likely to cite institutional support (AOR=0.3, 95% CI=0.1, 0.8) as a factor contributing to their success, than motor vehicle injury researchers. Firearm injury researchers were more likely to report fear of personal threats (AOR=10.4, 95% CI=2.4, 44.4) and experiencing personal threats (AOR=16.1, 95% CI=1.6, 165.4). Thematic analysis revealed 4 themes: career, political, funding, and harassment.

Conclusions: When compared with motor vehicle injury researchers, firearm injury researchers are significantly more likely to report limited support and threats to personal safety as barriers to research. Further research to understand the impact of these barriers and methods to overcome them is needed.
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http://dx.doi.org/10.1016/j.amepre.2020.01.005DOI Listing
June 2020

Utility of the DIVA score for experienced emergency department technicians.

Br J Nurs 2020 Jan;29(2):S35-S40

MD, Division of Emergency Medicine, Children's National Health System, Washington, DC; Department of Pediatrics and Emergency Medicine, George Washington University, Washington, DC, USA.

Background: The DIVA score is validated for predicting success of the initial attempt at peripheral intravenous insertion by nurses and physicians. A score of 4 or greater is 50% to 60% likely to have a failed first attempt. The study objective was to assess the validity of this score for emergency department technicians.

Methods: This study used a prospective convenience sample of 181 children presenting to the emergency department with intravenous access attempt by one of 29 emergency department technicians. DIVA score, total number of attempts, and median time to successful intravenous cannulation were obtained.

Results: Comparing patients with a DIVA score <4 to ≥4, first-time IV placement failure rates were lower (9% [95% CI, 3-24] vs. 41% [95% CI, 33-49]) and median time to IV placement was shorter (75 [interquartile range (IQR) 42-157] vs. 254 [IQR 91-806]) seconds. In patients with scores ≥4, emergency department technicians with ≥5 years of experience were significantly more likely to be successful on the first attempt (OR 2.8; 95% CI, 1.03-7.63). For every year of technician experience, the time to catheter placement, adjusted for DIVA score, decreased by 25 minutes (≤0.05, =0.05). Comparing our receiver operating curve to the derivation study, the areas were similar (0.67 vs. 0.65).

Conclusions: This study provides preliminary evidence for the validity of the DIVA score when applied to IVs placed by emergency department technicians. For patients with high DIVA scores, ≥5 years of IV experience was associated with higher odds of successful first-time IV placement and shorter time to placement. The difficult intravenous access (DIVA) score may be generalizable to IVs placed by experienced emergency department technicians (EDTs) Higher odds of first-time success in difficult patients with ≥5 years EDT experience Early identification of difficult access may allow for aid of alternative technology Likely first study to evaluate EDTs IV skills in patients with varying DIVA scores.
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http://dx.doi.org/10.12968/bjon.2020.29.2.S35DOI Listing
January 2020

Impact of Transcervical Ultrasound for the Diagnosis of Pediatric Peritonsillar Abscesses on Emergency Department Performance Measures.

J Ultrasound Med 2020 Apr 11;39(4):715-720. Epub 2019 Nov 11.

Division of Emergency Medicine, Children's National Health System, Washington, DC, USA.

Objectives: To evaluate the impact of transcervical ultrasound (US) as the initial imaging study for suspected peritonsillar abscesses (PTAs) on pediatric emergency department (ED) throughput measures.

Methods: A retrospective cohort study of patients evaluated for suspected PTAs between January 2009 and April 2017 was conducted. We compared the ED length of stay (LOS) before and after implementation of transcervical US to diagnose a PTA. The balancing measure was the rate of return visits within 2 weeks.

Results: There were 387 eligible patients over the study period. A total of 101 patients were evaluated for PTAs with computed tomography and 286 with US. The mean LOS was significantly less for patients who had US (347 minutes; 95% confidence interval [CI], 330, 364 minutes) compared to computed tomography (426 minutes; 95% CI, 392, 459 minutes), with an absolute difference of 79 minutes (95% CI, 44, 113 minutes). Patients who were evaluated with US did not have an increased rate of return visits (5.9% versus 8.0%; P = .66).

Conclusions: The introduction of transcervical US was associated with a decrease of greater than 1 hour in the ED LOS for patients with suspected PTAs. Given the better radiation profile of US and no increase in the rate of return visits after its implementation, we propose the adoption of a transcervical US-first approach for the diagnosis of PTAs in pediatrics.
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http://dx.doi.org/10.1002/jum.15150DOI Listing
April 2020

Quality Assurance for Point-of-Care Ultrasound in North American Pediatric Emergency Medicine Fellowships.

Pediatr Emerg Care 2021 Sep;37(9):e534-e537

Objectives: The American Academy of Pediatrics, the Society for Academic Emergency Medicine, and the American College of Emergency Physicians released a policy statement endorsing the use of point-of-care ultrasound (POCUS) by pediatric emergency medicine (PEM) providers. This statement specifically recommends that emergency departments have a credentialing and quality assurance (QA) program for POCUS. There is limited knowledge of how QA for POCUS is currently carried out in pediatric emergency departments with PEM training programs.

Methods: We sent a cross-sectional web-based survey to all 81 PEM fellowship-training programs in the United States and Canada between June 2016 and June 2017.

Results: Sixty-six of 81 programs (81.2%) responded. Sixty-five percent of responding PEM training programs had POCUS-trained faculty or a POCUS champion at their institution. Forty-six percent had a POCUS fellowship in their institution, with 10 programs having PEM-specific POCUS fellowships. Programs with POCUS fellowships were more likely to save all images, review all scans, review scans more frequently, provide feedback, and bill compared with programs without POCUS fellowships.

Conclusions: Point-of-care ultrasound is growing in PEM fellowship-training programs, with a majority of programs now having faculty members trained or interested specifically in POCUS. Most programs prefer more frequent and thorough QA processes, and programs with POCUS fellowships are more likely to have more frequent and thorough QA processes.
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http://dx.doi.org/10.1097/PEC.0000000000001871DOI Listing
September 2021

Interpretation errors in focused cardiac ultrasound by novice pediatric emergency medicine fellow sonologists.

Crit Ultrasound J 2018 Dec 9;10(1):33. Epub 2018 Dec 9.

Department of Emergency Medicine and Trauma Services, Children's National Medical Center, Washington, DC, USA.

Background: Focused cardiac ultrasound (FOCUS) is a core competency for pediatric emergency medicine (PEM) fellows. The objectives of this study were (1) to evaluate test characteristics of PEM-fellow-performed FOCUS for pericardial effusion and diminished cardiac function and (2) to assess image interpretation independent of image acquisition.

Methods: PEM fellows performed and interpreted FOCUS on patients who also received cardiology service echocardiograms, the reference standard. Subsequently, eight different PEM fellows remotely interpreted a subset of the PEM-acquired and cardiology-acquired echocardiograms.

Results: Eight PEM fellows performed 54 FOCUS exams, of which two had pericardial effusion and four had diminished function. PEM fellow FOCUS had a sensitivity of 50.0% (95% CI 9.19-90.8) and specificity of 100.0% (95% CI 91.1-100.0) for detecting diminished function, and sensitivity of 50.0% (95% CI 2.67-97.33) and specificity of 98.1% (95% CI 88.42-99.9) for detecting pericardial effusions. When PEM fellows remotely interpreted 15 echocardiograms, the sensitivity was 81.3% (95% CI 70.7-88.8) and specificity 75% (95% CI 67.0-81.0) for detecting diminished function, and sensitivity of 76.3% (95% CI 65.0-85.0) and specificity 94.4% (95% CI 89.0-97.0) for detecting pericardial effusion. There were no differences in sensitivity and specificity of PEM fellows' interpretation of FOCUS studies compared to their interpretation of cardiology echocardiograms. Interrater reliability for interpretation of remote images (kappa) was 0.66 (95% CI 0.59-0.73) for effusion and 0.31 (95% CI 0.24-0.38) for function among the fellows.

Conclusion: Novice PEM fellow sonologists (a physician who performs and interprets ultrasound) in the majority of instances were able to acquire and remotely interpret FOCUS images with limited training. However, they made real-time interpretation errors and likely need further training to incorporate real-time image acquisition and interpretation into their practice.
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http://dx.doi.org/10.1186/s13089-018-0113-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6286908PMC
December 2018

US Emergency Department Trends in Imaging for Pediatric Nontraumatic Abdominal Pain.

Pediatrics 2017 Oct 15;140(4). Epub 2017 Sep 15.

Department of Pediatrics and Emergency Medicine, School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia; and

Objectives: To describe national emergency department (ED) trends in computed tomography (CT) and ultrasound imaging for the evaluation of pediatric nontraumatic abdominal pain from 2007 through 2014.

Methods: We used data from the National Hospital Ambulatory Medical Care Survey to measure trends in CT and ultrasound use among children with nontraumatic abdominal pain. We performed multivariable logistic regression to measure the strength of the association of ED type (pediatric versus general ED) with CT and ultrasound use adjusting for potential confounding variables.

Results: Of an estimated 21.1 million ED visits for nontraumatic abdominal pain, 14.6% (95% confidence interval [CI], 13.2%-16.0%) had CT imaging only, 10.9% (95% CI, 9.7%-12.1%) had ultrasound imaging only, and 1.9% (95% CI, 1.4%-2.4%) received both CT and ultrasound. The overall use of CT and ultrasound did not significantly change over the study period ( trend .63 and .90, respectively). CT use was lower among children treated in pediatric EDs compared with general EDs (adjusted odds ratio 0.34; 95% CI, 0.17-0.69). Conversely, ultrasound use was higher among children treated in pediatric EDs compared with general EDs (adjusted odds ratio 2.14; 95% CI, 1.29-3.55).

Conclusions: CT imaging for pediatric patients with nontraumatic abdominal pain has plateaued since 2007 after the steady increase seen in the preceding 9 years. Among this population, an increased likelihood of CT imaging was demonstrated in general EDs compared with pediatric EDs, in which there was a higher likelihood of ultrasound imaging. Dissemination of pediatric-focused radiology protocols to general EDs may help optimize radiation exposure in children.
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http://dx.doi.org/10.1542/peds.2017-0615DOI Listing
October 2017

Diagnosis of an Intraventricular Cyst Using Point-of-Care Cranial Ultrasound in the Pediatric Emergency Department.

Pediatr Emerg Care 2017 Mar;33(3):216-218

From the *Division of Emergency Medicine, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE; †Children's National Medical Center; and ‡George Washington University School of Medicine, Washington, DC.

A 2-month-old previously healthy male infant presents with 2 days of unusual eye movements and increased fatigue. During evaluation in the pediatric emergency department, point-of-care cranial ultrasound identified a cyst-like mass. Subsequent magnetic resonance imaging confirmed the presence of a cyst within the third ventricle causing obstructive hydrocephalus.
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http://dx.doi.org/10.1097/PEC.0000000000001052DOI Listing
March 2017

Doppler Ultrasonography of the Central Retinal Vessels in Children With Brain Death.

Pediatr Crit Care Med 2017 Mar;18(3):258-264

1Division of Pediatric Anesthesiology and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD. 2Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC. 3Division of Emergency Medicine, Children's National Health System, Washington, DC. 4Division of Ophthalmology, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA. 5Division of Cardiac Intensive Care Medicine, Children's National Health System, Washington, DC. 6Division of Pediatric Critical Care, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA. 7Division of Critical Care Medicine, Children's National Health System, Washington, DC.

Objective: The purpose of this observational study is to explore if bedside Doppler ultrasonography of the central retinal vessels has the potential to become an ancillary study to support the timely diagnosis of brain death in children.

Design: Seventeen-month prospective observational cohort.

Setting: Forty-four bed pediatric medical and surgical ICU in an academic teaching hospital.

Patients: All children 0-18 years old who were clinically evaluated for brain death at Children's National Health Systems were enrolled and followed until discharge or death.

Interventions: None.

Measurements And Main Results: All patients had at least one ophthalmic ultrasound within 30 minutes of each brain death examination. The central retinal artery peak systolic blood flow velocity, resistive index, pulsatility index, and Doppler waveforms were evaluated in each patient. Thirty-five ophthalmic ultrasounds were obtained on 13 patients, 3 months to 15 years old, who each had two clinical examinations consistent with brain death. The average systolic blood pressure during the ultrasound examinations was 102 mm Hg (± 28), diastolic blood pressure 65 mm Hg (± 24), mean arterial pressure 79 mm Hg (± 23), heart rate 133 beats/min (± 27), temperature 36°C (± 0.96), arterial CO2 35 mm Hg (± 9), and end-tidal CO2 23 mm Hg (± 6). For all examinations, the average peak systolic velocity of the central retinal artery was significantly decreased at 4.66 cm/s (± 3.2). Twelve of 13 patients had both resistive indexes greater than or equal to 1, average pulsatility indexes of 3.6 (± 3.5) with transcranial Doppler waveforms consistent with brain death. Waveform analysis of the 35 ultrasound examinations revealed 11% with tall systolic peaks without diastolic flow, 17% with oscillatory flow, 29% showed short systolic spikes, and 23% had no Doppler movement detected. A rippling "tardus-parvus" waveform was present in 20% of examinations.

Conclusion: This study supports that the combination of qualitative waveform analysis and quantitative blood flow variables of the central retinal vessels may have the potential to be developed as an ancillary study for supporting the diagnosis of brain death in children.
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http://dx.doi.org/10.1097/PCC.0000000000001087DOI Listing
March 2017

The Utility of Bedside Lung Ultrasound Findings in Bronchiolitis.

Pediatr Emerg Care 2017 Feb;33(2):97-100

From the *Division of Emergency Medicine, Children's National Medical Center; †School of Medicine and Health Sciences, The George Washington University; ‡Center for Community and Clinical Research, Children's National Medical Center; and §Department of Emergency Medicine, The George Washington University Hospital, Washington, DC.

Objectives: Recent literature suggests that bedside lung ultrasound may have a role in the evaluation of infants with bronchiolitis. B lines, which are multiple and diffuse vertical artifacts spreading from the lung pleural interface to the edge of the ultrasound screen, have been associated with thickened interlobular septa, extravascular lung water, and diffuse parenchymal disease. The aims of this study were (1) to describe the prevalence of B lines in children younger than 24 months presenting to the emergency department with wheezing, (2) to determine the interrater reliability of lung ultrasound findings in this setting, and (3) to determine the association of B lines with atopy and other clinical findings.

Methods: This was a pilot, prospective, observational study of a convenience sample of patients younger than 2 years presenting with wheezing to a large academic pediatric hospital emergency department. Investigators performed lung ultrasound examinations, and a second provider reviewed the ultrasound examinations to determine interrater reliability. We performed univariate analyses to test for associations between ultrasound findings and atopy, acute illness severity, age, and treatment response.

Results: Studies were obtained on 29 patients (mean [SD] age, 291 [187] days; 62% male). Twenty-one patients (72%) had compact B lines. B lines were significantly associated with older age and an absence of atopic features. There was poor correlation of lung ultrasound examination interpretation among enrolling providers.

Conclusions: In this small sample of patients with bronchiolitis, B lines were associated with older age and an absence of atopic features. Lung ultrasound interpretation had poor interrater reliability.
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http://dx.doi.org/10.1097/PEC.0000000000000820DOI Listing
February 2017

The Use of Ophthalmic Ultrasonography to Identify Retinal Injuries Associated With Abusive Head Trauma.

Ann Emerg Med 2016 05 17;67(5):620-4. Epub 2015 Oct 17.

Division of Emergency Medicine, Children's National Health System, Washington, DC; Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC.

Abusive head trauma includes any nonaccidental injury inflicted to a child's head and body. It is often characterized by, but not limited to, the repetitive acceleration-deceleration forces with or without blunt head impact. It has a mortality rate of 30%, and 80% of survivors experience permanent neurologic damage. In this case series, we hypothesize that bedside ultrasonography can be useful in the identification of retinal injuries that are consistent with abusive head trauma. Ocular manifestations of abusive head trauma are identified by dilated ophthalmic examination showing retinal hemorrhages that are too numerous to count, multilayered, and extending to the periphery. Traumatic retinoschisis, splitting of the retinal layers with or without blood accumulating in the intervening space, is exclusive for abusive head trauma in infants without a history of significant cerebral crush injury. Direct visualization of intraocular structures is difficult when the eyelids are swollen shut or when dilatation must be delayed. We present a series of 11 patients with brain injuries who underwent ophthalmic point-of-care ultrasonography that revealed traumatic retinoschisis on average 60 hours earlier than direct ophthalmic visualization. Dilated ophthalmic examinations and autopsy reports confirmed retinoschisis and other forms of retinal hemorrhages that were too numerous to count, multilayered, and extending to the periphery in all 11 patients. One patient did not have a dilated ophthalmic examination; however, traumatic retinoschisis and retinal hemorrhages were confirmed on autopsy. Ocular point-of-care ultrasonography is a promising tool to investigate abusive head trauma through the identification of traumatic retinoschisis and retinal hemorrhages when pupillary dilatation and direct ophthalmic examination is delayed.
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http://dx.doi.org/10.1016/j.annemergmed.2015.09.027DOI Listing
May 2016

Incidental renal mass found on focused assessment with sonography in trauma.

Pediatr Emerg Care 2014 Oct;30(10):752-4

From the *Children's National Medical Center and †George Washington University School of Medicine, Washington, DC.

We present the case of a 9-year-old female who presented after minor blunt abdominal trauma during a sporting event. On focused assessment with sonography for trauma, she was found to have an incidental renal mass, which was ultimately diagnosed as a renal cell carcinoma. In this report, we focus on the use of bedside ultrasound as a screening test and the management of incidental findings.
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http://dx.doi.org/10.1097/PEC.0000000000000242DOI Listing
October 2014

Cranial computed tomography utilization for suspected ventriculoperitoneal shunt malfunction in a pediatric emergency department.

J Emerg Med 2014 Apr 25;46(4):449-55. Epub 2014 Jan 25.

Division of Emergency Medicine, Children's National Medical Center, The George Washington University School of Medicine, Washington, DC.

Background: Computed tomography (CT) scan, the largest medical source of ionizing radiation in the United States, is used to test for failure of ventricular peritoneal shunts.

Study Objectives: To quantify the exposure to cranial CT scans in pediatric patients presenting with symptoms of shunt malfunction, and to measure the association of signs and symptoms with clinical shunt malfunction and the need for neurosurgical intervention within 30 days of presentation.

Method: This was a quality improvement study evaluating a pathway used by providers in a tertiary care pediatric emergency department with 85,000 patient visits per year, by retrospective chart review of 223 patient visits for suspected shunt malfunction. We determined the median CT scan per patient per year and the association of signs and symptoms on the pathway with radiological signs of shunt failure and neurosurgical intervention within 30 days of scan.

Results: The median exposure was 2.6 (interquartile range 1.44-4.63) scans per patient per year. Among 11 signs and symptoms, none was associated with radiologic shunt failure. Neurosurgical intervention within 30 days was positively associated with bulging fontanelle (adjusted odds ratio [AOR] 11.78; 95% confidence interval [CI] 1.67-83.0) and behavioral change (AOR 3.01; 95% CI 1.14-7.93), and negatively associated with seizure (AOR 0.13; 95% CI 0.02-0.79) and fever (AOR 0.15; 95% CI 0.04-0.55).

Conclusions: Patients with ventricular peritoneal shunts underwent many cranial CT scans each year. None of the signs or symptoms included on the clinical pathway was predictive of changes on CT scan.
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http://dx.doi.org/10.1016/j.jemermed.2013.08.137DOI Listing
April 2014

Ultrasound-guided arthrocentesis of the elbow: a posterior approach.

J Emerg Med 2013 Nov 26;45(5):698-701. Epub 2013 Aug 26.

George Washington University Medical Center, Washington, DC.

Background: Identification of fluid in the elbow joint by physical examination alone can be challenging. Ultrasound can assist in the diagnosis of elbow effusion, and guide aspiration of the effusion.

Objectives: We illustrate the anatomy and ultrasound guidance technique of a posterior approach to elbow arthrocentesis using examples of normal and pathologic elbow joint ultrasound images.

Discussion: The posterior distal humerus at the level of the olecranon fossa provides an excellent acoustic window into the joint space. This location also provides a safe path for the performance of ultrasound-guided arthrocentesis.

Conclusion: Ultrasound-guided arthrocentesis of the elbow from a posterior approach is a helpful technique to guide the aspiration of the painful swollen elbow.
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http://dx.doi.org/10.1016/j.jemermed.2013.04.053DOI Listing
November 2013

Bedside ultrasound education in pediatric emergency medicine fellowship programs in the United States.

Pediatr Emerg Care 2012 Sep;28(9):845-50

Division of Emergency Medicine, Children's National Medical Center, Washington, DC, USA.

Objectives: As the use of bedside ultrasound becomes more prevalent in pediatric emergency departments, the need for a national curriculum for fellows' training in pediatric emergency medicine (PEM) has increased. The objectives of this study were to describe the current state of bedside ultrasound education among existing PEM fellowship programs and to explore the interest in a national curriculum.

Methods: A 20-question survey was sent to all 57 PEM fellowship directors in the United States in February 2011. Weekly reminders were sent for 4 weeks.

Results: The response rate was 58% (33/57). Although 91% of respondents reported having an ultrasound machine available, only 16% reported an ultrasound curriculum designed specifically for PEM. Another 25% reported no curriculum, and 28% use a curriculum designed for general emergency medicine physicians. Most (>83%) directors thought an ultrasound curriculum for PEM fellows should include the focused assessment with sonography for trauma, bladder size assessment, soft tissue foreign body localization, skin and soft tissue infection evaluation, guidance for central and peripheral line insertion, and arthrocentesis. Some directors (40%-68%) thought that cardiac ultrasound, thoracic ultrasound, abdominal ultrasound, lumbar puncture guidance, fracture reduction, nerve blocks, and testicular ultrasounds should also be included. Forty-two percent plan to create a bedside ultrasound curriculum in the next 5 years, and 40% reported the lack of a national curriculum as a barrier to creating a curriculum.

Conclusions: Bedside ultrasound use in pediatric emergency departments is very common, and PEM fellowship directors would welcome the development of a standard curriculum.
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http://dx.doi.org/10.1097/PEC.0b013e318267a771DOI Listing
September 2012

P-glycoprotein transporter expression on a549 respiratory epithelial cells is positively correlated with intracellular dexamethasone levels.

J Investig Med 2010 Dec;58(8):991-4

Center for Genetic Medicine Research, Children's National Medical Center, 111 Michigan Ave. NW, Washington, DC 20010, USA.

Background: Several mechanisms of glucocorticoid resistance in asthma have been proposed. P-glycoprotein (P-gp), a ubiquitous efflux transport protein, is associated with variability in the disposition of many drugs and interindividual variability in drug treatment response. This study was undertaken to determine the effect of P-gp expression on glucocorticoid efflux from airway epithelial cells.

Hypothesis: Decreasing respiratory epithelial P-gp expression in dexamethasone-exposed airway epithelial cells in vitro will increase intracellular dexamethasone concentration.

Methods: A549 lung epithelial cells, transfected with small interfering RNA (siRNA) targeted at messenger RNA for the gene encoding P-gp, were exposed to 100-nM dexamethasone for 15 minutes. Transfection efficiency of siRNA, P-gp expression, and intracellular dexamethasone were measured with flow cytometry.

Results: Cells transfected with both negative siRNA and siRNA targeted at P-gp exhibited a positive correlation of P-gp expression with intracellular dexamethasone. The mean ± SEM correlation coefficients were 0.78 ± 0.07 for cells transfected with negative siRNA and 0.79 ± 0.08 for cells transfected with siRNA targeted at P-gp.

Discussion: Contrary to our hypothesis, the positive correlation between P-gp expression and intracellular dexamethasone suggests that P-gp is not a primary transporter of glucocorticoids from airway epithelial cells. Increased P-gp expression is unlikely to be an important mechanism of glucocorticoid resistance in asthma.
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http://dx.doi.org/10.231/JIM.0b013e3181f88503DOI Listing
December 2010

Sports-related concussions in pediatrics.

Curr Opin Pediatr 2009 Jun;21(3):288-93

Division of Emergency Medicine, Children's National Medical Center, Washington, DC 20010, USA.

Purpose Of Review: Mild traumatic brain injury (mTBI) accompanied by concussion is a common presenting complaint among children presenting to emergency departments (EDs). There is wide practice variation regarding diagnosis and management of sports-related concussions in children. Our aim is to review the most recent evidence and expert recommendations regarding initial diagnosis and management of sports-related concussions in children.

Recent Findings: Previous classifications and return-to-play guidelines for sports-related concussions in children were inadequate and have been abandoned. The most recent recommendations, from the Third International Conference on Concussion in Sport (CIS), reinforce an individualized evaluation of the athlete's neurocognitive functioning, symptoms and balance. They further reinforce a step-wise approach in the return-to-play process once neurocognitive function has returned to baseline and all symptoms have resolved. The need for a standardized and objective tool to aid in the initial evaluation and diagnosis of mTBI in the clinical setting led to the development of the Acute Concussion Evaluation (ACE) protocol, which is currently being modified for specific use in the ED. Computed tomography (CT) in the acute setting is not likely to be useful for children with mTBI. Newer functional imaging techniques may prove relevant in the future.

Summary: Further research on both the incidence of sports-related concussions in children and management paradigms is needed. The role of novel imaging modalities in clinical assessment also needs to be elucidated. An individualized approach to evaluation and management of sports-related concussions is recommended. It should incorporate standard symptom assessment, neuropsychological testing and postural stability testing.
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http://dx.doi.org/10.1097/MOP.0b013e32832b1195DOI Listing
June 2009
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