Publications by authors named "Michael C Monuteaux"

253 Publications

A Statewide Collaboration to Deliver and Evaluate a Pediatric Critical Care Simulation Curriculum for Emergency Medical Services.

Front Pediatr 2022 14;10:903950. Epub 2022 Jun 14.

Division of Emergency Medicine, Department of Pediatrics, Harvard Medical School, Boston, MA, United States.

Objective: Care of the critically ill child is a rare but stressful event for emergency medical services (EMS) providers. Simulation training can improve resuscitation care and prehospital outcomes but limited access to experts, simulation equipment, and cost have limited adoption by EMS systems. Our objective was to form a statewide collaboration to develop, deliver, and evaluate a pediatric critical care simulation curriculum for EMS providers.

Methods: We describe a statewide collaboration between five academic centers to develop a simulation curriculum and deliver it to EMS providers. Cases were developed by the collaborating PEM faculty, reviewed by EMS regional directors, and based on previously published EMS curricula, a statewide needs assessment, and updated state EMS protocols. The simulation curriculum was comprised of 3 scenarios requiring recognition and acute management of critically ill infants and children. The curriculum was implemented through 5 separate education sessions, led by a faculty lead at each site, over a 6 month time period. We evaluated curriculum effectiveness with a prospective, interventional, single-arm educational study using pre-post assessment design to assess the impact on EMS provider knowledge and confidence. To assess the intervention effect on knowledge scores while accounting for nested data, we estimated a mixed effects generalized regression model with random effects for region and participant. We assessed for knowledge retention and self-reported practice change at 6 months post-curriculum. Qualitative analysis of participants' written responses immediately following the curriculum and at 6 month follow-up was performed using the framework method.

Results: Overall, 78 emergency medical technicians (EMTs) and 109 paramedics participated in the curriculum over five separate sessions. Most participants were male (69%) and paramedics (58%). One third had over 15 years of clinical experience. In the regression analysis, mean pediatric knowledge scores increased by 9.8% (95% CI: 7.2%, 12.4%). Most (93% [95% CI: 87.2%, 96.5%]) participants reported improved confidence caring for pediatric patients. Though follow-up responses were limited, participants who completed follow up surveys reported they had used skills acquired during the curriculum in clinical practice.

Conclusion: Through statewide collaboration, we delivered a pediatric critical care simulation curriculum for EMS providers that impacted participant knowledge and confidence caring for pediatric patients. Follow-up data suggest that knowledge and skills obtained as part of the curriculum was translated into practice. This strategy could be used in future efforts to integrate simulation into EMS practice.
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http://dx.doi.org/10.3389/fped.2022.903950DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9237480PMC
June 2022

The impact of pediatric early warning score and rapid response algorithm training and implementation on interprofessional collaboration in a resource-limited setting.

PLoS One 2022 22;17(6):e0270253. Epub 2022 Jun 22.

Department of Pediatrics, Centre Hospitalier Universitaire de Kigali (CHUK), Kigali, Rwanda.

Introduction: Improved teamwork and communication have been associated with improved quality of care. Early Warning Scores (EWS) and rapid response algorithms are a way of identifying deteriorating patients and providing a common framework for communication and response between physicians and nurses. The impact of EWS implementation on interprofessional collaboration (IPC) has been minimally studied, especially in resource-limited settings.

Methods: The study took place in the Pediatric Department of the main academic referral hospital in Rwanda between April 2019 and January 2020. Pediatric nurses and residents were trained on the use of the Pediatric Warning Score for Resource-Limited Settings (PEWS-RL) and a rapid response algorithm. Training included vital sign collection, PEWS-RL calculation, IPC and rapid response algorithm implementation. Prior to training, participants completed surveys on IPC with Likert scale responses (from "strongly disagree" to "strongly agree"). Follow-up surveys were then administered nine months later and also included an open-response question on the impact of the PEWS-RL implementation on IPC.

Results: Sixty-five (96%) nurses were trained and completed the pre-survey and thirty-seven (54%) of the trained nurses completed the post-survey. Twenty-two (59%) pediatric residents were trained in the workshop and completed the pre-survey and twenty-four physicians (4 pediatricians (40%) and 20 pediatric residents (53%)) completed the post-implementation survey. There was a statistically significant increase in the percent of nurses indicating strong agreement across all domains of communication and collaboration from the pre- to the post-survey. Although the percent of physicians indicating strong agreement increased in the post-survey for all items, only the "share information" item was statistically significant.

Conclusion: Training and implementation of a PEWS-RL and a rapid response algorithm at a tertiary hospital in Rwanda resulted in significant improvement of nurse and physician ratings of IPC nine months later.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0270253PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9216488PMC
June 2022

The authors reply.

Crit Care Med 2022 Jul 13;50(7):e654-e655e. Epub 2022 Jun 13.

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

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http://dx.doi.org/10.1097/CCM.0000000000005552DOI Listing
July 2022

Pediatric Fracture Epidemiology and US Emergency Department Resource Utilization.

Pediatr Emerg Care 2022 Jul 8;38(7):e1342-e1347. Epub 2022 Jun 8.

From the Division of Emergency Medicine.

Objective: Fractures are common childhood injuries that result in emergency department (ED) visits. National trends in pediatric fracture epidemiology and resource utilization are not well described. Our objective is to analyze national trends in pediatric fracture epidemiology, ED disposition, and ED resource utilization from 2010 to 2015.

Methods: This is an epidemiological study of fracture care in US EDs from 2010 to 2015 for children 0 to 18 years old using the Nationwide Emergency Department Sample. We calculated frequencies and national rates using weighted analyses and census data. We used the test for linear trend to analyze incidence, hospital admission, transfer, and procedural sedation over time. Multivariate logistic regression analyses identified encounter- and hospital-level predictors of transfer, admission, operative care, and use of procedural sedation.

Results: During the study period, from 2010 to 2015, a total of 5,398,827 children received ED care for fractures. The pediatric fracture rate was 11.5 ED visits/1000 persons (95% confidence interval [CI], 10.6-12.5) and decreased over time. The admission rate for pediatric fracture patients was 5% and stable over time. The transfer rate increased from 3.3 to 4.1/100 fracture visits (linear trend: odds ratio, 1.06; 95% CI, 1.03-1.09). Utilization of procedural sedation increased from 1.5% to 2.9% of fracture visits (linear trend: odds ratio, 1.17; 95% CI, 1.09-1.25). Predictors associated with disposition and resource utilization include patient age, fracture location, insurance type, hospital type, and region.

Conclusions: The national incidence rate of pediatric fractures decreased slightly. Emergency department resource utilization increased over time. With high national volume, understanding pediatric fracture epidemiology and resource utilization is important to the health care system.
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http://dx.doi.org/10.1097/PEC.0000000000002752DOI Listing
July 2022

Disparities and Trends in Migraine Management in Pediatric Emergency Departments, 2009-19.

Acad Pediatr 2022 May 21. Epub 2022 May 21.

Department of Pediatrics, Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School (KC Genadry, MC Monuteaux, MI Neuman, and LK Lee), Boston, Mass.

Objective: To assess the variation in migraine management over time across US children's hospitals and to identify factors associated with disparities in management.

Methods: We conducted a retrospective study of 32 hospitals in the Pediatric Health Information System from 2009 to 2019. We included children 7 to 21 years old with primary ICD-9 or ICD-10 diagnosis codes for migraine headache. We surveyed hospitals to assess for clinical guideline presence. We assessed medication use trends over time. To examine differences in medication and advanced head imaging use by patient characteristics and presence of clinical guideline, we performed multivariable logistic regression analyses reporting adjusted odds ratios (aOR) with 95% confidence intervals (CI).

Results: We identified 112,077 eligible visits. Opioid use decreased over time, while nonopioid analgesic, dopamine antagonist, and diphenhydramine use increased. Multivariable analysis for opioids revealed increased odds of use for those 14 to 17 (aOR 1.19; 95% CI, 1.06, 1.34) and 18 to 21 years old (aOR 1.69; CI, 1.37, 2.08), and clinical guideline presence had decreased odds (aOR 0.64; CI, 0.48, 0.84). For head computed tomography, increased odds of use were reported for Hispanic ethnicity (aOR 1.15; CI, 1.06, 1.24) and decreased odds for 14 to 17 years (aOR 0.85; CI, 0.80, 0.90), 18 to 21 years (aOR 0.87; CI, 0.77, 0.98), and female sex (aOR 0.74; CI, 0.70, 0.79).

Conclusions: Opioid use decreased while other medications increased over time. Medication and imaging differed by demographic characteristics. Opioid use was less likely in hospitals with clinical guidelines. Standardization in management may decrease care disparities and variability.
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http://dx.doi.org/10.1016/j.acap.2022.04.007DOI Listing
May 2022

Nonoperative Management of Uncomplicated Appendicitis.

Pediatrics 2022 05;149(5)

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

Background And Objectives: Several studies have revealed the success of nonoperative management (NOM) of uncomplicated appendicitis in children. Large studies of current NOM utilization and its outcomes in children are lacking.

Methods: We queried the Pediatric Health Information System database to identify children <19 years of age with a diagnosis code for appendicitis. We used linear trend analysis to assess the subsequent utilization and outcomes of NOM in children with nonperforated appendicitis over time. We calculated the proportion of children experiencing treatment failure, defined as either a subsequent appendectomy or hospitalization with a diagnosis code of perforated appendicitis.

Results: We identified 117 705 children with appendicitis over the 9-year study period. Of the 73 544 children with nonperforated appendicitis, 10 394 (14.1%) underwent NOM. The odds of NOM significantly increased (odds ratio 1.10 per study quarter, 95% confidence interval [CI] 1.05-1.15). The 1-year and 5-year failure rates were 18.6% and 23.3%, respectively. Children who experienced failure of NOM had higher rates of perforation at the time of failure than did the general cohort at the time of initial presentation (45.7% vs 37.5%, P < .001). Patients undergoing NOM had higher rates of subsequent related emergency department visits (8.0% vs 5.1%, P < .001) and hospitalizations (4.2% vs 1.4%, P < .001) over a 12-month follow-up period.

Conclusions: NOM of nonperforated appendicitis in children is increasing. Although the majority of children who undergo NOM remain recurrence-free years later, they carry a substantial risk of perforation at the time of recurrence and may experience a higher rate of postoperative complications than children undergoing an immediate appendectomy.
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http://dx.doi.org/10.1542/peds.2021-054693DOI Listing
May 2022

Mortality During Readmission Among Children in United States Children's Hospitals.

J Pediatr 2022 07 29;246:161-169.e7. Epub 2022 Mar 29.

Department of Pediatrics, Harvard Medical School, Boston, MA; Division of Gastroenterology, Hepatology, and Nutrition, Center for Nutrition, Boston Children's Hospital, Boston, MA.

Objective: To identify demographic, clinical, and hospital factors associated with mortality on readmission within 180 days following an inpatient hospitalization.

Study Design: We conducted a retrospective cohort study including 33 US children's hospitals in the Pediatric Health Information System from January 2010 to June 2020. Our primary outcome was death during readmission within 180 days of an index hospitalization among children aged 0-18 years. Illness severity during the index hospitalization was defined according to the All Patient-Refined Diagnosis-Related Group-categorized illness severity (ie, minor, moderate, or major/extreme). We performed multivariable logistic regression analysis to identify factors during the index hospitalization associated with mortality during readmission.

Results: Among 2 677 111 children discharged, 337 385 (12.6%) were readmitted within 180 days of the index hospitalization and 2913 (0.8%) died during readmission. More than one-quarter (26.2%) of deaths among children who were readmitted and died occurred within 10 days after discharge from the index hospitalization. Factors independently associated with mortality during readmission included multiple complex chronic conditions, index admissions lasting >7 days, moderate or severe/extreme illness during the index hospitalization, and public insurance. Children whose race was reported as Black had greater odds of mortality during readmission compared with children of other races.

Conclusions: Among hospitalized children, several demographic and clinical factors present during index hospitalizations were associated with mortality during readmission. Greater odds of mortality during readmission among children whose race was reported as Black likely reflects disparities in social determinants of health and clinical care. Interventions to reduce mortality during readmission may target high-risk populations in the period immediately following discharge.
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http://dx.doi.org/10.1016/j.jpeds.2022.03.040DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9233053PMC
July 2022

Severity of Illness in Bronchiolitis Amid Unusual Seasonal Pattern During the COVID-19 Pandemic.

Hosp Pediatr 2022 04;12(4):e119-e123

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

Objective: We aimed to characterize recent trends in bronchiolitis at US children's hospitals and to compare severity of illness in bronchiolitis in the most recent year to the previous seasonal epidemics.

Methods: This is a cross-sectional study of visits for bronchiolitis in infants <24 months old from October 2016 to September 2021 at 46 US children's hospitals participating in the Pediatric Health Information Systems database. Study years were defined by 12-month periods beginning in October to account for typical winter epidemics that crossover calendar years. We used logistic and Fourier Poisson regression models to examine trends in outcomes and compare seasonality, respectively.

Results: The study included 389 411 emergency visits for bronchiolitis. Median age of infants with bronchiolitis was higher in October 2020 to September 2021 compared to previous epidemics (8 and 6 months, respectively, P < .001) The odds of hospitalization, ICU admission, invasive mechanical ventilation, and noninvasive ventilation did not differ in October 2020 to September 2021 compared to previous epidemics from October 2016 to September 2020 (all P > .05 for unadjusted models and models adjusted for age). Seasonality varied significantly among these 2 periods (P < .001).

Conclusions: Although the seasonality of bronchiolitis differed in October 2020 to September 2021, severity of illness in infants with bronchiolitis was consistent with previous epidemics.
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http://dx.doi.org/10.1542/hpeds.2021-006405DOI Listing
April 2022

The First 15 Minutes: A Novel Disaster Simulation Exercise.

Disaster Med Public Health Prep 2022 Mar 25:1-7. Epub 2022 Mar 25.

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

Objective: The objective was to describe a feasible, multidisciplinary pediatric mass casualty event (MCE) simulation format that was less than 2 h within emergency department space and equipment constraints.

Methods: This was a prospective cohort study of an MCE in situ simulation program from June-October 2019. Participants rotated through 3 modules: (1) triage, (2) caring for a critical patient in an MCE setting, and (3) being in a disaster leadership role. Triage accuracy, knowledge, self-evaluation of preparedness, and MCE skills by means of pre- and post-test surveys were measured. Wilcoxon matched pairs signed rank test scores and McNemar's matched pair chi-squared test were performed to evaluate for statistically significant differences.

Results: Forty-six physicians (MD), 1 physician's assistant (PA), and 22 nurses participated over 4 simulation d. Among the MD/PA group, there was a statistically significant 7% knowledge increase (95% confidence interval [CI], 3%-11%). Nurses did not show a statistically significant knowledge difference (0.04, 95% CI, 0.04%, 14%). There was a statistically significant increase in triage and resource use preparedness (P < 0.01) for all participants.

Conclusion: This efficient, feasible model for a multidisciplinary ED disaster drill provides a multi-modular exposure while improving both MD and PA knowledge and all staff preparedness for MCE.
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http://dx.doi.org/10.1017/dmp.2022.42DOI Listing
March 2022

Refining sonographic criteria for paediatric appendicitis: combined effects of age-based appendiceal size and secondary findings.

Emerg Med J 2022 Mar 7. Epub 2022 Mar 7.

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

Objective: Appendiceal diameter is a primary sonographic determinant of paediatric appendicitis. We sought to determine if the diagnostic performance of outer appendiceal diameter differs based on age or with the addition of secondary sonographic findings.

Methods: We retrospectively reviewed patients aged less than 19 years who presented to the Boston Children's Hospital ED and had an ultrasound (US) for the evaluation of appendicitis between November 2015 and October 2018. Our primary outcome was the presence of appendicitis. We analysed the cases to evaluate the optimal outer appendiceal diameter as a predictor for appendicitis stratified by age (<6, 6 to <11, 11 to <19 years), and with the addition of one or more secondary sonographic findings.

Results: Overall, 945 patients met criteria for inclusion, of which 43.9% had appendicitis. Overall, appendiceal diameter as a continuous measure demonstrated excellent test performance across all age groups (area under the curve (AUC) >0.95) but was most predictive of appendicitis in the youngest age group (AUC=0.99 (0.98-1.00)). Although there was no significant difference in optimal diameter threshold between age groups, both 7- and 8-mm thresholds were more predictive than 6 mm across all groups (p<0.001). The addition of individual (particularly appendicolith or echogenic fat) or combinations of secondary sonographic findings increased the diagnostic value for appendicitis above diameter alone.

Conclusions: Appendiceal diameter as a continuous measure was more predictive of appendicitis in the youngest group. Across all age groups, the optimal diameter threshold was 7 mm for the diagnosis of paediatric appendicitis. The addition of individual or combination secondary sonographic findings increases diagnostic performance.
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http://dx.doi.org/10.1136/emermed-2021-211751DOI Listing
March 2022

Physician Risk Perception and Testing Behaviors for Children With Fever.

Pediatr Emerg Care 2022 Feb;38(2):e805-e810

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

Objectives: Risk tolerance and risk perceptions may impact clinicians' decisions to obtain diagnostic tests. We sought to determine whether physician risk perception was associated with the decision to obtain blood or imaging tests among children who present to the emergency department with fever.

Methods: We conducted a retrospective, cross-sectional study in the Boston Children's Hospital emergency department. We included children aged 6 months to 18 years from May 1, 2014 to April 30, 2019, with fever. Our primary outcome was diagnostic testing: obtaining a blood and/or imaging test. We assessed risk perception using 3 scales: the Risk Tolerance Scale (RTS), Stress From Uncertainty Scale (SUS), and Malpractice Fear Scale (MFS). A z score was assigned to each physician for each scale. Mixed-effects logistic regression assessed the association between physician risk perception and blood or imaging testing. We also examined the relationship between each risk perception scale and several secondary outcomes: blood testing, urine testing, diagnostic imaging, specialist consultation, hospitalization, and revisit within 72 hours.

Results: The response rate was 55/56 (98%). We analyzed 12,527 encounters. Blood/imaging testing varied between physicians (median, 48%; interquartile range, 41%-53%; range, 30%-71%). Risk Tolerance Scale responses were not associated with blood/imaging testing (odds ratio [OR], 1.03 per SD of increased risk perception; 95% confidence interval [CI], 0.95-1.13). Stress From Uncertainty Scale responses were not associated with blood/imaging testing (OR, 1.04 per SD; 95% CI, 0.95-1.14). Malpractice Fear Scale responses were not associated with blood/imaging testing (OR, 1.00 per SD; 95% CI, 0.91-1.09). There was no significant association between RTS, MFS, or SUS and any secondary outcome, except that there was a weak association between SUS and specialist consultation (OR, 1.12; 95% CI, 1.00-1.24).

Conclusions: Across 55 pediatric emergency physicians with variable testing practices, there was no association between risk perception and blood/imaging testing in febrile children.
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http://dx.doi.org/10.1097/PEC.0000000000002413DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9340816PMC
February 2022

Physician Risk Perception and Testing Behaviors for Children With Fever.

Pediatr Emerg Care 2022 Feb;38(2):e805-e810

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

Objectives: Risk tolerance and risk perceptions may impact clinicians' decisions to obtain diagnostic tests. We sought to determine whether physician risk perception was associated with the decision to obtain blood or imaging tests among children who present to the emergency department with fever.

Methods: We conducted a retrospective, cross-sectional study in the Boston Children's Hospital emergency department. We included children aged 6 months to 18 years from May 1, 2014 to April 30, 2019, with fever. Our primary outcome was diagnostic testing: obtaining a blood and/or imaging test. We assessed risk perception using 3 scales: the Risk Tolerance Scale (RTS), Stress From Uncertainty Scale (SUS), and Malpractice Fear Scale (MFS). A z score was assigned to each physician for each scale. Mixed-effects logistic regression assessed the association between physician risk perception and blood or imaging testing. We also examined the relationship between each risk perception scale and several secondary outcomes: blood testing, urine testing, diagnostic imaging, specialist consultation, hospitalization, and revisit within 72 hours.

Results: The response rate was 55/56 (98%). We analyzed 12,527 encounters. Blood/imaging testing varied between physicians (median, 48%; interquartile range, 41%-53%; range, 30%-71%). Risk Tolerance Scale responses were not associated with blood/imaging testing (odds ratio [OR], 1.03 per SD of increased risk perception; 95% confidence interval [CI], 0.95-1.13). Stress From Uncertainty Scale responses were not associated with blood/imaging testing (OR, 1.04 per SD; 95% CI, 0.95-1.14). Malpractice Fear Scale responses were not associated with blood/imaging testing (OR, 1.00 per SD; 95% CI, 0.91-1.09). There was no significant association between RTS, MFS, or SUS and any secondary outcome, except that there was a weak association between SUS and specialist consultation (OR, 1.12; 95% CI, 1.00-1.24).

Conclusions: Across 55 pediatric emergency physicians with variable testing practices, there was no association between risk perception and blood/imaging testing in febrile children.
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http://dx.doi.org/10.1097/PEC.0000000000002413DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9340816PMC
February 2022

National assessment of anti-epileptic drug exposures among pre-teens and adolescents, 2000-2020.

Clin Toxicol (Phila) 2022 06 13;60(6):681-687. Epub 2022 Jan 13.

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

Background And Objectives: Anti-epileptic drugs (AEDs) are increasingly used to treat psychiatric conditions, exposing many children to potentially harmful medications. This includes adolescents, who are at higher risk for self-harm. The purpose of this study was to describe the epidemiology of pediatric AED poisonings and assess which AEDs are associated with more severe clinical outcomes.

Methods: This retrospective cross-sectional analysis examined single-substance AED exposure cases in pre-teens (10-14 years) and adolescents (15-19 years) reported to the National Poison Database System (NPDS) between 2000 and 2020 (cases through 2019 were included for trend analysis due to incomplete population data). We described characteristics of ingestions by age group, including AEDs implicated.

Results: There were 74,818 AED exposure cases reported to the NPDS, including 25,928 (34.7%) in pre-teens and 48,890 (65.3%) in adolescents. Among adolescents, 35,570 (72.8%) exposure cases were intentional, with 27,655 (56.6%) specifically related to a suspected suicide attempt. The most common AEDs implicated in poisonings were clonazepam (19.8%), valproic acid (15.3%), and lamotrigine (13.8%). The odds of hospitalization (adjusted odds ratio [aOR] 2.0 [95% confidence interval [CI], 2.0-2.1]), intubation (aOR 2.1 [95% CI, 1.8-2.4]), seizure (aOR 1.6 [95% CI, 1.4-1.9]), and serious outcome (aOR 1.8 [95% CI, 1.7-1.9]) were higher in the adolescent group compared to the pre-teen group. Intentional ingestions increased by a yearly rate of 2.8% (95% CI, 2.3-3.2). Intentional tiagabine exposure was associated with the greatest increased odds of serious outcome (aOR 4.7 [95% CI, 3.6-6.3]).

Discussion: In this cross-sectional analysis of pediatric AED exposure cases reported to the NPDS, AED poisonings among pre-teens and adolescents increased significantly between 2000 and 2019. Of particular concern is the large increase in intentional exposure cases related to AEDs. With the population-adjusted rate of epilepsy diagnoses remaining relatively unchanged, these results may indicate that the rise in AED exposure cases may be related to increased prescribing of AEDs for psychiatric indications as opposed to epilepsy.

Conclusions: Pediatric AED poisonings reported to the NPDS are increasing, especially among adolescents engaging in intentional ingestions. These findings provide additional information for consideration in risk-benefit assessments when selecting medications for the treatment of psychiatric conditions in children.
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http://dx.doi.org/10.1080/15563650.2021.2023747DOI Listing
June 2022

Impact of Viral Radiographic Features on Antibiotic Treatment for Pediatric Pneumonia.

J Pediatric Infect Dis Soc 2022 May;11(5):207-213

Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA.

Background/objectives: Chest radiograph (CXR) is routinely performed among children with suspected pneumonia, though it is not clear how specific radiographic findings impact antibiotic treatment for pneumonia. We evaluated the impact of viral radiographic features on antibiotic treatment among children undergoing pneumonia evaluation in the emergency department (ED).

Methods: Children presenting to a pediatric ED who underwent a CXR for pneumonia evaluation were prospectively enrolled. Prior to CXR performance, physicians indicated their level of suspicion for pneumonia. The CXR report was reviewed to assess for the presence of viral features (peribronchial cuffing, perihilar markings, and interstitial infiltrate) as well as radiographic features suggestive of pneumonia (consolidation, infiltrate, and opacity). The relationship between viral radiographic features and antibiotic treatment was assessed based on the level of clinical suspicion for pneumonia prior to CXR.

Results: Patients with normal CXRs (n = 400) and viral features alone (n = 370) were managed similarly, with 8.0% and 8.6% of patients receiving antibiotic treatment, respectively (P = .75). Compared with children with radiographic pneumonia (n = 174), patients with concurrent viral features and radiographic pneumonia (n = 177) were treated with antibiotics less frequently (86.2% vs 54.3%, P < .001). Among children with isolated viral features on CXR, antibiotic treatment rates were correlated with pre-CXR level of suspicion for pneumonia.

Conclusions: Among children with suspected pneumonia, the presence of viral features alone on CXR is not associated with increased rates of antibiotic use. Among children with radiographic pneumonia, the addition of viral features on CXR is associated with lower rates of antibiotic use, as compared to children with radiographic pneumonia alone.
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http://dx.doi.org/10.1093/jpids/piab132DOI Listing
May 2022

Significance of Sonographic Subcentimeter, Subpleural Consolidations in Pediatric Patients Evaluated for Pneumonia.

J Pediatr 2022 04 27;243:193-199.e2. Epub 2021 Dec 27.

Division of Emergency Medicine, Boston Children's Hospital Department of Pediatrics, Harvard Medical School, Boston, MA.

Objectives: To investigate the rates of radiographic pneumonia and clinical outcomes of children with suspected pneumonia and subcentimeter, subpleural consolidations on point-of-care lung ultrasound.

Study Design: We enrolled a prospective convenience sample of children aged 6 months to 18 years undergoing chest radiography (CXR) for pneumonia evaluation in a single tertiary-care pediatric emergency department. Point-of-care lung ultrasound was performed by an emergency medicine physician with subsequent expert review. We determined rates of radiographic pneumonia and clinical outcomes in the children with subcentimeter, subpleural consolidations, stratified by the presence of larger (>1 cm) sonographic consolidations. The children were followed prospectively for 2 weeks to identify a delayed diagnosis of pneumonia.

Results: A total of 188 patients, with a median age of 5.8 years (IQR, 3.5-11.0 years), were evaluated. Of these patients, 62 (33%) had subcentimeter, subpleural consolidations on lung ultrasound, and 23 (37%) also had larger (>1 cm) consolidations. Patients with subcentimeter, subpleural consolidations and larger consolidations had the highest rates of definite radiographic pneumonia (61%), compared with 21% among children with isolated subcentimeter, subpleural consolidations. Overall, 23 children with isolated subcentimeter, subpleural consolidations (59%) had no evidence of pneumonia on CXR. Among 16 children with isolated subcentimeter, subpleural consolidations and not treated with antibiotics, none had a subsequent pneumonia diagnosis within the 2-week follow-up period.

Conclusions: Children with subcentimeter, subpleural consolidations often had radiographic pneumonia; however, this occurred most frequently when subcentimeter, subpleural consolidations were identified in combination with larger consolidations. Isolated subcentimeter, subpleural consolidations in the absence of larger consolidations should not be viewed as synonymous with pneumonia; CXR may provide adjunctive information in these cases.
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http://dx.doi.org/10.1016/j.jpeds.2021.12.052DOI Listing
April 2022

National Institutes of Health Funding Priorities-Reply.

JAMA Pediatr 2022 03;176(3):325

Pediatric Therapeutics and Regulatory Science Initiative, Computational Health Informatics Program, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamapediatrics.2021.5368DOI Listing
March 2022

Association between the number of endotracheal intubation attempts and rates of adverse events in a paediatric emergency department.

Emerg Med J 2022 Aug 6;39(8):601-607. Epub 2021 Dec 6.

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

Background: Challenges in emergent airway management in children can affect intubation success. It is unknown if number of endotracheal intubation attempts is associated with rates of adverse events in the paediatric ED setting.

Objective: We sought to (1) Identify rates of intubation-related adverse events, (2) Evaluate the association between the number of intubation attempts and adverse events in a paediatric ED, and (3) Determine the effect of videolaryngoscopy on these associations.

Design And Methods: We performed a retrospective observational study of patients who underwent endotracheal intubation in a paediatric ED in the USA between January 2004 and December 2018. Data on patient-related, provider-related and procedure-related characteristics were obtained from a quality assurance database and the health record. Our primary outcome was frequency of intubation-related adverse events, categorised as major and minor. The number of intubation attempts was trichotomised to 1, 2, and 3 or greater. Multivariable logistic regression models were used to determine the relationship between the number of intubation attempts and odds of adverse events, adjusting for demographic and clinical factors.

Results: During the study period, 628 patients were intubated in the ED. The overall rate of adverse events was 39%. Hypoxia (19%) was the most common major event and mainstem intubation (15%) the most common minor event. 72% patients were successfully intubated on the first attempt. With two intubation attempts, the adjusted odds of any adverse event were 3.26 (95% CI 2.11 to 5.03) and with ≥3 attempts the odds were 4.59 (95% CI 2.23 to 9.46). Odds similarly increased in analyses of both major and minor adverse events. This association was consistent for both traditional and videolaryngoscopy.

Conclusion: Increasing number of endotracheal intubation attempts was associated with higher odds of adverse events. Efforts to optimise first attempt success in children undergoing intubation may mitigate this risk and improve clinical outcomes.
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http://dx.doi.org/10.1136/emermed-2021-211570DOI Listing
August 2022

Seasonality of Acute Lyme Disease in Children.

Trop Med Infect Dis 2021 Nov 9;6(4). Epub 2021 Nov 9.

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

Due to the life cycle of its vector, Lyme disease has known seasonal variation. However, investigations focused on children have been limited. Our objective was to evaluate the seasonality of pediatric Lyme disease in three endemic regions in the United States. We enrolled children presenting to one of eight Pedi Lyme Net participating emergency departments. Cases were classified based on presenting symptoms: early (single erythema migrans (EM) lesion), early-disseminated (multiple EM lesions, headache, cranial neuropathy, or carditis), or late (arthritis). We defined a case of Lyme disease by the presence of an EM lesion or a positive two-tier Lyme disease serology. To measure seasonal variability, we estimated Fourier regression models to capture cyclical patterns in Lyme disease incidence. While most children with early or early-disseminated Lyme disease presented during the summer months, children with Lyme arthritis presented throughout the year. Clinicians should consider Lyme disease when evaluating children with acute arthritis throughout the year.
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http://dx.doi.org/10.3390/tropicalmed6040196DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8628899PMC
November 2021

Trends in ED Resource Use for Infants 0 to 60 Days Evaluated for Serious Bacterial Infection.

Hosp Pediatr 2021 Dec 1. Epub 2021 Dec 1.

Division of Emergency and Transport Medicine, Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California.

Objectives: We examined trends in resource use for infants undergoing emergency department evaluation for serious bacterial infection, including lumbar puncture (LP), antibiotic administration, hospitalization, and procalcitonin testing, as well as the association between procalcitonin testing and LP, administration of parenteral antibiotics, and hospitalization.

Methods: We performed a cross-sectional study of infants aged 0 to 60 days who underwent emergency department evaluation for serious bacterial infection with blood and urine cultures from 2010 to 2019 in 27 hospitals in the Pediatric Health Information System. We examined temporal trends in LP, antibiotic administration, hospitalization, and procalcitonin testing from 2010 to 2019. We also estimated multivariable logistic regression models for 2017-2019, adjusted for demographic factors and stratified by age (<28 and 29-60 days), with LP, antibiotic administration, and hospitalization as dependent variables and hospital-level procalcitonin testing as the independent variable.

Results: We studied 106 547 index visits. From 2010 to 2019, rates of LP, antibiotic administration, and hospitalization decreased more for infants aged 29 to 60 days compared with infants aged 0 to 28 days (annual decrease in odds of LP, antibiotics administration, and hospitalization: 0 to 28 days: 5%, 5%, and 3%, respectively; 29-60 days: 15%, 12%, and 7%, respectively). Procalcitonin testing increased significantly each calendar year (odds ratio per calendar year 2.19; 95% confidence interval 1.82-2.62), with the majority (91.1%) performed during 2017-2019. From 2017 to 2019, there was no association between hospital-level procalcitonin testing and any outcome studied (all P values > .05).

Conclusions: Rates of LP, antibiotic administration, and hospitalization decreased significantly for infants 29 to 60 days during 2010-2019. Although procalcitonin testing increased during 2017-2019, we found no association with hospital-level procalcitonin testing and patterns of resource use.
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http://dx.doi.org/10.1542/hpeds.2021-005966DOI Listing
December 2021

Association of County-Level Poverty and Inequities With Firearm-Related Mortality in US Youth.

JAMA Pediatr 2022 02 7;176(2):e214822. Epub 2022 Feb 7.

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

Importance: Youth firearm-related deaths are a public health crisis in the US. The association between county-level poverty and the risk of firearm-related deaths among youth is unknown, however.

Objective: To examine the association between county-level poverty concentration and firearm-related mortality rates in US youth.

Design, Setting, And Participants: This cross-sectional study analyzed US firearm fatalities in children and young adults aged 5 to 24 years that occurred between January 1, 2007, and December 31, 2016. Data were obtained from the Centers for Disease Control and Prevention's Compressed Mortality File, and annual intercensal county population data were obtained from the US Census Bureau. Data analyses were conducted between November 1, 2019, and June 30, 2020.

Exposures: County-level poverty was categorized into 5 groups: 0% to 4.9%, 5% to 9.9%, 10% to 14.9%, 15% to 19.9%, and ≥20% of the population living below the federal poverty level.

Main Outcomes And Measures: The main outcomes were firearm-related deaths in total and by specific intent (homicide, suicide, and unintentional) per 100 000 youths over the entire study period. Multivariable negative binomial regression models were used to analyze the association between firearm-related mortality rates and county poverty concentration, controlling for demographic variables, urbanicity, and statewide firearm prevalence. Adjusted incidence rate ratios (IRRs) were calculated, and statewide firearm prevalence was estimated. The population-attributable fraction (PAF) and years of potential life lost for each intent were calculated.

Results: A total of 67 905 firearm-related deaths among youth (predominantly composed of 60 164 male individuals [88.6%]) from 2007 to 2016 were analyzed. Of these deaths, 42 512 were homicides (62.6%), 23 034 were suicides (33.9%), and 1627 were unintentional (2.4%). Firearm-related mortality risk increased in a stepwise manner with increasing county poverty concentration. Compared with counties with the lowest poverty concentration, counties with the highest poverty concentration had an increased rate of total firearm-related deaths (adjusted IRR, 2.29; 95% CI, 1.96-2.67), homicides (adjusted IRR, 3.55; 95% CI, 2.80-4.51), suicides (adjusted IRR, 1.45; 95% CI, 1.20-1.75), and unintentional deaths (adjusted IRR, 9.32; 95% CI, 2.32-37.4). The PAF was 0.51 (95% CI, 0.43-0.57) for all firearm-related deaths, 0.66 (95% CI, 0.57-0.73) for homicides, 0.30 (95% CI, 0.17-0.42) for suicides, and 0.86 (95% CI, 0.46-0.97) for unintentional deaths. This calculation translated to 34 292 firearm-related deaths that would not have occurred if all counties had the same risk as counties with the lowest poverty concentration. A total of 3 833 105 years of potential life lost was observed.

Conclusions And Relevance: This study found an association between firearm-related mortality rates among youth and county-level poverty concentration. With more than half of firearm-related deaths and two-thirds of firearm-related homicides potentially associated with living in an area with a high concentration of poverty, a multidimensional strategy to reduce poverty and firearm-related deaths is urgently needed.
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http://dx.doi.org/10.1001/jamapediatrics.2021.4822DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8609463PMC
February 2022

Disparities in School Referrals for Agitation and Aggression to the Emergency Department.

Acad Pediatr 2022 May-Jun;22(4):598-605. Epub 2021 Nov 12.

Division of General Pediatrics (CJ Kistin), Boston Medical Center, Boston, Mass.

Objectives: Describe the demographic and clinical characteristics of children presenting to the emergency department (ED) for agitation and aggression from school versus other sites.

Methods: We performed a retrospective cross-sectional study of children 5 to 18 years old who were evaluated in an urban tertiary care pediatric ED with a chief complaint of agitation or aggression. We examined demographics, disposition, and payments for children presenting from school versus other sites. We conducted multivariable logistic regression to identify predictors of referral site (school versus all other sites, school versus home) and discharge status (home versus higher level of psychiatric care).

Results: Of the 513 included children, 147 (29%) presented from school. Children were more likely to present from school versus other sites if they were Black (adjusted odds ratio [aOR] 2.26, 95% confidence interval [CI] 1.32, 3.88), Latinx (aOR 2.91, 95% CI 1.42, 5.97), or had special educational needs (aOR 2.55, 95% CI 1.64, 3.97). These associations persisted in the analysis of school versus home referrals. Children presenting from school versus all other sites were more likely to be discharged home (aOR 1.60, 95% CI 1.05, 2.44), although this difference did not persist when comparing school versus only home referral. A total of $154,269 (median $367 per encounter) was paid for school referrals to the ED.

Conclusions: Children with agitation and aggression referred from school were more likely to be Black, Latinx, or have special educational needs. Future efforts should identify and address root causes of this disparity to decrease ED referrals, reduce healthcare spending, and address inequities.
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http://dx.doi.org/10.1016/j.acap.2021.11.002DOI Listing
November 2021

Implementation of a pediatric early warning score tool in a pediatric oncology Ward in Palestine.

BMC Health Serv Res 2021 Oct 26;21(1):1159. Epub 2021 Oct 26.

Boston Children's Hospital, Boston, USA.

Background: Pediatric Early Warning Scores (PEWS) are nurse-administered clinical assessment tools utilizing vital signs and patient signs and symptoms to screen for patients at risk for clinical deterioration. When utilizing a PEWS system, which consists of an escalation algorithm to alert physicians of high risk patients requiring a bedside evaluation and assessment, studies have demonstrated that PEWS systems can decrease pediatric intensive care (PICU) utilization, in-hospital cardiac arrests, and overall decreased mortality in high income settings. Yet, many hospital based settings in low and lower middle income countries (LMIC) lack systems in place for early identification of patients at risk for clinical deterioration.

Methods: A contextually adapted 16-h pediatric resuscitation program included training of a PEWS tool followed by implementation and integration of a PEWS system in a pediatric hematology/oncology ward in Beit Jala, Palestine. Four PDSA cycles were implemented post-implementation to improve uptake and scoring of PEWS which included PEWS tool integration into an existing electronic medical record (EMR), escalation algorithm and job aid implementation, data audits and ward feedback.

Results: Frequency of complete PEWS vital sign documentation reached a mean of 89.9%. The frequency and accuracy of PEWS scores steadily increased during the post-implementation period, consistently above 89% in both categories starting from data audit four and continuing thereafter. Accuracy of PEWS scoring was unable to be assessed during week 1 and 2 of data audits due to challenges with PEWS integration into the existing EMR (PDSA cycle 1) which were resolved by the 3rd week of data auditing (PDSA cycle 2).

Conclusions: Implementation of a PEWS scoring tool in an LMIC pediatric oncology inpatient unit is feasible and can improve frequency of vital sign collection and generate accurate PEWS scores.

Contribution To The Literature: This study demonstrates how to effectively implement a PEWS scoring tool into an LMIC clinical setting. This study demonstrates how to utilize a robust feedback mechanism to ensure a quality program uptake. This study demonstrates an effective international partnership model that other institutions may utilize for implementation science.
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http://dx.doi.org/10.1186/s12913-021-07157-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8549265PMC
October 2021

Development of the Novel Pneumonia Risk Score to Predict Radiographic Pneumonia in Children.

Pediatr Infect Dis J 2022 01;41(1):24-30

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

Background: The diagnosis of pneumonia in children is challenging, given the wide overlap of many of the symptoms and physical examination findings with other common respiratory illnesses. We sought to derive and validate the novel Pneumonia Risk Score (PRS), a clinical tool utilizing signs and symptoms available to clinicians to determine a child's risk of radiographic pneumonia.

Methods: We prospectively enrolled children 3 months to 18 years in whom a chest radiograph (CXR) was obtained in the emergency department to evaluate for pneumonia. Before CXR, we collected information regarding symptoms, physical examination findings, and the physician-estimated probability of radiographic pneumonia. Logistic regression was used to predict the presence of radiographic pneumonia, and the PRS was validated in a distinct cohort of children with suspected pneumonia.

Results: Among 1181 children included in the study, 206 (17%) had radiographic pneumonia. The PRS included age in years, triage oxygen saturation, presence of fever, presence of rales, and presence of wheeze. The area under the curve (AUC) of the PRS was 0.71 (95% confidence interval [CI]: 0.68-0.75), while the AUC of clinician judgment was 0.61 (95% CI: 0.56-0.66) (P < 0.001). Among 2132 children included in the validation cohort, the PRS demonstrated an AUC of 0.69 (95% CI: 0.65-0.73).

Conclusions: In children with suspected pneumonia, the PRS is superior to clinician judgment in predicting the presence of radiographic pneumonia. Use of the PRS may help efforts to support the judicious use of antibiotics and chest radiography among children with suspected pneumonia.
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http://dx.doi.org/10.1097/INF.0000000000003361DOI Listing
January 2022

Pediatric sepsis survival in pediatric and general emergency departments.

Am J Emerg Med 2022 01 9;51:53-57. Epub 2021 Oct 9.

Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA.

Objective: Understanding differences in mortality rate secondary to sepsis between pediatric and general emergency departments (EDs) would help identify strategies to improve pediatric sepsis care. We aimed to determine if pediatric sepsis mortality differs between pediatric and general EDs.

Methods: We performed a nationally representative, retrospective cohort study using the 2008-2017 Nationwide Emergency Department Sample (NEDS) to examine visits by patients less than 19 years old with a diagnostic code of severe sepsis or septic shock. We generated national estimates of study outcomes using NEDS survey weights. We compared pediatric to general EDs on the outcomes of ED mortality and hospital mortality. We determined adjusted mortality risk using logistic regression, controlling for age, gender, complex care code, and geographic region.

Results: There were 54,129 weighted pediatric ED visits during the study period with a diagnosis code of severe sepsis or septic shock. Of these visits, 285 died in the ED (0.58%) and 5065 died during their hospital stay (9.8%). Mortality risk prior to ED disposition in pediatric and general EDs was 0.31% and 0.72%, respectively (adjusted odds ratio (aOR), 95% confidence interval (CI): 0.36 (0.14-0.93)). Mortality risk prior to hospital discharge in pediatric and general EDs was 7.5% and 10.9%, respectively (aOR, 95% CI: 0.55 (0.41-0.72)).

Conclusions: In a nationally representative sample, pediatric mortality from severe sepsis or septic shock was lower in pediatric EDs than in general EDs. Identifying features of pediatric ED care associated with improved sepsis mortality could translate into improved survival for children wherever they present with sepsis.
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http://dx.doi.org/10.1016/j.ajem.2021.10.007DOI Listing
January 2022

Changes in Antibiotic Treatment for Children With Lyme Meningitis 2015-2020.

Hosp Pediatr 2021 10;11(10):e243-e248

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

Objectives: Although ceftriaxone has been the first-line treatment of Lyme meningitis, the 2020 Infectious Disease Society of America, American College of Rheumatology, and American Academy of Neurology guideline recommends either doxycycline or ceftriaxone. Our objective was to explore recent trends in enteral antibiotic treatment of children with Lyme meningitis.

Methods: Using codes for case identification, we performed a multicenter retrospective study of patients ≤21 years of age presenting to a pediatric hospital contributing to the Pediatric Health Information System who were diagnosed with Lyme meningitis from 2015 to 2020. Our primary outcome was treatment with parenteral antibiotics, defined by either a procedure code for indwelling catheter placement or >7 days of inpatient parenteral Lyme disease-specific therapy. To examine trends over the study period, we used a generalized estimating equation, with parenteral antibiotics as the dependent variable and study year as the independent variable, adjusted for patient age, sex, race, ethnicity, and insurance status clustered by hospital.

Results: We identified 239 patients with Lyme meningitis treated at 24 participating centers. Overall, 48 (20.0%) were treated with parenteral antibiotics, with a declining rate over the study period (43.8% in 2015 to 8.9% in 2020). After adjustment, the odds of treatment with a parenteral antibiotic decreased over the study period (adjusted odds ratio 0.57; 95% confidence interval 0.41-0.80).

Conclusions: Parenteral antibiotic treatment of children with Lyme meningitis has been on the decline in advance of the published clinical guideline. Carefully designed comparative effectiveness studies are needed to examine the effect of oral versus parenteral treatment regimens on clinical outcomes.
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http://dx.doi.org/10.1542/hpeds.2021-005909DOI Listing
October 2021

Correlation Between National Institutes of Health Funding for Pediatric Research and Pediatric Disease Burden in the US.

JAMA Pediatr 2021 12;175(12):1236-1243

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

Importance: The US National Institutes of Health (NIH) is the largest government funding source for biomedical research globally. Burden of disease is one of the factors considered by the NIH in making funding allocations, though it is not known how funding patterns are associated with disease burden for pediatric conditions.

Objective: To determine the correlation between NIH funding and disease burden across pediatric conditions.

Design, Setting, And Participants: This cross-sectional study evaluates NIH grants funding pediatric research from 2015 to 2018 in the US. Pediatric grants were classified according to disease categories studied. Disease burden for each category was determined using measures from the Institute of Health Metrics and Evaluation and hospitalization data from the 2016 Kids' Inpatient Database.

Main Outcome And Measure: Correlation between NIH funding and pediatric disease burden using Spearman rank order coefficients and predicted amounts of disease-specific funding based on disease burden estimated from linear regression models.

Results: This study analyzed 14 060 disease-specific pediatric grants awarded by the NIH from 2015 to 2018 in the US. Annual funding for disease categories ranged from $0 to $382 849 631. Funding for pediatric research was correlated with pediatric disability-adjusted life-years (DALYs), deaths, years lived with disability, and years of life lost (r, 0.56-0.63; P < 0.001 for all measures). There was also a correlation between funding and hospital-based metrics, including hospital days, number of hospital admissions, and hospital charges (r, 0.67-0.69; P < .001 for all measures). Eight disease categories received greater than $500 million more than predicted levels relative to DALYs, while 5 disease categories were funded more than $50 million less than predicted levels. Based on predicted levels of funding, congenital birth defects; endocrine, metabolic, blood, and immune disorders; and HIV/AIDS were the most overfunded categories relative to DALYs and hospital days. Conditions identified as most underfunded differed depending on use of DALYs or hospital days in estimating predicted funding levels.

Conclusions And Relevance: NIH funding for pediatric research was correlated with pediatric disease burden in the US with variable correlation based on the disease metric applied. There was substantial overfunding and underfunding of certain conditions. Ongoing evaluation of pediatric funding patterns using a complementary set of disease measures may help inform and prioritize pediatric research funding.
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http://dx.doi.org/10.1001/jamapediatrics.2021.3360DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8438620PMC
December 2021

Association of limited English proficiency and increased pediatric emergency department revisits.

Acad Emerg Med 2021 09 25;28(9):1001-1011. Epub 2021 Aug 25.

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

Objective: Limited English proficiency (LEP) is a risk factor for health care inequity and an important focus for improving communication and care quality. This study examines the association between LEP and pediatric emergency department (ED) revisits.

Methods: This was a retrospective, cross-sectional study of patients 0 to 21 years old discharged home after an initial visit from an academic, tertiary care pediatric ED from January 1, 2017, to June 30, 2018. We calculated rates of ED revisits within 72 h resulting in discharge or hospitalization and assessed rate differences between LEP and English-proficient (EP) patients. Multivariable logistic regression models examined the association between revisits and LEP status controlling for age, race, ethnicity, triage acuity, clinical complexity, and ED arrival time. Sensitivity models including insurance were also conducted.

Results: There were 63,601 index visits in the study period; 12,986 (20%) were by patients with LEP. There were 2,387 (3.8%) revisits within 72 h of initial ED visit. Among LEP and EP patient visits, there were 4.53 and 3.55 revisits/100 initial ED visits, respectively (rate difference = 0.97, 95% confidence interval [CI] = 0.58 to 1.37). In the multivariable analyses, LEP was associated with increased odds of revisits resulting in discharge (odds ratio [OR] = 1.15, 95% CI = 1.01 to 1.30) and in hospitalization (OR = 1.28, 95% CI = 1.03 to 1.58). Sensitivity analyses additionally adjusting for insurance status attenuated these results.

Conclusions: These results suggest that LEP was associated with increased pediatric ED revisits. Improved understanding of language barrier effects on clinical care is important for decreasing health care disparities in the ED.
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http://dx.doi.org/10.1111/acem.14359DOI Listing
September 2021

Noninvasive Ventilation and Outcomes in Bronchiolitis.

Crit Care Med 2021 12;49(12):e1234-e1240

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

Objectives: Evaluation of potential benefits of noninvasive ventilation for bronchiolitis has been precluded in part by the absence of large, adequately powered studies. The objectives of this study were to characterize temporal trends in and associations between the use of noninvasive ventilation in bronchiolitis and two clinical outcomes, invasive ventilation, and cardiac arrest.

Design: Multicenter retrospective cross-sectional study.

Setting: Forty-nine U.S. children's hospitals participating in the Pediatric Health Information System database.

Patients: Infants under 12 months old who were admitted from the emergency department with bronchiolitis between January 1, 2010, and December 31, 2018.

Measurements And Main Results: Primary outcomes were rates of noninvasive ventilation, invasive ventilation, and cardiac arrest. Trends over time were assessed with univariate logistic regression. In the main analysis, hospital-level multivariable logistic regression evaluated rates of outcomes including invasive ventilation and cardiac arrest among hospitals with high and low utilization of noninvasive ventilation. The study included 147,288 hospitalizations of infants with bronchiolitis. Across the entire study population, noninvasive and invasive ventilation increased between 2010 and 2018 (2.9-8.7%, 2.1-4.0%, respectively; p < 0·001). After adjustment for markers of severity of illness, hospital-level noninvasive ventilation (high vs low utilization) was not associated with differences in invasive ventilation (5.0%, 1.8%, respectively, adjusted odds ratio, 1.8; 95% CI, 0·7-4·6) but was associated with increased cardiac arrest (0.36%, 0.02%, respectively, adjusted odds ratio, 25.4; 95% CI, 4.9-131.0).

Conclusions: In a large cohort of infants at children's hospitals, noninvasive and invasive ventilation increased significantly from 2010 to 2018. Hospital-level noninvasive ventilation utilization was not associated with a reduction in invasive ventilation but was associated with higher rates of cardiac arrest even after controlling for severity. Noninvasive ventilation in bronchiolitis may incur an unintended higher risk of cardiac arrest, and this requires further investigation.
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http://dx.doi.org/10.1097/CCM.0000000000005210DOI Listing
December 2021

Adolescent alcohol use predicts cannabis use over a three year follow-up period.

Subst Abus 2022 8;43(1):514-519. Epub 2021 Jul 8.

Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.

Alcohol and cannabis use frequently co-occur, which can result in problems from social and academic impairment to dependence (i.e., alcohol use disorder [AUD] and/or cannabis use disorder [CUD]). The Emergency Department (ED) is an excellent site to identify adolescents with alcohol misuse, conduct a brief intervention, and refer to treatment; however, given time constraints, alcohol use may be the only substance assessed due to its common role in unintentional injury. The current study, a secondary data analysis, assessed the relationship between adolescent alcohol and cannabis use by examining the National Institute of Alcohol Abuse and Alcoholism (NIAAA) two question screen's (2QS) ability to predict future CUD at one, two, and three years post-ED visit. At baseline, data was collected via tablet self-report surveys from medically and behaviorally stable adolescents 12-17 years old ( = 1,689) treated in 16 pediatric EDs for non-life-threatening injury, illness, or mental health condition. Follow-up surveys were completed via telephone or web-based survey. Logistic regression compared CUD diagnosis odds at one, two, or three-year follow-up between levels constituting a single-level change in baseline risk categorization on the NIAAA 2QS (nondrinker versus low-risk, low- versus moderate-risk, moderate- versus high-risk). Receiver operating characteristic curve methods examined the predictive ability of the baseline NIAAA 2QS cut points for CUD at one, two, or three-year follow-up. Adolescents with low alcohol risk had significantly higher rates of CUD versus nondrinkers (OR range: 1.94-2.76, < .0001). For low and moderate alcohol risk, there was no difference in CUD rates (OR range: 1.00-1.08). CUD rates were higher in adolescents with high alcohol risk versus moderate risk (OR range: 2.39-4.81, < .05). Even low levels of baseline alcohol use are associated with risk for a later CUD. The NIAAA 2QS is an appropriate assessment measure to gauge risk for future cannabis use.
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http://dx.doi.org/10.1080/08897077.2021.1949665DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8759759PMC
April 2022

Does Timing Matter?: Timing and Outcomes Among Early Unplanned PICU Transfers.

Hosp Pediatr 2021 08 7;11(8):896-901. Epub 2021 Jul 7.

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

Background: Many institutions track early ICU transfers (transfer from an inpatient floor to an ICU within 24 hours of admission) as a marker of quality of emergency department (ED) care. There are limited data evaluating whether patient characteristics or clinical outcomes differ on the basis of timing of ICU transfer within this 24-hour window.

Methods: We conducted a retrospective cohort study examining all patients ≤21 years old admitted to an inpatient pediatric floor from the ED and subsequently transferred to an ICU within 24 hours of hospitalization. Patient characteristics and clinical outcomes were compared on the basis of timing (0-6 hours, 6-12 hours, 12-24 hours) of ICU transfer. Outcomes assessed included receipt of critical intervention, timing of intervention with respect to transfer, type of intervention received, hospital and ICU length of stay, and mortality at 72 hours and during hospitalization.

Results: A total of 841 patients were transferred to an ICU within 24 hours from admission to a pediatric ward from the ED; 266 patients (32%) transferred within 6 hours of admission, 269 patients (32%) transferred between 6 and 12 hours, and 306 patients (36%) transferred between 12 and 24 hours. Patient characteristics did not materially differ on the basis of timing of ICU transfer, nor did clinical outcomes.

Conclusions: Among children transferred to an ICU within 24 hours of hospitalization, patient characteristics and clinical outcomes did not materially differ based on the timing of transfer relative to admission from the ED.
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http://dx.doi.org/10.1542/hpeds.2020-004978DOI Listing
August 2021
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