Publications by authors named "Michael N Levas"

25 Publications

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Injury free Coalition for Kids® forges on amid the COVID-19 pandemic.

Authors:
Michael N Levas

Inj Epidemiol 2021 Sep 13;8(Suppl 1):48. Epub 2021 Sep 13.

Department of Pediatrics, Section of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.

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http://dx.doi.org/10.1186/s40621-021-00340-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8436028PMC
September 2021

Assessing improvements in emergency department referrals to a hospital-based violence intervention program.

Inj Epidemiol 2021 Sep 13;8(Suppl 1):44. Epub 2021 Sep 13.

Pediatrics, Medical College of Wisconsin, Milwaukee, WI, 53226, USA.

Background: Youth violence is a major public health concern in the United States. Hospital-based Violence Intervention Programs (HVIPs) are integral in connecting youth sustaining interpersonal violence-related injuries to medical, mental health, and social services. At our pediatric emergency department, our baseline referral rate to the established HVIP was 32.5%. From November 2018-2019, we aimed to increase the percent of eligible patients referred to our HVIP from 32.5 to 70% for patients aged 7-18 years who present to our Level 1 emergency department/trauma center with a violent injury.

Methods: For this quality improvement project, we recorded key aspects of the referral process, such as patient eligibility, who placed referrals, and when referrals were placed in relation to the ED admission. Key stakeholders were interviewed to identify specific interventions. Our key interventions were: 1. Educating providers on eligibility requirements. 2. Encouraging nurses to enter consults at the time of admission. 3. Publishing information about program referrals in the weekly nursing newsletter. 4. Updating social workers on eligibility requirements for the HVIP. We used PDSA cycles to inform our project. Our primary outcome measure was the number of eligible patients referred to our HVIP and measures were analyzed using statistical process control charts.

Results: The HVIP-eligible population had the following demographics: 31.1% female and a mean age 14.3 ± 2.7, 82.6% assaults and 17.4% gunshot wounds. From 11/2018 to 11/2019, there were 78 referrals to the HVIP, out of 167 eligible patients. The referral rate improved from 32.5% pre-interventions to 61.1% post-interventions, showing an 88% increase.

Conclusion(s): We noted an increase in referrals to our HVIP following our interventions that centered on educating, advertising, and encouraging. Future studies will focus on analyzing other aspects of the enrollment process, such as obtaining patient consent.
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http://dx.doi.org/10.1186/s40621-021-00333-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8436440PMC
September 2021

Serologic response to antigens varies with clinical phenotype in children and young adults with Lyme disease.

J Clin Microbiol 2021 Aug 11:JCM0134421. Epub 2021 Aug 11.

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

Lyme disease is commonly diagnosed by serologic response to and related species, but the relationship between serologic targets and clinical features is unknown. We developed a multi-antigen Luminex-based panel and evaluated IgG responses in 527 children 1 to 21 years of age assessed for Lyme disease across 4 Pedi Lyme Net emergency departments, including 127 Lyme cases defined by either an erythema migrans (EM) lesion or positive C6 enzyme immunoassay followed by immunoblot and 400 patients considered clinical mimics. Of 42 antigens tested, 26 elicited specific reactivity in Lyme patients, without marked age-dependent variation. Children with single EM lesions typically lacked -specific IgG. By principal component analysis, children with early disseminated and late Lyme disease clustered separately from clinical mimics and also from each other. Neurological disease and arthritis exhibited distinct serologic responses, with OspC variants overrepresented in neurological disease and p100, BmpA, p58 and p45 overrepresented in arthritis. Machine learning identified a 3-antigen panel (VlsE_Bb, p41_Bb, OspC_Bafz) that distinguished Lyme disease from clinical mimics with a sensitivity of 86.6% (95% confidence interval [CI] 80.3-92.1) and a specificity of 95.5% (95% CI 93.4-97.4). Sensitivity was much lower in early Lyme disease (38.5%, 95% CI 15.4-69.2). Interestingly, 17 children classified as Lyme mimics had a positive 3-antigen panel, suggesting that more comprehensive serologic analysis could help refine Lyme diagnosis. In conclusion, multiplex antigen panels provide a novel approach to understanding the immune response in Lyme disease, potentially helping to facilitate accurate diagnosis and to understand differences between clinical stages.
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http://dx.doi.org/10.1128/JCM.01344-21DOI Listing
August 2021

Electrocardiogram as a Lyme Disease Screening Test.

J Pediatr 2021 Jul 12. Epub 2021 Jul 12.

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

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

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

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

Conclusions: ECG evidence of carditis, especially AV block, was associated with a diagnosis of Lyme disease. ECG evidence of carditis can be used as a diagnostic biomarker for Lyme disease to guide initial management while awaiting Lyme disease test results.
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http://dx.doi.org/10.1016/j.jpeds.2021.07.010DOI Listing
July 2021

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

Subst Abus 2021 Jul 8:1-6. Epub 2021 Jul 8.

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

Background: 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
July 2021

Validation of the Rule of 7's for Identifying Children at Low-risk for Lyme Meningitis.

Pediatr Infect Dis J 2021 04;40(4):306-309

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

Background: The Rule of 7's classifies children as low-risk for Lyme meningitis with the absence of the following: ≥7 days of headache, any cranial neuritis or ≥70% cerebrospinal fluid mononuclear cells. We sought to broadly validate this clinical prediction rule in children with meningitis undergoing evaluation for Lyme disease.

Methods: We performed a patient-level data meta-analysis of 2 prospective and 2 retrospective cohorts of children ≤21 years of age with cerebrospinal fluid pleocytosis who underwent evaluation for Lyme disease. We defined a case of Lyme meningitis with a positive 2-tier serology result (positive or equivocal first-tier enzyme immunoassay followed by a positive supplemental immunoblot). We applied the Rule of 7's and report the accuracy for the identification of Lyme meningitis.

Results: Of 721 included children with meningitis, 178 had Lyme meningitis (24.7%) and 543 had aseptic meningitis (75.3%). The pooled data from the 4 studies showed the Rule of 7's has a sensitivity of 98% [95% confidence interval (CI): 89%-100%, I2 = 71%], specificity 40% (95% CI: 30%-50%, I2 = 75%), and a negative predictive value of 100% (95% CI: 95%-100%, I2 = 55%).

Conclusions: The Rule of 7's accurately identified children with meningitis at low-risk for Lyme meningitis for whom clinicians should consider outpatient management while awaiting Lyme disease test results.
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http://dx.doi.org/10.1097/INF.0000000000003003DOI Listing
April 2021

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

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

In 2015, we founded Pedi Lyme Net, a pediatric Lyme disease research network comprising 8 emergency departments in the United States. Of 2,497 children evaluated at 1 of these sites for Lyme disease, 515 (20.6%) were infected. This network is a unique resource for evaluating new approaches for diagnosing Lyme disease in children.
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http://dx.doi.org/10.3201/eid2612.200920DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7706969PMC
December 2020

Diagnostic Performance of C6 Enzyme Immunoassay for Lyme Arthritis.

Pediatrics 2020 01 13;145(1). Epub 2019 Dec 13.

Department of Pediatrics and Emergency Medicine, Hasbro Children's Hospital and Alpert Medical School, Brown University, Providence, Rhode Island.

Objectives: In Lyme disease endemic areas, initial management of children with arthritis can be challenging because diagnostic tests take several days to return results, leading to potentially unnecessary invasive procedures. Our objective was to examine the role of the C6 peptide enzyme immunoassay (EIA) test to guide initial management.

Methods: We enrolled children with acute arthritis undergoing evaluation for Lyme disease presenting to a participating Pedi Lyme Net emergency department (2015-2019) and performed a C6 EIA test. We defined Lyme arthritis with a positive or equivocal C6 EIA test result followed by a positive supplemental immunoblot result and defined septic arthritis as a positive synovial fluid culture result or a positive blood culture result with synovial fluid pleocytosis. Otherwise, children were considered to have inflammatory arthritis. We report the sensitivity and specificity of the C6 EIA for the diagnosis of Lyme arthritis.

Results: Of the 911 study patients, 211 children (23.2%) had Lyme arthritis, 11 (1.2%) had septic arthritis, and 689 (75.6%) had other inflammatory arthritis. A positive or equivocal C6 EIA result had a sensitivity of 100% (211 out of 211; 95% confidence interval [CI]: 98.2%-100%) and specificity of 94.2% (661 out of 700; 95% CI: 92.5%-95.9%) for Lyme arthritis. None of the 250 children with a positive or equivocal C6 EIA result had septic arthritis (0%; 95% CI: 0%-1.5%), although 75 children underwent diagnostic arthrocentesis and 27 underwent operative joint washout.

Conclusions: In Lyme disease endemic areas, a C6 EIA result could be used to guide initial clinical decision-making, without misclassifying children with septic arthritis.
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http://dx.doi.org/10.1542/peds.2019-0593DOI Listing
January 2020

The Lyme Disease Polymerase Chain Reaction Test Has Low Sensitivity.

Vector Borne Zoonotic Dis 2020 04 10;20(4):310-313. Epub 2019 Dec 10.

Departments of Pediatrics and Emergency Medicine, Rhode Island Hospital, Providence, Rhode Island.

The Lyme PCR is a direct detection test, but has not been rigorously evaluated in children undergoing evaluation for acute Lyme disease. We performed a six-center prospective cohort study of children aged 1 to 21 years undergoing acute evaluation for Lyme disease. For this planned secondary analysis, we limited our cohort to children undergoing evaluation for Lyme disease who had any Lyme PCR test obtained by a treating clinician (blood, synovial fluid, or cerebrospinal fluid). We defined a case of Lyme disease with a positive two-tier Lyme disease serology: a positive or equivocal enzyme immunoassay followed by a positive supplemental immunoblot interpreted using standard criteria. We report the test characteristics of Lyme PCR for the diagnosis of Lyme disease. We identified 124 children of whom 54 (43.5%) had Lyme disease. Overall, 23 had a positive PCR test (sensitivity 41.8%; 95% confidence interval [CI] 29.7-55.0; specificity 100%, 95% CI: 94.2-100). All children with a positive Lyme PCR also had a positive two-tiered Lyme disease serology. The Lyme disease PCR test did not improve the diagnosis of children undergoing evaluation for acute Lyme disease. Given the additional costs of this low utility test, clinicians should not order Lyme PCR testing in the acute care setting.
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http://dx.doi.org/10.1089/vbz.2019.2547DOI Listing
April 2020

A minority of children diagnosed with Lyme disease recall a preceding tick bite.

Ticks Tick Borne Dis 2019 04 26;10(3):694-696. Epub 2019 Feb 26.

Division of Emergency Medicine, Rhode Island Hospital, Providence, RI, United States.

Of 1770 children undergoing emergency department evaluation for Lyme disease, 362 (20.5%) children had Lyme disease. Of those with an available tick bite history, only a minority of those with Lyme disease had a recognized tick bite (60/325; 18.5%, 95% confidence interval 14.6-23.0%). Lack of a tick bite history does not reliably exclude Lyme disease.
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http://dx.doi.org/10.1016/j.ttbdis.2019.02.015DOI Listing
April 2019

Two-Tier Lyme Disease Serology Test Results Can Vary According to the Specific First-Tier Test Used.

J Pediatric Infect Dis Soc 2020 Apr;9(2):128-133

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

Background: Variability in 2-tier Lyme disease test results according to the specific first-tier enzyme immunoassay (EIA) in children has not been examined rigorously. In this study, we compared paired results of clinical 2-tier Lyme disease tests to those of the C6 peptide EIA followed by supplemental immunoblotting (C6 2-tier test).

Methods: We performed a prospective cohort study of children aged ≥1 to ≤21 years who were undergoing evaluation for Lyme disease in the emergency department at 1 of 6 centers located in regions in which Lyme disease is endemic. The clinical first-tier test and a C6 EIA were performed on the same serum sample with supplemental immunoblotting if the first-tier test result was either positive or equivocal. We compared the results of the paired clinical and C6 2-tier Lyme disease test results using the McNemar test.

Results: Of the 1714 children enrolled, we collected a research serum sample from 1584 (92.4%). The clinical 2-tier EIA result was positive in 316 (19.9%) children, and the C6 2-tier test result was positive or equivocal in 295 (18.6%) children. The clinical and C6 2-tier test results disagreed more often than they would have by chance alone (P = .002). Of the 39 children with either a positive clinical or C6 2-tier test result alone, 2 children had an erythema migrans (EM) lesion, and 29 had symptoms compatible with early disseminated Lyme disease.

Conclusions: Two-tier Lyme disease test results differed for a substantial number of children on the basis of the specific first-tier test used. In children for whom there is a high clinical suspicion for Lyme disease and who have an initially negative test result, clinicians should consider retesting for Lyme disease.
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http://dx.doi.org/10.1093/jpids/piy133DOI Listing
April 2020

Predictive Validity of a 2-Question Alcohol Screen at 1-, 2-, and 3-Year Follow-up.

Pediatrics 2019 03 19;143(3). Epub 2019 Feb 19.

The Warren Alpert Medical School, Brown University, Providence, Rhode Island.

Background: The National Institute on Alcohol Abuse and Alcoholism (NIAAA) 2-question screen is a valid adolescent alcohol screening tool. No studies have examined if this tool predicts future alcohol problems. We conducted a study at 16 pediatric emergency departments to determine the tool's predictive validity for alcohol misuse and alcohol use disorders (AUDs).

Methods: Participants ( = 4834) completed a baseline assessment battery. A subsample of participants completed the battery at 1, 2, and 3 years follow up.

Results: Of the 2209 participants assigned to follow-up, 1611 (73%) completed a 1-year follow-up, 1591 (72%) completed a 2-year follow-up, and 1377 (62%) completed a 3-year follow-up. The differences in AUDs between baseline NIAAA screen nondrinkers and lower-risk drinkers were statistically significant at 1 year ( = .0002), 2 years ( <.0001), and 3 years ( = .0005), as were the differences between moderate- and highest-risk drinkers at 1 and 2 years ( < .0001 and = .0088, respectively) but not at 3 years ( = .0758). The best combined score for sensitivity (86.2% at 1 year, 75.6% at 2 years, and 60.0% at 3 years) and specificity (78.1% at 1 year, 79.2% at 2 years, and 80.0% at 3 years) was achieved by using "lower risk" and higher as a cutoff for the prediction of a diagnosis.

Conclusions: The NIAAA 2-question screen can accurately characterize adolescent risk for future AUDs. Future studies are needed to determine optimaluse of the screen.
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http://dx.doi.org/10.1542/peds.2018-2001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6398369PMC
March 2019

Screening for Adolescent Alcohol Use in the Emergency Department: What Does It Tell Us About Cannabis, Tobacco, and Other Drug Use?

Subst Use Misuse 2019 6;54(6):1007-1016. Epub 2019 Feb 6.

a The Warren Alpert Medical School of Brown University, Departments of Psychiatry and Human Behavior, Pediatrics, Emergency Medicine, Providence, Rhode Island, USA.

Background: The pediatric emergency department (PED) represents an opportune time for alcohol and drug screening. The National Institute of Alcohol Abuse and Alcoholism (NIAAA) recommends a two-question alcohol screen for adolescents as a predictor of alcohol and drug misuse.

Objective: A multi-site PED study was conducted to determine the association between the NIAAA two-question alcohol screen and adolescent cannabis use disorders (CUD), cigarette smoking, and lifetime use of other drugs.

Methods: Participants included 12-17-year olds (n = 4834) treated in one of 16 participating PEDs. An assessment battery, including the NIAAA two-question screen and other measures of alcohol, tobacco and drug use, was self-administered on a tablet computer.

Results: A diagnosis of CUD, lifetime tobacco use or lifetime drug use was predicted by any self-reported alcohol use in the past year, which indicates a classification of moderate risk for middle school ages and low risk for high school ages on the NIAAA two-question screen. Drinking was most strongly predictive of a CUD, somewhat weaker for lifetime tobacco use, and weakest for lifetime drug use. This same pattern held for high school and middle school students and was stronger for high school students over middle school students for all three categories. This association was also found across gender, ethnicity and race. The association was strongest for CUD for high school students, sensitivity 81.7% (95% CI, 77.0, 86.5) and specificity 70.4% (95% CI, 68.6, 72.1). Conclusions/Importance: A single question about past year alcohol use can provide valuable information about other substance use, particularly marijuana.
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http://dx.doi.org/10.1080/10826084.2018.1558251DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6476662PMC
January 2020

Higher C6 enzyme immunoassay index values correlate with a diagnosis of noncutaneous Lyme disease.

Diagn Microbiol Infect Dis 2019 Jun 8;94(2):160-164. Epub 2018 Dec 8.

Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA.

The correlation between the Food and Drug Administration-cleared C6 enzyme immunoassay (EIA) C6 index values and a diagnosis of Lyme disease has not been examined. We used pooled patient-level data from 5 studies of adults and children with Lyme disease and control subjects who were tested with the C6 EIA. We constructed a receiver operating characteristic curve using regression clustered by study and measured the area under the curve (AUC) to examine the accuracy of the C6 index values in differentiating between patients with noncutaneous Lyme disease and control subjects. In the 4821 included patients, the C6 index value had excellent ability to distinguish between patients with noncutaneous Lyme disease and control subjects [AUC 0.99; 95% confidence interval (CI) 0.99-1.00]. An index value cut point of ≥3.0 had a sensitivity of 90.9% (95% CI, 87.8-93.3) and specificity of 99.0% (95% CI, 98.6-99.2%) for Lyme disease.
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http://dx.doi.org/10.1016/j.diagmicrobio.2018.12.001DOI Listing
June 2019

Positive 2-Tiered Lyme Disease Serology is Uncommon in Asymptomatic Children Living in Endemic Areas of the United States.

Pediatr Infect Dis J 2019 05;38(5):e105-e107

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

Knowing the frequency of positive Lyme disease serology in children without signs of infection facilitates test interpretation. Of 315 asymptomatic children from Lyme disease endemic regions, 32 had positive or equivocal C6 enzyme-linked immunoassays, but only 5 had positive IgG or IgM supplemental immunoblots (1.6%; 95% confidence interval: 0.7%-3.7%).
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http://dx.doi.org/10.1097/INF.0000000000002157DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6355375PMC
May 2019

Integrating Population Health Data on Violence Into the Emergency Department: A Feasibility and Implementation Study.

J Trauma Nurs 2018 May/Jun;25(3):149-158

Department of Pediatrics, Section of Emergency Medicine (Dr Levas), Comprehensive Injury Center (Drs Hernandez-Meier and Hargarten and Ms Kohlbeck), and Department of Emergency Medicine (Dr Hargarten), Medical College of Wisconsin, Milwaukee; and Children's Hospital of Wisconsin, Milwaukee (Dr Levas and Ms Piotrowski).

Geocoded emergency department (ED) data have allowed for the development and evaluation of novel interventions for the prevention of violence in cities outside of the United States. First implemented in Cardiff, United Kingdom, collection of these data provides public health agencies, community organizations, and law enforcement with place-based information on assaults. The purpose of this study was to assess the feasibility of translating this model within the electronic medical record (EMR) in the United States. A new EMR module based on the Cardiff Model was developed and integrated into the existing ED EMR. Data were collected for all patients reporting an assaultive injury upon arrival to the ED. Emergency department nurses were subsequently recruited to participate in 2 surveys and a focus group to evaluate the implementation and to provide qualitative feedback to enhance integration. Nurses completed EMR questions in 98.2% of patients reporting to the ED over the study period. More than 90% of survey respondents were satisfied with their participation, and most felt that the questions were useful for clinical care (79/70%), were integrated well into workflow (89/90%), and were congruent with the ED and hospital goals and mission (93/98%). Focus group themes centered on ED culture, external factors, and internal workflow. It is feasible to implement place-based, assault-related injury-specific questions into the EMR with minimal disruption of workflow and triage times. Nurses, as key members of the ED team, are receptive to participating in the collection of population health data that may inform community violence prevention activities.
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http://dx.doi.org/10.1097/JTN.0000000000000361DOI Listing
October 2018

Youth Victims of Violence Report Worse Quality of Life Than Youth With Chronic Diseases.

Pediatr Emerg Care 2020 Feb;36(2):e72-e78

Section of Hematology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI.

Objectives: Measuring health-related quality of life (HRQOL) provides the patient's perspective of his/her well-being and offers a unique outcome measure to demonstrate the impact of violence on the victim. To date, no study has described HRQOL in youth victims of violence in the United States. The purpose of this study was to describe HRQOL in youth victims of violence as compared with healthy youth and youth with chronic disease.

Methods: We conducted an exploratory cross-sectional study of the HRQOL of victims of violence aged 8 to 18 years. Descriptive statistics were reported for participant and injury demographics. One sample t tests were used to compare the sample population's HRQOL to known HRQOL of healthy populations and specific disease populations.

Results: Fifty-eight victims of violence participated in the study. Youth victims of violence had significantly worse mean HRQOL scores (mean, 71.4) compared with healthy youth in overall functioning (mean, 83.9), P < 0.001. Youth victims of violence reported worse psychosocial (mean, 67.6), emotional (mean, 62.9), and school (mean, 63.8) functioning than youth with obesity (mean, 72.1, 68.6, 75.0, respectively) and cancer (mean, 72.1, 72.2, 68.3, respectively). Mean Patient-Reported Outcomes Measurement Information System T scores for youth victims of violence were significantly worse in anxiety (T = 51.9) and depression (T = 52.4) compared with youth with obesity (T = 48.3, 49.2), cancer (T = 47.7, 47.6), and sickle cell disease (T = 43, 44).

Conclusions: Youth victims of violence suffer significant impairment in HRQOL compared with healthy populations and youth with specific disease burdens. Future studies into violence prevention effectiveness should use HRQOL as a comparative outcome measure to better tailor post injury management and interventions.
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http://dx.doi.org/10.1097/PEC.0000000000001423DOI Listing
February 2020

Accuracy of Clinician Suspicion of Lyme Disease in the Emergency Department.

Pediatrics 2017 Dec;140(6)

Departments of Pediatrics and Emergency Medicine, Brown University and Rhode Island Hospital, Providence, Rhode Island.

Background: To make initial management decisions, clinicians must estimate the probability of Lyme disease before diagnostic test results are available. Our objective was to examine the accuracy of clinician suspicion for Lyme disease in children undergoing evaluation for Lyme disease.

Methods: We assembled a prospective cohort of children aged 1 to 21 years who were evaluated for Lyme disease at 1 of the 5 participating emergency departments. Treating physicians were asked to estimate the probability of Lyme disease (on a 10-point scale). We defined a Lyme disease case as a patient with an erythema migrans lesion or positive 2-tiered serology results in a patient with compatible symptoms. We calculated the area under the curve for the receiver operating curve as a measure of the ability of clinician suspicion to diagnose Lyme disease.

Results: We enrolled 1021 children with a median age of 9 years (interquartile range, 5-13 years). Of these, 238 (23%) had Lyme disease. Clinician suspicion had a minimal ability to discriminate between children with and without Lyme disease: area under the curve, 0.75 (95% confidence interval, 0.71-0.79). Of the 554 children who the treating clinicians thought were unlikely to have Lyme disease (score 1-3), 65 (12%) had Lyme disease, and of the 127 children who the treating clinicians thought were very likely to have Lyme disease (score 8-10), 39 (31%) did not have Lyme disease.

Conclusions: Because clinician suspicion had only minimal accuracy for the diagnosis of Lyme disease, laboratory confirmation is required to avoid both under- and overdiagnosis.
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http://dx.doi.org/10.1542/peds.2017-1975DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5703778PMC
December 2017

Methodology and Demographics of a Brief Adolescent Alcohol Screen Validation Study.

Pediatr Emerg Care 2019 Nov;35(11):737-744

From the Rhode Island Hospital.

Objective: The aim of this study was to determine the psychometric properties of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) 2-question alcohol screen within 16 Pediatric Emergency Care Applied Research Network pediatric emergency departments. This article describes the study methodology, sample characteristics, and baseline outcomes of the NIAAA 2-question screen.

Methods: Participants included 12- to 17-year-olds treated in one of the participating pediatric emergency departments across the United States. After enrollment, a criterion assessment battery including the NIAAA 2-question screen and other measures of alcohol, drug use, and risk behavior was self-administered by participants on a tablet computer. Two subsamples were derived from the sample. The first subsample was readministered the NIAAA 2-question screen 1 week after their initial visit to assess test-retest reliability. The second subsample is being reassessed at 12 and 24 months to examine predictive validity of the NIAAA 2-question screen.

Results: There were 4834 participants enrolled into the study who completed baseline assessments. Participants were equally distributed across sex and age. Forty-six percent of the participants identified as white, and 26% identified as black. Approximately one quarter identified as Hispanic. Using the NIAAA 2-question screen algorithm, approximately 8% were classified as low risk, 12% were classified as moderate risk, and 4% were classified as highest risk. Alcohol use was less likely to be reported by black participants, non-Hispanic participants, and those younger than 16 years.

Discussion: This study successfully recruited a large, demographically diverse sample to establish rates of the NIAAA screen risk categories across age, sex, ethnicity, and race within pediatric emergency departments.
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http://dx.doi.org/10.1097/PEC.0000000000001221DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5752626PMC
November 2019

Improvement in quality of life among violently injured youth after a brief intervention.

J Trauma Acute Care Surg 2016 10;81(4 Suppl 1):S61-6

Pediatrics, Section of Emergency Medicine (M.N.L., M.M.L.), Medical College of Wisconsin, Milwaukee, WI, Medical College of Wisconsin (E.A.B.), Milwaukee, WI; and Section of Hematology (J.P.), Medical College of Wisconsin, Milwaukee, WI.

Background: Youth directly exposed to violence are at risk for experiencing elevated rates of emotional and behavioral problems, revictimization, and becoming future perpetrators of violence. Violence intervention and prevention programs throughout the country attempt to alleviate some of this burden. To date, outcomes have been positive but largely qualitative. Patient-reported outcomes offer objective measures to evaluate well-being in youth victimization. Our primary aim was to use objective patient-reported quantitative measures to assess the change in health-related quality-of-life (HRQOL) scores of youth who attended a violence intervention summer camp. This is the first study to evaluate such measures in youth victims of violence during an intervention.

Methods: Eight- to 18-year-old youth who attended a violence intervention summer camp in a Midwest urban city over a two-year period participated in a HRQOL survey at baseline and at the end of programming (6 weeks). Consented youth used an electronic platform to answer validated HRQOL measures. Mean differences in scores from baseline to six weeks were calculated and reported.

Results: A total of 64 youth were recruited and consented to the study. Average change in scores improved in most HRQOL domains with the largest change in scores observed in school functioning (mean diff, +5.00), emotional functioning (mean diff, +5.26), and patient anxiety (mean diff, +3.04). Only participant anger scored worse following the intervention (mean diff, -2.26).

Conclusion: A community-based summer program hosting violently injured youth resulted in overall improved HRQOL. This was especially significant in the school, anxiety, and emotional domains. Future evaluation into the effectiveness of youth programs should measure HRQOL to identify at-risk participants and to measure effectiveness.

Level Of Evidence: Therapeutic/care management study, level III.
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http://dx.doi.org/10.1097/TA.0000000000001061DOI Listing
October 2016

A Randomized Clinical Trial of Jet-Injected Lidocaine to Reduce Venipuncture Pain for Young Children.

Ann Emerg Med 2015 Nov 29;66(5):466-74. Epub 2015 Apr 29.

Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI.

Study Objective: The J-Tip (National Medical Products Inc, Irvine, CA) uses air instead of a needle to push lidocaine into the skin. To our knowledge, no studies have investigated its use for venipuncture in young children. We determine whether the J-Tip decreased venipuncture pain in young children compared with vapocoolant spray.

Methods: Children aged 1 to 6 years were randomized into 3 groups: intervention (J-Tip), control (vapocoolant spray), and sham (vapocoolant spray and pop of an empty J-Tip). The procedure was videotaped and scored with the Face, Legs, Activity, Cry and Consolability (FLACC) tool at 3 points; baseline, before approach; device, at J-Tip deployment; and at venipuncture. The FLACC tool was scored 0 (none) to 10 (severe). Comparisons of pain scores over time were made with the generalized estimating equation. Venipuncture success and adverse effects were assessed and compared with χ(2).

Results: Two hundred five children enrolled: intervention 96, control 53, and sham 56. There were no between-group differences in baseline characteristics. There was no mean change in pain scores from device to venipuncture in the intervention group (0.26; 95% confidence interval [CI] -0.31 to 0.82), but there was an increase in pain in the control (2.82; 95% CI 1.91 to 3.74) and sham (1.68; 95% CI 0.83 to 2.52) groups. This change was greater for the control and sham compared to the intervention group. There was no difference in venipuncture success between groups. No severe adverse events occurred. Minor adverse events were the same between groups.

Conclusion: Use of the J-Tip for children aged 1 to 6 years reduced venipuncture pain compared with vapocoolant spray or sham treatment.
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http://dx.doi.org/10.1016/j.annemergmed.2015.04.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4863077PMC
November 2015

Health literacy affects likelihood of radiology testing in the pediatric emergency department.

J Pediatr 2015 Apr 13;166(4):1037-41.e1. Epub 2015 Jan 13.

Department of Pediatrics, Section of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI.

Objective: To test the hypothesis that the effect of race/ethnicity on decreased radiologic testing in the pediatric emergency department (ED) varies by caregiver health literacy.

Study Design: This was a secondary analysis of a cross-sectional study of caregivers accompanying children ≤ 12 years to a pediatric ED. Caregiver health literacy was measured using the Newest Vital Sign. A blinded chart review determined whether radiologic testing was utilized. Bivariate and multivariate analyses, adjusting for ED triage level, child insurance, and chronic illness were used to determine the relationship between race/ethnicity, health literacy, and radiologic testing. Stratified analyses by caregiver health literacy were conducted.

Results: Five hundred four caregivers participated; the median age was 31 years, 47% were white, 37% black, 10% Hispanic, and 49% had low health literacy. Black race and low health literacy were associated with less radiologic testing (P < .01). In stratified analysis, minority race was associated with less radiologic testing only if a caregiver had low health literacy (aOR 0.5; 95% CI 0.3-0.9), and no difference existed in those with adequate health literacy (aOR 0.7; 95% CI 0.4-1.3).

Conclusions: Caregiver low health literacy modifies whether minority race/ethnicity is associated with decreased radiologic testing, with only children of minority caregivers with low health literacy receiving fewer radiologic studies. Future interventions to eliminate disparities in healthcare resource utilization should consider health literacy as a mutable factor.
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http://dx.doi.org/10.1016/j.jpeds.2014.12.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4380861PMC
April 2015

Effect of Hispanic ethnicity and language barriers on appendiceal perforation rates and imaging in children.

J Pediatr 2014 Jun 22;164(6):1286-91.e2. Epub 2014 Feb 22.

Department of Pediatric Emergency Medicine, Children's Hospital and Clinics of Minnesota, Minneapolis, MN.

Objective: To determine the association between Hispanic ethnicity and limited English proficiency (LEP) and the rates of appendiceal perforation and advanced radiologic imaging (computed tomography and ultrasound) in children with abdominal pain.

Study Design: We performed a secondary analysis of a prospective, cross-sectional, multicenter study of children aged 3-18 years presenting with abdominal pain concerning for appendicitis between March 2009 and April 2010 at 10 tertiary care pediatric emergency departments in the US. Appendiceal perforation and advanced imaging rates were compared between ethnic and language proficiency groups using simple and multivariate regression models.

Results: Of 2590 patients enrolled, 1001 (38%) had appendicitis, including 36% of non-Hispanics and 44% of Hispanics. In multivariate modeling, Hispanics with LEP had a significantly greater odds of appendiceal perforation (OR, 1.44; 95% CI, 1.20-1.74). Hispanics with LEP with appendiceal perforation of moderate clinical severity were less likely to undergo advanced imaging compared with English-speaking non-Hispanics (OR, 0.64; 95% CI, 0.43-0.95).

Conclusion: Hispanic ethnicity with LEP is an important risk factor for appendiceal perforation in pediatric patients brought to the emergency department with possible appendicitis. Among patients with moderate clinical severity, Hispanic ethnicity with LEP appears to be associated with lower imaging rates. This effect of English proficiency and Hispanic ethnicity warrants further investigation to understand and overcome barriers, which may lead to increased appendiceal perforation rates and differential diagnostic evaluation.
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http://dx.doi.org/10.1016/j.jpeds.2014.01.006DOI Listing
June 2014

Dexamethasone for acute asthma exacerbations in children: a meta-analysis.

Pediatrics 2014 Mar 10;133(3):493-9. Epub 2014 Feb 10.

Departments of Pediatrics, and.

Background And Objective: Dexamethasone has been proposed as an equivalent therapy to prednisone/prednisolone for acute asthma exacerbations in pediatric patients. Although multiple small trials exist, clear consensus data are lacking. This systematic review and meta-analysis aimed to determine whether intramuscular or oral dexamethasone is equivalent or superior to a 5-day course of oral prednisone or prednisolone. The primary outcome of interest was return visits or hospital readmissions.

Methods: A search of PubMed (Medline) through October 19, 2013, by using the keywords dexamethasone or decadron and asthma or status asthmaticus identified potential studies. Six randomized controlled trials in the emergency department of children ≤18 years of age comparing dexamethasone with prednisone/prednisolone for the treatment of acute asthma exacerbations were included. Data were abstracted by 4 authors and verified by a second author. Two reviewers evaluated study quality independently and interrater agreement was assessed.

Results: There was no difference in relative risk (RR) of relapse between the 2 groups at any time point (5 days RR 0.90, 95% confidence interval [CI] 0.46-1.78, Q = 1.86, df = 3, I2 = 0.0%, 10-14 days RR 1.14, 95% CI 0.77-1.67, Q = 0.84, df = 2, I2 = 0.0%, or 30 days RR 1.20, 95% CI 0.03-56.93). Patients who received dexamethasone were less likely to experience vomiting in either the emergency department (RR 0.29, 95% CI 0.12-0.69, Q = 3.78, df = 3, I2 = 20.7%) or at home (RR 0.32, 95% CI 0.14-0.74, Q = 2.09, df = 2, I2 = 4.2%).

Conclusions: Practitioners should consider single or 2-dose regimens of dexamethasone as a viable alternative to a 5-day course of prednisone/prednisolone.
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http://dx.doi.org/10.1542/peds.2013-2273DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3934336PMC
March 2014

Effects of the limited English proficiency of parents on hospital length of stay and home health care referral for their home health care-eligible children with infections.

Arch Pediatr Adolesc Med 2011 Sep 2;165(9):831-6. Epub 2011 May 2.

Division of Emergency Medical Services, Children's Mercy Hospital and Clinics, Kansas City, MO, USA.

Objective: To examine the relationship of limited English proficiency of parents to hospital length of stay (LOS) and to home health care referral for their home health care eligible-children with infections.

Design: A retrospective cohort study.

Setting: Regional urban pediatric hospital.

Participants: A total of 1257 children aged 0 to 18 years admitted for infection requiring prolonged antibiotic treatment during the period from January 1, 2000, to December 31, 2008.

Main Exposures: The cohort of patients were defined by primary caregivers who had to report on their English proficiency.

Main Outcome Measures: Number of home health care referrals and LOS.

Results: The median LOS for the study group was 4.1 days (interquartile range, 2.6-7.2 days). Limited English proficiency was associated with longer LOS (adjusted relative LOS, 1.6 [95% confidence interval, 1.1-2.3]), indicating that patients who had caregivers with limited English proficiency stayed 60% longer, on average, than patients with English-proficient primary caregivers. Insurance status (Medicaid), absence of a primary care provider, home health care utilization, and presence of comorbidity were also associated with longer LOS. Limited English proficiency was associated with a significantly decreased number of home health care referrals (odds ratio, 0.2 [95% confidence interval, 0.04-0.8]). Patient insurance (Medicaid) and presence of any comorbidity were also significantly associated with decreased number of home health care referrals.

Conclusions: Among pediatric inpatients with infections requiring long-term antibiotics, a primary caregiver with limited English proficiency was identified as an important independent risk factor for both increased LOS and decreased number of home health care referrals.
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http://dx.doi.org/10.1001/archpediatrics.2011.61DOI Listing
September 2011
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