Publications by authors named "Rakesh D Mistry"

108 Publications

Predictors of Invasive Herpes Simplex Virus Infection in Young Infants.

Pediatrics 2021 Sep;148(3)

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

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

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

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

Conclusions: A novel HSV risk score identified infants at extremely low risk for invasive HSV who may not require routine testing or empirical treatment.
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http://dx.doi.org/10.1542/peds.2021-050052DOI Listing
September 2021

Anaphylaxis knowledge gaps and future research priorities: A consensus report.

J Allergy Clin Immunol 2021 Aug 12. Epub 2021 Aug 12.

Division of Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York, NY.

Background: Despite a better understanding of the epidemiology, pathogenesis, and management of patients with anaphylaxis, there remain knowledge gaps. Enumerating and prioritizing these gaps would allow limited scientific resources to be directed more effectively.

Objective: We sought to systematically describe and appraise anaphylaxis knowledge gaps and future research priorities based on their potential impact and feasibility.

Methods: We convened a 25-member multidisciplinary panel of anaphylaxis experts. Panelists formulated knowledge gaps/research priority statements in an anonymous electronic survey. Four anaphylaxis themed writing groups were formed to refine statements: (1) Population Science, (2) Basic and Translational Sciences, (3) Emergency Department Care/Acute Management, and (4) Long-Term Management Strategies and Prevention. Revised statements were incorporated into an anonymous electronic survey, and panelists were asked to rate the impact and feasibility of addressing statements on a continuous 0 to 100 scale.

Results: The panel generated 98 statements across the 4 anaphylaxis themes: Population Science (29), Basic and Translational Sciences (27), Emergency Department Care/Acute Management (24), and Long-Term Management Strategies and Prevention (18). Median scores for impact and feasibility ranged from 50.0 to 95.0 and from 40.0 to 90.0, respectively. Key statements based on median rating for impact/feasibility included the need to refine anaphylaxis diagnostic criteria, identify reliable diagnostic, predictive, and prognostic anaphylaxis bioassays, develop clinical prediction models to standardize postanaphylaxis observation periods and hospitalization criteria, and determine immunotherapy best practices.

Conclusions: We identified and systematically appraised anaphylaxis knowledge gaps and future research priorities. This study reinforces the need to harmonize scientific pursuits to optimize the outcomes of patients with and at risk of anaphylaxis.
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http://dx.doi.org/10.1016/j.jaci.2021.07.035DOI Listing
August 2021

Association between secondhand marijuana smoke and respiratory infections in children.

Pediatr Res 2021 Jul 29. Epub 2021 Jul 29.

Children's Hospital Colorado, University of Colorado Denver Anschutz Medical Campus, Aurora, CO, USA.

Background: Little is known about the effects of secondhand marijuana smoke on children. We aimed to determine caregiver marijuana use prevalence and evaluate any association between secondhand marijuana smoke, childhood emergency department (ED) or urgent care (UC) visitation, and several tobacco-related illnesses: otitis media, viral respiratory infections (VRIs), and asthma exacerbations.

Methods: This study was a cross-sectional, convenience sample survey of 1500 subjects presenting to a pediatric ED. The inclusion criteria were as follows: caregivers aged 21-85 years, English- or Spanish-speaking. The exclusion criteria were as follows: children who were critically ill, medically complex, over 11 years old, or using medical marijuana.

Results: Of 1500 caregivers, 158 (10.5%) reported smoking marijuana and 294 (19.6%) reported smoking tobacco. Using negative-binomial regression, we estimated rates of reported ED/UC visits and specific illnesses among children with marijuana exposure and those with tobacco exposure, compared to unexposed children. Caregivers who used marijuana reported an increased rate of VRIs in their children (1.31 episodes/year) compared to caregivers with no marijuana use (1.04 episodes/year) (p = 0.02).

Conclusions: Our cohort did not report any difference with ED/UC visits, otitis media episodes, or asthma exacerbations, regardless of smoke exposure. However, caregivers of children with secondhand marijuana smoke exposure reported increased VRIs compared to children with no smoke exposure.

Impact: Approximately 10% of caregivers in our study were regular users of marijuana. Prior studies have shown that secondhand tobacco smoke exposure is associated with negative health outcomes in children, including increased ED utilization and respiratory illnesses. Prior studies have shown primary marijuana use is linked to negative health outcomes in adults and adolescents, including increased ED utilization and respiratory illnesses. Our study reveals an association between secondhand marijuana smoke exposure and increased VRIs in children. Our study did not find an association between secondhand marijuana smoke exposure and increased ED or UC visitation in children.
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http://dx.doi.org/10.1038/s41390-021-01641-0DOI Listing
July 2021

The Pediatric Emergency Research Network (PERN): A decade of global research cooperation in paediatric emergency care.

Emerg Med Australas 2021 Oct 3;33(5):900-910. Epub 2021 Jul 3.

Pediatric Emergency Care Applied Research Network (PECARN).

Objectives: The Pediatric Emergency Research Network (PERN) was launched in 2009 with the intent for existing national and regional research networks in paediatric emergency care to organise globally for the conduct of collaborative research across networks.

Methods: PERN has grown from five to eight member networks over the past decade. With an executive committee comprising representatives from all member networks, PERN plays a supportive and collaborative rather than governing role. The full impact of PERN's facilitation of international collaborative research, although somewhat difficult to quantify empirically, can be measured indirectly by the observed growth of the field, the nature of the increasingly challenging research questions now being addressed and the collective capacity to generate and implement new knowledge in treating acutely ill and injured children.

Results: Beginning as a pandemic response studying H1N1 influenza risk factors in children, PERN research has progressed to multiple observational studies and ongoing global randomised controlled trials (RCTs). As a recent example, PERN has developed sufficient network infrastructure to enable the rapid initiation of a prospective observational study in response to the current COVID-19 pandemic.

Conclusions: Following its success with developing global research, the PERN goal now is to promote the implementation of scientific advances into everyday clinical practice by: (i) expanding the capacity for global RCTs; (ii) deepening the focus on implementation science; (iii) increasing attention to healthcare disparities; and (iv) expanding PERN's reach into resource-restricted regions. Through these actions, PERN aims to meet the needs of acutely ill and injured children throughout the world.
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http://dx.doi.org/10.1111/1742-6723.13801DOI Listing
October 2021

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

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

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

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

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

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

Conclusion: PEM fellows were not consistently aware of resources available to support research training. To better support PEM fellows' research training, many programs may need to expand mentorship and increase fellows' awareness of local and external resources and opportunities.
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http://dx.doi.org/10.1002/aet2.10585DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8171771PMC
July 2021

The Pediatric Emergency Research Network: A Decade of Global Research Cooperation in Pediatric Emergency Care.

Pediatr Emerg Care 2021 07;37(7):389-396

Objectives: The Pediatric Emergency Research Network (PERN) was launched in 2009 with the intent for existing national and regional research networks in pediatric emergency care to organize globally for the conduct of collaborative research across networks.

Methods: The Pediatric Emergency Research Network has grown from 5- to 8-member networks over the past decade. With an executive committee comprising representatives from all member networks, PERN plays a supportive and collaborative rather than governing role. The full impact of PERN's facilitation of international collaborative research, although somewhat difficult to quantify empirically, can be measured indirectly by the observed growth of the field, the nature of the increasingly challenging research questions now being addressed, and the collective capacity to generate and implement new knowledge in treating acutely ill and injured children.

Results: Beginning as a pandemic response with a high-quality retrospective case-controlled study of H1N1 influenza risk factors, PERN research has progressed to multiple observational studies and ongoing global randomized controlled trials. As a recent example, PERN has developed sufficient network infrastructure to enable the rapid initiation of a prospective observational study in response to the current coronavirus disease 2019 pandemic. In light of the ongoing need for translation of research knowledge into equitable clinical practice and to promote health equity, PERN is committed to a coordinated international effort to increase the uptake of evidence-based management of common and treatable acute conditions in all emergency department settings.

Conclusions: The Pediatric Emergency Research Network's successes with global research, measured by prospective observational and interventional studies, mean that the network can now move to improve its ability to promote the implementation of scientific advances into everyday clinical practice. Achieving this goal will involve focus in 4 areas: (1) expanding the capacity for global randomized controlled trials; (2) deepening the focus on implementation science; (3) increasing attention to healthcare disparities and their origins, with growing momentum toward equity; and (4) expanding PERN's global reach through addition of sites and networks from resource-restricted regions. Through these actions, PERN will be able to build on successes to face the challenges ahead and meet the needs of acutely ill and injured children throughout the world.
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http://dx.doi.org/10.1097/PEC.0000000000002466DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8244934PMC
July 2021

Facilitators and barriers for parental consent to pediatric emergency research.

Pediatr Res 2021 Jun 4. Epub 2021 Jun 4.

Department of Pediatrics, Section of Emergency Medicine, University of Colorado Denver, Aurora, CO, USA.

Background: Obtaining informed consent for clinical research in the pediatric emergency department (ED) is challenging. Our objective was to understand the factors that influence parental consent for ED studies.

Methods: This was a cross-sectional survey assessing parents' willingness to enroll their children into an ED research study. Parents reporting a willingness to enroll in ED studies were presented with two hypothetical scenarios, a low-risk and a high-risk study, and then asked about decision influencers affecting consent. Parents expressing a lack of willingness to enroll were asked which decision influencers impacted their consent decision.

Results: Among 118 parents, 90 (76%) stated they would be willing to enroll their child into an ED study; of these, 86 (96%) would consent for a low-risk study and 54 (60%) would consent for a high-risk study. Caucasian parents, and those with previous research exposure, were more likely to report willingness to participate. Those who would consent to the high-risk study cited "benefits that research would provide to future children" most strongly influenced their decision to agree.

Conclusions: ED investigators should highlight the benefits for future children and inquire about parents' previous exposure to research to enhance ED research enrollment. Barriers to consent in non-Caucasian families should be further investigated.

Impact: Obtaining consent for pediatric emergency research is challenging and this study identified factors influencing parental consent for research in EDs. Benefits for future children and parents' previous research experience were two of the most influential factors in parents' willingness to consent to ED research studies. These findings will help to improve enrollment in ED research studies and better our understanding of how to promote the health and well-being of pediatric patients.
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http://dx.doi.org/10.1038/s41390-021-01600-9DOI Listing
June 2021

Effect of Rapid Respiratory Virus Testing on Antibiotic Prescribing Among Children Presenting to the Emergency Department With Acute Respiratory Illness: A Randomized Clinical Trial.

JAMA Netw Open 2021 Jun 1;4(6):e2111836. Epub 2021 Jun 1.

Department of Pediatrics (Infectious Diseases and Epidemiology), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora.

Importance: There is high usage of antibiotics in the emergency department (ED) for children with acute respiratory illnesses. Studies have reported decreased antibiotic use among inpatients with rapid respiratory pathogen (RRP) testing.

Objective: To determine whether RRP testing leads to decreased antibiotic use and health care use among children with influenzalike illness (ILI) in an ED.

Design, Setting, And Participants: A randomized clinical trial among children aged 1 month to 18 years presenting to an ED with ILI from December 1, 2018, to November 30, 2019, was conducted. Data were analyzed March 23, 2020, to April 2, 2021. All children received a nasopharyngeal swab for RRP testing and were randomized 1:1 to the intervention group or control group (results not given, routine clinical care). Results were available in 45 minutes. Intention-to-treat analyses and modified intention-to-treat (clinician knows results) analyses were conducted using multivariable Poisson regression.

Interventions: Rapid respiratory pathogen test results given to clinicians.

Main Outcomes And Measures: Antibiotic prescribing was the primary outcome; influenza antiviral prescribing, ED length of stay, hospital admission, and recurrent health care visits were the secondary outcomes.

Results: Among 931 ED visits (intervention group, 452 children group and control group, 456 children after exclusion of those not meeting criteria or protocol violations), a total of 795 RRP test results (85%) were positive. The median age of the children was 2.1 years (interquartile range, 0.9-5.6 years); 509 (56%) were boys. Most children (478 [53%]) were Hispanic, 688 children (76%) received government insurance, and 314 (35%) had a high-risk medical condition. In the intention-to-treat intervention group, children were more likely to receive antibiotics (relative risk [RR], 1.3; 95% CI, 1.0-1.7), with no significant differences in antiviral prescribing, medical visits, and hospitalization. In inverse propensity-weighted modified intention-to-treat analyses, children with test results known were more likely to receive antivirals (RR, 2.6; 95% CI, 1.6-4.5) and be hospitalized (RR, 1.8; 95% CI, 1.4-2.5); there was no significant difference in antibiotic prescribing (RR, 1.1; 95% CI, 0.9-1.4).

Conclusions And Relevance: The use of RRP testing in the ED for ILI did not decrease antibiotic prescribing in this randomized clinical trial. There is a limited role for RRP pathogen testing in children in this setting.

Trial Registration: ClinicalTrials.gov Identifier: NCT03756753.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.11836DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8178728PMC
June 2021

Maintenance of Certification Pediatrics: Pediatric Emergency Medicine (PEM): The New Part 3 Maintenance of Certification Assessment Option.

Pediatr Emerg Care 2021 06;37(6):329-333

The American Board of Pediatrics, Chapel Hill, NC.

Abstract: Starting in 2022, the American Board of Pediatrics will launch the Maintenance of Certification Assessment for Pediatrics: Pediatric Emergency Medicine (MOCA-Peds: PEM) longitudinal assessment, which will provide an at-home alternative to the point-in-time examination. This longitudinal assessment will help engage PEM physicians participating in continuing certification in a more flexible and continuous lifelong, self-directed learning process while still providing a summative assessment of their knowledge. This commentary provides background information on MOCA-Peds and an introduction to MOCA-Peds: PEM and how it gives the PEM physician another option to participate in continuing certification.
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http://dx.doi.org/10.1097/PEC.0000000000002451DOI Listing
June 2021

Maintenance of Certification Pediatrics: Pediatric Emergency Medicine (PEM): The New Part 3 Maintenance of Certification Assessment Option.

Pediatr Emerg Care 2021 06;37(6):329-333

The American Board of Pediatrics, Chapel Hill, NC.

Abstract: Starting in 2022, the American Board of Pediatrics will launch the Maintenance of Certification Assessment for Pediatrics: Pediatric Emergency Medicine (MOCA-Peds: PEM) longitudinal assessment, which will provide an at-home alternative to the point-in-time examination. This longitudinal assessment will help engage PEM physicians participating in continuing certification in a more flexible and continuous lifelong, self-directed learning process while still providing a summative assessment of their knowledge. This commentary provides background information on MOCA-Peds and an introduction to MOCA-Peds: PEM and how it gives the PEM physician another option to participate in continuing certification.
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http://dx.doi.org/10.1097/PEC.0000000000002451DOI Listing
June 2021

Severity grading system for acute allergic reactions: A multidisciplinary Delphi study.

J Allergy Clin Immunol 2021 Jul 19;148(1):173-181. Epub 2021 Jan 19.

Division of Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York, NY.

Background: There is no widely adopted severity grading system for acute allergic reactions, including anaphylactic and nonanaphylactic reactions, thus limiting the ability to optimize and standardize management practices and advance research.

Objective: The aim of this study was to develop a severity grading system for acute allergic reactions for use in clinical care and research.

Methods: From May to September 2020, we convened a 21-member multidisciplinary panel of allergy and emergency care experts; 9 members formed a writing group to critically appraise and assess the strengths and limitations of prior severity grading systems and develop the structure and content for an optimal severity grading system. The entire study panel then revised the grading system and sought consensus by utilizing Delphi methodology.

Results: The writing group recommended that an optimal grading system encompass the severity of acute allergic reactions on a continuum from mild allergic reactions to anaphylactic shock. Additionally, the severity grading system must be able to discriminate between clinically important differences in reaction severity to be relevant in research while also being intuitive and straightforward to apply in clinical care. Consensus was reached for all elements of the proposed severity grading system.

Conclusion: We developed a consensus severity grading system for acute allergic reactions, including anaphylactic and nonanaphylactic reactions. Successful international validation, refinement, dissemination, and application of the grading system will improve communication among providers and patients about the severity of allergic reactions and will help advance future research.
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http://dx.doi.org/10.1016/j.jaci.2021.01.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8273088PMC
July 2021

Exposure and confidence across critical airway procedures in pediatric emergency medicine: An international survey study.

Am J Emerg Med 2021 04 31;42:70-77. Epub 2020 Dec 31.

Paediatric Research in Emergency Departments International Collaborative (PREDICT), Australia and New Zealand; Paediatric Emergency Department, Monash Medical Centre, Melbourne, Australia; Department of Paediatrics, School of Clinical Sciences at Monash Health, Monash University, Australia.

Background: Airway management procedures are critical for emergency medicine (EM) physicians, but rarely performed skills in pediatric patients. Worldwide experience with respect to frequency and confidence in performing airway management skills has not been previously described.

Objectives: Our aims were 1) to determine the frequency with which emergency medicine physicians perform airway procedures including: bag-mask ventilation (BMV), endotracheal intubation (ETI), laryngeal mask airway (LMA) insertion, tracheostomy tube change (TTC), and surgical airways, and 2) to investigate predictors of procedural confidence regarding advanced airway management in children.

Methods: A web-based survey of senior emergency physicians was distributed through the six research networks associated with Pediatric Emergency Research Network (PERN). Senior physician was defined as anyone working without direct supervision at any point in a 24-h cycle. Physicians were queried regarding their most recent clinical experience performing or supervising airway procedures, as well as with hands on practice time or procedural teaching. Reponses were dichotomized to within the last year, or ≥ 1 year. Confidence was assessed using a Likert scale for each procedure, with results for ETI and LMA stratified by age. Response levels were dichotomized to "not confident" or "confident." Multivariate regression models were used to assess relevant associations.

Results: 1602 of 2446 (65%) eligible clinicians at 96 PERN sites responded. In the previous year, 1297 (85%) physicians reported having performed bag-mask ventilation, 900 (59%) had performed intubation, 248 (17%) had placed a laryngeal mask airway, 348 (23%) had changed a tracheostomy tube, and 18 (1%) had performed a surgical airway. Of respondents, 13% of physicians reported the opportunity to supervise but not provide ETI, 5% for LMA and 5% for BMV. The percentage of physicians reporting "confidence" in performing each procedure was: BMV (95%) TTC (43%), and surgical airway (16%). Clinician confidence in ETT and LMA varied by patient age. Supervision of an airway procedure was the strongest predictor of procedural confidence across airway procedures.

Conclusion: BMV and ETI were the most commonly performed pediatric airway procedures by emergency medicine physicians, and surgical airways are very infrequent. Supervising airway procedures may serve to maintain procedural confidence for physicians despite infrequent opportunities as the primary proceduralist.
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http://dx.doi.org/10.1016/j.ajem.2020.12.075DOI Listing
April 2021

PEMCRC anaphylaxis study protocol: a multicentre cohort study to derive and validate clinical decision models for the emergency department management of children with anaphylaxis.

BMJ Open 2021 01 5;11(1):e037341. Epub 2021 Jan 5.

Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.

Introduction: There remain significant knowledge gaps about the management and outcomes of children with anaphylaxis. These gaps have led to practice variation regarding decisions to hospitalise children and length of observation periods following treatment with epinephrine. The objectives of this multicentre study are to (1) determine the prevalence of and risk factors for severe, persistent, refractory and biphasic anaphylaxis, as well as persistent and biphasic non-anaphylactic reactions; (2) derive and validate prediction models for emergency department (ED) discharge; and (3) determine data-driven lengths of ED and inpatient observation prior to discharge to home based on initial reaction severity.

Methods And Analysis: The study is being conducted through the Pediatric Emergency Medicine Collaborative Research Committee (PEMCRC). Children 6 months to less than 18 years of age presenting to 30 participating EDs for anaphylaxis from October 2015 to December 2019 will be eligible. The primary outcomes for each objective are (1) severe, persistent, refractory or biphasic anaphylaxis, as well as persistent or biphasic non-anaphylactic reactions; (2) safe ED discharge, defined as no receipt of acute anaphylaxis medications or hypotension beyond 4 hours from first administered dose of epinephrine; and (3) time from first to last administered dose of epinephrine and vasopressor cessation. Analyses for each objective include (1) descriptive statistics to estimate prevalence and generalised estimating equations that will be used to investigate risk factors for anaphylaxis outcomes, (2) least absolute shrinkage and selection operator regression and binary recursive partitioning to derive and validate prediction models of children who may be candidates for safe ED discharge, and (3) Kaplan-Meier analyses to assess timing from first to last epinephrine doses and vasopressor cessation based on initial reaction severity.

Ethics And Dissemination: All sites will obtain institutional review board approval; results will be published in peer-reviewed journals and disseminated via traditional and social media, blogs and online education platforms.
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http://dx.doi.org/10.1136/bmjopen-2020-037341DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7786808PMC
January 2021

A randomized trial comparing physostigmine vs lorazepam for treatment of antimuscarinic (anticholinergic) toxidrome.

Clin Toxicol (Phila) 2021 Aug 9;59(8):698-704. Epub 2020 Dec 9.

Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, University of Colorado Hospital, Aurora, CO, USA.

Background: Toxicity from antimuscarinic agents precipitates a constellation of signs and symptoms; two of the most significant are agitation and delirium. Benzodiazepines are commonly used for treatment; physostigmine is also effective but is underutilized due to concerns for safety and short duration of action. The objective of this study was to compare lorazepam to physostigmine for the treatment of antimuscarinic delirium and agitation.

Methods: This was a blinded, randomized clinical trial in patients presenting for antimuscarinic toxidrome. Inclusion criteria were: ≥10-<18 years old, at least one central and two peripheral antimuscarinic symptoms, delirium and moderate agitation. Subjects were randomized to either (1) lorazepam bolus (0.05 mg/kg) followed by a 4-h normal saline infusion, or (2) physostigmine 0.02 mg/kg bolus followed by a 4-h physostigmine infusion (0.02 mg/kg/h). Primary outcomes were the control of delirium and agitation after bolus and during the infusion.

Results: Ten (53%) subjects were enrolled in the lorazepam arm, 9 (47%) in the physostigmine arm. Diphenhydramine was the most common agent ingested (16, 84%). Fewer patients receiving physostigmine had delirium after the initial bolus (44% vs 100%,  = 0.01) and at the 4th hour of infusion (22% vs 100%,  < 0.001) compared to patients who received lorazepam. There was a significant decrease in agitation scores in the physostigmine arm compared to the lorazepam arm after the initial bolus (89% vs 30%,  = 0.02), but no difference at the 4th hour of infusion ( > 0.99). There were no seizures, bradycardia, bronchorrhea, bronchospasm, intubation, or cardiac dysrhythmias.

Conclusion: Physostigmine was superior to lorazepam in controlling antimuscarinic delirium and agitation after bolus dosing, and control of delirium after a 4-h infusion. There were no serious adverse events in either treatment arm. Physostigmine bolus and infusion should be considered in adolescent patients with significant delirium and agitation from antimuscarinic agents.
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http://dx.doi.org/10.1080/15563650.2020.1854281DOI Listing
August 2021

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

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

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

Objectives: To determine the prevalence of invasive bacterial infections (IBIs) and adverse events in afebrile infants with acute otitis media (AOM).

Methods: We conducted a 33-site cross-sectional study of afebrile infants ≤90 days of age with AOM seen in emergency departments from 2007 to 2017. Eligible infants were identified using emergency department diagnosis codes and confirmed by chart review. IBIs (bacteremia and meningitis) were determined by the growth of pathogenic bacteria in blood or cerebrospinal fluid (CSF) culture. Adverse events were defined as substantial complications resulting from or potentially associated with AOM. We used generalized linear mixed-effects models to identify factors associated with IBI diagnostic testing, controlling for site-level clustering effect.

Results: Of 5270 infants screened, 1637 met study criteria. None of the 278 (0%; 95% confidence interval [CI]: 0%-1.4%) infants with blood cultures had bacteremia; 0 of 102 (0%; 95% CI: 0%-3.6%) with CSF cultures had bacterial meningitis; 2 of 645 (0.3%; 95% CI: 0.1%-1.1%) infants with 30-day follow-up had adverse events, including lymphadenitis (1) and culture-negative sepsis (1). Diagnostic testing for IBI varied across sites and by age; overall, 278 (17.0%) had blood cultures, and 102 (6.2%) had CSF cultures obtained. Compared with infants 0 to 28 days old, older infants were less likely to have blood cultures ( < .001) or CSF cultures ( < .001) obtained.

Conclusion: Afebrile infants with clinician-diagnosed AOM have a low prevalence of IBIs and adverse events; therefore, outpatient management without diagnostic testing may be reasonable.
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http://dx.doi.org/10.1542/peds.2020-1571DOI Listing
January 2021

Considerations for Designing EHR-Embedded Clinical Decision Support Systems for Antimicrobial Stewardship in Pediatric Emergency Departments.

Appl Clin Inform 2020 08 9;11(4):589-597. Epub 2020 Sep 9.

Department of Pediatrics and Emergency Medicine, Section of Emergency Medicine, School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, United States.

Objective: This study was aimed to explore the intersection between organizational environment, workflow, and technology in pediatric emergency departments (EDs) and how these factors impact antibiotic prescribing decisions.

Methods: Semistructured interviews with 17 providers (1 fellow and 16 attending faculty), and observations of 21 providers (1 physician assistant, 5 residents, 3 fellows, and 12 attendings) were conducted at three EDs in the United States. We analyzed interview transcripts and observation notes using thematic analysis.

Results: Seven themes relating to antibiotic prescribing decisions emerged as follows: (1) professional judgement, (2) cognition as a critical individual resource, (3) decision support as a critical organizational resource, (4) patient management with imperfect information, (5) information-seeking as a primary task, (6) time management, and (7) broad process boundaries of antibiotic prescribing.

Discussion: The emerging interrelated themes identified in this study can be used as a blueprint to design, implement, and evaluate clinical decision support (CDS) systems that support antibiotic prescribing in EDs. The process boundaries of antibiotic prescribing are broader than the current boundaries covered by existing CDS systems. Incongruities between process boundaries and CDS can under-support clinicians and lead to suboptimal decisions. We identified two incongruities: (1) the lack of acknowledgment that the process boundaries go beyond the physical boundaries of the ED and (2) the lack of integration of information sources (e.g., accessibility to prior cultures on an individual patient outside of the organization).

Conclusion: Significant opportunities exist to improve appropriateness of antibiotic prescribing by considering process boundaries in the design, implementation, and evaluation of CDS systems.
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http://dx.doi.org/10.1055/s-0040-1715893DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7557324PMC
August 2020

Updated Approaches to Cardiac Electrical Stimulation and Pacing in Pediatrics.

Pediatr Emerg Care 2020 Sep;36(9):430-439

From the Assistant Professors and Professor, Section of Emergency Medicine, Department of Pediatrics (Neubrand, Topoz and Mistry), University of Colorado/Children's Hospital Colorado, Aurora, CO.

Cardiac electrical stimulation is a rarely used but required skill for pediatric emergency physicians. Children who are in cardiac arrest or who demonstrate evidence of hypoperfusion because of cardiac reasons require rapid diagnosis and intervention to minimize patient morbidity and mortality. Both hospital- and community-based personnel must have sufficient access to, and knowledge of, appropriate equipment to provide potentially lifesaving defibrillation, cardioversion, or cardiac pacing. In this review, we will discuss the primary clinical indications for cardioelectrical stimulation in pediatric patients, including the use of automated external defibrillators, internal defibrillators, and pacemakers. We discuss the types of devices that are currently available, emergency management of internal defibrillation and pacemaker devices, and the role of advocacy in improving delivery of emergency cardiovascular care of pediatric patients in the community.
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http://dx.doi.org/10.1097/PEC.0000000000002201DOI Listing
September 2020

Persistent, refractory, and biphasic anaphylaxis: A multidisciplinary Delphi study.

J Allergy Clin Immunol 2020 11 24;146(5):1089-1096. Epub 2020 Aug 24.

Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.

Background: The use of inconsistent definitions for anaphylaxis outcomes limits our understanding of the natural history and epidemiology of anaphylaxis, hindering clinical practice and research efforts.

Objective: Our aim was to develop consensus definitions for clinically relevant anaphylaxis outcomes by utilizing a multidisciplinary group of clinical and research experts in anaphylaxis.

Methods: Using Delphi methodology, we developed agenda topics and drafted questions to review during monthly conference calls. Through online surveys, a 19-member panel consisting of experts in allergy and/or immunology and emergency medicine rated their level of agreement with the appropriateness of statements on a scale of 1 to 9. A median value of 1.0 to 3.4 was considered inappropriate, a median value of 3.5 to 6.9 was considered uncertain, and a median value of 7.0 to 9.0 was considered appropriate. A disagreement index was then calculated, with values less than 1.0 categorized as "consensus reached." If consensus was not reached after the initial survey, subsequent surveys incorporating the aggregate de-identified responses from prior surveys were sent to panel members. This process was repeated until consensus was reached or 4 survey rounds had been completed, after which the question was categorized as "no consensus reached."

Results: The panel developed outcome definitions for persistent, refractory, and biphasic anaphylaxis, as well as for persistent and biphasic nonanaphylactic reactions. There was also consensus among panel members regarding the need to develop an anaphylaxis severity grading system.

Conclusion: Dissemination and application of these definitions in clinical care and research will help standardize the terminology used to describe anaphylaxis outcomes and serve as the foundation for future research, including research aimed at development of an anaphylaxis severity grading system.
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http://dx.doi.org/10.1016/j.jaci.2020.08.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8006564PMC
November 2020

Oscillometry for acute asthma in the pediatric emergency department: A feasibility study.

Ann Allergy Asthma Immunol 2020 11 9;125(5):607-609. Epub 2020 Jul 9.

Section of Pulmonary and Sleep Medicine, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado.

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http://dx.doi.org/10.1016/j.anai.2020.07.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7606793PMC
November 2020

Dog Bites in Children Surge during Coronavirus Disease-2019: A Case for Enhanced Prevention.

J Pediatr 2020 10 25;225:231-232. Epub 2020 Jun 25.

Section of Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO.

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http://dx.doi.org/10.1016/j.jpeds.2020.06.071DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7316443PMC
October 2020

Emergency Department Prescribing Patterns for Pharyngitis in Children.

Clin Pediatr (Phila) 2020 10 5;59(11):995-1003. Epub 2020 Jun 5.

Children's Hospital Colorado, Aurora, CO, USA.

Pharyngitis is commonly diagnosed in the emergency department (ED) and accounts for substantial antibiotic burden in pediatrics. This study describes ED patterns of group A streptococcal (GAS) pharyngitis diagnosis and antibiotic prescribing patterns. This was a secondary data analysis of the National Hospital Ambulatory Medical Care Survey. Diagnosis and antibiotic treatment for GAS and non-GAS (viral) pharyngitis were reported in all ages and specifically examined in children <3 years of age from 2010 to 2015. GAS pharyngitis was diagnosed in 29% of visits for children with pharyngitis; however, 60% of patients with any pharyngitis received antibiotics. Twenty percent of children <3 years were diagnosed with GAS pharyngitis, yet over half were given antibiotics. Broad-spectrum antibiotics were commonly prescribed. Antibiotic treatment of pharyngitis, including broad-spectrum antibiotics, remains high when compared with the known prevalence of GAS pharyngitis. Diagnosis and treatment of GAS pharyngitis in patients <3 years persists despite recommendations against testing.
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http://dx.doi.org/10.1177/0009922820927042DOI Listing
October 2020

Interobserver Agreement in the Assessment of Clinical Findings in Children with Headaches.

J Pediatr 2020 06;221:207-214

Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY.

Objective: To determine the interobserver agreement of history and physical examination findings in children undergoing evaluation in the emergency department (ED) for headaches.

Study Design: We conducted a prospective, cross-sectional study of children aged 2-17 years evaluated at 3 tertiary-care pediatric EDs for non-traumatic headaches. Two clinicians independently completed a standardized assessment of each child and documented the presence or absence of history and physical examination variables. Unweighted κ statistics were determined for 68 history and 24 physical examination variables.

Results: We analyzed 191 paired observations; median age was 12 years, with 19 (9.9%) children younger than 7 years. Interrater reliability was at least moderate (κ ≥ 0.41) for 41 (60.3%) patient history variables. Eleven (61.1%) of 18 physical examination variables for which κ statistics could be calculated had a κ that was at least moderate.

Conclusions: A substantial number of history and physical examination findings demonstrated at least moderate κ statistic values when assessed in children with headaches in the ED. These variables may be generalizable across different types of clinicians for evaluation of children with headaches. If also found to predict the presence or absence of emergent intracranial abnormalities, the more reliable clinical findings may be helpful in the development of clinical prediction rules or risk stratification models that could be used across settings for children with headaches.
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http://dx.doi.org/10.1016/j.jpeds.2020.02.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7251971PMC
June 2020

Exposure and Confidence With Critical Nonairway Procedures: A Global Survey of Pediatric Emergency Medicine Physicians.

Pediatr Emerg Care 2021 Sep;37(9):e551-e559

School of Clinical Sciences at Monash Health, Monash University Melbourne, Australia.

Background: Children rarely experience critical illness, resulting in low exposure of emergency physicians (EPs) to critical procedures. Our primary objective was to describe senior EP confidence, most recent performance, and/or supervision of critical nonairway procedures. Secondary objectives were to compare responses between those who work exclusively in PEM and those who do not and to determine whether confidence changed for selected procedures according to increasing patient age.

Methods: Survey of senior EPs working in 96 emergency departments (EDs) affiliated with the Pediatric Emergency Research Networks. Questions assessed training, performance, supervision, and confidence in 11 nonairway critical procedures, including cardiopulmonary resuscitation (CPR), vascular access, chest decompression, and cardiac procedures.

Results: Of 2446 physicians, 1503 (61%) responded to the survey. Within the previous year, only CPR and insertion of an intraosseous needle had been performed by at least 50% of respondents: over 20% had performed defibrillation/direct current cardioversion. More than 50% of respondents had never performed or supervised ED thoracotomy, pericardiocentesis, venous cutdown, or transcutaneous pacing. Self-reported confidence was high for all patient age groups for CPR, needle thoracocentesis, tube thoracostomy, intraosseous needle insertion, and defibrillation/DC cardioversion. Confidence levels increased with increasing patient age for central venous and arterial line insertion. Respondents working exclusively in PEM were more likely to report being at least somewhat confident in defibrillation/DC cardioversion, intraosseous needle insertion, and central venous line insertion in particular age groups; however, they were less likely to be at least somewhat confident in ED thoracotomy and transcutaneous pacing.

Conclusions: Cardiopulmonary resuscitation and intraosseous needle insertion were the only critical nonairway procedures performed by at least half of EPs within the previous year. Confidence was higher for these procedures, and needle and tube thoracostomy. These data may inform the development of continuing medical education activities to maintain pediatric procedural skills for emergency physicians.
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http://dx.doi.org/10.1097/PEC.0000000000002092DOI Listing
September 2021

The Champagne Tap: Time to Pop the Cork?

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

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

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

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

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

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

Conclusions: In infants, a lumbar puncture with a CSF RBC count of 0 cells/mm regardless of the CSF WBC count occurred eight-times more frequently than one with both CSF WBC and RBC counts of 0 cells/mm . A broader champagne tap definition would allow more frequent recognition of procedural success, with the potential to foster a supportive community during medical training, potentially protecting against burnout.
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http://dx.doi.org/10.1111/acem.13966DOI Listing
November 2020

Antibiotic Prescribing for Viral Respiratory Infections in the Pediatric Emergency Department and Urgent Care.

Pediatr Infect Dis J 2020 05;39(5):406-410

Section of Pediatric Emergency Medicine, University of Colorado.

Background: Viral acute respiratory tract infections (vARTI) are a frequent source of inappropriate antibiotic prescribing. We describe the prevalence of antibiotic prescribing for vARTI in the pediatric emergency department (ED) and urgent care (UC) within a health system, and identify factors associated with overall and broad-spectrum antibiotic prescribing.

Methods: Retrospective chart review within a single pediatric referral health system. Visits of patients, 3 months- 17 years old, with a discharge diagnosis of a vARTI from 2010 to 2015. Data collected included specific vARTI diagnosis, site type (ED or UC), provider type [pediatric emergency medicine subspecialist or physicians, nurse practitioners, physician assistants (non-PEM)] and discharge antibiotics. Odds ratios and 95% confidence intervals (CI) were calculated where appropriate.

Results: There were 132,458 eligible visits, mean age 4.1 ± 4.3 years. Fifty-three percent were treated in an ED. Advanced practice providers, a term encompassing nurse practitioners and physician assistants, were the most common provider type (47.7%); 16.5% of patients were treated by a pediatric emergency medicine subspecialist. Antibiotics were prescribed for 3.8% (95% CI: 3.72-3.92) of children with vARTI; 25.4% (95% CI: 24.2-26.6) of these were broad-spectrum, most commonly first-generation cephalosporins (11%; 95% CI 10.2-11.9). Patients treated in an ED or by a non-PEM and those receiving chest radiograph (CXR) received antibiotics most frequently. Prescribing rates varied by specific vARTI diagnosis.

Conclusions: Patients discharged from the pediatric ED or UC with vARTI receive inappropriate antibiotics at a lower rate than reported in other community settings; however, they frequently receive broad-spectrum agents.
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http://dx.doi.org/10.1097/INF.0000000000002586DOI Listing
May 2020

Primary care provider preferences for glucocorticoid management of acute asthma exacerbations in children.

J Asthma 2021 04 14;58(4):547-553. Epub 2020 Jan 14.

Section of Pediatric Emergency Medicine, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA.

Objective: Primary care providers (PCP) frequently care for children with acute asthma exacerbations in the outpatient setting. The objective of this study is to evaluate PCP preferences and perceptions regarding oral glucocorticoids prescribed from both outpatient primary care and ED settings for the treatment of children with acute asthma exacerbations.

Methods: PCPs belonging to the Colorado Chapter of the American Academy of Pediatrics were surveyed between February and May 2019. Survey items were generated by a multidisciplinary team and underwent content and criteria validation and pilot testing. Survey items evaluated PCP preferred oral glucocorticoid and dosing regimen for children with acute asthma exacerbations, provider- and patient-level factors contributing to glucocorticoid preferences, and perception of glucocorticoid regimens in terms of treatment failure, resolution of symptoms and adherence.

Results: A total of 109 of 600 (18.2%) PCPs responded. Equal proportions of PCPs reported preferring oral prednisone/prednisolone (50.5%) and oral dexamethasone (49.5%) for children with acute asthma exacerbations. Forty-four percent of PCPs reported no preference in type of glucocorticoid utilized by surrounding emergency departments (EDs). However, for children receiving dexamethasone in the ED but with persistent symptoms on PCP follow-up, 50.5% of PCPs would switch patients to prednisone/prednisolone. PCPs did not perceive more treatment failure or rapid resolution of symptoms with dexamethasone but reported better adherence with dexamethasone.

Conclusion: There is variability in PCP glucocorticoid management of pediatric acute asthma exacerbations. There is a need for further investigations to evaluate for differences in clinical outcomes based on PCP glucocorticoid treatment choices.
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http://dx.doi.org/10.1080/02770903.2019.1709869DOI Listing
April 2021

Evaluation of a New Clinical Endpoint for Moderate to Severe Influenza Disease in Children: A Prospective Cohort Study.

J Pediatric Infect Dis Soc 2020 Sep;9(4):460-467

Department of Pediatrics, University of Colorado School of Medicine, Department of Epidemiology and Center for Global Health, Colorado School of Public Health, Aurora, Colorado, USA.

Background: A moderate to severe (M/S) influenza clinical endpoint has been proposed in children, defined as fever >39°C, otitis media, lower respiratory tract infection, or serious extrapulmonary manifestations. The objective of the study was to evaluate the M/S measure against clinically relevant outcomes including hospitalization, emergency room visits, antimicrobial use, and child/parental absenteeism.

Methods: We conducted a prospective observational study of children aged 6 months-8 years at the Children's Hospital Colorado emergency department (ED) and urgent care site during 2016-2017 and 2017-2018. Children with influenza-like illness (ILI) underwent influenza testing by polymerase chain reaction (PCR); children who tested positive and a subset of matched test-negative controls underwent follow-up at 2 weeks. The primary outcome was the proportion of children who were hospitalized. Secondary outcomes included recurrent ED visits, antimicrobial use, hospital charges, and child/parental absenteeism within 14 days.

Results: Among 1478 children enrolled with ILI, 411 (28%) tested positive for influenza by PCR. Of children with influenza illness, 313 (76%) met the M/S definition. Children with M/S influenza were younger (3.8 years vs 4.8 years), infected with influenza A (59% vs 44%), and more frequently hospitalized (unadjusted risk difference [RD], 6.3%; 95% confidence interval [CI], 2.1-10.4; P = .03) and treated with antibiotics (unadjusted RD, 13.3%; 95% CI, 4.3-22.4; P < .01) compared to those with mild disease.

Conclusions: Children with M/S influenza have a higher risk of hospitalization and antibiotic use compared with mild disease. This proposed definition may be a useful clinical endpoint to study the public health and clinical impact of influenza interventions in children.

Clinical Trials Registration: NCT02979626.
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http://dx.doi.org/10.1093/jpids/piz075DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7495912PMC
September 2020

An Implementation Science Approach to Antibiotic Stewardship in Emergency Departments and Urgent Care Centers.

Acad Emerg Med 2020 01 22;27(1):31-42. Epub 2019 Nov 22.

Department of Emergency Medicine, University of California-Davis, Sacramento, CA.

Background: Antibiotic stewardship efforts have expanded focus from inpatient to include outpatient settings. However, stewardship is urgently needed in acute care ambulatory settings: emergency departments (EDs) and urgent care centers (UCCs). Implementation of antibiotic stewardship in acute ambulatory care settings has been limited. Two major barriers to effective implementation exist: 1) lack of adaptation of successful outpatient stewardship interventions to the acute care ambulatory setting and 2) absence of rigorous measurement of implementation processes in EDs and UCCs in a manner that informs future scale and spread.

Objectives: Our objective was to apply an implementation science approach to address antibiotic overuse and inappropriate use in EDs and UCCs.

Methods: This study was a redesign of an evidence-based outpatient antibiotic stewardship intervention at participating EDs and UCCs using an innovative implementation science framework (dynamic adaptation process), adaptable for local clinical workflow and local champion provision. We evaluated multiple implementation outcome metrics throughout a cluster-randomized comparative effectiveness clinical trial of two approaches to the adapted antibiotic stewardship interventions.

Results: Our preimplementation phase included 21 in-depth interviews and online provider surveys (52% response rate). For the postimplementation survey, we had a 39% response rate. We identified common themes including patient expectations, lack of knowledge of existing guidelines, and maintenance of education over time. Additional themes indicated differences in modifications needed by type of clinical setting. Adoption of public commitment was high, with 79% of providers signing a commitment log, and 84% received public commitment flair. Signing of public commitment posters rate was 62%, as several sites chose not to use this component. Acceptability, fidelity, and appropriateness were also measured.

Conclusions: We demonstrate that implementation science approaches can help address the problem of unnecessary antibiotic use in EDs and UCCs with high acceptability and adoption. Similar approaches could be used to tailor quality improvement interventions in these settings.
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http://dx.doi.org/10.1111/acem.13873DOI Listing
January 2020

Skin and Soft Tissue Infections in Ambulatory Care Settings: Setting a New Trend.

Authors:
Rakesh D Mistry

Clin Infect Dis 2020 06;70(12):2719-2720

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

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http://dx.doi.org/10.1093/cid/ciz980DOI Listing
June 2020
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