Publications by authors named "Sriram Ramgopal"

66 Publications

Pediatric Craniofacial Fractures From Canine Bites.

J Craniofac Surg 2021 Mar 17. Epub 2021 Mar 17.

Department of Plastic Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Chicago, IL.

Abstract: Craniofacial fractures from canine bites are rare, but can be devastating events that lead to complex surgical management, long-term functional deficits, and psychological sequelae. The objective of this case-control study was to identify risks associated with craniofacial fractures in pediatric dog bite victims. From 2008 to 2019 at our quaternary center, all children with craniofacial fractures from dog bites were included in this study. Controls were obtained in a 2:1 ratio via a random sample of all dog bite encounters. Logistic regression was used to calculate odds ratios (OR) with 95% confidence intervals (CI). Of 3602 dog bite encounters, 114 children were included in the study with an average age of 4.8 years (interquartile range = 2.4-9.1 years) and 51 patients (45%) were female. Seventy-four children (65%) were bitten by a family-owned dog. Thirty-eight patients with 60 craniofacial fractures were identified. The following factors were significantly associated with increased risk for craniofacial fractures: Caucasian race (OR 7.3, CI 1.6-16.7), age under five (OR 4.1, CI 1.6-10.7), rural location (OR 3.9, CI 1.3-12.3), child location on the floor (OR 6.2, CI 2.4-16.2), and dogs weighing over 30 pounds (OR 19.6, CI 5.8-82.3). Nine patients (12%) required multiple reconstructive operations, and four patients (5%) developed post-traumatic stress disorder. In conclusion, toddlers in rural households with large dogs are at high risk for sustaining craniofacial fractures from bite injuries. Craniofacial surgeons, pediatricians, and emergency department physicians should use these data to lead prevention efforts in the community.
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http://dx.doi.org/10.1097/SCS.0000000000007546DOI Listing
March 2021

External Validation of an Invasive Bacterial Infection Score for Young Febrile Infants.

Hosp Pediatr 2021 Mar;11(3):239-244

Feinberg School of Medicine, Northwestern University, Chicago, Illinois; and

Objectives: The Aronson rule is a point-based clinical decision rule for the identification of febrile infants ≤60 days of age at low risk of invasive bacterial infection (IBI) in the emergency department. This rule uses variables of temperature, age, urinalysis, and absolute neutrophil count. We sought to externally validate this decision rule.

Methods: We conducted a secondary analysis of a multicenter prospective cohort of febrile infants ≤60 days old presenting to the emergency department between December 2008 and May 2013. Infants were excluded if they had clinical sepsis or chronic conditions or were missing any laboratory components of the Aronson score. Our outcome was IBI (bacteremia and/or bacterial meningitis). We assessed the accuracy of the Aronson rule by reporting metrics of diagnostic accuracy with 95% confidence intervals (CIs) at different point thresholds.

Results: Of 4130 included patients (780 <21 days of age; 2362 boys), 87 (2.1%) had an IBI, including 65 with isolated bacteremia and 22 with meningitis. Using an Aronson cutoff score of 2 resulted in a sensitivity of 93.1% (95% CI 85.6%-97.4%), specificity of 26.6% (95% CI 25.3%-28.0%), and negative predictive value of 99.4% (95% CI 98.8%-99.8%). Six patients with IBI (3 with bacterial meningitis) were misclassified as low risk when using a threshold of 2.

Conclusions: The Aronson rule demonstrates metrics of diagnostic accuracy that are comparable to the derivation study. Our findings suggest that the rule may be generalizable for the risk stratification of well-appearing febrile infants.
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http://dx.doi.org/10.1542/hpeds.2020-003178DOI Listing
March 2021

EMS responses and non-transports during the COVID-19 pandemic.

Am J Emerg Med 2021 Apr 31;42:1-8. Epub 2020 Dec 31.

Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America. Electronic address:

Introduction: The COVID-19 pandemic may affect both use of 9-1-1 systems and prehospital treatment and transport practices. We evaluated EMS responses in an EMS region when it experienced low to moderate burden of COVID-19 disease to assess overall trends, response and management characteristics, and non-transport rates. Our goal is to inform current and future pandemic response in similar regions.

Methods: We performed a retrospective review of prehospital EMS responses from 22 urban, suburban, and rural EMS agencies in Western Pennsylvania. To account for seasonal variation, we compared demographic, response, and management characteristics for the 2-month period of March 15 to May 15, 2020 with the corresponding 2-month periods in 2016-2019. We then tested for an association between study period (pandemic vs historical control) and incidence of non-transport in unadjusted and adjusted regression. Finally, we described the continuous trends in responses and non-transports that occurred during the year before and initial phase of the COVID-19 pandemic from January 1, 2019 to May 31, 2020.

Results: Among 103,607 EMS responses in the 2-month comparative periods of March 15 to May 15, 2016-2020, we found a 26.5% [95% CI 26.9%, 27.1%] decrease in responses in 2020 compared to the same months from the four prior years. There was a small increase in respiratory cases (0.6% [95%CI 0.1%, 1.1%]) and greater frequency of abnormal vital signs suggesting a sicker patient cohort. There was a relative increase (46.6%) in non-transports between periods. The pandemic period was independently associated with an increase in non-transport (adjusted OR 1.68; 95%CI 1.59, 1.78). Among 177,194 EMS responses occurring in the year before and during the early period of the pandemic, between January 1, 2019, and May 31, 2020, we identified a 31% decrease in responses and a 48% relative increase in non-transports for April 2020 compared to the previous year's monthly averages.

Conclusion: Despite a low to moderate burden of infection during the initial period of the COVID-19 pandemic, we found a decline in overall EMS response volumes and an increase in the rate of non-transports independent of patient demographics and other response characteristics.
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http://dx.doi.org/10.1016/j.ajem.2020.12.078DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7836527PMC
April 2021

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

J Pediatr 2021 Jan 5. Epub 2021 Jan 5.

Division of Environmental Health Sciences, University of Minnesota, Minneapolis, MN. Electronic address:

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

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

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

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

Rates of Presentation, Treatments and Serious Neurologic Disorders Among Children and Young Adults Presenting to US Emergency Departments With Headache.

J Child Neurol 2021 May 24;36(6):475-481. Epub 2020 Dec 24.

Division of Pediatric Emergency Medicine, Department of Pediatrics, 6619UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.

Objective: To evaluate rates of presentation, neuroimaging, therapies, and serious neurologic disorders (SNDs) among children and young adults presenting to the emergency department with headache.

Methods: We performed a cross-sectional study of a nationally representative sample survey of visits to US emergency departments between 2002 and 2017. We identified encounters of patients ≤25 years old with chief complaint of headache. We report the rates of presentation, imaging, and treatments and report proportions having concomitant diagnoses of serious neurologic disorders.

Results: Among encounters ≤25 years, 2.0% had a chief complaint of headache, with no change in the yearly rates of encounters ( = .98). Overall, 20.8% had a head computed tomography (CT), with a reduction in performance between 2007 and 2016 ( < .01). One-quarter (25.2%, 95% confidence interval [CI] 22.2%-28.3%) were given narcotics and 2.5% (95% CI 1.7%-3.2%) had serious neurologic disorders.

Conclusion: Overall, 2.0% of emergency department encounters among patients ≤25 years were for headache, with low rates of serious neurologic disorders. CT use appeared to be declining.
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http://dx.doi.org/10.1177/0883073820979137DOI Listing
May 2021

United States' Emergency Department Visits for Fever by Young Children 2007-2017.

West J Emerg Med 2020 Oct 27;21(6):146-151. Epub 2020 Oct 27.

University of Pittsburgh School of Medicine, Departments of Pediatrics and Emergency Medicine, Pittsburgh, Pennsylvania.

Introduction: Our goal in this study was to estimate rates of emergency department (ED) visits for fever by children <2 years of age, and evaluate frequencies of testing and treatment during these visits.

Methods: We performed a cross-sectional study of ED encounters from 2007-2017 using the National Hospital Ambulatory Medical Care Survey, a cross-sectional, multi-stage probability sample survey of visits to nonfederal United States EDs. We included encounters with a visit reason of "fever" or recorded fever in the ED. We report demographics and management strategies in two groups: infants ≤90 days in age; and children 91 days to <2 years old. For patients 91 days to <2 years, we compared testing and treatment strategies between general and pediatric EDs using chi-squared tests.

Results: Of 1.5 billion encounters over 11 years, 2.1% (95% confidence interval [CI], 1.9-2.2%) were by children <2 years old with fever. Two million encounters (95% CI, 1.7-2.4 million) were by infants ≤90 days, and 28.4 million (95% CI, 25.5-31.4 million) were by children 91 days to <2 years. Among infants ≤90 days, 27.6% (95% CI, 21.1-34.1%) had blood and 21.3% (95% CI, 13.6-29.1%) had urine cultures; 26.8% (95% CI, 20.9-32.7%) were given antibiotics, and 21.1% (95% CI, 15.3-26.9%) were admitted or transferred. Among patients 91 days to <2 years in age, 6.8% (95% CI, 5.8-7.8%) had blood and 7.7% (95% CI 6.1-9.4%) had urine cultures; 40.5% (95% CI, 40.5-40.5%) were given antibiotics, and 4.4% (95% CI, 3.5-5.3%) were admitted or transferred. Patients 91 days to <2 years who were evaluated in general EDs had higher rates of radiography (27.1% vs 15.2%; P<0.01) and antibiotic utilization (42.3% vs 34.2%; P<0.01), but lower rates of urine culture testing (6.4% vs 11.6%, p = 0.03), compared with patients evaluated in pediatric EDs.

Conclusion: Approximately 180,000 patients ≤90 days old and 2.6 million patients 91 days to <2 years in age with fever present to US EDs annually. Given existing guidelines, blood and urine culture performance was low for infants ≤90 days old. For children 91 days to <2 years, rates of radiography and antibiotic use were higher in general EDs compared to pediatric EDs. These findings suggest opportunities to improve care among febrile young children in the ED.
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http://dx.doi.org/10.5811/westjem.2020.8.47455DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7673886PMC
October 2020

Weather and temporal models for emergency medical services: An assessment of generalizability.

Am J Emerg Med 2020 Aug 16. Epub 2020 Aug 16.

Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America.

Background: Emergency medical services (EMS) response volume has been linked to weather and temporal factors in a regional EMS system. We aimed to identify if models of EMS utilization incorporating these data are generalizable through geographically disparate areas in the United States.

Methods: We performed a retrospective analysis of EMS dispatch data from four regions: New York City, San Francisco, Cincinnati, and Marin County for years 2016-2019. For each model, we used local weather data summarized from the prior 6 h into hourly bins. Our outcome for each model was EMS dispatches as count data. We fit and optimized a negative binomial regression model for each region, to estimate incidence rate ratios. We compared findings to a prior study performed in Western Pennsylvania.

Results: We included 5,940,637 EMS dispatches from New York City, 809,405 from San Francisco, 260,412 from Cincinnati, and 77,461 from Marin County. Models demonstrated consistency with the Western Pennsylvania model with respect to temperature, season, wind speed, dew point, and time of day; both in terms of direction and effect size when expressed as incidence rate ratios. Precipitation was associated with increasing dispatches in the New York City, Cincinnati, and Marin County models, but not the San Francisco model.

Conclusion: With minor differences, regional models demonstrated consistent associations between dispatches and time and weather variables. Findings demonstrate the generalizability of associations between these variables with respect to EMS use. Weather and temporal factors should be considered in predictive modeling to optimize EMS staffing and resource allocation.
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http://dx.doi.org/10.1016/j.ajem.2020.08.033DOI Listing
August 2020

Serious Diagnoses for Headaches After ED Discharge.

Pediatrics 2020 11 2;146(5). Epub 2020 Oct 2.

Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois.

Background: Headache is a common complaint among children presenting to the emergency department (ED) and can be due to serious neurologic and nonneurologic diagnoses (SNNDs). We sought to characterize the children discharged from the ED with headache found to have SNNDs at revisits.

Methods: We performed a multicenter retrospective cohort study using data from 45 pediatric hospitals from October 1, 2015, to March 31, 2019. We included pediatric patients (≤18 years) discharged from the ED with a principal diagnosis of headache, excluding patients with concurrent or previous SNNDs or neurosurgeries. We identified rates and types of SNNDs diagnosed within 30 days of initial visit and compared these rates with those of control groups defined as patients with discharge diagnoses of cough, chest pain, abdominal pain, and soft tissue complaints.

Results: Of 121 621 included patients (57% female, median age 12.4 years, interquartile range: 8.8-15.4), 608 (0.5%, 95% confidence interval: 0.5%-0.5%) were diagnosed with SNNDs within 30 days. Most were diagnosed at the first revisit (80.8%); 37.5% were diagnosed within 7 days. The most common SNNDs were benign intracranial hypertension, cerebral edema and compression, and seizures. A greater proportion of patients with SNNDs underwent neuroimaging, blood, and cerebrospinal fluid testing compared with those without SNNDs ( < .001 for each). The proportion of SNNDs among patients diagnosed with headache (0.5%) was higher than for control cohorts (0.0%-0.1%) ( < .001 for each).

Conclusions: A total 0.5% of pediatric patients discharged from the ED with headache were diagnosed with an SNND within 30 days. Further efforts to identify at-risk patients remain a challenge.
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http://dx.doi.org/10.1542/peds.2020-1647DOI Listing
November 2020

Maximum Pao in the First 72 Hours of Intensive Care Is Associated With Risk-Adjusted Mortality in Pediatric Patients Undergoing Mechanical Ventilation.

Crit Care Explor 2020 Sep 14;2(9):e0186. Epub 2020 Sep 14.

Department of Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, and Division of Pediatric Critical Care Medicine, Health Informatics for Clinical Effectiveness, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA.

A relationship between Pao and mortality has previously been observed in single-center studies. We performed a retrospective cohort study of the Pediatric Health Information System plus database including patients less than or equal to 21 years old admitted to a medical or cardiac ICU who received invasive ventilation within 72 hours of admission. We trained and validated a multivariable logistic regression mortality prediction model with very good discrimination (-statistic, 0.86; 95% CI, 0.79-0.92; area under the precision-recall curve, 0.39) and acceptable calibration (standardized mortality ratio, 0.96; 95% CI, 0.75-1.23; calibration belt = 0.07). Maximum Pao measurements demonstrated a parabolic ("U-shaped") relationship with PICU mortality (Box-Tidwell < 0.01). Maximum Pao was a statistically significant predictor of risk-adjusted mortality (standardized odds ratio, 1.27; 95% CI, 1.23-1.32; < 0.001). This analysis is the first multicenter pediatric study to identify a relationship between the extremes in Pao values and PICU mortality. Clinicians should remain judicious in the use of oxygen when caring for children.
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http://dx.doi.org/10.1097/CCE.0000000000000186DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7491884PMC
September 2020

Machine learning approaches for the identification of children at low risk of intra-abdominal injury requiring intervention.

J Trauma Acute Care Surg 2020 Aug 28. Epub 2020 Aug 28.

Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America.

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http://dx.doi.org/10.1097/TA.0000000000002906DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7914296PMC
August 2020

Machine Learning To Predict Serious Bacterial Infections in Young Febrile Infants.

Pediatrics 2020 09;146(3)

Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois.

Background: Recent decision rules for the management of febrile infants support the identification of infants at higher risk of serious bacterial infections (SBIs) without the performance of routine lumbar puncture. We derive and validate a model to identify febrile infants ≤60 days of age at low risk for SBIs using supervised machine learning approaches.

Methods: We conducted a secondary analysis of a multicenter prospective study performed between December 2008 and May 2013 of febrile infants. Our outcome was SBI, (culture-positive urinary tract infection, bacteremia, and/or bacterial meningitis). We developed and validated 4 supervised learning models: logistic regression, random forest, support vector machine, and a single-hidden layer neural network.

Results: A total of 1470 patients were included (1014 >28 days old). One hundred thirty-eight (9.3%) had SBIs (122 urinary tract infections, 20 bacteremia, and 8 meningitis; 11 with concurrent SBIs). Using 4 features (urinalysis, white blood cell count, absolute neutrophil count, and procalcitonin), we demonstrated with the random forest model the highest specificity (74.9, 95% confidence interval: 71.5%-78.2%) with a sensitivity of 98.6% (95% confidence interval: 92.2%-100.0%) in the validation cohort. One patient with bacteremia was misclassified. Among 1240 patients who received a lumbar puncture, this model could have prevented 849 (68.5%) such procedures.

Conclusions: We derived and internally validated a supervised learning model for the risk-stratification of febrile infants. Although computationally complex, lacking parameter cutoffs, and in need of external validation, this strategy may allow for reductions in unnecessary procedures, hospitalizations, and antibiotics while maintaining excellent sensitivity.
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http://dx.doi.org/10.1542/peds.2019-4096DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7461239PMC
September 2020

Association of triage hypothermia with in-hospital mortality among patients in the emergency department with suspected sepsis.

J Crit Care 2020 12 16;60:27-31. Epub 2020 Jul 16.

Division of Emergency Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America.

Purpose: To identify if triage hypothermia (<36.0 °C) among emergency department (ED) encounters with sepsis are independently associated with mortality.

Methods: We analyzed data from a multi-stage probability sample survey of visits to United States EDs between 2007 and 2015, using two inclusion approaches: an explicit definition based on diagnosis codes for sepsis and a severe sepsis definition, combining evidence of infection with organ dysfunction. We used multivariable regression to determine an association between hypothermia and in-hospital mortality.

Results: Of 1.2 billion ED encounters (95% confidence interval [CI] 1.0-1.3 billion), 3.1 million (95% CI 2.7-3.5 million) met the explicit sepsis definition; 7.4% (95% CI 75.2-9.7%) had triage hypothermia. The adjusted odds ratio (aOR) for hypothermia for in-hospital mortality was 6.82 (95% CI 3.08-15.22). The severe sepsis definition identified 3.5 million (95% 3.1-4.0 million) encounters; 30.3% (95% CI 25.0-34.6%) had triage hypothermia. The aOR for hypothermia with mortality was 4.08 (95% CI 2.09-7.95). Depending on sepsis definition, 78.1-84.4% had other systemic inflammatory response syndrome vital sign abnormalities.

Conclusion: Up to one in three patients with sepsis have triage hypothermia, which is independently associated with mortality. 10-20% of patients with hypothermic sepsis do not have other vital sign abnormalities.
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http://dx.doi.org/10.1016/j.jcrc.2020.07.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7872398PMC
December 2020

Interfacility transports by emergency medical services in the United States: Estimates from the National Hospital Ambulatory Medical Care Survey.

Authors:
Sriram Ramgopal

Am J Emerg Med 2020 10 22;38(10):2244.e3-2244.e6. Epub 2020 May 22.

Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America. Electronic address:

Objective: To describe characteristics of encounters in U.S. emergency departments (EDs) brought by interfacility transport by emergency medical services (EMS) from other EDs or urgent care settings.

Methods: We performed a cross-sectional study of the National Hospital Ambulatory Medical Care Survey, a multistage probability survey of nonfederal of visits to U.S. EDS. We evaluated patients who were brought to the ED as an interfacility transport by EMS from another ED or urgent care setting between 2014 and 2017. We report demographics, clinical characteristics and treatment factors of ED encounters brought interfacility transport and assessed factors associated with discharge from the receiving ED.

Results: Of 562.9 million ED encounters during the assessed period, 4.5 million were brought by interfacility transport by EMS (1.1 million per year). This represented 0.8% (95% CI 0.6-1.0%) of all ED encounters and 5.3% (95% CI 4.4-6.3%) of ED encounters transported by EMS. Most encounters brought by interfacility transport were adults (85%) who were publicly insured (62%). 39% had at least one abnormal vital sign. Most encounters received diagnostic testing (84%) and were seen within 30 min of presentation (61%). 54% were admitted, and 36% were discharged from the ED. Encounters without chronic complex conditions and with normal triage vital signs were associated with ED discharge (p < 0.01).

Discussion: Interfacility transports between EDs transported by EMS account for <1% of ED encounters in the U.S. Nearly 40% of such encounters are ultimately discharged. Further research is needed to identify a low-risk cohort among patients in need of secondary transport.
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http://dx.doi.org/10.1016/j.ajem.2020.05.047DOI Listing
October 2020

Outcomes of Young Infants with Hypothermia Evaluated in the Emergency Department.

J Pediatr 2020 06;221:132-137.e2

Division of Pediatric Emergency Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA.

Objective: To assess the prevalence of serious infections and mortality among infants ≤90 days of age presenting to the emergency department with hypothermia.

Study Design: We performed a cross-sectional cohort study of infants ≤90 days presenting to any of 40 EDs in the Pediatric Health Information Systems between January 1, 2009, and December 31, 2018. Infants with an International Classification of Diseases, ninth or tenth edition, admission/discharge diagnosis code of hypothermia were included. We determined the prevalence of serious bacterial infection (urinary tract infection, bacteremia, and/or bacterial meningitis), pneumonia, herpes simplex virus (HSV) infection, and emergency department/hospital mortality.

Results: We included 3565 infants (1633 male [50.9%] and 3225 ≤30 days of age [90.5%]). Most (65.0%) presented in the first week of life. There were 389 infants (10.8%) with a complex chronic condition. The prevalence of serious bacterial infection was 8.0% (n = 284), including 2.4% (n = 87) with urinary tract infection, 5.6% (n = 199) with bacteremia, and 0.3% (n = 11) with bacterial meningitis. There were 7 patients (0.2%) with neonatal HSV and 9 (0.3%) with pneumonia; 0.2% (n = 6) died. The presence of a complex chronic condition was associated with the presence of serious bacterial infection (P < .001) and was present in 3 of 6 patients who died. In a sensitivity analysis including patients with any diagnosis code of hypothermia (n = 8122), 14.9% had serious bacterial infection, 0.6% had HSV, and 3.3% had pneumonia; 2.0% died.

Conclusions: Of infants with hypothermia ≤90 days of age, 8.3% had serious bacterial infections or HSV. Compared with literature from febrile infants, hypothermia is associated with a high mortality rate. Complex chronic conditions were particularly associated with poor outcomes. Additional research is required to risk stratify young infants with hypothermia.
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http://dx.doi.org/10.1016/j.jpeds.2020.03.002DOI Listing
June 2020

Diagnosis and Management of Neonatal Herpes Simplex Infection in the Emergency Department.

Pediatr Emerg Care 2020 Apr;36(4):196-202

Assistant Professor for Pediatrics, Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America.

Neonatal herpes simplex virus infection (HSV) is rare in neonates, with an estimated global incidence of 10 per 100,000 live births. Neonatal HSV is challenging to diagnose due to often vague signs and symptoms. Untreated, the mortality of some HSV subtypes exceeds 80%. Overtesting and overtreatment can result in prolonged hospitalizations and expose neonates to medication toxicity. In contrast, prompt evaluation and use of empiric antiviral therapy before the results of definitive testing can improve outcomes for infants with HSV. A wide degree of practice variation exists with respect to testing and treatment for neonatal HSV, and more research is required to safely risk-stratify this population. This review presents the epidemiology, risk factors, presenting features, and emergency department management of neonatal HSV infection.
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http://dx.doi.org/10.1097/PEC.0000000000002077DOI Listing
April 2020

Automated Versus Manual Band Counts for the Diagnosis of Invasive Bacterial Infections in Infants Who Are Febrile.

J Pediatr 2020 06 4;221:246-250.e3. Epub 2020 Mar 4.

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

We conducted a secondary analysis of a prospective study of infants ≤60 days of age who were febrile to assess the diagnostic accuracy of automated vs manual immature neutrophils for invasive bacterial infections. Although manual counts were superior compared with automated counts, bands had suboptimal accuracy overall and had significant variability in test characteristics based on methodology.
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http://dx.doi.org/10.1016/j.jpeds.2020.01.065DOI Listing
June 2020

Variation in Prehospital Protocols for Pediatric Seizure Within the United States.

Pediatr Emerg Care 2020 Feb 1. Epub 2020 Feb 1.

Division of Pediatric Emergency Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA.

Objective: The objective of this study was to compare statewide prehospital protocols for the management of pediatric seizures.

Methods: We performed a descriptive analysis comparing statewide protocols for emergency medical services management of pediatric seizures within the United States, excluding states for which no statewide protocol/model was available. We compared antiepileptic drugs (AEDs), routes and doses of administration, and differences in febrile seizure management.

Results: Of 50 states, 34 had either statewide protocols or models and were included. All had a protocol for the management of seizures and provided specific recommendations for the management of pediatric seizures. Twelve states (35%) preferentially recommended midazolam over other benzodiazepines. Thirty-two (94%) of 34 allowed for use of midazolam, with variable use of other AEDs. All allowed for use of intramuscular AED. Twenty-six (77%) allowed for intranasal AED. Nine (27%) allowed emergency medical services to administer a patient's own abortive AED, and 6 (18%) allowed for use of a patient's vagal nerve stimulator, when present. There was a wide variability with respect to dosing ranges for medications. Thirty-two (94%) of 34 included blood glucose measurement within the protocol. Twenty-one protocols (62%) provided recommendations for febrile seizures, including recommending active/passive cooling (8/34, 24%) and antipyretic administration (9/34, 26%).

Conclusions: All statewide protocols carried specific guidelines for the prehospital management of pediatric seizures; however, there was wide variability with respect to specific AEDs, routes of administration, and drug dosages. In addition to broader availability of statewide guidance, areas of potential protocol improvement and research include AED dose optimization, reprioritization of blood glucose, and greater emphasis on intranasal or intramuscular medication dosing.
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http://dx.doi.org/10.1097/PEC.0000000000002029DOI Listing
February 2020

Rapid brain MRI protocols reduce head computerized tomography use in the pediatric emergency department.

BMC Pediatr 2020 01 13;20(1):14. Epub 2020 Jan 13.

University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.

Background: Rapid magnetic resonance imaging (MRI) protocols may be effective in the emergency department (ED) to evaluate nontraumatic neurologic complaints. We evaluate neuroimaging (rapid MRI [rMRI]), head computerized tomography [HCT], and full MRI) use following widespread implementation of rMRI protocols in a pediatric emergency department (ED).

Methods: We conducted a retrospective study in a tertiary care pediatric ED of encounters with neuroimaging during two 9-month periods: one prior to (control period) and one after generalized availability of 4 rMRI protocols (rMRI period). The primary outcome was differences in neuroimaging rates between the two periods. Secondary outcomes included ED process measures, unsuccessful imaging, and undetected pathology, with full MRI within 14 days as the reference standard.

Results: There were 1052 encounters with neuroimaging during the control and 1308 during the rMRI periods. Differences in neuroimaging between periods were 27.7% for rMRI (95% CI, 24.4, 31.0), - 21.5% for HCT (95% CI, - 25.5, - 17.5), and - 6.2% for full MRI (95% CI, - 9.3, - 3.1%.) Time to imaging (182 [IQR 138-255] versus 86 [IQR 52-137] minutes) as well as ED length of stay (396 [IQR 304-484] versus 257 [IQR 196-334] minutes) was longer for rMRI versus HCT (p < 0.01). Between the control and rMRI periods, there were differences in types of neuroimaging performed for patients with altered mental status, headache, seizure, shunt dysfunction, stroke, syncope, trauma, vomiting, infection, and other neurologic complaints (p < 0.05). rMRI studies were unsuccessful in 3.6% of studies versus 0.0% of HCTs (p < 0.01). The 22 unsuccessful rMRI studies were unsuccessful due to artifacts from dental hardware (n = 2) and patient motion (n = 20). None of the rMRI studies with full MRI follow-up imaging had undetected pathology; the false negative rate for the HCT exams was as high as 25%.

Conclusions: After routine ED use of 4 rMRI protocols, there was a more than 20% decrease in HCT use without missed diagnoses. Time to neuroimaging and length of stay were longer for rMRI than HCT, with higher rates of unsuccessful imaging. Despite these limitations, rMRI may be an alternative to HCT for nontraumatic complaints in the ED.
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http://dx.doi.org/10.1186/s12887-020-1919-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6956479PMC
January 2020

Early Hyperoxemia and Outcome Among Critically Ill Children.

Pediatr Crit Care Med 2020 02;21(2):e129-e132

Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA.

Objective: To identify whether a high PaO2 (hyperoxemia) at the time of presentation to the PICU is associated with in-hospital mortality.

Design: Single-center observational study.

Setting: Quaternary-care PICU.

Patients: Encounters admitted between January 1, 2009, and December 31, 2018.

Interventions: None.

Measurements And Main Results: Encounters with a measured PaO2 were included. To account for severity of illness upon presentation, we calculated a modified Pediatric Risk of Mortality IV score excluding PaO2 for each encounter, calibrated for institutional data. Logistic regression was used to determine whether hyperoxemia (PaO2 ≥ 300 torr [39.99 kPa]) in the 12 hours surrounding PICU admission was associated with in-hospital mortality. We reperformed our analysis using a cutoff for hyperoxemia obtained by comparisons of observed versus predicted mortality when encounters were classified by highest PaO2 in 50 torr (6.67 kPa) bins. Results are reported as adjusted odds ratios with 95% CIs. Of 23,719 encounters, 4,093 had a PaO2 recorded in the period -6 to +6 hours after admission. Two hundred seventy-four of 4,093 (6.7%) had in-hospital mortality. The prevalence of hyperoxemia increased with rising modified Pediatric Risk of Mortality IV and was not associated with mortality in multivariable models (adjusted odds ratio, 1.38; 95% CI, 0.98-1.93). When using a higher cutoff of hyperoxemia derived from comparison of observed versus predicted rates of mortality of greater than or equal to 550 torr (73.32 kPa), hyperoxemia was associated with mortality (adjusted odds ratio, 2.78; 95% CI, 2.54-3.05).

Conclusions: A conventional threshold for hyperoxemia at presentation to the PICU was not associated with in-hospital mortality in a model using a calibrated acuity score. Extreme states of hyperoxemia (≥ 73.32 kPa) were significantly associated with in-hospital mortality. Prospective research is required to identify if hyperoxemia before and/or after PICU admission contributes to poor outcomes.
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http://dx.doi.org/10.1097/PCC.0000000000002203DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7304556PMC
February 2020

Success of Pediatric Intubations Performed by a Critical Care Transport Service.

Prehosp Emerg Care 2020 Sep-Oct;24(5):683-692. Epub 2020 Jan 9.

Prehospital pediatric endotracheal intubation (ETI) is rarely performed. Previous research has suggested that pediatric prehospital ETI, when performed by ground advanced life support crews, is associated with poor outcomes. In this study, we aim to evaluate the first-attempt success rate, overall success rate and complications of pediatric prehospital ETI performed by critical care transport (CCT) personnel. We conducted a retrospective observational study in a multi-state CCT service performing rotor wing, ground, and fixed wing missions. We included pediatric patients (<18 years) for whom ETI was performed by CCT personnel (flight nurse or flight paramedic).Our primary outcome of interest was rate of first-attempt ETI. Secondary outcomes were overall rates of successful ETI, complications encountered, and outcomes of patients with unsuccessful intubation. 993 patients were included (63.2% male, median age 12 years, IQR 4-16 years). 807/993 (81.3%) patients were intubated on the first attempt. Lower rates of successful first-attempt intubation were seen in younger ages (42.9% in infants ≤30 days of age). In multivariable logistic regression, lower odds (adjusted odds ratio, 95% confidence interval) of successful first-attempt ETI were associated with ages >30 days to <1 year (0.33, 0.18-0.61) and 2 to <6 years (0.60, 0.39-0.94) compared to patients 12 to <18 years. Patients given an induction agent and neuromuscular blockade (NMB) had a higher odds of first-attempt ETI success (1.53, 1.06-2.15). 13 (1.3%) had immediately recognized esophageal intubation and 33 (3.3%) had vomiting. No episodes of pneumothorax were reported. 962/993 (96.9%) patients were successfully intubated after all attempts. In patients without successful ETI (n = 31), supraglottic airways were used in 24, bag-valve mask ventilation in 5, and surgical cricothyroidotomy in 2, with an overall advanced airway success rate of 988/993 (99.5%).: Critical care flight nurses and paramedics performed successful intubations in pediatric patients at a high rate of success. Younger age was associated with lower success rates. Improved ETI training for younger patients and use of an induction agent and NMB may improve airway management in critically ill children.
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http://dx.doi.org/10.1080/10903127.2019.1699212DOI Listing
January 2020

Prehospital management of pediatric asthma patients in a large emergency medical services system.

Pediatr Pulmonol 2020 01 18;55(1):83-89. Epub 2019 Oct 18.

Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania.

Background: Asthma is a common pediatric diagnosis for emergency medical services (EMS) transports, however there is a paucity of data on prehospital asthma management. The purpose of this study was to describe prehospital management of pediatric patients with suspected asthma exacerbation.

Methods: We conducted a retrospective review of electronic medical records from 24 ground EMS agencies in Southwestern Pennsylvania between 1 January 2014 to 31 December 2017. We identified patients 2 to 17 years with documented wheezing, excluding those with suspected anaphylaxis. Patients with documented respiratory distress were classified as severe asthma. We report descriptive statistics of demographics, vital signs, and management including administration of medications and performance of procedures.

Results: Of 19 246 pediatric transports, 1078 (5.6%) patients had wheezing. Of these, 532 (49%) met criteria for severe asthma. Patients with severe asthma were more likely to be adolescents compared to those with nonsevere asthma (49.6% vs 6%; P < .001). While rates of intravenous methylprednisolone administration were higher in patients with severe asthma (68/532, 12.8%) compared to those with nonsevere asthma (13/546, 2.4%; P < .001), overall use of steroids was low (7.5%). Other therapies provided included albuterol (n = 699, 64.8%), ipratropium bromide (n = 271, 25.1%), and oxygen (n = 280, 26.0%). One hundred eighty patients (16.7%) received a peripheral IV line. Two patients (0.4%) were given continuous positive airway pressure.

Conclusion: Approximately 6% of pediatric EMS transports are for asthma. Steroid usage was low in even those with severe asthma, representing an area of process improvement. These data provide a baseline to future research to identify interventions that may improve outcomes.
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http://dx.doi.org/10.1002/ppul.24542DOI Listing
January 2020

Visual Diagnosis: The Blue Baby: An Infant Presenting with Severe Respiratory Distress.

Pediatr Rev 2019 Oct;40(10):e35-e38

Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, PA.

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http://dx.doi.org/10.1542/pir.2017-0324DOI Listing
October 2019

Changes in the Management of Children With Brief Resolved Unexplained Events (BRUEs).

Pediatrics 2019 10 5;144(4). Epub 2019 Sep 5.

Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania; and.

Background: In May 2016, the American Academy of Pediatrics published a clinical practice guideline for brief resolved unexplained events (BRUEs). We evaluated for changes in the management of BRUE after guideline publication.

Methods: Using a pediatric multicenter administrative database, we compared rates of admission, testing, revisits, and diagnoses in patients diagnosed with a BRUE or apparent life-threatening event (ALTE) during 2017 with rates of admission, testing, revisits, and diagnoses in patients diagnosed with ALTE during 2015. We used interrupted time series analysis to test if the guideline was associated with changes in admission rate for all patients with ALTE or BRUE between 2015 and 2017. We stratified analyses by age (0-60 and 61-365 days).

Results: A total of 9501 patients were included (5608 in 2015 and 3893 in 2017). The admission rate decreased by 5.7% (95% confidence interval, 3.8% to 7.5%) for infants 0 to 60 days and by 18.0% (95% confidence interval, 15.3% to 20.7%) for infants 61 to 365 days from 2015 to 2017. Patients in 2017 had lower rates of EEG, brain MRI, chest radiography, laboratory testing, and urinalyses compared with patients in 2015. In the interrupted time series analysis model ( = 13 977), guideline publication was associated with decreasing admission rates (0.2% per week) for infants 61 to 365 days ( < .001).

Conclusions: Compared with patients evaluated in 2015, patients with BRUE or ALTE in 2017 have lower rate of admissions and testing. Findings may be due to changes in the definition of BRUE and guideline recommendations.
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http://dx.doi.org/10.1542/peds.2019-0375DOI Listing
October 2019

Association of Severe Hyperoxemia Events and Mortality Among Patients Admitted to a Pediatric Intensive Care Unit.

JAMA Netw Open 2019 08 2;2(8):e199812. Epub 2019 Aug 2.

Department of Pediatrics, University of Pittsburgh School of Medicine; UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania.

Importance: A high Pao2, termed hyperoxemia, is postulated to have deleterious health outcomes. To date, the association between hyperoxemia during the ongoing management of critical illness and mortality has been incompletely evaluated in children.

Objective: To examine whether severe hyperoxemia events are associated with mortality among patients admitted to a pediatric intensive care unit (PICU).

Design, Setting, And Participants: A retrospective cohort study was conducted over a 10-year period (January 1, 2009, to December 31, 2018); all 23 719 PICU encounters at a quaternary children's hospital with a documented arterial blood gas measurement were evaluated.

Exposures: Severe hyperoxemia, defined as Pao2 level greater than or equal to 300 mm Hg (40 kPa).

Main Outcomes And Measures: The highest Pao2 values during hospitalization were dichotomized according to the definition of severe hyperoxemia and assessed for association with in-hospital mortality using logistic regression models incorporating a calibrated measure of multiple organ dysfunction, extracorporeal life support, and the total number of arterial blood gas measurements obtained during an encounter.

Results: Of 23 719 PICU encounters during the inclusion period, 6250 patients (13 422 [56.6%] boys; mean [SD] age, 7.5 [6.6] years) had at least 1 measured Pao2 value. Severe hyperoxemia was independently associated with in-hospital mortality (adjusted odds ratio [aOR], 1.78; 95% CI, 1.36-2.33; P < .001). Increasing odds of in-hospital mortality were observed with 1 (aOR, 1.47; 95% CI, 1.05-2.08; P = .03), 2 (aOR, 2.01; 95% CI, 1.27-3.18; P = .002), and 3 or more (aOR, 2.53; 95% CI, 1.62-3.94; P < .001) severely hyperoxemic Pao2 values obtained greater than or equal to 3 hours apart from one another compared with encounters without hyperoxemia. A sensitivity analysis examining the hypothetical outcomes of residual confounding indicated that an unmeasured binary confounder with an aOR of 2 would have to be present in 37% of the encounters with severe hyperoxemia and 0% of the remaining cohort to fail to reject the null hypothesis (aOR of severe hyperoxemia, 1.31; 95% CI, 0.99-1.72).

Conclusions And Relevance: Greater numbers of severe hyperoxemia events appeared to be associated with increased mortality in this large, diverse cohort of critically ill children, supporting a possible exposure-response association between severe hyperoxemia and outcome in this population. Although further prospective evaluation appears to be warranted, this study's findings suggest that guidelines for ongoing management of critically ill children should take into consideration the possible detrimental effects of severe hyperoxemia.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.9812DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6707098PMC
August 2019

Brief Resolved Unexplained Events: Analysis of an Apparent Life Threatening Event Database.

Acad Pediatr 2019 Nov - Dec;19(8):963-968. Epub 2019 Aug 8.

Division of Pediatric Emergency Medicine, Department of Pediatrics (S Ramgopal, J Soung, RD Pitetti), UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pa.

Objective: To identify the proportion of patients previously diagnosed with apparent life-threatening events (ALTE) who would meet criteria for brief resolved unexplained events (BRUE) and to identify rates of adverse outcomes in subgroups: ALTE not meeting criteria for BRUE, lower-risk BRUE, and higher-risk ALTE.

Methods: We performed a secondary analysis of a single-center prospective registry of patients diagnosed with ALTE in a tertiary care emergency department from March 1, 1997 to October 31, 2007. We identified the proportion of patients meeting criteria for BRUE, and the proportion of patients with BRUE meeting lower-risk criteria. We assessed outcomes of patients in subgroups.

Results: Seven hundred and sixty-two patients were included. Adverse outcomes included recurrent ALTE (n = 49), aspiration (n = 9), trauma (n = 8), and death (n = 4). Three hundred and twenty-six of 762 (42.8%) met criteria for BRUE. Seventy of 326 (21.5%) met criteria for lower-risk BRUE. Adverse outcomes occurred in 40 of 436 (9.2%) with ALTE not meeting criteria for BRUE, 2 of 70 (2.9%) with lower-risk BRUE, and 23 of 256 (9.0%) with higher-risk BRUE. Of 4 patients who died, 1 had an ALTE not meeting criteria for BRUE and 3 had non-lower-risk BRUE. The BRUE risk criteria identified all BRUE patients that died or had substantial morbidity as higher-risk.

Conclusions: Less than half of patients with ALTE meet criteria for BRUE. Of those who do, one-fifth is lower-risk. In this series, the risk-stratification in the BRUE criteria identified those patients at highest risk of adverse outcomes. Further research is required to risk-stratify patients with BRUE.
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http://dx.doi.org/10.1016/j.acap.2019.08.001DOI Listing
August 2020

Serious Bacterial Infections in Neonates Presenting Afebrile With History of Fever.

Pediatrics 2019 08;144(2)

Divisions of Pediatric Emergency Medicine and.

Background: Infants ≤28 days of age with fever are frequently hospitalized while undergoing infectious evaluation. We assessed differences in rates of serious bacterial infection (SBI; bacteremia, bacterial meningitis, urinary tract infection) and invasive bacterial infection (IBI; bacteremia, bacterial meningitis) among the following neonates: (1) febrile at presentation (FP), (2) afebrile with history of fever without subsequent fever during hospitalization, and (3) afebrile with history of fever with subsequent fever during hospitalization.

Methods: We performed a single-center retrospective study of neonates evaluated for SBI during emergency department evaluation between January 1, 2006, and December 31, 2017. Patients were categorized into FP, afebrile with no subsequent fever (ANF), and afebrile with subsequent fever (ASF) groups. We compared rates of SBI and IBI between groups using logistic regression and assessed time to fever development using time-to-event analysis.

Results: Of 931 neonates, 278 (29.9%) were in the ANF group, 93 (10.0%) were in the ASF group, and 560 (60.2%) were in the FP group. Odds of SBI in neonates ANF were 0.42 (95% confidence interval [CI] 0.23-0.79) compared with infants FP, although differences in IBI were not statistically significant (0.52, 95% CI 0.19-1.51). In infants ASF, median time to fever was 5.6 hours (interquartile range, 3.1-11.4). Infants ASF had higher odds of SBI compared to infants FP (odds ratio 1.93, 95% CI 1.07-3.50).

Conclusions: Neonates with history of fever who remain afebrile during hospitalization may have lower odds for SBI and be candidates for early discharge after an observation period.
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http://dx.doi.org/10.1542/peds.2018-3964DOI Listing
August 2019

Inpatient use of racemic epinephrine for children admitted with croup.

World J Pediatr 2019 Dec 25;15(6):586-594. Epub 2019 Jul 25.

Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.

Background: Pediatric patients with croup are frequently admitted if they require two doses of racemic epinephrine (RE) in the emergency department (ED). We aimed to identify factors associated with the need for additional therapy (> 2 RE doses) among pediatric patients with croup.

Methods: We performed a single-center retrospective study of consecutive patients admitted from the ED with a diagnosis of croup between January 1, 2011 and December 31, 2015. Primary outcome was need for > 2 doses of RE. Secondary outcomes included time to third RE and 72-hour return visits. We performed logistic regression to identify factors associated with use of > 2 RE doses during hospitalization, and survival analysis to identify time to dosing of 3rd RE from 2nd RE.

Results: Of 353 included admissions [250 (70.8%) males, median age 1.48, interquartile range 0.97-2.51 years], 106/353 (30.0%) required > 2 RE. In univariate logistic regression, only recent use of steroids within 1 day prior to presentation (4.18, 1.48-11.83; P = 0.007) was associated with need for > 2 RE. Survival from third RE was 0.74 (95% CI 0.69-0.78), which was similar to the survival at 12 hours (0.70, 95% CI 0.65-0.75). Return visits occurred in 19 (5.4%) patients, of whom 12/19 (63.2%) were given RE.

Conclusions: Patients hospitalized for croup with recent use of steroids prior to ED presentation have a greater need for > 2 RE during hospitalization. The majority who require inpatient RE will do so within 8-12 hours. These data provide information for risk stratification and duration of monitoring for patients hospitalized with croup.
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http://dx.doi.org/10.1007/s12519-019-00291-xDOI Listing
December 2019

Immature neutrophils in young febrile infants.

Arch Dis Child 2019 09 20;104(9):884-886. Epub 2019 Jun 20.

Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania, USA.

Background: To describe the diagnostic value of the absolute band count (ABC) and ratio of immature to total neutrophils (I:T) for invasive bacterial infections (IBIs; bacterial meningitis and bacteraemia) among young febrile infants.

Methods: We performed a cross-sectional study in a paediatric emergency department of febrile infants ≤60 days over 12 years to evaluate the accuracy of the ABC and I:T for IBI.

Results: Of 2930 included patients, 75 (2.6%) had IBIs. The area under the curve (AUC; 95% CI) for ABC was 0.69 (0.62 to 0.76) with sensitivity 0.27 (0.17 to 0.38) and specificity 0.94 (0.93 to 0.95) at cutoff ≥1500 cells/µL. The AUC for I:T was 0.65 (0.59 to 0.72) with sensitivity 0.29 (0.19 to 0.41) and specificity 0.88 (0.87 to 0.89) at cutoff ≥0.2. Only the ABC in infants 29-60 days was minimally accurate.

Conclusion: The ABC and I:T were generally inaccurate for detecting IBI in febrile infants. Guidelines without these parameters may be better for risk assessment.
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http://dx.doi.org/10.1136/archdischild-2019-317143DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7266081PMC
September 2019

Risk Factors and Outcomes From All-Terrain Vehicle Injuries Compared With Motor Vehicle Collisions in Children.

Clin Pediatr (Phila) 2019 10 12;58(11-12):1255-1261. Epub 2019 Jun 12.

University of Pittsburgh, Pittsburgh, PA, USA.

We compared risk factors and outcomes of children injured from all-terrain vehicle (ATV) injuries to those injured from motor vehicle collisions (MVC). We reviewed records of patients ≤18 years of age admitted to a trauma center with ATV- or MVC-related injuries between January 1, 2000, and December 31, 2015. Demographics were compared using logistic regression. Rates of injuries were compared using χ tests. Of 6293 patients, 1140 (18%) ATV and 5153 (82%) MVC events were identified. In multivariable analysis (adjusted odds ratio [aOR], 95% confidence interval [CI]), patients with ATV-related injuries occurred more at older age (≥12 years; aOR = 4.29, 95% CI = 3.20-5.77), in rural counties (aOR = 3.72, 95% CI = 2.62-5.28), in regions with lower median household income (aOR = 1.37, 95% CI = 1.03-1.83), and in the spring (aOR = 2.44, 95% CI = 1.87-3.18), and summer (aOR = 2.50, 95% CI = 1.93-3.25) compared with winter. ATV-related injuries occurred less frequently among females (aOR = 0.76, 95% CI = 0.65-0.89). Upper extremity injuries were associated with ATV-related injuries ( ≤ .001). Findings may facilitate identification of at-risk groups for targeted interventions.
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http://dx.doi.org/10.1177/0009922819855808DOI Listing
October 2019

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

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

Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital and Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada.

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

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

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

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