ABSTRACT
Study Objective: In the emergency department (ED), chemical restraints are utilized for patients who present imminent danger to self or others. In children and adults, increased restraint has been associated with black males for both chemical and physical restraints. Further although most pediatric ED visits occur in community hospitals, pediatric studies have analyzed only those seen at freestanding children's hospitals. With the rising pediatric behavioral health crisis, we sought to evaluate trends and hospital variation in the use of chemical restraint for pediatric behavioral health patients and assess for any association with race/ethnicity or hospital-level factors. Study Methods: This was a retrospective cohort study of pediatric ED patients ages 8-17 treated at hospitals contributing to the Premier Database between January 1, 2018-December 31, 2020 who had an ED discharge diagnosis associated with a mental health or behavioral condition, identified via the presence of an International Classification of Diseases, Tenth Revision code using the Child and Adolescent Mental Health Disorders Classification System (CAMHD-CS). Hospitals contributing fewer than 50 cases during the study period were excluded. The primary outcome was the proportion of patients with a behavioral health ED diagnosis who underwent chemical restraint. This was defined as receipt of an intramuscular benzodiazepine or antipsychotic medication. We also developed a hierarchical model, adjusting for patient and hospital variables, to compute a median odds ratio (MOR) to quantify the contribution of the individual hospital on the odds of a patient being discharged from the ED. Additionally, we performed a descriptive analysis of medications used and the proportion chemically restrained before or during the COVID-19 pandemic. Result(s): A total of 630,399 patients from 822 hospitals were included in the overall cohort and 29,399 (4.7%) were administered medication associated with chemical restraint. The median age was 15 (IQR 13-16), 54.6% were female, and 59.3% were white. Compared to those who did not receive chemical restraint, those who were chemical restrained were more likely to be older (13-17 years [OR 1.61, 95% CI 1.56-1.67]), privately insured (OR 1.21, 95% CI 1.18-1.25), or have a concurrent ED diagnosis of anxiety disorders (OR 1.72, 95% CI 1.67-1.77), and disruptive mental health diagnosis (OR 1.69, 95% CI 1.61-1.77). There was no difference in chemical restraint for race/ethnicity (Black OR 0.97 [95% CI 0.94-1.01], Hispanic OR 0.99 [95% CI 0.95-1.03], or sex (female OR 0.94 [95% CI 0.92-0.97]). Overall, 4.7% received medications associated with chemical restraint. After adjusting for patient and hospital factors, the influence of the individual hospital on the odds of chemical restraint was 1.44 (MOR;95% CI 1.40-1.47). Overall, chemical restraint rates were similar across hospital covariates except for geographical region, where the median restraint rate was much lower in the Northeast (3.8%;IQR 2.9-5.1). During the COVID-19 pandemic, median rates of chemical restraint were higher (6.0%, 95% CI 5.8-6.1) compared to pre-pandemic (4.4%, 95% CI 4.3-4.4). Conclusion(s): We found that age, but not race/ethnicity or sex, was associated with a higher odds of chemical restraint during ED visits associated with a mental health or behavioral diagnosis. Although hospital-level restraint rates were low, we found that practice varied across hospitals and regions. [Formula presented] [Formula presented] No, authors do not have interests to disclose Copyright © 2022
ABSTRACT
Introduction: Renal disease in COVID-19 is often due to acute tubular injury but can include multiple glomerular lesions such as collapsing glomerulopathy. This is the first reported case of COVID-19-associated PGNMID. Case Description: A 71-year-old woman with normal baseline creatinine (Cr) was admitted with COVID-19 and discharged on oxygen and dexamethasone (Dex). She improved but returned a month later with edema and nausea. She was found to have nephrotic syndrome, hematuria, and AKI (peak Cr 8.5 mg/dL) requiring HD. Kidney biopsy revealed PGNMID with clonal IgG3-kappa. SPEP, serum free light chains (sFLC), 24h urine UPEP, bone marrow biopsy with flow cytometry, fat pad biopsy, and PET-CT were negative for monoclonal immunoglobulin (Ig) or cell line, amyloid, or malignancy. Though symptoms had long since resolved, she was still PCR-positive for SARS-CoV-2 on nasal swab. Upon discharge she was given cyclophosphamide (Cy). Her renal function improved (Cr 2.5) and she came off HD 2 weeks later. Her outpatient oncologist opted not to continue therapy. However, 2 months later she was readmitted with nausea, dyspnea, and anasarca with recurrent AKI (Cr 6.7) and nephrotic syndrome. HD was restarted. Repeat kidney biopsy [Figure] was noted to be a carbon copy of the first. SPEP, spot UPEP, and sFLC were again negative. She was started on Cy, bortezomib, and Dex with similar partial response (Cr <2.5). Discussion: PGNMID is a rare type of monoclonal gammopathy of renal significance (MGRS) that often has no detectable extrarenal monoclonal Ig or cell line. MGRS and PGNMID, though usually not postinfectious, have been reported with other viruses (e.g., viral hepatitis, parvovirus-B19). However, though causality is unclear, this is the first case of MGRS reported in association with COVID-19.