Pediatric Discharge From the Emergency Department Against Medical Advice.

In this Ethics Rounds we present a conflict regarding discharge planning for a febrile infant in the emergency department. The physician believes discharge would be unsafe and would constitute a discharge against medical advice. The child's mother believes her son has been through an already extensive and painful evaluation and would prefer to monitor her well-appearing son closely at home with a safety plan and a next-day outpatient visit. Commentators assess this case from the perspective of best interest, harm-benefit, conflict management, and nondiscriminatory care principles and prioritize a high-quality informed consent process. They characterize the formalization of discharge against medical advice as problematic. Pediatricians, a pediatric resident, ethicists, an attorney, and mediator provide a range of perspectives to inform ethically justifiable options and conflict resolution practices.

Asthma Screening in Pediatric Sickle Cell Disease: A Clinic-Based Program Using Questionnaires and Spirometry.

A clinician diagnosis of asthma is associated with increased morbidity and mortality in people with sickle cell disease (SCD). We hypothesized that a screening program would help identify children with asthma needing referral to pulmonary clinic. We conducted a single-center project to screen patients with SCD for asthma using a previously validated questionnaire (Breathmobile) and for pulmonary function abnormalities with portable spirometry. Participants with a positive questionnaire and/or abnormal spirometry were referred to pediatric pulmonary clinic. We evaluated clinical associations with abnormal spirometry and questionnaire responses. Of the 157 participants, 58 (37%) had a positive asthma screening questionnaire. Interpretable spirometry was available for 105 (83% of those eligible) and of these, 35 (34%) had abnormal results. The asthma questionnaire was 87.5% sensitive [95% confidence interval (CI) 74.8-95.3] and 85.3% specific (95% CI 77.3-91.4) to detect a clinician diagnosis of asthma. Participants with positive questionnaires were older (mean age 12.2 vs. 9.9 years, P = 0.012). Spirometry identified 16 additional participants who had normal asthma questionnaires. Seventy-four participants (47%) were referred to pediatric pulmonary clinic and 25 (34%) of these participants scheduled clinic appointments; however, only 13 (52%) were evaluated in pulmonary clinic. Clinic-based asthma screening and spirometry frequently identified individuals with asthma and pulmonary function abnormalities. Only 22% of those referred were eventually seen in pulmonary clinic. The impact of improved screening and treatment on the pulmonary morbidity in SCD needs to be defined and is an area for future investigation. In addition, case management or multidisciplinary clinics may enhance future screening programs.

Human Papillomavirus Co-Testing Results Effectively Triage Normal Cervical Cytology in HIV-Positive Women Aged 30 Years and Older.

OBJECTIVE: The aim of the study was to assess whether HIV-positive (HIV+) women aged 30 years and older with concurrent normal cervical cytology and undetectable cervical HPV have a low 3-year risk of developing cervical intraepithelial neoplasia grade 2 or higher (CIN 2+) in a clinical setting. MATERIALS AND METHODS: We conducted a retrospective chart review of HIV+ women aged 30 years and older at a single institution with normal cervical cytology and concurrent human papillomavirus (HPV) testing between November 2008 and December 2010. The participants were stratified by initial HPV testing results and followed to either the study end point (CIN 2+) or until the last cervical cytology or colposcopy before January 2015. Kaplan-Meier survival curves were used to analyze CIN 2+ diagnosis for follow-up with log-rank testing of the null hypothesis. Cox proportional hazard regression was performed to calculate crude and adjusted hazard ratios controlling for ethnicity and CD4 levels. RESULTS: We identified 325 HIV+ women with normal cytology and follow-up; 66 (20%) of these women had detectable HPV. The cumulative diagnosis of CIN 2+ at 4 years was significantly lower in the HPV-negative cohort compared with the HPV-positive cohort (1.4%, 95% CI = 0.3%-4.6% vs 14.5%, 95% CI = 5.8%-27.1%), respectively; the median duration to CIN 2+ diagnosis was longer in the HPV-negative cohort compared with the HPV-positive cohort (4.2 years vs 1.5 years, respectively, p < .02). CONCLUSIONS: HIV+ women aged 30 years and older with concurrent normal cervical cytology and undetectable cervical HPV have a low 3-year risk of subsequent diagnosis of CIN 2+. The study validates the recently updated US recommendations for the use of co-testing in screening HIV+ women.

Secondhand smoke is associated with more frequent hospitalizations in children with sickle cell disease.

Tobacco smoke exposure has been associated with more frequent hospitalizations in children with sickle cell disease (SCD), but previous studies have not quantified the exposure by objective methods. We enrolled 50 children and young adults with SCD in a retrospective and prospective cohort study and quantified tobacco smoke exposure by objective (salivary cotinine) and survey measures. We used a multivariable negative binomial regression model to evaluate the association between salivary cotinine and hospital admissions. Forty-five percent (22/49) of participants had significant elevation of salivary cotinine (≥ 0.5 ng/ml). The incidence risk ratio (IRR) for hospital admission for those with elevated cotinine was 3.7 (95% CI 1.8-8). Those exposed to secondhand smoke but not primary smokers (cotinine between 0.5 and 10 ng/ml) had a similarly increased risk of hospitalization [IRR 4.3 (95% CI 1.8-10)]. We show that an objective measure of tobacco smoke exposure, salivary cotinine, is strongly associated with the rate of hospital admissions in children and young adults with SCD. This association underscores the importance of screening for tobacco smoke exposure in people with SCD. Further investigation is warranted to determine the mechanisms of and to evaluate interventions to decrease tobacco smoke exposure.