Management of Pediatric Mild Traumatic Brain Injury Patients: S100b, Glial Fibrillary Acidic Protein, and Heart Fatty-Acid-Binding Protein Promising Biomarkers.

Children are highly vulnerable to mild traumatic brain injury (mTBI). Blood biomarkers can help in their management. This study evaluated the performances of biomarkers, in discriminating between children with mTBI who had intracranial injuries (ICIs) on computed tomography (CT+) and (1) patients without ICI (CT-) or (2) both CT- and in-hospital-observation without CT patients. The aim was to rule out the need of unnecessary CT scans and decrease the length of stay in observation in the emergency department (ED). Newborns to teenagers (≤16 years old) with mTBI (Glasgow Coma Scale > 13) were included. S100b, glial fibrillary acidic protein (GFAP), and heart fatty-acid-binding protein (HFABP) performances to identify patients without ICI were evaluated through receiver operating characteristic curves, where sensitivity was set at 100%. A total of 222 mTBI children sampled within 6 h since their trauma were reported. Nineteen percent (n = 43/222) underwent CT scan examination, whereas the others (n = 179/222) were kept in observation at the ED. Sixteen percent (n = 7/43) of the children who underwent a CT scan had ICI, corresponding to 3% of all mTBI-included patients. When sensibility (SE) was set at 100% to exclude all patients with ICI, GFAP yielded 39% specificity (SP), HFABP 37%, and S100b 34% to rule out the need of CT scans. These biomarkers were even more performant: 52% SP for GFAP, 41% for HFABP, and 39% for S100b, when discriminating CT+ versus both in-hospital-observation and CT- patients. These markers can significantly help in the management of patients in the ED, avoiding unnecessary CT scans, and reducing length of stay for children and their families.

Impact of Rapid On-demand Molecular Diagnosis of Pediatric Seasonal Influenza on Laboratory Workflow and Testing Costs: A Retrospective Study.

BACKGROUND: Seasonal influenza imposes a considerable burden worldwide. We aimed to evaluate impact of rapid pediatric seasonal influenza diagnosis on laboratory workflow and cost using a rapid antigen detection-based test combined with either a reverse transcriptase polymerase chain reaction (RT-PCR) or the Alere i Influenza A and B (Alere i) assay for confirmation of negative results as well as single Alere i testing on nasopharyngeal aspirates. A secondary objective was assessing performance of Alere i against RT-PCR. METHODS: Effects of implementing the 3 diagnostic algorithms were assessed in the Emergency Department of Hospital Sant Joan de Déu (Barcelona, Spain) across the 2014-2015, 2015-2016 and 2016-2017 influenza seasons. Alere i performance against RT-PCR was determined during the 2015-2016 epidemic period. RESULTS: Median time to result decreased when using Alere i as a confirmatory test of previous antigen detection and RT-PCR results or alone (9.7vs. 3.5/2.0 and 0.7 hours, P < 0.001) along with mean testing costs (&OV0556;87.3 vs. &OV0556;38.2 and &OV0556;25.0, P < 0.001). Results available before patient discharge from the emergency department increased from 42.7% for sequential testing by antigen detection and RT-PCR to 80.0% when Alere i was utilized as a stand-alone test. Alere i sensitivity and specificity values were 96.6% (95% confidence interval: 82.8%-99.4%) and 94.4% (95% confidence interval: 86.6%-97.8%), respectively. CONCLUSIONS: Rapid Alere i testing facilitated efficient laboratory workflow near the patient during influenza epidemics while contributing cost savings when compared with serial testing by antigen and RT-PCR assays.

Evaluation and Impact of the "Advanced Pediatric Life Support" Course in the Care of Pediatric Emergencies in Spain.

INTRODUCTION: The Advanced Pediatric Life Support (APLS) course was introduced in the training of professionals who care for pediatric emergencies in Spain in 2005. OBJECTIVE: To analyze the impact of the APLS course in the current clinical practice in Spanish PEDs. METHODS: The directors of APLS courses were asked about information regarding the courses given to date, especially on the results of the satisfaction survey completed by students at the end of the course. Furthermore, in December 2014, a survey was conducted through Google Drive, specifically asking APLS students about the usefulness of the APLS course in their current clinical practice. RESULTS: In the last 10 years since the APLS course was introduced in Spain, there have been 40 courses in 6 different venues. They involved a total of 1520 students, of whom 958 (63.0%) felt that the course was very useful for daily clinical practice. The survey was sent to 1,200 students and answered by 402 (33.5%). The respondent group most represented was pediatricians, 223 (55.5%), of whom 61 (27.3%) were pediatric emergency physicians, followed by pediatric residents, 122 (30.3%). One hundred three (25.6%) respondents had more than 10 years of professional practice and 291 (72.4%) had completed the course in the preceding four years. Three hundred forty-one of the respondents (84.9%: 95% confidence interval [CI], 81.9-87.9) said that they always use the pediatric assessment triangle (PAT) and 131 (32.6%: 95% CI, 28-37.1) reported that their organization has introduced this tool into their protocols. Two hundred twenty-three (55.5%: 95% CI, 50.6-60.3) believed that management of critically ill patients has improved, 328 (81.6%: 95% CI, 77.8-85.3) said that the PAT and the systematic approach, ABCDE, help to establish a diagnosis, and 315 (78.4%: 95% CI, 74.3-82.4) reported that the overall number of treatments has increased but that these treatments are beneficial for patients. Hospital professionals (191; 47.5%) include the PAT in their protocols more frequently than pre-hospital professionals (68.5% vs 55.4%; p <0.01) and consider PAT useful in the management of patients (60.2% vs 51.1%; p <0.05). Neither the time elapsed since the completion of the course, nor category and years of professional experience had any influence on the views expressed about the impact of the APLS course in clinical practice. CONCLUSIONS: Most health professionals who have received the APLS course, especially those working in the hospital setting, think that the application of the systematic methods learned, the PAT and ABCDE, has a major impact on clinical practice.

Errors de prescripció a urgències: un problema deseguretat del pacient / Errores de prescripción en urgencias: un problema de seguridad del paciente / Prescription errors in emergencies: a problem of patient safety

Fonament: els errors de prescripció farmacològica són unacausa important i prevenible de morbimortalitat, especialment en infants. Objectiu: per minimitzar aquests errors és necessari co-nèixer quins són i quins factors els provoquen. Mètode: revisió bibliogràfica mitjançant PubMed, Cochrane Library i Embase fins al juliol del 2013. Es revisen elsarticles en què es reporten errors de prescripció, especialment en infants i als serveis d'urgències, factors associatsa errors i estratègies per prevenir-los. Resultats: els fàrmacs que s'han associat amb més errors són els broncodilatadors, els corticoides i els antiinflamatoris. Entre els errors de medicació, els de prescripció sónels més comuns i entre aquests, els de dosi i indicació. Lamajoria són lleus. S'han descrit factors que afavoreixen laproducció d'errors, com el grau baix d'experiència del facultatiu, la urgència més gran de les prescripcions, els diesfestius i les nits i la poca edat del pacient. Algunes estratègies han demostrat reduir errors, com latecnologia (introducció informatitzada de dades, alarmes, dispensadors automatitzats de fàrmacs), la formació i el reciclatge del personal (sobretot el primer any), la cultura deseguretat, la incorporació d'un farmacèutic, les taules estandarditzades per pes per als fàrmacs de reanimació, elssistemes de torns i una bona comunicació a l'equip i ambels pacients. Conclusions: els errors més freqüents són els de dosi i enels fàrmacs de més ús. Una cultura de seguretat que fomenti expressar els errors i busqui estratègies preventivesés fonamental per reduir-los

Fundamento. Los errores de prescripción farmacológica son una causa importante y prevenible de morbimortalidad, especialmente en niños. Objetivo. Para minimizar estos errores es necesario conocer cuáles son y qué factores los provocan. Método. Revisión bibliográfica a través de PubMed, Cochrane Library y Embase hasta julio de 2013. Se revisan los artículos donde se reportan errores de prescripción, especialmente en niños y en los servicios de urgencias, los factores asociados a éstos y estrategias para prevenirlos. Resultados. Los fármacos que se han asociado con más errores son los broncodilatadores, corticoides y antiinflamatorios. Dentro de los errores de medicación, los de prescripción son los más comunes y entre éstos, los de dosis e indicación. La mayoría son leves. Se han descrito factores que favorecen la producción de errores, como la menor experiencia del facultativo, mayor urgencia de las prescripciones, días festivos y noches y menor edad del paciente. Algunas estrategias han demostrado reducir errores, como la tecnología (introducción informatizada de datos, alarmas, dispensadores automatizados de fármacos), la formación y reciclaje del personal (sobre todo durante el primer año), la cultura de seguridad, la incorporación de un farmacéutico, las tablas estandarizadas por peso para los fármacos de reanimación, los sistemas de turnos y una buena comunicación en el equipo y con los pacientes. Conclusiones. Los errores más frecuentes son los de dosis y en los fármacos de más uso. Una cultura de seguridad que fomente expresar los errores y busque estrategias preventivas es fundamental para reducirlos (AU)

Background. Prescription errors are an important and preventable cause of morbidity, especially for children. Objective. The first step towards reducing prescription errors involves knowing the most common errors and their risk factors. Method. Literature review of manuscripts published until July 2013 using the PubMed, Chochrane Library, and EMBASE databases. Articles reporting prescription errors, especially in children and in the emergency departments, factors associated to those, and strategies to prevent them, were reviewed. Results. The drugs most commonly involved in errors are bronchodilators, systemic steroids, and anti-inflammatory agents. The most common medication errors are related to prescription, particularly in dosing and indication. The majority of errors are of low impact. Factors associated with errors include urgency, physician’s experience, holidays and nights, and younger patient’s age. Some strategies have shown to reduce drug errors, such as technology innovations (computerized data entry, alarms, and automated drug dispensers), training and education (especially during the first year of practice), existence of patient safety culture, incorporation of a pharmacist, weight-adjusted dose tables for resuscitation drugs, well-regulated shifts, and good communication within staff members and with families. Conclusions. The most frequent medication errors are related to dosing and involve the most common drugs. A safety culture that fosters reporting errors and looks for preventive strategies is fundamental to reduce them (AU)

Lack of value of midregional pro-adrenomedullin and C-terminal pro-endothelin-1 for prediction of severe bacterial infections in infants with fever without a source.

UNLABELLED: The study was performed to assess the usefulness of two new biomarkers, midregional pro-adrenomedullin (MR-pro-ADM) and C-pro-endothelin-1 (CT-pro-ET-1), in predicting bacterial infection (BI) and especially invasive bacterial infection (IBI) in well-appearing infants with fever without source (FWS). For this purpose, a multicenter prospective study was conducted between February 2008 and March 2009 including well-appearing infants less than 36 months of age with FWS. MR-pro-ADM, CT-pro-ET-1, procalcitonin (PCT), CRP, and WBC were measured and compared. Among the 1,035 infants included, a bacterial infection was diagnosed in 75 patients (7.2 %), and 16 (1.54 %) had an invasive bacterial infection (bacterial meningitis, 8; occult bacteremia, 6; and sepsis, 1). MR-pro-ADM and CT-pro-ET-1 levels were less reliable for diagnosis than the other biomarkers. The area under receiver operating characteristic curve for infants with BI and IBI was 0.59 (95 % confidence interval (CI) 0.52-0.67) and 0.63 (95 % CI 0.46-0.80) for MR-pro-ADM and 0.58 (95 % CI 0.51-0.66) and 0.62 (95 % CI 0.47-0.67) for CT-pro-ET-1, respectively. Multivariate analysis showed that PCT ≥ 0.5 ng/mL, CRP ≥ 40 mg/L, and CT-pro-ET-1 ≥ 105 pmol/mL were independent risk factors for having a BI (odds ratio (OR) 6.12, 3.61, and 2.84, respectively). PCT was the only independent risk factor for having an IBI (OR 17.53 if PCT ≥ 0.5 ng/mL). CONCLUSION: Although baseline MR-pro-ADM and CT-pro-ET-1 levels are significantly elevated in well-appearing febrile infants with a bacterial infection, their overall performance as diagnostic markers is very poor.

Procalcitonin to detect invasive bacterial infection in non-toxic-appearing infants with fever without apparent source in the emergency department.

The reliability of procalcitonin as a predictor of invasive infection in infants <36 months of age with fever and nontoxic appearance was assessed in 868 patients, 15 (1.7%) of whom had invasive infection. The area under the receiver operating characteristic curve for procalcitonin was 0.87 (optimum cutoff 0.9 ng/mL, sensitivity 86.7%, specificity 90.5%), whereas for C-reactive protein it was 0.79 (optimum cutoff 91 mg/L, sensitivity 33.3%, specificity 95.9%). In infants with fever of <8 hours duration, the area under the receiver operating characteristic curve was 0.97 for procalcitonin and 0.76 for C-reactive protein. Procalcitonin was a useful biomarker to predict invasive infection in non-toxic-appearing infants with fever without apparent focus, particularly in febrile episodes of <8 hours duration.

Procalcitonin is a predictor for high-grade vesicoureteral reflux in children: meta-analysis of individual patient data.

OBJECTIVE: To assess the predictive value of procalcitonin, a serum inflammatory marker, in the identification of children with first urinary tract infection (UTI) who might have high-grade (≥3) vesicoureteral reflux (VUR). STUDY DESIGN: We conducted a meta-analysis of individual data, including all series of children aged 1 month to 4 years with a first UTI, a procalcitonin (PCT) level measurement, cystograms, and an early dimercaptosuccinic acid scan. RESULTS: Of the 152 relevant identified articles, 12 studies representing 526 patients (10% with VUR ≥3) were included. PCT level was associated with VUR ≥3 as a continuous (P = .001), and as a binary variable, with a 0.5 ng/mL preferred threshold (adjusted OR, 2.5; 95% CI, 1.1 to 5.4). The sensitivity of PCT ≥0.5 ng/mL was 83% (95% CI, 71 to 91) with 43% specificity rate (95% CI, 38 to 47). In the subgroup of children with a positive results on dimercaptosuccinic acid scan, PCT ≥0.5 ng/mL was also associated with high-grade VUR (adjusted OR, 4.8; 95% CI, 1.3 to 17.6). CONCLUSIONS: We confirmed that PCT is a sensitive and validated predictor strongly associated with VUR ≥3, regardless of the presence of early renal parenchymal involvement in children with a first UTI.

Prospective validation of two systems of classification for the diagnosis of acute appendicitis.

OBJECTIVES: The objectives of this study were (1) to validate the Alvarado score and pediatric appendicitis score (PAS) in a prospectively identified pediatric cohort and (2) to assess abdominal ultrasonography (AUS) as a tool to increase the diagnostic reliability of both scores. PATIENTS AND METHODS: Prospective study conducted from January 10, 2008, to January 1, 2009. All patients attended at the emergency department with suspected acute appendicitis (AA) who had a blood sample collected were included. Items from both scores were recorded. The performance of an AUS, the decision to admit the patient, and the therapeutics were decided by the physician, disregarding the scores values. Nonadmitted patients were contacted by telephone. RESULTS: Ninety-nine patients were included. Mean age was 11 years, and 62.6% were males. Appendectomy was performed in 44.4% patients. The area under the receiver operating characteristic curve for the Alvarado score was 0.96 and that for PAS was 0.97. Not a single patient with an Alvarado score less than 5 or PAS less than 4 had AA. All patients with an Alvarado score greater than 8 or PAS greater than 7 had AA. For both scores, the optimum cutoff point was 6 (sensibility of 90.4% and specificity of 91.2% for the Alvarado score and sensibility of 88.1% and specificity of 98.2% for PAS). Abdominal ultrasonography was performed on 31 patients (sensibility of 84.6% and specificity of 94.4%). We studied the value of scores and AUS together. Assuming an Alvarado score from 1 to 4 and PAS from 1 to 3 as no AA, an Alvarado score from 9 to 10 and PAS from 8 to 9 as AA, and proceeding according to the AUS for intermediate values, a sensibility of 93.3% and 97.2% and a specificity of 100% and 97.6%, respectively, were obtained. CONCLUSIONS: Both scores are a useful tool in the evaluation of children with possible AA. For extreme values of scores, the results really ensure their use in the emergency department. The AUS can help on decision making for intermediate values.

Family presence during invasive procedures at the emergency department: what is the opinion of Spanish medical staff?

OBJECTIVES: Family presence (FP) during invasive procedures (IPs) in children remains controversial among pediatric emergency department (PED) staff. The authors aimed to determine health care providers' attitudes toward FP during IPs in Spain, to learn whether parents are given the option of being present during different IPs, and to study which factors influence the providers' opinions. METHODS: Observational study. Physicians and nurses were asked to answer a questionnaire, which was sent to 43 PEDs and was available at the Spanish Pediatric Emergency Society Web site. RESULTS: We obtained 222 questionnaires from 36 Spanish hospitals. A total of 65.8% of the surveys were answered by physicians (66.4% pediatricians) and 34.2% by nurses. The median age of the respondents was 32 years, and 69.2% were women. Parents were given the option of being present during blood sampling (36.4%), intravenous line placement (32.7%), urethral catheterization (32.1%), lumbar puncture (13.5%), and resuscitation (1%). More than 60% of providers approved of FP during blood sampling, sutures, intravenous line placement, and urethral catheterization; however, only 10.8% of providers encourages FP during resuscitation. Against FP, health care staff argue procedural invasiveness (75.6%), parents' anxiety (87.6%), and worsened performance of the procedure (66%). Commonly expressed advantages were reducing patient distress (72.9%) and parent anxiety (62.3%). Physicians, especially the older ones, are more likely to encourage FP than nurses for some IPs. CONCLUSIONS: The PED staff tend to prefer parents not to be present during IPs as the level of invasiveness increases. Family presence is not common in Spanish PEDs. Older physicians are more likely to support FP than nurses.

Prediction of high-grade vesicoureteral reflux after pediatric urinary tract infection: external validation study of procalcitonin-based decision rule.

BACKGROUND: Predicting vesico-ureteral reflux (VUR) ≥3 at the time of the first urinary tract infection (UTI) would make it possible to restrict cystography to high-risk children. We previously derived the following clinical decision rule for that purpose: cystography should be performed in cases with ureteral dilation and a serum procalcitonin level ≥0.17 ng/mL, or without ureteral dilatation when the serum procalcitonin level ≥0.63 ng/mL. The rule yielded a 86% sensitivity with a 46% specificity. We aimed to test its reproducibility. STUDY DESIGN: A secondary analysis of prospective series of children with a first UTI. The rule was applied, and predictive ability was calculated. RESULTS: The study included 413 patients (157 boys, VUR ≥3 in 11%) from eight centers in five countries. The rule offered a 46% specificity (95% CI, 41-52), not different from the one in the derivation study. However, the sensitivity significantly decreased to 64% (95%CI, 50-76), leading to a difference of 20% (95%CI, 17-36). In all, 16 (34%) patients among the 47 with VUR ≥3 were misdiagnosed by the rule. This lack of reproducibility might result primarily from a difference between derivation and validation populations regarding inflammatory parameters (CRP, PCT); the validation set samples may have been collected earlier than for the derivation one. CONCLUSIONS: The rule built to predict VUR ≥3 had a stable specificity (ie. 46%), but a decreased sensitivity (ie. 64%) because of the time variability of PCT measurement. Some refinement may be warranted.