Clinical predictors of respiratory syncytial virus infection in children.

AIM: The aim of this study was to develop a clinical prediction model that identifies respiratory syncytial virus (RSV) infection in infants and young children. METHODS: Children < or = 36 months of age with respiratory illness, who were suspected of having RSV infection, were enrolled in this prospective cohort study during the study period between January and February 2002. RSV testing was performed on all patients. RESULTS: Of the 197 patients enrolled in the study, 126 (64%) were positive for RSV and 71 (36%) patients were either negative for RSV or had a positive culture for viruses other than RSV. The mean age of patients was 5 months and 57% were male. Backwards stepwise logistic regression analysis identified cough (p = 0.000), wheezing (p = 0.002), and retractions (p = 0.008) as independent variables predictive of RSV infection. The prediction model had a sensitivity of 80% (95% CI, 71-87%), specificity of 68% (95% CI, 54-79%), positive predictive value 82% (95% CI, 74-89%), negative predictive value 66% (95% CI, 52-77), positive likelihood ratio 2.5 (95% CI, 1.8-3.7) and post-test probability of 82%. CONCLUSION: The combination of cough, wheezing and retractions predicts RSV infection in infants and young children.

Childhood seizures.

Seizures are a common neurologic problem in childhood affecting 4% to 10% of children before the age of 16 years. Seizures must be differentiated from other childhood disorders and correctly classified with regard to type. Emergency treatment focuses on patient stabilization, termination of seizure activity, and determination of seizure cause. Various long-term treatment modalities exist. Appropriate treatment depends on accurate diagnosis and knowledge of medication side effects and benefits.

Seizures in children.

Seizures are the most common pediatric neurologic disorder. Four to ten percent of children suffer at least one seizure in the first 16 years of life. The incidence is highest in children less than 3 years of age, with a decreasing frequency in older children. Epidemiologic studies reveal that approximately 150,000 children will sustain a first-time unprovoked seizure each year, and of those, 30,000 will develop epilepsy. This article describes the types, diagnoses, and management and disposition of this pediatric neurologic disorder.

Epidemiology and etiology of malpractice lawsuits involving children in US emergency departments and urgent care centers.

OBJECTIVE: To obtain epidemiologic outcome information about pediatric lawsuits that originate in the emergency department and urgent care center. METHODS: This was an anonymous retrospective review of all closed pediatric claims in the Physician Insurers Association of America database during a 16-year period (1985-2000). This database, containing data from 20 major malpractice insurance firms, insuring 25% US physicians, was queried for epidemiologic outcome information about pediatric lawsuits originating in US emergency departments and urgent care centers. RESULTS: There were 2283 closed claims reviewed. Of these, 96% originated in the emergency department, and 4% originated in an urgent care center. Nonteaching hospitals were the sites for 79% of claims. Suits involved emergency department physicians in 29%, pediatricians in 19%, board-certified physicians in 46%, US graduates in 70%, and full-time physicians in 96% of cases. In 66% of cases, doctors had a previous claim. In 65% of cases, more than 1 defendant was involved. Patients were boys in 59% and were younger than 2 years in 47%. The most common diagnoses involved in the lawsuits were meningitis, appendicitis, arm fracture, and testicular torsion. Cases in which the child died were most often from meningitis or pneumonia. The most common misadventures were diagnostic error (39%), and no medical error identified in 18%. OUTCOME: Cases were settled in 93% (indemnity paid in 30%). There was a judgment for the doctor in 5.5% and for the patient in 1.4%. The average indemnity/claim was US66,000 dollars in 1985 versus US218,000 dollars (+330%) in 1997. The average indemnity ranged from US7000 dollars for emotional injury, US149,000 dollars for death of the patient, US300,000 dollars for major permanent injury, and US540,000 dollars for quadriplegic from injury. There was no significant difference between teaching versus nonteaching hospitals, between urgent care center versus emergency department, US graduate physician versus non-US graduate, or physician age. Indemnity paid/claim for full-time physicians was US161,000 dollars versus US91,000 dollars for part-time physicians. Total paid to plaintiffs was US116 million dollars. Legal cost of defending the cases was US36 million dollars (including defense attorney fees, US24 million dollars, and expert witness fees, US3.4 million dollars). CONCLUSIONS: Malpractice suits most often involved fractures, meningitis, and appendicitis. Most suits are settled; many are apparently frivolous. Paid indemnities have dramatically increased in recent years. Verdicts decided by juries favored the doctor in 80% of suits.

Clinical predictors of influenza in children.

BACKGROUND: It is difficult to diagnose influenza infection on clinical grounds alone. Available rapid diagnostic tests have limited sensitivities. OBJECTIVE: To develop a prediction model that identifies children likely to have influenza infection. DESIGN: Prospective study. SETTING: Emergency department of a children's hospital. Patients All patients with a febrile respiratory illness during the influenza season of winter 2002 were eligible. A prospective sample of 128 children who were suspected of having influenza infection based on predetermined criteria was enrolled. Each patient received a nasal wash for viral culture. MAIN OUTCOME MEASURE: Clinical features that are most predictive of influenza infection in children. RESULTS: The mean +/- SD age of patients was 6.2 +/- 5.2 years; 50% were boys. Viral isolates included the following: influenza A, 45 patients (35%); influenza B, 13 (10%); other viruses, 10 (8%); negative results, 60 (47%). Demographic and clinical findings were not significantly different between the influenza A and influenza B groups. Cough (P =.003), headache (P =.04), and pharyngitis (P =.04) were independently associated with influenza infection. This triad used as a prediction model for influenza infection had a sensitivity of 80% (95% confidence interval [CI], 69%-91%); specificity, 78% (95% CI, 67%-89%); and likelihood ratio for a positive viral culture for influenza, 3.7 (95% CI, 2.3-6.3). The posttest probability of this clinical definition is 77% (95% CI, 63%-91%). CONCLUSION: The triad of cough, headache, and pharyngitis is a predictor of influenza infection in children.

Influenza a in young children with suspected respiratory syncytial virus infection.

OBJECTIVES: To determine the prevalence of influenza A in young children suspected of having respiratory syncytial virus (RSV) infection and to compare the clinical presentation of these patients with those who have proven RSV infection. METHODS: Children younger than or at 36 months of age who presented to a pediatric emergency department (ED) with suspected RSV infection during the influenza A season of 2001-2002 were eligible. Eligible children had an RSV antigen test ordered as part of their initial clinical management. A consecutive sample of children was enrolled for prospective observational analysis. The main outcome measure was the prevalence of influenza A in young children with suspected RSV infection. The secondary outcome measure was a comparison of the clinical presentations, of the two groups. RESULTS: During the study period, 420 patients presented for evaluation of respiratory illness. RSV tests were ordered on 251 patients. Of 197 eligible patients, 124 (63%) tested positive for RSV and 33 (17%) for influenza A. Influenza A patients were more likely to have temperatures at or above 39 degrees C than RSV patients (36% vs. 15%; p = 0.01). RSV patients were more tachypneic (54 vs. 43 breaths/minute; p < 0.0001) and more often had wheezing (90% vs. 8%; p < 0.0001). Twenty influenza patients (61%) were hospitalized. CONCLUSIONS: This study found a high prevalence of influenza A in young children suspected of having RSV infection. Clinicians should consider influenza A in young febrile children presenting with respiratory illnesses.

Prolonged QT syndrome in children: an uncommon but potentially fatal entity.

Prolonged QT syndrome may be either congenital, as in Jervell and Lange-Nielsen or Romano-Ward syndromes, or acquired in nature. Affected children are at risk for syncope, seizures, dysrhythmias and sudden death. Physicians should consider long QT syndrome (LQTS) in all patients who present with syncope. A thorough personal and family history should be documented, with particular attention to prior syncopal episodes, congenital deafness, and unexplained sudden death. Syncope that is either recurrent or induced by exercise or stress is concerning and also should be noted. An electrocardiogram with manual calculation of the QT interval should be performed on all patients with a suggestive history. Furthermore, the diagnosis of LQTS warrants evaluation of all other family members. With recognition and appropriate treatment of affected patients, the potentially fatal consequences of LQTS may be prevented.