Evaluation of Ventricle Size Measurements in Infants by Pediatric Emergency Medicine Physicians.

OBJECTIVES: The identification of hydrocephalus in infants by pediatric emergency medicine (PEM) physicians using cranial point-of-care ultrasound (POCUS) has not been evaluated. We aimed to conduct a pilot/proof-of-concept study to evaluate whether PEM physicians can identify hydrocephalus (anterior horn width >5 mm) in 15 infants (mean 69 ± 42 days old) from the neonatal intensive care unit using POCUS. Our exploratory aims were to determine the test characteristics of cranial POCUS performed by PEM physicians for diagnosing hydrocephalus and the interrater reliability between measurements made by the PEM physicians and the radiologist. METHODS: Depending on the availability, 1 or 2 PEM physicians performed a cranial POCUS through the open anterior fontanel for each infant after a 30-minute didactic lecture to determine the size of the left and right ventricles by measuring the anterior horn width at the foramen of Monroe in coronal view. Within 1 week, an ultrasound (US) technologist performed a cranial US and a radiologist determined the ventricle sizes from the US images; these measurements were the criterion standard. RESULTS: A radiologist determined 12 of the 30 ventricles as hydrocephalic. The sensitivity and specificity of the PEM physicians performed cranial POCUS was 66.7% (95% confidence interval [CI], 34.9%-90.1%) and 94.4% (95% CI, 72.7%-99.9%), whereas the positive and negative predictive values were 88.9% (95% CI, 53.3%-98.2%) and 81.0% (95% CI, 65.5%-90.5%), respectively. The interrater reliability between the PEM physician's and radiologist's measurements was r = 0.91. The entire POCUS examinations performed by the PEM physicians took an average of 1.5 minutes. The time between the cranial POCUS and the radiology US was, on average, 4 days. CONCLUSIONS: While the PEM physicians in our study were able to determine the absence of hydrocephalus in infants with high specificity using cranial POCUS, there was insufficient evidence to support the use of this modality for identifying hydrocephalus. Future studies with more participants are warranted to accurately determine test characteristics.

Diagnosis of an Acute Lobar Nephronia in the Emergency Department Using POINT-OF-CARE Ultrasound.

BACKGROUND: Over the past decade, point-of-care ultrasound (POCUS) has been performed increasingly in pediatric emergency medicine for a variety of indications. POCUS is a focused, limited, goal-directed examination at the bedside performed and interpreted by a physician trained in POCUS with the purpose of answering a specific question. Applying POCUS for immediate evaluation of specific emergent complaints may allow for faster and safer management of ill patients in the pediatric emergency department (ED). CASE REPORT: A 5-year-old female presented to the pediatric ED with fever, vomiting, and back pain. Based on the real-time gray scale and color Doppler POCUS findings, a diagnosis of an acute lobar nephronia (ALN) was made by a pediatric emergency physician and the patient was admitted to the hospital before laboratory and urinalysis findings were resulted. This case report illustrates how POCUS and knowledge of the sonographic characteristics of an ALN were beneficial for shortening the time to decision for admission, rapidly ruling out hydronephrosis (which may have required other interventions), and conveying important information to the admitting team. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Performing a kidney POCUS and knowing the sonographic characteristics of an ALN can assist in its diagnosis, especially in patients where pyuria is absent. In addition, performing a kidney POCUS in patients with a suspected upper urinary tract infection may shorten the time to decision for admission and improve communication with the pediatric admitting resident regarding diagnosis and indication.

Diagnosis of a Posterior Fracture Dislocation of the Medial Clavicle in an Adolescent With Point-of-Care Ultrasound.

We report a case of an adolescent patient with medial clavicular tenderness after a fall on the lateral left shoulder. Initial radiographs did not reveal a fracture or dislocation. Point-of-care ultrasound was used to diagnose a posterior clavicular fracture dislocation.

Color Flow Doppler Point of Care Ultrasound to Evaluate Vessels before Infant Lumbar Puncture.

BACKGROUND: Infant lumbar punctures (LPs) are common procedures performed in the emergency department. However, 10% to 35% of these LPs are unsuccessful or grossly bloody, which can lead to increased hospitalization, increased costs, and prolonged exposure to antibiotics or antivirals. Point of care ultrasound (POCUS) may help to surmount the intrinsic causes of LP failure by providing a visual guide of the vascular structures in the needle path before a LP is performed. CASE REPORT: We report two cases where color flow Doppler POCUS was used to identify vascular structures around the spinal canal in infants before attempting a LP. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Color flow Doppler POCUS directly visualizes the spinal vascular structures in infants and may help guide the physician in the decision-making process of what intervertebral space and stylet placement to use for a LP.

Diagnosis of a Peritonsillar Abscess by Transcutaneous Point-of-Care Ultrasound in the Pediatric Emergency Department.

We report a case of a pediatric patient with an initial diagnosis of peritonsillar cellulitis made by otolaryngology. The findings from a subsequent transcutaneous point-of-care ultrasound by a pediatric emergency physician directly affected the decision to perform needle aspiration. Sonographic characteristics of a peritonsillar abscess may be helpful in the prompt diagnosis of peritonsillar abscess.

Pilot study for the establishment of biomarkers for radiation damage after computed tomography in children.

Computed tomography (CT) is an imaging modality that exposes patients to ionizing radiation (IR). We review and report findings from our pilot study evaluating whether blood markers are altered in 17 children undergoing medically indicated CT scans. Blood was drawn before ('pre-CT') and 1 hour after ('post-CT' CT scans. Plasma carotenoids, tocopherols, Q10, ascorbic acid (AA) and uric acid (UA) were analyzed by RP-HPLC with diode-array and electrochemical detection. Dehydroascorbic acid (DHAA) was calculated by subtraction from total AA. Total antioxidant capacity (TAC) was measured using the ORAC assay. Cytokines were quantified using a multiplex immunoassay. γ-H2AX foci were visualized using immunofluorescence. Mean pre- and post-CT changes were compared using t-tests; P-levels < .05 indicated significance. All major plasma lipid soluble antioxidant levels were lower post- vs pre-CT (P < .05) possibly from the scavenging of free radicals formed by CT-induced IR. Average AA levels increased (134%) while DHAA levels were decreased (29%) post-CT, probably due to intracellular recycling of AA from DHAA. TAC levels in lipophilic and hydrophilic extracts were unchanged, suggesting that other antioxidants may have assisted in free radical quenching, which would corroborate their lower concentrations post-CT. Cytokine levels were unchanged and dose-dependent increases in γ-H2AX foci, a measure of double strand DNA breaks, were observed (P = .046, n = 3 children). Our results suggest that CT-derived IR can influence the antioxidant system and may elicit detrimental responses on the cellular level of young children. When possible and if appropriate non-IR based techniques such as ultrasound or magnetic resonance imaging should be used.

Absorption, distribution, metabolism, and excretion of isoflavonoids after soy intake.

Soy is the major source of dietary exposure to isoflavonoids (IFLs). Accumulating evidence supports a role for soy and IFLs in the protection against many chronic diseases including cancer. After soy intake we found a biphasic IFL appearance pattern in plasma as well as in urine that we suggest to be due to IFL absorption in the small intestine (ca. 10%) during the first 2h after intake and IFL absorption in the large intestine (ca. 90%) 4-6 h after intake. While each IFL disappears from the circulation at different times excellent correlations between urinary and circulating IFL values were discovered and algorithms to convert urinary excretion values into circulating levels were established. We suggest the term 'apparent bioavailability' when using urinary data to describe IFL exposure. The IFL bioavailability was found to be influenced by gut bacteria, oral antibiotic treatment (OABX), and an individual's age and health status. While daidzein (DE) and genistein start to be absorbed minutes after intake, equol (EQ) appears in plasma only after a minimum of 8h following soy intake owing to the required transit time of DE to the colon where the conversion of DE to EQ takes place by intestinal microbiota. We have also shown that the apparent IFL bioavailability is higher in children than adults, higher in healthy versus non-healthy individuals, and decreased in children but increased in adults during OABX. Finally, we propose to use a urinary EQ/DE ratio of 0.018 with a DE threshold to identify EQ producers. With this cutoff definition we observed that EQ production is inconsistent over time in 5-30% of both premenopausal and postmenopausal women.

γ-H2AX foci are increased in lymphocytes in vivo in young children 1 h after very low-dose X-irradiation: a pilot study.

BACKGROUND: Computed tomography (CT) is an imaging modality involving ionizing radiation. The presence of γ-H2AX foci after low to moderate ionizing radiation exposure has been demonstrated; however it is unknown whether very low ionizing radiation exposure doses from CT exams can induce γ-H2AX formation in vivo in young children. OBJECTIVE: To test whether very low ionizing radiation doses from CT exams can induce lymphocytic γ-H2AX foci (phosphorylated histones used as a marker of DNA damage) formation in vivo in young children. MATERIALS AND METHODS: Parents of participating children signed a consent form. Blood samples from three children (ages 3-21 months) undergoing CT exams involving very low blood ionizing radiation exposure doses (blood doses of 0.22-1.22 mGy) were collected immediately before and 1 h post CT exams. Isolated lymphocytes were quantified for γ-H2AX foci by a technician blinded to the radiation status and dose of the patients. Paired t-tests and regression analyses were performed with significance levels set at P < 0.05. RESULTS: We observed a dose-dependent increase in γ-H2AX foci post-CT exams (P = 0.046) among the three children. Ionizing radiation exposure doses led to a linear increase of foci per cell in post-CT samples (102% between lowest and highest dose). CONCLUSION: We found a significant induction of γ-H2AX foci in lymphocytes from post-CT samples of three very young children. When possible, CT exams should be limited or avoided by possibly applying non-ionizing radiation exposure techniques such as US or MRI.

In vivo changes in plasma coenzyme Q10, carotenoid, tocopherol, and retinol levels in children after computer tomography.

BACKGROUND: Low dose X-irradiation (IR) from computer tomography (CT) can generate free radicals, which can damage biologically relevant molecules and ultimately lead to cancer. These effects are especially concerning for children owing to their higher radiosensitivity and longer life expectancy than adults. The lipid phase micronutrients (LPM) coenzyme Q10, carotenoids, E vitamers, and vitamin A are potent radical scavengers that can act as intracellular antioxidants. METHODS: We investigated changes in circulating levels of these LPM in 17 children (0.25-6 y) undergoing medically indicated CT scans involving relatively low IR doses. Blood was drawn before and 1h after CT scans and analyzed using HPLC with electrochemical and UV/VIS detection. RESULTS: We found significant decreases (p<0.05) in post-CT plasma levels in several LPM which suggests that these LPM can serve as biodosimeters and may protect against damage from IR during clinical procedures such as CT. The strongest predictors for pre- to post-CT changes for many LPM were their baseline levels. CONCLUSION: Future larger studies are warranted to confirm our findings and to test whether high circulating antioxidant levels protect against IR damage in vivo with an ultimate goal of establishing prophylactic modalities for CT-induced IR damage.

Diagnosis of intussusception using bedside ultrasound by a pediatric resident in the emergency department.

The use of bedside ultrasound in the emergency department has been gaining favor among emergency medicine physicians and can be invaluable in the prompt diagnosis and treatment of acutely ill patients, especially when radiology evaluation is unavailable or delayed. Although pediatric ultrasound examinations are taught in some pediatric residency programs, they are not part of the required pediatric residency curriculum in the United States. This is the first case report of a pediatric resident diagnosing intussusception by bedside ultrasound in a 4-year-old boy under the guidance of a pediatric emergency attending with ultrasound training. This report illustrates the ease of using bedside ultrasound even among early learners and highlights its potential importance in medical education for fellows and residents.

Vitamin D deficiency in cord plasma from multiethnic subjects living in the tropics.

BACKGROUND: Vitamin D deficiency is commonly reported in high-latitude areas and in dark-pigmented individuals. However, nothing is known about vitamin D in cord blood from multiethnic subjects living in the tropics. OBJECTIVE: Our study objective was to determine the prevalence of vitamin D deficiency in summer and winter in cord blood from multiethnic individuals in Hawai'i where sufficient sun irradiance occurs year-round for cutaneous vitamin D production. METHODS: 25-Hydroxyvitamin D (25(OH)D) levels were quantified by enzyme immunoassay in 100 cord plasma samples from apparently healthy full-term newborns and their mothers. Stratification was performed by birth season and ethnicity. RESULTS: Mean 25(OH)D levels were 24.5 ng/mL (9.1-68.3 ng/mL). Overall, 28% of samples were vitamin D deficient (<20 ng/mL) and 50% were insufficient (20-30 ng/mL). 25(OH)D levels (ng/mL) were highest in Caucasians (30.5, n = 19), followed by Asians (25.1, n = 43), Hispanics (21.5, n = 3), Pacific Islanders (20.0, n = 25), and African Americans (19.6, n = 2). Differences among groups were significant (p = 0.008). Cord plasmas from summer versus winter were higher overall (p = 0.001) and among Asians (p = 0.0003). Seasonal changes were correlated with sun irradiance overall (r = 0.43, p = 0.0001), among Caucasians (r = 0.45, p = 0.05), and among Asians (r = 0.45, p = 0.0001). CONCLUSION: Our results suggest that prenatal supplement recommendations of 400 IU vitamin D/day do not protect against vitamin D deficiency, even in subjects living in the tropics where ample sun irradiance exists for cutaneous vitamin D synthesis. The high prevalence of vitamin D deficiency we observed emphasizes the necessity for regular 25(OH)D monitoring, particularly during pregnancy and lactation, in dark-pigmented individuals, and during winter months.

Reducing the time in making the diagnosis and improving workflow with point-of-care ultrasound.

BACKGROUND: During the past decade, point-of-care ultrasound (POC US) has been increasingly performed in emergency medicine for a variety of indications. However, pediatric emergency physicians have been slower to understand the importance of POC US in the diagnosis of critical care cases. OBJECTIVE: This study aimed to illustrate the usefulness of POC US in improving workflow in the emergency department (ED) with an early diagnosis in a critically ill child by a pediatric emergency attending physician. CASE: On arrival to the ED, an early diagnosis of intussusception was made using real-time POC US by a pediatric emergency medicine attending physician well trained in pediatric US. CONCLUSIONS: This report illustrates the impact that POC US can make during an early diagnosis of intussusception. With thorough knowledge of the US features characteristic of intussusception, its accurate diagnosis using POC US has the potential to reduce morbidity and mortality as well as improve patient flow and throughput time in the ED.

Equol production changes over time in postmenopausal women.

Equol (EQ) is produced by intestinal bacteria from the soy isoflavone daidzein (DE) in 30%-60% of the population and is believed to provide benefits from soy intake. A robust EQ status definition is lacking, and it is uncertain whether EQ is formed consistently within an individual and ceases upon oral antibiotic treatment. In a randomized, double-blind, placebo-controlled soy intervention trial with 350 postmenopausal women, DE and EQ were analyzed by liquid chromatography/tandem mass spectrometry at baseline and every 6 months over 2.5 years in overnight urine, spot urine and plasma. Equol production changes and status (remaining an EQ producer or nonproducer or changing towards an EQ producer or nonproducer) were assessed. Equol status was determined most dependably by overnight urine applying as cutoff a ratio of EQ/DE≥0.018 with a DE threshold ≥2 nmol/mg creatinine: the soy and placebo groups had approximately 30% consistent EQ producers during the study, but 14% and 35%, respectively, changed EQ status (mean 1.4-1.7 times), while 27% and 17%, respectively, had antibiotic treatment (P<.01 for inverse association). No significant trend in change of EQ production or status was observed when overnight urine was limited to collections closest to before and after antibiotic treatment. Similarly, antibiotic type or class, duration, dose or time between antibiotic treatment and overnight urine collection showed no consistent influence on EQ production. Equol production can markedly change intraindividually over 2.5 years, and antibiotic treatment impacts it inconsistently. Factors other than antibiotic treatment must be considered as causes for EQ production changes.

Improving toxicology knowledge in preclinical medical students using high-fidelity patient simulators.

BACKGROUND: Superior patient care and optimal physician training are often mutually elusive in the Emergency Department setting. Highfidelity patient simulators (HFPSs) are being used with increasing frequency in the training of medical students (MS) because they enable students to develop and refine medical competency in a non-threatening and safe environment. However, learner outcomes using HFPSs in this setting have not been well studied. OBJECTIVES: The objective of this pilot study was to determine the effectiveness of HFPSs in simulation (SIM) training as a learning tool for preclinical second-year MS to further increase their toxicology knowledge. METHODS: Second-year MS at a Problem Based Learning (PBL) medical school received a PBL toxicology teaching session in the middle of the semester. One week later, the students participated in a SIM exercise based on issues taken from the PBL case. The SIM exercise required that students address learning issues such as identifying abnormal findings, ordering tests, and, ultimately, initiating treatment on a full-scale HFPS mannequin. A supervised on-line test consisting of 10 multiple choice questions regarding the student's understanding of the learning issues was completed before the PBL class and directly before and after the SIM to determine the effectiveness of the HFPS use. Immediate video-assisted feedback was provided by emergency medicine attendings. RESULTS: Use of HFPSs during SIM exercises and in combination with PBL significantly increased toxicology knowledge in secondyear MS as determined by the improvement of on-line test scores (% correct answers) from 59% before PBL / before SIM to 69% after PBL / before SIM to 80% after PBL / after SIM. CONCLUSION: This study suggests that HFPS may be a valuable tool in helping to improve toxicology knowledge in second-year MS at a key transition period prior to beginning clerkship experiences. Incorporation of HFPS into PBL curricula may also be beneficial to MS in other areas of study where interactive learning could assist in evoking emotional realism while also enhancing critical thinking and acquisition of knowledge thereby facilitating the transition from theory to practice.

Diagnosis of an intraventricular hemorrhage by a pediatric emergency medicine attending using point-of-care ultrasound: a case report.

For the past 2 decades, point-of-care ultrasound (POCU) has been increasingly performed in adult emergency medicine for a variety of indications. However, the incorporation of POCU into pediatric emergency medicine has been much slower. Cranial ultrasound is an integral part in neonatology and is routinely used to diagnose intraventricular hemorrhage (IVH). Although cranial ultrasound is not considered a core emergency ultrasound application in the 2008 American College of Emergency Physicians ultrasound guidelines, this novel approach may prove beneficial in the emergency department (ED) setting. We report a case of a 16-day-old male that presented to the pediatric ED with fussiness and found to be anemic. An IVH was diagnosed for the first time using POCU by a pediatric ED attending. Sonographic characteristics of an IVH may be helpful in the prompt diagnosis of this condition, thereby reducing morbidity and mortality and improving the final outcome.

Diagnosis of appendicitis by a pediatric emergency medicine attending using Point-of-Care Ultrasound/ a case report.

Over the past decade Point/of/Care Ultrasound (POC US) is increasingly performed in adult emergency medicine for a variety of indications. Pediatric emergency medicine has been much slower to embrace POC US. The authors report a case of a 15/year/old boy that presented to the pediatric emergency department with abdominal pain. A diagnosis of appendicitis was made using real/time POC US by a pediatric emergency medicine attending. Knowledge of the sonographic characteristics of appendicitis can help the physician in the prompt diagnosis of this condition, thereby reducing morbidity and mortality that may result from a delay in diagnosis.

Improving medical student toxicology knowledge and self-confidence using mannequin simulation.

BACKGROUND: Learning medicine without placing patients at increased risk of complications is of utmost importance in the medical profession. High-fidelity patient simulators can potentially achieve this and are therefore increasingly used in the training of medical students. Preclinical medical students have minimal exposure to clinical rotations and commonly feel anxious and apprehensive when starting their clinical years. OBJECTIVES: The objective of this pilot study was to determine if toxicology knowledge and confidence of preclinical second-year medical students could be augmented with simulation training. METHODS: We designed and implemented a simulation exercise for second-year medical students to enhance learning of Basic Life Support, toxidromes, and management of a semiconscious overdose victim. Groups of 5-6 students were tasked to identify abnormal findings, order tests, and initiate treatment on a mannequin. Faculty observers provided video-assisted feedback immediately afterwards. On-line pre- and posttests were completed in the simulation lab before and after the exercise. RESULTS: This simulation exercise, completed by 52 students, increased test scores on average from 60% to 71% compared to a pre-test. Among the topics tested, students scored worst in identifying normal/abnormal vital signs. Mean confidence increased from 2.0 to 2.6 using a 5-point Likert scale (1-very low to 5-very high). CONCLUSION: This study suggests that simulation exercises for second-year medical students may be a valuable tool to increase knowledge and student self-confidence at a key transition period prior to beginning clerkship experiences. Further research is needed to prove long-term educational benefits of simulation interventions in the preclinical setting.

Apparent bioavailability of isoflavones after intake of liquid and solid soya foods.

Isoflavone (IFL) intake may provide numerous health benefits, but IFL bioavailability differences among soya foods remains uncertain. Urinary IFL excretion (UIE) was shown to provide a reliable surrogate for systemic IFL exposure and therefore can be used as a measure of 'apparent bioavailability' (AB). We investigated the AB of IFL in fourteen healthy adults, consuming two liquid and two solid soya foods in a crossover designed study. Volunteers consumed the foods with a self-selected breakfast, which was kept identical for all four soya items (soya nuts, soya milk, soya protein bar and soya protein powder drink in water; average 23.7 mg IFL, 88-96 % glycosides, by HPLC analysis) and collected all urine up to 26 h. Liquid foods showed initially higher UIE values than solid foods, but this difference was considerably reduced or disappeared entirely after 24-26 h. Conclusive AB results were obtained only after 24-26 h; earlier collections were not reliable. At 26 h, adjusted UIE values for daidzein (DE) were 20 micromol in the milk and bar and 17 micromol for the nut and powder; urinary genistein excretion was the highest in the milk group (10 micromol) followed by the nut, bar (both 6 micromol) and powder groups (5 micromol); the UIE for glycitein was the highest for bars (4 micromol), followed by powder and nuts (3 micromol), and milk (2 micromol). DE makes the largest contribution to urinary total IFL. The AB of IFL was found to be variable depending on the analyte and soya food consumed.

Phytoestrogenic isoflavonoids in epidemiologic and clinical research.

Isoflavones (IFLs) are natural products to which humans have been traditionally exposed predominantly through soy foods; more recently humans are also exposed to them through soy protein addition to processed foods or through supplements. They are structurally similar to steroidal estrogens and can exert estrogenic or antiestrogenic effects depending on their concentrations and on the tissue considered. These properties qualify IFLs to be classified as phytoestrogens and are believed to account for many of the biological effects observed for soy and/or IFL exposure including benefits for bone and heart health or prevention of menopausal symptoms and certain types of cancer. In order to evaluate the function of IFLs, alone or when exposure happens through soy intake, pharmacokinetics and bioavailability are critical issues to be considered in epidemiologic and clinical research. For this purpose precise, accurate, robust, fast, and affordable techniques for IFL analyses are required.