Utility of Pediatric Appendicitis Score in Female Adolescent Patients.

OBJECTIVES: Acute appendicitis is common in the pediatric population and is difficult to diagnose in adolescent females. The validated Pediatric Appendicitis Score (PAS) has unclear utility in female adolescents. The purpose of this study is to determine the sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of the PAS for female adolescents compared to all other patients. METHODS: This study examined a retrospective observational cohort of patients ages 3 to 21 years in a pediatric emergency department with prospectively assigned PAS from an existing database. We compared the sensitivity, specificity, PPV, and NPV of the PAS for acute appendicitis among female adolescent patients (13 to 21 years) and all other patients. RESULTS: Of the 1,228 patients enrolled, 901 (73.4%) had a complete PAS. Among the 901 patients, 249 (27.6%) had pathology-proven appendicitis, 494 (54.8%) were female, and 272 (30.2%) were adolescent females. At a cutoff of ≥8, the PAS showed a specificity of 89% for adolescent females and 78% for all other patients (p < 0.001), although the specificities did not differ at a cutoff of ≥7. At both cutoffs, the PPVs were poor in both groups. At a cutoff of ≥3, the PAS showed similar sensitivities in both groups. At a cutoff of <3, the NPVs did not significantly differ between groups. CONCLUSION: At a cutoff of ≥8 (although not ≥7), the PAS demonstrated a higher specificity among female adolescents compared to all other patients. The PPV for both cutoffs in both groups were poor. At a cutoff of ≥3, sensitivities were equivalent. The NPV for a cutoff of <3 was acceptable but similar in both groups. While sensitivities were similar to previously reported, specificities in both groups were lower. This highlights the need for further investigation of the PAS's performance in specific subpopulations.

Variation in suicide occurrence by day and during major American holidays.

BACKGROUND: Due to temporal variations in completed suicides, it has been suggested that impulsivity and environmental factors may influence suicide. STUDY OBJECTIVE: Our intent was to determine if particular days of the week, seasons, or holidays were associated with increased attempted and completed suicides by poisoning. METHODS: All calls recorded in the National Poison Database System coded as "suspected suicide" from 2006 through 2010 were included. Exposures were evaluated by day, season, and holidays, and compared to control dates. RESULTS: There were 1,065,067 exposures (63% female) related to suicide attempts, with completions in 0.4% of cases. Sundays and Mondays for adults, and Mondays and Tuesdays for age < 19 years were the most common. Spring and fall had higher numbers of exposures than summer and winter. New Year's Day had a higher number of exposures, whereas Independence Day, Thanksgiving, and Christmas had fewer exposures. CONCLUSIONS: The beginning of the week, spring and fall, and New Year's Day were associated with higher numbers of ingestions with suicidal intent. This has implications for clinicians advising potential victims and providing emergency care for these patients.

Biomarkers to distinguish surgical etiologies in females with lower quadrant abdominal pain.

OBJECTIVES: Lower abdominal pain is a common complaint in girls and young women presenting to a pediatric emergency department (PED). An extensive evaluation may be required to exclude surgical emergencies such as appendicitis and ovarian torsion. However, clinicians and families prefer to limit invasive procedures and radiation exposure. The literature suggests that serum biomarkers such as the cytokine interleukin-6 (IL-6) can predict ovarian torsion in adults, while the membrane glycoprotein cluster of differentiation-64 (CD64) has been linked with bacterial infections and sepsis. Therefore, the study objective was to assess whether plasma IL-6 or neutrophil CD64 surface levels would assist clinicians in distinguishing surgical diagnoses (ovarian torsion and appendicitis) from nonsurgical diagnoses in young females with lower abdominal pain. METHODS: This study was a prospective, cross-sectional, pilot study of young females presenting with lower abdominal pain. Demographics, clinical and laboratory data, and final diagnoses were recorded. Plasma IL-6 and neutrophil CD64 were quantified. Nonparametric Kruskal-Wallis test was used to detect significant differences in IL-6 and CD64 values between surgical and nonsurgical patients. Further analysis was done to detect differences among the surgical patients (appendicitis vs. ovarian torsion). A bivariate analysis using the Wilcoxon rank sum was used to test for significant differences in IL-6 and CD64 by selected clinical factors. RESULTS: There were 112 female subjects ages 6 to 21 years enrolled. Final diagnoses were grouped as appendicitis (n = 38, 34%), ovarian torsion (n = 15, 13%), and nonsurgical (n = 59, 53%). Surgical cases had significantly higher levels of IL-6 compared to nonsurgical cases (p < 0.0001), and appendicitis patients had significantly higher CD64 indexes compared to ovarian torsion patients (p = 0.007). The clinical characteristics of fever of ≥38°C (p = 0.0002) and constant pain (p = 0.02) were significantly associated with elevated IL-6. Fever of ≥38°C (p = 0.02) was significantly associated with a higher CD64 index. CONCLUSIONS: Interleukin-6 was significantly elevated in surgical patients compared to nonsurgical patients in this sample of young females, and CD64 was significantly elevated in appendicitis patients compared to ovarian torsion patients. These data suggest that with larger sample sizes and future confirmatory studies, these biomarkers may be useful in the evaluation of young women with lower quadrant abdominal pain.

The acceptability of mental health screening in a pediatric emergency department.

OBJECTIVES: The purposes of the study were (1) to assess the acceptability of mental health screening in the pediatric emergency department (ED) for children and their parents; (2) to measure providers' perceptions on whether screening has an impact on patient care; and (3) to determine the impact of screening status on acceptability. METHODS: A validated pediatric mental health screening instrument was administered to 384 parent-child dyads. A 6-item satisfaction questionnaire was administered by a trained research coordinator to assess parent-child reactions to the screen. Emergency department providers rated how difficult the screening made it for them to care for the patient. Research staff reported the difficulty of conducting screening during the ED visit and the amount of time parents/children spent completing the screen. RESULTS: Most parents (82%) and children (75%) felt the screening was acceptable. Parent reports of pediatric mental health problems were not associated with lower acceptability scores. The number of mental health problems reported by a child was associated with an increased likelihood that the screening made the child upset (P = 0.02). Parents who reported pediatric mental health problems were more likely to find the screening helpful (odds ratio,1.84 [95% confidence interval, 1.15-2.93]), with black parents more likely to report that the screen was helpful (odds ratio, 2.5 [95% confidence interval, 1.43-4.33]). Nearly all doctors (99%) and nurses (97%) reported that the screening did not make it difficult for them to care for the patient. CONCLUSIONS: Overall, mental health screening appears to be acceptable in the pediatric ED.

Pediatric emergency department overcrowding and impact on patient flow outcomes.

BACKGROUND: Understanding the impact of overcrowding in pediatric emergency departments (PEDs) on quality of care is a growing concern. Boarding admitted patients in the PED and increasing emergency department (ED) visits are two potentially significant factors affecting quality of care. OBJECTIVES: The objective was to describe the impact ED boarding time and daily census have on the timeliness of care in a PED. METHODS: Pediatric ED boarding time and daily census were determined each day from July 2003 to July 2007. Outcome measures included mean length of stay (LOS), time to triage, time to physician, and patient elopement during a 24-hour period. RESULTS: For every 50 patients seen above the average daily volume of 250, LOS increased 14.8 minutes, time to triage increased 6.6 minutes, time to physician increased 18.2 minutes, and number of patient elopements increased by three. For each increment of 24 hours to total ED boarding time, LOS increased 7.6 minutes, time to triage increased 0.6 minutes, time to physician increased 3 minutes, and number of patient elopements increased by 0.6 patients. CONCLUSIONS: ED boarding time and ED daily census show independent associations with increasing overall LOS, time to triage, time to physician, and number of patient elopements in a PED.

Mental health problems in children and caregivers in the emergency department setting.

INTRODUCTION: Although mental health problems are increasing in the primary care sector, the prevalence of mental health problems in families presenting for nonpsychiatric complaints in the emergency department (ED) setting is generally unknown. As such, we set out to assess the frequency of mental health concerns and associated risk factors in children presenting for care in a pediatric ED. METHODS: A total of 411 mother-child dyads were randomly selected during a 2-year period from the less acute area of a large pediatric ED. Mothers were interviewed for child mental health concerns using structured diagnostic instruments. Mothers were also interviewed for their own mental health symptoms. Risk factor analysis for the outcome of a pediatric mental health concern was performed using bivariate and multivariate techniques. RESULTS: Of all children, 45% met criteria for a mental health concern, with 23% of all children meeting criteria for two or more mental health concerns; 21% of mothers screened positive for a mental health problem themselves. Once adjusted, children whose mothers' screened positive for a mental illness were more likely to have a mental health concern themselves. CONCLUSION: There is a large burden of mental health concerns in children and their mothers presenting to the ED for medical care. Efficiently and accurately identifying mental illness in children presenting to a pediatric ED is the first step in the intervention process for a population that might otherwise slip through the system.

Religion, spirituality, and depressive symptoms in patients with HIV/AIDS.

BACKGROUND: Depression has been linked to immune function and mortality in patients with chronic illnesses. Factors such as poorer spiritual well-being has been linked to increased risk for depression and other mood disorders in patients with HIV. OBJECTIVE: We sought to determine how specific dimensions of religion, spirituality, and other factors relate to depressive symptoms in a contemporary, multi-center cohort of patients with HIV/AIDS. DESIGN: Patients were recruited from 4 medical centers in 3 cities in 2002 to 2003, and trained interviewers administered the questionnaires. The level of depressive symptoms was measured with the 10-item Center for Epidemiologic Studies Depression (CESD-10) Scale. Independent variables included socio-demographics, clinical information, 8 dimensions of health status and concerns, symptoms, social support, risk attitudes, self-esteem, spirituality, religious affiliation, religiosity, and religious coping. We examined the bivariate and multivariable associations of religiosity, spirituality, and depressive symptoms. MEASUREMENTS AND MAIN RESULTS: We collected data from 450 subjects. Their mean (SD) age was 43.8 (8.4) years; 387 (86.0%) were male; 204 (45.3%) were white; and their mean CD4 count was 420.5 (301.0). Two hundred forty-one (53.6%) fit the criteria for significant depressive symptoms (CESD-10 score > or = 10). In multivariable analyses, having greater health worries, less comfort with how one contracted HIV, more HIV-related symptoms, less social support, and lower spiritual well-being was associated with significant depressive symptoms (P<.05). CONCLUSION: A majority of patients with HIV reported having significant depressive symptoms. Poorer health status and perceptions, less social support, and lower spiritual well-being were related to significant depressive symptoms, while personal religiosity and having a religious affiliation was not associated when controlling for other factors. Helping to address the spiritual needs of patients in the medical or community setting may be one way to decrease depressive symptoms in patients with HIV/AIDS.

Are internal medicine residency programs adequately preparing physicians to care for the baby boomers? A national survey from the Association of Directors of Geriatric Academic Programs Status of Geriatrics Workforce Study.

Patients aged 65 and older account for 39% of ambulatory visits to internal medicine physicians. This article describes the progress made in training internal medicine residents to care for older Americans. Program directors in internal medicine residency programs accredited by the Accreditation Council for Graduate Medical Education were surveyed in the spring of 2005. Findings from this survey were compared with those from a similar 2002 survey to determine whether any changes had occurred. A 60% response rate was achieved (n=235). In these 3-year residency training programs, 20 programs (9%) required less than 2 weeks of clinical instruction that was specifically structured to teach geriatric care principles, 48 (21%) at least 2 weeks but less than 4 weeks, 144 (62%) at least 4 weeks but less than 6 weeks, and 21 (9%) required 6 or more weeks. As in 2002, internal medicine residency programs continue to depend on nursing home facilities, geriatric preceptors in nongeriatric clinical ambulatory settings, and outpatient geriatric assessment centers for their geriatrics training. Training was most often offered in a block format. The mean number of physician faculty per residency program dedicated to teaching geriatric medicine was 3.5 full-time equivalents (FTEs) (range 0-50), compared with a mean of 2.2 FTE faculty in 2002 (P

A national survey of family medicine residency education in geriatric medicine: comparing findings in 2004 to 2001.

BACKGROUND AND OBJECTIVES: We compared findings from this 2004 survey with our 2001 survey to determine progress in family medicine residency programs' efforts to better train residents to care for America's aging population. METHODS: A survey was mailed and made available on-line to all 470 family medicine residency directors in the United States. RESULTS: The response rate was 71%. Ninety-six percent of family medicine residencies have a required geriatrics curriculum, compared to 92% in 2001. There was a significant increase in the number of required lecture hours in geriatrics in 2004 as compared to 2001. Since 2001, the median number of MD geriatrics faculty per program has nearly doubled from .5 full-time equivalent (FTE) to .9 FTE. Conflicting time demands with other curricula was ranked as the most significant barrier to geriatrics education in both 2004 and 2001. However, in 2001, the attitude of residents was listed as a significant barrier by 32.1% of the program directors as compared to just 3.6% in 2004. CONCLUSIONS: Family medicine educators are continuing to improve the training of residents to provide state-of-the-art care for the aging population. Faculty must take advantage of this period of experimentation in residency education to identify best practices for geriatrics education.

Chronic ankle morbidity in obese children following an acute ankle injury.

OBJECTIVE: To examine the relationship between childhood obesity as measured by body mass index (BMI) and long-term morbidity after an acute ankle sprain. DESIGN: Six-month prospective cohort study with follow-up telephone questionnaires at 6 weeks and 6 months. SETTING: Cincinnati Children's Hospital Medical Center emergency department. PATIENTS: Children between the ages of 8 and 18 years who presented with a chief complaint of an acute ankle injury were enrolled in the study. Children with ankle fractures were excluded. Exposed children were defined as those with a BMI in the 85th or greater percentile for age. Nonexposed children were defined as those with a BMI in the less than 85th percentile for age. MAIN OUTCOME MEASURES: Persistent symptoms of pain, swelling, or weakness; pain during or after exercise; and recurrent ankle injury. RESULTS: A total of 199 children were enrolled. The exposed and nonexposed groups were similar in terms of sex, age, and ethnicity. A total of 164 (93%) had complete follow-up at 6 months. Six months after an ankle injury, children with a BMI in the 85th or greater percentile for age were more likely to sustain persistent symptoms (relative risk, 1.70; 95% confidence interval, 1.10-2.61). CONCLUSION: Overweight children are more likely to have persistent symptoms 6 months after an acute ankle sprain.

Weaning success among ventilator-dependent patients in a rehabilitation facility.

OBJECTIVES: To determine outcomes of difficult-to-wean, ventilator-dependent patients transferred from intensive care units to rehabilitation hospitals and to determine predictors of weaning success in such patients. DESIGN: A retrospective cohort study. SETTING: A rehabilitation facility. PARTICIPANTS: One hundred forty-five difficult-to-wean patients (55.2% men; 83.4% white; mean age +/- standard deviation, 65.8 +/- 16.4y) transferred to a rehabilitation facility between July 1994 and June 1996. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Demographic and clinical data, including variables identified previously as predictive of weaning success among highly selected populations. RESULTS: Patients' Gillespie categories (reason for ventilator dependency) included "other medical conditions" (eg, pneumonia, neurologic) in 42.1% of the cases, postoperative in 24.8%, previous lung disease (eg, chronic obstructive pulmonary disease, interstitial lung disease) in 15.2%, trauma in 11.7%, respiratory failure with multisystem failure in 3.4%, and uncomplicated acute lung injury (acute respiratory distress syndrome) in 2.8%. Of 145 patients, 50.3% were completely weaned, 4.8% were partially weaned, and 44.8% remained ventilator dependent. In a stepwise multivariable logistic regression analysis, significant predictors of weaning success included white race (odds ratio [OR] = 3.4), serum albumin level (OR = 2.1g/dL), and blood urea nitrogen (BUN) level (OR = .97mg/dL); in addition, compared with postoperative patients, patients with "other medical conditions" (OR = .15) or previous lung disease (OR = .08) were less likely to be weaned (area under receiver operating characteristic curve = .76). Among 31 long-term survivors who were interviewed at least 6 months after discharge from the rehabilitation facility, 58.1% rated their health-related quality of life as good or better. CONCLUSIONS: Half of the patients admitted to a rehabilitation facility were weaned from their ventilators. Predictors of weaning success included race, BUN level, albumin level, and reason for ventilator dependency.