Clinical Characteristics of Acute Hematogenous Osteomyelitis With and Without Subperiosteal Abscesses in the Acute Care Setting.

BACKGROUND: Acute hematogenous osteomyelitis (AHO) is a common pediatric disease that can progress to involve nearby structures leading to complications including subperiosteal abscesses (SPAs). Those with SPAs, in particular, often require surgical intervention for complete treatment. Staphylococcus aureus remains one of the most common causes of AHO. With the emergence of community-associated methicillin-resistant Ataphylococcus aureus and its propensity to form abscesses, there has been an observed increased frequency of AHO with SPAs in children. Although magnetic resonance imaging (MRI) remains the gold standard of imaging for AHO, it is not readily available on a 24/7 basis and often necessitates procedural sedation in children. Delay in MRI and surgical intervention in patients with SPAs may lead to increased complications. The goal of this study is to identify, using clinical features easily obtained in the acute care setting, patients at high risk for AHO with SPAs who may benefit from emergent MRI and/or surgical intervention. DESIGN/METHODS: A retrospective chart review of patients aged birth to younger than 18 years diagnosed with AHO, who presented to a tertiary pediatric hospital from June 10, 2012, to November 1, 2017, were evaluated. Demographic, clinical, laboratory, and imaging data were collected. Patients were divided into 2 groups: AHO alone and AHO with SPAs. RESULTS: A final cohort of 110 subjects were included and analyzed. Of these, 73 (66%) were identified as having AHO alone and 37 (33.6%) as having AHO with SPAs. Patients had a higher risk of AHO with SPAs if they had a history of fever, decreased range of motion, edema, or elevated laboratory studies including white blood cell, absolute neutrophil count, erythrocyte sedimentation rate, and C-reactive protein. C-reactive protein was shown to have the highest correlation of AHO with SPAs, with an optimal cut point of 10.3 mg/dL, yielding a sensitivity of 67.7% and specificity of 77.6%. Patients with AHO with SPAs were at higher risk of having a positive blood culture for methicillin-resistant Staphylococcus aureus. CONCLUSIONS: Clinicians in acute care settings should have a high index of suspicion of AHO with SPAs in children with history of fever, decreased range of motion, or elevated laboratory values (white blood cell, absolute neutrophil count, erythrocyte sedimentation rate, and C-reactive protein). In particular, those with a significantly elevated CRP are at a higher risk for having AHO with SPAs in comparison with an uncomplicated AHO. However, with the significant overlap in historical and clinical variables in the initial presentations of children with AHO with and without SPAs, the clinical urgency in obtaining a magnetic resonance imaging must continue to be individualized based on overall clinical suspicion and availability of resources.

Systematic review and meta-analysis of outcomes in patients with suspected pulmonary embolism.

Prompt evaluation and therapeutic intervention of suspected pulmonary embolism (PE) are of paramount importance for improvement in outcomes. We systematically reviewed outcomes in patients with suspected PE, including mortality, incidence of recurrent PE, major bleeding, intracranial hemorrhage, and postthrombotic sequelae. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, and Embase for eligible studies, reference lists of relevant reviews, registered trials, and relevant conference proceedings. We included 22 studies with 15 865 patients. Among patients who were diagnosed with PE and discharged with anticoagulation, 3-month follow-up revealed that all-cause mortality was 5.69% (91/1599; 95% confidence interval [CI], 4.56-6.83), mortality from PE was 1.19% (19/1597; 95% CI, 0.66-1.72), recurrent venous thromboembolism (VTE) occurred in 1.38% (22/1597; 95% CI: 0.81-1.95), and major bleeding occurred in 0.90% (2/221%; 95% CI, 0-2.15). In patients with a low pretest probability (PTP) and negative D-dimer, 3-month follow-up revealed mortality from PE was 0% (0/808) and incidence of VTE was 0.37% (4/1094; 95% CI: 0.007-0.72). In patients with intermediate PTP and negative D-dimer, 3-month follow-up revealed that mortality from PE was 0% (0/2747) and incidence of VTE was 0.46% (14/3015; 95% CI: 0.22-0.71). In patients with high PTP and negative computed tomography (CT) scan, 3-month follow-up revealed mortality from PE was 0% (0/651) and incidence of VTE was 0.84% (11/1302; 95% CI: 0.35-1.34). We further summarize outcomes evaluated by various diagnostic tests and diagnostic pathways (ie, D-dimer followed by CT scan).

Impact of Guidelines Regarding Brief Resolved Unexplained Events on Care of Patients in a Pediatric Emergency Department.

OBJECTIVES: This study aimed to determine if the 2016 clinical practice guidelines regarding brief resolved unexplained events (BRUE) impacted our institutional approach to infants with BRUE. We sought to determine the statement's impact on admission rates, emergency department (ED) length of stay, and return ED visits or readmissions. METHODS: We conducted a retrospective chart review of patients who presented to the ED at a tertiary pediatric hospital from January 2014 to June 2019. Diagnostic workup (laboratory testing, imaging, monitoring) in the ED was recorded. Cohorts of patients presenting pre- and post-2016 guideline were compared using χ2 and t tests. Subanalysis of higher-risk and lower-risk infant groups was also performed. RESULTS: The demographics of the 2 cohorts were not significantly different. Comparison showed significant reductions in invasive testing after the guideline, both overall (P = 0.005), and specifically regarding comprehensive metabolic panel, blood culture, urine culture, and chest x-ray. Infants meeting higher-risk criteria also showed decreases in invasive testing (P = 0.02). Admission to the hospital and ED lengths of stay decreased in the post-American Academy of Pediatrics statement cohort (P < 0.001 and P = 0.007, respectively). There were no increases in readmissions or repeat ED visits. CONCLUSIONS: This study revealed significant reduction in invasive testing, shorter lengths of ED stays, and lower admission rates at a tertiary care children's hospital after the release of the American Academy of Pediatrics BRUE guideline with no increase in return ED visits or readmissions.

Systematic review and meta-analysis of test accuracy for the diagnosis of suspected pulmonary embolism.

Pulmonary embolism (PE) is a common, potentially life-threatening yet treatable condition. Prompt diagnosis and expeditious therapeutic intervention is of paramount importance for optimal patient management. Our objective was to systematically review the accuracy of D-dimer assay, compression ultrasonography (CUS), computed tomography pulmonary angiography (CTPA), and ventilation-perfusion (V/Q) scanning for the diagnosis of suspected first and recurrent PE. We searched Cochrane Central, MEDLINE, and EMBASE for eligible studies, reference lists of relevant reviews, registered trials, and relevant conference proceedings. 2 investigators screened and abstracted data. Risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies-2 and certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework. We pooled estimates of sensitivity and specificity. The review included 61 studies. The pooled estimates for D-dimer sensitivity and specificity were 0.97 (95% confidence interval [CI], 0.96-0.98) and 0.41 (95% CI, 0.36-0.46) respectively, whereas CTPA sensitivity and specificity were 0.94 (95% CI, 0.89-0.97) and 0.98 (95% CI, 0.97-0.99), respectively, and CUS sensitivity and specificity were 0.49 (95% CI, 0.31-0.66) and 0.96 (95% CI, 0.95-0.98), respectively. Three variations of pooled estimates for sensitivity and specificity of V/Q scan were carried out, based on interpretation of test results. D-dimer had the highest sensitivity when compared with imaging. CTPA and V/Q scans (high probability scan as a positive and low/non-diagnostic/normal scan as negative) both had the highest specificity. This systematic review was registered on PROSPERO as CRD42018084669.

Diagnosis of deep vein thrombosis of the upper extremity: a systematic review and meta-analysis of test accuracy.

Upper extremity deep vein thrombosis (UEDVT) accounts for ≤10% of DVT and can be associated with morbidity and mortality. Accurate diagnosis and treatment are necessary for safe and effective patient management. We systematically reviewed the accuracy of D-dimer and duplex ultrasonography (US) for the evaluation of suspected first-episode UEDVT. We searched the Cochrane Central Register, OVID MEDLINE, EMBASE, and PubMed for eligible studies, reference lists of relevant reviews, registered trials, and relevant conference proceedings. We included prospective cross-sectional and cohort studies that evaluated test accuracy. Two investigators independently screened and collected data. The risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies 2 and certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework. We pooled estimates of sensitivity and specificity. The review included 9 studies. The pooled estimates for D-dimer sensitivity and specificity were 0.96 (95% confidence interval [CI], 0.87-0.99) and 0.47 (95% CI, 0.43-0.52), respectively. The pooled estimates for duplex US sensitivity and specificity were 0.87 (95% CI, 0.73-0.94) and 0.85 (95% CI, 0.72-0.93), respectively. Certainty of evidence was moderate. In this review, we summarized the test accuracy (sensitivity and specificity) of D-dimer and duplex US for this indication. The sensitivity and specificity of the tests found in the present review should be considered in the context of whether they are used alone or in combination, which is dependent on the prevalence of disease in the population, the clinical setting in which the patient is being evaluated, cost, potential harms, and patient outcomes. This study was registered at PROSPERO as Systematic Review Registration Number CRD42018098488.

Systematic review and meta-analysis of outcomes in patients with suspected deep vein thrombosis.

After deep vein thrombosis (DVT) is diagnosed, prompt evaluation and therapeutic intervention are of paramount importance for improvement in patient-important outcomes. We systematically reviewed patient-important outcomes in patients with suspected DVT, including mortality, incidence of pulmonary embolism (PE) and DVT, major bleeding, intracranial hemorrhage, and postthrombotic sequelae. We searched the Cochrane Central Register of Controlled Trials, Ovid Medline, Embase for eligible studies, references lists of relevant reviews, registered trials, and relevant conference proceedings. Two investigators screened and abstracted data. Nine studies with 5126 patients were included for lower extremity DVT. Three studies with 500 patients were included for upper extremity DVT. Among patients with lower extremity DVT, 0.85% (95% confidence interval [CI], 0% to 2.10%) and 0% developed recurrent DVT and PE, respectively, at 3 months. Among patients with upper extremity DVT, 0.49% (95% CI, 0% to 1.16%) and 1.98% (95% CI, 0.62% to 3.33%) developed recurrent DVT and PE, respectively, at 3 months. No major bleeding events were reported for those anticoagulated, which is lower than in other systematic reviews. For both upper and lower extremity DVT, low pretest probability patients with a negative D-dimer had a comparable incidence of VTE at 3 months (∼1%) as patients with a negative ultrasound (US). At higher pretest probabilities, negative US testing with or without serial US appears to be the safer option. In this review, we summarized the outcomes of patients evaluated by various diagnostic pathways. In most instances, there was significant limitation due to small population size or lack of direct evidence of effects of using a specific pathway. This systematic review was registered at PROSPERO as CRD42018100502.

Diagnosis of deep vein thrombosis of the lower extremity: a systematic review and meta-analysis of test accuracy.

Deep vein thrombosis (DVT) of the lower extremities can be associated with significant morbidity and may progress to pulmonary embolism and postthrombotic syndrome. Early diagnosis and treatment are important to minimize the risk of these complications. We systematically reviewed the accuracy of diagnostic tests for first-episode and recurrent DVT of the lower extremities, including proximal compression ultrasonography (US), whole leg US, serial US, and high-sensitivity quantitative D-dimer assays. We searched Cochrane Central, MEDLINE, and EMBASE for eligible studies, reference lists of relevant reviews, registered trials, and relevant conference proceedings. Two investigators screened and abstracted data. Risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies-2 and certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework. We pooled estimates of sensitivity and specificity. The review included 43 studies. For any suspected DVT, the pooled estimates for sensitivity and specificity of proximal compression US were 90.1% (95% confidence interval [CI], 86.5-92.8) and 98.5% (95% CI, 97.6-99.1), respectively. For whole-leg US, pooled estimates were 94.0% (95% CI, 91.3-95.9) and 97.3% (95% CI, 94.8-98.6); for serial US pooled estimates were 97.9% (95% CI, 96.0-98.9) and 99.8% (95% CI, 99.3-99.9). For D-dimer, pooled estimates were 96.1% (95% CI, 92.6-98.0) and 35.7% (95% CI, 29.5-42.4). Recurrent DVT studies were not pooled. Certainty of evidence varied from low to high. This systematic review of current diagnostic tests for DVT of the lower extremities provides accuracy estimates. The tests are evaluated when performed in a stand-alone fashion, and in a diagnostic pathway. The pretest probability of DVT often assessed by a clinical decision rule will influence how, together with sensitivity and specificity estimates, patients will be managed.