Standardized reporting of appendicitis-related findings improves reliability of ultrasound in diagnosing appendicitis in children.

PURPOSE: Our objective was to increase ultrasound reliability for diagnosing appendicitis in an academic children's hospital emergency department (ED) through a multidisciplinary quality improvement initiative. METHODS: A retrospective review of ultrasound use in patients diagnosed with appendicitis in our ED from 1/1/2011 to 6/30/2014 established a baseline cohort. From 8/1/2014 to 7/31/2015 a diagnostic algorithm that prioritized ultrasound over CT was used in our ED, and a standardized template was implemented for the reporting of appendicitis-related ultrasound findings by our radiologists. RESULTS: Of 627 patients diagnosed with appendicitis in the ED during the retrospective review, 46.1% (n=289) had an ultrasound. After implementation of the diagnostic algorithm and standardized ultrasound report, 88.4% (n=236) of 267 patients diagnosed with appendicitis had an ultrasound (p<0.01). The frequency of indeterminate results decreased from 44.3% to 13.1%, and positive results increased from 46.4% to 66.1% in patients with appendicitis (p<0.01). The sensitivity of ultrasound (indeterminate counted as negative) increased from 50.6% to 69.2% (p<0.01). CONCLUSIONS: Ultrasound reliability for the diagnosis of appendicitis in children can be improved through standardized results reporting. However, these changes should be made as part of a multidisciplinary quality improvement initiative to account for the initial learning curve necessary to increase experience. LEVEL OF EVIDENCE: Level II, Study of Diagnostic Test.

Computed Tomography Utilization for the Diagnosis of Acute Appendicitis in Children Decreases With a Diagnostic Algorithm.

OBJECTIVE: The primary objective of this project was to decrease computed tomography (CT) utilization for the diagnosis of appendicitis in an academic children's hospital emergency department (ED) through a multidisciplinary quality improvement initiative. BACKGROUND: Appendicitis is the most common abdominal diagnosis leading to the hospitalization of children in the United States. However, the diagnosis of appendicitis in children can be difficult and many centers rely heavily upon CT scans. Recent recommendations emphasize decreasing CT use among pediatric patients because of an increased lifetime risk of radiation-induced malignancies. METHODS: A retrospective review was conducted of patients diagnosed with appendicitis in the ED at Children's Mercy Hospital from January 1, 2011 to February 28, 2014 to establish a baseline cohort. From August 1, 2014 to July 31, 2015, a newly designed diagnostic algorithm was used in the ED and patients were prospectively followed. Any patient discharged from the ED received a follow-up phone call. Patients treated for appendicitis before and after pathway implementation were compared. In addition, any patient evaluated for appendicitis after implementation of the algorithm was analyzed for adherence to the clinical pathway. Differences between the 2 groups were analyzed using ANOVA, Wilcoxon Rank Sum, χ, and Fisher Exact tests. RESULTS: Of 840 patients seen after implementation of the diagnostic algorithm, 267 were diagnosed with appendicitis. After implementation of the algorithm, CT utilization decreased from 75.4% to 24.2% (P < 0.0001) in patients with appendicitis. CT utilization was 27.3% after implementation, regardless of the ultimate diagnosis or algorithm adherence. The diagnostic pathway had a sensitivity of 98.6% and specificity of 94.4%. CONCLUSIONS: Implementation of a diagnostic algorithm for appendicitis in children significantly decreases CT utilization, whereas maintaining a high sensitivity and specificity.

Use of computed tomography in the emergency department for the diagnosis of pediatric peritonsillar abscess.

OBJECTIVE: The objective of this study was to review our pediatric emergency department's (ED's) utilization of computed tomography (CT) in the diagnosis of peritonsillar abscess (PTA) and treatment outcomes. METHODS: This study used case series with chart review. RESULTS: From January 2007 to January 2009, 148 patients were seen in our ED for possible PTA. Mean age at presentation was 11.8 years (range, 10 months to 18 years); 81 (54.7%) of 148 were females. Computed tomography was ordered in 96 (64.9%) of 148 patients, of which 73 (49.3%) 148 were confirmed to have PTA. Mean age of patients who underwent CT was younger when compared with those who did not have CT performed (mean, 11 vs 13 years; P = 0.02). Unilateral PTA was found in 65 (43.9%) of 148, bilateral in 8 (5.4%) of 148, and intratonsillar in 25 patients (16.9%). Concomitant CT findings of parapharyngeal space involvement were found in 19 (12.8%), and retropharyngeal space involvement in 11 (7.4%). Admission was necessary for 104 (71.2%) of 148 patients, whereas 42 were discharged from the ED. Transoral needle aspiration and/or incision and drainage were performed in the ED in 41 patients, with purulence identified in 33 (80.5%) of 41. Rapid strep testing was positive in 40 (32%) of 124 patients tested. Operative treatment was necessary in 44 patients (29.7%), 34 underwent incision and drainage, and 10 underwent quinsy tonsillectomy. CONCLUSIONS: Computed tomography is commonly utilized in the ED for the evaluation of PTA and is ordered more often in younger children.

Case records of the Children's Mercy Hospital: A 12-year-old girl with a straddle injury.

Straddle injuries are common in children. At the end of this case presentation, you should be able to describe the approach to the evaluation and treatment of a straddle injury, list indications for gynecologic consultation and/or sedation, plan disposition, and discuss pitfalls to avoid in evaluating patients with straddle injuries.

Parenting behaviors and attitudes about supervision among parents of acutely poisoned children.

OBJECTIVE: This study describes the supervision beliefs of parents of children with unintentional poisonings and examines the relationship between supervision beliefs, household composition, and parental age. METHODS: Children aged <60 months presenting with an unintentional poisoning to an emergency department or urgent care of an urban, academic medical center in Kansas City, Missouri, were identified. Parents completed the Beliefs About Supervision Questionnaire (BAS-Q) by phone within 2 weeks of their child's visit. The questionnaire consisted of 14 child activity scenarios, each followed by 2 questions: What age would you permit your child to perform this activity without constant supervision? How often would you check on a child of this age while engaged in the activity? Two scores were derived: mean age across all scenarios (BAS-Age) and mean time until child is checked on across all scenarios (BAS-Time). RESULTS: One hundred parents completed the BAS-Q. The majority of respondents were mothers (82%), 40% had 2 or more children in the home aged 5 years or younger, and 61% had 2 or more adults living in the home. Pearson correlations revealed associations for BAS-Time with total children within the home (r = .28, P < .005) and number of children aged 6 to 12 years in the home (r = .28, P < .005). BAS-Age was not related to any aspect of household composition. CONCLUSION: Less vigorous parental supervision was associated with an increased number of children in the home. Parental supervision may be influenced by reliance on other children in the home.

Anogenital and respiratory tract human papillomavirus infections among children: age, gender, and potential transmission through sexual abuse.

OBJECTIVES: To evaluate human papillomavirus (HPV) presentation among children <13 years of age and its association with suspected child sexual abuse (CSA), and to assess sexual abuse consideration among different clinical services treating these children. METHODS: Records of children <13 years of age from 1985 to 2003 were selected for review if the children had a HPV-related International Classification of Diseases, Ninth Revision, code or had been examined in the CSA clinic. Abstracted data included demographic features, clinical findings, clinical services involved, age at diagnosis, age when care was first sought, and age when symptoms were first noted. RESULTS: HPV was identified by clinical examination and/or biopsy for 124 children, 40 with laryngeal lesions, 67 with anogenital lesions, 10 with oral lesions, and 7 with both anogenital and oral lesions. The mean age at HPV diagnosis was 4.0 +/- 2.9 years, compared with 6.4 +/- 3.0 years for 1565 HPV-negative children. Among 108 HPV cases with data for age when symptoms were first noted, the mean age was 3.3 +/- 2.9 years (median: 2.2 years) for children with anogenital and oral HPV and 2.4 +/- 2.3 years (median: 1.9 years) for children with laryngeal HPV. Among HPV-positive patients, 56% were female, compared with 82% of HPV-negative children. Fifty-five (73%) of 75 children with anogenital HPV infections were referred to the CSA clinic for evaluation, compared with none of 49 children with laryngeal or oral HPV infections treated by the otolaryngology service. Laryngeal cases presented earlier than anogenital and oral lesions. Abuse was considered at least possible for 17 of 55 children with any CSA evaluation. The mean age of likely abused, HPV-positive children was 6.5 +/- 3.8 years (median: 5.3 years), compared with 3.6 +/- 2.3 years (median: 2.6 years) for likely not abused, HPV-positive children. The likelihood of possible abuse as a source of HPV infection increased with age. The positive predictive value of HPV for possible sexual abuse was 36% (95% confidence interval: 13-65%) for children 4 to 8 years of age and 70% (95% confidence interval: 35-93%) for children >8 years of age. CONCLUSIONS: The data from this epidemiologic study of HPV suggest that many anogenital and laryngeal HPV infections among preadolescent children are a result of nonsexual horizontal transmission, acquired either perinatally or postnatally. It seems that many children >2 years of age acquire HPV infection from nonsexual contact. Different subspecialties vary greatly in their suspicion and evaluation of CSA. At this time, there remains no clear age below which sexual abuse is never a concern for children with anogenital HPV infections. Every case needs a medical evaluation to determine whether enough concern for abuse exists to pursue additional investigations.