Increased Fellow Scholarly Publication Rate After Implementation of a Comprehensive Research Curriculum and Milestone-Based Research Timeline for Pediatric Emergency Medicine Fellows.

OBJECTIVE: Pediatric subspecialty fellows are required to complete a scholarly product during training; however, many do not bring the work to publication. To amplify our fellows' publication success, our pediatric emergency medicine fellowship program implemented a comprehensive research curriculum and established a milestone-based research timeline for each component of a project. Our objective was to assess whether these interventions increased the publication rate and enhanced the graduated fellows' perceived ability to perform independent research. METHODS: Our study was conducted at a tertiary children's hospital affiliated with an academic university, enrolling 3 fellows each year in its pediatric emergency medicine program. A comprehensive research curriculum and a milestone-based research timeline were implemented in 2011. We analyzed the publication rate of our graduating fellows before (2004-2011) and after (2012-2016) our intervention. In addition, in 2017 we surveyed our previous fellows who graduated from 2004 to 2016 and analyzed factors favoring manuscript publication and confidence with various research skills. RESULTS: During the study period, 38 trainees completed the fellowship program. Publication rate increased from 26% ± 17% to 87% ± 30 % ( P < 0.05). When scoring the importance of various factors, fellows most valued mentorship (5 ± 0 vs 4.3 ± 1.0, P < 0.05, postintervention vs preintervention) for the completion of the fellowship study and manuscript. Fellows after the intervention reported greater confidence in performing an analysis of variance (89% vs 36%, odds ratio, 6.3; 95% confidence interval, 1.4-150.1). CONCLUSIONS: Implementation of a comprehensive research curriculum and a milestone-based research timeline was associated with an increase in the publication rate within 3 years of graduation of our pediatric emergency medicine fellows. After implementation, fellows reported an increased importance of mentorship and greater confidence in performing an analysis of variance. We provide a comprehensive curriculum and a research timeline that may serve as a model for other fellowship programs.

Serious Bacterial Infections in Neonates Presenting Afebrile With History of Fever.

BACKGROUND: Infants ≤28 days of age with fever are frequently hospitalized while undergoing infectious evaluation. We assessed differences in rates of serious bacterial infection (SBI; bacteremia, bacterial meningitis, urinary tract infection) and invasive bacterial infection (IBI; bacteremia, bacterial meningitis) among the following neonates: (1) febrile at presentation (FP), (2) afebrile with history of fever without subsequent fever during hospitalization, and (3) afebrile with history of fever with subsequent fever during hospitalization. METHODS: We performed a single-center retrospective study of neonates evaluated for SBI during emergency department evaluation between January 1, 2006, and December 31, 2017. Patients were categorized into FP, afebrile with no subsequent fever (ANF), and afebrile with subsequent fever (ASF) groups. We compared rates of SBI and IBI between groups using logistic regression and assessed time to fever development using time-to-event analysis. RESULTS: Of 931 neonates, 278 (29.9%) were in the ANF group, 93 (10.0%) were in the ASF group, and 560 (60.2%) were in the FP group. Odds of SBI in neonates ANF were 0.42 (95% confidence interval [CI] 0.23-0.79) compared with infants FP, although differences in IBI were not statistically significant (0.52, 95% CI 0.19-1.51). In infants ASF, median time to fever was 5.6 hours (interquartile range, 3.1-11.4). Infants ASF had higher odds of SBI compared to infants FP (odds ratio 1.93, 95% CI 1.07-3.50). CONCLUSIONS: Neonates with history of fever who remain afebrile during hospitalization may have lower odds for SBI and be candidates for early discharge after an observation period.

Immature neutrophils in young febrile infants.

BACKGROUND: To describe the diagnostic value of the absolute band count (ABC) and ratio of immature to total neutrophils (I:T) for invasive bacterial infections (IBIs; bacterial meningitis and bacteraemia) among young febrile infants. METHODS: We performed a cross-sectional study in a paediatric emergency department of febrile infants ≤60 days over 12 years to evaluate the accuracy of the ABC and I:T for IBI. RESULTS: Of 2930 included patients, 75 (2.6%) had IBIs. The area under the curve (AUC; 95% CI) for ABC was 0.69 (0.62 to 0.76) with sensitivity 0.27 (0.17 to 0.38) and specificity 0.94 (0.93 to 0.95) at cutoff ≥1500 cells/µL. The AUC for I:T was 0.65 (0.59 to 0.72) with sensitivity 0.29 (0.19 to 0.41) and specificity 0.88 (0.87 to 0.89) at cutoff ≥0.2. Only the ABC in infants 29-60 days was minimally accurate. CONCLUSION: The ABC and I:T were generally inaccurate for detecting IBI in febrile infants. Guidelines without these parameters may be better for risk assessment.

Factors associated with serious bacterial infections in infants ≤60 days with hypothermia in the emergency department.

BACKGROUND: We sought to investigate risk factors for serious bacterial infection (SBI: bacterial meningitis, bacteremia, and urinary tract infection [UTI]) among infants ≤60 days of age presenting to the emergency department (ED) with hypothermia (temperature < 36 °C). METHODS: We performed a single center study over a 12-year period including all patients ≤60 days old with hypothermia, excluding patients who did not receive a blood culture and patients who received antibiotics prior to culture acquisition. The primary outcome was SBI. Secondary outcomes were mortality and herpes simplex infection. We performed multivariable logistic regression to identify risk factors for primary outcomes reporting adjusted odds ratios with 95% confidence intervals (aOR, 95% CI). RESULTS: 360 infants were identified. 10/360 (2.8%) had an SBI. All episodes of SBI occurred in infants ≤28 days of age. Two patients had meningitis, two had meningitis with bacteremia, one had isolated bacteremia, and five had UTI. Associated diagnoses included prematurity (46.9%), hyperbilirubinemia (28.3%) and dehydration (14.7%). In multivariable analysis, presentation at 15-28 days (7.60, 1.81-31.86; p = 0.005) compared to 0-14 days, higher absolute neutrophil count (1.25, 1.04-1.50; p = 0.015) and lower platelet count (0.99, 0.99-1.00; p = 0.046) were associated with SBI. Three patients without SBI died during or soon after their hospitalization. One patient had positive testing for herpes simplex. CONCLUSION: In this cohort of hypothermic infants, 2.8% had a SBI. Age of presentation, ANC, and lower platelet count were associated with serious infections. Hypothermic infants presenting to the ED carry significant morbidity and require prospective study to better risk-stratify this population.

Risk of Serious Bacterial Infection in Infants Aged ≤60 Days Presenting to Emergency Departments with a History of Fever Only.

OBJECTIVE: To compare the risk of serious bacterial infection between infants aged ≤60 days who are febrile in the emergency department (ED) and those who have only a history of fever and are afebrile on arrival to the ED. STUDY DESIGN: In this secondary analysis of a multicenter prospective study using data collected between December 2008 and May 2013, we compared the rate of serious bacterial infection (urinary tract infection [UTI], bacteremia, and/or bacterial meningitis) between infants who have a history of fever but are afebrile on arrival to the ED and those with fever documented in the ED (rectal temperature ≥38.0 °C) using relative risk (RR) with 95% CI. Stratified analyses were performed for age (≤28 and 29-60 days) and serious bacterial infection type. Infants born prematurely and those with a clinical focal infection or serious illness were excluded. RESULTS: A total of 3825 infants (mean age, 35.2 days; 56.9% male) were included. Of the 1233 (32.2%) who were afebrile in the ED, 108 (8.8%) had a serious bacterial infection (UTI, n = 94 [7.6%]; bacteremia, n = 19 [1.5%]; bacterial meningitis, n = 8 [0.6%]). Of the 2592 infants (67.8%) who were febrile in the ED, 331 (12.8%) had a serious bacterial infection (UTI, n = 285 [11.0%]; bacteremia, n = 61 [2.4%]; bacterial meningitis, n = 17 [0.7%]). The RR for serious bacterial infection for afebrile vs febrile infants was 0.68 (95% CI, 0.56-0.84). A lower risk of serious bacterial infection was also seen among afebrile vs febrile infants aged ≤28 days (RR, 0.69; 95% CI, 0.52-0.93) and age 29-60 days (RR, 0.67; 95% CI, 0.50-0.89). CONCLUSIONS: The prevalence of serious bacterial infection is lower in infants aged ≤60 days with a history of fever compared with those who are febrile on arrival to the ED. The small risk reduction in this group is unlikely to alter decision making.

Feasibility of the Digital Retinography System Camera in the Pediatric Emergency Department.

PURPOSE: Direct ophthalmoscopy may be difficult without pupillary dilation and patient cooperation. Nonmydriatic ocular fundus photography (NMOFP) has been shown to be easily and efficiently accomplished by medical providers and improve the detection of abnormalities in adult emergency department (ED) patients. Nonmydriatic ocular fundus photography for pediatric ED patients has not been studied. The purpose of this study was to assess the ease of use of the Digital Retinography System (DRS) camera for NMOFP in ED patients aged 5 to 12 years and the quality of retinal images obtained with the DRS. METHODS: Retinal images were obtained with the DRS by a pediatric emergency medicine physician using a convenience sample of ED patients aged 5 to 12 years. Time to procedure completion, patient cooperation (Likert scale 1-5, with 5 being most cooperative), and satisfaction with the images (Likert scale 1-5, with 5 being completely satisfied) were recorded. Any satisfaction score less than 5 required the physician to describe a reason for dissatisfaction (brightness, field of view, focus). An ophthalmologist was consulted regarding any abnormal image. The accompanying parent completed a survey following the procedure. Estimated time to completion of the procedure and a rating of the overall comfort and cooperation of the child during the procedure (Likert scale 1-5) were recorded. A second pediatric emergency medicine physician reviewed all images and rated the level of satisfaction, reasons for dissatisfaction, and whether the images were normal. Descriptive statistics were used to analyze survey responses. A Mann-Whitney U test was used to compare continuous data for age groups 5 to 8 and 9 to 12 years. A Krippendorff α or κ coefficient was used to measure agreement between the physician obtaining the images and the secondary reviewer for image satisfaction and image abnormalities. RESULTS: One hundred three patients were enrolled: 50 aged 5 to 8 years and 53 aged 9-12 years (mean, 9.1 [SD, 2.1] years). Five patients failed to cooperate, and no images were obtained. The mean length of time (LOT) to procedure completion was 1.8 (SD, 0.86) minutes. Overall, mean cooperation score was 4.4, and mean image satisfaction score was 4.6. One or more reasons for image dissatisfaction were given in 27 patients (imperfect focus most commonly). There was moderate agreement between the 2 physicians for image satisfaction (Krippendorff α coefficient = 0.48) and image abnormalities (κ coefficient = 0.38). Mean LOT did not differ between 5- to 8-year-olds and 9- to 12-year-olds (P = 0.23). Older patients had higher mean cooperation scores and image satisfaction scores (P < 0.001 and P = 0.04 respectively). Parental mean score for perceived LOT was 4.6 (5 = very short), 4.8 for patient comfort (5 = very comfortable), and 4.8 for patient cooperation (5 = very cooperative). CONCLUSIONS: Our data suggest that NMOFP using the DRS camera is a rapid and easy method of obtaining high-quality images of the retina in pediatric ED patients.

Bloodstream Infections in Patients With Intestinal Failure Presenting to a Pediatric Emergency Department With Fever and a Central Line.

OBJECTIVE: Previous small studies have found a high occurrence of bloodstream infections (BSIs) in patients with intestinal failure, and these rates are higher than reported rates in other pediatric populations with central lines. The primary study objective was to describe the occurrence of BSIs in patients with intestinal failure who present to the pediatric emergency department (ED) with fever. METHODS: This 5-year retrospective chart review included febrile patients with intestinal failure and central lines who presented to the Children's Hospital of Pittsburgh ED between 2006 and 2011. Each febrile episode was analyzed at the visit level. RESULTS: During the study, 72 patients with 519 febrile episodes were identified. Central blood cultures were obtained in 93% (480/519) of episodes and 69% (330/480) were positive. Of all BSIs, 38% (124/330) were polymicrobial, 32% (105/330) were a single gram-positive organism, 25% (84/330) were a single gram-negative organism, and 5% (17/330) were a single fungal organism. Of the bacterial pathogens, 48% (223/460) were gram-negative. Overall, 60% were enteric organisms. CONCLUSIONS: Pediatric patients with intestinal failure and central lines have a high occurrence of BSIs with 69% of cultures positive in this study of ED febrile episodes. In contrast to reports in other populations with central lines, BSI occurrence in patients with intestinal failure and fever is higher and larger proportions are gram-negative and enteric organisms. For these patients, we recommend central and peripheral blood cultures, empiric broad spectrum antibiotics targeting gram-negative and enteric organisms, and hospital admission.

Morbidity associated with golf-related injuries among children: findings from a pediatric trauma center.

OBJECTIVE: To describe injuries due to golf-related activities among pediatric patients requiring hospital admission. METHODS: We conducted a retrospective analysis of all sports-related injuries from 2000 to 2006 using a level 1 trauma center database. RESULTS: Of 1005 children admitted with sports-related injuries, 60 (6%) had golf-related injuries. The mean injury severity score was significantly higher for golf-related injuries (11.0) than that for all other sports-related injuries (6.8). Most golf-related injuries occurred in children younger than 12 years (80%), at home (48%), and by a strike from a club (57%) and resulted in trauma to the head or neck (68%). CONCLUSIONS: Golf-related injuries, although an infrequent cause of sports-related injuries, have the potential to result in severe injuries, especially in younger children. Preventive efforts should target use of golf clubs by younger children in the home setting.

Evaluation of the siblings of physically abused children: a comparison of child protective services caseworkers and child abuse physicians.

Current theories suggest that all children in a home are at risk for physical abuse, when one child is abused. However, little evidence exists to guide decisions regarding the medical management of siblings of physically abused children (contact children [CC]). This study sought to compare child protective services (CPS) caseworkers' and child abuse physicians' (CAP) recommendations regarding the need for medical evaluation of CC in case scenarios of unequivocal physical abuse. In all cases, caseworkers and physicians disagreed on which CC warranted a medical evaluation. In addition, 25% of caseworkers did not think that physicians should make recommendations on the need for medical evaluation of CC. The findings of the authors suggest that the home visit is a critical part of the decision-making process for caseworkers and that it often acts as a substitute for a medical evaluation. Caseworkers indicated that visible injury to the contact child and severity of injury to the index child were among the most important factors in deciding which CC need a medical evaluation. Although caseworkers and physicians disagree on certain issues related to the evaluation of CC, it is clear that limited resources should be directed at CC at highest risk for physical abuse.

The impact of pediatric trauma in the Amish community.

OBJECTIVE: To describe the epidemiology of trauma in Amish children and to determine differences in treatment and outcome related to injury mechanism. STUDY DESIGN: In this retrospective review, data were collected on all Amish children with trauma requiring hospital admission. Demographic, interventional, and outcome data were collected. Categorical outcomes were compared by using chi-square, logistic regression, or Fisher exact test; continuous outcomes were compared with analysis of variance. RESULTS: A total of 135 trauma admissions were studied. There was a significant difference of proportion of injury by month (P < .01). The most common mechanisms of injury were falls (39%), buggy versus motor vehicle accidents (MVA; 16%), and animal injuries (14%). A total of 41% of patients required operative procedures, and 50% of subjects required intensive care. Animal injuries and buggy versus MVA were significantly associated with a requirement for surgery, increased length of stay, and increased severity (all P < .01). The overall mortality rate was 3%. There were significant associations between mechanism of injury and outcome scores (P < .05) and hospital charges (P < .05). CONCLUSIONS: The spectrum of traumatic injuries is unique among Amish children. These injuries contribute significantly to morbidity and mortality and impose a large monetary burden on the Amish community. Education may decrease the incidence of these events.