The Mortality of Ill Infants with False Tooth Extraction in a Rural Ugandan Emergency Department.

False tooth extraction (FTE), a cultural practice in East Africa used to treat fever and diarrhea in infants, has been thought to increase infant mortality. The mortality of clinically similar infants with and without false tooth extraction has not previously been examined. The objective of our retrospective cohort study was to examine the mortality, clinical presentation, and treatment of infants with and without false tooth extraction. We conducted a retrospective chart review of records of infants with diarrhea, sepsis, dehydration, and fever in a rural Ugandan emergency department. Univariate analysis was used to test statistical significance. We found the mortality of infants with false tooth extraction (FTE+) was 18% and without false tooth extraction (FTE-) was 14% (P=0.22). The FTE+ study group, and FTE- comparison group, had similar proportions of infants with abnormal heart rate and with hypoxia. There was a significant difference in the portion of infants that received antibiotics (P=0.001), and fluid bolus (P=0.002). Although FTE+ infants had clinically similar ED presentations to FTE- infants, the FTE+ infants were significantly more likely to receive emergency department interventions, and had a higher mortality than FTE- infants.

The association of overweight and ankle injuries in children.

OBJECTIVES: Overweight children are at increased risk for many medical problems. Trauma is the leading etiology of childhood morbidity and mortality. No previous study has evaluated the association between overweight and acute ankle injuries in children. We hypothesized that being overweight is associated with an increased risk of ankle injury in children. METHODS: We conducted a case-control study in an urban pediatric emergency department. Subjects aged 5 to 19 years were recruited from June 2005 through July 2006. Children with acute ankle trauma were enrolled as cases. A convenience sample of children with a chief complaint of fever, headache, or sore throat was enrolled as controls. Demographic information and anthropometric measurements were obtained. Age- and gender-specific body mass index percentiles (BMI-Ps) were calculated using pediatric norms. Multivariate unconditional logistic regression was used to assess the relationship between overweight and ankle injury, adjusting for demographic variables. Through medical records, we obtained demographic information and weight, but not height, of all cases that were not enrolled. This allowed us to conduct a sensitivity analysis in which we combined the enrolled and nonenrolled cases into a single case group and made increasingly more unlikely assumptions about the height percentiles of the nonenrolled cases. RESULTS: One hundred eighty cases and 180 controls were enrolled in the study. We observed a significant association between overweight and ankle injury (multivariate-adjusted odds ratio 3.26, 95% confidence interval, 1.86-5.72; P value for trend <.0001). Although this result may be an overestimate of the magnitude of the association due to a possible bias in the selection of cases, sensitivity analysis demonstrated the robustness of the statistical significance of the finding. CONCLUSIONS: Overweight children may be at increased risk of ankle injury.

A randomized trial to assess the efficacy of point-of-care testing in decreasing length of stay in a pediatric emergency department.

OBJECTIVES: To compare the effect of point-of-care (POC) testing versus traditional laboratory methods on length of stay in a pediatric emergency department (ED). METHODS: This study was a prospective, randomized, controlled trial of patients solely requiring blood work that a POC device was capable of performing. Two hundred twenty-five patients presenting to a tertiary hospital ED in an urban setting enrolled after informed consent. Of all patients studied, 114 were randomized to the POC group, 111 to routine laboratory analysis. Exact times of critical phases of management and patient flow were recorded by dedicated research assistants. Medical management decisions were made at the discretion of the supervising physicians. RESULTS: Similar waiting periods were noted in both groups for time spent in the waiting room, time waiting for first physician contact, and time waiting for blood draw. Significantly less time was required for results to become available to physicians when POC testing was used (65.0 minutes; P < 0.001). Significant decrease in overall length of stay was also noted, with patients randomized to the POC group spending an average of 38.5 minutes (P < 0.001) less time in the ED. CONCLUSIONS: Point-of-care testing can significantly decrease the length of stay in select pediatric patients in an ED setting. Point-of-care devices may prove to facilitate patient flow during busiest periods of service demand.

Novel applications of ultrasound in pediatric emergency medicine.

A new field, termed emergency ultrasound (EUS), has recently been established. The past decade saw rapid development in the field of EUS in adult patients, especially as performed by emergency medicine physicians. Ultrasound imaging offers several advantages over traditional radiographic techniques, many of which are especially relevant to patients in the pediatric emergency department. Recent literature has documented increased use of EUS for pediatric patients. This review will examine basic principles of ultrasound relevant to pediatric emergency medicine physicians. Emphasis will be placed on understanding the instrument and its limitations. In addition, we will review recent developments in this field. It is our goal that the reader will gain an understanding of the strengths and limitations of this instrument and will therefore be in a position to plan their own program in EUS in pediatrics. Furthermore, it is hoped that this review will serve as an impetus for innovative research, to refine and extend the indications of this modality to benefit patients in the pediatric emergency department.

Incidence and predictors of serious bacterial infections among 57- to 180-day-old infants.

BACKGROUND: Numerous researchers have investigated fever in infants <2 months of age. However, the etiology of fever and usefulness of screening tests in older (2-6 months) infants is not well studied. METHODS: This was a prospective study of febrile infants 57-180 days old. Evaluation included blood and urine tests and direct fluorescent antibody (DFA) of nasal swabs for respiratory viruses. Additional studies were performed at the discretion of managing clinicians. RESULTS: Serious bacterial illness (SBI) was diagnosed in 44 (10.3%) of 429 infants: 41 with bacteruria and 4 with bacteremia (1 infant had concurrent Escherichia coli bacteruria and bacteremia). Lumbar puncture, performed in 58 (13.5%) infants, revealed no cases of bacterial meningitis. DFAs were positive in 163 (38.0%) infants: the majority were respiratory syncytial virus or influenza A. SBI was noted in 4.9% of infants with positive DFA. Age and height of fever were not significant predictors of SBI. White blood cell count (17.1 K/mm3 vs 12.4 K/mm3) and CRP (2.6 mg/dL vs 0.9 mg/dL) were elevated in infants with SBI, as was the Yale Observation Score (9.4 vs 8.0). CONCLUSIONS: A substantial proportion (10.3%) of older febrile infants has SBI. In the postpneumococcal vaccine era, only 1 infant had pneumococcal disease; bacteremia was noted in 0.9%. Bacteruria is commonly associated with fever in this age range. Infants older than 8 weeks remain at risk for bacteremia and bacteruria, regardless of positive DFA or other apparent source of fever. CRP is a better indicator than white blood cell count, but no single ideal indicator of SBI was identified for this age group.

Fever in the new millennium: a review of recent studies of markers of serious bacterial infection in febrile children.

PURPOSE OF REVIEW: Evaluation of a febrile infant or child for serious bacterial infections (SBI) can be a challenging task; there is no single reliable predictor of SBI in infants. This review examines some of the recent work evaluating the usefulness of indicators for SBI, such as white blood cell count (WBC), C-reactive protein (CRP), procalcitonin (PCT), and interleukin-6 (IL-6). RECENT FINDINGS: While WBC is traditionally used as an indicator of serious infection, it appears to be the least specific and sensitive test in children. CRP and PCT are the most promising, but neither is an ideal single indicator by itself, especially in infants. There has been very limited experience with PCT in this country, however. IL-6 is more useful than WBC but less accurate than either CRP or PCT. SUMMARY: Much progress has been made in recent years in finding more accurate indicators of SBI than WBC. However, while recent developments have given clinicians some new tools in evaluating febrile infants and children, it remains a formidable undertaking. In the especially vulnerable infant population, the holy grail of a single ideal SBI indicator remains elusive.

Emergency medicine training programs' educational requirements in the management of psychiatric emergencies: current perspective.

OBJECTIVE: The purpose of this study was to determine the extent of training in clinical psychiatry that is provided and/or required by emergency medicine (EM) residency training programs and pediatric emergency medicine (PEM) subspecialty residency training programs. DESIGN/METHODS: A questionnaire was mailed to 114 EM residency directors and to all 50 PEM fellowship directors. Each director was asked to indicate the amount of psychiatric training that was required of residents or fellows in his or her program. Details concerning the exact structure of psychiatric training were solicited from those offering such training. RESULTS: There was a 76% response rate (n = 88) among EM programs, and 76% (n = 59) of the respondents reported no formal training in the management of acute psychiatric emergencies. Only 14% (12 programs) provide a 1-month rotation in psychiatry. Of the 3-year programs, 14% (n = 11) offer 2-week psychiatric electives, and 9% (n = 8) offer some training. There was a 72% response rate among the PEM training programs. Only one of the 36 respondents provided a required 1-month rotation in psychiatry. Six programs stated the availability of a 1-month elective in psychiatry. Two programs reported 2 to 3 hours per year of core lecture time dedicated to psychiatric emergencies. CONCLUSIONS: Standardized psychiatric training is not required of most trainees in EM and PEM. Few (24%) training programs provide formal psychiatric training for their EM residents, and even fewer (< 3%) provide such training for their PEM fellows.

Management of fever in infants and children.

There is no question that fever is a source of great consternation for parent and physician alike; however, it is impossible to predict with certainty the outcome of every febrile illness. Inherent in the words diagnostic impression is a degree of uncertainty. The only question remaining is how much uncertainty is in the best interest of the child. Physicians try to use the existing scientific data to best determine the prevalence of disease and outcome. At the same time, they must recognize the limitations of both the data and their ability to be generalized to every population. Everything clinicians do has risks and costs, which they must balance against the incidence of complications and the benefits of testing. To take away clinical judgment makes physicians technicians not clinicians.