The Association Between Early Initiation of Systemic Corticosteroids and the Hospital Length of Stay in Patients With Multisystem Inflammatory Syndrome in Children.

OBJECTIVE: Patients with multisystem inflammatory syndrome in children (MIS-C) often require hospital admission. Treatment of MIS-C has included intravenous immunoglobulin, systemic corticosteroids, and/or immunomodulators. There is no standardized approach to when steroids should be initiated during treatment. The study objective was to determine whether early initiation of steroids in patients with MIS-C is associated with the duration of hospital length of stay (LOS). METHODS: This is a single-center retrospective cohort study of patients younger than 21 years who were hospitalized with MIS-C between March 2020 and September 2021 and received steroids. Cases were obtained from an institutional MIS-C log. Patients with culture proven sepsis and/or those who received intravenous immunoglobulin or steroids within the previous 30 days were excluded. We used a multivariable linear regression model, controlling for potential confounders, to assess the association between early steroids and LOS. RESULTS: A total of 56 patients hospitalized with MIS-C were identified; 38 received systemic corticosteroids and were included in the study. The mean time from admission to steroid administration was 9.8 hours (SD = 7.7) in the early group and 44.6 hours (SD = 14.2) in the late group. There was a statistically significant difference in baseline characteristics of patients receiving early versus late steroids in initial C-reactive peptide, procalcitonin, brain natriuretic peptide, and cardiac dysfunction. After controlling for confounders, initiating steroids within 24 hours of admission for MIS-C was associated with a decreased hospital LOS: in patients treated with early steroids, LOS was 58.3 hours less (95% confidence interval, -100.0 to -16.6; P = 0.007) than in those who received late steroids. CONCLUSIONS: Among patients with MIS-C, initiating systemic corticosteroids within 24 hours of admission was associated with decreased hospital LOS.

Poor Perception and Knowledge of Electronic Cigarettes Among Adolescents and Their Parents.

OBJECTIVES: Electronic cigarettes (e-cigs) and vaping are a popular form of substance abuse among adolescents. Studies have shown that adolescents have a poor understanding of e-cigs but little is known about parental understanding. The primary objective was to assess if a discrepancy in perception and knowledge regarding the content and safety profile of e-cigs between adolescents and their parents exists. METHODS: Single-site prospective questionnaire analysis of adolescents (12-21 years) and their parents between November 2018 and March 2019 was performed. Each participant pair received an anonymous, confidential, electronic questionnaire. Data were collected via Research Electronic Data Capture. χ2 and independent t tests were used for comparative analysis. RESULTS: A total of 300 adolescent/parent pairs were included for analysis. The mean age of adolescents was 15.1 years (SD, 2.1), and that of parents was 43.9 years (SD, 8.7). Overall knowledge of e-cigs was inadequate in both adolescents and parents: 93.7% and 88.3%, respectively (P < 0.0001). Less adolescents (49.0%) compared with parents (71.0%) perceived any health risks to smoking e-cigs (P < 0.0001). Among adolescents, 17% admitted to smoking e-cigs compared with 5.4% smoking conventional tobacco cigarettes (P < 0.0001), and they reported using e-cigs (17.0%) more often than any other substance except alcohol (27.3%). Only 49.7% of adolescents reported receiving formal education at school regarding e-cigs. Parents reported discussing e-cigs risks/benefits with adolescents less often than other topics (71.3% vs 79.0% to 84.3%; P < 0.0007). CONCLUSIONS: This analysis suggests that perception and knowledge regarding the content and safety profile of e-cigs are poor among both adolescents and parents. These findings support the need for tighter federal regulation and an increase in public health awareness programs.

Comparison of the Demographics and Visit Characteristics of Patients Who Left the Pediatric Emergency Department Without Being Seen With Those Who Were Evaluated in the Emergency Department.

BACKGROUND: We compared those patients who left without being seen (LWBS) with those who stay for evaluation and determined which subsets were more likely to depart prematurely in the largest pediatric population studied to date. METHODS: We retrospectively extracted data from the electronic medical records of all pediatric patients who visited the emergency department between January 1, 2013, and December 31, 2015. The demographics and visit characteristics were compared between patients who LWBS and those seen by a provider. Bivariate and multivariate analyses were used to determine the odds for premature departure of specific groups within the population. RESULTS: Of the 271,364 pediatric patients visiting the emergency department during the 3-year study period, 3835 (1.4%) LWBS by a provider. The mean age of those LWBS was younger, and the odds of leaving slightly decreased as the patient's age increased (odds ratio [OR], 0.98). Those triaged as having "nonurgent" medical conditions had a statistically significant increase in odds of premature departure when compared with those with "urgent" medical conditions (OR, 1.16). Patients arriving during the evening and overnight hours had a much greater odds of LWBS (OR, 6.7 and 7.3, respectively). CONCLUSIONS: Our findings demonstrated and confirmed that age, time of arrival, and acuity level upon presentation were predictors of patients leaving before evaluation. This can guide institutions with staffing and flow processes as they attempt to reduce LWBS rates but also raises further questions as to whether these subsets go forward to have worse clinical outcomes after leaving prematurely.

Performance of Emergency Medical Service Providers in Pediatric and Adult Simulation of Unstable Supraventricular Tachycardia.

OBJECTIVE: The aim of the study was to compare emergency medical service resuscitation of pediatric and adult high-fidelity manikins in unstable supraventricular tachycardia. The primary objective was time to cardioversion. The secondary objective was to assess if the cardioversion was synchronized at the correct dosage for the manikin's weight. METHODS: Emergency medical service providers were voluntarily enrolled as part of an emergency medical service training program. Participants were randomized to either a pediatric or adult resuscitation as their study scenario. They then completed the second resuscitation as part of the training program. Participants completed presurvey and postsurvey. Resuscitations were videotaped and analyzed by a blinded reviewer. The study was powered to detect a 60-second difference in performance between pediatric and adult scenarios with a ß of 0.8 and 2-tailed α of 0.05 using an independent-samples t test. RESULTS: A total of 37 participants were enrolled. Participants in the pediatric arm had a longer mean time to cardioversion, but the difference was not statistically significant. The mean delay to cardioversion in the pediatric scenario was 34 seconds (197 vs 163 seconds; difference 95% confidence interval [CI], -5 to 73 seconds; P = 0.09). There was no significant difference in the percentage of participants who administered a correct dose (32% vs 50%; difference 95% CI, -50% to 13%; P = 0.75) or regarding synchronization of cardioversion (74% vs 83%; difference 95% CI, -36% to 17%; P = 0.42). CONCLUSIONS: Emergency medical service providers did not have a significant difference in time to cardioversion between pediatric and adult unstable supraventricular tachycardia simulations.

Use of a Metronome in Cardiopulmonary Resuscitation: A Simulation Study.

OBJECTIVE: Determine whether the use of a metronome improves chest compression rate and depth during cardiopulmonary resuscitation (CPR) on a pediatric manikin. METHODS: A prospective, simulation-based, crossover, randomized controlled trial was conducted. Participants included pediatric residents, fellows, nurses, and medical students who were randomly assigned to perform chest compressions on a pediatric manikin with and without an audible metronome. Each participant performed 2 rounds of 2 minutes of chest compressions separated by a 15-minute break. RESULTS: A total of 155 participants performed 2 rounds of chest compressions (74 with the metronome on during the first round and 81 with the metronome on during the second round of CPR). There was a significant improvement in the mean percentage of compressions delivered within an adequate rate (90-100 compressions per minute) with the metronome on compared with off (72% vs 50%; mean difference [MD] 22%; 95% confidence interval [CI], 15% to 29%). No significant difference was noted in the mean percentage of compressions within acceptable depth (38-51 mm) (72% vs 70%; MD 2%; 95% CI, -2% to 6%). The metronome had a larger effect among medical students (73% vs 55%; MD 18%; 95% CI, 8% to 28%) and pediatric residents and fellows (84% vs 48%; MD 37%; 95% CI, 27% to 46%) but not among pediatric nurses (46% vs 48%; MD -3%; 95% CI, -19% to 14%). CONCLUSIONS: The rate of chest compressions during CPR can be optimized by the use of a metronome. These findings will help medical professionals comply with the American Heart Association guidelines.

Cervical Spine Motion During Airway Management Using Two Manual In-line Immobilization Techniques: A Human Simulator Model Study.

OBJECTIVE: The aim of this study is to evaluate cervical spine motion using 2 manual inline immobilization techniques with the use of a human simulator model. METHODS: Medical students, pediatric and family practice residents, and pediatric emergency medicine fellows were recruited to maintain cervical manual in line immobilization above the head of the bed and across the chest of a human simulator while orotracheal intubation was performed. Participants were then instructed on appropriate holding techniques after the initial session took place. Orotracheal intubation followed. A tilt sensor measured time to intubation and cervical extension and rotation angle. RESULTS: Seventy-one subjects participated in a total of 284 successful orotracheal intubations. No change in cervical spine movement or time to intubation was observed when using 2 different inline manual immobilization techniques with no training. However, a statistically significant difference with assistants above the head versus across the chest was observed after training in: extension 2.1° (95% confidence interval [95% CI], 1.15 to 3.00; P < 0.0001); rotation 0.7° (95% CI, 0.26 to 1.19; P = 0.003) and intubation time of -1.9 seconds (95% CI, -3.45 to -0.13; P = 0.035) after training. CONCLUSIONS: Cervical spine movement did not change when maintaining cervical spine immobilization from above the head versus across the chest before training. There was a statistically significant change in extension and rotation when assistants were above the head and in time to intubation when assistants were across the chest after training. The clinical significance of these results is unclear.

Pediatric psychiatric emergency department visits during a full moon.

OBJECTIVE: This study aimed to verify the hypothesis that the lunar cycle influences the number of pediatric psychiatric emergency department (ED) visits. METHODS: Pediatric psychiatric ED visits between 2009 and 2011 were obtained retrospectively. Patients aged between 4 and 21 years presenting to Miami Children's Hospital ED with a primary psychiatric complaint were included in the study. Patients with a concomitant psychiatric problem and a secondary medical condition were excluded. The number of psychiatric visits was retrieved for the full moon dates, control dates as well as the day before and after the full moon when the moon appears full to the naked eye (full moon effect). A comparison was made using the 2-sample independent t test. RESULTS: Between 2009 and 2011, 36 dates were considered as the true full moon dates and 108 dates as the "full moon effect." A total of 559 patients were included in the study. The 2-sample independent t tests were performed between the actual full moon date and control dates, as well as between the "full moon effect" dates and control dates. Our results failed to show a statistical significance when comparing the number of pediatric psychiatric patients presenting to a children's hospital ED during a full moon and a non-full moon date. CONCLUSIONS: Our study's results are in agreement with those involving adult patients. The full moon does not affect psychiatric visits in a children's hospital.

Accuracy of laceration length estimation in a pediatric emergency department and its impact on billing practices.

OBJECTIVES: This study aimed to determine the accuracy of laceration length estimation in a pediatric emergency department among health care providers of varying levels of training and its impact on billing practices. METHODS: This study involves a prospective case series. Children younger than 21 years with lacerations evaluated and repaired in the pediatric emergency department between January 1 and April 30, 2012, were eligible for enrollment. Each laceration was evaluated by a trainee/midlevel provider (frontline provider) and by an attending physician; each one offered an estimated laceration length. The true measurement was then documented by 1 of 6 pediatric emergency medicine fellows on shift. Data were analyzed using descriptive statistics. The mean error of estimation (the absolute differences between the estimated and the true laceration length) of attending physicians and frontline providers were determined and compared. The proportions of lacerations whose estimated length was in a different billing category were compared using χ(2). Cost analysis was documented. RESULTS: One hundred ninety patients were enrolled. The mean age was 5.9 years. A total of 119 patients (62.6%) were male, and 134 lacerations (70.5%) were located on the face. Most repairs were simple (79%). There was no difference between the estimated and measured length among attendings and frontline providers (P = 0.583). An average of 8.2% of lacerations were misclassified and billed incorrectly with 20% (4/20) of facial lacerations up-coded. The mean overcharge was $12.04. Of 11 lacerations elsewhere on the body, 3 (27%) were down-coded, with an average difference of $6.97 for simple and $38.51 for layered repairs. CONCLUSIONS: Pediatric emergency medicine practitioners are accurate estimators of laceration length. Eight percent of lacerations are misclassified and billed incorrectly. Physicians should be required to report measured lengths for billing.

Procalcitonin levels in febrile infants after recent immunization.

BACKGROUND: Procalcitonin has been identified as a useful blood marker of serious bacterial infection in febrile infants. Many infants present with a febrile reaction after receiving immunizations. The effects of immunization on procalcitonin have not been investigated. METHODS: We performed a prospective observational cohort study at a large, urban pediatric emergency department. Infants or=38 degrees C were enrolled. Subjects were divided into 3 groups: infants with serious bacterial infection; subjects without serious bacterial infection who received recent (<48 hours) immunizations; and subjects without serious bacterial infection who did not recently receive immunizations. Procalcitonin was measured by using a quantitative immunometric assay. RESULTS: Over 13 months, procalcitonin was measured for 271 infants. There were 44 (16%) patients with serious bacterial infection, 35 in the recent-immunization group, and 192 in the no-recent-immunization group. The median procalcitonin level for serious bacterial infection was 0.53 ng/mL, for recent immunization was 0.29 ng/mL, and for no recent immunizations was 0.17 ng/mL. Procalcitonin values were elevated for patients with serious bacterial infection compared with patients both with and without recent immunizations. Compared with patients who had no recent immunizations, procalcitonin levels were elevated in patients with recent immunization. Using a cut point of 0.12 ng/mL, the sensitivity of procalcitonin for serious bacterial infection was 96%, specificity was 23%, and negative predictive value was 96%. Two patients with recent immunization who had serious bacterial infection were identified with this cut point. CONCLUSIONS: Among febrile infants with recent immunization, procalcitonin levels are increased compared with patients with fever and no identified bacterial infection. Despite this increase, procalcitonin can still reliably discriminate infants with serious bacterial infection.

Procalcitonin in young febrile infants for the detection of serious bacterial infections.

OBJECTIVES: The objectives of the study were (1) to study the test performance of procalcitonin for identifying serious bacterial infections in febrile infants

Acute lymphoblastic leukemia presenting in fulminant hepatic failure.

A previously healthy 4-year-old boy was admitted because of acute liver failure. He was icteric, lethargic, had elevated ammonia and abnormal liver function tests. Serology was negative for viral hepatitis. There was no history of hepatotoxic drugs. Family history was unremarkable. The child was taken to the operating room for a living-related hepatic transplant. Frozen section showed massive hepatic leukemic infiltration and hepatocellular necrosis. Bone marrow aspiration confirmed the diagnosis of acute lymphoblastic leukemia (ALL). Transplant was withheld and chemotherapy was attempted. He died the following day due to systemic leukemic infiltration, cerebral edema, and severe anoxic ischemic encephalopathy.