Multisystem Inflammatory Syndrome of Children: Subphenotypes, Risk Factors, Biomarkers, Cytokine Profiles, and Viral Sequencing.

OBJECTIVE: To assess demographic, clinical, and biomarker features distinguishing patients with multisystem inflammatory syndrome in children (MIS-C); compare MIS-C sub-phenotypes; identify cytokine biosignatures; and characterize viral genome sequences. STUDY DESIGN: We performed a prospective observational cohort study of 124 children hospitalized and treated under the institutional MIS-C Task Force protocol from March to September 2020 at Children's National, a quaternary freestanding children's hospital in Washington, DC. Of this cohort, 63 of the patients had the diagnosis of MIS-C (39 confirmed, 24 probable) and 61 were from the same cohort of admitted patients who subsequently had an alternative diagnosis (controls). RESULTS: Median age and sex were similar between MIS-C and controls. Black (46%) and Latino (35%) children were over-represented in the MIS-C cohort, with Black children at greatest risk (OR 4.62, 95% CI 1.151-14.10; P = .007). Cardiac complications were more frequent in critically ill patients with MIS-C (55% vs 28%; P = .04) including systolic myocardial dysfunction (39% vs 3%; P = .001) and valvular regurgitation (33% vs 7%; P = .01). Median cycle threshold was 31.8 (27.95-35.1 IQR) in MIS-C cases, significantly greater (indicating lower viral load) than in primary severe acute respiratory syndrome coronavirus 2 infection. Cytokines soluble interleukin 2 receptor, interleukin [IL]-10, and IL-6 were greater in patients with MIS-C compared with controls. Cytokine analysis revealed subphenotype differences between critically ill vs noncritically ill (IL-2, soluble interleukin 2 receptor, IL-10, IL-6); polymerase chain reaction positive vs negative (tumor necrosis factor-α, IL-10, IL-6); and presence vs absence of cardiac abnormalities (IL-17). Phylogenetic analysis of viral genome sequences revealed predominance of GH clade originating in Europe, with no differences comparing patients with MIS-C with patients with primary coronavirus disease 19. Treatment was well tolerated, and no children died. CONCLUSIONS: This study establishes a well-characterized large cohort of MIS-C evaluated and treated following a standardized protocol and identifies key clinical, biomarker, cytokine, viral load, and sequencing features. Long-term follow-up will provide opportunity for future insights into MIS-C and its sequelae.

Severe Coronavirus Disease-2019 in Children and Young Adults in the Washington, DC, Metropolitan Region.

Despite worldwide spread of severe acute respiratory syndrome coronavirus-2, few publications have reported the potential for severe disease in the pediatric population. We report 177 infected children and young adults, including 44 hospitalized and 9 critically ill patients, with a comparison of patient characteristics between infected hospitalized and nonhospitalized cohorts, as well as critically ill and noncritically ill cohorts. Children <1 year and adolescents and young adults >15 years of age were over-represented among hospitalized patients (P = .07). Adolescents and young adults were over-represented among the critically ill cohort (P = .02).

Factors Associated With Return Visits at 7 Days After Hospital Discharge.

OBJECTIVE: To identify variables associated with return visits to the hospital within 7 days after discharge. METHODS: We performed a retrospective study of 7-day revisits and readmissions between October 2012 and September 2015 using the Pediatric Health Information System database supplemented by electronic medical record data from a tertiary-care children's hospital. We examined factors associated with revisits among the top 10 most frequent indications for hospitalization using generalized estimating equations. RESULTS: There were 736 (4.2%) revisits and 416 (2.3%) readmissions within 7 days. Predictors of 7-day revisits and readmissions included age, length of hospital stay, and presence of a chronic medical condition. In addition, insurance status was associated with risk of revisits and race was associated with risk of readmissions in the bivariate analysis. CONCLUSIONS: In this study, we identified patient characteristics that may be associated with a higher risk of early return to the emergency department and/or readmissions. Early identification of this at-risk group of patients may provide opportunities for intervention and enhanced care coordination at discharge.

Imaging Strategies for Suspected Acute Cranial Shunt Failure: A Cost-Effectiveness Analysis.

OBJECTIVES: We compared cost-effectiveness of cranial computed tomography (CT), fast sequence magnetic resonance imaging (fsMRI), and ultrasonography measurement of optic nerve sheath diameter (ONSD) for suspected acute shunt failure from the perspective of a health care organization. METHODS: We modeled 4 diagnostic imaging strategies: (1) CT scan, (2) fsMRI, (3) screening ONSD by using point of care ultrasound (POCUS) first, combined with CT, and (4) screening ONSD by using POCUS first, combined with fsMRI. All patients received an initial plain radiographic shunt series (SS). Short- and long-term costs of radiation-induced cancer were assessed with a Markov model. Effectiveness was measured as quality-adjusted life-years. Utilities and inputs for clinical variables were obtained from published literature. Sensitivity analyses were performed to evaluate the effects of parameter uncertainty. RESULTS: At a previous probability of shunt failure of 30%, a screening POCUS in patients with a normal SS was the most cost-effective. For children with abnormal SS or ONSD measurement, fsMRI was the preferred option over CT. Performing fsMRI on all patients would cost $269 770 to gain 1 additional quality-adjusted life-year compared with POCUS. An imaging pathway that involves CT alone was dominated by ONSD and fsMRI because it was more expensive and less effective. CONCLUSIONS: In children with low pretest probability of cranial shunt failure, an ultrasonographic measurement of ONSD is the preferred initial screening test. fsMRI is the more cost-effective, definitive imaging test when compared with cranial CT.

Cost-effectiveness of diagnostic approaches to suspected appendicitis in children.

BACKGROUND: Our group recently published a clinical pathway (Le Bonheur Clinical Pathway [LeB-P]) that used the Samuel Pediatric Appendicitis Score with selective use of ultrasonography (USG) for diagnosis of children at risk for appendicitis. The objective of this study was to model the cost-effectiveness of implementing the LeB-P compared with usual care. STUDY DESIGN: We constructed a decision analytic model comparing hospital costs for the following diagnostic strategies for suspected appendicitis: emergency department clinician judgment alone, USG on all patients, CT on all patients, overnight observation with surgical evaluation without studies, and the LeB-P. Prevalence of disease, outcomes probabilities, and hospital and professional costs for each option were derived from published literature, national cost data, and our previous study results. Cost-effectiveness was calculated using these 3 sets of parameters. RESULTS: In the base case model, USG was the preferred strategy over LeB-P and overnight observation with surgical evaluation without studies. Emergency department clinician judgment alone and CT were dominated by the other pathways, based on either lower diagnostic accuracy or increased costs. Compared with LeB-P, USG costs $337 less per patient evaluated, but increased the diagnostic error rate by 2%. Using LeB-P rather than USG would cost an institution an additional $17,206 to eliminate one misdiagnosis, which is known as the incremental cost-effectiveness ratio. CONCLUSIONS: Although performing USG on all children with suspected appendicitis was determined to be the most cost-effective strategy, using the Pediatric Appendicitis Score with selective use of USG (LeB-P) improved diagnostic accuracy at a moderate increase in cost and decreased CT use.

Prospective evaluation of a clinical pathway for suspected appendicitis.

OBJECTIVE: To evaluate the diagnostic accuracy of a clinical pathway for suspected appendicitis combining the Samuel's pediatric appendicitis score (PAS) and selective use of ultrasonography (US) as the primary imaging modality. METHODS: Prospective, observational cohort study conducted at an urban, academic pediatric emergency department. After initial evaluation, patients were determined to be at low (PAS 1-3), intermediate (PAS 4-7), or high (PAS 8-10) risk for appendicitis. Low-risk patients were discharged with telephone follow-up. High-risk patients received immediate surgical consultation. Patients at intermediate risk for appendicitis underwent US. RESULTS: Of the 196 patients enrolled, 65 (33.2%) had appendicitis. An initial PAS of 1-3 was noted in 44 (22.4%), 4-7 in 119 (60.7%), and 8-10 in 33 (16.9%) patients. Ultrasonography was performed in 128 (65.3%) patients, and 48 (37.5%) were positive. An abdominal computed tomography scan was requested by the surgical consultants in 13 (6.6%) patients. The negative appendectomy rate was 3 of 68 (4.4%). Follow-up was established on 190 of 196 (96.9%) patients. Overall diagnostic accuracy of the pathway was 94% (95% confidence interval [CI] 91%-97%) with a sensitivity of 92.3% (95% CI 83.0%-97.5%), specificity of 94.7% (95% CI 89.3%-97.8%), likelihood ratio (+) 17.3 (95% CI 8.4-35.6) and likelihood ratio (-) 0.08 (95% CI 0.04-0.19). CONCLUSIONS: Our protocol demonstrates high sensitivity and specificity for diagnosis of appendicitis in children. Institutions should consider investing in resources that increase the availability of expertise in pediatric US. Standardization of care may decrease radiation exposure associated with use of computed tomography scans.

7% Hypertonic saline in acute bronchiolitis: a randomized controlled trial.

BACKGROUND: Research suggests that hypertonic saline (HS) may improve mucous flow in infants with acute bronchiolitis. Data suggest a trend favoring reduced length of hospital stay and improved pulmonary scores with increasing concentration of nebulized solution to 3% and 5% saline as compared with 0.9% saline mixed with epinephrine. To our knowledge, 7% HS has not been previously investigated. METHODS: We conducted a prospective, double-blind, randomized controlled trial in 101 infants presenting with moderate to severe acute bronchiolitis. Subjects received either 7% saline or 0.9% saline, both with epinephrine. Our primary outcome was a change in bronchiolitis severity score (BSS), obtained before and after treatment, and at the time of disposition from the emergency department (ED). Secondary outcomes measured were hospitalization rate, proportion of admitted patients discharged at 23 hours, and ED and inpatient length of stay. RESULTS: At baseline, study groups were similar in demographic and clinical characteristics. The decrease in mean BSS was not statistically significant between groups (2.6 vs 2.4 for HS and control groups, respectively). The difference between the groups in proportion of admitted patients (42% in HS versus 49% in normal saline), ED or inpatient length of stay, and proportion of admitted patients discharged at 23 hours was not statistically significant. CONCLUSIONS: In moderate to severe acute bronchiolitis, inhalation of 7% HS with epinephrine does not appear to confer any clinically significant decrease in BSS when compared with 0.9% saline with epinephrine.

Cost analysis and provider satisfaction with pediatrician in triage.

OBJECTIVES: The goals of this study were to (1) conduct a cost-benefit analysis, from a hospital's perspective, of using a pediatrician in triage (PIT) in the emergency department (ED) and (2) assess the impact of a physician in triage on provider satisfaction. METHODS: This was a prospective, controlled trial of PIT (intervention) versus conventional registered nurse-driven triage (control), at an urban, academic, tertiary level pediatric ED, which led to a cost-benefit analysis by looking at the effect that PIT has on length of stay (LOS) and thus on ED revenue. Provider satisfaction was assessed through surveys. RESULTS: During the 8-week study period, a total of 6579 patients were triaged: 3242 in the PIT group and 3337 in the control group. The 2 groups were similar in age, sex, admission rate, left-without-being-seen rate, and level of acuity. The mean LOS in the PIT group was 24.3 minutes shorter than in the control group. The costs of PIT seem to be increased and are not offset by savings; the net margin (total revenue minus costs) was $42,883 per year lower in the PIT than in the control group. Sensitivity analysis showed that if the LOS were reduced by more than 98.4 minutes, the cost savings would favor PIT. Most of the physicians and nurses (67%) reported that PIT facilitated their job. CONCLUSIONS: Placement of a PIT during periods of peak census resulted in shorter stay and notable provider satisfaction but at an incremental cost of $42,883 per year.

Use of tent for screening during H1N1 pandemic: impact on quality and cost of care.

OBJECTIVE: This article aimed to assess the impact on quality and cost of care of using a tent in the emergency department (ED) parking lot to screen patients with an influenza-like illness (ILI). METHODS: A nurse-driven protocol was used to triage and perform a medical screening examination for patients with ILI who could be safely discharged from the tent. A before-after study design was used to assess the intervention, focusing on the immediate pre-tent and tent periods, when the average daily census exceeded 250 visits (67% above our historic baseline). We compared quality and cost data on patients treated for ILI before and while the tent was in operation. RESULTS: During the pre-tent and tent periods, 5809 and 5864 encounters, respectively, were recorded in the ED; elopement rates were 12.9% and 1.8% of patients, respectively. Of the 1141 patients screened in the tent, 838 were triaged out. Average ED turnaround time for all patients was 282 and 152 minutes, with an overall rate of ED recidivism of 5.03% and 5.36% (1.8% for ILI-related revisit for tent patients) during the pre-tent and tent periods, respectively. The average cost of screening was $30.45 per patient. The incremental cost-effectiveness ratio, representing the additional cost to decrease the elopement rate by 1%, was $697.30, with the tent being the dominant strategy. CONCLUSIONS: The tent provided cost-effective care with measurable improvements in quality of care indicators. Our analytic model demonstrated that the incremental cost-effectiveness ratio of tent during the H1N1 surge was modest. The tent may be a useful model during future pandemics.

Point-of-care echocardiography by pediatric emergency physicians.

OBJECTIVE: Currently, pediatric emergency medicine (PEM) physicians have limited data on point-of-care echocardiography (POCE). Our goals were to (1) determine the overall accuracy of POCE by PEMs in assessing left ventricular (LV) systolic function visually, presence or absence of pericardial effusion, and cardiac preload by estimating inferior vena cava (IVC) collapsibility, in acutely ill children in the pediatric emergency department; and (2) assess interobserver agreement between the PEM physician and pediatric cardiologist. METHODS: This is a prospective, observational study conducted in an urban, tertiary pediatric facility with an annual census of 67,000 emergency department visits. Patients between the ages of 0 and 18 years meeting 1 or more of the following inclusion criteria were recruited: (1) cardiopulmonary arrest, (2) fluid refractory shock requiring vasoactive infusions, (3) undifferentiated cardiomegaly on chest radiography, and (4) receiving emergent formal echocardiography. All eligible patients underwent POCE by 1 of 2 trained PEM physicians. Dynamic video clips were recorded and reviewed by a pediatric cardiologist who was unaware of the clinical condition of the study patients. RESULTS: For a period of 18 months, we recruited 70 patients. Diminished LV function was noted in 17, pericardial effusion in 16, and abnormal IVC collapsibility in 35 patients. The κ statistics of agreement between the PEM and the cardiologist for detection of LV function, IVC collapsibility, and effusion were 0.87 (95% confidence interval [CI], 0.73-1.00), 0.73 (95% CI, 0.59-0.88), and 0.77 (95% CI, 0.58-0.95), respectively. The overall sensitivity and specificity of POCE compared with a formal echocardiogram was 95% (95% CI, 82%-99%) and 83% (95% CI, 64%-93%), respectively. CONCLUSIONS: With goal-directed training, PEM physicians may be able to perform POCE and accurately assess for significant LV systolic dysfunction, vascular filling, and the presence of pericardial effusion. The model may be expanded to train physicians to use POCE.

Closed reduction of distal forearm fractures by pediatric emergency physicians.

OBJECTIVES: The objective of this study was to determine if there exist differences in length of stay (LOS) in the emergency department (ED) and need for reintervention to restore alignment after distal forearm fracture reduction by pediatric emergency physicians (EPs) versus postgraduate year 3 or 4 orthopedic residents. METHODS: In a prospective trial at a busy urban pediatric ED, children with closed distal forearm fractures that met predefined criteria for manipulation were randomized to treatment by a postgraduate year 3 or 4 orthopedic resident or by a pediatric EP who had received focused training in forearm fracture reduction. Prereduction, postreduction, and follow-up radiographs were evaluated by an attending pediatric orthopedic surgeon who was unaware of the assigned group. The following outcomes were assessed: LOS during the initial ED encounter, adequacy of alignment immediately postreduction and at follow-up visits after discharge from the ED, the need for remanipulation, unscheduled ED visits, and radiographic healing at 6-8 weeks after injury. RESULTS: A total of 103 children were randomized into the pediatric EP (52 patients, mean age 9.1 years) and orthopedic resident (51 patients, mean age 9.7 years) groups. Patients in the two groups were similar in age, involvement of the physes, degree of angulation, percentage of displacement, and need for procedural sedation. The mean LOS in the ED was 4.5 hours in the pediatric EP group versus 5.0 hours in the orthopedic resident group (difference in means -0.5 hours, 95% confidence interval [CI] = -1.26 to 0.37 hours). Remanipulation was required in 4 of 48 (8.3%) in the pediatric EP group versus 6 of 48 (12.5%) in the orthopedic resident group (odds ratio [OR] = 0.64; 95% CI = 0.16 to 2.67). Unscheduled ED visits for cast-related problems occurred in 6 of 51 (11.8%) in the pediatric EP group and 4 of 52 (7.7%) in the orthopedic resident group (OR = 1.59; 95% CI = 0.38 to 6.39). None of these patients with unscheduled ED visits developed compartment syndrome or required admission. CONCLUSIONS: Length of stay in the ED and clinical outcomes after closed reduction of forearm fractures by trained pediatric EPs are comparable to those after closed reduction by orthopedic residents.

A systematic data review of the cost of rehydration therapy.

Dehydration secondary to acute gastroenteritis is a commonly encountered condition among patients presenting to physicians' offices and hospital EDs. Treatment options consist of oral rehydration therapy (ORT), intravenous rehydration therapy (IVRT) and subcutaneous rehydration therapy (SCRT). Although most patients with dehydration can be effectively treated in an outpatient setting, hospitalization is frequently warranted, with estimated annual inpatient costs for dehydration therapy exceeding $US1 billion in the US in 1999 for elderly patients alone. Although most treatment guidelines recommend ORT as first-line treatment for mild to moderate dehydration, IVRT remains the predominant route of administration for rehydration fluids in the acute care setting in the US. To evaluate the current state of the literature examining costs associated with dehydration therapy, a systematic review of articles published on MEDLINE from 2000 to 2009 was conducted. A total of 20 reports containing pharmacoeconomic data on rehydration therapy were evaluated. Findings suggest that ORT and SCRT may be less costly than IVRT in the treatment of mild to moderate dehydration; however, variability in cost parameters examined or data collection methods described in the literature precluded a comprehensive comparative cost-effectiveness analysis of treatment options. Future pharmacoeconomic analyses of rehydration therapy should incorporate time-motion analyses comprising a consistent set of variables to determine the most cost-effective treatment modality for patients with mild to moderate dehydration.

Pediatric distal radial fractures treated by emergency physicians.

BACKGROUND: The initial management of distal radius fractures in children is part of the usual practice of Emergency Medicine. However, no data are available evaluating the outcome of pediatric forearm fractures that undergo closed reduction and casting by emergency physicians. STUDY OBJECTIVE: To assess short-term outcomes after distal forearm fracture reductions performed by emergency physicians. METHODS: A retrospective cohort study with matched controls was performed on children with a closed, displaced, or angulated distal forearm fracture that required manipulation. The study group was defined as patients in whom emergency physicians performed closed manipulation and cast immobilization without orthopedic consultation. The control group was defined as patients who had closed reduction by an orthopedic resident. Two controls were identified for each study patient on or around the same date of visit. During the 20-month period, the medical records of 22 study patients and 42 controls were reviewed. The two groups were similar in age, fracture angulation and displacement, and skeletal maturity. RESULTS: All patients had acceptable alignment at 3-5-day follow-up. Two study patients and one control required re-manipulation at subsequent follow-up (p = 0.34). All other patients in both groups who were seen at follow-up had satisfactory healing and function at 6-8 weeks after injury. Three study patients and 4 controls had an unscheduled outpatient visit to the Emergency Department (ED) for cast-related problems (p = 0.80). None of these patients developed compartment syndrome. The mean length of stay in the ED was lower in the study group than in the control group (3.1 h compared to 5.1 h, respectively; p = 0.0026). The mean facility charge also was lower in the study group ($2182.50 compared to $3031 in the control group; p = 0.0006). CONCLUSIONS: Our results suggest that emergency physicians may be able to successfully provide restorative care for distal forearm fractures using closed reduction technique. Care rendered by emergency physicians was associated with a shorter length of stay and lower facility charges.

Bedside sonographic measurement of optic nerve sheath diameter as a predictor of increased intracranial pressure in children.

STUDY OBJECTIVE: We investigate the test performance of emergency physician-performed sonographic measurement of optic nerve sheath diameter for diagnosis of increased intracranial pressure. METHODS: Children between the ages of 0 and 18 years with suspected increased intracranial pressure were prospectively recruited from the emergency department and ICU of an urban, tertiary-level, freestanding pediatric facility. Pediatric emergency physicians with goal-directed training in ophthalmic sonography measured optic nerve sheath diameter. Images were recorded and subsequently reviewed by a pediatric ophthalmologist and an ophthalmic sonographer, both of whom were blind to the patient's clinical condition. Measurements obtained by the ophthalmic sonographer were considered the criterion standard. An optic nerve sheath diameter greater than 4.0 mm in subjects younger than 1 year and greater than 4.5 mm in older children was considered abnormal. The diagnosis of increased intracranial pressure was based on results of cranial imaging or direct measurement of intracranial pressure. RESULTS: Sixty-four patients were recruited, of whom 24 (37%) had a confirmed diagnosis of increased intracranial pressure. The sensitivity of optic nerve sheath diameter as a screening test for increased intracranial pressure was 83% (95% confidence interval [CI] 0.60 to 0.94); specificity was 38% (95% CI 0.23 to 0.54); positive likelihood ratio was 1.32 (95% CI 0.97 to 1.79) and negative likelihood ratio was 0.46 (95% CI 0.18 to 1.23). There was fair to good interobserver agreement between the pediatric emergency physician and ophthalmic sonographer (kappa 0.52) and pediatric ophthalmologist (kappa 0.64). CONCLUSION: The sensitivity and specificity of bedside sonographic measurement of optic nerve sheath diameter is inadequate to aid medical decisionmaking in children with suspected increased intracranial pressure. Pediatric emergency physicians with focused training by a pediatric ophthalmologist familiar with ophthalmic sonography can measure optic nerve sheath diameter accurately.

Cost-effectiveness analysis of anesthetic agents during peripheral intravenous cannulation in the pediatric emergency department.

OBJECTIVE: To conduct a cost-effectiveness analysis of anesthetic agents to reduce the pain of peripheral intravenous cannulation in an emergency department (ED) setting. DESIGN: Cost-effectiveness analysis in which costs were measured as the cost of the agent plus costs associated with time in the ED using data from our hospital cost accounting system. Outcomes were measured as improvements in the self-reported visual analog scale (VAS) pain scores. Variables considered unique to the various agents were cost of the agent, time to peak onset, success rates of cannulation, and mean reduction in VAS scores. SETTING: Decision model. Patients A cohort of patients aged 3 through 18 years enrolled in randomized controlled trials that compared analgesic modalities to facilitate peripheral intravenous cannulation was identified through medical databases searched from their inception (earliest year, 1966) through June 2007. MAIN OUTCOME MEASURES: The main outcome measure was the incremental cost-effectiveness ratio, which represented the additional cost that must be incurred by the hospital to obtain a reduction of 1 additional unit (10 mm or 1 cm) in the VAS score compared with a baseline option of no anesthetic. RESULTS: Our results suggest that the needle-free jet injection of lidocaine device had the lowest incremental cost-effectiveness ratio, followed by intradermal injection of buffered lidocaine; lidocaine iontophoresis; nitrous oxide inhalation analgesia; a heated lidocaine and tetracaine patch; sonophoresis with lidocaine cream, 4%; lidocaine cream alone, 4%; and use of a eutectic mixture of lidocaine and prilocaine cream. CONCLUSION: Currently, the needle-free jet injection of lidocaine device and injection of buffered lidocaine appear to provide the most cost-effective alternatives to pediatric ED physicians.