Objective To characterize the management of acute pediatric supraventricular tachycardia (SVT), placing special emphasis on infants, patients refractory to adenosine (refractory SVT), and patients ...with hypotension, poor perfusion, or altered mental status (unstable SVT). Study design Retrospective cohort study of patients 0-18 years of age without congenital heart disease who presented to our pediatric hospital from January 2003 to December 2012 for the treatment of acute SVT. Multiple logistic regression was applied to identify whether age was a risk factor for different SVT therapies. Model fit and residuals also were examined. Results We identified 179 episodes for SVT. First dose of adenosine was effective in 72 (56%) episodes, and a second dose was effective in 27 of 54 (50%) episodes, leaving 27 (15%) episodes with refractory SVT. The response to the first dose of adenosine increased proportionally with age (OR 1.13, 95% CI 1.05-1.2). Only 1 of 17 episodes in infants responded to the first dose of adenosine. Refractory SVT was more frequent in infants vs older children (χ2 = 5.9 1 df, P = .01). Unstable SVT was present in 13 episodes and was treated with adenosine and antiarrhythmics. Synchronized cardioversion was performed on 3 patients, 2 patients with unstable SVT, and 1 with refractory SVT. Conclusion In children with SVT, young age is associated with decreased response to the first dose of adenosine and increased odds of adenosine-refractory SVT. In the treatment of unstable SVT, medical management with various antiarrhythmics before cardioversion may have a role in a subset of patients. Synchronized cardioversion rarely is performed for acute SVT.
Abstract Background Foreign body (FB) ingestions are frequent in children. Whereas the majority of FBs pass spontaneously through the gastrointestinal tract, ingestion of magnetic FBs pose a ...particular risk for obstruction due to proximate attraction through the intestinal wall. Study Objectives We aimed to identify the prevalence, clinical presentation, and management of magnetic FB ingestions at our tertiary care institution. Methods We performed a retrospective chart review of medical records of patients presenting to the pediatric Emergency Department (ED) or admitted to the hospital with FB ingestions from June 2003–July 2009. From those cases, patients with magnetic FB ingestions were identified. Results During the study period, 337,839 patients presented to the ED; 38 cases of magnetic FB ingestion were identified (prevalence 0.01%). Abdominal radiography was obtained in all cases. Ingestion of a single magnet occurred in 30 of 38 cases (79%). Of those, 4 patients underwent endoscopic removal due to signs of FB impaction in the esophagus or pylorus; no complications were noted. Ingestion of multiple magnets (range 2–6) occurred in 8 of 38 cases. Four of the 8 patients with multiple magnetic FBs (50%) presented with signs of peritonitis and required operative repair of multiple intestinal perforations. No deaths were identified. Conclusion Although ingestion of a single magnetic FB may, in most cases, be managed as a simple FB ingestion, the ingestion of multiple magnetic FB is associated with a high risk of complication and requires aggressive management. We propose an algorithm for management of children with magnetic FB ingestions.
Purpose
The aims of this study are to identify neuro-oncological patients’ and their caregivers’ needs during hospitalization (T0) and at 4 months after discharge (T1); to analyze the longitudinal ...changes in patients’ and caregivers’ needs and burden; to identify correlations between patients’ needs and caregivers’ burden and needs.
Methods
A pilot observational longitudinal study was conducted on 94 neuro-oncological patients and their caregivers using NEQ to evaluate patients’ needs, CNA, and FSQ for caregivers’ needs and burden at T0 and T1. Descriptive statistics were performed to illustrate the distribution of questionnaires’ scores. The longitudinal change of NEQ, FSQ, and CNA scores were investigated using Wilcoxon test. Spearman’s correlation was used to measure the relation between NEQ and FSQ and CNA scores.
Results
The most frequent patients and caregivers’ needs were material and informative. Needs tend to decrease over time; in particular FSQ factor “need for knowledge about the disease”, CNA factor “Information/communication needs” and CNA total score significantly decreased (
p
< 0.001). NEQ total score significantly correlated with FSQ factors “emotional burden” and “need for knowledge about the disease” and CNA total and factors scores at T0 and T1. At T0, NEQ correlated significantly with FSQ factor “thoughts about death”, while at T1, it correlated with FSQ factor “problems in social involvement”.
Conclusions
It is crucial to plan an assessment of patients’ and caregivers’ needs from the very beginning, in order to identify those individuals potentially at risk of developing high level of distress and to provide information and support following the illness trajectory of the brain tumor.
Over the past 15 years, with alarming and illustrative reports released from the Institute of Medicine, quality improvement and patient safety have come to the forefront of medical care. This article ...reviews quality improvement frameworks and methodology and the use of evidence-based guidelines for pediatric emergency medicine. Top performance measures in pediatric emergency care are described, with examples of ongoing process and quality improvement work in our pediatric emergency department.
Abstract
Objective
Physical abuse is a leading cause of pediatric morbidity and mortality. Physicians do not consistently screen for abuse, even in high-risk situations. Alerts in the electronic ...medical record may help improve screening rates, resulting in early identification and improved outcomes.
Methods
Triggers to identify children < 2 years old at risk for physical abuse were coded into the electronic medical record at a freestanding pediatric hospital with a level 1 trauma center. The system was run in “silent mode”; physicians were unaware of the system, but study personnel received data on children who triggered the alert system. Sensitivity, specificity, and negative and positive predictive values of the child abuse alert system for identifying physical abuse were calculated.
Results
Thirty age-specific triggers were embedded into the electronic medical record. From October 21, 2014, through April 6, 2015, the system was in silent mode. All 226 children who triggered the alert system were considered subjects. Mean (SD) age was 9.1 (6.5) months. All triggers were activated at least once. Sensitivity was 96.8% (95% CI, 92.4–100.0%), specificity was 98.5% (95% CI, 98.3.5–98.7), and positive and negative predictive values were 26.5% (95% CI, 21.2–32.8%) and 99.9% (95% CI, 99.9–100.0%), respectively, for identifying children < 2 years old with possible, probable, or definite physical abuse.
Discussion/Conclusion
Triggers embedded into the electronic medical record can identify young children with who need to be evaluated for physical abuse with high sensitivity and specificity.
Objectives
The emergency department (ED) is characterized by stressors (e.g., fatigue, stress, time pressure, and complex decision‐making) that can pose challenges to delivering high‐quality, ...equitable care. Although it has been suggested that characteristics of the ED may exacerbate reliance on cognitive heuristics, no research has directly investigated whether stressors in the ED impact physician racial bias, a common heuristic. We seek to determine if physicians have different levels of implicit racial bias post‐ED shift versus preshift and to examine associations between demographics and cognitive stressors with bias.
Methods
This repeated‐measures study of resident physicians in a pediatric ED used electronic pre‐ and postshift assessments of implicit racial bias, demographics, and cognitive stressors. Implicit bias was measured using the Race Implicit Association Test (IAT). Linear regression models compared differences in IAT scores pre‐ to postshift and determined associations between participant demographics and cognitive stressors with postshift IAT and pre‐ to postshift difference scores.
Results
Participants (n = 91) displayed moderate prowhite/antiblack bias on preshift (mean ± SD = 0.50 ± 0.34, d = 1.48) and postshift (mean ± SD = 0.55 ± 0.39, d = 1.40) IAT scores. Overall, IAT scores did not differ preshift to postshift (mean increase = 0.05, 95% CI = –0.02 to 0.14, d = 0.13). Subanalyses revealed increased pre‐ to postshift bias among participants working when the ED was more overcrowded (mean increase = 0.09, 95% CI = 0.01 to 0.17, d = 0.24) and among those caring for >10 patients (mean increase = 0.17, 95% CI = 0.05 to 0.27, d = 0.47). Residents' demographics (including specialty), fatigue, busyness, stressfulness, and number of shifts were not associated with postshift IAT or difference scores. In multivariable models, ED overcrowding was associated with greater postshift bias (coefficient = 0.11 per 1 unit of NEDOCS score, SE = 0.05, 95% CI = 0.00 to 0.21).
Conclusions
While resident implicit bias remained stable overall preshift to postshift, cognitive stressors (overcrowding and patient load) were associated with increased implicit bias. Physicians in the ED should be aware of how cognitive stressors may exacerbate implicit racial bias.
Abusive head trauma is the leading cause of death from physical abuse. Misdiagnosis of abusive head trauma as well as other types of brain abnormalities in infants is common and contributes to ...increased morbidity and mortality. We previously derived the Pittsburgh Infant Brain Injury Score (PIBIS), a clinical prediction rule to assist physicians deciding which high-risk infants should undergo computed tomography of the head.
Well-appearing infants 30 to 364 days of age with temperature <38.3°C, no history of trauma, and a symptom associated with an increased risk of having a brain abnormality were eligible for enrollment in this prospective, multicenter clinical prediction rule validation. By using a predefined neuroimaging paradigm, subjects were classified as cases or controls. The sensitivity, specificity, and negative and positive predictive values of the rule for prediction of brain injury were calculated.
A total of 1040 infants were enrolled: 214 cases and 826 controls. The 5-point PIBIS included abnormality on dermatologic examination (2 points), age ≥3.0 months (1 point), head circumference >85th percentile (1 point), and serum hemoglobin <11.2g/dL (1 point). At a score of 2, the sensitivity and specificity for abnormal neuroimaging was 93.3% (95% confidence interval 89.0%-96.3%) and 53% (95% confidence interval 49.3%-57.1%), respectively.
Our data suggest that the PIBIS accurately identifies infants who would benefit from neuroimaging to evaluate for brain injury. An implementation analysis is needed before the PIBIS can be integrated into clinical practice.
Background
Few scientific reports to date describe the histological modification of structures outlining a hernia opening. This article is focused on the identification of the pathological changes in ...vascular structures in tissues excised from cadavers with inguinal hernia. A deeper comprehension of this topic could lead to essential improvements in the detection of hernia genesis.
Materials and methods
Different kinds of hernia, including indirect, direct and mixed, were identified in 30 autopsied subjects. Tissue samples were resected for histological study from abdominal wall structures close to the hernia opening. Histological examination focused on the detection of structural changes in arteries and veins. The results were compared with tissue specimens excised from equivalent sites of the inguinal area in a control group of 15 fresh cadavers without hernia.
Results
Significant modification of vascular structures were identified in the tissue specimens examined. The veins demonstrated parietal fibrosis, perivascular edema and vascular dilation due to congestion and stasis. The arterial structures detected showed thickening of the media due to medial hyperplasia, ranging from luminal sub-occlusion to a manifest artery occlusion. These findings are present independent of hernia type in cadavers with inguinal hernia. These pathological changes were lacking in the control group of cadavers without hernia.
Conclusions
The notable changes in vascular structures described in the report could be the result of a steady compressive effect exerted by the abdominal viscera in the inguinal area. These pathological changes could represent one of the factors involved in the weakening of the inguinal region leading to hernia protrusion.
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