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Importance Young febrile infants are at substantial risk of serious bacterial infections; however, the current culture-based diagnosis has limitations. Analysis of host expression patterns (“RNA biosignatures”) in response to infections may provide an alternative diagnostic approach. Objective To assess whether RNA biosignatures can distinguish febrile infants aged 60 days or younger with and without serious bacterial infections. Design, Setting, and Participants Prospective observational study involving a convenience sample of febrile infants 60 days or younger evaluated for fever (temperature >38 ° C) in 22 emergency departments from December 2008 to December 2010 who underwent laboratory evaluations including blood cultures. A random sample of infants with and without bacterial infections was selected for RNA biosignature analysis. Afebrile healthy infants served as controls. Blood samples were collected for cultures and RNA biosignatures. Bioinformatics tools were applied to define RNA biosignatures to classify febrile infants by infection type. Exposure RNA biosignatures compared with cultures for discriminating febrile infants with and without bacterial infections and infants with bacteremia from those without bacterial infections. Main Outcomes and Measures Bacterial infection confirmed by culture. Performance of RNA biosignatures was compared with routine laboratory screening tests and Yale Observation Scale (YOS) scores. Results Of 1883 febrile infants (median age, 37 days; 55.7% boys), RNA biosignatures were measured in 279 randomly selected infants (89 with bacterial infections—including 32 with bacteremia and 190 without bacterial infections), and 19 afebrile healthy infants. Sixty-six classifier genes were identified that distinguished infants with and without bacterial infections in the test set with 87% (95% CI, 73%-95%) sensitivity and 89% (95% CI, 81%-93%) specificity. Ten classifier genes distinguished infants with bacteremia from those without bacterial infections in the test set with 94% (95% CI, 70%-100%) sensitivity and 95% (95% CI, 88%-98%) specificity. The incremental C statistic for the RNA biosignatures over the YOS score was 0.37 (95% CI, 0.30-0.43). Conclusions and Relevance In this preliminary study, RNA biosignatures were defined to distinguish febrile infants aged 60 days or younger with and without bacterial infections. Further research with larger populations is needed to refine and validate the estimates of test accuracy and to assess the clinical utility of RNA biosignatures in practice.

Heated, humidified, high-flow nasal cannula oxygen therapy (HHHFNC) has been used to improve ventilation in preterm infants. There are no data on airway pressures generated and efficacy in bronchiolitis.The objective of this study was to determine nasopharyngeal (NP) pressures generated with HHHFNC therapy in bronchiolitis.We conducted a prospective, observational study to measure NP pressures at varying flow rates of HHHFNC therapy in moderate to severe bronchiolitis. Vital signs, bronchiolitis severity scores, and oxygen saturation were also noted.Twenty-five patients were enrolled (mean, 78.1 [SD, 30.9] days; weight, 5.3 [SD, 1.1] kg). Nasopharyngeal pressures increased linearly with flow rates up to 6 L/min. Beyond 6 L/min, pressure increase was linear but less accelerated. On average, NP pressure increased by 0.45 cm H2O for each 1-L/min increase in flow rate. There were significant differences between pressures in open- and closed-mouth states for flow rates up to 6 L/min. At 6 L/min, the pressure in open-mouth state was 2.47 cm H2O and that in closed-mouth state was 2.74 cm H2O (P0.001). Linear regression analysis revealed that only flow (not weight or gender) had an effect on generated pressure. Bronchiolitis severity scores improved significantly with HHHFNC therapy (pre: 14.5 [SD, 1.4], post: 10.4 [SD, 1.2]; P0.001).Increasing flow rates of HHHFNC therapy are associated with linear increases in NP pressures in bronchiolitis patients. Larger studies are needed to assess the clinical efficacy of HHHFNC therapy in bronchiolitis.

OBJECTIVE Our objective was to prospectively compare sedation medication requirements and adverse events related to sedation in children with and without developmental disabilities. METHODS We conducted a prospective, observational, age-matched, 1:2 case-control study of children (3-10 years) sedated for brain magnetic resonance imaging at a tertiary-care children's hospital. Developmental assessment was performed using the Vineland Adaptive Behavioral Scale and by a pediatric neurologist. Patients were sedated according to institutional sedation protocol. Patient demographics, type and dose of sedation medications, depth of sedation, and adverse events were collected. We defined hypoxia as oxygen saturation 90% or less for 30 seconds or longer and requiring airway maneuvers. RESULTS Seventy children were designated as cases (DD) and 140 as controls (DN). DD had a significantly lower mean Vineland Adaptive Behavioral Scale score than did DN (DD: 62.34 ± 9.70, DN: 103.0 ± 13.71; P < 0.001). A combination of pentobarbital and fentanyl (DD: 32/70 [45.7%], DN: 60/140 [42.9%]) and combination of pentobarbital and midazolam (DD: 28/70 [40%], DN: 43/140 [30.7%]) were the most common sedatives used in both groups. There was no difference in the mean dose of pentobarbital (DD:4.68 ± 1.63 mg/kg, DN:4.67 ± 1.69 mg/kg; P = 0.9), fentanyl (DD: 0.61 ± 0.65 μg/kg, DN: 0.64 ± 0.65 μg/kg; P = 0.7), and midazolam (DD: 0.15 ± 0.17 mg/kg, DN: 0.11 ± 0.14 mg/kg; P = 0.1). There was no difference in the overall adverse events (DD: 30%, DN: 32.9%; P = 0.7) as well as hypoxia (DD: 10%; DN: 9.3%, P = 0.9). CONCLUSIONS When compared with DN children, DD children do not require a higher dose of sedatives and do not have a higher incidence of adverse events.

Study objective We derive a prediction rule to identify children at very low risk for intra-abdominal injuries undergoing acute intervention and for whom computed tomography (CT) could be obviated. Methods We prospectively enrolled children with blunt torso trauma in 20 emergency departments. We used binary recursive partitioning to create a prediction rule to identify children at very low risk of intra-abdominal injuries undergoing acute intervention (therapeutic laparotomy, angiographic embolization, blood transfusion for abdominal hemorrhage, or intravenous fluid for ≥2 nights for pancreatic/gastrointestinal injuries). We considered only historical and physical examination variables with acceptable interrater reliability. Results We enrolled 12,044 children with a median age of 11.1 years (interquartile range 5.8, 15.1 years). Of the 761 (6.3%) children with intra-abdominal injuries, 203 (26.7%) received acute interventions. The prediction rule consisted of (in descending order of importance) no evidence of abdominal wall trauma or seat belt sign, Glasgow Coma Scale score greater than 13, no abdominal tenderness, no evidence of thoracic wall trauma, no complaints of abdominal pain, no decreased breath sounds, and no vomiting. The rule had a negative predictive value of 5,028 of 5,034 (99.9%; 95% confidence interval [CI] 99.7% to 100%), sensitivity of 197 of 203 (97%; 95% CI 94% to 99%), specificity of 5,028 of 11,841 (42.5%; 95% CI 41.6% to 43.4%), and negative likelihood ratio of 0.07 (95% CI 0.03 to 0.15). Conclusion A prediction rule consisting of 7 patient history and physical examination findings, and without laboratory or ultrasonographic information, identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention. These findings require external validation before implementation.

Bronchiolitis is a leading cause of infant hospitalization in the United States; the mean length of stay (LOS) is 3.3 days. We sought to identify the initial clinical characteristics of bronchiolitis associated with admission and with longer LOS in a large multicenter clinical trial.This study was a secondary analysis of a randomized trial conducted in 20 emergency departments in the Pediatric Emergency Care Applied Research Network. We examined age, sex, days of illness, Respiratory Distress Assessment Instrument score, vital signs, and oxygen saturation by pulse oximetry (SpO(2)) at presentation in 598 infants aged 2 to 12 months with moderate to severe bronchiolitis. We used classification and regression tree and logistic regression analyses to identify associations with admission and longer LOS (defined as LOS1 night).Of the 598 infants, 240 (40%) were hospitalized; two thirds underwent longer LOS. The best predictor of hospitalization was initial SpO(2) value of less than 94%, followed by Respiratory Distress Assessment Instrument score of greater than 11 and respiratory rate of greater than 60. For this model, the sensitivity was 56% (95% confidence interval, 50%-62%) and the specificity was 74% (95% confidence interval, 70%-79%). Among admitted patients, the only decision point for prediction of longer LOS was initial SpO(2) value of 97% or less.A model using objective findings had limited accuracy for predicting hospitalization after emergency department evaluation for bronchiolitis. In these infants with moderate to severe bronchiolitis, however, initial SpO(2) was the best predictor of hospital admission and of longer LOS. Efforts to better define and manage hypoxemia in bronchiolitis may be helpful.

This paper describes an alternative approach to the rules-of-thumb-based design of metal stampings. The design for manufacturing system (DFM) presented here highlights those manufacturing-related features that significantly increase cost so that designers can minimize difficult-to-produce features. The DFM system is not dependent on the creation of a geometric model, and can be used to qualitatively and quantitatively assess a preliminary concept sketch. The system focuses on stampings produced by “hard tooling” and is based on expertise gained from stampers who produce parts for the office automation, computer, electromechanical, and small consumer appliance industries. The application of the system to a real-life part is illustrated.

The design of parts for metal stamping is often accomplished following a rules-of-thumb-based design process. The approach descnbed here, as part of a broader design for manufacturability (DFM) strategy, is based upon detailed models in contrast to rules of thumb and is developed through extensive interactions with toolmakers and stampers. The design for stamping (DFS) system includes consideration of costs due to rooling, costs due to processing, and costs due to material where these costs are functions of the part design, thus enabling qualitative and quantitative assessments at a preliminary concept sketch as well as further developed design stages.

Previous studies have shown that limited-English-proficient (LEP) patients are less likely to utilize health care services. Objective. To assess the knowledge and perceived barriers to utilization of emergency medical services (EMS) by LEP caregivers of children served by an urban EMS system.We prospectively surveyed a convenience sample of caregivers of children presenting to the emergency department (ED) from January to December 2008. Caregivers were identified as LEP using their response to the U.S. Census question ;;How well do you speak English?'' Caregivers were assigned to one of three cohorts: 1) LEP Spanish- and Arabic-speaking caregivers (n = 50), 2) proficient-in-English (PE) Spanish- and Arabic-speaking caregivers (n = 50), and (3) native English-speaking (NES) caregivers (n = 100). We collected data on EMS awareness and perceived barriers to EMS utilization using a written survey administered in the caregivers' preferred language (English, Spanish, or Arabic). We used descriptive methods to summarize sample characteristics and comparative methods (chi-square test, analysis of variance [ANOVA], and t-test) to compare group differences.There were no differences in the patient age groups, triage categories, caregiver age, and payer status among the three groups. The LEP caregivers were less aware of EMS (93% NES vs. 94% PE vs. 60% LEP; p0.01) and had called EMS significantly fewer times when compared with the NES and PE groups (16% LEP vs. 58% NES vs. 48% PE; p0.01). Fourteen percent of the LEP caregivers were unaware of the telephone number to call for EMS. Concerns about inability to communicate with the operator and cost were cited by the LEP caregivers as the main barriers to EMS utilization.Caregivers with limited English proficiency are less aware of and are less likely to utilize EMS for their children. Barriers to utilization include concerns of cost and communication with the operator.

CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was to identify children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary.We enrolled patients younger than 18 years presenting within 24 h of head trauma with Glasgow Coma Scale scores of 14-15 in 25 North American emergency departments. We derived and validated age-specific prediction rules for ciTBI (death from traumatic brain injury, neurosurgery, intubation24 h, or hospital admissionor=2 nights).We enrolled and analysed 42 412 children (derivation and validation populations: 8502 and 2216 younger than 2 years, and 25 283 and 6411 aged 2 years and older). We obtained CT scans on 14 969 (35.3%); ciTBIs occurred in 376 (0.9%), and 60 (0.1%) underwent neurosurgery. In the validation population, the prediction rule for children younger than 2 years (normal mental status, no scalp haematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents) had a negative predictive value for ciTBI of 1176/1176 (100.0%, 95% CI 99.7-100 0) and sensitivity of 25/25 (100%, 86.3-100.0). 167 (24.1%) of 694 CT-imaged patients younger than 2 years were in this low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) had a negative predictive value of 3798/3800 (99.95%, 99.81-99.99) and sensitivity of 61/63 (96.8%, 89.0-99.6). 446 (20.1%) of 2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in validation populations.These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely be obviated.The Emergency Medical Services for Children Programme of the Maternal and Child Health Bureau, and the Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Department of Health and Human Services.

Background: Access to primary care is often a problem for children living in urban areas and the rate of emergency department (ED) use can be high. For acute childhood illnesses, primary care follow-up is often recommended to prevent subsequent ED visits. Methods: We conducted an observational study of 455 children with common childhood illnesses, between 6 weeks and 8 years of age, presenting to 1 of 3 EDs, and discharged to the community. ED physicians recommended that the child visit their primary care physician within 1 to 4 days of discharge (ie, “short-term” follow-up). Caregivers were surveyed during the ED index visit and after discharge to assess primary care follow-up adherence. We collected data on child and caregiver characteristics, type and severity of illness at the ED index visit, and ED return visits in the 2-month period after the ED index visit. Results: A total of 45.3% of caregivers adhered to short-term primary care follow-up. Short-term follow-up adherence was associated with greater ED use for the same illness over the subsequent 2 months (odds ratio = 2.97; 95% confidence interval, 1.31–6.72). Subsequent ED use was greatest for children with short-term primary care follow-up and: (1) prior ED use, (2) single caregivers, (3) mild severity illnesses at the ED index visit, or (4) younger children. ED use after the initial visit did not vary by type of illness or site. Conclusions: There was no evidence that primary care follow-up soon after an ED visit was associated with a lower rate of subsequent ED use for common pediatric illnesses.

Urinary retention can be described as the inability to void volitionally despite an adequate volume of urine in the bladder. It is a common complaint in adults, especially among elderly males with benign prostatic hyperplasia. Children, in contrast, are more likely to have voluntary retention of urine due to urethral irritation or dysuria. Gently massaging the suprapubic region while the child is in a warm bath often relieves the retention in these cases. Other patients described as lazy voiders can present with acute urinary retention. These patients are typically young girls who are embarrassed to void at school. Retraining or timed voiding is often successful managing lazy voiders. However, these benign disorders should only be diagnosed after anatomical or organic causes for their symptoms have been considered and ruled out.

Background Bronchiolitis, the most common infection of the lower respiratory tract in infants, is a leading cause of hospitalization in childhood. Corticosteroids are commonly used to treat bronchiolitis, but evidence of their effectiveness is limited. Methods We conducted a double-blind, randomized trial comparing a single dose of oral dexamethasone (1 mg per kilogram of body weight) with placebo in 600 children (age range, 2 to 12 months) with a first episode of wheezing diagnosed in the emergency department as moderate-to-severe bronchiolitis (defined by a Respiratory Distress Assessment Instrument score ≥6). We enrolled patients at 20 emergency departments during the months of November through April over a 3-year period. The primary outcome was hospital admission after 4 hours of emergency department observation. The secondary outcome was the Respiratory Assessment Change Score (RACS). We also evaluated later outcomes: length of hospital stay, later medical visits or admissions, and adverse events. Results Baseline characteristics were similar in the two groups. The admission rate was 39.7% for children assigned to dexamethasone, as compared with 41.0% for those assigned to placebo (absolute difference, −1.3%; 95% confidence interval [CI], −9.2 to 6.5). Both groups had respiratory improvement during observation; the mean 4-hour RACS was −5.3 for dexamethasone, as compared with −4.8 for placebo (absolute difference, −0.5; 95% CI, −1.3 to 0.3). Multivariate adjustment did not significantly alter the results, nor were differences detected in later outcomes. Conclusions In infants with acute moderate-to-severe bronchiolitis who were treated in the emergency department, a single dose of 1 mg of oral dexamethasone per kilogram did not significantly alter the rate of hospital admission, the respiratory status after 4 hours of observation, or later outcomes. (ClinicalTrials.gov number, NCT00119002.)

Background:Variation in the management of acute pediatric asthma within emergency departments is largely unexplored. Objectives:To investigate whether ancillary testing for patients with asthma would be associated with patient, physician, and hospital characteristics. Methods:The authors performed an analysis of a subset of patients from an extensive retrospective chart review of randomly selected charts at all 25 member emergency departments of the Pediatric Emergency Care Applied Research Network. Patients with a diagnosis of asthma were selected for supplemental review and included in this study. Ancillary tests analyzed were chest radiographs and selected blood tests. Hierarchical analyses were performed to describe the associations between ancillary testing and the variables of interest. Results:A total of 12,744 chart abstractions were completed, of which 734 (6%) were patients with acute exacerbations of asthma. Overall, 302 patients with asthma (41%) had ancillary testing. Of the 734 patients with asthma, 198 (27%) had chest radiographs and 104 (14%) had blood tests. Chest radiographs were more likely to be ordered in patients with fever. Less blood testing was associated with physician subspecialty training in pediatric emergency medicine, patients treated at children's hospitals, higher patient oxygen saturation, and patient disposition to home. Conclusions:Ancillary testing occurred in more than one third of children with asthma, with chest radiographs ordered most frequently. Efforts to reduce the use of chest radiographs should target the management of febrile patients with asthma, whereas efforts to reduce blood testing should target providers without subspecialty training in pediatric emergency medicine and patients treated in nonchildren's hospitals who are more ill.

OBJECTIVE: To examine pediatric emergency department (ED) visits over 5 years, trends in injury severity, and associations between injury-related ED visit outcome and patient and community-level sociodemographic characteristics. STUDY DESIGN: Retrospective analysis of administrative data provided to the Pediatric Emergency Care Applied Research Network Core Data Project, 2004-2008. Home addresses were geocoded to determine census block group and associated sociodemographic characteristics. Maximum Abbreviated Injury Scale severity and Severity Classification System scores were calculated. Generalized estimating equations were used to test for associations between sociodemographic characteristics and admission or transfer among injury-related ED visits. RESULTS: Overall ED visits and injury-related visits increased from 2004 to 2008 at study sites. Of 2 833 676 successfully geocoded visits, 700 821 (24.7%) were injury-related. The proportion of higher severity injury-related visits remained consistent. Nearly 10% of injury-related visits resulted in admission or transfer each year. After adjusting for age, sex, payer, and injury severity, odds of admission or transfer were lower among minority children and children from areas with moderate and high prevalence of poverty. CONCLUSIONS: Pediatric injury-related ED visits to included sites increased over the study period while injury severity, anticipated resource utilization, and visit outcomes remained stable, with low rates of admission or transfer. Sociodemographic differences in injury-related visits and ED disposition were apparent. ED-based injury surveillance is essential to understand disparities, inform targets for prevention programs, and reduce the overall burden of childhood injuries. Language: en

We compare test characteristics of abdominal computed tomography (CT) with and without oral contrast for identifying intra-abdominal injuries.This was a planned subanalysis of a prospective, multicenter study of children (18 years) with blunt torso trauma. Children imaged in the emergency department with abdominal CT using intravenous contrast were eligible. Oral contrast use was based on the participating centers' guidelines and discretions. Clinical courses were followed to identify patients with intra-abdominal injuries. Abdominal CTs were considered positive for intra-abdominal injury if a specific intra-abdominal injury was identified and considered abnormal if any findings suggestive of intra-abdominal injury were identified on the CT.A total of 12,044 patients were enrolled, with 5,276 undergoing abdominal CT with intravenous contrast. Of the 4,987 CTs (95%) with documented use or nonuse of oral contrast, 1,010 (20%) were with and 3,977 (80%) were without oral contrast; 686 patients (14%) had intra-abdominal injuries, including 127 CTs (19%) with and 559 (81%) without oral contrast. The sensitivity in the detection of any intra-abdominal injury in the oral contrast versus no oral contrast groups was sensitivitycontrast 99.2% (95% confidence interval [CI] 95.7% to 100.0%) versus sensitivityno contrast 97.7% (95% CI 96.1% to 98.8%), difference 1.5% (95% CI -0.4% to 3.5%). The specificity of the oral contrast versus no oral contrast groups was specificitycontrast 84.7% (95% CI 82.2% to 87.0%) versus specificityno contrast 80.8% (95% CI 79.4% to 82.1%), difference 4.0% (95% CI 1.3% to 6.7%).Oral contrast is still used in a substantial portion of children undergoing abdominal CT after blunt torso trauma. With the exception of a slightly better specificity, test characteristics for detecting intra-abdominal injury were similar between CT with and without oral contrast.

OBJECTIVE:: To examine the epidemiology of pediatric patient visits to emergency departments (ED). METHODS:: We conducted a cross-sectional study of pediatric ED visits at the participating Pediatric Emergency Care Applied Research Network (PECARN) hospitals in 2002. We provide descriptive characteristics of pediatric ED visits and a comparison of the study database to the National Hospital Ambulatory Medical Care Survey (NHAMCS). Bivariate analyses were calculated to assess characteristics associated with hospital admission, death in the ED, and length of ED visit. We also performed multivariate regression to model the likelihood of admission to the hospital. RESULTS:: Mean patient age was 6.2 years; 53.5% were boys; 47.5% black; and 43.2% had Medicaid insurance. The most common ED diagnoses were fever, upper respiratory infection, asthma, otitis media, and viral syndromes. The inpatient admission rate was 11.6%. The most common diagnoses requiring hospitalization were asthma, dehydration, fever, bronchiolitis, and pneumonia. In multivariate analysis, patients who were black or Hispanic, had Medicaid insurance or were uninsured, or were older than 1 year were less likely to be hospitalized. Demographics of the PECARN population were similar to NHAMCS, with notable exceptions of a larger proportion of black patients and of admitted patients from the PECARN EDs. CONCLUSION:: We describe previously unavailable epidemiological information about childhood illnesses and injuries that can inform development of future studies on the effectiveness, outcomes, and quality of emergency medical services for children. Most pediatric ED patients in our study sought care for infectious causes or asthma and were discharged from the ED. Hospital admission rate differed according to age, payer type, race/ethnicity, and diagnosis. Language: en

Rickets develops when growing bones fail to mineralize. In most cases, the diagnosis is established with a thorough history and physical examination and confirmed by laboratory evaluation. Nutritional rickets can be caused by inadequate intake of nutrients (vitamin D in particular); however, it is not uncommon in dark-skinned children who have limited sun exposure and in infants who are breastfed exclusively. Vitamin D-dependent rickets, type I results from abnormalities in the gene coding for 25(OH)D3-1-alpha-hydroxylase, and type II results from defective vitamin D receptors. The vitamin D-resistant types are familial hypophosphatemic rickets and hereditary hypophosphatemic rickets with hypercalciuria. Other causes of rickets include renal disease, medications, and malabsorption syndromes. Nutritional rickets is treated by replacing the deficient nutrient. Mothers who breastfeed exclusively need to be informed of the recommendation to give their infants vitamin D supplements beginning in the first two months of life to prevent nutritional rickets. Vitamin D-dependent rickets, type I is treated with vitamin D; management of type II is more challenging. Familial hypophosphatemic rickets is treated with phosphorus and vitamin D, whereas hereditary hypophosphatemic rickets with hypercalciuria is treated with phosphorus alone. Families with inherited rickets may seek genetic counseling. The aim of early diagnosis and treatment is to resolve biochemical derangements and prevent complications such as severe deformities that may require surgical intervention.

Bleeding from the proximal part of the gastrointestinal (GI) tract is not uncommon in children. Children could present with anemia secondary to chronic occult bleeding in the gastrointestinal tract or as anemia secondary to acute exsanguinations and can present in hypovolemic shock. There are various causes of upper GI bleeding in children. A systematic approach in evaluating these children is essential so that the diagnosis is made in timely manner and appropriate management is begun early.

Disulfiram is used worldwide to treat alcoholism. The presence of this drug in the home makes it a potential agent encountered in accidental poisoning. We report a child who ingested disulfiram and subsequently had unusual and prolonged neurologic manifestations of dystonia, complete loss of developmental milestones, and spastic tetraparesis. A 5-year-old girl was seen at the referring hospital for upper respiratory tract infection for 7 days and vomiting for 2 days. She was incoherent and unresponsive, with significant dehydration and cold clammy extremities on the day of admission. A bedside glucose test indicated low blood sugar. Two doses of 25% dextrose (2 mL/kg) and 0.1 mg/kg naloxone were administered. Laboratory data obtained before the above intervention included serum sodium, 141 mEq/L; potassium, 6.0 mEq/L; chlorides, 106 mEq/L; carbon dioxide content, 5 mEq/L; blood urea nitrogen, 90 mg/dL; creatinine, 1.4 mg/dL; glucose, 359 mg/dL; lactic acid, 1.3 mmol/L; and osmolality, 340 mOsm/kg. Capillary blood gas measurement showed a pH of 7.12, Pco2 of 18 mm Hg, Po2 of 98 mm Hg, and serum bicarbonate of 5.5 mEq/L. A complete blood count and spinal fluid showed no abnormalities. Subsequently, a diagnosis of diabetic ketoacidosis was made. Intravascular volume expansion was carried out using 300 mL of lactated Ringer's solution. She was transferred to the Children's Hospital of Michigan. At arrival to the intensive care unit, the physical examination revealed the following: temperature, 36.6°C (rectal); heart rate, 132 beats/min; Kussmaul breathing at a rate of 36 breaths/min; and blood pressure, 122/76 mm Hg. She had cold, clammy extremities. She remained comatose, with occasional spontaneous, nonpurposeful movements. No focal neurologic deficits were noted. Serum glucose was 551 mg/dL. A comprehensive toxicologic screen including an alcohol panel did not reveal the presence of any drugs or toxins in the urine or serum. Continuous infusions …

A prospective, randomized, double blinded study was conducted to determine whether a combination of nebulized magnesium sulfate and albuterol as a single dose adds any benefit in management of children with mild to moderate asthma when compared to nebulized albuterol with saline. The difference in FEV1 was significant at 10 and 20 min after a single dose of the combined treatment with magnesium and albuterol when compared with the albuterol and saline group (1.41 L ± 0.53 vs. 1.13 L ± 0.34, respectively, p = 0.03). The addition of magnesium to albuterol seems to provide short-term benefits in children with acute exacerbations of mild to moderate asthma.

Introduction: There are approximately 18,000 hospitalizations and 75,000 hospitalization days annually in the United States for children experiencing sickle cell vasoocclusive crises. Despite advances in the management of other comorbidities of sickle cell disease, little has changed in the management of sickle cell pain crises. Magnesium, a known vasodilator, anti-inflammatory and pain reliever, has the potential to alter the pathophysiology of pain crises, shortening length of stay and decreasing opioid use. A previous pilot study showed IV magnesium shortened length of stay compared to historical controls. A randomized trial conducted in Canada showed no decrease in length of stay with the use of intravenous magnesium. In the MAGiC (MAGnesium for children in Crisis) study, we hypothesized that the addition of intravenous (IV) magnesium to standard therapy would shorten hospital length of stay, result in decreased opioid use and improve quality of life for pediatric patients hospitalized with sickle cell pain crises. Methods: The MAGiC study was a multi-center, randomized, double-blind, placebo-controlled trial of IV magnesium versus normal saline for the treatment of pediatric sickle cell pain crisis conducted at 8 sites. Participating sites were members of the Pediatric Emergency Care Applied Research Network (PECARN), and collaborations between Pediatric Emergency Medicine physicians and Pediatric sickle cell experts facilitated enrollment. Children aged 4 to 21 years, with hemoglobin SS or hemoglobin SB° thalassemia were eligible if they required inpatient hospitalization after failing emergency department (ED) management for pain. Enrollment occurred at 8 sites between December 2010 and December 2013, with a total of 217 eligible site enrollment months. Children received 40 mg/kg of IV magnesium every eight hours for a total of 6 doses or normal saline placebo of equivalent volume (1 ml/kg). Randomization was stratified by site, age and hydroxyurea use. The primary outcome was length of stay from the time of first drug infusion until 12 hours after the last IV opioid dose or time of discharge, whichever occurred first. Secondary outcomes included opioid use, recorded as morphine equivalents, and quality of life, as measured using the PedsQL Sickle cell disease specific module, fatigue module and generic module. Side effects, specifically hypotension, weakness, warmth on infusion, or the development of acute chest syndrome (ACS) were documented. Using an intention-to-treat analysis, we compared length of stay using a Van Elteren test, stratified by the same factors used to stratify randomization. Results: 208 children were enrolled. Four children were excluded prior to receipt of any study drug, resulting in 101 children receiving magnesium and 103 receiving placebo. The 2 groups were similar with respect to age, sex ,genotype, weight, history of ACS or asthma, previous hospitalizations within the past three years and days of pain prior to arrival. The median time from first ED opioid to first study drug infusion was 7.4 hours, similar between the two groups. The median (interquartile range) length of stay was 56.0 (27.0 - 109.0) hours in the magnesium group compared to 47.0 (24.0 - 99.0) hours in the placebo group, p = 0.264. Patients who received magnesium received 1.46 mg/kg of morphine equivalents compared to 1.28 mg/kg in the placebo group (p=0.11). Quality of life scores were similar between the two groups after 48 hours on study drug and one week after discharge (p > 0.10 at both time points). Safety analysis revealed no differences in hypotension (3% for magnesium versus 1% for placebo) or weakness (7% versus 4%) between the 2 groups. Of those who received magnesium, 26% reported warmth on infusion compared to 2% of children who received placebo, p < .0001. Other adverse events, serious adverse events, and rehospitalizations within 7 days were similar between the groups. Conclusion: Intravenous magnesium does not shorten length of stay, lessen opioid use or improve quality of life in children who require hospitalization for sickle cell pain crisis. Close collaboration between Pediatric Emergency Medicine physicians and Pediatric Hematologists allows for the successful enrollment of large numbers of children in an acute intervention trial for children with sickle cell disease. Disclosures Off Label Use: magnesium for sickle cell pain crisis.

RESULTS Cessation of status epilepticus for 10 minutes without recurrence within 30 minutes occurred in 101 of 140 (72.1%) in the diazepam group and 97 of 133 (72.9%) in the lorazepam group, with an absolute efficacy difference of 0.8% (95% CI, −11.4% to 9.8%). Twenty-six patients in each group required assisted ventilation (16.0% given diazepam and 17.6% given lorazepam; absolute risk difference, 1.6%; 95% CI, −9.9% to 6.8%). There were no statistically significant differences in secondary outcomes except that lorazepam patients were more likely to be sedated (66.9% vs 50%, respectively; absolute risk difference, 16.9%; 95% CI, 6.1% to 27.7%).

(0.4%, 95% CI 0.3-0.5%) had IAIAI. Abdominal CT scans were obtained in the ED for 2,302 or 86% of patients (86%, 95% CI 85-88%) with clinician suspicion 1% for IAIAI and in 3,016 patients or 33% (33%, 95% CI 32-34%) with clinician suspicion 1% for IAIAI.

Objective To determine if patient race/ethnicity is independently associated with cranial computed tomography (CT) use among children with minor blunt head trauma. Design Secondary analysis of a prospective cohort study. Setting Pediatric research network of 25 North American emergency departments. Patients In total, 42 412 children younger than 18 years were seen within 24 hours of minor blunt head trauma. Of these, 39 717 were of documented white non-Hispanic, black non-Hispanic, or Hispanic race/ethnicity. Using a previously validated clinical prediction rule, we classified each child's risk for clinically important traumatic brain injury to describe injury severity. Because no meaningful differences in cranial CT rates were observed between children of black non-Hispanic race/ethnicity vs Hispanic race/ethnicity, we combined these 2 groups. Main Outcome Measure Cranial CT use in the emergency department, stratified by race/ethnicity. Results In total, 13 793 children (34.7%) underwent cranial CT. The odds of undergoing cranial CT among children with minor blunt head trauma who were at higher risk for clinically important traumatic brain injury did not differ by race/ethnicity. In adjusted analyses, children of black non-Hispanic or Hispanic race/ethnicity had lower odds of undergoing cranial CT among those who were at intermediate risk (odds ratio, 0.84; 95% CI, 0.76-0.94) or lowest risk (odds ratio, 0.73; 95% CI, 0.66-0.81) for clinically important traumatic brain injury. Regardless of risk for clinically important traumatic brain injury, parental anxiety and request was commonly cited by physicians as an important influence for ordering cranial CT in children of white non-Hispanic race/ethnicity. Conclusions Disparities may arise from the overuse of cranial CT among patients of nonminority races/ethnicities. Further studies should focus on explaining how medically irrelevant factors, such as patient race/ethnicity, can affect physician decision making, resulting in exposure of children to unnecessary health care risks.

Objective To evaluate the single dose pharmacokinetics of an intravenous dose of lorazepam in pediatric patients treated for status epilepticus (SE) or with a history of SE. Study design Ten hospitals in the Pediatric Emergency Care Applied Research Network enlisted patients 3 months to 17 years with convulsive SE (status cohort) or for a traditional pharmacokinetics study (elective cohort). Sparse sampling was used for the status cohort, and intensive sampling was used for the elective cohort. Non-compartmental analyses were performed on the elective cohort, and served to nest compartmental population pharmacokinetics analysis for both cohorts. Results A total of 48 patients in the status cohort and 15 patients in the elective cohort were enrolled. Median age was 7 years, 2 months. The population pharmacokinetics parameters were: clearance, 1.2 mL/min/kg; half-life, 16.8 hours; and volume of distribution, 1.5 L/kg. On the basis of the pharmacokinetics model, a 0.1 mg/kg dose is expected to achieve concentrations of approximately 100 ng/mL and maintain concentrations >30 to 50 ng/mL for 6 to 12 hours. A second dose of 0.05 mg/kg would achieve desired therapeutic serum levels for approximately 12 hours without excessive sedation. Age-dependent dosing is not necessary beyond using a maximum initial dose of 4 mg. Conclusions Lorazepam pharmacokinetics in convulsive SE is similar to earlier pharmacokinetics measured in pediatric patients with cancer, except for longer half-life, and similar to adult pharmacokinetics parameters except for increased clearance.

Concerns about rising costs, coupled with variable care provided, has fueled quality improvement (QI) efforts in health care. QI tools borrowed from the manufacturing industry, such as six sigma and lean methods, are being used to address variation, waste, and sometimes inappropriate or even dangerous health care practices. The emergency department (ED) is an integral component of the health care system and, in some instances, represents the only means of access to care. There are substantial challenges to delivering high quality care in the ED including overcrowding, undifferentiated illness, lack of resources, and liability concerns, just to name a few. Experts have recognized that delivery of emergency medical services is highly fragmented and have underscored the need for performance oversight, making the ED an ideal setting for QI efforts. Pediatric emergency medicine is catching up on the QI front, and this issue of Clinical Pediatric Emergency Medicine is dedicated to highlighting efforts undertaken at various institutions. The first article (Mahajan) aims to expose the reader to terminology used in QI and is then followed by “Acute Care Model” by Iyer et al—a conceptual framework for addressing various aspects of quality for pediatric patients presenting with an acute

Dear Editors, Your article “Clinical research 101: Why should you care?” [1] was very interesting and I applaud the journal, which in its infancy is addressing issues such as importance of clinical research. As you correctly mention, the emergency department (ED) is a clinical laboratory, and clinical research apart from answering some of the most pertinent questions has the additional value of being immediately relevant to patient care. As a research director of a very busy pediatric ED with an active fellowship in pediatric emergency medicine, I am constantly struggling to convey the message that research is not an entity which gets conducted solely in laboratories or demands extensive knowledge of statistics to my colleagues. Research is a very important step in improving patient care by applying what is known to the patient immediately in front of you. Research provides the foundation for evidence-based medicine and the tools for evidence-based practice. I would also add that research can vary in its quality and comprehensiveness. Practitioners of emergency medicine must be discerning enough to critically appraise research as there are many instances of “published” studies that either lack the appropriate methodology, adequate sample size, or rigorous analysis. Additionally, research is constantly evolving and what is considered as gospel may be eventually refuted with a well-conducted study. Use of steroids in bronchiolitis is an example. A well-conducted double-blinded randomized controlled trial (n = 70) performed at one ED comparing a single dose of oral dexamethasone with a placebo in children with moderate to severe bronchiolitis showed a substantial reduction in hospitalization along with clinical improvement. This study was powered to detect a difference in a clinical score not rates of hospitalization [2]. Yet, using these efficacy data, many practitioners changed their practice and started using oral dexamethasone in the management of bronchiolitis. A subsequent larger, multicenter study (effectiveness study) showed no effect of a single dose of oral dexamethasone when the study was powered to detect a 12% difference in admission rates (n = 600). This second study clearly showed that there was no difference in hospitalization rates [3]. The challenge now is to disseminate these findings—translating research into practice (TRIP). In conclusion, I think it is important for journals such as yours to enhance the research experience by (a) publishing articles on research methodology, (b) being more discerning as to which articles get accepted, and (c) broadening the scope of emergency research by publishing articles on research ethics in varied settings, i.e., international emergency medicine.

Two large field studies were conducted to test the validity of the Job Severity Index (JSI) as an engineering tool for the control of manual materials-handling injury. Comparisons were made between the calculated JSIs of 453 individuals working in 101 different jobs and the injuries sustained by the same individuals over a period of 1057881 exposure hours (529 exposure years). The results revealed the existence of a job severity threshold above which the incidence, severity, and cost of injury dramatically increased. It was concluded that the JSI method can effectively be used to control injuries caused by the manual lifting of loads.

Background: COVID-19 has impacted Indian engineering institutions (EIs) enormously. It has tightened its knot around EIs that forced their previous half-shut shades completely down to prevent the risk of spreading COVID-19. In such a situation, fetching new enrollments on EI campuses is a difficult and challenging task, as students’ behavior and family preferences have changed drastically due to mental stress and emotions attached to them. Historically, during crisis situations, institutions have struggled to return to the normal track. Consequently, it becomes a prerequisite to examine the choice characteristics influencing the selection of EI during the COVID-19 pandemic to make it ‘normal’ for ‘new’ enrollments. The purpose of this study is to critically examine choice characteristics that affect students’ choice for EI and consequently to explore relationships between institutions’ characteristics and the suitability of EI during the COVID-19 pandemic across students’ characteristics. Quantitative research, conducted through a self-reported survey composed of a closed-ended structured questionnaire, was purposefully incorporated into the students who recently were enrolled in EIs (batch years 2020-2021) belonging to the North Maharashtra region of India. Results: The findings of this study revealed dissimilarities across students’ characteristics regarding the suitability of EIs under pandemic conditions. Regression analysis revealed that EI characteristics such as proximity, image and reputation, quality education and curriculum delivery have significantly contributed to suitability under COVID-19. At the micro level, multiple relationships were noted between EI characteristics and the suitability of EI under the pandemic across students’ characteristics. Conclusion: Bringing ‘normality’ to ‘new’ enrollments totally depends on EI’s resilience in meeting the needs of diversity in the COVID-19 pandemic situation, which repositions themselves to govern student-centric strategies instituted for the overall suitability of EI under pandemic conditions. The study has successfully demonstrated how choice characteristics can be executed to regulate the ‘suitability’ of EI under the COVID-19 pandemic for the inclusion of diversity. It is useful for policy makers and academicians to reposition EIs that fetch diversity during the pandemic. This study is the first to provide insights into the performance of choice characteristics and their relationship with the suitability of EIs under a pandemic and can be a yardstick in administering new enrollments.