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Objectives In children with sickle cell disease treated for vasoocclusive episodes (VOEs), it is unknown if the temperature of infused fluids impacts clinical outcomes. We compared infusions of warmed and nonwarmed saline for treatment of VOE. We also assessed the tolerability and feasibility of infusing warmed saline in patients with VOEs. Methods Patients aged 4 to 21 years with sickle cell disease presenting to the emergency department with VOE were randomized to infusions of warmed (37.5°C, experimental arm) versus nonwarmed (22°C-24°C, controls) saline. Intravenous opioids were administered according to previously established guidelines. We compared hospital admission rates, pain scores, disposition times, dosages of opioid, and comfort. Results Eighty of 92 visits were eligible (40 per arm). The mean age of enrollees was 14 years, and 53% were female. Hospital admission rates were comparable (63% experimental arm and 55% control arm, P = 0.5). Pain score reduction (-2.9 and -2.6, P = 0.52), median morphine equivalents (0.23 mg/kg and 0.25 mg/kg, P = 0.58), and mean treatment-to-disposition times (158 minutes and 155 minutes, P = 0.85) were also similar. Global comfort was higher in children who received warmed saline (4 vs 3, P = 0.01). There were no adverse events reported in patients who received warmed saline. Conclusions It is feasible and tolerable to infuse warmed saline for the treatment of VOE, and it is well tolerated. Patient comfort was higher in those patients who received warmed saline, but there was no improvement in admission rates, disposition times, pain scores, and opioid dosages.

Objectives To determine whether the use of dry-erase boards for communicating the plan of care of children evaluated in the pediatric emergency department (PED) improves the family experience of care. Methods Dry-erase boards were mounted at eye level in patient examination rooms. The study was conducted during a 4-week period during which physicians were instructed to use the boards on alternating weeks. During the 2 intervention weeks, they were instructed to write their name and plan of care in addition to their standard verbal communication. A questionnaire was administered to a convenience sample of caregivers that measured their perceptions of physician listening skills, time spent with the physician, their understanding of the care plan, their willingness to ask questions, likelihood to recommend the PED, and overall physician care. Differences between intervention and nonintervention weeks were analyzed using adjusted multivariable modeling taking into account clustered observations within physician. Results Surveys were completed by 672 caregivers. There were no significant differences in reported experience of care between the intervention and nonintervention weeks. During the intervention weeks, 59% of caregivers recalled use of the dry-erase boards, whereas 10% of caregivers recalled use during nonintervention weeks. Caregivers who recalled the use of dry-erase boards were more likely to report better physician listening skills, better understanding of the plan of care, and higher overall physician ratings. Conclusions Recommending use of dry-erase boards in pediatric emergency department rooms did not increase overall measures of experience of care, although patients who recalled dry-erase board use did report higher performance. Further study could explore how to effectively and efficiently use these boards.

Background: Urinary tract infections (UTIs) are the most common serious bacterial infection in young febrile infants, and the urinalysis (UA) is an accurate screening test for emergency department (ED) evaluation. Precise estimates of risk of concomitant bacteremia and/or bacterial meningitis (invasive bacterial infections; IBI) in febrile infants ≤ 60 days have been based on presence of UTIs rather than positive UAs, and lack large prospective study. Objective: We sought to determine the prevalence of IBIs in febrile infants 0-28 …

Importance In young febrile infants, serious bacterial infections (SBIs), including urinary tract infections, bacteremia, and meningitis, may lead to dangerous complications. However, lumbar punctures and hospitalizations involve risks and costs. Clinical prediction rules using biomarkers beyond the white blood cell count (WBC) may accurately identify febrile infants at low risk for SBIs. Objective To derive and validate a prediction rule to identify febrile infants 60 days and younger at low risk for SBIs. Design, Setting, and Participants Prospective, observational study between March 2011 and May 2013 at 26 emergency departments. Convenience sample of previously healthy febrile infants 60 days and younger who were evaluated for SBIs. Data were analyzed between April 2014 and April 2018. Exposures Clinical and laboratory data (blood and urine) including patient demographics, fever height and duration, clinical appearance, WBC, absolute neutrophil count (ANC), serum procalcitonin, and urinalysis. We derived and validated a prediction rule based on these variables using binary recursive partitioning analysis. Main Outcomes and Measures Serious bacterial infection, defined as urinary tract infection, bacteremia, or bacterial meningitis. Results We derived the prediction rule on a random sample of 908 infants and validated it on 913 infants (mean age was 36 days, 765 were girls [42%], 781 were white and non-Hispanic [43%], 366 were black [20%], and 535 were Hispanic [29%]). Serious bacterial infections were present in 170 of 1821 infants (9.3%), including 26 (1.4%) with bacteremia, 151 (8.3%) with urinary tract infections, and 10 (0.5%) with bacterial meningitis; 16 (0.9%) had concurrent SBIs. The prediction rule identified infants at low risk of SBI using a negative urinalysis result, an ANC of 4090/µL or less (to convert to ×109per liter, multiply by 0.001), and serum procalcitonin of 1.71 ng/mL or less. In the validation cohort, the rule sensitivity was 97.7% (95% CI, 91.3-99.6), specificity was 60.0% (95% CI, 56.6-63.3), negative predictive value was 99.6% (95% CI, 98.4-99.9), and negative likelihood ratio was 0.04 (95% CI, 0.01-0.15). One infant with bacteremia and 2 infants with urinary tract infections were misclassified. No patients with bacterial meningitis were missed by the rule. The rule performance was nearly identical when the outcome was restricted to bacteremia and/or bacterial meningitis, missing the same infant with bacteremia. Conclusions and Relevance We derived and validated an accurate prediction rule to identify febrile infants 60 days and younger at low risk for SBIs using the urinalysis, ANC, and procalcitonin levels. Once further validated on an independent cohort, clinical application of the rule has the potential to decrease unnecessary lumbar punctures, antibiotic administration, and hospitalizations.

Objectives Child life interventions reduce the anxiety of medical procedures but are not always available in emergency departments. In this study, we determined the effect of parent-directed tablet computer use without child life direction on patient anxiety and on parent and suturing clinician experience during pediatric facial laceration repair. Methods In a children's hospital emergency department, we enrolled children 2 to 12 years of age undergoing unsedated facial laceration repairs and randomized them to parent-directed tablet computer distraction or standard supportive care. We measured anxiety using the Observational Scale of Behavioral Distress-Revised (OSBD-R) for 5 procedure phases from videotaped laceration repairs. We compared OSBD-R scores for 5 phases and weighted averages between the tablet and standard care groups. Parents and suturing clinicians completed surveys about their experiences after the procedures. Results From April 2014 to July 2015, 77 patients (39 tablet, 38 standard) underwent repairs. Age, use of restraint, procedure duration, and number of sutures were similar between the 2 groups. The groups did not differ in procedure phase or weighted-average OSBD-R scores. Parents in the tablet group reported less personal anxiety compared with parents in the standard group (P = 0.01). In a post hoc subgroup analysis, subjects in the unrestrained tablet group had lower OSBD-R scores during the anesthetic injection phase than did subjects in the unrestrained standard group (P = 0.04). If restrained, subjects in the tablet group had higher OSBD-R scores during the anesthetic injection phase than did subjects in the standard group (P = 0.048). Conclusions Unrestrained children may benefit from parent-directed tablet computer distraction. Parents who operate the device are less anxious during their children's procedures.

Objectives Emergency department (ED) identification and radiographic evaluation of children with intra-abdominal injuries who need acute intervention can be challenging. To date, it is unclear if a clinical prediction rule is superior to unstructured clinician judgment in identifying these children. The objective of this study was to compare the test characteristics of clinician suspicion with a derived clinical prediction rule to identify children at risk of intra-abdominal injuries undergoing acute intervention following blunt torso trauma. Methods This was a planned subanalysis of a prospective, multicenter observational study of children ( 50% prior to knowledge of abdominal computed tomography (CT) scanning (if performed). Intra-abdominal injuries undergoing acute intervention were defined by a therapeutic laparotomy, angiographic embolization, blood transfusion for abdominal hemorrhage, or intravenous fluid administration for 2 or more days in those with pancreatic or gastrointestinal injuries. Patients were considered to be positive for clinician suspicion if suspicion was documented as ≥1%. Suspicion ≥ 1% was compared to the presence of any variable in the prediction rule for identifying children with intra-abdominal injuries undergoing acute intervention. Results Clinicians recorded their suspicion in 11,919 (99%) of 12,044 patients enrolled in the parent study. Intra-abdominal injuries undergoing acute intervention were diagnosed in 203 (2%) patients. Abdominal CT scans were obtained in the ED in 2,302 of the 2,667 (86%, 95% confidence interval [CI] = 85% to 88%) enrolled patients with clinician suspicion ≥1% and in 3,016 of the 9,252 (33%, 95% CI = 32% to 34%) patients with clinician suspicion 1% se comparo con la presencia de cualquier variable en la regla de prediccion para la identificacion de ninos con LIA con necesidad de una intervencion urgente. Resultados Los clinicos documentaron su sospecha en 11.919 (99%) de los 12.044 pacientes incluidos en el estudio original. La LIA con necesidad de intervencion urgente se diagnostico en 203 (2%) pacientes. Las TC abdominales se obtuvieron en el SU en 2.302 de los 2.667 pacientes (86%, IC95% = 85% a 88%) incluidos con sospecha clinica ≥1%; y en 3.016 de los 9.252 pacientes (33%, IC95% = 32% a 34%) con sospecha clinica

Objectives: To estimate sample sizes available for clinical trials of severe traumatic brain injury (TBI) in children, we described the patient demographics and hospital characteristics associated with children hospitalized with severe TBI in the United States. Methods: We analyzed the 2006 Kids’ Inpatient Database. Severe TBI hospitalizations were defined as children discharged with TBI who required mechanical ventilation or intubation. Types of high-volume severe TBI hospitals were categorized based on the numbers of discharged patients with severe TBI in 2006. National estimates of demographics and hospital characteristics were calculated for pediatric severe TBI. Simulation analyses were performed to assess the potential number of severe TBI cases from randomly selected hospitals for inclusion in future clinical trials. Results: The majority of children with severe TBI were discharged from either a children’s unit in general hospitals (41%) or a nonchildren’s hospital (34%). Less than 5% of all hospitals were high-volume TBI hospitals, which discharged >78% of severe TBI cases and were more likely to be a children’s unit in a general hospital or a children’s hospital. Simulation analyses indicate that there is a saturation point after which the benefit of adding additional recruitment sites decreases significantly. Conclusions: Children with severe TBI are infrequent at any one hospital in the United States, and few hospitals treat large numbers of children with severe TBI. To effectively plan trials of therapies for severe TBI, much attention has to be paid to selecting the right types of centers to maximize enrollment efficiency.

Rapid antigen testing of upper respiratory secretions collected with various swab types is often utilized for laboratory diagnoses of influenza virus infection. There are limited data on the effects of swab composition on test performance. This study compared the performance of the Quidel QuickVue Influenza A+B test on secretions from the anterior nares when a polyurethane foam swab was used for collection to that when a nylon flocked swab was used for collection. One hundred subjects who presented to a pediatric emergency department with symptoms suggestive of an influenza virus infection were recruited for the study. Foam and flocked swabs of the anterior nares were obtained from separate nares of each subject before a posterior nasopharyngeal swab was collected and placed into viral transport medium. The QuickVue test was performed directly on each swab type, and the results were compared to the results of reverse transcription-PCR (RT-PCR), direct fluorescent antibody (DFA) test, and viral culture performed on the transport medium. RT-PCR alone and DFA combined with culture were utilized as separate gold standards. There were 56 cases of influenza detected by RT-PCR; the QuickVue test was positive for 40 foam and 30 flocked swabs, for sensitivities of 71% and 54%, respectively ( P = 0.01). Similarly, there were 49 influenza cases detected by DFA and/or culture; the QuickVue test was positive for 38 foam and 30 flocked swabs, for sensitivities of 78% and 61%, respectively ( P = 0.13). This study suggests that polyurethane foam swabs perform better than nylon flocked swabs for the collection of secretions from anterior nares in the Quidel QuickVue Influenza A+B test.

Objective: Children with attention-deficit/hyperactivity disorder (ADHD) have a higher rate of more severe injuries than the general population. However, their ADHD may cause them to respond differently to procedural sedation required for treatment. The purpose of this article is to compare procedural sedation for children with and without ADHD. Methods: Retrospectively, 44 patients with ADHD and 41 controls sedated with fentanyl and midazolam for forearm-fracture reduction in the emergency department (ED) at a children's hospital were identified. Drug dosages, vital signs, and sedation scores were compared. Results: Drug dosages, vital signs, and sedation scores did not significantly differ between cases and controls. Mean ED visit duration was significantly longer for patients with ADHD than for controls as was sedation duration. Conclusions: Children with and without ADHD were equally sedated with the same total drug dosages. The differences in sedation duration and visit duration warrant further investigation.

Transmission of micro-organisms from the hands of healthcare workers to patients is a major cause of healthcare-acquired infections. In 2002, the US Centers for Disease Control and Prevention (CDC) published guidelines for healthcare workers that included the recommendation for alcohol-based hand rub for hand hygiene during patient visits. In this prospective study we surveyed parental and healthcare workers' preferences for the hand hygiene practices of emergency physicians. The study comprised 99 parents of ill or injured children presenting to our emergency department and 100 healthcare providers (64 nurses, 29 physicians and seven nurse practitioners) within the department. There was a clear and similar preference by parents and healthcare workers for hand hygiene using soap and water over alcohol cleansing rubs. Furthermore, both groups preferred hand hygiene before and after the examination and wanted to observe the physician perform this procedure. In conclusion, families and healthcare worker preferences for hand hygiene are not in keeping with recommendations published by the CDC. Educational interventions are needed to disseminate the CDC's guidelines and to promote compliance with evidence-based recommendations for hand hygiene.

O RIGINAL C ONTRIBUTION Relationship of Physician-identified Patient Race and Ethnicity to Use of Computed Tomography in Pediatric Blunt Torso Trauma JoAnne E. Natale, MD, PhD, Jill G. Joseph, MD, PhD, Alexander J. Rogers, MD, Michael Tunik, MD, David Monroe, MD, Benjamin Kerrey, MD, MS, Bema K. Bonsu, MD, Lawrence J. Cook, MStat, PhD, Kent Page, MStat, Kathleen Adelgais, MD, MPH, Kimberly Quayle, MD, Nathan Kuppermann, MD, MPH, and James F. Holmes, MD, MPH Abstract Objectives: The objective was to determine whether a child’s race or ethnicity as determined by the treating physician is independently associated with receiving abdominal computed tomography (CT) after blunt torso trauma. Methods: We performed a planned secondary analysis of a prospective observational cohort of children < 18 years old presenting within 24 hours of blunt torso trauma to 20 North American emergency departments (EDs) participating in a pediatric research network, 2007–2010. Treating physicians documented race/ethnicity as white non-Hispanic, black non-Hispanic, or Hispanic. Using a previously derived clinical prediction rule, we classified each child’s risk for having an intra-abdominal injury undergoing acute intervention to define injury severity. We performed multivariable analyses using generalized estimating equations to control for confounding and for clustering of children within hospitals. Results: Among 12,044 enrolled patients, treating physicians documented race/ethnicity as white non- Hispanic (n = 5,847, 54.0%), black non-Hispanic (n = 3,687, 34.1%), or Hispanic of any race (n = 1,291, 11.9%). Overall, 51.8% of white non-Hispanic, 32.7% of black non-Hispanic, and 44.2% of Hispanic children underwent abdominal CT imaging. After age, sex, abdominal ultrasound use, risk for intra- abdominal injury undergoing acute intervention, and hospital clustering were adjusted for, the likelihood of receiving an abdominal CT was lower (odds ratio [OR] = 0.8, 95% confidence interval [CI] = 0.7 to 0.9) for black non-Hispanic than for white non-Hispanic children. For Hispanic children, the likelihood of receiving an abdominal CT did not differ from that observed in white non-Hispanic children (OR = 0.9, 95% CI = 0.8 to 1.1). Conclusions: After blunt torso trauma, pediatric patients identified by the treating physicians as black non-Hispanic were less likely to receive abdominal CT imaging than those identified as white non- Hispanic. This suggests that nonclinical factors influence clinician decision-making regarding use of From the Department of Pediatrics (JEN, NK), the Betty Irene Moore School of Nursing (JGJ), and the Department of Emergency Medicine (NK, JFH), University of California at Davis, Sacramento, CA; the Departments of Emergency Medicine and Pediatrics, University of Michigan Medical Center and University of Michigan School of Medicine (AJR), Ann Arbor, MI; the Departments of Pediatrics and Emergency Medicine, New York University School of Medicine (MT), New York City, NY; Howard County General Hospital, Columbia (DM), MD; the Department of Pediatrics, Cincinnati Children’s Hospital, Cincinnati (BK), OH; the Department of Pediatrics, Nationwide Children’s Hospital (BKB), Columbus, OH; the Department of Pediatrics, University of California at San Diego (BKB), San Diego, CA; the University of Utah (LJC, KP), Salt Lake City, UT; the Department of Pediatrics and Emergency Medicine, University of Colorado (KA), Denver, CO; and the St. Louis Children’s Hospital, Washington University (KQ), St. Louis, MO. Participating centers and site investigators for the Pediatric Emergency Care Applied Research Network (PECARN) are listed in Appendix A. Received September 7, 2015; revision received December 2, 2015; accepted December 14, 2015. This work was presented in part at the Society for Academic Emergency Medicine Annual Meeting, Dallas, TX, May 2014. This work was supported by a grant from the Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 1 R49CE00100201. The Pediatric Emergency Care Applied Research Network (PECARN) is supported by cooperative agreements U03MC00001, U03MC00003, U03MC00006, U03MC00007, U03MC00008, U03MC22684, and U03MC22685 from the EMSC program of the MCHB/HRSA. Supervising Editor: Jennifer D. H. Walthall, MD. Address for correspondence and reprints: JoAnne E. Natale, MD, PhD, FAAP; e-mail: jenatale@ucdavis.edu. ISSN 1069-6563 PII ISSN 1069-6563583 © 2016 by the Society for Academic Emergency Medicine doi: 10.1111/acem.12943

Rapid carbohydrate antigen tests are frequently used to diagnose group A streptococcal (GAS) pharyngitis. Despite evidence of modest sensitivity in medical settings, rapid antigen tests are available to the public for self-testing. We sought to determine if the personnel performing a rapid streptococcal antigen test influence the test's performance characteristics. Throat swabs of pediatric patients performed for GAS pharyngitis in a tertiary-care children's hospital network were included during two study periods in 2004 and 2005. The performance characteristics of a rapid carbohydrate antigen test were evaluated in three clinical settings against a nucleic acid probe test method according to the personnel performing the test (laboratory technologist versus nonlaboratory personnel). Between the study periods, nonlaboratory personnel from one site underwent retraining. Subsequently, the performance characteristics of the rapid antigen test were reassessed. The sensitivity of the rapid antigen test varied widely among the different testing sites (56 to 90%). Notably, test sensitivity was consistently greater when the test was performed by laboratory technologists than when it was performed by nonlaboratory personnel ( P < 0.0001). Although the rapid antigen test sensitivity significantly improved after nonlaboratory personnel at one testing site were retrained (sensitivity before versus after retraining; P < 0.0001), the sensitivity remained greater in the laboratory technologist cohort ( P < 0.0001). These data confirm the important relationship of the operator performing a rapid streptococcal antigen test with the test's accuracy, even in a clinical setting, where operator training is mandated. Therefore, its use outside the medical setting by lay persons cannot be recommended without culture backup.

Objectives To determine whether ancillary tests of cerebrospinal fluid (CSF), specifically, the total protein concentration, glucose concentration, and percent neutrophils, provide information for diagnosing acute bacterial meningitis among children with low white blood cell (WBC) count in CSF. Methods The authors retrospectively reviewed CSF from children aged 1 month to 18 years undergoing lumbar puncture at Children's Hospital in Boston from 1993 to 1999. Data were supplemented with CSF test results obtained from children with 0-30 WBCs/mm(3) in CSF diagnosed with acute bacterial meningitis at the same institution from 1984 to 1992. For each test, the incremental value of ancillary tests was estimated by calculating indices of performance such as the area under receiver operator characteristic curves (AUC) and interval likelihood ratios that are relatively insensitive to disease prevalence. Results Among children with 0-30 WBCs/mm(3) in CSF who met study criteria, acute bacterial meningitis was identified in ten of 7,701 (0.1%) for the period from 1993 to 1999 and supplemented with 11 additional cases for the period from 1984 to 1992. AUC values for ancillary tests were 0.61 for total protein concentration, 0.69 for glucose concentration, and 0.90 for percent neutrophils. Interval likelihood ratios were unremarkable for mildly abnormal test results. In contrast, interval likelihood ratios for markedly abnormal test results were higher: 22 for total protein concentration >120 mg/dL, 57 for neutrophils >75%, 15 for glucose concentration 120 mg/dL. Conclusions When markedly abnormal, results of CSF total protein concentration, glucose concentration, and percent neutrophils have value for diagnosing acute bacterial meningitis, even among children with a low WBC count in CSF.

Study objective: We assess the utility of the peripheral blood WBC count as a screen for lumbar puncture among young infants evaluated for serious bacterial infections. Methods: We performed logistic regression modeling and receiver operating characteristic curve analysis of peripheral blood WBC count and cerebrospinal fluid WBC count for results obtained from 3- to 89-day-old infants undergoing a full sepsis evaluation. Results: Twenty-two of 5,353 (4.1 per 1,000) infants had acute bacterial meningitis. For diagnosing acute bacterial meningitis, the peripheral blood WBC count was poorly discriminating and significantly inferior to the cerebrospinal fluid WBC count. This was true both when the odds of meningitis were modeled to vary linearly and as a U-shaped function of the peripheral blood WBC count. When relying on single and interval-based high-risk thresholds of peripheral blood WBC counts alone, the majority of infants with acute bacterial meningitis would have been missed. Conclusion: Decisions to perform or withhold lumbar puncture should not be based on prevailing interpretations of the total peripheral blood WBC counts to maximize detection of bacterial meningitis in young infants. [ Ann Emerg Med. 2003;41:206-214.]

IMPORTANCE: Clinicians often risk stratify young febrile infants for invasive bacterial infections (IBIs), defined as bacteremia and/or bacterial meningitis, using complete blood cell count parameters. OBJECTIVE: To estimate the accuracy of individual complete blood cell count parameters to identify febrile infants with IBIs. DESIGN, SETTING, AND PARTICIPANTS: Planned secondary analysis of a prospective observational cohort study comprising 26 emergency departments in the Pediatric Emergency Care Applied Research Network from 2008 to 2013. We included febrile (≥38°C), previously healthy, full-term infants younger than 60 days for whom blood cultures were obtained. All infants had either cerebrospinal fluid cultures or 7-day follow-up. MAIN OUTCOMES AND MEASURES: We tested the accuracy of the white blood cell count, absolute neutrophil count, and platelet count at commonly used thresholds for IBIs. We determined optimal thresholds using receiver operating characteristic curves. RESULTS: Of 4313 enrolled infants, 1340 (31%; 95% CI, 30% to 32%) were aged 0 to 28 days, 2412 were boys (56%), and 2471 were white (57%). Ninety-seven (2.2%; 95% CI, 1.8% to 2.7%) had IBIs. Sensitivities were low for common complete blood cell count parameter thresholds: white blood cell count less than 5000/µL, 10% (95% CI, 4% to 16%) (to convert to 10(9) per liter, multiply by 0.001); white blood cell count ≥15 000/µL, 27% (95% CI, 18% to 36%); absolute neutrophil count ≥10 000/µL, 18% (95% CI, 10% to 25%) (to convert to × 10(9) per liter, multiply by 0.001); and platelets

OBJECTIVES: The objective was to determine the association between the abdominal seat belt sign and intra-abdominal injuries (IAIs) in children presenting to emergency departments with blunt torso trauma after motor vehicle collisions (MVCs). METHODS: This was a planned subgroup analysis of prospective data from a multicenter cohort study of children with blunt torso trauma after MVCs. Patient history and physical examination findings were documented before abdominal computed tomography (CT) or laparotomy. Seat belt sign was defined as a continuous area of erythema, ecchymosis, or abrasion across the abdomen secondary to a seat belt restraint. The relative risk (RR) of IAI with 95% confidence intervals (CIs) was calculated for children with seat belt signs compared to those without. The risk of IAI in those patients with seat belt sign who were without abdominal pain or tenderness, and with Glasgow Coma Scale (GCS) scores of 14 or 15, was also calculated. RESULTS: A total of 3,740 children with seat belt sign documentation after blunt torso trauma in MVCs were enrolled; 585 (16%) had seat belt signs. Among the 1,864 children undergoing definitive abdominal testing (CT, laparotomy/laparoscopy, or autopsy), IAIs were more common in patients with seat belt signs than those without (19% vs. 12%; RR = 1.6, 95% CI = 1.3 to 2.1). This difference was primarily due to a greater risk of gastrointestinal injuries (hollow viscous or associated mesentery) in those with seat belt signs (11% vs. 1%; RR = 9.4, 95% CI = 5.4 to 16.4). IAI was diagnosed in 11 of 194 patients (5.7%; 95% CI = 2.9% to 9.9%) with seat belt signs who did not have initial complaints of abdominal pain or tenderness and had GCS scores of 14 or 15. CONCLUSIONS: Patients with seat belt signs after MVCs are at greater risk of IAI than those without seat belt signs, predominately due to gastrointestinal injuries. Although IAIs are less common in alert patients with seat belt signs who do not have initial complaints of abdominal pain or tenderness, the risk of IAI is sufficient that additional evaluation such as observation, laboratory studies, and potentially abdominal CT scanning is generally necessary. Language: en

Plain anteroposterior pelvic radiographs are commonly used to screen children for pelvic fractures or dislocations after blunt torso trauma. The test sensitivity and utility, however, are unclear. We assessed the sensitivity of anteroposterior pelvic radiographs for identifying children with pelvic fractures or dislocations after blunt torso trauma. We hypothesized that anteroposterior pelvic radiographs fail to identify all children with pelvic fractures or dislocations, including patients undergoing operative intervention and those with hypotension.We conducted a prospective multicenter observational study of children (18 years) with blunt torso trauma in the Pediatric Emergency Care Applied Research Network. We compared plain anteroposterior pelvic radiographs to the final diagnosis of pelvic fractures or dislocations as documented by the orthopedic faculty physician before emergency department (ED)/hospital discharge. We described the data with descriptive statistics, including 95% confidence intervals (CIs).Of 12,044 patients enrolled in the parent study, 451 (3.7%; 95% CI 3.4% to 4.1%) had pelvic fractures or dislocations. Of these patients, 65 (14%; 95% CI 11% to 18%) underwent operative intervention and 21 (4.7%; 95% CI 2.9% to 7.0%) had age-adjusted hypotension on initial presentation. In the ED, 382 of the 451 patients underwent plain anteroposterior pelvic radiographs, with a sensitivity of 297 of 382 (78%; 95% CI 73% to 82%) for patients with pelvic fractures or dislocations, 55 of 60 (92%; 95% CI 82% to 97%) for patients undergoing operative intervention, and 14 of 17 (82%; 95% CI 57% to 96%) for patients with hypotension.Plain anteroposterior pelvic radiographs have a limited sensitivity for identifying children with pelvic fractures or dislocations after blunt trauma, including patients undergoing operative intervention and those with hypotension.

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.

Objective To describe variations in emergency department (ED) quality measures and determine the association between ED costs and outcomes for 3 pediatric conditions: asthma, gastroenteritis, and simple febrile seizure. Study design This cross-sectional analysis of ED visits used the Pediatric Health Information System database. Children aged ≤18 years who were evaluated in an ED between July 2009 and June 2011 and had a discharge diagnosis of asthma, gastroenteritis, or simple febrile seizure were included. Two quality of care metrics were evaluated for each target condition, and Spearman correlation was applied to evaluate the relationship between ED costs (reflecting overall resource utilization) and admission and revisit rates among institutions. Results More than 250 000 ED visits at 21 member hospitals were analyzed. Among children with asthma, the median rate of chest radiography utilization was 35.1% (IQR, 31.3%-41.7%), and that of corticosteroid administration was 82.6% (IQR, 78.5%-86.5%). For children with gastroenteritis, the median rate of ondansetron administration was 52% (IQR, 43.2%-57.0%), and that of intravenous fluid administration was 18.1% (IQR, 15.3%-21.3%). Among children with febrile seizures, the median rate of computed tomography utilization was 3.1% (IQR, 2.7%-4.3%), and that of lumbar puncture was 4.0% (IQR, 2.3%-5.6%). Increased costs were not associated with lower admission rate or 3-day ED revisit rate for the 3 conditions. Conclusion We observed variation in quality measures for patients presenting to pediatric EDs with common conditions. Higher costs were not associated with lower hospitalization or ED revisit rates.

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.

OBJECTIVE. The goal of this study was to evaluate the effect of antibiotic administration before lumbar puncture on cerebrospinal fluid profiles in children with bacterial meningitis.METHODS. We reviewed the medical records of all children (1 month to 18 years of age) with bacterial meningitis who presented to 20 pediatric emergency departments between 2001 and 2004. Bacterial meningitis was defined by positive cerebrospinal fluid culture results for a bacterial pathogen or cerebrospinal fluid pleocytosis with positive blood culture and/or cerebrospinal fluid latex agglutination results. Probable bacterial meningitis was defined as positive cerebrospinal fluid Gram stain results with negative results of bacterial cultures of blood and cerebrospinal fluid. Antibiotic pretreatment was defined as any antibiotic administered within 72 hours before the lumbar puncture.RESULTS. We identified 231 patients with bacterial meningitis and another 14 with probable bacterial meningitis. Of those 245 patients, 85 (35%) had received antibiotic pretreatment. After adjustment for patient age, duration and severity of illness at presentation, and bacterial pathogen, longer duration of antibiotic pretreatment was not significantly associated with cerebrospinal fluid white blood cell count, cerebrospinal fluid absolute neutrophil count. However, antibiotic pretreatment was significantly associated with higher cerebrospinal fluid glucose and lower cerebrospinal fluid protein levels. Although these effects became apparent earlier, patients with ≥12 hours of pretreatment, compared with patients who either were not pretreated or were pretreated for CONCLUSIONS. In patients with bacterial meningitis, antibiotic pretreatment is associated with higher cerebrospinal fluid glucose levels and lower cerebrospinal fluid protein levels, although pretreatment does not modify cerebrospinal fluid white blood cell count or absolute neutrophil count results.

Introduction of the heptavalent conjugate vaccine for Streptococcus pneumoniae (PCV7) has led to a dramatic decline in meningitis by PCV7 serotypes, raising the possibility of similar trends by PCV7-related serogroups through cross-protection. A present concern, however, is of serotype replacement by pneumococci not related to PCV7 serogroups. If this occurs, there are currently few data to predict whether clinical outcomes will change substantially.To address these questions, we analyzed medical records of 86 cases of pneumococcal meningitis treated at Nationwide Children's Hospital (1993-2004). Adverse neurologic sequelae and death were compared between cases with cerebrospinal fluid isolates characterized as vaccine-related serogroups-serotypes belonging to PCV7 or related to PCV7 serogroups, and those designated nonvaccine serogroups-serotypes neither belonging to PCV7 nor related to PCV7 serogroups. Serotype 19A, because of recent reports of increased incidence, was subanalyzed separately.Thirty-six of 86 (42%) subjects had serious complications, including 6 who died. All 6 deaths occurred in patients with vaccine-related serogroups. Deafness was the most common complication, occurring in 26 (32.5%) survivors. There was no difference in the frequency of total complications between PCV7-related and non-PCV7 groups: 5 of 12 (42%) for non-PCV7 serogroups versus 31 of 74 (42%) for PCV-related serogroups (OR: 1.0; 95% CI: 0.2-4.0). Serious outcomes occurred in 3 of 4 cases due to serogroup 19A. Non-PCV7 serogroups increased slightly at the end of the study period.In children with pneumococcal meningitis, infections with non-PCV7 serogroups seem less likely to result in death. Among survivors, there is preliminary evidence of parity in neurologic sequelae between PCV7 and non-PCV7 serogroups.

Among children with cerebrospinal fluid (CSF) pleocytosis, the task of separating aseptic from bacterial meningitis is hampered when the CSF Gram stain result is unavailable, delayed, or negative. In this study, the authors derive and validate a clinical decision rule for use in this setting.This was a review of peripheral blood and CSF test results from 78 children (19 years) presenting to Children's Hospital Columbus from 1998 to 2002. For those with a CSF leukocyte count of7/microL, a rule was created for separating bacterial from viral meningitis that was based on routine laboratory tests, but excluded Gram stain. The rule was validated in 158 subjects seen at the same site (Columbus, 2002-2004) and in 871 subjects selected from a separate site (Boston, 1993-1999).One point each (maximum, 6 points) was assigned for leukocytes597/microL, neutrophils74%, glucose38 mg/dL, and protein97 mg/dL in CSF and for leukocytes17,000/mL and bands to neutrophils11% in peripheral blood. Areas under receiver-operator-characteristic curves (AROCs) for the resultant score were 0.98 for the derivation set and 0.90 and 0.97, respectively, for validation sets from Columbus and Boston. Sensitivity and specificity pairs for the Boston data set were 100 and 44%, respectively, at a score of 0 and 97 and 81% at a score of 1. Likelihood ratios (LRs) increased from 0 at a score of 0 to 40 at a score ofor = 4.Among children with CSF pleocytosis, a prediction score based on common tests of CSF and peripheral blood and intended for children with unavailable, negative, or delayed CSF Gram stain results has value for diagnosing bacterial meningitis.

Background Time series methods are commonly used to detect disease outbreak signatures (e.g., signals due to influenza outbreaks and anthrax attacks) from varying respiratory-related diagnostic or syndromic data sources. Typically this involves two components: (i) Using time series methods to model the baseline background distribution (the time series process that is assumed to contain no outbreak signatures), (ii) Detecting outbreak signatures using filter-based time series methods. Methods We consider time series models for chest radiograph data obtained from Midwest children's emergency departments. These models incorporate available covariate information such as patient visit counts and smoothed ambient temperature series, as well as time series dependencies on daily and weekly seasonal scales. Respiratory-related outbreak signature detection is based on filtering the one-step-ahead prediction errors obtained from the time series models for the respiratory-complaint background. Results Using simulation experiments based on a stochastic model for an anthrax attack, we illustrate the effect of the choice of filter and the statistical models upon radiograph-attributed outbreak signature detection. Conclusion We demonstrate the importance of using seasonal autoregressive integrated average time series models (SARIMA) with covariates in the modeling of respiratory-related time series data. We find some homogeneity in the time series models for the respiratory-complaint backgrounds across the Midwest emergency departments studied. Our simulations show that the balance between specificity, sensitivity, and timeliness to detect an outbreak signature differs by the emergency department and the choice of filter. The linear and exponential filters provide a good balance.

Background When urine infections are missed in febrile young infants with normal urinalysis, clinicians may worry about the risk – hitherto unverified – of concomitant invasion of blood and cerebrospinal fluid by uropathogens. In this study, we determine the extent of this risk. Methods In a retrospective cohort study of febrile 0–89 day old infants evaluated for sepsis in an urban academic pediatric emergency department (1993–1999), we estimated rates of bacteriuric sepsis (urinary tract infections complicated by sepsis) after stratifying infants by urine leukocyte counts higher, or lower than 10 cells/hpf. We compared the global accuracy of leukocytes in urine, leukocytes in peripheral blood, body temperature, and age for predicting bacteruric sepsis. The global accuracy of each test was estimated by calculating the area under its receiver operating characteristic curve (AUC). Chi-square and Fisher exact tests compared count data. Medians for data not normally distributed were compared by the Kruskal-Wallis test. Results Two thousand two hundred forty-nine young infants had a normal screening dipstick. None of these developed bacteremia or meningitis despite positive urine culture in 41 (1.8%). Of 1516 additional urine specimens sent for formal urinalysis, 1279 had 0–9 leukocytes/hpf. Urine pathogens were isolated less commonly (6% vs. 76%) and at lower concentrations in infants with few, compared to many urine leukocytes. Urine leukocytes (AUC: 0.94) were the most accurate predictors of bacteruric sepsis. Infants with urinary leukocytes < 10 cells/hpf were significantly less likely (0%; CI:0–0.3%) than those with higher leukocyte counts (5%; CI:2.6–8.7%) to have urinary tract infections complicated by bacteremia (N = 11) or bacterial meningitis (N = 1) – relative risk, 0 (CI:0–0.06) [RR, 0 (CI: 0–0.02), when including infants with negative dipstick]. Bands in peripheral blood had modest value for detecting bacteriuric sepsis (AUC: 0.78). Cases of sepsis without concomitant bacteriuria were comparatively rare (0.8%) and equally common in febrile young infants with low and high concentrations of urine leukocytes. Conclusion In young infants evaluated for fever, leukocytes in urine reflect the likelihood of bacteriuric sepsis. Infants with urinary tract infections missed because of few leukocytes in urine are at relatively low risk of invasive bacterial sepsis by pathogens isolated from urine.

ContextChildren with cerebrospinal fluid (CSF) pleocytosis are routinely admitted to the hospital and treated with parenteral antibiotics, although few have bacterial meningitis. We previously developed a clinical prediction rule, the Bacterial Meningitis Score, that classifies patients at very low risk of bacterial meningitis if they lack all of the following criteria: positive CSF Gram stain, CSF absolute neutrophil count (ANC) of at least 1000 cells/μL, CSF protein of at least 80 mg/dL, peripheral blood ANC of at least 10 000 cells/μL, and a history of seizure before or at the time of presentation.ObjectiveTo validate the Bacterial Meningitis Score in the era of widespread pneumococcal conjugate vaccination.Design, Setting, and PatientsA multicenter, retrospective cohort study conducted in emergency departments of 20 US academic medical centers through the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. All children aged 29 days to 19 years who presented at participating emergency departments between January 1, 2001, and June 30, 2004, with CSF pleocytosis (CSF white blood cells ≥10 cells/μL) and who had not received antibiotic treatment before lumbar puncture.Main Outcome MeasureThe sensitivity and negative predictive value of the Bacterial Meningitis Score.ResultsAmong 3295 patients with CSF pleocytosis, 121 (3.7%; 95% confidence interval [CI], 3.1%-4.4%) had bacterial meningitis and 3174 (96.3%; 95% CI, 95.5%-96.9%) had aseptic meningitis. Of the 1714 patients categorized as very low risk for bacterial meningitis by the Bacterial Meningitis Score, only 2 had bacterial meningitis (sensitivity, 98.3%; 95% CI, 94.2%-99.8%; negative predictive value, 99.9%; 95% CI, 99.6%-100%), and both were younger than 2 months old. A total of 2518 patients (80%) with aseptic meningitis were hospitalized.ConclusionsThis large multicenter study validates the Bacterial Meningitis Score prediction rule in the era of conjugate pneumococcal vaccine as an accurate decision support tool. The risk of bacterial meningitis is very low (0.1%) in patients with none of the criteria. The Bacterial Meningitis Score may be helpful to guide clinical decision making for the management of children presenting to emergency departments with CSF pleocytosis.

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.

The Quidel QuickVue influenza test was compared to viral culture and reverse transcriptase PCR by the use of three different respiratory specimen types. Of 122 pediatric subjects enrolled, 59 had influenza virus infections: 44 were infected with influenza A virus and 15 were infected with influenza B virus. The sensitivity of the QuickVue test was 85% with nasopharyngeal swabs, 78% with nasal swabs, and 69% with nasopharyngeal washes. Specificities were equivalent (97% to 98%) for all three collection methods.

Studies in adults, but not in children, have shown a beneficial effect of one dose of steroid on the severity and duration of throat pain in acute pharyngitis. The effectiveness of longer steroid treatment has not been evaluated in children.We performed a randomized, double-blind, 3-arm, placebo-controlled trial to estimate the effectiveness of one dose versus 3 daily doses of oral dexamethasone in the treatment of 4- to 21-year-old patients with group A beta-hemolytic streptococcal (GABHS) pharyngitis. Participants used the Wong-Baker FACES scale to rate their symptoms at enrollment and twice daily for 5 days. Patient-completed diaries and telephone interviews provided follow-up data. Primary end points-severity of throat pain, improvement in general condition and improvement in activity level-were evaluated by survival analysis.Ninety patients were enrolled. For each end point, we rejected the null hypothesis of a common survival experience for the 3 study arms. With the exception of 2 days for throat pain in participants receiving one dose of dexamethasone, the median time to improvement for all end points was 1 day for both arms of dexamethasone and 2 days for placebo. There was no difference between study arms in return to a clinical setting for symptoms related to GABHS pharyngitis or absenteeism from work/school. No patient experienced complications related to GABHS pharyngitis in the 30 days after enrollment.In this pilot study, children with GABHS pharyngitis who receive dexamethasone as add-on therapy have a more rapid improvement in general condition and level of activity and, for those receiving 3 daily doses of dexamethasone, in resolution of throat pain.

OBJECTIVE: The ability to forecast atypical emergency department (ED) volumes may aid staff/resource allocation. We determine whether deviations from short-term predictions of weather can be used to forecast deviations from short-term predictions of ED volumes. METHODS: In this retrospective study, we attempted to predict the volume of patient visits to an academic pediatric ED based on short-interval local weather patterns (2000). Local temperature and precipitation data in 1- and 3-hour increments were obtained. Precipitation was coded to be present if it exceeded 0.04 in and subclassified as cold rain/snow if the ambient temperature was lower than 40 degrees F. ED visits were categorized as injuries, emergent, or nonemergent visits. For each category of visit, Box-Jenkins Auto-Regressive Integrated Moving Average time-series models were created of natural trends and cycles in temperature and patient volumes. From these models, differences (residuals) between predicted and observed values of these variables were estimated. The correlation between residuals for temperature and ED volumes was derived for various kinds of ED visit, after controlling for type/volume of precipitation. RESULTS: Residuals for ambient temperature controlled for precipitation correlated poorly with residuals for patient volumes, accounting for 1% to 6% of the variability in the volume of injuries, emergent, and nonemergent visits (R2 = 1%, 1%, and 6%, respectively). CONCLUSIONS: Deviations from short-term predictions of temperature correlate poorly with deviations from predictions of patient volume after adjusting for natural trends and cycles in these variables and controlling for precipitation. These weather variables are of little practical benefit for predicting fluctuations in the rates of ED utilization.

Background The utility of published adjustments for leukocytes in blood-contaminated cerebrospinal fluid (CSF) is controversial. In this study, we assess how these adjustments and a novel rule for predicting percent of neutrophils match observations in CSF. We also determine the incremental value of corrected over uncorrected cells in CSF for discriminating between bacterial and viral meningitis. Methods We analyzed blood-contaminated CSF specimens collected from 1-month to 18-year-old children presenting to an urban academic pediatric emergency department between 1993 and 2003. Predictions of leukocytes (total) and neutrophils in CSF were derived from a standard rule and from an alternative rule based on a regression between neutrophils in peripheral blood and CSF. The match between observed and predicted cell counts was estimated by the coefficient of determination (R(2)). The value of corrected over uncorrected cells for diagnosing bacterial meningitis was evaluated by comparing the areas under respective receiver operator characteristic curves (AUC). Results At an R(2) of 0.11, predicted leukocytes matched observed leukocytes poorly for 682 CSF specimens that met study criteria. The percent of neutrophils in CSF predicted by the regression 7% + (0.5 x percent of neutrophils in peripheral blood) also fit observed neutrophils only modestly (R(2) 0.27). For diagnosing bacterial meningitis, there was no difference between AUC values for corrected and uncorrected leukocytes and percent of neutrophils. Conclusion In blood-contaminated CSF, there is poor to modest correlation between observed and predicted counts of leukocytes and of neutrophils. Adjusted blood counts in CSF have no advantage over uncorrected counts for predicting bacterial meningitis.

Background: Cefdinir, an extended-spectrum cephalosporin administered orally, is approved by the U.S. Federal Drug Administration for treatment of skin and respiratory tract infections. During the last two years at the authors' institution, this agent has been used as an off-label treatment for urinary tract infections in children. Objectives: To evaluate antimicrobial susceptibility testing data in children to determine whether there is support for this prescribing practice. Methods: In this retrospective study (2003–2004), the authors compared the susceptibility patterns of urinary pathogens to cefdinir and selected antibiotics in children who were evaluated for urinary tract infections in an urban tertiary academic pediatric emergency department. Pathogens (community acquired vs. opportunistic or nosocomial) were categorized as susceptible, indeterminate, or resistant on the basis of antibiotic susceptibility breakpoints. The frequency of these categorizations for individual drugs was determined. Results: Seven hundred five isolates were recovered from urine during the study period. Pathogens isolated most frequently were Escherichia coli, Klebsiella spp, and Proteus spp. Of 431 isolates retained in the data set, 412 (95.6%) were susceptible to cefdinir. This rate was comparable or superior to rates observed for other antibiotics: 49.4% for ampicillin, 84.9% for trimethoprim–sulfamethoxazole, 88.4% for cefazolin, 93.3% for nitrofurantoin, 94.2% for ticarcillin–clavulanate potassium, 97.5% for gentamicin, and 97.7% for ceftriaxone. Cefdinir, however, had lower activity (64.7%) against 17 bacterial isolates categorized as opportunistic or nosocomial pathogens. Conclusions: Cefdinir provides good coverage against common pathogens responsible for urinary tract infections in children and compares favorably with other oral and parenteral antibiotics that are used in the empiric treatment of this infection.

Objective. To compare the accuracy of biomarkers for identifying acute chest syndrome (ACS) in patients with sickle cell disease presenting to a pediatric emergency department (ED). Methods. We conducted a 13-month-long (2002–2003) cohort study with nested case-control in patients with sickle cell disease presenting to the pediatric ED with vaso-occlusive crises or fever in which we compared levels of secretory phospholipase A2 (sPLA2), endothelin-1, interleukin-6 (IL-6), and peripheral white blood cell count (WBC) in cases that were complicated by ACS and in control subjects with uncomplicated illnesses. For diagnosis, a test was considered to be accurate when the area under its receiver operator characteristic curve (AUC) was >0.70. Laboratory tests with AUC values ≥0.70 were entered into a binary recursive partitioning model for diagnosis. Results. For the period of study, samples from 72 visits were obtained from 51 patients who presented with vaso-occlusive crises (range: 1–4 visits per patient; 15 were enrolled more than once). ACS complicated 19 of 72 visits (26%, 95% confidence interval: 17%–38%). At an AUC value of 0.79, only the sPLA2 test was accurate for diagnosing ACS. AUC values for peripheral WBC, endothelin-1, and IL-6 were 0.68, 0.51, and 0.52, respectively. Binary recursive partitioning retained only sPLA2 at a cutoff of 13.7 ng/mL to be accurate for diagnosis. This cutoff had a sensitivity of 74% (14 of 19), a specificity of 87% (46 of 53), a positive likelihood ratio of 5.6, and a negative likelihood ratio of 0.18. Conclusions. Secretory phospholipase A2 but not endothelin-1, IL-6, or WBC is an accurate test for identifying present or incipient ACS in young patients who present to the ED with sickle cell pain crises.

UNLABELLED In relying on the peripheral blood white blood cell (WBC) count to identify infants at high risk for acute bacterial meningitis and bacteremia, to the best of the authors' knowledge, it has not been reported previously whether high and low values of the test have similar implications for predicting these separate infections. OBJECTIVE To analyze the relationship between the peripheral WBC count and the odds of acute bacterial meningitis relative to bacteremia among sick infants aged 3 to 89 days. METHODS Areas under the receiver operating characteristic curve (AUCs) and likelihood ratios at various intervals of the total peripheral blood WBC count were computed. RESULTS A pathogen was isolated from blood or cerebrospinal fluid (CSF) from 72 infants aged 3 to 89 days. Fifty-two infants had growth of a pathogen from the blood only, and 20 had growth from the CSF. The most common bacteria isolated were Escherichia coli (32) and group B streptococci (32). The AUC for the peripheral WBC count when differentiating between acute bacterial meningitis and bacteremia was 0.75 (95% CI = 0.63 to 0.88). The odds of acute bacterial meningitis relative to bacteremia were sevenfold higher for a peripheral WBC cutoff below 5,000 cells/mm(3) and threefold lower for a peripheral WBC cutoff at or above 15,000 cells/mm(3). CONCLUSIONS In young infants, the peripheral blood WBC count is useful for estimating the odds of acute bacterial meningitis relative to isolated bacteremia. A low peripheral blood WBC count should be considered a much more worrisome laboratory finding because it is associated with a relatively high risk for acute bacterial meningitis relative to the potential for bacteremia.

The purpose of this study was to determine whether blood counts discriminate between sickle cell pain episodes that lead to successful discharge from the emergency department (ED) and those that result in complications. This retrospective review compared the hemoglobin, reticulocyte count, and white blood cell count with differential during complicated and uncomplicated ED visits. Complicated visits were pain episodes followed by admission, by readmission within 48 hours, by acute chest syndrome, by an aplastic crisis, or by the administration of blood or antibiotics. There were 2 statistically important differences between complicated and uncomplicated pain episodes. Children successfully discharged were younger than those experiencing a complicated visit (8.9 v 11.2, P = 0.04). At a difference of 0.4 g/dL, the change in hemoglobin from baseline among children with complicated versus uncomplicated pain crises was not clinically useful. Routinely performed blood counts do not reliably identify the course of sickle cell pain crises.

Background: Although accurate models for predicting acute bacterial meningitis exist, most have narrow application because of the specific variables selected for them. In this study, we estimate the accuracy of a simple new model with potentially broader applicability. Methods: On the basis of previous reports, we created a reduced multivariable logistic regression model for predicting bacterial meningitis that relies on age (years) (AGE), cerebrospinal fluid (CSF), total protein (TP) and total neutrophil count (TNC) alone. Data were from children ages 1 month-18 years diagnosed with acute enteroviral or bacterial meningitis whose initial CSF revealed >7 white blood cells/mm 3 . A fractional polynomial model was specified and validated internally by the bootstrap procedure. The area under the receiver operating characteristic curve (discrimination: criterion standard, >0.7), the Hosmer-Lemeshow deciles-of-risk statistic (calibration: criterion standard, P > 0.05) and sensitivity-specificity pairs at prespecified probability thresholds of the model were computed. Results: We identified 60 children with bacterial meningitis and 82 with enteroviral meningitis. At an area under the receiver operating characteristic curve of 0.97, our model represented by the equation: log odds of bacterial meningitis = 0.343 - 0.003 TNC - 34.802 TP 0.5 + 21.991 TP - 0.345 AGE, was highly accurate when differentiating between bacterial and enteroviral meningitis. The model fit the data well (Hosmer-Lemeshow statistic; P =[r] 0.53). At probability cutoffs between 0.1 and 0.4, the model had sensitivity values between 98 and 92% and specificity values between 62 and 94%. Conclusions: Among children with CSF pleocytosis, a prediction model based exclusively on age, CSF total protein and CSF neutrophils differentiates accurately between acute bacterial and viral meningitis.

Study objective: We estimated the accuracy of the total peripheral WBC count as a screen for bacteremia in febrile young infants. Methods: We evaluated, retrospectively, the performance characteristics of linear and nonlinear (U-shaped) logistic models for predicting bacteremia that are based on the total peripheral WBC count. Research subjects were consecutive 0- to 89-day-old infants who had a temperature in triage of greater than or equal to 38°C (≥100.4°F) and were evaluated for infection at a pediatric emergency department (1993 to 1999). Infants with leukemia were excluded. Areas under the receiver operator characteristic curves (AUC), as well as sensitivity, specificity, interval likelihood ratios, and the corresponding odds of bacteremia predicted at various thresholds of the test, were calculated. Results: The rate of bacteremia was 1% (38/3,810). The U-shaped model was more accurate (AUC 0.69 versus 0.56); however, no threshold of the total peripheral WBC count had both good sensitivity and specificity. Sensitivity and specificity values were 79% and 5%, respectively, at a peripheral WBC count cutoff of 5,000 cells/mm 3 , and 45% and 78%, respectively, at a cutoff of 15,000 cells/mm 3 . The odds of bacteremia were not decreased substantially at any cutoff and were increased only modestly at values outside published norms of the test. Conclusion: The total peripheral WBC count is an inaccurate screen for bacteremia in febrile young infants; thus, decisions to obtain blood cultures should not rely on this test.

In young children, meningitis due to Streptococcus pneumoniae is preceded by a long interval from onset of fever to diagnosis of bacterial meningitis (hereafter known as "fever interval"), during which time the patient frequently contacts a clinician. By means of retrospective chart review, we compared the fever interval that preceded diagnosis with the complication rate among 288 young children (age, 3--36 months) who had bacterial meningitis (1984--1996), as stratified by causative organism and prior antibiotic treatment. Pathogens included S. pneumoniae, Haemophilus influenzae type b, and Neisseria meningitidis. Pneumococcus species were associated with the longest fever interval prior to diagnosis of meningitis, the highest frequency of contact with a clinician before hospitalization, and the highest rate of documented morbidity or mortality. For S. pneumoniae, there was an association between antibiotic treatment received at prior meetings with a clinician and a reduced rate of meningitis-related complications (odds ratio, 0.14; P=.02). Antibiotic treatment during such meetings is associated with a substantial reduction in disease-related sequelae.

Carbohydrate antigen detection, nucleic acid probe detection, and bacterial culture are commonly used to confirm group A streptococcus (GAS) pharyngitis. Compared to standard throat swab specimens, the sensitivities of these tests with mouth specimens are poor. When testing for GAS pharyngitis, the throat remains the optimum site for sampling.

BACKGROUND: Patients 3 to 36 months of age with bacteremia are at risk of developing acute bacterial meningitis(ABM). The opportunity to intervene is determined by the time from onset of fever to development of meningitis and the presence or absence of prior physician contact.