Faculty Bibliography

OBJECTIVE:New York City (NYC) is home to the largest public healthcare system in the United States and was an early epicenter of coronavirus disease 2019 (COVID-19) infections. This system serves as the safety net for underserved and marginalized communities disproportionately affected by the pandemic. Prior studies reported substantial declines in pediatric emergency department (ED) volume during the initial pandemic surge, but few describe the ongoing impact of COVID-19 throughout the year. We evaluated the characteristics of pediatric ED visits to NYC public hospitals during the pandemic lockdown and reopening periods of 2020 compared to the prior year. METHODS:Retrospective cross-sectional analysis of pediatric ED visits from 11 NYC public hospitals from January 2019-December 2020. Visit demographics, throughput times, and diagnosis information during the early (3/7/20-6/7/20) and late (6/8/20-12/31/20) pandemic periods coinciding with the New York State of emergency declaration (3/7/20) and the first reopening date (6/7/20) were compared to similar time periods in 2019. Findings were correlated with key pandemic shutdown and reopening events. RESULTS:There was a 47% decrease in ED volume in 2020 compared to 2019 (125,649 versus 238,024 visits). After reopening orders began in June 2020, volumes increased but peaked at <60% of 2019 volumes. Admission rates, triage acuity, and risk of presenting with a serious medical illness were significantly higher in 2020 versus 2019 (P < 0.001). Time-to-provider times decreased however provider-to-disposition times increased during the pandemic (P < 0.001). Infectious and asthma diagnoses declined >70% during the pandemic in contrast to the year prior. After reopening periods began, penetrating traumatic injuries significantly increased compared to 2019 [+34%, Relative Risk: 3.2 (2.6, 3.8)]. CONCLUSIONS:NYC public hospitals experienced a sharp decrease in pediatric volume but an increase in patient acuity during both the initial pandemic surge and through the reopening periods. As COVID-19 variants emerge, the threat of the current pandemic expanding remains. Understanding its influence on pediatric ED utilization can optimize resource allocation and ensure equitable care for future surge events.

BACKGROUND:Protocols for diagnosing urinary tract infection (UTI) often use arbitrary cutoff values of urinalysis components to guide management. Interval likelihood ratios (ILRs) of urinalysis results may improve the test's precision in predicting UTIs. We calculated the ILR of urinalysis components to estimate the posttest probabilities of UTIs in young children. METHODS:Review of 2144 visits to the pediatric emergency department of an urban academic hospital from December 2011 to December 2019. Inclusion criteria were age <2 years and having a urinalysis and urine culture sent. ILR boundaries for hemoglobin, protein, and leukocyte esterase were "negative," "trace," "1+," "2+" and "3+." Nitrite was positive or negative. Red blood cells and white blood cells (WBCs) were 0 to 5, 5 to 10, 10 to 20, 20 to 50, 50 to 100, and 100 to 250. Bacteria counts ranged from negative to "loaded." ILRs for each component were calculated and posttest probabilities for UTI were estimated. RESULTS:(75.2%). The ILR for leukocyte esterase ranged from 0.20 (negative) to 37.68 (3+) and WBCs ranged from 0.24 (0-5 WBCs) to 47.50 (100-250 WBCs). The ILRs for nitrites were 0.76 (negative) and 25.35 (positive). The ILR for negative bacteria on urinalysis was 0.26 and 14.04 for many bacteria. CONCLUSIONS:The probability of UTI in young children significantly increases with 3+ leukocyte esterase, positive nitrite results, 20 to 50 or higher WBCs, and/or many or greater bacteria on urinalysis. The probability of UTI only marginally increases with trace or 1+ leukocyte esterase or 5 to 20 WBCs. Our findings can be used to more accurately predict the probability of true UTI in children.

BACKGROUND:Febrile neonates undergo lumbar puncture (LP), empiric antibiotic administration, and admission for increased risk of invasive bacterial infection (IBI), defined as bacteremia and meningitis. OBJECTIVE:Measure IBI prevalence in febrile neonates, and operating characteristics of Rochester Criteria (RC), Yale Observation Scale (YOS) score, and demographics as a low-risk screening tool. METHODS:Secondary analysis of healthy febrile infants < 60 days old presenting to any of 26 emergency departments in the Pediatric Emergency Care Applied Research Network between December 2008 and May 2013. Of 7334 infants, 1524 met our inclusion criteria of age ≤ 28 days. All had fevers and underwent evaluation for IBI. Receiver operator characteristic (ROC) curve and transparent decision tree analysis were used to determine the applicability of reassuring RC, YOS, and age parameters as an IBI low-risk screening tool. RESULTS:Of 1524 neonates, 2.9% had bacteremia and 1.5% had meningitis. After applying RC and YOS, 15 neonates were incorrectly identified as low risk for IBI (10 bacteremia, 4 meningitis, 1 bacteremia, and meningitis). Age ≤ 18 days was a statistically significant variable ROC (area under curve 0.63, p < 0.05). Incorporating age > 18 days as low-risk criteria with reassuring RC and YOS misclassified 7 IBI patients (6 bacteremia, 1 meningitis). CONCLUSION/CONCLUSIONS:Thirty percent of febrile neonates met low-risk criteria, age > 18 days, reassuring RC and YOS, and could avoid LP and empiric antibiotics. Our low-risk guidelines may improve patient safety and reduce health care costs by decreasing lab testing for cerebrospinal fluid, empiric antibiotic administration, and prolonged hospitalization. These results are hypothesis-generating and should be verified with a randomized prospective study.

OBJECTIVES/OBJECTIVE:Patients with multisystem inflammatory disease in children (MIS-C) are at risk of developing shock. Our objectives were to determine independent predictors associated with development of delayed shock (≥3 hours from emergency department [ED] arrival) in patients with MIS-C and to derive a model predicting those at low risk for delayed shock. METHODS:We conducted a retrospective cross-sectional study of 22 pediatric EDs in the New York City tri-state area. We included patients meeting World Health Organization criteria for MIS-C and presented April 1 to June 30, 2020. Our main outcomes were to determine the association between clinical and laboratory factors to the development of delayed shock and to derive a laboratory-based prediction model based on identified independent predictors. RESULTS:Of 248 children with MIS-C, 87 (35%) had shock and 58 (66%) had delayed shock. A C-reactive protein (CRP) level greater than 20 mg/dL (adjusted odds ratio [aOR], 5.3; 95% confidence interval [CI], 2.4-12.1), lymphocyte percent less than 11% (aOR, 3.8; 95% CI, 1.7-8.6), and platelet count less than 220,000/uL (aOR, 4.2; 95% CI, 1.8-9.8) were independently associated with delayed shock. A prediction model including a CRP level less than 6 mg/dL, lymphocyte percent more than 20%, and platelet count more than 260,000/uL, categorized patients with MIS-C at low risk of developing delayed shock (sensitivity 93% [95% CI, 66-100], specificity 38% [95% CI, 22-55]). CONCLUSIONS:Serum CRP, lymphocyte percent, and platelet count differentiated children at higher and lower risk for developing delayed shock. Use of these data can stratify the risk of progression to shock in patients with MIS-C, providing situational awareness and helping guide their level of care.

BACKGROUND:Multisystem inflammatory syndrome in children (MIS-C) is a newly recognized condition affecting children with recent infection or exposure to coronavirus disease 2019 (COVID-19). MIS-C has symptoms that affect multiple organs systems, with some clinical features resembling Kawasaki disease (KD) and toxic shock syndrome (TSS). OBJECTIVE OF THE REVIEW/UNASSIGNED:Our goal was to review the current literature and describe the evaluation and treatment algorithms for children suspected of having MIS-C who present to the emergency department. DISCUSSION/CONCLUSIONS:MIS-C has a wide clinical spectrum and diagnosis is based on a combination of both clinical and laboratory findings. The exact mechanism of immune dysregulation of MIS-C is not well understood. Physical findings may evolve and do not necessarily appear at the same time. Gastrointestinal, cardiac, inflammatory, and coagulopathy manifestations and dysfunction are seen frequently in MIS-C. CONCLUSIONS:The diagnosis of MIS-C is based on clinical presentation and specific laboratory findings. In the emergency setting, a high level of suspicion for MIS-C is required in patients exposed to COVID-19. Early diagnosis and prompt initiation of therapy offer the best chance for optimal outcomes.

CONTEXT/BACKGROUND:Febrile neutropenic immunocompromised children are at a high risk of Serious Bacterial Infections (SBI). OBJECTIVE:This systematic review and meta-analysis report the prevalence of SBI in healthy children with febrile neutropenia. DATA SOURCE/METHODS:PubMed, EMBASE, and Web of Science from their inception to August 2020. STUDY SELECTION/METHODS:up to 18 years of age presenting to the ED with a chief complaint of fever (temperature > 38°C) and who had a workup for SBI as defined by each study. DATA ABSTRACTION/METHODS:Data from individual studies was abstracted by a subset of the authors and checked independently by the senior author. Any discrepancies were adjudicated by the joint agreement of all the authors. We calculated the prevalence of SBI by using the number of SBI's as the numerator and the total number of febrile events in patients as the denominator. Bias in our studies was quantified by the Newcastle Ottawa Scale. RESULTS:We identified 2066 citations of which five studies (1693 patients) our inclusion criteria. None of our reviewed studies consistently tested every included patient for SBI. Spectrum bias in every study resulted in a wide range of the SBI prevalence of 1.9% (<0.01% - 11%) similar to non-neutropenic children. LIMITATIONS/CONCLUSIONS:All of our studies were retrospective and many did not consistently screen all subjects for SBI. CONCLUSION/CONCLUSIONS:If the clinical suspicion is low, the risk for SBI is similar between febrile healthy neutropenic and non-neutropenic children.

OBJECTIVE:To evaluate the utility of the Point of Care Ultrasound (POCUS) Focused Assessment with Sonography for Trauma (FAST) examination for diagnosis of intra-abdominal injury (IAI) in children presenting with blunt abdominal trauma. METHODS:We searched medical literature from January 1966 to March 2018 in PubMed, EMBASE, and Web of Science. Prospective studies of POCUS FAST examinations in diagnosing IAI in pediatric trauma were included. Sensitivity, specificity, and likelihood ratios (LR) were calculated using a random-effects model (95% confidence interval). Study quality and bias risk were assessed, and test-treatment threshold estimates were performed. RESULTS:Eight prospective studies were included encompassing 2135 patients with a weighted prevalence of IAI of 13.5%. Studies had variable quality, with most at risk for partial and differential verification bias. The results from POCUS FAST examinations for IAI showed a pooled sensitivity of 35%, specificity of 96%, LR+ of 10.84, and LR- of 0.64. A positive POCUS FAST posttest probability for IAI (63%) exceeds the upper limit (57%) of our test-treatment threshold model for computed tomography of the abdomen with contrast. A negative POCUS FAST posttest probability for IAI (9%) does not cross the lower limit (0.23%) of our test-treatment threshold model. CONCLUSIONS:In a hemodynamically stable child presenting with blunt abdominal trauma, a positive POCUS FAST examination result means that IAI is likely, but a negative examination result alone cannot preclude further diagnostic workup for IAI. The need for computed tomography scan may be obviated in a subset of low-risk pediatric blunt abdominal trauma patients presenting with a Glasgow Coma Scale of 14 to 15, a normal abdominal examination result, and a negative POCUS FAST result.