The difference of Use of CT in the general versus pediatric emergency departments for adolescent patients in the same tertiary hospital

Objective The use of computed tomography (CT) in pediatric patients has decreased since the association between radiation and cancer risk has been reported. However, in adolescent patients being treated as adult patients, there has been a high incidence of CT use in emergency departments (EDs). Thus, this study aimed to evaluate the CT use in adolescent patients with complaints of headache or abdominal pain in the general and pediatric EDs of the same hospital. Methods A retrospective chart review of patients aged 15 to 18 years, who presented with headache or abdominal pain at the general and pediatric EDs of Seoul National University Hospital from January 2010 to December 2014, was conducted. Results A total of 407 adolescent patients with complaints of headache and 980 with abdominal pain were included in this study. The adolescent patients in the general ED were more likely to undergo CT scans than those in the pediatric ED, with both patients having headache (42.4% vs. 20.5%, respectively, P<0.001) and abdominal pain (29.0% vs. 18.4%, respectively, P<0.001). There was no statistical difference in the rates of positive CT findings between the general and pediatric EDs. The frequency of visits to the general ED was associated with high rates of CT use in adolescent patients with complaints of headache (odds ratio, 3.95; 95% confidence interval, 2.01 to 7.77) and those with abdominal pain (odds ratio, 1.76; 95% confidence interval, 1.18 to 2.64). Conclusion The ED setting influences the use of CT on adolescent patients, and a child-friendly environment could reduce the radiation risks

Long-term changes in computed tomography and ultrasound utilization in a pediatric emergency department

Objective Many studies have proposed reducing unnecessary use of computed tomography (CT), and ongoing studies in pediatric populations are aiming to decrease radiation dosages whenever possible. We aimed to evaluate the long-term changes in the utilization patterns of CT and ultrasound (US) in pediatric emergency departments (PEDs). Methods This retrospective study reviewed the electronic medical data of patients who underwent CT and/or US in the PED of a tertiary referral hospital from 2000 to 2014. We compared the changes in utilization patterns of brain and abdominal CT scans in pediatric patients and analyzed changes in abdominal US utilization in the PED. Results During the study period, 196,371 patients visited the PED. A total of 12,996 brain and abdominal CT scans and 12,424 abdominal US were performed in the PED. Comparison of CT use in pediatric patients before and after 2007 showed statistically decreasing trends after 2007, expressed as the coefficient values of the differences in groups. The numbers of brain and abdominal CT scans showed a significant decreasing trend in children, except for abdominal CT in adolescents. The abdominal US/CT ratio in the PED showed a statistically significant increase (2.68; 95% confidence interval, 1.87 to 3.49) except for the adolescent group (5.82; 95% confidence interval, -2.06 to 13.69). Conclusion Overall, CT use in pediatric patients has decreased since 2007. Pediatric US use has also shown a decreasing trend; however, the abdominal US/CT ratio in pediatric patients showed an increasing trend, except for adolescents

Early Detection of Cerebral Infarction With Middle Cerebral Artery Occlusion With Functional Near-Infrared Spectroscopy: A Pilot Study

Background: NIRSIT, a functional near-infrared spectroscopy (fNIRS) device with 204 channels, can measure oxyhemoglobin (HbO2) and deoxyhemoglobin (HbR) in non-pulsatile blood flow non-invasively using the absorption difference between HbO2 and HbR at a wavelength of 700–1,000 nm and can display the perfusion status in real time.Objective: We applied NIRSIT to patients with stroke to evaluate the usefulness of NIRSIT as an fNIRS device for the early detection of stroke.Methods: We performed a prospective pilot study in an emergency department (ED). Adult patients who had suspected symptoms and signs of stroke within 12 h of the first abnormal time and who underwent intravenous thrombolysis (IVT) or intra-arterial thrombectomy with acute middle cerebral artery (MCA) or internal carotid artery (ICA) infarction were enrolled. NIRSIT was applied to the patients before the imaging study, and the perfusion status of the brain was displayed in real time at the bedside. We compared the NIRSIT results with the mean transit time (MTT) map from perfusion computed tomography (PCT) and the time-to-peak (TTP) map from perfusion-weighted magnetic resonance imaging (PWI).Results: Six male and three female patients were enrolled, and the median age was 74 years. The most common symptom was unilateral extremity weakness (77.8%), followed by dysarthria (33.3%) and aphasia (11.1%). The median National Institutes of Health Stroke Scale (NIHSS) score was 17. All cases of MCA infarction showed different cerebral oxygen saturation values between bilateral lobes of the brain in fNIRS imaging, and these values matched the PCT and PWI results.Conclusions: The brain hemisphere with low oxygen saturation on fNIRS showed hypoperfusion on PCT or PWI. The fNIRS device could be useful in assessing the perfusion status of the brain and detecting MCA or ICA infarction in real time at the bedside

Quality improvement activity for improving pain management in acute extremity injuries in the emergency department

Objective The aim of this study was to investigate the effectiveness of a quality improvement activity for pain management in patients with extremity injury in the emergency department (ED). Methods This was a retrospective interventional study. The patient group consisted of those at least 19 years of age who visited the ED and were diagnosed with International Classification of Diseases codes S40–S99 (extremity injuries). The quality improvement activity consisted of three measures: a survey regarding activities, education, and the triage nurse’s pain assessment, including change of pain documentation on electronic medical records. The intervention was conducted from January to April in 2014 and outcome was compared between May and August in 2013 and 2014. The primary outcome was the rate of analgesic prescription, and the secondary outcome was the time to analgesic prescription. Results A total of 1,739 patients were included, and 20.3% of 867 patients in the pre-intervention period, and 28.8% of 872 patients in the post-intervention period received analgesics (P< 0.001). The prescription rate of analgesics for moderate-to-severe injuries was 36.4% in 2013 and 44.5% in 2014 (P=0.026). The time to analgesics prescription was 116.6 minutes (standard deviation 225.6) in 2013 and 64 minutes (standard deviation 75.5) in 2014 for all extremity injuries. The pain scoring increased from 1.4% to 51.6%. Conclusion ED-based quality improvement activities including education and change of pain score documentation can improve the rate of analgesic prescription and time to prescription for patients with extremity injury in the ED

Changes in Biomarkers and Hemodynamics According to Antibiotic Susceptibility in a Model of Bacteremia

Proper selection of susceptible antibiotics in drug-resistant bacteria is critical to treat bloodstream infection. Although biomarkers that guide antibiotic therapy have been extensively evaluated, little is known about host biomarkers targeting in vivo antibiotic susceptibility. Therefore, we aimed to evaluate the trends of hemodynamics and biomarkers in a porcine bacteremia model treated with insusceptible antibiotics compared to those in susceptible models. Extended-spectrum beta-lactamase (ESBL)-producing Escherichia colt (E coli, 5.0 * 10&lt;^&gt;9 CFU) was intravenously administered to 11 male pigs. One hour after bacterial infusion, pigs were assigned to two groups of antibiotics, ceftriaxone (n = 6) or ertapenem (n = 5). Pigs were monitored up to 7 h after bacterial injection with fluid and vasopressor support to maintain the mean arterial blood pressure over 65 mmHg. Blood sampling for blood culture and plasma acquisition was performed before and every predefined hour after E. coli injection. Cytokine (tumor necrosis factor-alpha, interleukin [IL]-1 beta, IL-6, IL-8, IL-10, C-reactive protein, procalcitonin, presepsin, heparan sulfate, syndecan, and soluble triggering receptor expressed on myeloid cells-1 [sTRE-M1]) levels in plasma were analyzed using enzyme-linked immunosorbent assays. Bacteremia developed after intravenous injection of E coil, and negative conversion was confirmed only in the ertapenem group. While trends of other biomarkers failed to show differences, the trend of sTREM-1 was significantly different between the two groups (P = 0.0001, two-way repeated measures analysis of variance). Among hemodynamics and biomarkers, the sTREM-1 level at post 2 h after antibiotics administration represented a significant difference depending on susceptibility, which can be suggested as a biomarker candidate of in vivo antibiotics susceptibility. Further clinical studies are warranted for validation. IMPORTANCE Early and appropriate antibiotic treatment is a keystone in treating patients with sepsis. Despite its importance, blood culture which requires a few days remains as a pillar of diagnostic method for microorganisms and their antibiotic susceptibility. Whether changes in biomarkers and hemodynamics indicate treatment response of susceptible antibiotic compared to resistant one is not well understood to date. In this study using extended-spectrum beta-lactamase -producing E. coli bacteremia porcine model, we have demonstrated the comprehensive cardiovascular hemodynamics and trends of plasma biomarkers in sepsis and compared them between two groups with susceptible and resistant antibiotics. While other hemodynamics and biomarkers have failed to differ, we have identified that levels of soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) significantly differed between the two groups over time. Based on the data in this study, trends of sTREM-1 obtained before the antibiotics and 2 similar to 4 h after the antibiotics could be a novel host biomarker that triggers the step-up choice of antibiotics

A guideline for differential diagnosis between septic arthritis and transient synovitis in the ED: A Delphi survey

Objective: Among the causes of limping gait in children, septic arthritis (SA) and transient synovitis (TS) are the 2 most likely etiologies. The aim of this study was to determine the medical histories, physical examinations, and other studies to use to create a clinical guideline for differential diagnosis between SA and TS in children in the emergency department (ED). The pediatric orthopedic emergency committee of our institution addressed the issue of developing a guideline for differential diagnosis. Methods: Two rounds of the modified Delphi survey were conducted, and a face-to-face committee meeting was held after each survey round. Delphi survey panelists included 10 pediatric orthopedic surgeons and 8 emergency physicians including 3 pediatric emergency physicians. Results: Response rates were 100% in each round. The panelists used a 6-point Likert scale to rate the clinical diagnostic guideline contents as having high (5 or 6), moderate (3 or 4), or low importance (1 or 2). Twenty-eight questionnaire items were included in the first round; and 18 items, in the second round. Factors for concern were selected, and a flowchart of the diagnostic guideline development process was based on the results of the survey. Conclusion: A diagnostic guideline for evaluating SA and TS in children in the ED was achieved using combined empirical evidence together with expert opinion, potentially resulting in a diagnostic strategy to be incorporated into existing guidelines or used on its own. (C) 2016 Elsevier Inc. All rights reserved.N

Artificial Intelligence-Enhanced Quantitative Ultrasound for Breast Cancer: Pilot Study on Quantitative Parameters and Biopsy Outcomes

Traditional B-mode ultrasound has difficulties distinguishing benign from malignant breast lesions. It appears that Quantitative Ultrasound (QUS) may offer advantages. We examined the QUS imaging system’s potential, utilizing parameters like Attenuation Coefficient (AC), Speed of Sound (SoS), Effective Scatterer Diameter (ESD), and Effective Scatterer Concentration (ESC) to enhance diagnostic accuracy. B-mode images and radiofrequency signals were gathered from breast lesions. These parameters were processed and analyzed by a QUS system trained on a simulated acoustic dataset and equipped with an encoder-decoder structure. Fifty-seven patients were enrolled over six months. Biopsies served as the diagnostic ground truth. AC, SoS, and ESD showed significant differences between benign and malignant lesions (p < 0.05), but ESC did not. A logistic regression model was developed, demonstrating an area under the receiver operating characteristic curve of 0.90 (95% CI: 0.78, 0.96) for distinguishing between benign and malignant lesions. In conclusion, the QUS system shows promise in enhancing diagnostic accuracy by leveraging AC, SoS, and ESD. Further studies are needed to validate these findings and optimize the system for clinical use