Development of a Consensus-Based Definition of Focused Assessment with Sonography for Trauma in Children

Importance: The wide variation in the accuracy and reliability of the Focused Assessment With Sonography for Trauma (FAST) and the extended FAST (E-FAST) for children after blunt abdominal trauma reflects user expertise. FAST and E-FAST that are performed by experts tend to be more complete, better quality, and more often clinically valuable. Objective: To develop definitions of a complete, high-quality, and accurate interpretation for the FAST and E-FAST in children with injury using an expert, consensus-based modified Delphi technique. Design, Setting, and Participants: This consensus-based qualitative study was conducted between May 1 to June 30, 2021. It used a scoping review and iterative Delphi technique and involved 2 rounds of online surveys and a live webinar to achieve consensus among a 26-member panel. This panel consisted of international experts in pediatric emergency point-of-care ultrasonography. Main Outcomes and Measures: Definitions of complete, high-quality, and accurate FAST and E-FAST studies for children after injury. Results: Of the 29 invited pediatric FAST experts, 26 (15 men [58%]) agreed to participate in the panel. All 26 panelists completed the 2 rounds of surveys, and 24 (92%) participated in the live and asynchronous online discussions. Consensus was reached on FAST and E-FAST study definitions, and the panelists rated these 5 anatomic views as important and appropriate for a complete FAST: right upper-quadrant abdominal view, left upper-quadrant abdominal view, suprapubic views (transverse and sagittal), and subxiphoid cardiac view. For E-FAST, the same FAST anatomic views with the addition of the lung or pneumothorax view were deemed appropriate and important. In addition, the panelists rated a total of 32 landmarks as important for assessing completeness. Similarly, the panelists rated 14 statements on quality and 20 statements on accurate interpretation as appropriate. Conclusions and Relevance: This qualitative study generated definitions for complete FAST and E-FAST studies with high image quality and accurate interpretation in children with injury. These definitions are similar to those in adults with injury and may be used for future education, quality assurance, and research. Future research may focus on interpretation of trace volumes of abdominal free fluid and the use of serial FAST

Association of SARS-CoV-2 nucleocapsid viral antigen and the receptor for advanced glycation end products with development of severe disease in patients presenting to the emergency department with COVID-19

IntroductionThere remains a need to better identify patients at highest risk for developing severe Coronavirus Disease 2019 (COVID-19) as additional waves of the pandemic continue to impact hospital systems. We sought to characterize the association of receptor for advanced glycation end products (RAGE), SARS-CoV-2 nucleocapsid viral antigen, and a panel of thromboinflammatory biomarkers with development of severe disease in patients presenting to the emergency department with symptomatic COVID-19.MethodsBlood samples were collected on arrival from 77 patients with symptomatic COVID-19, and plasma levels of thromboinflammatory biomarkers were measured.ResultsDifferences in biomarkers between those who did and did not develop severe disease or death 7 days after presentation were analyzed. After adjustment for multiple comparisons, RAGE, SARS-CoV-2 nucleocapsid viral antigen, interleukin (IL)-6, IL-10 and tumor necrosis factor receptor (TNFR)-1 were significantly elevated in the group who developed severe disease (all p<0.05). In a multivariable regression model, RAGE and SARS-CoV-2 nucleocapsid viral antigen remained significant risk factors for development of severe disease (both p<0.05), and each had sensitivity and specificity >80% on cut-point analysis.DiscussionElevated RAGE and SARS-CoV-2 nucleocapsid viral antigen on emergency department presentation are strongly associated with development of severe disease at 7 days. These findings are of clinical relevance for patient prognostication and triage as hospital systems continue to be overwhelmed. Further studies are warranted to determine the feasibility and utility of point-of care measurements of these biomarkers in the emergency department setting to improve patient prognostication and triage

Predictors for under-prescribing antibiotics in children with respiratory infections requiring antibiotics.

Background/objectivePrevious studies showed variability in the use of diagnostic and therapeutic resources for children with febrile acute respiratory tract infections (ARTI), including antibiotics. Unnecessary antibiotic use has important public and individual health outcomes, but missed antibiotic prescribing also has important consequences. We sought to determine factors associated with antibiotic prescribing in pediatric ARTI, specifically those with pneumonia.MethodsWe assessed national trends in the evaluation and treatment of ARTI for pediatric emergency department (ED) patients by analyzing the National Hospital Ambulatory Medical Care Survey from 2002 to 2013. We identified ED patients aged ≤18 with a reason for visit of ARTI, and created 4 diagnostic categories: pneumonia, ARTI where antibiotics are typically indicated, ARTI where antibiotics are typically not indicated, and "other" diagnoses. Our primary outcome was factors associated with the administration or prescription of antibiotics. A multivariate logistic regression model was fit to identify risk factors for underuse of antibiotics when they were indicated.ResultsWe analyzed 6461 visits, of which 10.2% of the population had a final diagnosis of pneumonia and 86% received antibiotics. 41.5% of patients were diagnosed with an ARTI requiring antibiotics, of which 53.8% received antibiotics. 26.6% were diagnosed with ARTI not requiring antibiotics, of which 36.0% received antibiotics. Black race was a predictor for the underuse of antibiotics in ARTIs that require antibiotics (OR: 0.72; 95% CI: 0.58-0.90).ConclusionsFor pediatric patients presenting to the ED with pneumonia and ARTI requiring antibiotics, we found that black race was an independent predictor of antibiotic underuse

Diagnostic Accuracy of Point-of-Care Ultrasound for Intussusception in Children Presenting to the Emergency Department: A Systematic Review and Meta-analysis

Introduction: Ileocolic intussusception is a common cause of pediatric bowel obstruction in youngchildren but can be difficult to diagnose clinically due to vague abdominal complaints. If left untreated,it may cause significant morbidity. Point-of-care ultrasound (POCUS) is a rapid, bedside method ofassessment that may potentially aid in the diagnosis of intussusception. The purpose of this systematicreview and meta-analysis was to determine the diagnostic accuracy of POCUS for children withsuspected ileocolic intussusception by emergency physicians (EP). Methods: We conducted a systematic search on PubMed, Embase, CINAHL, LILACS, the Cochranedatabases, Google Scholar, as well as conference abstracts, and assessed bibliographies of selectedarticles for all studies evaluating the accuracy of POCUS for the diagnosis of intussusception in children.We dual extracted data into a predefined worksheet and performed quality analysis with the QUADAS-2tool. Data were summarized and a meta-analysis was performed Results: Six studies (n = 1303 children) met our inclusion criteria. Overall, 11.9% of children hadintussusception. POCUS was 94.9% (95% confidence interval [CI], 89.9% to 97.5%) sensitive and 99.1%(95% CI, 94.7% to 99.8%) specific with a likelihood ratio (LR)+ of 105 (95% CI, 18 to 625) and a LR− of0.05 (95% CI, 0.03 to 0.10). Conclusions: POCUS by EPs is highly sensitive and specific for the identification of intussusception forchildren presenting to the emergency department

Diagnostic Accuracy of Point-of-Care Ultrasound for Intussusception in Children Presenting to the Emergency Department: A Systematic Review and Meta-analysis

Introduction: Ileocolic intussusception is a common cause of pediatric bowel obstruction in youngchildren but can be difficult to diagnose clinically due to vague abdominal complaints. If left untreated,it may cause significant morbidity. Point-of-care ultrasound (POCUS) is a rapid, bedside method ofassessment that may potentially aid in the diagnosis of intussusception. The purpose of this systematicreview and meta-analysis was to determine the diagnostic accuracy of POCUS for children withsuspected ileocolic intussusception by emergency physicians (EP). Methods: We conducted a systematic search on PubMed, Embase, CINAHL, LILACS, the Cochranedatabases, Google Scholar, as well as conference abstracts, and assessed bibliographies of selectedarticles for all studies evaluating the accuracy of POCUS for the diagnosis of intussusception in children.We dual extracted data into a predefined worksheet and performed quality analysis with the QUADAS-2tool. Data were summarized and a meta-analysis was performed Results: Six studies (n = 1303 children) met our inclusion criteria. Overall, 11.9% of children hadintussusception. POCUS was 94.9% (95% confidence interval [CI], 89.9% to 97.5%) sensitive and 99.1%(95% CI, 94.7% to 99.8%) specific with a likelihood ratio (LR)+ of 105 (95% CI, 18 to 625) and a LR− of0.05 (95% CI, 0.03 to 0.10). Conclusions: POCUS by EPs is highly sensitive and specific for the identification of intussusception forchildren presenting to the emergency department