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Introduction The objective is to determine how outcomes from unintentional falls differ for children with and without developmental disabilities, with a sensitivity analysis specifically examining those with ADHD. Materials and Methods This is a retrospective observational cohort study of 2010-2015 data from the Nationwide Emergency Department Sample (NEDS). The NEDS is a sampling of ED visits across 953 hospitals in 36 states. Unintentional falls for children with and without developmental disabilities were compared, adjusting for age, sex, payment source, income, mechanism, injury severity score (ISS). A sensitivity analysis was then performed for children with ADHD (n=139,642) and those without any developmental disabilities. A priori chosen outcomes included hospital admission, length of stay, intubation, and surgery. Logistic regression analysis estimated adjusted odds ratios for outcomes. Results Among children who presented to the ED with unintentional falls (n=13,217,237), there were 223,445 (1.7%) with developmental disabilities. The majority of those with developmental disabilities were male, ages 10-14 years. Compared to children without developmental disabilities, those with developmental disabilities were more likely to have an inpatient admission (aOR=2.27, 95% CI=2.10-2.44), length of stay more than 2 days (aOR=1.73, 95% CI=1.51-1.98), intubation (aOR=4.77, 95% CI=3.62-6.27) and surgery (aOR=2.11, 95% CI=1.93-2.32). A sensitivity analysis showed that 139,642 (1%) of children ages 5-17 years had ADHD. Of those with ADHD, the majority was also male, ages 10-14 years. Compared to children without ADHD, those with ADHD had a higher odds of inpatient admission (aOR=1.74, 95% CI=1.58-1.91), length of stay greater than 2 days (aOR=1.59, 95% CI=1.37-1.85), intubation (aOR=3.96, 95% CI=2.73-5.73), and surgery (aOR=1.82, 95% CI=1.60-2.06). Conclusions Children with developmental disabilities, in particular those with ADHD, who experience falls are often older and male. They had greater odds of poor outcomes. These children need additional anticipatory guidance and attention to adequate treatment to prevent injuries from unintentional falls.

Background In the past decade, the U.S. immigration detention system regularly detained more than 30,000 people per day; in 2019 prior to the pandemic, the daily detention population exceeded 52,000 people. Inhumane detention conditions have been documented by internal government watchdogs, and news media and human rights groups who have observed over-crowding, poor hygiene and sanitation and poor and delayed medical care, as well as verbal, physical and sexual abuse. Methods This study surveyed health professionals across the United States who had provided care for immigrants who were recently released from immigration detention to assess clinician perceptions about the adverse health impact of immigration detention on migrant populations based on real-life clinical encounters. There were 150 survey responses, of which 85 clinicians observed medical conditions attributed to detention. Results These 85 clinicians reported seeing a combined estimate of 1300 patients with a medical issue related to their time in detention, including patients with delayed access to medical care or medicine in detention, patients with new or acute health conditions such as infection and injury attributed to detention, and patients with worsened chronic or special needs conditions. Clinicians also provided details regarding sentinel cases, categorized into the following themes: Pregnant women, Children, Mentally Ill, COVID-19, and Other serious health issue. Conclusions This is the first survey, to our knowledge, of health care professionals treating individuals upon release from detention. Due to the lack of transparency by federal entities and limited access to detainees, this survey serves as a source of credible information about conditions experienced within immigration detention facilities and is a means of corroborating immigrant testimonials and media reports. These findings can help inform policy discussions regarding systematic changes to the delivery of healthcare in detention, quality assurance and transparent reporting.

Objective Mental health emergencies among young people are increasing. There is growing pressure for emergency departments to screen patients for mental health needs even when it is not their chief complaint. We hypothesized that young people with an initial non‐specific condition and emergency department (ED) revisits have increased mental health needs. Methods Retrospective, observational study of the California Office of Statewide Health Planning and Development Emergency Department Discharge Dataset (2010–2014) of young people (11–24 years) with an index visit for International Classification of Diseases, Ninth Revision diagnostic codes of “Symptoms, signs, and ill‐defined conditions” (Non‐Specific); “Diseases of the respiratory system” (Respiratory) and “Unintentional injury” (Trauma) who were discharged from a California ED. Patients were excluded if they had a prior mental health visit, chronic disease, or were pregnant. ED visit frequency was counted over 12 months. Regression models were created to analyze characteristics associated with a mental health visit. Results Patients in the Non‐Specific category compared to the Respiratory category had 1.2 times the odds of a future mental health visit (OR 1.20; 95% CI 1.17–1.24). Patients with ≥1 ED revisit, regardless of diagnostic category, had 1.3 times the odds of a future mental health visit. Patients with both a Non‐Specific index visit and 1, 2, and 3 or more revisits with non‐specific diagnoses had increasing odds of a mental health visit (OR 1.38; 95% CI 1.29–1.47; OR 1.70; 95% CI 1.46–1.98; OR 2.20; 95% CI 1.70–2.87, respectively.) Conclusions Young people who go to the ED for non‐specific conditions and revisits may benefit from targeted ED mental health screening.

Background Trauma is a major cause of death and disability in the United States, and significant disparities exist in access to care, especially in non-urban settings. From 2007 to 2017 New Mexico expanded its trauma system by focusing on building capacity at the hospital level. Methods We conducted a geospatial analysis at the census block level of access to a trauma center in New Mexico within 1 h by ground or air transportation for the years 2007 and 2017. We then examined the characteristics of the population with access to care. A multiple logistic regression model assessed for remaining disparities in access to trauma centers in 2017. Results The proportion of the population in New Mexico with access to a trauma center within 1 h increased from 73.8% in 2007 to 94.8% in 2017. The largest increases in access to trauma care within 1 h were found among American Indian/Alaska Native populations (AI/AN) (35.2%) and people living in suburban areas (62.9%). In 2017, the most rural communities (aOR 58.0), communities on an AI/AN reservation (aOR 25.6), communities with a high proportion of Hispanic/Latino persons (aOR 8.4), and a high proportion of elderly persons (aOR 3.2) were more likely to lack access to a trauma center within 1 h. Conclusion The New Mexico trauma system expansion significantly increased access to trauma care within 1 h for most of New Mexico, but some notable disparities remain. Barriers persist for very rural parts of the state and for its sizable American Indian community.

Social emergency medicine, the expansion of the structure and practice of emergency care to incorporate the social context of patients and their communities, has a rich and varied history, despite its youth as a unified, named concept. This chapter presents a brief introduction to the three strands of history that have created the fabric of social emergency medicine: the evolution of the social medicine movement; the birth and growth of the specialty of emergency medicine; and the development of the field of social epidemiology.

To evaluate variation in care nationwide for children with splenic injuries at pediatric trauma, adult trauma, and nontrauma centers. We used the National Inpatient Sample from 2001 to 2010 to identify pediatric patients with splenic injury. We analyzed demographic, clinical, and hospital status characteristics. The primary objective was comparison of splenectomy rates at pediatric, adult, and nontrauma centers. We identified 34,599 patients with splenic injury. Throughout the study, 3,979 (11.5%) patients underwent splenectomy: 8.2 per cent of patients at pediatric trauma, 17.6 per cent at adult trauma, and 14.5 per cent at nontrauma centers. Multivariate regression analysis demonstrated patients had decreased odds of splenectomy at pediatric trauma centers compared with adult and nontrauma centers (OR = 0.42, P < 0.001). In addition, children aged 14 to 17 years (OR = 2.5) with injury severity score > 14 (OR = 5.8) had increased odds of undergoing splenectomy. In this nationwide sample, children with splenic injury treated at adult trauma and nontrauma centers had significantly higher rates of splenectomy compared with children treated at pediatric trauma centers. We highlight the need for interventions that ensure all injured children receive appropriate and high quality trauma care.

Background While ultrasound (US), given its lack of ionizing radiation, is currently the recommended initial imaging study of choice for the diagnosis of appendicitis in pediatric and young adult patients, it does have significant shortcomings. US is time-intensive and operator dependent and results in frequent inconclusive studies, thus necessitating further imaging and admission for observation or repeat clinical visits. A rapid focused magnetic resonance imaging (MRI) for appendicitis has been shown to have definitive sensitivity and specificity, similar to computed tomography but without radiation and offers a potential alternative to US. Objective In this single-center prospective cohort study, we sought to determine the difference in total length of stay and charges between rapid MRI and US as the initial imaging modality in pediatric and young adult patients presenting to the emergency department (ED) with suspected appendicitis. We hypothesized that rapid MRI would be more efficient and cost-effective than US as the initial imaging modality in the ED diagnosis of appendicitis. Methods A prospective randomized cohort study of consecutive patients was conducted in patients 2 to 30 years of age in an academic ED with access to both rapid MRI and US imaging modalities 24/7. Prior to the start of the study, the days of the week were randomized to either rapid MRI or US as the initial imaging modality. Physicians evaluated patients with suspected appendicitis per their usual manner. If the physician decided to obtain radiologic imaging, the predetermined imaging modality for the day of the week was used. All decisions regarding other diagnostic testing and/or further imaging were left to the physician's discretion. Time intervals (minutes) between triage, order placement, start of imaging, end of imaging, image result, and disposition (discharge vs. admission), as well as total charges (diagnostic testing, imaging, and repeat ED visits) were recorded. Results Over a 100-day period, 82 patients were imaged to evaluate for appendicitis; 45 of 82 (55%) of patients were in the US-first group, and 37 of 82 (45%) patients were in the rapid MRI–first group. There were no differences in patient demographics or clinical characteristics between the groups and no cases of missed appendicitis in either group. Eleven of 45 (24%) of US-first patients had inconclusive studies, resulting in follow-up rapid MRI and five return ED visits contrasted with no inconclusive studies or return visits (p

To evaluate variation in care nationwide for children with splenic injuries at pediatric trauma, adult trauma, and nontrauma centers. We used the National Inpatient Sample from 2001 to 2010 to identify pediatric patients with splenic injury. We analyzed demographic, clinical, and hospital status characteristics. The primary objective was comparison of splenectomy rates at pediatric, adult, and nontrauma centers. We identified 34,599 patients with splenic injury. Throughout the study, 3,979 (11.5%) patients underwent splenectomy: 8.2 per cent of patients at pediatric trauma, 17.6 per cent at adult trauma, and 14.5 per cent at nontrauma centers. Multivariate regression analysis demonstrated patients had decreased odds of splenectomy at pediatric trauma centers compared with adult and nontrauma centers (OR = 0.42, P0.001). In addition, children aged 14 to 17 years (OR = 2.5) with injury severity score14 (OR = 5.8) had increased odds of undergoing splenectomy. In this nationwide sample, children with splenic injury treated at adult trauma and nontrauma centers had significantly higher rates of splenectomy compared with children treated at pediatric trauma centers. We highlight the need for interventions that ensure all injured children receive appropriate and high quality trauma care.

Innovations in topical burn treatment along with a drive toward value-based care are steering burn care to the outpatient setting. Little is known regarding what characteristics predict outpatient treatment of pediatric minor burns and whether there is a temporal trend toward this treatment paradigm.A retrospective cohort study was performed using California's Office of Statewide Health Planning and Development linked emergency department and inpatient database (2005-2013). All patients under 18years of age with a primary burn diagnosis were extracted. Using patient and facility level variables, we used regression modeling to evaluate predictors of outpatient burn treatment and temporal trends.There were 16,480 pediatric minor burn encounters during the period. 56.4% were male, 85.3% had10% total body surface area (TBSA), 76.3% were scald or contact, and 77.3% were at deepest depth 2nd degree. Multiple variables predicted an increased likelihood of discharge home including older age(p0.001), smaller TBSA(p0.001), and superficial/partial thickness burns( 0.001). Children of Hispanic and Black race were less likely to be discharged home compared to White and Asian peers(p=0.001). On Poisson modeling, the incidence rate ratio over the 9-year period for home discharge was 1.004 (95% CI 1.001-1.008, p=0.032).Older patients and those with more superficial burns were more likely to be treated as outpatients. Black and non-white Hispanic race was associated with inpatient admission. There is a growing trend toward ambulatory treatment of minor burns in the pediatric population. Further research is needed to assess whether outpatient treatment of pediatric minor burns results in greater readmissions.

OBJECTIVES Although 40% of emergency departments (EDs) report having an insurance linkage program, no studies have evaluated the long-term success of these programs. This study aimed to examine insurance retention and utilization by children initially referred to insurance by our ED insurance linkage program. METHODS We retrospectively examined insurance records of all uninsured children successfully enrolled in public insurance by the insurance linkage program established in our suburban academic ED between 2004 and 2009. Emergency department-enrolled children were matched by age, sex, program, and year of enrollment to a control group of children from the same county who were enrolled in non-ED settings. Wilcoxon signed rank and χ tests were used to compare enrollment and claims variables. RESULTS Emergency department-enrolled children retained insurance for longer, had a higher reenrollment rate, and were higher users of insurance. The average length of enrollment for ED children was 734 days versus 597 days in the control group. Eighty percent of the ED cohort reenrolled in insurance after initial eligibility expiration versus 64% of the control group. Children enrolled via the ED averaged 26 claims (vs 12 claims) and $20,087 (vs $5216) in hospital charges per year of enrollment. This higher utilization was reflected in increased primary care, specialty care, ED visits, inpatient, and mental health claims in the ED group. CONCLUSIONS Emergency department-based insurance enrollment programs have the potential to improve access to health care for children. Policies aimed at expanding insurance enrollment among the uninsured population, including the Affordable Care Act, may consider the ED's potential as an effective enrollment site.

BACKGROUND A multicenter study in the late 1990s demonstrated suboptimal emergency asthma care for pregnant women in US EDs. After a decade, follow-up data are lacking. We aimed to examine changes in emergency asthma care of pregnant women since the 1990s. METHODS We combined data from four multicenter observational studies of ED patients with acute asthma performed in 1996 to 2001 (three studies) and 2011 to 2012 (one study). We restricted the data so that comparisons were based on the same 48 EDs in both time periods. We identified all pregnant patients aged 18 to 44 years with acute asthma. Primary outcomes were treatment with systemic corticosteroids in the ED and, among those sent home, at ED discharge. RESULTS Of 4, 895 ED patients with acute asthma, the analytic cohort comprised 125 pregnant women. Between the two time periods, there were no significant changes in patient demographics, chronic asthma severity, or initial peak expiratory flow. In contrast, ED systemic corticosteroid treatment increased significantly from 51% to 78% across the time periods (OR, 3.11; 95% CI, 1.27-7.60; P = .01); systemic corticosteroids at discharge increased from 42% to 63% (OR, 2.49; 95% CI, 0.97-6.37; P = .054). In the adjusted analyses, pregnant women in recent years were more likely to receive systemic corticosteroids, both in the ED (OR, 4.76; 95% CI, 1.63-13.9; P = .004) and at discharge (OR, 3.18; 95% CI, 1.05-9.61; P = .04). CONCLUSIONS Between the two time periods, emergency asthma care in pregnant women significantly improved. However, with one in three pregnant women being discharged home without systemic corticosteroids, further improvement is warranted.

OBJECTIVES: To determine if injured children presenting to nondesignated trauma centers are more or less likely to be transferred relative to being admitted based on insurance status. METHODS: We conducted a cross-sectional study by using the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample. Pediatric trauma patients receiving care in emergency departments (EDs) at nontrauma centers who were either admitted locally or transferred to another hospital were included. We performed logistic regression analysis adjusting for injury severity and other confounders and incorporated nationally representative weights to determine the association between insurance and transfer or admission. RESULTS: Nine thousand four hundred and sixty-one ED pediatric trauma events at 386 nontrauma centers met inclusion criteria. EDs that treated a higher proportion of patients with Medicaid had higher odds of transfer relative to admission (odds ratio [OR]: 1.2 per 10% increase in Medicaid; 95% confidence interval [CI]: 1.1–1.4), resulting in overall higher odds of transfer among patients with Medicaid compared with patients with private insurance (OR: 1.3; 95% CI: 1.0–1.5). A patient’s insurance status was not associated with different odds of transfer relative to admission within individual EDs after adjusting for the ED’s proportion of patients with Medicaid (Medicaid OR: 1.0; 95% CI: 0.8–1.1). CONCLUSIONS: Injured pediatric patients presenting to nondesignated trauma centers are slightly more likely to be transferred than admitted when the ED treats a higher proportion of Medicaid patients. In this study, ongoing concerns about inequities in the delivery of care among hospitals treating high proportions of children with Medicaid are reinforced.

The review article “Pediatric Firearm-Related Injuries in the United States” in this issue of Hospital Pediatrics serves as a timely reminder for all health care providers that we cannot afford to be silent about gun violence. An average of 7 children and teens ages 1 to 19 are killed by guns every day in the United States.1 Pediatric hospitalists are on the front lines of this public health crisis. To uphold our duty as pediatricians to protect and improve the health of children, we must educate ourselves about gun violence and become vocal advocates for sensible, effective solutions. Although firearm safety has been highly politicized, we as physicians know that this is first and foremost a public health issue. Many analogies can be drawn from history. When motor vehicle collisions became a leading cause of mortality, auto manufacturers blamed collisions on the drivers. When evidence emerged regarding the health threat of tobacco, tobacco companies denied the association of cigarette smoke with disease. After hard-fought battles with these industries, regulations were put in place that dramatically decreased morbidity and mortality from these public health threats.2 It is clearly time to do the same for firearms. As with automobile and tobacco regulations, our advocacy must be a pragmatic one. Pediatricians must understand patient and family values and concerns regarding gun ownership. Pediatricians must be able to communicate the risks of firearm ownership to families and children, address controversies and myths, and understand which interventions have been demonstrated by existing data to be most effective in decreasing injury and death. We must understand federal law and the laws in states where we practice. In this commentary, we present a guideline for pragmatic firearm advocacy for pediatricians: key firearm facts that all pediatricians should know, common myths about firearms, interventions that have …

ObjectivePatients receiving interfacility transfer to a higher level of medical care for ruptured abdominal aortic aneurysms (rAAAs) are an important minority that are not well characterized and are typically omitted from outcomes and quality indicator studies. Our objective was to compare patients transferred for treatment of rAAAs with those treated without transfer, with particular emphasis on mortality and resource utilization.MethodsWe linked longitudinal data from 2005 to 2010 Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases and Emergency Department Databases from California, Florida, and New York. Patients were identified using International Classification of Diseases-Ninth Revision-Clinical Modification codes. Our main outcome variables were mortality, length of stay, and cost. Data included discharge information on the transfer-out and transfer-in hospital. We used univariate and multivariate analysis to identify variables independently associated with transfer and in-hospital mortality.ResultsOf 4439 rAAA patients identified with intent to treat, 847 (19.1%) were transferred before receiving operative repair. Of those transferred, 141 (17%) died without undergoing AAA repair. By multivariate analysis, increasing age in years (odds ratio [OR] 0.98; 95% confidence interval [CI], 0.97-0.99; P < .001), private insurance vs Medicare (OR, 0.62; 95% CI, 0.47-0.80; P < .001), and increasing comorbidities as measured by the Elixhauser Comorbidity Index (OR, 0.90; 95% CI, 0.86-0.95; P < .001) were negatively associated with transfer. Weekend presentation (OR, 1.23; 95% CI, 1.02-1.47; P = .03) was positively associated with transfer. Transfer was associated with a lower operative mortality (adjusted OR, 0.81; 95% CI, 0.68-0.97; P < .02) but an increased overall mortality when including transferred patients who died without surgery (OR, 1.30; 95% CI, 1.05-1.60; P = .01). Among the transferred patients, there was no significant difference in travel distance between those who survived and those who died (median, 28.7 vs 25.8 miles; P = .07). Length of stay (median, 10 vs 9 days; P = .008), and hospital costs ($161,000 vs $146,000; P = .02) were higher for those transferred.ConclusionsThe survival advantage for patients transferred who received treatment was eclipsed by increased mortality of the transfer process. Including 17% of transferred patients who died without receiving definitive repair, mortality was increased for patients transferred for rAAA repair compared with those not transferred after adjusting for demographic, clinical, and hospital factors. Transferred patients used significantly more hospital resources. Improving systems and guidelines for interfacility transfer may further improve the outcomes for these patients and decrease associated hospital resource utilization.

Tetanus is a life-threatening disease that continues to have a high prevalence in developing countries. Severe muscle spasms often require patients to receive tracheostomy, high-dose sedatives, and sometimes prolonged neuromuscular blockade. Magnesium sulfate (MgSO4) infusion has great promise as an adjunct treatment for severe tetanus, as it may allow clinicians to decrease the dose of other sedative medications. Although the mechanism of action of MgSO4 is not well understood, it appears to attenuate both the muscle spasms and autonomic instability associated with severe tetanus infections. However, MgSO4 infusions are often managed based on serial measurements of serum magnesium levels and other laboratory tests such as arterial blood gases, which can be difficult to obtain in resource-poor settings. We describe a case of severe tetanus in Bhutan managed through the use of magnesium infusion titrated solely to physical examination findings.

Background Although follow-up CT is recommended for pediatric appendicitis if initial ultrasound (US) is equivocal, many physicians observe the patient at home. There are limited data to understand currently how common or safe this practice is. Our objectives are to assess prevalence of acute appendicitis and outcomes in patients with equivocal US with and without follow-up CT and to identify variables associated with ordering a follow-up CT. Methods Retrospective analysis of the prevalence of appendicitis and outcomes of patients 1–18 years old with an equivocal US at a pediatric emergency department from 2003 to 2008. Recursive partitioning analysis and multivariate logistic regression were used to identify variables associated with ordering follow-up CT. Results Fifty-five percent (340/620) of children with equivocal US did not receive CT, none of whom returned with a missed appendicitis. The prevalence of appendicitis in children with equivocal US was 12.5% (78/620). In children with follow-up CT, the prevalence was 22.1% (62/280); in those without follow-up CT, the prevalence was 4.7% (16/340). Recursive partitioning identified age >11 years, leukocytosis >15,000 cells/ml, and secondary signs predisposing toward acute appendicitis on US as significant predictors of CT. Conclusions We view our study as a fundamental part of the incremental progress to understand how best to use US and CT imaging to diagnose pediatric appendicitis while minimizing ionizing radiation. Children at low risk for appendicitis with equivocal US are amenable to observation and reassessment prior to reimaging with US or CT. © 2014 Wiley Periodicals, Inc. J Clin Ultrasound 42:385–394, 2014

BACKGROUND: This study aimed to characterize initial clinical presentations of patients served by emergency medical services (EMS) who die following injury, with particular attention to patients with occult ("talk-and-die") presentations. METHODS: This was a population-based, multiregion, mixed-methods retrospective cohort study of fatally injured children and adults evaluated by 94 EMS agencies transporting to 122 hospitals in seven Western US regions from 2006 to 2008. Fatalities were divided into two main groups: occult injuries (talk-and-die; Glasgow Coma Scale [GCS] score ≥ 13, no cardiopulmonary arrest, and no intubation) versus overt injuries (all other patients). These groups were further subdivided by timing of death: early (48 hours). We then compared demographic, physiologic, procedural, and injury patterns using descriptive statistics. We also used qualitative methods to analyze available EMS chart narratives for contextual information from the out-of-hospital encounter. RESULTS: During the 3-year study period, 3,358 persons served by 9-1-1 EMS providers died, with 1,225 (37.1%) in the field, 1,016 (30.8%) early in the hospital, and 1,060 (32.1%) late in the hospital. Of the 2,133 patients transported to a hospital, there were 612 (28.7%) talk-and-die patients, of whom 114 (18.6%) died early. Talk-and-die patients were older (median age, 81 years; interquartile range, 67-87 years), normotensive (median systolic blood pressure, 138 mm Hg; interquartile range, 116-160 mm Hg), commonly injured by falls (71.3%), and frequently (52.4%) died in nontrauma hospitals. Compared with overtly injured patients, talk-and-die patients had relatively fewer serious head injuries (13.7%) but more frequent extremity injuries (20.3% vs. 10.6%) and orthopedic interventions (25.3% vs. 5.0%). EMS personnel often found talk-and-die patients lying on the ground with hip pain or extremity injuries. CONCLUSION: Patients served by EMS who "talk-and-die" are typically older adults with falls, transported to nontrauma hospitals, with subtle clinical indications of the severity of their injuries. Improving recognition of talk-and-die patients may avoid fatal outcomes in a portion of these patients. LEVEL OF EVIDENCE: Epidemiologic study, level III. Language: en

BACKGROUND With increasing budget cuts to education and social services, rigorous evaluation needs to document school nurses' impact on student health, academic outcomes, and district funding. METHODS Utilizing a quasi-experimental design, we evaluated outcomes in 4 schools with added full-time nurses and 5 matched schools with part-time nurses in the San Jose Unified School District. Student data and logistic regression models were used to examine predictors of illness-related absenteeism for 2006-2007 and 2008-2009. We calculated average daily attendance (ADA) funding and parent wages associated with an improvement in illness-related absenteeism. Utilizing parent surveys, we also estimated the cost of services for asthma-related visits to the emergency room (ER; N = 2489). RESULTS Children with asthma were more likely to be absent due to illness; however, mean absenteeism due to illness decreased when full-time nurses were added to demonstration schools but increased in comparison schools during 2008-2009, resulting in a potential savings of $48,518.62 in ADA funding (N = 6081). Parents in demonstration schools reported fewer ER visits, and the estimated savings in ER services and parent wages were significant. CONCLUSION Full-time school nurses play an important role in improving asthma management among students in underserved schools, which can impact school absenteeism and attendance-related economic costs.

BACKGROUND: Trauma centers (TCs) have been shown to decrease mortality in adults, but this has not been demonstrated at a population level in all children. We hypothesized that seriously injured children would have increased survival in a TC versus nontrauma center (nTC), but there would be no increased benefit from pediatric-designated versus adult TC care. METHODS: This was a retrospective study of the unmasked California Office of Statewide Health and Planning Department patient discharge database (1999-2011). DRG International Classification of Diseases-9th Rev. (ICD-9) diagnostic codes indicating trauma were identified for children (0-18 years), and injury severity was calculated from ICD-9 codes using validated algorithms. To adjust for hospital case mix, we selected patients with ICD-9 codes that were capable of causing death and which appeared at both TCs and nTCs. Instrumental variable (IV) analysis using differential distance between the child's residence to a TC and to the nearest hospital was applied to further adjust for unobservable differences in TC and nTC populations. Instrumental variable regression models analyzed the association between mortality and TC versus nTC care as well as for pediatric versus adult TC designations, adjusting for demographic and clinical variables. RESULTS: Unadjusted mortality for the entire population of children with nontrivial trauma (n = 445,236) was 1.2%. In the final study population (n = 77,874), mortality was 5.3%, 3.8% in nTCs and 6.1% in TCs. IV regression analysis demonstrated a 0.79 percentage point (95% confidence interval, -0.80 to -0.30; p = 0.044) decrease in mortality for children cared for in TC versus nTC. No decrease in mortality was demonstrated for children cared for in pediatric versus adult TCs. CONCLUSION: Our IV TC outcome models use improved injury severity and case mix adjustment to demonstrate decreased mortality for seriously injured California children treated in TCs. These results can be used to take evidence-based steps to decrease disparities in pediatric access to, and subsequent outcomes for, trauma care. LEVEL OF EVIDENCE: Therapeutic/care management, level III. Language: en

Ionizing radiation and cost make ultrasound (US), when available, the first imaging study for the diagnosis of suspected pediatric appendicitis. US is less sensitive and specific than computed tomography (CT) or magnetic resonance imaging (MRI) scans, which are often performed after nondiagnostic US.We sought to determine predictors of nondiagnostic US in order to guide efficient ordering of imaging studies.A prospective cohort study of consecutive patients 4 to 30 years of age with suspected appendicitis took place at an emergency department with access to 24/7 US, MRI, and CT capabilities. Patients with US as their initial study were identified. Clinical (i.e., duration of illness, highest fever, and right lower quadrant pain) and demographic (i.e., age and sex) variables were collected. Body mass index (BMI) was calculated based on Centers for Disease Control and Prevention criteria; BMI85th percentile was categorized as overweight. Patients were followed until day 7. Univariate and stepwise multivariate logistic regression analysis was performed.Over 3 months, 106 patients had US first for suspected appendicitis; 52 (49%) had nondiagnostic US results. Eighteen patients had appendicitis, and there were no missed cases after discharge. On univariate analysis, male sex, a yearly increase in age, and overweight BMI were associated with nondiagnostic US (p 0.05). In the multivariate model, only BMI (odds ratio 4.9 [95% CI 2.0-12.2]) and age (odds ratio 1.1 [95% CI 1.02-1.20]) were predictors. Sixty-eight percent of nondiagnostic US results occurred in overweight patients.Overweight and older patients are more likely to have a nondiagnostic US or appendicitis, and it may be more efficient to consider alternatives to US first for these patients. Also, this information about the accuracy of US to diagnose suspected appendicitis may be useful to clinicians who wish to engage in shared decision-making with the parents or guardians of children regarding imaging options for children with acute abdominal pain.

A multicenter study in the late 1990s demonstrated suboptimal emergency asthma care for pregnant women in US EDs. After a decade, follow-up data are lacking. We aimed to examine changes in emergency asthma care of pregnant women since the 1990s.We combined data from four multicenter observational studies of ED patients with acute asthma performed in 1996 to 2001 (three studies) and 2011 to 2012 (one study). We restricted the data so that comparisons were based on the same 48 EDs in both time periods. We identified all pregnant patients aged 18 to 44 years with acute asthma. Primary outcomes were treatment with systemic corticosteroids in the ED and, among those sent home, at ED discharge.Of 4,895 ED patients with acute asthma, the analytic cohort comprised 125 pregnant women. Between the two time periods, there were no significant changes in patient demographics, chronic asthma severity, or initial peak expiratory flow. In contrast, ED systemic corticosteroid treatment increased significantly from 51% to 78% across the time periods (OR, 3.11; 95% CI, 1.27-7.60; P = .01); systemic corticosteroids at discharge increased from 42% to 63% (OR, 2.49; 95% CI, 0.97-6.37; P = .054). In the adjusted analyses, pregnant women in recent years were more likely to receive systemic corticosteroids, both in the ED (OR, 4.76; 95% CI, 1.63-13.9; P = .004) and at discharge (OR, 3.18; 95% CI, 1.05-9.61; P = .04).Between the two time periods, emergency asthma care in pregnant women significantly improved. However, with one in three pregnant women being discharged home without systemic corticosteroids, further improvement is warranted.

Although follow-up CT is recommended for pediatric appendicitis if initial ultrasound (US) is equivocal, many physicians observe the patient at home. There are limited data to understand currently how common or safe this practice is. Our objectives are to assess prevalence of acute appendicitis and outcomes in patients with equivocal US with and without follow-up CT and to identify variables associated with ordering a follow-up CT.Retrospective analysis of the prevalence of appendicitis and outcomes of patients 1-18 years old with an equivocal US at a pediatric emergency department from 2003 to 2008. Recursive partitioning analysis and multivariate logistic regression were used to identify variables associated with ordering follow-up CT.Fifty-five percent (340/620) of children with equivocal US did not receive CT, none of whom returned with a missed appendicitis. The prevalence of appendicitis in children with equivocal US was 12.5% (78/620). In children with follow-up CT, the prevalence was 22.1% (62/280); in those without follow-up CT, the prevalence was 4.7% (16/340). Recursive partitioning identified age11 years, leukocytosis15,000 cells/ml, and secondary signs predisposing toward acute appendicitis on US as significant predictors of CT.We view our study as a fundamental part of the incremental progress to understand how best to use US and CT imaging to diagnose pediatric appendicitis while minimizing ionizing radiation. Children at low risk for appendicitis with equivocal US are amenable to observation and reassessment prior to reimaging with US or CT.

Mastoiditis was a common complication of otitis media in the preantibiotic era. Because its incidence has decreased dramatically in recent years, its diagnosis can be delayed or missed, particularly in infants and young children. This delay can result in significant morbidity and increased costs, owing to longer inpatient treatment and surgical intervention. We offer a current, case-based review of the pathogenesis, presentation, and treatment of mastoiditis.

Djenkolism is an uncommon but important cause of acute kidney injury. It sporadically occurs after an ingestion of the djenkol bean (Archidendron pauciflorum), which is native to Southeast Asia. The clinical features defining djenkolism include: spasmodic suprapubic and/or flank pain; urinary obstruction; and acute kidney injury. The precise pathogenesis of acute kidney injury following djenkol ingestion remains unknown. However, it is proposed that an interaction between the characteristics of the ingested beans and the host factors causes hypersaturation of djenkolic acid crystals within the urinary system, resulting in subsequent obstructive nephropathy with sludge, stones, or possible spasms. We report a case of djenkolism from our rural clinic in Borneo, Indonesia. Our systematic literature review identified 96 reported cases of djenkolism. The majority of patients recovered with hydration, bicarbonate therapy, and pain medication. Three patients required surgical intervention; one patient required ureteral stenting for the obstructing djenkolic acid stones. Four of the 96 reported patients died from acute kidney failure. We stress the importance of awareness of djenkolism to guide medical practitioners in the treatment of this rare disease in resource-poor areas in Southeast Asia., Video abstract