Epidemiology of brief resolved unexplained events and impact of clinical practice guidelines in general and pediatric emergency departments

OBJECTIVES

The aim of this study was to describe the incidence of brief resolved unexplained events (BRUEs) and compare the impact of a national clinical practice guideline (CPG) on admission and diagnostic testing practices between general and pediatric emergency departments (EDs).

METHODS

Using the Nationwide Emergency Department Sample for 2012-2019, we conducted a cross-sectional study of children <1 year of age with an International Classification of Diseases diagnostic code for BRUE. Population incidence rate was estimated using Centers for Disease Control and Prevention birth data. ED incidence rate was estimated for all ED encounters. We used interrupted time series to evaluate the associated impact of the CPG publication on the outcomes of ED disposition (discharge, admission, and transfer) and electrocardiogram (ECG) use.

RESULTS

Of 133,972 encounters for BRUE, 80.0% occurred in general EDs. BRUE population incidence was 4.28 per 1000 live births and the annual incidence remained stable (p = 0.19). BRUE ED incidence was 5.06 per 1000 infant ED encounters (p = 0.14). The impact of the BRUE CPG on admission rates was limited to pediatric EDs (level shift -23.3%, p = 0.002). Transfers from general EDs did not change with the CPG (level shift 2.2%, p = 0.17). After the CPG was published, ECGs increased by 13.7% in pediatric EDs (p = 0.005) but did not change in general EDs (level shift -0.2%, p = 0.82).

CONCLUSIONS

BRUEs remain a common pediatric problem at a population level and in EDs. Although a disproportionate number of infants present to general EDs, there is differential uptake of the CPG recommendations between pediatric and general EDs. These findings may support quality improvement opportunities aimed at improving care for these infants and decreasing unnecessary hospital admissions or transfers.

Diagnostic testing for evaluation of brief resolved unexplained events

BACKGROUND

Since the publication of the American Academy of Pediatrics (AAP) clinical practice guideline for brief resolved unexplained events (BRUEs), a few small, single-center studies have suggested low yield of diagnostic testing in infants presenting with such an event. We conducted this large retrospective multicenter study to determine the role of diagnostic testing in leading to a confirmatory diagnosis in BRUE patients.

METHODS

Secondary analysis from a large multicenter cohort derived from 15 hospitals participating in the BRUE Quality Improvement and Research Collaborative. The study subjects were infants < 1 year of age presenting with a BRUE to the emergency departments (EDs) of these hospitals between October 1, 2015, and September 30, 2018. Potential BRUE cases were identified using a validated algorithm that relies on administrative data. Chart review was conducted to confirm study inclusion/exclusion, AAP risk criteria, final diagnosis, and contribution of test results. Findings were stratified by ED or hospital discharge and AAP risk criteria. For each patient, we identified whether any diagnostic test contributed to the final diagnosis. We distinguished true (contributory) results from false-positive results.

RESULTS

Of 2036 patients meeting study criteria, 63.2% were hospitalized, 87.1% qualified as AAP higher risk, and 45.3% received an explanatory diagnosis. Overall, a laboratory test, imaging, or an ancillary test supported the final diagnosis in 3.2% (65/2036, 95% confidence interval [CI] 2.7%-4.4%) of patients. Out of 5163 diagnostic tests overall, 1.1% (33/2897, 95% CI 0.8%-1.5%) laboratory tests and 1.5% (33/2266, 95% CI 1.0%-1.9%) of imaging and ancillary studies contributed to a diagnosis. Although 861 electrocardiograms were performed, no new cardiac diagnoses were identified during the index visit.

CONCLUSIONS

Diagnostic testing to explain BRUE including for those with AAP higher risk criteria is low yield and rarely contributes to an explanation. Future research is needed to evaluate the role of testing in more specific, at-risk populations.

Diagnostic testing for and detection of physical abuse in infants with brief resolved unexplained events

BACKGROUND

A Brief Resolved Unexplained Event (BRUE) can be a sign of occult physical abuse.

OBJECTIVES

To identify rates of diagnostic testing able to detect physical abuse (head imaging, skeletal survey, and liver transaminases) at BRUE presentation. The secondary objective was to estimate the rate of physical abuse diagnosed at initial BRUE presentation through 1 year of age.

PARTICIPANTS AND SETTING

Infants who presented with a BRUE at one of 15 academic or community hospitals were followed from initial BRUE presentation until 1 year of age for BRUE recurrence or revisits.

METHODS

This study was part of the BRUE Research and Quality Improvement Network, a multicenter retrospective cohort examining infants with BRUE. Generalized estimating equations assessed associations with performance of diagnostic testing (adjusted odds ratio (aOR)).

RESULTS

Of the 2036 infants presenting with a BRUE, 6.2 % underwent head imaging, 7.0 % skeletal survey, and 12.1 % liver transaminases. Infants were more likely to undergo skeletal survey if there were physical examination findings concerning for trauma (aOR 8.23, 95 % CI [1.92, 35.24], p < 0.005) or concerning social history (aOR 1.89, 95 % CI [1.13, 3.16], p = 0.015). There were 7 (0.3 %) infants diagnosed with physical abuse: one at BRUE presentation, one <3 days after BRUE presentation, and five >30 days after BRUE presentation.

CONCLUSION

There were low rates of diagnostic testing and physical abuse identified in infants presenting with BRUE. Further study including standardized testing protocols is warranted to identify physical abuse in infants presenting with a BRUE.

Concussion severity and functional outcome using biomarkers in children and youth involved in organized sports, recreational activities and non-sport related incidents

This prospective multicenter study evaluated differences in concussion severity and functional outcome using glial and neuronal biomarkers glial Fibrillary Acidic (GFAP) and Ubiquitin C-terminal Hydrolase (UCH-L1) in children and youth involved in non-sport related trauma, organized sports, and recreational activities. Children and youth presenting to three Level 1 trauma centersfollowing blunt head trauma with a GCS 15 with a verified diagnosis of a concussion were enrolled within 6 hours of injury. Traumatic intracranial lesions on CT scan and functional outcome within 3 months of injury were evaluated. 131 children and youth with concussion were enrolled, 81 in the no sports group, 22 in the organized sports group and 28 in the recreational activities group. Median GFAP levels were 0.18, 0.07, and 0.39 ng/mL in the respective groups (p = 0.014). Median UCH-L1 levels were 0.18, 0.27, and 0.32 ng/mL respectively (p = 0.025). A CT scan of the head was performed in 110 (84%) patients. CT was positive in 5 (7%), 4 (27%), and 5 (20%) patients, respectively. The AUC for GFAP for detecting +CT was 0.84 (95%CI 0.75-0.93) and for UCH-L1 was 0.82 (95%CI 0.71-0.94). In those without CT lesions, elevations in UCH-L1 were significantly associated with unfavorable 3-month outcome. Concussions in the 3 groups were of similar severity and functional outcome. GFAP and UCH-L1 were both associated with severity of concussion and intracranial lesions, with the most elevated concentrations in recreational activities .

Incidence of Postoperative Cerebral Aneurysm Clip Slippage: Review of a Consecutive Case Series of 115 Clipped Aneurysms

OBJECTIVE

Although delayed postoperative clip slippage has been reported in previous case reports and case series, its true incidence with high rate of follow-up imaging has not been reported. We attempted to determine the incidence of clip slippage in a cohort of consecutive aneurysm clippings.

METHODS

We performed a retrospective review of a prospectively maintained database of 115 consecutive saccular aneurysm clippings at a single institution. Postoperative imaging was reviewed for clip slippage within 24 hours and at 3-12 months. Eighty-six aneurysms (75.8%) were exclusively clipped with Sugitaclip (Mizuho Medical, Tokyo, Japan) Titanium II clips, 16 aneurysms were exclusively clipped with Yaşargil (Aesculap, Center Valley, PA) titanium clips (13.9%), 5 aneurysms were only clipped with Sugita aneurysm clips (4.3%), and 3 aneurysms were only clipped with Peter Lazic (Peter Lazic Microsurgical Innovations, Tuttlingen, Germany) clips (2.6%).

RESULTS

In this cohort, 94.7% of clipped aneurysms had follow-up imaging within 24 hours, and 51.3% had delayed follow-up imaging within 3-12 months. We identified 3 cases of clip slippage in 115 consecutive aneurysm clippings, resulting in an incidence of 2.6%. The average cumulative closing force of clips per aneurysm across the study was 2.32 N, and the median number of clips placed was 1. Two of the 3 cases of clip slippage had a closing force <2.32 N and only placement of a single clip.

CONCLUSIONS

Because our series showed a 2.6% incidence of clip slippage, clipped aneurysms should be monitored with early and delayed vascular follow-up imaging. Lower cumulative clip closing force, single clip placement, and oversized clip blade length may be risk factors for postoperative aneurysmal clip slippage.

CT Perfusion in Evaluation of Cervical Lymph Node Metastasis in Head and Neck Malignancies: A Cross-sectional Study

Introduction: Though, many cross-sectional modalities are available for evaluation of cervical lymph node metastasis but their results are highly variable. There is paucity of the literature in India, regarding lymph nodal assessment using Computed Tomography (CT) perfusion in head and neck malignancies even though, there is high incidence of oral cancer in India. Aim: To assess the role of Computed Tomography Perfusion (CTP) in evaluation of cervical lymph nodes in head and neck malignancies, by using CT perfusion parameters as compared to histopathology. Materials and Methods: This cross-sectional study was conducted in the Department of Radiodiagnosis in collaboration with the Department of Surgery and Pathology at Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi, India, from October 2017 to April 2019. The study included 30 newly diagnosed head and neck cancer patients, with 46 nodes planned for surgical neck dissection. Computed tomography scan of neck was acquired using Siemens Somatom Definition Flash 256CT scanner. Reconstruction and post processing was performed on workstation and perfusion parameters were obtained to generate the CT perfusion maps. Differentiation between benign and malignant lymph nodes was done, on the basis of CT perfusion parameters such as Blood Flow (BF), Blood Volume (BV), Mean Transit Time (MTT) and Permeability Surface (PS), which were compared with histopathological findings of resected lymph nodes. McNemar’s test was applied for comparison and statistical analysis. Receiver Operating Characteristic (ROC) curve of quantitative parameters were obtained, for the detection of sensitivity, specificity, Positive Predictive Value (PPV), Negative Predictive Value (NPP) and diagnostic accuracy. Results: Out of 46 nodes, 23 were metastatic and 23 were non metastatic. The average value of BF in metastatic nodes was 174.61±71.76 mL/100g/min, BV was 16.32±11.9 mL/100g, MTT was 4.83±2.54 seconds and PS was 49.3±28.59 mL/100g/min. The average values for non metastatic nodes were: BF 88.06±34.4 mL/100g/min, BV: 9.89±7.63 mL/100g, MTT: 13.11±18.58 seconds and PS: 37.07±29.26 mL/100g/ min. The differences between the parameters like blood flow (p-value <0.0001), blood volume (p-value=0.005) and MTT (p-value=0.002) in malignant and benign nodes were significant. In case of blood flow, sensitivity was 82.61% and diagnostic accuracy was 84.78%. In case of blood volume, sensitivity was 91.30% and diagnostic accuracy was 73.91%. In case of mean transit time, sensitivity was 56.52% and diagnostic accuracy was 73.91%. In case of permeability surface, sensitivity was 91.30% and diagnostic accuracy was 67.39%. Conclusion: Blood flow and blood volume values were significantly increased in metastatic cervical lymph nodes as compared to non metastatic nodes, whereas MTT was significantly low. Permeability surface showed equivocal results.

Explanatory Diagnoses Following Hospitalization for a Brief Resolved Unexplained Event

BACKGROUND AND OBJECTIVES

Most young infants presenting to the emergency department (ED) with a brief resolved unexplained event (BRUE) are hospitalized. We sought to determine the rate of explanatory diagnosis after hospitalization for a BRUE.

METHODS

This was a multicenter retrospective cohort study of infants hospitalized with a BRUE after an ED visit between October 1, 2015, and September 30, 2018. We included infants without an explanatory diagnosis at admission. We determined the proportion of patients with an explanatory diagnosis at the time of hospital discharge and whether diagnostic testing, consultation, or observed events occurring during hospitalization were associated with identification of an explanatory diagnosis.

RESULTS

Among 980 infants hospitalized after an ED visit for a BRUE without an explanatory diagnosis at admission, 363 (37.0%) had an explanatory diagnosis identified during hospitalization. In 805 (82.1%) infants, diagnostic testing, specialty consultations, and observed events did not contribute to an explanatory diagnosis, and, in 175 (17.9%) infants, they contributed to the explanatory diagnosis (7.0%, 10.0%, and 7.0%, respectively). A total of 15 infants had a serious diagnosis (4.1% of explanatory diagnoses; 1.5% of all infants hospitalized with a BRUE), the most common being seizure and infantile spasms, occurring in 4 patients.

CONCLUSIONS

Most infants hospitalized with a BRUE did not receive an explanation during the hospitalization, and a majority of diagnoses were benign or self-limited conditions. More research is needed to identify which infants with a BRUE are most likely to benefit from hospitalization for determining the etiology of the event.

Risk Factors and Outcomes After a Brief Resolved Unexplained Event: A Multicenter Study

BACKGROUND

The accuracy of the risk criteria for brief resolved unexplained events (BRUEs) from the American Academy of Pediatrics (AAP) is unknown. We sought to evaluate if AAP risk criteria and event characteristics predict BRUE outcomes.

METHODS

This retrospective cohort included infants <1 year of age evaluated in the emergency departments (EDs) of 15 pediatric and community hospitals for a BRUE between October 1, 2015, and September 30, 2018. A multivariable regression model was used to evaluate the association of AAP risk factors and event characteristics with risk for event recurrence, revisits, and serious diagnoses explaining the BRUE.

RESULTS

Of 2036 patients presenting with a BRUE, 87% had at least 1 AAP higher-risk factor. Revisits occurred in 6.9% of ED and 10.7% of hospital discharges. A serious diagnosis was made in 4.0% (82) of cases; 45% (37) of these diagnoses were identified after the index visit. The most common serious diagnoses included seizures (1.1% [23]) and airway abnormalities (0.64% [13]). Risk is increased for a serious underlying diagnosis for patients discharged from the ED with a history of a similar event, an event duration >1 minute, an abnormal medical history, and an altered responsiveness (P < .05). AAP risk criteria for all outcomes had a negative predictive value of 90% and a positive predictive value of 23%.

CONCLUSIONS

AAP BRUE risk criteria are used to accurately identify patients at low risk for event recurrence, readmission, and a serious underlying diagnosis; however, their use results in the inaccurate identification of many patients as higher risk. This is likely because many AAP risk factors, such as age, are not associated with these outcomes.

Accuracy of Diagnostic Codes for Identifying Brief Resolved Unexplained Events

OBJECTIVES

To evaluate International Classification of Diseases, 10th Revision (ICD-10) coding strategies for the identification of patients with a brief resolved unexplained event (BRUE).

METHODS

Multicenter retrospective cohort study, including patients aged <1 year with an emergency department (ED) visit between October 1, 2015, and September 30, 2018, and an ICD-10 code for the following: (1) BRUE; (2) characteristics of BRUE; (3) serious underlying diagnoses presenting as a BRUE; and (4) nonserious diagnoses presenting as a BRUE. Sixteen algorithms were developed by using various combinations of these 4 groups of ICD-10 codes. Manual chart review was used to assess the performance of these ICD-10 algorithms for the identification of (1) patients presenting to an ED who met the American Academy of Pediatrics clinical definition for a BRUE and (2) the subset of these patients discharged from the ED or hospital without an explanation for the BRUE.

RESULTS

Of 4512 records reviewed, 1646 (36.5%) of these patients met the American Academy of Pediatrics criteria for BRUE on ED presentation, 1016 (61.7%) were hospitalized, and 959 (58.3%) had no explanation on discharge. Among ED discharges, the BRUE ICD-10 code alone was optimal for case ascertainment (sensitivity: 89.8% to 92.8%; positive predictive value: 51.7% to 72.0%). For hospitalized patients, ICD-10 codes related to the clinical characteristics of BRUE are preferred (specificity 93.2%, positive predictive value 32.7% to 46.3%).

CONCLUSIONS

The BRUE ICD-10 code and/or the diagnostic codes for the characteristics of BRUE are recommended, but the choice between approaches depends on the investigative purpose and the specific BRUE population and setting of interest.

Evaluating glial and neuronal blood biomarkers GFAP and UCH-L1 as gradients of brain injury in concussive, subconcussive and non-concussive trauma: a prospective cohort study

OBJECTIVES

To evaluate the ability of glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase (UCH-L1) to detect concussion in children and adult trauma patients with a normal mental status and assess biomarker concentrations over time as gradients of injury in concussive and non-concussive head and body trauma.

DESIGN

Large prospective cohort study.

SETTING

Three level I trauma centres in the USA.

PARTICIPANTS

Paediatric and adult trauma patients of all ages, with and without head trauma, presenting with a normal mental status (Glasgow Coma Scale score of 15) within 4 hours of injury. Rigorous screening for concussive symptoms was conducted. Of 3462 trauma patients screened, 751 were enrolled and 712 had biomarker data. Repeated blood sampling was conducted at 4, 8, 12, 16, 24, 36, 48, 60, 72, 84, 96, 108, 120, 132, 144, 156, 168 and 180 hours postinjury in adults.

MAIN OUTCOMES

Detection of concussion and gradients of injury in children versus adults by comparing three groups of patients: (1) those with concussion; (2) those with head trauma without overt signs of concussion (non-concussive head trauma controls) and (3) those with peripheral (body) trauma without head trauma or concussion (non-concussive body trauma controls).

RESULTS

A total of 1904 samples from 712 trauma patients were analysed. Within 4 hours of injury, there were incremental increases in levels of both GFAP and UCH-L1 from non-concussive body trauma (lowest), to mild elevations in non-concussive head trauma, to highest levels in patients with concussion. In concussion patients, GFAP concentrations were significantly higher compared with body trauma controls (p<0.001) and with head trauma controls (p<0.001) in both children and adults, after controlling for multiple comparisons. However, for UCH-L1, there were no significant differences between concussion patients and head trauma controls (p=0.894) and between body trauma and head trauma controls in children. The AUC for initial GFAP levels to detect concussion was 0.80 (0.73-0.87) in children and 0.76 (0.71-0.80) in adults. This differed significantly from UCH-L1 with AUCs of 0.62 (0.53-0.72) in children and 0.69 (0.64-0.74) in adults.

CONCLUSIONS

In a cohort of trauma patients with normal mental status, GFAP outperformed UCH-L1 in detecting concussion in both children and adults. Blood levels of GFAP and UCH-L1 showed incremental elevations across three injury groups: from non-concussive body trauma, to non-concussive head trauma, to concussion. However, UCH-L1 was expressed at much higher levels than GFAP in those with non-concussive trauma, particularly in children. Elevations in both biomarkers in patients with non-concussive head trauma may be reflective of a subconcussive brain injury. This will require further study.

Economic Analysis of Diagnostic Imaging in Pediatric Patients With Suspected Appendicitis

OBJECTIVE

The use of computed tomography (CT) and ultrasound (US) in patients with acute abdominal pain has substantial variation across pediatric emergency departments (EDs). This study compares the cost of diagnosing and treating suspected appendicitis across a multicenter network of children's hospitals.

METHODS

This study is a secondary analysis using deidentified data of a prospective, observational study of patients with suspected appendicitis at nine pediatric EDs. The study included patients 3 to 18 years old who presented to the ED with acute abdominal pain of <96 hours' duration.

RESULTS

Our data set contained 2,300 cases across nine sites. There was an appendicitis rate of 31.8% and perforation rate of 25.7%. Sites correctly diagnosed appendicitis in over 95% of cases. The negative appendicitis rate ranged from 2.5% to 4.7% while the missed appendicitis rate ranged from 0.3% to 1.1% with no significant differences in these rates across site. Across sites, we found a strong positive correlation (0.95) between CT rate and total cost per case and a strong negative correlation (-0.71) between US rate and cost. The cost per case at US sites was 5.2% ($367) less than at CT sites (p < 0.001). Similarly, costs per case at mixed sites were 3.4% ($244) less than at CT sites (p < 0.001). Comparing costs among CT sites or among US sites, the cost per case generally increased as the images per case increased among both CT sites and US sites, but the costs were universally higher at CT sites.

CONCLUSIONS

Our results provide support for US as the primary imaging modality for appendicitis. Sites that preferentially utilized US had lower costs per case than sites that primarily used CT. Imaging rates across sites varied due to practice patterns and resulted in a significant cost consequence without higher rates for negative appendectomies or missed appendicitis cases.

Anorectal malformations: Role of MRI in preoperative evaluation

PURPOSE

To evaluate the spectrum of magnetic resonance imaging (MRI) findings in pediatric patients with anorectal malformation (ARM) and compare the accuracy of MRI and distal cologram (DC) findings using surgery as reference standard.

MATERIALS AND METHODS

Thirty pediatric patients of age less than 14 years (19 boys and 11 girls) with ARM underwent preoperative MRI. MRI images were evaluated for the level of rectal pouch in relation to the pelvic floor, fistula, and development of sphincter muscle complex (SMC). Associated spinal and other anomalies in lumbar region and pelvis were also evaluated. DC was done in 26 patients who underwent colostomy. Ultrasound of abdomen and pelvis was also done for associated anomalies.

RESULTS

Overall accuracy of MRI and DC to detect the exact level of rectal pouch including cloacal malformation was 93.33% and 76.9% respectively. MRI and DC could correctly identify presence or absence of fistula in 76.6% and 76.9% cases respectively. MRI and DC correctly identified the anatomy of fistula in 76% and 65% cases respectively. On MRI, correlation of development of levator ani and puborectalis with the level of rectal pouch as found on surgery was significant (P = 0.008; 0.024 respectively). Subjective assessment of sphincter muscle development on MRI correlated well with the surgical assessment [P = 0.019 and 0.016 for puborectalis and external anal sphincter (EAS) respectively]. Lumbosacral spine anomalies were present in 33.3% of patients and were most common in high type of ARM. Vesicoureteric reflux and renal agenesis were the most common renal and urinary tract anomalies and were present in 40% of cases.

CONCLUSION

MRI allows reliable preoperative evaluation of ARM and should be considered as a complementary imaging modality for preoperative imaging in ARM.

Hyponatremia in Guillain-Barré Syndrome

OBJECTIVES

To evaluate incidence, risk factors, and in-hospital outcomes associated with hyponatremia in patients hospitalized for Guillain-Barré Syndrome (GBS).

METHODS

We identified adult patients with GBS in the Nationwide Inpatient Sample (2002-2011). Univariate and multivariable analyses were used.

RESULTS

Among 54,778 patients hospitalized for GBS, the incidence of hyponatremia was 11.8% (compared with 4.0% in non-GBS patients) and increased from 6.9% in 2002 to 13.5% in 2011 (P < 0.0001). Risk factors associated with hyponatremia in multivariable analysis included advanced age, deficiency anemia, alcohol abuse, hypertension, and intravenous immunoglobulin (all P < 0.0001). Hyponatremia was associated with prolonged length of stay (16.07 vs. 10.41, days), increased costs (54,001 vs. 34,125, $USD), and mortality (20.5% vs. 11.6%) (all P < 0.0001). In multivariable analysis, hyponatremia was independently associated with adverse discharge disposition (odds ratio: 2.07, 95% confidence interval, 1.91-2.25, P < 0.0001).

CONCLUSIONS

Hyponatremia is prevalent in GBS and is detrimental to patient-centered outcomes and health care costs. Sodium levels should be carefully monitored in high-risk patients.

Time From Emergency Department Evaluation to Operation and Appendiceal Perforation

BACKGROUND AND OBJECTIVES

In patients with appendicitis, the risk of perforation increases with time from onset of symptoms. We sought to determine if time from emergency department (ED) physician evaluation until operative intervention is independently associated with appendiceal perforation (AP) in children.

METHODS

We conducted a planned secondary analysis of children aged 3 to 18 years with appendicitis enrolled in a prospective, multicenter, cross-sectional study of patients with abdominal pain (<96 hours). Time of initial physical examination and time of operation were recorded. The presence of AP was determined using operative reports. We analyzed whether duration of time from initial ED physician evaluation to operation impacted the odds of AP using multivariable logistic regression, adjusting for traditionally suggested risk factors that increase the risk of perforation. We also modeled the odds of perforation in a subpopulation of patients without perforation on computed tomography.

RESULTS

Of 955 children with appendicitis, 25.9% (n = 247) had AP. The median time from ED physician evaluation to operation was 7.2 hours (interquartile range: 4.8-8.5). Adjusting for variables associated with perforation, duration of time (≤ 24 hours) between initial ED evaluation and operation did not significantly increase the odds of AP (odds ratio = 1.0, 95% confidence interval, 0.96-1.05), even among children without perforation on initial computed tomography (odds ratio = 0.95, 95% confidence interval, 0.89-1.02).

CONCLUSIONS

Although duration of abdominal pain is associated with AP, short time delays from ED evaluation to operation did not independently increase the odds of perforation.

Gastrointestinal Bowel Obstruction in Acute Ischemic Stroke: Incidence, Risk Factors, and Outcomes in a U.S. Nationwide Analysis of 3,998,667 Hospitalizations

OBJECTIVE

The prognosis from acute ischemic stroke (AIS) is worsened by poststroke medical complications. The incidence, risk factors, and outcomes of gastrointestinal bowel obstruction (GIBO) in AIS are not known.

METHODS

We queried the Nationwide Inpatient Sample (2002-2011) to identify all patients with a primary diagnosis of AIS and subsets with and without a secondary diagnosis of GIBO without hernia. Multivariable analysis was utilized to identify risk factors for GIBO in AIS patients and the association between GIBO, in-hospital complications, and outcomes.

RESULTS

We identified 16,987 patients with GIBO (.43%) among 3,988,667 AIS hospitalizations and 4.2% of these patients underwent surgery. In multivariable analysis, patients with 75+ years of age were two times as likely to suffer GIBO compared to younger patients (P < .0001). African Americans were 42% more likely to have GIBO compared to Whites (P < .0001). Stroke patients with pre-existing comorbidities (coagulopathy, cancer, blood loss anemia, and fluid/electrolyte disorder) were more likely to experience GIBO (all P < .0001). AIS patients with GIBO were 184% and 39% times more likely to face moderate-to-severe disability and in-hospital death, respectively (P < .0001). GIBO occurrence increased length of stay and total costs by an average of 9.7 days and $22,342 (P < .0001).

CONCLUSION

GIBO is a rare but burdensome complication of AIS, associated with complications, disability, and mortality. The risk factors identified in this study aim to encourage the monitoring of patients at highest risk for GIBO. The predominant form of stroke-related GIBO is nonmechanical obstruction, although the causative relationship remains unknown.

Neuronal Biomarker Ubiquitin C-Terminal Hydrolase Detects Traumatic Intracranial Lesions on Computed Tomography in Children and Youth with Mild Traumatic Brain Injury

This study examined the performance of serum ubiquitin C-terminal hydrolase (UCH-L1) in detecting traumatic intracranial lesions on computed tomography (CT) scan (+CT) in children and youth with mild and moderate TBI (mmTBI) and assessed its performance in trauma control patients without head trauma. This prospective cohort study enrolled children and youth presenting to three level 1 trauma centers after blunt head trauma and a Glasgow Coma Scale (GCS) score of 9-15 as well as trauma control patients with GCS 15 that did not have blunt head trauma. The primary outcome measure was the presence of intracranial lesions on initial CT scan. Blood samples were obtained in all patients within 6 h of injury and measured by enzyme-linked immunosorbent assay ELISA for UCH-L1 (ng/mL). A total of 256 children and youth were enrolled in the study and had serum samples drawn within 6 h of injury for analysis; 196 had blunt head trauma and 60 were trauma controls. CT scan of the head was performed in 151 patients and traumatic intracranial lesions on CT scan were evident in 17 (11%), all of whom had a GCS of 13-15. The area under the receiver operating characteristic curve (AUC) for UCH-L1 in detecting children and youth with traumatic intracranial lesions on CT was 0.83 (95% confidence interval [CI], 0.73-0.93). In those presenting with a GCS of 15, the AUC for detecting lesions was 0.83 (95% CI, 0.72-0.94). Similarly, in children under 5 years of age, the AUC was 0.79 (95% CI, 0.59-1.00). Performance for detecting intracranial lesions at a UCH-L1 cut-off level of 0.18 ng/mL yielded a sensitivity of 100%, a specificity of 47%, and a negative predictive value of 100%. UCH-L1 showed good performance in infants and toddlers younger than 5 years and performed well in children and youth with a GCS score of 15. Before clinical application, further study in larger cohort of children and youth with mild TBI is warranted.

A Clinical Score to Predict Appendicitis in Older Male Children

OBJECTIVE

To develop a clinical score to predict appendicitis among older, male children who present to the emergency department with suspected appendicitis.

METHODS

Patients with suspected appendicitis were prospectively enrolled at 9 pediatric emergency departments. A total of 2625 patients enrolled; a subset of 961 male patients, age 8-18 were analyzed in this secondary analysis. Outcomes were determined using pathology, operative reports, and follow-up calls. Clinical and laboratory predictors with <10% missing data and kappa > 0.4 were entered into a multivariable model. Resultant β-coefficients were used to develop a clinical score. Test performance was assessed by calculating the sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratios.

RESULTS

The mean age was 12.2 years; 49.9% (480) had appendicitis, 22.3% (107) had perforation, and the negative appendectomy rate was 3%. In patients with and without appendicitis, overall imaging rates were 68.6% (329) and 84.4% (406), respectively. Variables retained in the model included maximum tenderness in the right lower quadrant, pain with walking/coughing or hopping, and the absolute neutrophil count. A score ≥8.1 had a sensitivity of 25% (95% confidence interval [CI], 20%-29%), specificity of 98% (95% CI, 96%-99%), and positive predictive value of 93% (95% CI, 86%-97%) for ruling in appendicitis.

CONCLUSIONS

We developed an accurate scoring system for predicting appendicitis in older boys. If validated, the score might allow clinicians to manage a proportion of male patients without diagnostic imaging.

Autoimmune Encephalitis in the ICU: Analysis of Phenotypes, Serologic Findings, and Outcomes

BACKGROUND

To report the clinical and laboratory characteristics, clinical courses, and outcomes of Mayo Clinic, Rochester, MN, ICU-managed autoimmune encephalitis patients (January 1st 2003-December 31st 2012).

METHODS

Based on medical record review, twenty-five patients were assigned to Group 1 (had ≥1 of classic autoimmune encephalitis-specific IgGs, n = 13) or Group 2 (had ≥3 other characteristics supporting autoimmunity, n = 12).

RESULTS

Median admission age was 47 years (range 22-88); 17 were women. Initial symptoms included ≥1 of subacute confusion or cognitive decline, 13; seizures, 12; craniocervical pain, 5; and personality change, 4. Thirteen Group 1 patients were seropositive for ≥1 of VGKC-complex-IgG (6; including Lgi1-IgG in 2), NMDA-R-IgG (4), AMPA-R-IgG (1), ANNA-1 (1), Ma1/Ma2 antibody (1), and PCA-1 (1). Twelve Group 2 patients had ≥3 other findings supportive of an autoimmune diagnosis (median 4; range 3-5): ≥1 other antibody type detected, 9; an inflammatory CSF, 8; ≥1 coexisting autoimmune disease, 7; an immunotherapy response, 7; limbic encephalitic MRI changes, 5; a paraneoplastic cause, 4; and diagnostic neuropathological findings, 2. Among 11 patients ICU-managed for ≥4 days, neurological improvements were attributable to corticosteroids (5/7 treated), plasmapheresis (3/7), or rituximab (1/3). At last follow-up, 10 patients had died. Of the remaining 15 patients, 6 (24%) had mild or no disability, 3 (12%) had moderate cognitive problems, and 6 (24%) had dementia (1 was bed bound). Median modified Rankin score at last follow-up was 3 (range 0-6).

CONCLUSIONS

Good outcomes may occur in ICU-managed autoimmune encephalitis patients. Clinical and testing characteristics are diverse. Comprehensive diagnostics should be pursued to facilitate timely treatment.

Intracerebral Hemorrhage: Perihemorrhagic Edema and Secondary Hematoma Expansion: From Bench Work to Ongoing Controversies

Intracerebral hemorrhage (ICH) is a medical emergency, which often leads to severe disability and death. ICH-related poor outcomes are due to primary injury causing structural damage and mass effect and secondary injury in the perihemorrhagic region over several days to weeks. Secondary injury after ICH can be due to hematoma expansion (HE) or a consequence of repair pathway along the continuum of neuroinflammation, neuronal death, and perihemorrhagic edema (PHE). This review article is focused on PHE and HE and will cover the animal studies, related human studies, and clinical trials relating to these mechanisms of secondary brain injury in ICH patients.

The Influence of Age on the Diagnostic Performance of White Blood Cell Count and Absolute Neutrophil Count in Suspected Pediatric Appendicitis

OBJECTIVE

White blood cell (WBC) count and absolute neutrophil count (ANC) are a standard part of the evaluation of suspected appendicitis. Specific threshold values are utilized in clinical pathways, but the discriminatory value of WBC count and ANC may vary by age. The objective of this study was to investigate whether the diagnostic value of WBC count and ANC varies across age groups and whether diagnostic thresholds should be age-adjusted.

METHODS

This is a multicenter prospective observational study of patients aged 3-18 years who were evaluated for appendicitis. Receiver operator characteristic curves were developed to assess overall discriminative power of WBC count and ANC across three age groups: <5, 5-11, and 12-18 years of age. Diagnostic performance of WBC count and ANC was then assessed at specific cut-points.

RESULTS

A total of 2,133 patients with a median age of 10.9 years (interquartile range = 8.0-13.9 years) were studied. Forty-one percent had appendicitis. The area under the curve (AUC) for WBC count was 0.69 (95% confidence interval [CI] = 0.61 to 0.77) for patients < 5 years of age, 0.76 (95% CI = 0.73 to 0.79) for 5-11 years of age, and 0.83 (95% CI = 0.81 to 0.86) for 12-18 years of age. The AUCs for ANC across age groups mirrored WBC performance. At a commonly utilized WBC cut-point of 10,000/mm³ , the sensitivity decreased with increasing age: 95% (<5 years), 91% (5-11 years), and 89% (12-18 years) whereas specificity increased by age: 36% (<5 years), 49% (5-12 years), and 64% (12-18 years).

CONCLUSION

WBC count and ANC had better diagnostic performance with increasing age. Age-adjusted values of WBC count or ANC should be considered in diagnostic strategies for suspected pediatric appendicitis.

Association of Parkinson's disease with hospitalization for traumatic brain injury

PURPOSE

The goal of our study was to determine if patients with Parkinson's disease (PD) are more susceptible to hospitalization for traumatic brain injury (TBI).

METHODS

The US Nationwide Inpatient Sample database was queried (2004-2011) to identify cohorts of patients with PD (N = 1 047 656) and without PD (N = 115 95 173). The age range of the study population was 60-89 years. The incidence of TBI among patients with PD was compared to the incidence of TBI in patients without PD. A multivariate logistic regression model, adjusted for all covariates that significantly differed in the bivariate analyses, was used to determine if PD was an independent predictor of TBI hospitalization.

RESULTS

The incidence of TBI hospitalization was significantly higher (relative risk: 1.76, 95% CI: 1.73-1.80) in the PD cohort. The PD cohort with TBI had fewer comorbidities and risk factors for falls/TBI compared to the non-PD cohort with TBI. The multivariable analysis, adjusting for other TBI risk factors, revealed that PD status increased the likelihood of TBI hospitalization (odds ratio: 2.99, 95% CI: 2.93-3.05).

CONCLUSION

Our study shows that patients with PD are more susceptible to hospitalization for TBI. A greater proportion of fall-related TBI occurs in patients with PD compared to patients without PD. Further research is needed to prevent falls in PD patients to avoid TBI.

Ambulatory Status Protects against Venous Thromboembolism in Acute Mild Ischemic Stroke Patients

INTRODUCTION

Ischemic stroke patients are at high risk (up to 18%) for venous thromboembolism. We conducted a retrospective cross-sectional study to understand the predictors of acute postmild ischemic stroke patient's ambulatory status and its relationship with venous thromboembolism, hospital length of stay, and in-hospital mortality.

METHODS

We identified 522 patients between February 2006 and May 2014 and collected data about patient demographics, admission NIHSS (National Institutes of Health Stroke Scale), venous thromboembolism prophylaxis, ambulatory status, diagnosis of venous thromboembolism, and hospital outcomes (length of stay, mortality). Chi-square test, t-test and Wilcoxon rank-sum test, and binary logistic regression were used for statistical analysis as appropriate.

RESULTS

A total of 61 (11.7%), 48 (9.2%), and 23 (4.4%) mild ischemic stroke patients developed venous thromboembolism, deep venous thrombosis, and pulmonary embolism, respectively. During hospitalization, 281 (53.8%) patients were ambulatory. Independent predictors of in-hospital ambulation were being married (OR 1.64, 95% CI 1.10-2.49), being nonreligious (OR 2.19, 95% CI 1.34-3.62), admission NIHSS (per unit decrease in NIHSS; OR 1.62, 95% CI 1.39-1.91), and nonuse of mechanical venous thromboembolism prophylaxis (OR 1.62, 95% CI 1.02-2.61). After adjusting for confounders, ambulatory patients had lower rates of venous thromboembolism (OR .47, 95% CI .25-.89), deep venous thrombosis (OR .36, 95% CI .17-.73), prolonged length of hospital stay (OR .24, 95% CI .16-.37), and mortality (OR .43, 95% CI .21-.84).

CONCLUSIONS

Our findings suggest that for hospitalized acute mild ischemic stroke patients, ambulatory status is an independent predictor of venous thromboembolism (specifically deep venous thrombosis), hospital length of stay, and in-hospital mortality.

A population-based study for 30-d hospital readmissions after acute ischemic stroke

OBJECTIVE

To determine post-stroke 30-d readmission rate, its predictors, its impact on mortality and to identify potentially preventable causes of post-stroke 30-d readmission in a population-based study.

PATIENTS AND METHODS

We identified all acute ischemic strokes (AIS) using the International Classification of Diseases 9th revision codes (433.x1, 434.xx and 436) via the Rochester Epidemiology Project (REP) between January 2007 and December 2011. Acute stroke care in Olmsted County is provided by two medical centers, Saint Marys Hospital and Olmsted Medical Center Hospital. All readmissions to these two hospitals were accounted for this study. Thirty-day readmission data was abstracted through manual chart review. The REP linkage database was used to identify the status (living/dead) of all patients at last follow up.

RESULTS

Forty-one (7.6%, 95% CI 5.7%-10.2%) of total 537 AIS patients were readmitted 30-d post-stroke. In a multivariable logistic regression model, discharge to nursing home following index stroke (OR: 0.29, 95% CI 0.08-0.84) was an independent negative predictor of unplanned 30-d readmission. In a subgroup of patients with dementia, being married at time of index stroke was found to be a negative predictor of readmission (OR: 0.10, 95% CI 0.005-0.58). Only 2.8% of the patients had potentially preventable readmissions. Hospital readmission had no significant impact on patient's short-term (three months) or long-term (one or two years) mortality (p > 0.05).

CONCLUSION

Post-stroke 30-d readmission rate is low in AIS patients from Olmsted County. Further research is needed in regarding discharge checklists, protocols and stroke transitional programs to reduce potentially preventable readmissions.

Myeloid translocation genes differentially regulate colorectal cancer programs

Myeloid translocation genes (MTGs), originally identified as chromosomal translocations in acute myelogenous leukemia, are transcriptional corepressors that regulate hematopoietic stem cell programs. Analysis of The Cancer Genome Atlas (TCGA) database revealed that MTGs were mutated in epithelial malignancy and suggested that loss of function might promote tumorigenesis. Genetic deletion of MTGR1 and MTG16 in the mouse has revealed unexpected and unique roles within the intestinal epithelium. Mtgr1^−/− mice have progressive depletion of all intestinal secretory cells, and Mtg16^−/− mice have a decrease in goblet cells. Furthermore, both Mtgr1^−/− and Mtg16^−/− mice have increased intestinal epithelial cell proliferation. We thus hypothesized that loss of MTGR1 or MTG16 would modify Apc^1638/+-dependent intestinal tumorigenesis. Mtgr1^−/− mice, but not Mtg16^−/− mice, had a 10-fold increase in tumor multiplicity. This was associated with more advanced dysplasia, including progression to invasive adenocarcinoma, and augmented intratumoral proliferation. Analysis of ChIP-seq datasets for MTGR1 and MTG16 targets indicated that MTGR1 can regulate Wnt and Notch signaling. In support of this, immunohistochemistry and gene expression analysis revealed that both Wnt and Notch signaling pathways were hyperactive in Mtgr1^−/− tumors. Furthermore, in human colorectal cancer (CRC) samples MTGR1 was downregulated at both the transcript and protein level. Overall our data indicates that MTGR1 has a context dependent effect on intestinal tumorigenesis.

Abstract WP316: Incidence, Risk Factors, and In-Hospital Outcomes Associated With Hospital-Acquired Conditions and Patient Safety Indicators In Spontaneous Intracerebral Hemorrhage

Introduction: The Centers for Medicare and Medicaid Services hospital-acquired conditions (HACs) and the Agency for Healthcare Research and Quality patient safety indicators (PSIs) are standardized quality metrics linked to reimbursement. Spontaneous intracerebral hemorrhage (ICH) is associated with a poorer prognosis than other types of stroke. The incidence, risk factors, and in-hospital outcomes associated with HACs and PSIs in ICH admissions have not previously been reported.

Methods: The Nationwide Inpatient Sample was queried from 2002 to 2011 to identify all ICH patients (ICD-9-CM code 431). The incidence of HACs and PSIs was determined. Multivariable logistic regression analyzed the effect of patient and hospital factors on HAC/PSI occurrence and the effect of HAC/PSI occurrence on prolonged length of stay (defined as ≥ 75th percentile), increased hospital costs (defined as ≥75th percentile), and adverse discharge (except routine).

Results: A total of 12,870 HACs and 260,048 PSIs were identified among 643,660 hospitalizations for spontaneous ICH. The HACs with the highest incidence were falls/trauma (n=1,198), postoperative poor glycemic control (n=895), stage III/IV pressure ulcers (n=622), and iatrogenic pneumothorax (n=620). The PSIs with the highest incidence were postoperative respiratory failure (n=194,859), postoperative sepsis (n=19,045), pressure ulcer (n=17,826), and deep vein thrombosis (n=15,759). Comorbidity score (19.7%, 18.9% increase per comorbidity, p<0.0001) and Medicaid insurance (31.5%, 21.4%, p<0.0001) were independent predictors of HAC and PSI occurrence, respectively. Black race (15.7%, p<0.0001), urban hospitals (69%, p<0.0001), and teaching hospitals (35.2%, p<0.0001) were independent predictors of PSI occurrence only. Both HAC and PSI occurrence increased the odds of prolonged LOS (64.9%, 36.9%, p<0.0001), increased hospital costs (70.8%, 72.9%, p<0.0001) and adverse discharge (32%, 167.1%, p<0.0001).

Conclusion: HACs and PSIs occur frequently in ICH hospitalizations and are associated with poor in-hospital outcomes. Awareness of the factors that increase the likelihood of incurring HACs and PSIs may contribute to new quality protocols targeted at these factors.

Abstract TP126: Intraoperative Neurophysiological Monitoring in Carotid Endarterectomy: An Analysis of the Nationwide Inpatient Sample

Introduction: Carotid endarterectomy (CEA) is an effective treatment for symptomatic carotid stenosis (CS) but the ischemic complications of the procedure can be detrimental. Intraoperative neurophysiological monitoring (IONM) is used to protect neural structures during surgery. The incidence, predictors, and in-hospital outcomes associated with the use of IONM in CEA have not previously been reported.

Methods: The Nationwide Inpatient Sample from 2007 to 2011 was queried to identify cases of CEA procedures (ICD-9-CM code 38.12) accompanied by occlusion or stenosis of the precerebral arteries (ICD-9-CM codes 433.10-1). Independent predictors of IONM utilization (ICD-9-CM code 00.94), perioperative/postoperative stroke, prolonged length of stay (LOS; defined as ≥ 75th percentile), increased hospital costs (defined as ≥ 75th percentile), and in-hospital mortality were identified using multivariable logistic regression analyses.

Results: A total of 518,685 CEA procedures for CS were identified. The utilization of IONM (0.74%) increased from 0.06% in 2007 to 1.74% in 2011 (P<0.0001). Multivariate predictors of IONM, adjusted for demographics, hospital characteristics, comorbidities, and presentation of symptoms, included increasing comorbidity score (OR: 1.045, 95% CI: 1.01-1.08, P=0.004), African American race (OR: 1.59, 95% CI: 1.36-1.85, P<0.0001), Medicaid status (OR: 1.35, 95% CI: 1.11-1.63, P<0.0001), large hospital bed size (OR: 3.70, 95% CI: 3.03-4.51, P<0.0001), urban location (OR: 4.97, 95% CI: 3.50-4.51, P<0.0001), teaching hospital status (OR: 3.56, 95% CI: 3.24-3.91, P<0.0001) and weekend admission (OR: 1.25, 95% CI: 1.04-1.49, P=0.015). The utilization of IONM decreased the likelihood of perioperative/postoperative stroke (OR: 0.61, 95% CI: 0.38-0.97, P=0.036) and in-hospital mortality (OR: 0.37, 95% CI: 0.15-0.89, P=0.027). The use of IONM increased the likelihood of prolonged LOS (OR: 1.21, 95% CI: 1.72-2.28, P<0.0001) and total hospital costs (OR: 1.98, 95% CI: 1.72-2.28, P<0.0001).

Conclusion: The use of IONM in CEA has increased over time. The utilization of IONM was shown to decrease perioperative/postoperative stroke and in-hospital mortality rates while increasing LOS and hospital costs.

Abstract TP161: Gastrointestinal Bowel Obstruction in Acute Ischemic Stroke: Incidence, Risk Factors, and Outcomes

Introduction: The prognosis of patients suffering acute ischemic stroke (AIS) is worsened by medical complications that occur during subsequent hospitalization. The incidence, risk factors, and outcomes of gastrointestinal bowel obstruction (GIBO) in AIS have not been previously reported.

Methods: We employed the Nationwide Inpatient Sample from 2002 to 2011 to identify all patients admitted with a primary diagnosis of AIS and subsets with and without a secondary diagnosis of GIBO without hernia. Multivariate logistic regression was utilized to analyze predictors of GIBO in AIS patients and the association between GIBO, in-hospital complications, and outcomes.

Results: We identified 16,987 patients with GIBO (425 per 100,000) among 3,988,667 AIS hospitalizations and 4.2% of patients of these patients underwent repair surgery for intestinal obstruction. Multivariate predictors of GIBO included: age 55-64 (OR: 1.52, 95% CI: 1.40-1.64), age 65-74 (OR: 1.69, 95% CI: 1.56-1.84), age 75+ (OR: 1.97, 95% CI: 1.81-2.13), black race (OR: 1.42, 95% CI: 1.36-1.49), coagulopathy (OR: 1.39, 95% CI: 1.29-1.50), cancer (OR: 1.59, 95% CI: 1.44-1.75), blood loss anemia (OR: 2.51, 95% CI: 2.22-2.84), fluid/electrolyte disorder (OR: 2.91, 95% CI: 2.81-3.02), weight loss (OR: 3.08, 95% CI: 2.93-3.25), and thrombolytic therapy (OR: 1.30, 95% CI: 1.20-1.42) (all p<0.0001). Patients with GIBO had a greater likelihood of suffering intubation (OR: 1.79, 95% CI: 1.70-1.90), deep vein thrombosis (OR: 1.35, 95% CI: 1.25-1.46), pulmonary embolism (OR: 1.84, 95% CI: 1.53-2.21), sepsis (OR: 2.39, 95% CI: 2.22-2.56), acute kidney injury (OR: 1.85, 95% CI: 1.76-1.95), gastrointestinal hemorrhage (OR: 2.82, 95% CI: 2.63-3.03), and blood transfusions (OR: 2.02, 95% CI: 1.90-2.15) (all p<0.0001). In adjusted analyses, AIS patients with GIBO were 284% and 39% more likely to face moderate to severe disability and in-hospital death, respectively (p<0.0001). GIBO occurrence increased length of stay and total costs by an average of 9.7 days and $22,342 (p<0.0001).

Conclusion: Advanced age, black race, and several pre-existing comorbidities increase the likelihood of post-AIS GIBO, which is an independent predictor of in-hospital complications, disability, and mortality.

Abstract TP316: Appraising the Quality of Patient Care in Hospitalization for Transient Ischemic Attack

Introduction: The Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSIs) and the Centers for Medicare and Medicaid Services (CMS) hospital-acquired conditions (HACs) are federally implemented quality metrics. The necessity of hospitalization for transient ischemic attack (TIA) remains controversial. Here, we report the incidence, risk factors, and in-hospital outcomes associated with HACs and PSIs in this population.

Methods: The Nationwide Inpatient Sample (2002-2011) was queried for all records coded as primary diagnoses of TIA. The impact of demographics, insurance status, comorbidities, and in-hospital procedures on the occurrence of PSIs and HACs and the effect of these events on length of stay (LOS), hospital costs, and mortality was examined in bivariate and multivariate analyses.

Results: A total of 52,969 PSIs and 21,612 HACs were identified among 2,117,247 TIA hospitalizations. The most frequent PSIs were pressure ulcers (1,173 per 100,000 patients), deep vein thrombosis (376 per 100,000 patients), and respiratory failure (329 per 100,000 patients) while the most frequent HACs were falls/trauma (942 per 100,000 patients), poor glycemic control (33 per 100,000 patients), and stage III/IV pressure ulcers (31 per 100,000 patients). In adjusted analyses, age 85+ (odds ratios [ORs]: 3.81, 1.50), Medicare (ORs: 1.62, 1.37), Medicaid (ORs: 2.01, 1.34), and 3+ comorbidities (ORs: 2.83, 1.30) were independent predictors of PSI or HAC occurrence, respectively (all p<0.0001). Adjusted risk factors of PSI occurrence included: black race (OR: 1.21), in-hospital ischemic stroke (OR: 1.97), thrombolytic therapy (OR: 2.54), coronary angioplasty (OR: 1.81), and coronary artery bypass graft (OR: 7.18) (all p<0.0001). PSI or HAC in TIA patients independently predicted prolonged LOS, increased total costs, and adverse discharges (all p<0.0001). In TIA patients suffering a PSI or HAC, odds of mortality were increased by factors of 30.1 and 4.08, respectively (all p<0.0001).

Conclusion: Among TIA hospitalizations, patient age, race, payer status, pre-existing comorbidity, hospital characteristics, and procedural management significantly impact the occurrence of PSIs and HACs, further affecting patient outcomes.

Abstract 137: Gastrointestinal Bleeding in Acute Ischemic Stroke: A Nationwide Inpatient Sample Study

Introduction: Gastrointestinal bleeding (GIB) has been reported as a complication in acute cerebrovascular ailments. Here, we examined the incidence, risk factors, and outcomes of GIB in acute ischemic stroke (AIS) using the largest all-payer inpatient database in the U.S.

Methods: The Nationwide Inpatient Sample (2002-2011) was queried to identify all adult patients with a primary diagnosis of AIS both with and without a secondary diagnosis of GIB. We utilized multivariate analyses, adjusting for patient and hospital factors, to identify risk factors for GIB in AIS patients and to determine the effect of GIB on in-hospital complications and outcomes.

Results: Of 3,988,667 patients admitted with AIS, there were 49,348 cases of GIB (1,237 per 100,000 patients) with 25.7% receiving blood transfusions. Multivariate analysis revealed several independent predictors of GIB in AIS: age 55-64 (OR: 1.39, 95% CI: 1.33-1.45), age 65-74 (OR: 1.52, 95% CI: 1.44-1.59), age 75+ (OR: 1.79, 95% CI: 1.71-1.88), alcohol use (OR: 1.23, 95% CI: 1.17-1.30), coagulopathy (OR: 1.69, 95% CI: 1.62-1.77), cancer (OR: 1.70, 95% CI: 1.60-1.80), fluid/electrolyte disturbance (OR: 1.91, 95% CI: 1.87-1.96), liver disease (OR: 2.44, 95% CI: 2.29-2.60), and history of peptic ulcer disease (OR: 2.47, 95% CI: 2.13-2.86) (all p<0.0001). Administration of thrombolytic therapy decreased the likelihood of GIB by 10% (p<0.0001). In further multivariate models, GIB was determined to be an independent predictor of septicemia (OR: 1.47, 95% CI: 1.39-1.55), gastrostomy (OR: 1.75, 95% CI: 1.70-1.81), pulmonary embolism (OR: 1.75, 95% CI: 1.55-2.00), intubation (OR: 2.04, 95% CI: 1.95-2.13), and blood transfusion (OR: 11.31, 95% CI: 11.00-11.63; all p<0.0001). The occurrence of GIB increased hospital length of stay by an average of 5.8 days and total costs by $14,120 per patient (all p<0.0001). GIB was independently associated with a 46% increased likelihood of severe disability and 82% increased likelihood of in-hospital death (all p<0.0001).

Conclusion: Age and several preexisting comorbidities are strong risk factors for GIB in AIS. GIB occurrence precipitates further in-hospital complications and adverse clinical outcomes in AIS, significantly increasing disability and mortality.

In Children and Youth with Mild and Moderate Traumatic Brain Injury, Glial Fibrillary Acidic Protein Out-Performs S100β in Detecting Traumatic Intracranial Lesions on Computed Tomography

In adults, glial fibrillary acidic protein (GFAP) has been shown to out-perform S100β in detecting intracranial lesions on computed tomography (CT) in mild traumatic brain injury (TBI). This study examined the ability of GFAP and S100β to detect intracranial lesions on CT in children and youth involved in trauma. This prospective cohort study enrolled a convenience sample of children and youth at two pediatric and one adult Level 1 trauma centers following trauma, including both those with and without head trauma. Serum samples were obtained within 6 h of injury. The primary outcome was the presence of traumatic intracranial lesions on CT scan. There were 155 pediatric trauma patients enrolled, 114 (74%) had head trauma and 41 (26%) had no head trauma. Out of the 92 patients who had a head CT, eight (9%) had intracranial lesions. The area under the receiver operating characteristic curve (AUC) for distinguishing head trauma from no head trauma for GFAP was 0.84 (0.77-0.91) and for S100β was 0.64 (0.55-0.74; p<0.001). Similarly, the AUC for predicting intracranial lesions on CT for GFAP was 0.85 (0.72-0.98) versus 0.67 (0.50-0.85) for S100β (p=0.013). Additionally, we assessed the performance of GFAP and S100β in predicting intracranial lesions in children ages 10 years or younger and found the AUC for GFAP was 0.96 (95% confidence interval [CI] 0.86-1.00) and for S100β was 0.72 (0.36-1.00). In children younger than 5 years old, the AUC for GFAP was 1.00 (95% CI 0.99-1.00) and for S100β 0.62 (0.15-1.00). In this population with mild TBI, GFAP out-performed S100β in detecting head trauma and predicting intracranial lesions on head CT. This study is among the first published to date to prospectively compare these two biomarkers in children and youth with mild TBI.

Performance of Glial Fibrillary Acidic Protein in Detecting Traumatic Intracranial Lesions on Computed Tomography in Children and Youth With Mild Head Trauma

OBJECTIVES

This study examined the performance of serum glial fibrillary acidic protein (GFAP) in detecting traumatic intracranial lesions on computed tomography (CT) scan in children and youth with mild and moderate traumatic brain injury (TBI) and assessed its performance in trauma control patients without head trauma.

METHODS

This prospective cohort study enrolled children and youth presenting to three Level I trauma centers following blunt head trauma with Glasgow Coma Scale (GCS) scores of 9 to 15, as well as trauma control patients with GCS scores of 15 who did not have blunt head trauma. The primary outcome measure was the presence of intracranial lesions on initial CT scan. Blood samples were obtained in all patients within 6 hours of injury and measured by enzyme-linked immunosorbent assay for GFAP (ng/mL).

RESULTS

A total of 257 children and youth were enrolled in the study and had serum samples drawn within 6 hours of injury for analysis: 197 had blunt head trauma and 60 were trauma controls. CT scan of the head was performed in 152 patients and traumatic intracranial lesions on CT scan were evident in 18 (11%), all of whom had GCS scores of 13 to 15. When serum levels of GFAP were compared in children and youth with traumatic intracranial lesions on CT scan to those without CT lesions, median GFAP levels were significantly higher in those with intracranial lesions (1.01, interquartile range [IQR] = 0.59 to 1.48) than those without lesions (0.18, IQR = 0.06 to 0.47). The area under the receiver operating characteristic curve (AUC) for GFAP in detecting children and youth with traumatic intracranial lesions on CT was 0.82 (95% confidence interval [CI] = 0.71 to 0.93). In those presenting with GCS scores of 15, the AUC for detecting lesions was 0.80 (95% CI = 0.68 to 0.92). Similarly, in children under 5 years old the AUC was 0.83 (95% CI = 0.56 to 1.00). Performance for detecting intracranial lesions at a GFAP cutoff level of 0.15 ng/mL yielded a sensitivity of 94%, a specificity of 47%, and a negative predictive value of 98%.

CONCLUSIONS

In children and youth of all ages, GFAP measured within 6 hours of injury was associated with traumatic intracranial lesions on CT and with severity of TBI. Further study is required to validate these findings before clinical application.

Effect of Hispanic ethnicity and language barriers on appendiceal perforation rates and imaging in children

OBJECTIVE

To determine the association between Hispanic ethnicity and limited English proficiency (LEP) and the rates of appendiceal perforation and advanced radiologic imaging (computed tomography and ultrasound) in children with abdominal pain.

STUDY DESIGN

We performed a secondary analysis of a prospective, cross-sectional, multicenter study of children aged 3-18 years presenting with abdominal pain concerning for appendicitis between March 2009 and April 2010 at 10 tertiary care pediatric emergency departments in the US. Appendiceal perforation and advanced imaging rates were compared between ethnic and language proficiency groups using simple and multivariate regression models.

RESULTS

Of 2590 patients enrolled, 1001 (38%) had appendicitis, including 36% of non-Hispanics and 44% of Hispanics. In multivariate modeling, Hispanics with LEP had a significantly greater odds of appendiceal perforation (OR, 1.44; 95% CI, 1.20-1.74). Hispanics with LEP with appendiceal perforation of moderate clinical severity were less likely to undergo advanced imaging compared with English-speaking non-Hispanics (OR, 0.64; 95% CI, 0.43-0.95).

CONCLUSION

Hispanic ethnicity with LEP is an important risk factor for appendiceal perforation in pediatric patients brought to the emergency department with possible appendicitis. Among patients with moderate clinical severity, Hispanic ethnicity with LEP appears to be associated with lower imaging rates. This effect of English proficiency and Hispanic ethnicity warrants further investigation to understand and overcome barriers, which may lead to increased appendiceal perforation rates and differential diagnostic evaluation.

Should infants presenting with an apparent life-threatening event undergo evaluation for serious bacterial infections and respiratory pathogens?

We sought to identify which patients with an apparent life-threatening event require infectious evaluation through an analysis of infants aged ≤12 months brought to an emergency department with an apparent life-threatening event. Among the 533 children evaluated, there were no cases of meningitis, 1 case of bacteremia, 17 cases of urinary tract infection, 22 cases of bacterial pneumonia, 22 cases of respiratory syncytial virus, and 2 cases of influenza virus identified in respiratory specimens.

Association of the Position of the Copper T 380A as Determined by the Ultrasonography Following its Insertion in the Immediate Postpartum Period with the Subsequent Complications: An Observational Study

PURPOSE

Incorrectly placed copper T 380A leads to increased contraception failure. This study aimed to find an association between the ultrasonographic position of the copper T 380A in the immediate postpartum period and the adverse effects observed during the period of 6 months after its insertion.

METHODS

This descriptive study was carried out in the Department of Obstetrics & Gynaecology of a tertiary-care-center of India from September 2011 to February 2013. The women eligible for immediate postpartum copper T 380A insertion with previous regular menstrual cycles for at least 6 months before the current pregnancy, and those who were willing for follow-up visits and had easy accessibility to the hospital, were recruited. A clinical evaluation and ultrasonographic assessment of Intra-Uterine-Contraceptive-Device (IUCD) after insertion was carried out after enrolment. The complications (expulsions, vaginal discharge, menstrual irregularity, and lower abdominal pain) were subsequently assessed during a 6-month follow-up period. The primary objective was the ultrasonographic assessment of the placement of IUCD immediately after insertion. The incidence of complications and their association with the presence of malposition was also studied.

RESULTS

Hundred patients were evaluated during the study period. Forty-four (44 %) women were found to have malpositioned IUCDs on ultrasonographic evaluation done following insertion. The complications among the IUCD users included menstrual irregularity (27.17 %), pain in lower abdomen (20.65 %), vaginal discharge (7.6 %), and expulsions (9.7 %). The IUCD expulsions, menstrual irregularities, and pain were significantly more in patients with malpositions (p < 0.05).

CONCLUSIONS

Malpositioning of IUCD is common immediately following insertion and is significantly associated with more complications during the follow-up.

Do infants less than 12 months of age with an apparent life-threatening event need transport to a pediatric critical care center?

BACKGROUND

Some emergency medical services (EMS) systems transport infants with an apparent life-threatening event (ALTE) directly to hospitals capable of pediatric critical care (PCC) monitoring.

OBJECTIVE

To describe factors identifiable by EMS providers that distinguish ALTE patients who may require PCC monitoring and management.

METHODS

This was an observational analysis of ALTE patients who were transported by EMS and presented to four emergency departments (EDs). ED data were prospectively collected. Hospital records or reports from contacted parents were reviewed for interventions that mandated PCC management. We defined a priori the criteria by which PCC monitoring and management were required: if the subject needed 1) airway intervention with bag-valve-mask ventilation or advanced airway (e.g., endotracheal intubation) in the field, ED, or pediatric intensive care unit (PICU); 2) administration of vasopressors; 3) invasive monitoring; 4) surgery during the hospitalization; or 5) subspecialty consultation. Univariate analysis was performed to describe factors associated with requiring PCC management, and a multivariable model, accounting for within-hospital correlations, was developed.

RESULTS

A total of 513 patients were enrolled. Of these, 51 (9.9%) had an intervention warranting PCC management. Univariate predictors for requiring PCC management included prematurity, past medical history, resuscitation attempt, upper respiratory infection, apnea, previous ALTE, more than one ALTE in 24 hours, and cyanosis. The multivariable model yielded the following independent predictors for requiring PCC management: resuscitation attempt before EMS arrival, cyanosis, and more than one ALTE in 24 hours. This model demonstrated a sensitivity of 96.3%, a specificity of 25.8%, a negative predictive value of 98.3%, and a positive predictive value of 13.5%.

CONCLUSION

Only 9.9% of infants presenting in the field with ALTE had an intervention warranting PCC management, suggesting that many ALTE patients may be safely transported to hospitals without PCC capability. This would allow for better resource utilization of specialty care hospitals and still provide an option for secondary transports for those few patients not correctly identified in the field as requiring PCC. History of resuscitation attempt, cyanosis, and more than one ALTE in 24 hours are independent risk factors for requiring PCC management.

Transient ischemic attacks: predictability of future ischemic stroke or transient ischemic attack events

The short-term risk of an ischemic stroke after a transient ischemic attack (TIA) is estimated to be approximately 3%–10% at 2 days, 5% at 7 days, and 9%–17% at 90 days, depending on active or passive ascertainment of ischemic stroke. Various risk prediction scores are available to identify high-risk patients. We present here a pragmatic review of the literature discussing the main scoring systems. We also provide the sensitivity, specificity, positive predictive value, and negative predictive value for each scoring system. Our review shows that scoring systems including brain imaging and vascular imaging are better at risk prediction than scores that do not include this information.