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Pediatrics

EEG and ECG are overused in children with breath-holding spells – Contemporary Pediatrics

EEG and ECG are overused in children with breath-holding spells | Image Credit: Contemporary Pediatrics

Electrocardiography (ECG) and electroencephalography (EEG) studies are conducted far more often than is necessary in children who experience breath-holding spells (BHSs). This was the main finding of a retrospective study in 519 Swedish patients younger than 10 years who were diagnosed with BHS during a 15-year period.

In most patients, BHS began and was diagnosed before the age of 2 years, and 26 patients (2.6%) were 3 months or younger at onset. Of the 61 children (11.8%) with comorbidities, asthma was the most frequent culprit. Anger was the most common trigger (in approximately half of patients), followed by pain and head trauma. Many patients were unresponsive during a spell; 43.4% experienced unconsciousness and 71.5% had seizures.

As for diagnostic procedures, although EEG was performed in 30.4% of patients, the study findings indicated pathology in only 6 children (3.6%), 4 of whom received a concomitant epilepsy diagnosis. An ECG was performed in 45.1% of patients, with pathology indicated in only 2 patients (0.9%). Blood samples were investigated at diagnosis in 37.2% of patients, and 10 patients (5.6%) had anemia, 2 of whom had iron deficiency. Another 13 patients had signs of iron deficiency.

Based on these results and those of earlier studies, investigators developed an algorithm indicating that only 7.7% of patients with BHS require an ECG at BHS diagnosis, a much lower proportion than the 45.1% of those who had undergone the test in the study sample. In addition, although almost one-third of children in the study group received an EEG, the algorithm would have called for the EEG in none of these children because they all had typical spells. Investigators also noted that they found pathological hemoglobin and iron levels in many patients who underwent blood analysis. As a result, their algorithm suggests an increase in blood sampling to recognize iron deficiency and anemia.

THOUGHTS FROM DR FARBER:

I was taught that a classic BHS, diagnosed by careful history, did not require any workup.Findings from this study support this with a useful algorithm, although it does suggest testing for iron deficiency (simple enough to do) in children with more than 1 episode.The authors do not routinely recommend an EEG, even though more than 70% of children (a huge number in my experience) had seizures with the BHS. Reference:

Schmidt SH, Smedenmark J, Jeremiasen I, Sigurdsson B, Eklund EA, Pronk CJ. Overuse of EEG and ECG in children with breath-holding spells and its implication for the management of the spells. Acta Paediatr. 2024;113(2):317-326. doi:10.1111/apa.17020

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EEG and ECG are overused in children with breath-holding spells - Contemporary Pediatrics

Pediatrics

New Close To Home Center to Open in Grove City – Newswise

Newswise (COLUMBUS, Ohio) Nationwide Childrens Hospital announced plans today to expand its Close To Home network by opening a new center in Grove City. The new center will expand convenient access to urgent care and specialized pediatric services for families in Grove City and surrounding areas.

Planned services at the center, to be located at 1350-1370 Stringtown Road east of Interstate 71, include urgent care, lab services, imaging and EKG testing, and clinical therapies. The Grove City Close To Home Center is anticipated to open in 2026.

Central Ohio continues to grow, and Nationwide Children's wants to provide the best access to pediatric care for the entire region, said Tim Robinson, chief executive officer of Nationwide Childrens Hospital. Our new Close To Home Center in Grove City will help more children receive the care they need, when they need it.

Close To Home centers offer community-based diagnostic and therapeutic services for newborns, children and young adults, with services varying by location. Nationwide Childrens currently operates 23 Close To Home centers in central Ohio, with plans to open locations in Zanesville and Athens this year.

We and our children are truly blessed to welcome a Nationwide Childrens Hospital Close To Home center with urgent care to our community, said Grove City Mayor Richard L. Ike Stage. For 130 years, Childrens has provided the highest level of care for every child in need, now caring for children in 45 countries across the globe.

About Nationwide Childrens Hospital

Named to the Top 10 Honor Roll on U.S. News & World Reports 2023-24 list of Best Childrens Hospitals, Nationwide Childrens Hospital is one of Americas largest not-for-profit free-standing pediatric health care systems providing unique expertise in pediatric population health, behavioral health, genomics and health equity as the next frontiers in pediatric medicine, leading to best outcomes for the health of the whole child. Integrated clinical and research programs, as well as prioritizing quality and safety, are part of what allows Nationwide Childrens to advance its unique model of care. Nationwide Childrens has a staff of more than 14,000 that provides state-of-the-art wellness, preventive and rehabilitative care and diagnostic treatment during more than 1.7 million patient visits annually. As home to the Department of Pediatrics of The Ohio State University College of Medicine, Nationwide Childrens physicians train the next generation of pediatricians and pediatric specialists. The Abigail Wexner Research Institute at Nationwide Childrens Hospital is one of the Top 10 National Institutes of Health-funded free-standing pediatric research facilities. More information is available at NationwideChildrens.org.

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New Close To Home Center to Open in Grove City - Newswise

Emergency Medicine

Emergency Docs at "Breaking Point" — Demand Action – Franklin Observer

(Image courtesy of American College of Emergency Physicians)

The overwhelming majority of emergency department (ED)physicians across the country have experienced, witnessed or been subjected to threats, abuse, assault and injury during their shifts, said Dr. Melisa Lai-Becker, chief of Mass General Brigham Community Emergency Medicine. Under existing law, a nurse can be punched and kicked by a patient or visitor and the crime is classified as simple assault, which is a misdemeanor, rather than a felony charge of assault and battery with a dangerous weapon, she said.

"There are, unfortunately, many people who have come at us, who knowingly and willingly have assaulted us and our staff, and they are our patients, and they have committed only a misdemeanor," Lai-Becker said. "And we call the police, and the police are just as frustrated. Our partners in law enforcement, they also tell us, 'I am sorry, this is a misdemeanor, I am not allowed to take them away, I can't take them into custody.'"

Instead, Lai-Becker said, violent patients end up staying at the hospital and taunting health care workers, whose colleagues may be admitted for care themselves after an attack.

Emergency physicians looking to strengthen safety protections for health care workers and stiffen penalties for assault charges had a powerful ally on hand during their Beacon Hill lobby day Thursday.

"I don't sponsor many bills because I'm the majority leader, but this bill was important to me," House Majority Leader Michael Moran said about his bid to crack down on violence in health care settings as he described learning about the issue from advocates. "We have a few months left in this session. It is my hope that we get this out of Health Care Finance -- which I believe is the committee it's in right now; it was reported to that committee from Public Safety -- and see if we can get this across the line between now and the end of July."

Moran's bill (H 2381) was reported favorably out of the Joint Committee on Public Safety and Homeland Security on May 22 and sent to the Joint Committee on Health Care Financing. It would create standards for hospitals to evaluate security risks, require hospitals to develop violence prevention plans, implement mandatory and protected reporting protocols tied to safety incidents, and classify assaults against health care providers and first responders as a felony.

Doctors and residents with the Massachusetts College of Emergency Physicians are also prioritizing their advocacy around overhauling the involuntary commitment landscape for individuals grappling with alcohol and substance use disorders, and establishing a 10-year pilot program for overdose prevention centers to stem the tide of opioid-related overdose deaths. Those proposals have gained some traction among legislators, but still need key committee votes to advance to the floor for debate before the end of formal sessions next month.

Physicians made their requests to lawmakers against the backdrop of deteriorating health care conditions, including the protracted emergency room boarding crisis that's leading to poorer outcomes for patients, avoidable deaths, burnout for providers and a worsening workforce shortage. The circumstances are making physicians feel like they are doing a "terrible" job and that the health care system is collapsing, said Dr. Joseph Kopp, an emergency physician at Faulkner Hospital and Brigham and Women's Hospital.

"It is at a breaking point. We can't solve the issues that we're having right now when we're trying to see patients in the waiting room," Kopp said. "Hospitals are trying different innovative ways to do this; whether it's hallway care upstairs or early discharges, there's lots of things that they can do. But quite frankly, it's going to take the government and legislative processes to actually fix this issue."

During their legislative briefing, MACEP advocates also sought to generate momentum for an involuntary commitment reform bill from Rep. Ruth Balser (H 1966), which is accompanied by a similar proposal from Sen. Cindy Friedman (S 1247). The legislation, which has been in the House Ways and Means Committee since mid-April, would block the state from sending men to correctional facilities when they are committed for alcohol and substance use disorder treatment.

The overhaul to what's known as Section 35, which physicians said is often seen as a last resort for families looking to keep their loved ones safe, would require men instead to go to treatment facilities administered by the Department of Public Health and the Department of Mental Health. Advocates said officials rely on prison beds when there's a shortage of space in more appropriate treatment settings, though Balser's bill would require the state to maintain an adequate bed supply for men under Section 35.

Women who are involuntarily committed under Section 35 stopped being sent to prisons in 2016, advocates said.

"Massachusetts is the only state in the country that sends individuals to carceral facilities -- the only one that will send them to jails to have this treatment. No other state does this," Dr. Scott Weiner, an emergency physician at Brigham and Women's Hospital, said.

"It's not the best place to be treated for this disease," Weiner continued. "Does it work? Short answer: No. Systematic reviews show that there's no evidence of benefit, and we know that when people get out of a carceral facility, their risk of overdose markedly increases."

Focusing on prevention strategies to tackle the opioid epidemic, emergency physicians support controversial bills to establish overdose prevention centers, where trained professionals are available and can intervene in overdose situations.

Proposals from Reps. Dylan Fernandes and Marjorie Decker and Sen. Julian Cyr (H 1981 / S 1242) that pave a path for the centers, also known as supervised injection sites, have been lodged in the House and Senate Ways and Means committees for months.

Boston could save $4 million annually if the city had an overdose prevention center, by cutting costs from ambulance rides, emergency department visits and hospitalizations, Weiner said, referencing a past study.

"Large studies have shown that there's no harm in using safe injection facilities. In fact, there are reductions in morbidity and mortality, improvement in harm reduction behaviors, there's more access to addiction treatment programs," Weiner said.

Cities and towns that want to open safe injection sites would still need approval from their local boards of health under the bills.

"It's not a mandate. There's a ton of requirements about what they need to provide to patients," Weiner told advocates ahead of their meetings with lawmakers. "We hope that people in this room to influence policy will help move it forward."

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Emergency Docs at "Breaking Point" -- Demand Action - Franklin Observer

Emergency Medicine

New study finds significant increase in heat-related ER visits last year: ‘Every year now we’re doing this earlier and earlier’ – The Cool Down

In 2023, record-breaking heat caused an increase in the number of people visiting the emergency room with heat-related illnesses, according to a Centers for Disease Control and Prevention study detailed by The New York Times.

A recent study by the CDC found that the rate of emergency room visits caused by heat illness increased significantly last year in many areas of the country compared to the previous five years.

The data, collected from an electronic surveillance program used by the government to detect the spread of diseases, showed nearly 120,000 heat-related emergency room visits. More than 90% of these occurred between May and September. The highest number of visits were recorded in the South, in states such as Arkansas, Louisiana, New Mexico, Oklahoma, and Texas.

2023 broke a lot of heat records. According to information from the National Oceanic and Atmospheric Administration, 2023 was the warmest year on Earth since global record-keeping began, and the U.S. experienced its 15th-hottest summer since record-keeping began. Some states felt the heat more than others Louisiana recorded its hottest summer ever, and it was among the top 10 hottest summers in six other states, per Yale Climate Connections.

Climate scientists have been warning for decades about the dangers of a warming planet. Every year we are seeing more deadly heat-related events, such as the astonishing 125-degree heat index that occurred in Puerto Rico last June.

This is having an impact on health. Heat illness often creeps up on people gradually over a few hours and requires immediate attention to cool the body down. Without treatment, it can cause major damage to the body's organs.

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Early symptoms of heat exhaustion include fatigue, dehydration, nausea, headaches, increased heart rate, and muscle spasms.

Trying to keep cool as the temperatures soar is the best way to avoid harm. State officials are working to coordinate cooling shelters in some areas, while in others hospitals are already trying to ensure they are ready to cope with the number of heat illness patients they are expecting this year.

Dr. Aneesh Narang, an emergency medicine specialist at Banner-University Medical Center in Phoenix, told the Times: "Every year now we're doing this earlier and earlier. We know that the chances are it's going to be the same or worse."

There are several ways we can all contribute to reducing the pollution that is causing global warming.

Using public transport or driving electric vehicles, reducing energy consumption, switching to renewable energies, and buying local produce are all steps that one can take to help cool the planet down.Voting for pro-climate candidates and taking local action can also ensure that our governments are working to reduce climate issues and help secure a more sustainable future for our planet.

Join our free newsletter for cool news and cool tips that make it easy to help yourself while helping the planet.

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New study finds significant increase in heat-related ER visits last year: 'Every year now we're doing this earlier and earlier' - The Cool Down

Emergency Medicine

RightCare Clinic offers patients emergency services at better value – Grand Rapids Business Journal

A physician group that staffs emergency rooms at hospitals including Corewell Health plans to open its own Grand Rapids clinic next month offering a new model for care that it hopes could expand to additional locations.

Emergency Care Specialists P.C.s RightCare Clinic will provide a level of care above whats available at an urgent care center, yet below what hospitals provide in an emergency room for cases such as trauma injuries, strokes and heart attacks.

RightCare Clinic will include services such as medical imaging X-ray, CT, and diagnostic ultrasound diagnostic labs and cardiac monitoring that urgent care centers lack and refer patients to a hospital to access.

We know there are a lot of things in the ED that could be seen elsewhere if there was the right provider mix, the right available tests and treatment, and those sorts of things, John Throop, president of Emergency Care Specialists, told Crains Grand Rapids Business. Wereintermediating ourselves between the urgent care and the ED, providing a higher level of service without having to do the strokes and the traumas and the heart attacks and those things.

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Emergency medicine physicians will staff the new RightCare Clinic when it is scheduled to open on July 8 in a former West Michigan Cardiology P.C. location at East Beltline Avenue and Bradford Street NE, just north of I-96.

Emergency Care Specialists projects serving 3,400 patients in the first six months of operations.

Conditions the clinic will handle range from minor injuries and illnesses to evaluations for patients with chest and abdominal pain, cardiac monitoring, and intravenous infusions and medication administration. The clinic will refer patients who need a higher level of care to a hospital.

Lacking the cost structure of a hospital and the facility fees that typically accompany an emergency room visit, which is on top of the physician fee, the clinic can provide much of what patients would otherwise get at an ER and for a lower cost, exexutives at Emergency Care Specialists said.

Where we came up with this concept is in realizing that the emergency department is an expensive place of care, largely from the hospital charge and were not a big portion of that equation on the physician side of things and looking for alternatives as patients and employers and patients look for better costs for areas of care, Throop said. The difference with this is its going to be near-ED clinical services without that large facility fee associated with it. We think its a better value.

A 2023 report by prescription service provider Universal Drugstore estimated the average cost of a Michigan ER visit at $1,273. Another analysis this year by benefits company Mira Health pegs the cost at $1,393. Other studies show the cost is much higher, sometimes double, for patients who lack health insurance.

This is going to save a lot of people a lot of money, said Dr. Todd Chassee, vice president of clinical services at Emergency Care Specialists and medical director for RightCare Clinic.

The 40-year-old Emergency Care Specialists staffs emergency rooms at 13 hospitals across the state, including Corewell Health and McLaren Health Care. The group employs nearly 200 physicians and 100 advanced practitioners who treat about 500,000 patients annually. The group also contracts with Cherry Health in Grand Rapids.

RightCare will not operate as a walk-in clinic, but rather focus on same- or next-day patient referrals and appointments, although staff will still accept patients who come in without scheduling an appointment or calling ahead of time, Throop said.

He added that Emergency Care Specialists is close to finalizing agreements with Priority Health and Blue Cross Blue Shield of Michigan to reimburse for members care.

Emergency Care Specialists also has been examining direct contracting with employers, particularly with large self-funded employers who operate their own on-site of near-site employee primary care clinics, Throop said.

If the RightCare Clinic model proves successful, Emergency Care Specialists will examine whether to open more locations in the region.

If this goes how we think it is going to go, therell be more RightCares, Throop said. Well need to see that its sustainable financially. It doesnt have to be operating with a huge margin. It needs to be sustainable and needs to be providing a quality service and doing what we envision that it was going to do in terms of access, convenience and cost.

Expanding hours beyond whats presently planned or adding additional locations will hinge on validating the model behind RightCare, Chassee said.

If we can prove the concept, then we can grow, he said.

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RightCare Clinic offers patients emergency services at better value - Grand Rapids Business Journal

Emergency Medicine

Using SI and DSI to Predict Septic Shock in Patients with Sepsis at ED Triage – Physician’s Weekly

The following is a summary of Predicting septic shock in patients with sepsis at emergency department triage using systolic and diastolic shock index, published in the April 2024 issue of Emergency Medicine by Jeon, et al.

Identifying patients at high risk of progressing to septic shock is crucial for timely intervention and improved outcomes. In the pathophysiology of septic shock, systemic vasodilation plays a pivotal role, prompting interest in utilizing diastolic blood pressure (DBP) as a potential predictor. For a study, researchers hypothesized that initial shock index (SI) and diastolic SI (DSI) measured at the emergency department (ED) triage could serve as predictive indicators for septic shock.

The observational study utilized data from a prospectively collected sepsis registry. The primary outcome assessed was the progression to septic shock, while secondary outcomes included time to vasopressor requirement, vasopressor dose, and disease severity based on SI and DSI. Patients were categorized into tertiles based on the first principal component of the shock index and diastolic shock index.

A total of 1,267 patients were analyzed. The area under the receiver operating characteristic curve (AUC) for predicting progression to septic shock was 0.717 for DSI and 0.707 for SI. These AUC values were significantly higher than those for conventional early warning scores. The middle tertile exhibited an adjusted odds ratio (aOR) of 1.448 (95% CI 1.0741.953), while the upper tertile showed an aOR of 3.704 (95% CI 2.2994.111) for progression to septic shock.

Both SI and DSI emerged as significant predictors of progression to septic shock, with DSI also showing an association with vasopressor requirement. Stratifying patients into lower, middle, and upper tertiles based on these indices could provide a simple risk assessment tool at the ED triage, facilitating early identification and intervention for patients at high risk of septic shock.

Reference: sciencedirect.com/science/article/abs/pii/S0735675724000287

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Using SI and DSI to Predict Septic Shock in Patients with Sepsis at ED Triage - Physician's Weekly

Emergency Medicine

Phoenix using ice immersion to treat heat stroke victims as Southwest bakes in triple digits – Bay to Bay News

By ANITA SNOW

PHOENIX (AP) The season's first heat wave is already baking the Southwest with triple-digit temperatures as firefighters in Phoenix America's hottest big city employ new tactics in hopes of saving more lives in a county that saw 645 heat-related deaths last year.

Starting this season, the Phoenix Fire Department is immersing heatstroke victims in ice on the way to area hospitals. The medical technique, known as cold water immersion, is familiar to marathon runners and military service members and has also recently been adopted by Phoenix hospitals as a go-to protocol, said Fire Capt. John Prato.

Prato demonstrated the method earlier this week outside the emergency department of Valleywise Health Medical Center in Phoenix, packing ice cubes inside an impermeable blue bag around a medical dummy representing a patient. He said the technique could dramatically lower body temperature in minutes.

Just last week we had a critical patient that we were able to bring back before we walked through the emergency room doors, Prato said. That's our goal to improve patient survivability.

The heatstroke treatment has made ice and human-sized immersion bags standard equipment on all Phoenix fire department emergency vehicles. It is among measures the city adopted this year as temperatures and their human toll soar ever higher. Phoenix for the first time is also keeping two cooling stations open overnight this season.

Emergency responders in much of an area stretching from southeast California to central Arizona are preparing for what the National Weather Service said would be easily their hottest weather since last September.

Excessive heat warnings were issued for Wednesday morning through Friday evening for parts of southern Nevada and Arizona, with highs expected to top 110 degrees Fahrenheit (43.3 Celsius) in Las Vegas and Phoenix. The unseasonably hot weather was expected to spread northward and make its way into parts of the Pacific Northwest by the weekend.

Officials in Maricopa County were stunned earlier this year when final numbers showed 645 heat-related deaths in Arizona's largest county, a majority of them in Phoenix. The most brutal period was a heat wave with 31 subsequent days of temperatures of 110 degrees Fahrenheit (43.4 Celsius) or higher, which claimed more than 400 lives.

Weve been seeing a severe uptick in the past three years in cases of severe heat illness, said Dr. Paul Pugsley, medical director of emergency medicine with Valleywise Health. Of those, about 40% do not survive.

Cooling down patients long before they get to the emergency department could change the equation, he said.

The technique is not very widely spread in non-military hospitals in the U.S., nor in the prehospital setting among fire departments or first responders, Pugsley said. He said part of that may be a longstanding perception that the technique's use for all cases of heatstroke by first responders or even hospitals was impractical or impossible.

Pugsley said he was aware of limited use of the technique in some places in California, including Stanford Medical Center in Palo Alto and Community Regional Medical Center in Fresno, and by the San Antonio Fire Department in Texas.

Banner University Medical Center in Phoenix embraced the protocol last summer, said Dr. Aneesh Narang, assistant medical director of emergency medicine there.

This cold water immersion therapy is really the standard of care to treat heatstroke patients, he said.

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Phoenix using ice immersion to treat heat stroke victims as Southwest bakes in triple digits - Bay to Bay News

Internal Medicine

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Should neonatal-perinatal medicine move to two-year fellowships? | Journal of Perinatology - Nature.com