Daniel Imler, MD

Abstract

An otherwise healthy 16-year-old male presented to the pediatric emergency department 12hours after accidental inhalation of 4-nitrophenyl chloroformate in a chemistry lab. His only pertinent findings were a complaint of chest tightness and decreased breath sounds on a pulmonary exam. He was found on chest radiograph to have a large right-sided pneumothorax with slight mediastinal shift and mild interstitial prominence. A chest tube was placed, and he recovered well. This case demonstrates pneumothorax as a possible complication of inhalation of caustic chemical substances and emphasizes the importance of thorough history-taking and clinical examination.

View details for DOI 10.1002/emp2.12928

View details for PubMedID 36923247

View details for PubMedCentralID PMC10009428

Abstract

Pediatric trauma patients undergo fewer computed tomography (CT) scans when evaluated at pediatric trauma centers (PTC) versus adult trauma centers (ATC) with no change in clinical outcome. Factors contributing to this difference are unclear. We sought to identify whether the training background of physicians, specifically emergency medicine (EM) versus pediatric emergency medicine (PEM), affected the CT rate of pediatric trauma patients within one institution.A single-center retrospective study of CT utilization based on attending physicians' training in trauma patients <18 years between November 2018 and November 2020. Attendings were categorized into two groups: EM residency with no PEM fellowship, or pediatrics/EM residency with PEM fellowship. Primary outcomes measured were the proportion of patients receiving a CT and CT positivity rate.Of 463 study patients, CTs were obtained in 145/228 (64%) patients by EM, and 130/235 (55%) by PEM (p=.07). CT positivity rate was 21% and 19% in EM and PEM, respectively (p=.46). The mean number of CTs per patient in EM was 2.8 compared to 2.1 in PEM (p<.01), and for patients with an injury severity score (ISS) >15, mean number of CTs per patient increased to 4.9 in EM versus 2.4 in PEM (p=.01).The mean number of CTs ordered per patient was statistically higher for EM attendings. The differences between CT rates highlight future opportunities for ongoing development of pediatric trauma imaging guidelines and radiation exposure reduction.Retrospective Study, Level III.

View details for DOI 10.1016/j.jpedsurg.2022.10.042

View details for PubMedID 36418201

View details for DOI 10.1001/jamapediatrics.2020.2222

View details for PubMedID 32744602

Abstract

Pediatric head injury is a common presenting complaint in the emergency department (ED), often requiring neuroimaging or ED observation for diagnosis. However, the traditional diagnostic neuroimaging modality, head computed tomography (CT), is associated with radiation exposure while prolonged ED observation impacts patient flow and resource utilization. Recent scientific literature supports abbreviated, or focused and shorter, brain magnetic resonance imaging (MRI) as a feasible and accurate diagnostic alternative to CT for traumatic brain injury. However, this is a relatively new application and its use is not widespread. The aims of this review are to describe the science and applications of abbreviated brain MRI and report a model protocol's development and ED implementation in the evaluation of children with head injury for replication in other institutions.

View details for DOI 10.1002/emp2.12055

View details for PubMedID 33145550

View details for PubMedCentralID PMC7593499

Abstract

Ionizing radiation and cost make ultrasound (US), when available, the first imaging study for the diagnosis of suspected pediatric appendicitis. US is less sensitive and specific than computed tomography (CT) or magnetic resonance imaging (MRI) scans, which are often performed after nondiagnostic US.We sought to determine predictors of nondiagnostic US in order to guide efficient ordering of imaging studies.A prospective cohort study of consecutive patients 4 to 30years of age with suspected appendicitis took place at an emergency department with access to 24/7 US, MRI, and CT capabilities. Patients with US as their initial study were identified. Clinical (i.e., duration of illness, highest fever, and right lower quadrant pain) and demographic (i.e., age and sex) variables were collected. Body mass index (BMI) was calculated based on Centers for Disease Control and Prevention criteria; BMI >85th percentile was categorized as overweight. Patients were followed until day 7. Univariate and stepwise multivariate logistic regression analysis was performed.Over 3months, 106 patients had US first for suspected appendicitis; 52 (49%) had nondiagnostic US results. Eighteen patients had appendicitis, and there were no missed cases after discharge. On univariate analysis, male sex, a yearly increase in age, and overweight BMI were associated with nondiagnostic US (p<0.05). In the multivariate model, only BMI (odds ratio 4.9 [95% CI 2.0-12.2]) and age (odds ratio 1.1 [95% CI 1.02-1.20]) were predictors. Sixty-eight percent of nondiagnostic US results occurred in overweight patients.Overweight and older patients are more likely to have a nondiagnostic US or appendicitis, and it may be more efficient to consider alternatives to US first for these patients. Also, this information about the accuracy of US to diagnose suspected appendicitis may be useful to clinicians who wish to engage in shared decision-making with the parents or guardians of children regarding imaging options for children with acute abdominal pain.

View details for DOI 10.1016/j.jemermed.2016.07.101

View details for Web of Science ID 000397089400023

Abstract

While ultrasound (US), given its lack of ionizing radiation is currently the recommended initial imaging study of choice for the diagnosis of appendicitis in pediatric and young adult patients, it does have significant shortcomings. US is time intensive, operator dependent, and results in frequent inconclusive studies, thus necessitating further imaging, and admission for observation or repeat clinical visits. A rapid focused Magnetic Resonance Imaging (MRI) for appendicitis has been shown to have definitive sensitivity and specificity, similar to Computed tomography (CT) but without radiation and offers a potential alternative to US.In this single-center prospective cohort study, we sought to determine the difference in total length of stay and charges between rapid MRI and US as the initial imaging modality in pediatric and young adult patients presenting to the Emergency Department (ED) with suspected appendicitis. We hypothesized that rapid MRI would be more efficient and cost effective than US as the initial imaging modality in the ED diagnosis of appendicitis.A prospective randomized cohort study of consecutive patients was conducted in patients 2-30 years of age in an academic ED with access to both rapid MRI and US imaging modalities 24/7. Prior to the start of the study, the days of the week were randomized to either rapid MRI or US as the initial imaging modality. Physicians evaluated patients with suspected appendicitis per their usual manner. If the physician decided to obtain radiologic imaging, the pre-determined imaging modality for the day of the week was used. All decisions regarding other diagnostic testing and/or further imaging were left to the physician's discretion. Time intervals (min) between triage, order placement, start of imaging, end of imaging, image result and disposition (discharge vs. admission), as well as total charges (diagnostic testing, imaging and repeat ED visits) were recorded.Over a 100-day period, 82 patients were imaged to evaluate for appendicitis; 45/82 (55%) of patients were in the US first group; and 37/82 (45%) patients were in the rapid MRI first group. There were no differences in patient demographics or clinical characteristics between the groups and no cases of missed appendicitis in either group. 11/45 (24%) of US first patients had inconclusive studies, resulting in follow-up rapid MRI and 5 return ED visits contrasted with no inconclusive studies or return visits (p< 0.05) in the rapid MRI group. The rapid MRI compared to US group was associated with longer ED length of stay (mean difference 100 min; 95% CI 35-169) and increased ED charges (mean difference $4,887; 95% CI $1,821 - $8,513).In the diagnosis of appendicitis, US first imaging is more time efficient and less costly than rapid MRI despite inconclusive studies after US imaging. Unless the process of obtaining a rapid MRI becomes more efficient and less expensive, US should be the first line imaging modality for appendicitis in patients 2-30 years of age. This article is protected by copyright. All rights reserved.

View details for DOI 10.1111/acem.13180

View details for PubMedID 28207968

View details for DOI 10.1016/j.jacr.2016.10.006

View details for PubMedID 28017272

Abstract

Several landmark studies based on the DASH diet have established the effectiveness of a lifestyle approach to blood pressure control that emphasizes a diet rich in fruits and vegetables with moderate portions of low-fat dairy and lean protein along with increased physical activity and reduced sodium intake. However, this evidence base remains underused due feasibility limitations of implementing these intense in-person interventions and poor engagement with desktop computer based versions. Mobile technologies such as smartphones and wireless sensors have the ability to deliver behavioral interventions in-the-moment and with reduced user burden. DASH Mobile is a new mHealth system being developed to deliver this evidence-based lifestyle intervention to hypertensive patients. The system consists of an Android based "app" that facilitates easy tracking of DASH food portions, integrated Bluetooth blood pressure, weight and pedometer monitoring, goal setting, simple data visualizations and multimedia video clips to train patients in the basic concepts of the lifestyle change plan. At present, the system is undergoing usability testing with a pilot clinical trial planned for Spring 2013.

View details for DOI 10.3233/978-1-61499-289-9-973

View details for Web of Science ID 000341021700241

View details for PubMedID 23920747

Abstract

In recent years, electronic sign-out notes have been identified as a means of enhancing the effective transfer of patient care between providers. Such a tool was developed and implemented within the electronic medical record (EMR) system, and its impact on physician work flow was assessed.A printable sign-out report was implemented within the EMR system at a tertiary academic children's hospital. Month 1 post go-live survey data were collected in June and July 2006, and 6-month post go-live survey data were collected in November and December 2006. Use of the sign-out form to document handoff data between go-live and Month 16 (September 2007) was measured using log data from the EMR. Housestaff physicians were asked to report the impact of the tool on their work flow and satisfaction with the sign-out process through a Web-based survey.The sign-out report was steadily adopted following its introduction. Between the first and second surveys, use of EMR-integrated sign-out increased from 37% to 81% of respondents for day-to-night sign-out (chi2 = 12.79, p < .001) and from 14% to 39% for night-to-day sign-out (chi 2 = 5.08, p < .05). With increased use of the report, housestaff reported less time devoted to redundant data entry and increased satisfaction with the sign-out process.EMR-integrated sign-out documents offer the advantages of other electronic network-accessible systems and can also incorporate information already in the medical record in an automated manner. Although the primary motivation for introducing standardized, EMR-integrated sign-out documents is to enhance the safety of patient handoffs, the perception of improved physician work flow is also a benefit of such an intervention.

View details for PubMedID 20180439

View details for DOI 10.1016/S1553-7250(10)36013-2

View details for Web of Science ID 000443789500004