To assess the utility of radiographs taken immediately after the application of a cast in the management of pediatric torus (or buckle) fractures and to determine the need for serial radiographs taken at follow-up visits. Design: Retrospective medical record review; survey questionnaire of a panel of experts. Setting: The pediatric emergency department (PED) and the pediatric orthopedic clinic at an urban, tertiary care hospital. Patients: All children with torus fractures referred to the pediatric orthopedic clinic for follow-up visits between February 1995 and February 1997. Main Outcome Measures: The number of patients whose postcast studies was obtained in the PED; number of follow-up visits and studies conducted at the pediatric orthopedic clinic; usual regional practices as extracted from a panel of experts by survey questionnaire. Results: Of 70 patients, 46 (66%) were evaluated by a single, precast study in the PED, and 24 (34%) were evaluated by both precast and postcast studies in the PED. The time range of the first follow-up study was the first to fifth week after the patient's injury. The range of the number of follow-up studies for each patient was 0 to 5. Our cohort's total radiology charges for 70 patients were $27 251. Regional directors of pediatric orthopedic surgery unanimously agreed that postcast studies in the PED are unnecessary. The range of the number of follow-up studies they obtained is 0 to 3 per patient. Conclusions: Postcast studies of torus fractures are unnecessary. Multiple radiographs taken during follow-up visits, especially early in the healing process, do not change fracture management. Relying on the clinical examination, perhaps combined with a single follow-up study, is a more appropriate regimen for the management of pediatric torus fractures and translates into a cost savings of over $10 000 for our 70 patients.

We safely reduced unnecessary hospitalizations for children with anaphylaxis and sustained the change over 3 years by using a QI initiative that included evidence-based guideline development and implementation, reinforced by provider reminders and structured feedback.

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ObjectiveOpportunity exists to reduce unnecessary hospitalizations for children with anaphylaxis given wide variation in admission rates across U.S. emergency departments (EDs). We sought to identify children hospitalized with anaphylaxis at low risk of receiving epinephrine and other acute inpatient therapies, as these patients may be candidates for ED discharge rather than inpatient hospitalization.MethodsWe conducted a single-center retrospective cohort study of children 1–21 years of age hospitalized with anaphylaxis from 2009 to 2016. Acute inpatient therapies included intramuscular (IM) or racemic epinephrine, bronchodilators, fluid boluses, vasopressors, non-invasive ventilation, or intubation. We derived age-specific (pre-verbal [<36 months] vs. verbal [≥ 36 months]) prediction rules using recursive partitioning to identify children at low risk of receiving acute inpatient therapies.ResultsDuring the study period 665 children were hospitalized for anaphylaxis, of whom 108 (16.2%) received acute inpatient therapies. The prediction rule for patients < 36 months (no wheezing, no cardiac involvement [hypotension or wide pulse pressure]) had a sensitivity of 90.5% (CI 69.6–98.8%) and a negative predictive value of 98.3% (CI 94.1–99.8%) for identifying children at low risk of receipt of acute inpatient therapies during hospitalization. For children ≥ 36 months, the prediction rule (no wheezing, no cardiac involvement, presence of gastrointestinal symptoms) had a sensitivity of 90.8% (CI 82.7–96.0%) and a negative predictive value of 92.4% (CI 85.6–96.7%).ConclusionsWe derived age specific prediction rules for children hospitalized with anaphylaxis at low risk of receiving epinephrine and other acute inpatient therapies. These children may be candidates for ED discharge rather than inpatient hospitalization.

Purpose of review-Anaphylaxis is a serious allergic reaction that can be life threatening. We will review the most recent evidence regarding the diagnosis, treatment, monitoring, and prevention of anaphylaxis in children.

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