Visits of concern in child neurology telemedicine.

2022

05/2022

1469-8749

AIM: To characterize child neurology telemedicine visits flagged as requiring in-person evaluation during the COVID-19 pandemic.

METHOD: We analyzed 7130 audio-video telemedicine visits between March and November 2020. Visits of concern (VOCs) were defined as telemedicine visits where the clinical scenario necessitated in-person follow-up evaluation sooner than if the visit had been conducted in-person.

RESULTS: VOCs occurred in 5% (333/7130) of visits for 292 individuals (148 females, 144 males). Providers noted technical challenges more often in VOCs (40%; 133/333) than visits without concern (non-VOCs) (28%; 1922/6797) (p < 0.05). The median age was younger in VOCs (9 years 3 months, interquartile range [IQR] 2 years 0 months-14 years 3 months) than non-VOCs (11 years 3 months, IQR 5 years 10 months-15 years 10 months) (p < 0.05). Median household income was lower for patients with VOCs ($74 K, IQR $55 K-$97 K) compared to non-VOCs ($80 K, IQR $61 K-$100 K) (p < 0.05). Compared with all other race categories, families who self-identified as Black were more likely to have a VOC (odds ratio 1.53, 95% confidence interval 1.21-2.06). Epilepsy and headache represented the highest percentages of VOCs, while neuromuscular disorders and developmental delay had a higher proportion of VOCs than other neurological disorders.

INTERPRETATION: These findings suggest that telemedicine is an effective platform for most child neurology visits. Younger children and those with neuromuscular disorders or developmental delays are more likely to require in-person evaluation.

10.1111/dmcn.15256

Dev Med Child Neurol

35514061

Ketamine for Management of Neonatal and Pediatric Refractory Status Epilepticus.

2022

07/2022

1526-632X

OBJECTIVE: Few data are available regarding the use of anesthetic infusions for refractory status epilepticus (RSE) in children and neonates, and ketamine use is increasing despite limited data. We aimed to describe the impact of ketamine for RSE in children and neonates.

METHODS: Retrospective single-center cohort study of consecutive patients admitted to the intensive care units of a quaternary care children's hospital treated with ketamine infusion for RSE.

RESULTS: Sixty-nine patients were treated with a ketamine infusion for RSE. The median age at onset of RSE was 0.7 years (IQR 0.15-7.2), and the cohort included 13 (19%) neonates. Three patients (4%) had adverse events requiring intervention during or within twelve hours of ketamine administration, including hypertension in 2 patients and delirium in 1 patient. Ketamine infusion was followed by seizure termination in 32 (46%) patients, seizure reduction in 19 (28%) patients, and no change in 18 (26%) patients.

DISCUSSION: Ketamine administration was associated with few adverse events, and seizures often terminated or improved after ketamine administration. Further data are needed comparing first-line and subsequent anesthetic medications for treatment of pediatric and neonatal RSE.

CLASSIFICATION OF EVIDENCE: This study provides Class IV evidence on the therapeutic utility of ketamine for treatment of RSE in children and neonates.

10.1212/WNL.0000000000200889

Neurology

35817569

Multicenter Study of the Impact of COVID-19 Shelter-In-Place on Tertiary Hospital-based Care for Pediatric Neurologic Disease.

2022

218-226

2022 Apr

1941-8744

<p><strong>Objective: </strong>To describe changes in hospital-based care for children with neurologic diagnoses during the initial 6&nbsp;weeks following regional Coronavirus 2019 Shelter-in-Place orders.</p>

<p><strong>Methods: </strong>This retrospective cross-sectional study of 7 US and Canadian pediatric tertiary care institutions included emergency and inpatient encounters with a neurologic primary discharge diagnosis code in the initial 6&nbsp;weeks of Shelter-in-Place (COVID-SiP), compared to the same period during the prior 3&nbsp;years (Pre-COVID). Patient demographics, encounter length, and neuroimaging and electroencephalography use were extracted from the medical record.</p>

<p><strong>Results: </strong>27,900 encounters over 4&nbsp;years were included. Compared to Pre-COVID, there was a 54% reduction in encounters during Shelter-in-Place. COVID-SiP patients were younger (median 5&nbsp;years vs 7&nbsp;years). The incidence of encounters for migraine fell by 72%, and encounters for acute diagnoses of status epilepticus, infantile spasms, and traumatic brain injury dropped by 53%, 55%, and 56%, respectively. There was an increase in hospital length of stay, relative utilization of intensive care, and diagnostic testing (long-term electroencephalography, brain MRI, and head CT (all &lt;.01)).</p>

<p><strong>Conclusion: </strong>During the initial 6&nbsp;weeks of SiP, there was a significant decrease in neurologic hospital-based encounters. Those admitted required a high level of care. Hospital-based neurologic services are needed to care for acutely ill patients. Precise factors causing these shifts are unknown and raise concern for changes in care seeking of patients with serious neurologic conditions. Impacts of potentially delayed diagnosis or treatment require further investigation.</p>

10.1177/19418744211063075

Neurohospitalist

35414846