Fellows journal Club
Fellow: Kate Donowitz, MD; Children’s Hospital of Richmond at Virginia Commonwealth University
Article: DeLaroche, A. M., Haddad, R., Farooqi, A., Sapién, R. E., & Tieder, J. S. (2020). Outcome Prediction of Higher-Risk Brief Resolved Unexplained Events. Hospital Pediatrics, hpeds-2019.
Summary: This is a retrospective chart review of patients under 1 year of life who were evaluated in the ED for complaints suggestive of a brief resolved unexplained event (BRUE). Patients who met criteria for BRUE were classified as higher-risk or lower-risk according to AAP clinical practice guidelines (CPG), and higher-risk criteria included age under 60 days, history of prematurity, history of requiring CPR by a medical provider during the event, an event lasting more than 1 minute, or multiple events prior to arrival. Demographic characteristics, clinical features, and diagnostic evaluation results were extracted from the medical record. The goal was to identify risk factors associated with adverse clinical outcomes (defined as serious underlying diagnosis, recurrent events, and return hospitalization). The authors found that the majority of patients who presented to the ED for BRUE fell into the higher-risk category (90%) and most of these underwent diagnostic testing and hospitalization. Prematurity was associated with repeat event, but otherwise higher-risk criteria were not found to be predictive of adverse clinical outcomes.
Key Strengths: Only 3 studies have retrospectively characterized patients with BRUE since the AAP CPG was published in 2016, and this is the first to look at whether higher-risk criteria are predictive of negative clinical outcomes. It confirms the findings of prior studies showing that the majority of patients who present with BRUE fall into the higher-risk category and that diagnostic testing is not standardized in these patients. Finally, the data suggest that most diagnostic testing is low yield, and provide support for further research to help determine what testing is warranted in higher-risk BRUE patients.
Limitations: Patients were identified using ICD codes suggestive of BRUE and then screened to see if they met criteria. There is no exhaustive list of ICD codes used for patients presenting with BRUE, so it is possible that patients with a serious underlying diagnosis who presented with BRUE may have been missed. The population studied is a tertiary care center with an urban population and therefore may not be generalizable to other populations. Finally, the sample size was too small to detect an association with rare outcomes.
Major takeaway: Most patients who present to a tertiary care center and meet BRUE criteria are likely to fit into the higher-risk category. Prematurity may be associated with recurrent events, but other higher-risk criteria did not predict serious underlying diagnoses or return admission. Further research is needed to guide our diagnostic workup and admission criteria in caring for these patients.
Impact on Practice: Patients presenting with BRUE pose a challenge to emergency and hospitalist physicians who care for them. These events are difficult for parents to describe, particularly since the event was usually very frightening. BRUE is a diagnosis of exclusion, the differential is broad, and is it difficult to determine which diagnostic testing is appropriate. Clinical practice guidelines have helped to identify patients who are lower-risk and can safely be discharged home with very low likelihood of recurrent events or adverse outcomes. However, as this study and several others have shown, the majority of patients do not meet lower-risk criteria. A framework for evaluation of higher-risk BRUE was recently proposed by Merrit et al. and recommends a tiered approach to clinical evaluation and management of these patients (1). This study suggests that even patients who are identified as higher-risk will have few positive diagnostic findings in their workup. While this supports the idea that our use of diagnostic testing in these patients should be judicious, further data would be needed to identify which testing is high yield and should be performed in higher-risk patients. Prematurity was the only higher-risk criteria associated with a negative outcome (specifically recurrence, not an underlying serious diagnosis). This could suggest that the criteria used to designate patients as higher-risk are not very meaningful in terms of predicting adverse outcomes. Again, further data would be needed to identify which risk factors are predictive of adverse outcomes in patients with BRUE in order to guide both diagnostic workup and plan of care.
While this article may not have significant impact on clinical practice at this time, it reinforces the need for further research to clarify which patients are at risk for negative outcomes when presenting with BRUE and what diagnostic workup is appropriate in these patients.
1. Merritt, J. L., Quinonez, R. A., Bonkowsky, J. L., Franklin, W. H., Gremse, D. A., Herman, B. E., ... & Sapién, R. E. (2019). A Framework for Evaluation of the Higher-Risk Infant After a Brief Resolved Unexplained Event. Pediatrics, 144(2).
Article: DeLaroche, A. M., Haddad, R., Farooqi, A., Sapién, R. E., & Tieder, J. S. (2020). Outcome Prediction of Higher-Risk Brief Resolved Unexplained Events. Hospital Pediatrics, hpeds-2019.
Summary: This is a retrospective chart review of patients under 1 year of life who were evaluated in the ED for complaints suggestive of a brief resolved unexplained event (BRUE). Patients who met criteria for BRUE were classified as higher-risk or lower-risk according to AAP clinical practice guidelines (CPG), and higher-risk criteria included age under 60 days, history of prematurity, history of requiring CPR by a medical provider during the event, an event lasting more than 1 minute, or multiple events prior to arrival. Demographic characteristics, clinical features, and diagnostic evaluation results were extracted from the medical record. The goal was to identify risk factors associated with adverse clinical outcomes (defined as serious underlying diagnosis, recurrent events, and return hospitalization). The authors found that the majority of patients who presented to the ED for BRUE fell into the higher-risk category (90%) and most of these underwent diagnostic testing and hospitalization. Prematurity was associated with repeat event, but otherwise higher-risk criteria were not found to be predictive of adverse clinical outcomes.
Key Strengths: Only 3 studies have retrospectively characterized patients with BRUE since the AAP CPG was published in 2016, and this is the first to look at whether higher-risk criteria are predictive of negative clinical outcomes. It confirms the findings of prior studies showing that the majority of patients who present with BRUE fall into the higher-risk category and that diagnostic testing is not standardized in these patients. Finally, the data suggest that most diagnostic testing is low yield, and provide support for further research to help determine what testing is warranted in higher-risk BRUE patients.
Limitations: Patients were identified using ICD codes suggestive of BRUE and then screened to see if they met criteria. There is no exhaustive list of ICD codes used for patients presenting with BRUE, so it is possible that patients with a serious underlying diagnosis who presented with BRUE may have been missed. The population studied is a tertiary care center with an urban population and therefore may not be generalizable to other populations. Finally, the sample size was too small to detect an association with rare outcomes.
Major takeaway: Most patients who present to a tertiary care center and meet BRUE criteria are likely to fit into the higher-risk category. Prematurity may be associated with recurrent events, but other higher-risk criteria did not predict serious underlying diagnoses or return admission. Further research is needed to guide our diagnostic workup and admission criteria in caring for these patients.
Impact on Practice: Patients presenting with BRUE pose a challenge to emergency and hospitalist physicians who care for them. These events are difficult for parents to describe, particularly since the event was usually very frightening. BRUE is a diagnosis of exclusion, the differential is broad, and is it difficult to determine which diagnostic testing is appropriate. Clinical practice guidelines have helped to identify patients who are lower-risk and can safely be discharged home with very low likelihood of recurrent events or adverse outcomes. However, as this study and several others have shown, the majority of patients do not meet lower-risk criteria. A framework for evaluation of higher-risk BRUE was recently proposed by Merrit et al. and recommends a tiered approach to clinical evaluation and management of these patients (1). This study suggests that even patients who are identified as higher-risk will have few positive diagnostic findings in their workup. While this supports the idea that our use of diagnostic testing in these patients should be judicious, further data would be needed to identify which testing is high yield and should be performed in higher-risk patients. Prematurity was the only higher-risk criteria associated with a negative outcome (specifically recurrence, not an underlying serious diagnosis). This could suggest that the criteria used to designate patients as higher-risk are not very meaningful in terms of predicting adverse outcomes. Again, further data would be needed to identify which risk factors are predictive of adverse outcomes in patients with BRUE in order to guide both diagnostic workup and plan of care.
While this article may not have significant impact on clinical practice at this time, it reinforces the need for further research to clarify which patients are at risk for negative outcomes when presenting with BRUE and what diagnostic workup is appropriate in these patients.
1. Merritt, J. L., Quinonez, R. A., Bonkowsky, J. L., Franklin, W. H., Gremse, D. A., Herman, B. E., ... & Sapién, R. E. (2019). A Framework for Evaluation of the Higher-Risk Infant After a Brief Resolved Unexplained Event. Pediatrics, 144(2).
Name: Kate Donowitz, MD; Children’s Hospital of Richmond at Virginia Commonwealth University
Fellowship accomplishments/current research: I am a first year fellow working on projects related to medical education and global health and currently working on research related to diagnostic workup in complex febrile seizure.
Goals/Plans for the Future: I would like to continue to work as a pediatric hospitalist at an academic center and continue to be involved in graduate medical education, specifically to global health education.
Fun Fact About Myself: I studied religion as an undergraduate and traveled the world before studying medicine.
Fellowship accomplishments/current research: I am a first year fellow working on projects related to medical education and global health and currently working on research related to diagnostic workup in complex febrile seizure.
Goals/Plans for the Future: I would like to continue to work as a pediatric hospitalist at an academic center and continue to be involved in graduate medical education, specifically to global health education.
Fun Fact About Myself: I studied religion as an undergraduate and traveled the world before studying medicine.
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- Hannah Neubauer - HHFNC vs. low flow
- Amanda Messer - UTIs and renal scarring
- Christiane Lenzen - procalcitonin and CAP
- Melanie Rudnick - dexamethasone and parapneumonic effusions
- Jane Im - empiric antibiotic therapy in infants
- Ashley Jenkins - AKI with vancomycin and piperacillin/tazobactam therapy
- Fatuma Barqadle - US for LPs
- Marni Shear - Hypotonic IV fluids and bronchiolitis
- Ivy Tam - Ipratropium and IV magnesium in asthmatics
- Daniela Burger - HSV in Infants
- Lindsay Weiss - macrolides in pneumonia
- Tiranun Rungvivatjarus - High Flow Nasal Cannula
- Karisa Grizzle - Empiric Antibiotics in Osteomyelitis
- Mike Fenster - Bacterial meningitis in positive UA
- Courtney Charvat - CSF bioplex assay
- Audrey Uong - Complex Care Discharges
- Adam Cohen - Early Master Clinician Traits
- Alice Lee - Variation in Orbital Cellulitis Care
- Joy Solano - Family centered interventions to improve education
- Sunita Hemani - Discharging after q3 albuterol in asthma
- Jennifer Chen - Discharge Instruction Literacy
- John Morrison - Readmission Models for Complex Care
- Hanna Siddiqui - Fever, PEWS, and deterioration
- Kate Kyler - Reducing Safety Events in Suicidal Patients via QI
- Sonya Tang Girwood - Antibiotics in RSV Related Respiratory Failure
- Maria Santos - Positive UA and Meningitis
- Chionye Ossai - Parent Perception of Patient Portal
- Sarah Bram - Predictors of bacteremia in CAP
- Kris Chang - Note Bloat
- Risa Bochner - SBI with fever alone <60 days
- Alexandra Kilinsky - Promoting Fellow Autonomy
- Sasha Wee - Somatic Symptom Pathway