Interobserver Agreement in the Assessment of Clinical Findings in Children With First Unprovoked Seizures
ABSTRACT Variables used in prediction rules and clinical guidelines should show acceptable agreement when assessed by different observers. Our objective was to determine the interobserver agreement of patient history and physical examination variables used to assess children undergoing emergency department (ED) evaluation for a first seizure not provoked by a known precipitant such as fever or trauma (ie, an unprovoked seizure).
We conducted a prospective cohort study of children aged 28 days to 18 years evaluated for unprovoked seizures at 6 tertiary care EDs. We excluded patients if previously evaluated for a similar event. Two clinicians independently completed a clinical assessment before neuroimaging. We determined agreement for each clinical variable by using the unweighted κ statistic.
A total of 217 paired observations were analyzed; median patient age was 53.5 months, and 38% were younger than 2 years. Agreement beyond chance was at least moderate (κ ≥ 0.41) for 21 of 31 (68%) variables for which κ could be calculated. κ was ≥0.41 for 7 of 11 (64%) general history variables, all 8 seizure-specific history variables (including seizure focality), and 6 of 12 (50%) physical examination variables. Agreement beyond chance was substantial or better (κ ≥ 0.61) for 2 of 11 (18%) general history variables, for 5 of 8 (63%) seizure-specific history variables, and for 2 of 12 (17%) physical examination variables.
For children with first unprovoked seizures evaluated in the ED, clinicians frequently assess findings from seizure-specific history with substantial agreement beyond chance. Those clinical variables that have been associated with the presence of intracranial abnormalities and show reliability between assessors, such as seizure focality and the presence of any focal neurological finding, may be more useful in the ED assessment of children with first unprovoked seizures.
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ABSTRACT: Purpose: To assess the prevalence of clinically urgent intra-cranial pathology among children who had imaging for a first episode of non-febrile seizure with focal manifestations. Methods: We performed a cross sectional study of all children age 1 month to 18 years evaluated for first episode of non-febrile seizure with focal manifestations and having neuroimaging performed within 24 h of presentation at a single pediatric ED between 1995 and 2012. We excluded intubated patients, those with known structural brain abnormality and trauma. A single neuro-radiologist reviewed all cranial computed tomography and/or magnetic resonance imaging performed. We defined clinically urgent intracranial pathology as any finding resulting in a change of initial patient management. We performed univariate analysis using chi(2) analysis for categorical data and Mann-Whitney U test for continuous data. Results: We identified 319 patients having a median age of 4.6 years [IQR 1.8-9.4] of which 45% were female. Two hundred sixty-two children had a CT scan, 15 had an MR and 42 had both. Clinically urgent intra-cranial pathology was identified on imaging of 13 patients (4.1%; 95% CI: 2.2, 7.0). Infarction, hemorrhage and thrombosis were most common (9/13). Twelve of 13 were evident on CT scan. Persistent Todd's paresis and age <= 18 months were predictors of clinically urgent intracranial pathology. Absence of secondary generalization and multiple seizures on presentation were not predictive. Conclusions: Four percent of children imaged with first time, afebrile focal seizures have findings important to initial management. Children younger than <= 18 months are at increased risk. (c) 2014 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.Seizure 06/2014; 23(9). DOI:10.1016/j.seizure.2014.06.003 · 2.06 Impact Factor
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ABSTRACT: The Bacterial Meningitis Score, a derived and validated clinical decision rule, identifies children with cerebrospinal fluid (CSF) pleocytosis who are at very low risk of bacterial meningitis. Low-risk features include the following: negative CSF Gram stain, CSF absolute neutrophil count (ANC) <1000 cells/μl, CSF protein <80 mg/dl, peripheral blood ANC <10 000 cells/μl and no seizure at or prior to initial presentation. The study objective of the present work was to calculate the performance of the Bacterial Meningitis Score by performing a meta-analysis of all published validation studies. A meta-analysis of all studies published between 2002 and 2012 was performed, evaluating the performance of the Bacterial Meningitis Score in children with CSF pleocytosis. Study quality was assessed using the assessment of diagnostic accuracy studies instrument and then the test performance of the prediction rule was calculated. From 8 studies, 5312 patients were identified, of whom 4896 (92%) had sufficient clinical data to calculate the Bacterial Meningitis Score. Bacterial meningitis was diagnosed in 1242 children (23% of study patients). The combined sensitivity of the Bacterial Meningitis Score for bacterial meningitis was 99.3% (1224/1233; 95% CI 98.7% to 99.7%), specificity 62.1% (2274/3663; 95% CI 60.5% to 63.7%) negative predictive value 99.7% (2274/2283, 95% CI 99.3% to 99.9%), positive likelihood ratio 2.6 (95% CI 2.5 to 2.7) and negative likelihood ratio 0.01 (95% CI 0.01 to 0.02). The Bacterial Meningitis Score is a highly accurate clinical scoring system that could be used to assist clinical decision making for the management of children with CSF pleocytosis.Archives of Disease in Childhood 07/2012; 97(9):799-805. DOI:10.1136/archdischild-2012-301798 · 2.91 Impact Factor
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ABSTRACT: OBJECTIVE:The Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) clinical prediction rules identify children with minor blunt head trauma who are at low risk for clinically important traumatic brain injuries. We measured the agreement between the registered nurse (RN) and physician (MD) assessments.METHODS:We performed a cross-sectional study of all children <18 years of age with minor blunt head trauma who presented to a single emergency department. RNs and MDs independently assessed each child and recorded age-based PECARN predictors. As symptoms can change over time, we included cases only when both evaluations were completed within 60 minutes. We used the κ statistic to measure RN-MD agreement, with the main analysis focusing on the overall PECARN rule agreement.RESULTS:Of the 1624 eligible children, 1191 (73%) had evaluations completed by both RN and ED providers, of which 437 (37%) were in children <2 years of age. The median time between completions of the provider forms was 12 minutes (interquartile range 4-25 minutes). The overall agreement between the RN and MD was higher for the older children (κ 0.55, 95% confidence interval 0.49-0.61 for children 2-18 years versus κ 0.32, 95% confidence interval 0.23-0.41 for children <2 years).CONCLUSIONS:The overall agreement between RN and MD for the PECARN TBI prediction rules was moderate for older children and fair for younger children. Initial RN assessments should be verified by the MD before clinical application, especially for the youngest children.PEDIATRICS 08/2013; 132(3). DOI:10.1542/peds.2013-0909 · 5.30 Impact Factor