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Objectives: Forgetting curves plot skill decay over time. After exposure to a simulation-based radiograph interpretation learning system, we determined the rate of learning decay and how this was impacted by testing (with and without feedback). Further, we examined the association of initial learning parameters on the forgetting curve. Methods: This was a multicenter, four-arm randomized control trial. Medical trainees completed 80 elbow radiographs and a 20-case post-test. Group 1 had no testing until 12 months; Groups 2–4 had testing every 2 months until 12 months. At 6 months, Group 3 testing was feedback-enhanced, while Group 4 had feedback-enhanced testing at 2, 6, and 10 months. Results: There were 106 participants (n = 42 Group 1; n = 22 Groups 2 and 3; n = 20 Group 4). Group 1 showed an –8.1% learning decay at 12-months relative to other groups. In Groups 2, 3, and 4, there was no significant learning decay (+0.8%), and there were no differences in skill decay between these groups. Initial score and learning curve slope were predictive of retained skill. Conclusions: Learning decay was mitigated by exposure to 20 test cases (with and without feedback) every two months. Initial learning parameters predicted learning retention and may inform refresher education scheduling. [ABSTRACT FROM AUTHOR]

Background: The accurate identification of children with a concussion by emergency physicians is important to initiate appropriate anticipatory guidance and management.Objectives: We compared the frequency of persistent concussion symptoms in children who were provided the diagnosis of concussion by an emergency physician versus those who met Berlin/Zurich international criteria for this diagnosis. We also determined the clinical variables independently associated with a physician-diagnosed concussion.Methods: This was a planned secondary analysis of a prospective, multicenter cohort study. Participants were 5-17 years of age and met the Zurich/Berlin International Consensus Statement criteria for concussion.Results: There were 2946 enrolled children. In those with physician-diagnosed concussion vs. no concussion, the frequency of persistent symptoms was 62.5% vs. 38.8% (p < 0.0001) at 1 week, 46.3% vs. 25.8% (p < 0.0001) at 2 weeks, and 33.0% vs. 23.0% (p < 0.0001) at 4 weeks. Of those meeting international criteria, 2340 (79.4%) were diagnosed with a concussion by an emergency physician and 12 variables were associated with this diagnosis. Five had an odds ratio (OR) > 1.5: older age (13-17 vs. 5-7 years, OR 2.9), longer time to presentation (≥16 vs. <16 h, OR 2.1), nausea (OR 1.7), sport mechanism (OR 1.7), and amnesia (OR 1.6).Conclusions: Relative to international criteria, the more selective assignment of concussion by emergency physicians was associated with a greater frequency of persistent concussion symptoms. In addition, while most children meeting international criteria for concussion were also provided this diagnosis for concussion by an emergency physician, the presence of 5 specific variables made this diagnosis more likely. [ABSTRACT FROM AUTHOR]

BACKGROUND: Evidence suggests that minor paediatric fractures can be followed by primary care paediatricians (PCPs). OBJECTIVES: To determine PCP opinions, knowledge and perceived barriers to managing minor paediatric fractures in the office. METHODS: An online survey was sent between June and September 2013 to all paediatricians who subscribed to the American Academy of Pediatrics PROS-Net Listerv and to those who were registered with the Scott's Canadian Medical Directory as paediatricians who treated children in a primary care capacity. The primary outcome was the proportion of PCPs who agreed with PCP follow-up of minor paediatric fractures. Secondary outcomes included PCP's perceived barriers to office follow-up. RESULTS: A total of 1752 surveys were sent; 1235 were eligible and 459 (37.2%) responded to the survey. Overall, 296 (69.5% [95% CI 65.2% to 74.0%]) PCPs agreed that minor paediatric fractures could be followed in a PCP office. The most frequently reported barriers were lack of materials to replace immobilization (58.1%), PCP knowledge deficits (44.8%) and a perceived parental preference for an orthopedic surgeon (38.6%). Finally, 58.8% of respondents believed that further education was necessary if PCPs assumed responsibility for follow-up of midshaft clavicle fractures, while 66.5% and 77.1% (P<0.0001) believed this was necessary for distal radius buckle and fibular fractures, respectively. CONCLUSIONS: More than two-thirds of responding PCPs in Canada and the United States agreed that minor common paediatric fractures can be followed-up by paediatricians. However, PCPs reported some barriers to this management strategy, including a desire for more education on this topic. [ABSTRACT FROM AUTHOR]

Abstract: Background: Disclosing potential future malignancy risks from diagnostic tests that expose children to ionizing radiation in the emergency department may be challenging. Objectives: We determined the proportion of pediatric emergency medicine (PEM) physicians who are aware of current malignancy risk estimates associated with head computed tomography (CT). We also examined reported risk and strategy disclosure practice patterns. Methods: We conducted an online survey of members of a national Canadian PEM physician association using a modified Dillman's technique. Results: Of 156 eligible participants, 126 (80.8%) responded to the survey. Of the 126 respondents, 124 (98.4%; 95% confidence interval [CI] 96.2–100) reported that there is a potential malignancy risk associated with head CT, and 46 (36.5%; 95% CI 28.1–44.9) correctly identified the best current estimate of this risk. The majority, 68.8% (95% CI 60.7–76.9), reported disclosing these possible risks “most of the time/almost always.” Although some physicians reported varying their strategy with the clinical scenario, the most frequently selected disclosure strategies were a comparison with chest radiographs and everyday risks. Frequently cited barriers to informed risk-benefit discussions were concerns that parents will worry excessively about cancer (27.8%), discussions during the treatment of a critically ill child (23.8%), and a concern that parents may not want the test (15.9%). Conclusions: Approximately one-third of pediatric emergency physicians were able to identify the best available estimate of the malignancy risk from a head CT. Although there are some barriers, many PEM physicians report regularly participating in risk-benefit disclosures. [Copyright &y& Elsevier]

Background: The Low Risk Ankle Rule is a valid ated clinical decision rule that has the potential to safely reduce radiography in children with acute ankle injuries. We performed a phased implementation of the Low Risk Ankle Rule and evaluated its effectiveness in reducing the frequency of radiography in children with ankle injuries. Methods: Six Canadian emergency departments participated in the study from Jan. 1, 2009, to Aug. 31, 2011. At the 3 intervention sites, there were 3 consecutive 26-week phases. In phase 1, no interventions were implemented. In phase 2, we activated strategies to implement the ankle rule, including physician education, reminders and a computerized decision support system. In phase 3, we included only the decision support system. No interventions were introduced at the 3 pair-matched control sites. We examined the management of ankle injuries among children aged 3- 16 years. The primary outcome was the proportion of children undergoing radiography. Results: We enrolled 2151 children with ankle injuries, 1055 at intervention and 1096 at control hospitals. During phase 1, the baseline frequency of pediatric ankle radiography at intervention and control sites was 96.5% and 90.2%, respectively. During phase 2, the frequency of ankle radiography decreased significantly at intervention sites relative to control sites (between-group difference -21.9% [95% confidence interval [CI] -28.6% to -15.2%]), without significant differences in patient or physician satisfaction. All effects were sustained in phase 3. The sensitivity of the Low Risk Ankle Rule during implementation was 100% (95% CI 85.4% to 100%), and the specificity was 53.1% (95% CI 48.1% to 58.1%). Interpretation: Implementation of the Low Risk Ankle Rule in several different emergency department settings reduced the rate of pediatric ankle radiography significantly and safely, without an accompanying change in physician or patient satisfaction. Trial registration: ClinicalTrials.gov, no. NCT00785876. [ABSTRACT FROM AUTHOR]

Decades of research on perception and prediction of randomness led us to speculate that the various response tendencies observed in these studies might manifest in multi-trial discrimination tasks used in medical education. By re-analyzing data from a previously published study in which 46 physicians and medical trainees judged 234 pediatric ankle radiographs, we show that (i) response tendencies can be differentially induced when individuals receive uniquely ordered sequences and (ii) response patterns consistent with win-stay/lose-shift and win-shift/lose-stay heuristics can be predicted from stimulus alternation rates and marginal distributions. Our results illustrate the importance of carefully arranging trials when studying discrimination and when using discrimination tasks to teach or to assess learners' skill levels. We call into question the wisdom of designing studies that present uniquely ordered stimulus sequences and discuss alternatives. Copyright © 2013 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Context We examined whether a 'hint' manoeuvre increases the time novice medical learners spend on reviewing a radiograph, thereby potentially increasing their interpretation accuracy. Methods Senior year medical students were recruited into a randomised control, three-arm, multicentre trial. Students reviewed an online 50-case learning set that varied in degree of 'hint' intervention. The 'hint' was a dialogue box that appeared after a student submitted an answer, encouraging the student to re-evaluate their interpretation. The students in the control group received no hints. In the weak intervention group, students received 'hints' with 66% of their incorrect interpretations and 33% of those that were correct. In the strong intervention group, the incorrect interpretation hint frequency was 80%, whereas for correct responses it was 20%. All students completed a 20-case post-test immediately and 2 weeks after the 50 cases. The primary outcome was student performance on the immediate post-test, measured as the ability to discriminate between normal and abnormal films (dPrime). Secondary outcomes included the probability of considering the hint, time spent on learning cases and knowledge retention at 2 weeks. Results We enrolled 117 medical students from three sites into the three study groups: control (36), weak intervention (40) and strong intervention (41) groups. The mean ( standard deviation) dPrime in the control, weak and strong groups were 0.4 (1.1), 0.7 (1.1) and 0.4 (0.9), respectively ( P = 0.4). In the weak and strong groups, participants reconsidered answers in 556 of 1944 (28.6%) hinting opportunities, and those who reconsidered their answers spent a mean (95% confidence interval) of 13.9 (11.9, 16.0) seconds longer on each case. There were no significant differences in knowledge retention at 2 weeks between the groups ( P = 0.2). Conclusions Although the implemented hinting strategy did result in students spending more time considering a proportion of the cases, overall it was not effective in improving student performance. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Computed tomography (CT) imaging of children is increasing in emergent settings without an understanding of parental knowledge of potential cancer risks. In children with head injuries, our primary objective was to determine the proportion of parents who were aware of the potential of CT to increase a child's lifetime risk of malignancy. We also examined willingness to proceed with recommended CT after risk disclosure and preference to be informed of potential risks. METHODS: This was a prospective cross-sectional survey of parents whose children presented to a tertiary care pediatric emergency department with a head injury. Survey questions were derived and validated by using expert opinion, available literature, and pre- and pilot testing of questions with the target audience. RESULTS: Of the 742 enrolled parents, 454 (61.2%) were female and 594 (80.0%) were aged 31 to 50 years. Importantly, 357 (46.8%) were aware of the potential for an increased lifetime malignancy risk from CT. Before risk estimate provision, the proportion of parents "very willing/ willing" to proceed with head CT was 90.4%; after disclosure, willingness decreased to 69.6% {P < .0001), and 42 (5.6%) would refuse the CT. Of note, 673 (90.3%) wished to be informed of potential malignancy risks. CONCLUSIONS: Approximately half of the participating parents were aware of the potential increased lifetime malignancy risk associated with head CT imaging. Willingness to proceed with CT testing was reduced after risk disclosure but was a significant barrier for a small minority of parents. Most parents wanted to be informed of potential malignancy risks before proceeding with imaging. Pediatrics 2013;132:305-311 [ABSTRACT FROM AUTHOR]

Background: Minimally angulated fractures of the distal radius are common in children and have excellent outcomes. We conducted a randomized controlled trial to determine whether the use of a prefabricated splint is as effective as a cast in the recovery of physical function. Methods: We included 96 children 5 to 12 years of age who were treated for a minimally angulated (≤15°) greenstick or transverse fracture of the wrist between April 2007 and September 2009 at a tertiary care pediatric hospital. Participants were randomly assigned to receive either a prefabricated wrist splint or a short arm cast for four weeks. The primary outcome was physical function at six weeks, measured using the performance version of the Activities Scale for Kids. Additional outcomes included the degree of angulation, range of motion, grip strength and complications. Results: Of the 96 children, 46 received a splint and 50 a cast. The mean Activities Scale for Kids score at six weeks was 92.8 in the splint group and 91.4 in the cast group (difference 1.44, 95% confidence interval [CI] .1.75 to 4.62). Thus, the null hypothesis that the splint is less effective by at least seven points was rejected. The between-group difference in angulation at four weeks was not statistically significant (9.85° in the splint group and 8.20° in the cast group; mean difference 1.65°, 95% CI .1.82° to 5.11°), nor was the between-group differences in range of motion, grip strength and complications. Interpretation: In children with minimally angulated fractures of the distal radius, use of a splint was as effective as a cast with respect to the recovery of physical function. In addition, the devices were comparable in terms of the maintenance of fracture stability and the occurrence of complications. (ClinicalTrials.gov trial register no. NCT00610220.) [ABSTRACT FROM AUTHOR]

Abstract: Objectives: In skeletally immature children, isolated lateral ankle injuries without radiograph-visible fractures are often diagnosed with Salter–Harris I fractures of the distal fibula (SH1DF). However, recent magnetic resonance imaging (MRI) evidence in children suggests that sprains may be more common than previously thought. Thus, the main objective of this study was to determine the rate of MRI-confirmed SH1DF among cases where this diagnosis was made presumptively, based on clinical findings. In ankle injuries where there is no MRI evidence of SH1DF, another aim is to detect the pathology which gives rise to this clinical scenario. Methods: This was a prospective cohort study performed at a tertiary care paediatric centre. Eligible patients included skeletally immature children with acute ankle injuries presenting with difficulty weight bearing and maximal tenderness and swelling over the distal fibular growth plate (lateral malleolus). Enrolled patients had ankle radiographs at the Emergency Department (ED) visit, MRI within 1 week of the injury, and repeat ankle X-rays at 4 weeks. All images were reviewed by two radiologists and an orthopaedic surgeon. Discrepancies between reading physicians were resolved by consensus agreement. Results: Eighteen patients were enrolled into the study from September 2008 to August 2009. Mean (SD) age of participants was 8.7 (2.0) years. None of the 18 patients had evidence of fibular growth plate injury on MR imaging. Patients often had more than one abnormal finding on MRI. Fourteen (78%) had evidence of ligamentous sprains, 11 (61%) had bony contusions, one patient (6%) had a subtle fibular avulsion fracture, and another was found to have a minor articular cartilage injury. At 4 weeks, only one patient''s radiographs demonstrated a healing fracture, which corresponded with the avulsion fracture case. All patients had returned to full weight bearing by 4 weeks. Conclusions: In this series, the clinical diagnosis of SH1DF was incorrect in 100% of cases. Instead, in almost 90% of these patients, MRI identified ligamentous sprains and/or bony contusions. These results may influence the way children who present with this common clinical scenario are managed since the vast majority of children in this study actually had sprain/contusion injuries and none had SH1DF. [Copyright &y& Elsevier]

The past decade has brought increasing coverage in the medical literature and lay media of the potential association between low-level radiation from diagnostic imaging and an increased lifetime cancer risk. Both physician and public opinion increasingly favour a greater discussion of benefit and risk with patients and their families when such imaging is being considered. Particular attention has been directed towards CT, its use in children and the emergency department setting. We will review the evolution of radiation dose awareness and knowledge among emergency physicians (EPs) alongside the parallel increase in public awareness. We will then discuss expectations for risk disclosure and the challenges faced by EPs and radiologists as we strive to provide this in a clinically balanced and meaningful way. [ABSTRACT FROM AUTHOR]

Context The unbiased selection of images representing a spectrum of diagnostic difficulty is an important first step in designing effective assessment and teaching interventions for X-ray interpretation. Objectives This study aimed to develop a scale that would reliably differentiate more difficult X-rays from those that are easier to interpret. Methods After pilot testing, an X-ray difficulty scale (XRDS) was developed. Raters of different learner levels from two universities were presented with 20 chest X-rays (CXRs) and asked to read them and then to answer the scale questions that would help to differentiate the level of difficulty of interpretation of each film. Reliability of the scale was evaluated. Face validity of the scale was assessed and the construct validity of two hypotheses was tested. Results The final scale consisted of five questions in which a given X-ray could score from − 10 (most difficult) to + 10 (easiest to interpret) by a single rater. Raters included 53 medical students, 10 paediatric residents and 10 emergency staff. The scale demonstrated excellent internal consistency ( r = 0.94), inter-rater reliability ( r = 0.95) and overall reliability ( r = 0.90) in medical students. Construct validity testing demonstrated good correlation ( r = 0.72) between diagnostic accuracy and mean XRDS score. Mean scores on the scale were significantly lower (indicating that CXRs were more difficult to interpret) for students than for resident and staff doctors ( P < 0.0001). Conclusions The scale developed in this study serves as a reliable and valid tool for categorising CXRs according to diagnostic difficulty, which reduces the bias inherent in the process of selecting radiographs by expert opinion alone. [ABSTRACT FROM AUTHOR]

Background: The Greater Toronto Area (GTA) was considered a "hot zone" for severe acute respiratory syndrome (SARS) in 2003. In accordance with mandated city-wide infection control measures, the Hospital for Sick Children (HSC) dastically reduced all services while maintaining a fully operational emergency department. Because of the GTA health service suspensions and the overlap of SARS-like symptoms with many common childhood illnesses, this introduced the potential for a change in the volumes of patients visiting the emergency department of the only regional tertiary care children's hospital. Methods: We compared HSC emergency department patient volumes, admission rates and length of stay in the emergency department in the baseline years of 2000-2002 (non-SARS years) with those in 2003 (SARS year). The data from the prior years were modeled as a time series. Using an interrupted time series analysis, we compared the 2003 data for the periods before, during and after the SARS periods with the modeled data for significant differences in the 3 aforementioned outcomes of interest. Results: Compared with the 2000-2002 data, we found no differences in visits, admission rates or length of stay in the pre-SARS period in 2003. There were significant decreases in visits and length of stay (p < 0.001) and increases in admission rates (p < 0.001) during the periods in 2003 when there were new and active cases of SARS in the GTA. All 3 outcomes returned to expected estimates coincident with the absence of SARS cases from September to December 2003. Interpretation: During the SARS outbreak in the GTA, the HSC emergency department experienced significantly reduced volumes of patients with low-acuity complaints. This gives insight into utilization rates of a pediatric emergency depart-ment during a time when there was additional perceived risk in using emergency department services and provides a foundation for emergency department preparedness policies for SARS-like p... [ABSTRACT FROM AUTHOR]

Summary: Background: Radiographs are ordered routinely for children with ankle trauma. We assessed the predictive value of a clinical examination to identify a predefined group of low-risk injuries, management of which would not be affected by absence of a radiograph. We aimed to show that no more than 1% of children with low-risk examinations (signs restricted to the distal fibula) would have high-risk fractures (all fractures except avulsion, buckle, and non-displaced Salter-Harris I and II fractures of the distal fibula), and to compare the potential reduction in radiography in children with low-risk examinations with that obtained by application of the Ottawa ankle rules (OAR). Methods: Standard clinical examinations and subsequent radiographs were prospectively and independently evaluated in two tertiary-care paediatric emergency departments in North America. Eligible participants were healthy children aged 3-16 years with acute ankle injuries. Sample size, negative and positive predictive values, sensitivity, and specificity were calculated. McNemar's test was used to compare differences in the potential reduction in radiographs between the low-risk examination and the OAR. Findings: 607 children were enrolled; 581 (95.7%) received follow-up. None of the 381 children with low-risk examinations had a high-risk fracture (negative predictive value 100% [95% CI 99.2-100]; sensitivity 100% [93.3-100]). Radiographs could be omitted in 62.8% of children with low-risk examinations, compared with only 12.0% reduction obtained by application of the OAR (p<0.0001). Interpretation: A low-risk clinical examination in children with ankle injuries identifies 100% of high-risk diagnoses and may result in greater reduction of radiographic referrals than the OAR. [ABSTRACT FROM AUTHOR]

Presents a study which determined the incidence of acetaminophen-related nephrotoxicity in adolescents with acute severe acetaminophen overdose. Characteristics of the participants; Methodology; Results and discussion.

The article offers information on several topics related to low-risk ankle injuries in children. Topics discussed include the low-risk injuries such as lateral ankle sprains and avulsion fractures; the Low Risk Ankle Rule which assists in reducing the use of unnecessary radiographs in children; and the effectiveness of ankle braces in the management of low-risk ankle fractures in children.

Introduction: There is limited knowledge on pediatric chest radiograph (pCXR) interpretation skill among practicing physicians. We systematically determined baseline interpretation skill, the number of pCXR cases physicians required complete to achieve a performance benchmark, and which diagnoses posed the greatest diagnostic challenge. Methods: Physicians interpreted 434 pCXR cases via a web-based platform until they achieved a performance benchmark of 85% accuracy, sensitivity, and specificity. Interpretation difficulty scores for each case were derived by applying one-parameter item response theory to participant data. We compared interpretation difficulty scores across diagnostic categories and described the diagnoses of the 30% most difficult-to-interpret cases. Results: 240 physicians who practice in one of three geographic areas interpreted cases, yielding 56,833 pCXR case interpretations. The initial diagnostic performance (first 50 cases) of our participants demonstrated an accuracy of 68.9%, sensitivity of 69.4%, and a specificity of 68.4%. The median number of cases completed to achieve the performance benchmark was 102 (interquartile range 69, 176; min, max, 54, 431). Among the 30% most difficult-to-interpret cases, 39.2% were normal pCXR and 32.3% were cases of lobar pneumonia. Cases with a single trauma-related imaging finding, cardiac, hilar, and diaphragmatic pathologies were also among the most challenging. Discussion: At baseline, practicing physicians misdiagnosed about one-third of pCXR and there was up to an eight-fold difference between participants in number of cases completed to achieve the standardized performance benchmark. We also identified the diagnoses with the greatest potential for educational intervention. [ABSTRACT FROM AUTHOR]

The article provides five things to know about buckle fractures of the distal radius in children. Topics include the occurrence of the disease when the body is compressed and bulges, the treatment option of removable splint which is effective as a short arm cast, and the importance of a routine follow-up with an orthopedic surgeon. The use of radiographs in diagnosing the disease is also discussed.

A letter to the editor and a reply are presented in response to the article "Cast versus splint in children with minimally angulated fractures of the distal radius: a randomized controlled trial," by K. Boutis and colleagues in the 2010 issue.

Importance: Gastroenteritis is a common pediatric illness. Electrolyte maintenance solution is recommended to treat and prevent dehydration. Its advantage in minimally dehydrated children is unproven.Objective: To determine if oral hydration with dilute apple juice/preferred fluids is noninferior to electrolyte maintenance solution in children with mild gastroenteritis.Design, Setting, and Participants: Randomized, single-blind noninferiority trial conducted between the months of October and April during the years 2010 to 2015 in a tertiary care pediatric emergency department in Toronto, Ontario, Canada. Study participants were children aged 6 to 60 months with gastroenteritis and minimal dehydration.Interventions: Participants were randomly assigned to receive color-matched half-strength apple juice/preferred fluids (n=323) or apple-flavored electrolyte maintenance solution (n=324). Oral rehydration therapy followed institutional protocols. After discharge, the half-strength apple juice/preferred fluids group was administered fluids as desired; the electrolyte maintenance solution group replaced losses with electrolyte maintenance solution.Main Outcomes and Measures: The primary outcome was a composite of treatment failure defined by any of the following occurring within 7 days of enrollment: intravenous rehydration, hospitalization, subsequent unscheduled physician encounter, protracted symptoms, crossover, and 3% or more weight loss or significant dehydration at in-person follow-up. Secondary outcomes included intravenous rehydration, hospitalization, and frequency of diarrhea and vomiting. The noninferiority margin was defined as a difference between groups of 7.5% for the primary outcome and was assessed with a 1-sided α=.025. If noninferiority was established, a 1-sided test for superiority was conducted.Results: Among 647 randomized children (mean age, 28.3 months; 331 boys [51.1%]; 441 (68.2%) without evidence of dehydration), 644 (99.5%) completed follow-up. Children who were administered dilute apple juice experienced treatment failure less often than those given electrolyte maintenance solution (16.7% vs 25.0%; difference, -8.3%; 97.5% CI, -∞ to -2.0%; P < .001 for inferiority and P = .006 for superiority). Fewer children administered apple juice/preferred fluids received intravenous rehydration (2.5% vs 9.0%; difference, -6.5%; 99% CI, -11.6% to -1.8%). Hospitalization rates and diarrhea and vomiting frequency were not significantly different between groups.Conclusions and Relevance: Among children with mild gastroenteritis and minimal dehydration, initial oral hydration with dilute apple juice followed by their preferred fluids, compared with electrolyte maintenance solution, resulted in fewer treatment failures. In many high-income countries, the use of dilute apple juice and preferred fluids as desired may be an appropriate alternative to electrolyte maintenance fluids in children with mild gastroenteritis and minimal dehydration.Trial Registration: clinicaltrials.gov Identifier: NCT01185054. [ABSTRACT FROM AUTHOR]

Prospective research studies often advance clinical practice in the emergency department (ED), but they can be costly and difficult to perform. In this report, we describe the implementation of a volunteer university student research assistant program that provides students exposure to medicine and clinical research while simultaneously increasing the capacity of an ED’s research program. This type of program provides 15 hours per day of research assistant coverage for patient screening and enrolment for minimal risk research studies, and screening for higher risk studies. The latter is true without the added burden or costs of co-administering university course credit or pay for service, which are common features of most of these types of programs currently in operation. We have shown that our volunteer-based program is effective for an ED’s research success as well as for its student participants. For other EDs interested in adopting similar programs, we provide the details on how to get such a program started and highlight the structure and non-monetary incentives that facilitate a program’s ongoing success. [ABSTRACT FROM PUBLISHER]

For assessing the skill of visual diagnosis such as radiograph interpretation, competency standards are often developed in an ad hoc method, with a poorly delineated connection to the target clinical population. Commonly used methods to assess for competency in radiograph interpretation are subjective and potentially biased due to a small sample size of cases, subjective evaluations, or include an expert-generated case-mix versus a representative sample from the clinical field. Further, while digital platforms are available to assess radiograph interpretation skill against an objective standard, they have not adopted a data-driven competency standard which informs educators and the public that a physician has achieved adequate mastery to enter practice where they will be making high-stakes clinical decisions. Operating on a purposeful sample of radiographs drawn from the clinical domain, we adapted the Ebel Method, an established standard setting method, to ascertain a defensible, clinically relevant mastery learning competency standard for the skill of radiograph interpretation as a model for deriving competency thresholds in visual diagnosis. Using a previously established digital platform, emergency physicians interpreted pediatric musculoskeletal extremity radiographs. Using one-parameter item response theory, these data were used to categorize radiographs by interpretation difficulty terciles (i.e. easy, intermediate, hard). A panel of emergency physicians, orthopedic surgeons, and plastic surgeons rated each radiograph with respect to clinical significance (low, medium, high). These data were then used to create a three-by-three matrix where radiographic diagnoses were categorized by interpretation difficulty and significance. Subsequently, a multidisciplinary panel that included medical and parent stakeholders determined acceptable accuracy for each of the nine cells. An overall competency standard was derived from the weighted sum. Finally, to examine consequences of implementing this standard, we reported on the types of diagnostic errors that may occur by adhering to the derived competency standard. To determine radiograph interpretation difficulty scores, 244 emergency physicians interpreted 1,835 pediatric musculoskeletal extremity radiographs. Analyses of these data demonstrated that the median interpretation difficulty rating of the radiographs was −1.8 logits (IQR −4.1, 3.2), with a significant difference of difficulty across body regions (p < 0.0001). Physician review classified the radiographs as 1,055 (57.8%) as low, 424 (23.1%) medium or 356 (19.1%) high clinical significance. The multidisciplinary panel suggested a range of acceptable scores between cells in the three-by-three table of 76% to 95% and the sum of equal-weighted scores resulted in an overall performance-based competency score of 85.5% accuracy. Of the 14.5% diagnostic interpretation errors that may occur at the bedside if this competency standard were implemented, 9.8% would be in radiographs of low-clinical significance, while 2.5% and 2.3% would be in radiographs of medium or high clinical significance, respectively. This study's novel integration of radiograph selection and a standard setting method could be used to empirically drive evidence-based competency standard for radiograph interpretation and can serve as a model for deriving competency thresholds for clinical tasks emphasizing visual diagnosis. [ABSTRACT FROM AUTHOR]

Background: Pediatric musculoskeletal (pMSK) radiograph interpretations are common, but the specific radiograph features at risk of incorrect diagnosis are relatively unknown.Objective: We determined the radiograph factors that resulted in diagnostic interpretation challenges for emergency physicians (EPs) reviewing pMSK radiographs.Methods: EPs interpreted 1850 pMSK radiographs via a web-based platform and we derived interpretation difficulty scores for each radiograph in 13 body regions using one-parameter item response theory. We compared the difficulty scores by presence or absence of a fracture and, where applicable, by fracture location and morphology; significance was adjusted for multiple comparisons. An expert panel reviewed the 65 most commonly misdiagnosed fracture-negative radiographs to identify imaging features mistaken for fractures.Results: We included data from 244 EPs, which resulted in 185,653 unique interpretations. For elbow, forearm, wrist, femur, knee, and tibia-fibula radiographs, those without a fracture had higher interpretation difficulty scores relative to those with a fracture; the opposite was true for the hand, pelvis, foot, and ankle radiographs (p < 0.004 for all comparisons). The descriptive review demonstrated that specific normal anatomy, overlapping bones, and external artefact from muscle or skin folds were often mistaken for fractures. There was a significant difference in difficulty score by anatomic locations of the fracture in the elbow, pelvis, and ankle (p < 0.004 for all comparisons). Ankle and elbow growth plate, fibular avulsion, and humerus condylar fractures were more difficult to diagnose than other fracture patterns (p < 0.004 for all comparisons).Conclusions: We identified actionable learning opportunities in pMSK radiograph interpretation for EPs. [ABSTRACT FROM AUTHOR]

Abstract: Objective: The results of two randomized clinical trials (RCTs) demonstrate the clinical effectiveness of alternatives to casting for certain ankle and wrist fractures. We illustrate the use of value of information (VOI) methods for evaluating the evidence provided by these studies with respect to decision making. Study Design and Setting: Using cost-effectiveness data from these studies, the expected value of sample information (EVSI) of a future RCT can be determined. If the EVSI exceeds the cost of the future trial for any sample size, then the current evidence is considered insufficient for decision making and a future trial is considered worthwhile. If, on the other hand, there is no sample size for which the EVSI exceeds the cost, then the evidence is considered sufficient, and no future trial is required. Results: We found that the evidence from the ankle study was insufficient to support the adoption of the removable device and determined the optimal sample size for a future trial. Conversely, the evidence from the wrist study was sufficient to support the adoption of the removable device. Conclusions: VOI methods provide a decision-analytic alternative to the standard hypothesis testing approach for assessing the evidence provided by cost-effectiveness studies and for determining sample sizes for RCTs. [Copyright &y& Elsevier]

Despite many children experiencing fatigue after childhood brain injury, little is known about the predictors of this complaint. To date, traditional indices of traumatic brain injury (TBI) severity have not predicted reliably persisting fatigue (up to three years post-injury). This study aimed to establish whether persisting fatigue is predicted by serum biomarker concentrations in child TBI. We examined whether acute serum biomarker expression would improve prediction models of 12-month fatigue based on injury severity. Blood samples were collected from 87 children (1–17 years at injury) sustaining mild to severe TBI (Glasgow Coma Scale [GCS] range 3–15; mean 12.43; classified as mild TBI [n = 50, 57%] vs. moderate/severe TBI [n = 37, 43%]), and presenting to the emergency departments (ED) and pediatric intensive care units (PICU) at one of three tertiary pediatric hospitals (Royal Children's Hospital (RCH); Hospital for Sick Children (HSC), Toronto; St Justine Children's Hospital (SJH), Montreal). Six serum biomarker concentrations were measured within 24 h of injury (interleukin-6, interleukin-8 [IL-8], soluble vascular cell adhesion molecule [SVCAM], S100 calcium binding protein B [S100B], neuron specific enolase [NSE], and soluble neural cell adhesion molecule [sNCAM]). Fatigue at 12 months post-injury was measured using the Pediatric Quality of Life Inventory Multidimensional Fatigue Scale (parent report), classified as present/absent using previously derived cut-points. At 12 months post-injury, 22% of participants experienced fatigue. A model including IL-8 was the best serum biomarker for estimating the probability of children experiencing fatigue at 12 months post-injury. The IL-8 also significantly improved predictive models of fatigue based on severity. [ABSTRACT FROM AUTHOR]

Objectives: Using a sample of pediatric chest radiographs (pCXR) taken to rule out pneumonia, we obtained diagnostic interpretations from physicians and used learning analytics to determine the radiographic variables and participant review processes that predicted for an incorrect diagnostic interpretation. Methods: This was a prospective cross‐sectional study. A convenience sample of frontline physicians with a range of experience levels interpreted 200 pCXR presented using a customized online radiograph presentation platform. Participants were asked to determine absence or presence (with respective location) of pneumonia. The pCXR were categorized for specific image‐based variables potentially associated with interpretation difficulty. We also generated heat maps displaying the locations of diagnostic error among normal pCXR. Finally, we compared image review processes in participants with higher versus lower levels of clinical experience. Results: We enrolled 83 participants (20 medical students, 40 postgraduate trainees, and 23 faculty) and obtained 12,178 case interpretations. Variables that predicted for increased pCXR interpretation difficulty were pneumonia versus no pneumonia (β = 8.7, 95% confidence interval [CI] = 7.4 to 10.0), low versus higher visibility of pneumonia (β = –2.2, 95% CI = –2.7 to –1.7), nonspecific lung pathology (β = 0.9, 95% CI = 0.40 to 1.5), localized versus multifocal pneumonia (β = –0.5, 95% CI = –0.8 to –0.1), and one versus two views (β = 0.9, 95% CI = 0.01 to 1.9). A review of diagnostic errors identified that bony structures, vessels in the perihilar region, peribronchial thickening, and thymus were often mistaken for pneumonia. Participants with lower experience were less accurate when they reviewed one of two available views (p < 0.0001), and accuracy of those with higher experience increased with increased confidence in their response (p < 0.0001). Conclusions: Using learning analytics, we identified actionable learning opportunities for pCXR interpretation, which can be used to allow for a customized weighting of which cases to practice. Furthermore, experienced–novice comparisons revealed image review processes that were associated with greater diagnostic accuracy, providing additional insight into skill development of image interpretation. [ABSTRACT FROM AUTHOR]

To determine diagnoses and image features that are associated with difficult prepubescent female genital image interpretations. This was a mixed-methods study conducted at a tertiary care pediatric center using images from a previously developed education platform. Participants comprised 107 medical students, residents, fellows, and attendings who interpreted 158 cases to derive case difficulty estimates. This was a planned secondary analysis of participant performance data obtained from a prospective multi-center cross-sectional study. An expert panel also performed a descriptive review of images with the highest frequency of diagnostic error. We derived the proportion of participants who interpreted an image correctly, and features that were common in images with the most frequent diagnostic errors. We obtained 16,906 image interpretations. The mean proportion correct scores for each diagnosis were as follows: normal/normal variants 0.84 (95% confidence interval [CI] 0.82, 0.87); infectious/dermatology pathology 0.59 (95% CI 0.45, 0.73); anatomic pathology 0.61 (95% CI 0.41, 0.81); and, traumatic pathology 0.64 (95% CI 0.49, 0.79). The mean proportion correct scores varied by diagnosis (P <.001). The descriptive review demonstrated that poor image quality, infant genitalia, normal variant anatomy, external material (eg, diaper cream) in the genital area, and nonspecific erythema were common features in images with lower accuracy scores. A quantitative and qualitative examination of prepubescent female genital examination image interpretations provided insight into diagnostic challenges for this complex examination. These data can be used to inform the design of teaching interventions to improve skill in this area. [ABSTRACT FROM AUTHOR]

Background: Preschool children with recurrent wheezing suffer high morbidity. It is unclear whether objective measures of asthma control, such as pulmonary function tests (PFTs), provide additional information to the clinical assessment. Methods: We recruited children between 3 and 6 years old, with a history of recurrent wheezing in the preceding year and treated for acute wheezing exacerbation in the emergency department (ED) into an observational cohort study. Children attended two outpatient visits: the first study visit within five days of discharge from the ED and the second study visit 12 weeks after the ED visit. We performed standardized symptom score (test for respiratory and asthma control in kids (TRACK)), multiple breath washout (MBW), spirometry, and clinical assessment at both visits. Results: Seventy‐four children, mean (standard deviation (SD)) age of 4.32 years (0.84), attended both visits. Paired FEV0.75 and lung clearance index (LCI) measurements at both time points were obtained in 37 and 34 subjects, respectively. Feasibility for all tests improved at visit 2 and was not age‐dependent. At the second study visit, a third had controlled asthma based on the TRACK score, and the mean lung clearance index (LCI) improved from 9.86 to 8.31 (P =.003); however, 46% had an LCI in the abnormal range. FEV0.75z‐score improved from −1.66 to −1.17 (P =.05) but remained in the abnormal range in 24%. LCI was abnormal in more than half of the children with "well‐controlled" asthma based on the TRACK score. There was no correlation between PFT measures and TRACK scores at either visit. Conclusions: Lung clearance index demonstrates a persistent deficit post‐exacerbation in a large proportion of preschoolers with recurrent wheezing, highlighting that symptom scores alone may not suffice for monitoring these children. [ABSTRACT FROM AUTHOR]

Objectives: To complement bedside learning of point‐of‐care ultrasound (POCUS), we developed an online learning assessment platform for the visual interpretation component of this skill. This study examined the amount and rate of skill acquisition in POCUS image interpretation in a cohort of pediatric emergency medicine (PEM) physician learners. Methods: This was a multicenter prospective cohort study. PEM physicians learned POCUS using a computer‐based image repository and learning assessment system that allowed participants to deliberately practice image interpretation of 400 images from four pediatric POCUS applications (soft tissue, lung, cardiac, and focused assessment sonography for trauma [FAST]). Participants completed at least one application (100 cases) over a 4‐week period. Results: We enrolled 172 PEM physicians (114 attendings, 65 fellows). The increase in accuracy from the initial to final 25 cases was 11.6%, 9.8%, 7.4%, and 8.6% for soft tissue, lung, cardiac, and FAST, respectively. For all applications, the average learners (50th percentile) required 0 to 45, 25 to 97, 66 to 175, and 141 to 290 cases to reach 80, 85, 90, and 95% accuracy, respectively. The least efficient (95th percentile) learners required 60 to 288, 109 to 456, 160 to 666, and 243 to 1040 cases to reach these same accuracy benchmarks. Generally, the soft tissue application required participants to complete the least number of cases to reach a given proficiency level, while the cardiac application required the most. Conclusions: Deliberate practice of pediatric POCUS image cases using an online learning and assessment platform may lead to skill improvement in POCUS image interpretation. Importantly, there was a highly variable rate of achievement across learners and applications. These data inform our understanding of POCUS image interpretation skill development and could complement bedside learning and performance assessments. [ABSTRACT FROM AUTHOR]

Objectives: As residency programs transition from time‐ to performance‐based competency standards, validated tools are needed to measure performance‐based learning outcomes and studies are required to characterize the learning experience for residents. Since pediatric musculoskeletal (MSK) radiograph interpretation can be challenging for emergency medicine trainees, we introduced Web‐based pediatric MSK radiograph learning system with performance endpoints into pediatric emergency medicine (PEM) fellowships and determined the feasibility and effectiveness of implementing this intervention. Methods: This was a multicenter prospective cohort study conducted over 12 months. The course offered 2,100 pediatric MSK radiographs organized into seven body regions. PEM fellows diagnosed each case and received feedback after each interpretation. Participants completed cases until they achieved a performance benchmark of at least 80% accuracy, sensitivity, and specificity. The main outcome measure was the median number of cases completed by participants to achieve the performance benchmark. Results: Fifty PEM fellows from nine programs in the US and Canada participated. There were 301 of 350 (86%) modules started and 250 of 350 (71%) completed to the predefined performance benchmark during the study period. The median (interquartile range [IQR]) number of cases to performance benchmark per participant was 78 (60–104; min = 56, max = 1,333). Between modules, the median number of cases to achieve the performance benchmark was different for the ankle versus other modules (ankle 366 vs. other 76; difference = 290, 95% confidence interval [CI] = 245 to 335). The performance benchmark was achieved for 90.7% of participants in all modules except the ankle/foot, where 34.9% achieved this goal (difference = 55.8%, 95% CI = 45.3 to 66.3). The mean (95% CI) change in accuracy, sensitivity, and specificity from baseline to performance benchmark was +14.6% (13.4 to 15.8), +16.5% (14.8 to 18.1), and +12.6% (10.7 to 14.5), respectively. Median (IQR) time on each case was 31.0 (21.0–45.3) seconds. Conclusions: Most participants completed the modules to the performance benchmark within 1 hour and demonstrated significant skill improvement. Further, there was a large variation in the number of cases completed to achieve the performance endpoint in any given module, and this impacted the feasibility of completing specific modules. [ABSTRACT FROM AUTHOR]

The identification of clinical phenotypes may help parse the substantial heterogeneity that characterizes children with concussion. This study used latent class analysis (LCA) to identify discernible phenotypes among children with acute concussion and examine the association between phenotypes and persistent post-concussive symptoms (PPCS) at 4 and 12 weeks post-injury. We conducted LCA of variables representing pre-injury history, clinical presentation, and parent symptom ratings, derived from a prospective cohort, observational study that recruited participants from August 2013 until June 2015 at nine pediatric emergency departments within the Pediatric Emergency Research Canada network. This substudy included 2323 children from the original cohort ages 8.00–17.99 years who had data for at least 80% of all variables included in each LCA. Concussion was defined according to Zurich consensus statement diagnostic criteria. The primary outcome was PPCS at 4 and 12 weeks after enrollment. Participants were 39.5% female and had a mean age of 12.8 years (standard deviation = 2.6). Follow-up was completed by 1980 (85%) at 4 weeks and 1744 (75%) at 12 weeks. LCA identified four groups with discrete pre-injury histories, four groups with discrete clinical presentations, and seven groups with discrete profiles of acute symptoms. Clinical phenotypes based on the profile of group membership across the three LCAs varied significantly in their predicted probability of PPCS at 4 and 12 weeks. The results indicate that children with concussion can be grouped into distinct clinical phenotypes, based on pre-injury history, clinical presentation, and acute symptoms, with markedly different risks of PPCS. With further validation, clinical phenotypes may provide a useful heuristic for clinical assessment and management. [ABSTRACT FROM AUTHOR]

Objective: Concussion in children and adolescents is a prevalent problem with implications for subsequent physical, cognitive, behavioral, and psychological functioning, as well as quality of life. While these consequences warrant attention, most concussed children recover well. This study aimed to determine what pre-injury, demographic, and injury-related factors are associated with optimal outcome ("wellness") after pediatric concussion. Method: A total of 311 children 6–18 years of age with concussion participated in a longitudinal, prospective cohort study. Pre-morbid conditions and acute injury variables, including post-concussive symptoms (PCS) and cognitive screening (Standardized Assessment of Concussion, SAC), were collected in the emergency department, and a neuropsychological assessment was performed at 4 and 12 weeks post-injury. Wellness, defined by the absence of PCS and cognitive inefficiency and the presence of good quality of life, was the main outcome. Stepwise logistic regression was performed using 19 predictor variables. Results: 41.5% and 52.2% of participants were classified as being well at 4 and 12 weeks post-injury, respectively. The final model indicated that children who were younger, who sustained sports/recreational injuries (vs. other types), who did not have a history of developmental problems, and who had better acute working memory (SAC concentration score) were significantly more likely to be well. Conclusions: Determining the variables associated with wellness after pediatric concussion has the potential to clarify which children are likely to show optimal recovery. Future work focusing on wellness and concussion should include appropriate control groups and document more extensively pre-injury and injury-related factors that could additionally contribute to wellness. (JINS , 2019, 25 , 375–389) [ABSTRACT FROM AUTHOR]

A significant proportion of children and adolescents report psychological distress following concussion, but little is known about the predictors of these problems. The purpose of this study was to examine predictive factors of psychological distress following pediatric concussion. It was hypothesized that the presence of pre-injury psychological distress would be the strongest predictor of psychological distress post-concussion, with other demographic and acute injury factors adding incrementally to prediction. This is a prospective, multi-center cohort. Children and adolescents (6–17 years old; n = 311) who sustained a concussion and were assessed through four pediatric emergency departments. Participants were reassessed at 4-weeks (n = 275) and 12-weeks (n = 190) post-injury. Emergency department (ED) assessment documented injury mechanism, acute symptomatology, acute cognitive functioning, and pre-injury functioning. Psychological distress at 4- and 12-weeks follow-up was categorized as present if one or more psychological scores from the parent-completed measures (Child Behavior Checklist, Strengths and Difficulties Questionnaire) exceeded established cutoffs. The presence of psychological distress at each follow-up was predicted using multi-variable logistic regressions. Psychological distress was reported in 23% of youth at both 4- and 12-weeks post-concussion. A pre-injury diagnosis of anxiety and acutely forgetting recent information were significant predictors of psychological distress at 4 weeks, whereas worse acute orientation assessment in the ED predicted psychological distress at 12 weeks. Nearly one of four youth experienced psychological distress after concussion. Clinicians in acute care settings should screen for the factors (pre-injury anxiety, acute mental status) associated with post-injury psychological distress and consider proactively referring patients for further assistance. [ABSTRACT FROM AUTHOR]

In contrast to other environmental allergens, the association with atopic dermatitis was present for Fel d 1, which may suggest that the skin is an important route of sensitization for this allergen. GLO:1X5/01dec19:all13927-fig-0002.jpg PHOTO (COLOR): Hierarchical clustering performed on patient sensitization profiles and allergen components indicating clusters by allergen source and biochemical family (sensitized: N = 37; nonsensitized: N = 18). In conclusion, we provide data describing a potentially high-risk preschool asthma cohort in Canada using a comprehensive approach capturing sensitization to allergens of paramount importance. By applying both allergen extracts and components, we identified that peanut and animal allergens from cat and dog were major allergen sources in this North American cohort of preschool asthmatics. [Extracted from the article]

Background: There is uncertainty about which children with minor head injury need to undergo computed tomography (CT). We sought to prospectively validate the accuracy and potential for refinement of a previously derived decision rule, Canadian Assessment of Tomography for Childhood Head injury (CATCH), to guide CT use in children with minor head injury.Methods: This multicentre cohort study in 9 Canadian pediatric emergency departments prospectively enrolled children with blunt head trauma presenting with a Glasgow Coma Scale score of 13-15 and loss of consciousness, amnesia, disorientation, persistent vomiting or irritability. Phys icians completed standardized assessment forms before CT, including clinical predictors of the rule. The primary outcome was neurosurgical intervention and the secondary outcome was brain injury on CT. We calculated test characteristics of the rule and used recursive partitioning to further refine the rule.Results: Of 4060 enrolled patients, 23 (0.6%) underwent neurosurgical intervention, and 197 (4.9%) had brain injury on CT. The original 7-item rule (CATCH) had sensitivities of 91.3% (95% confidence interval [CI] 72.0%-98.9%) for neurosurgical intervention and 97.5% (95% CI 94.2%-99.2%) for predicting brain injury. Adding "≥ 4 episodes of vomiting" resulted in a refined 8-item rule (CATCH2) with 100% (95% CI 85.2%-100%) sensitivity for neurosurgical intervention and 99.5% (95% CI 97.2%-100%) sensitivity for brain injury.Interpretation: Among children presenting to the emergency department with minor head injury, the CATCH2 rule was highly sensitive for identifying those children requiring neurosurgical intervention and those with any brain injury on CT. The CATCH2 rule should be further validated in an implementation study designed to assess its clinical impact. [ABSTRACT FROM AUTHOR]

Introduction: Given the potential malignancy risks associated with computed tomography (CT), some physicians are increasingly advocating for risk disclosure to patients/families. Our goal was to evaluate the practices and attitudes of pediatric emergency medicine (PEM) fellowship program leaders' regarding CT radiation-risk disclosure. Methods: We conducted a cross-sectional survey study of the United States and Canadian PEM fellowship directors and associate/assistant directors. We developed a web-based survey using a modified Dillman technique. Primary outcome was the prop ortion who "almost always" or "most of the time" discussed potential malignancy risks from CT prior to ordering this test. Results: Of 128 physicians who received the survey, 108 (86%) responded. Of those respondents, 73%, 95% confidence interval (CI) [64-81] reported "almost always" or "most of the time" discussing potential malignancy risks when ordering a CT for infants; proportions for toddlers, school-age children, and teenagers were 72% (95% CI [63-80]), 66% (95% CI [56-75]), and 58% (95% CI [48-67]), respectively (test for trend, p=0.008). Eighty percent reported being "extremely" or "very" comfortable discussing radiation risks. Factors of "high" or "very high" importance in disclosing risks included parent request for a CT not deemed clinically indicated for 94% of respondents, and parent-initiated queries about radiation risks for 79%. If risk disclosure became mandatory, 82% favored verbal discussion over written informed consent. Conclusion: PEM fellowship program leaders report frequently disclosing potential malignancy risks from CT, with the frequency varying inversely with patient age. Motivating factors for discussions included parental request for a CT deemed clinically unnecessary and parental inquiry about risks. [ABSTRACT FROM AUTHOR]

Objectives: Fatigue is a common and persisting symptom after childhood brain injury. This study examined whether child characteristics and symptomatology preinjury or 6 months postinjury (pain, sleep, and mood, inattention) predicted fatigue at 12months postinjury. Methods: Parents of 79 children (0–18 years) rated fatigue at 12 months after injury on a multidimensional scale (general, sleep/rest, and cognitive). Demographic and clinical data were collected at injury. Parents rated child sleep, pain, physical/motor function, mood, and inattention at injury (preinjury description), and 6 months postinjury. Children were divided into two traumatic brain injury severity groups: mild TBI (n=57) and moderate/severe TBI (n=27). Hierarchical regression models were used to examine (i) preinjury factors and (ii) symptoms 6 months postinjury predictive of fatigue (general, sleep/rest, and cognitive) at 12 months postinjury. Results: Sleep/rest fatigue was predicted by preinjury fatigue (7% of variance) and psychological symptoms preinjury (10% of variance). General fatigue was predicted by physical/motor symptoms (27%), sleep (10%) and mood symptoms (9%) 6 months postinjury. Sleep/rest fatigue was predicted by physical/motor symptoms (10%), sleep symptoms (13%) and mood symptoms (9%) 6 months postinjury. Cognitive fatigue was predicted by physical/motor symptoms (17%) 6 months postinjury. Conclusions: Preinjury fatigue and psychological functioning identified those at greatest risk of fatigue 12 months post-TBI. Predictors of specific fatigue domains at 12 months differed across each of the domains, although consistently included physical/motor function as well as sleep and mood symptoms postinjury. (JINS, 2018, 24, 224–236) [ABSTRACT FROM AUTHOR]

Purpose: The purposes of this study were to evaluate the frequency with which emergency physicians involved in residency leadership disclose potential malignancy risks from computed tomography (CT), assess comfort with these discussions, and evaluate factors influencing risk disclosure.Methods: We surveyed emergency medicine residency program directors and associate/assistant directors. Primary outcome was the proportion who "almost always" or "most of the time" discussed potential risks.Results: Two hundred and seventy-four (50.6%) of 542 eligible physicians responded. There were 82.1% (95% CI 76.8%, 86.6%) who reported almost always or most of the time discussing potential risks for patients ≤18 years; proportions for adults 19-40, 41-65, and >65 years were 50.6% (95% CI 44.4, 56.7%), 20.7% (95% CI 16.0, 26.0%), and 5.2% (95% CI 2.9, 8.5%), respectively (test for trend, p < 0.001). The proportion reporting being "extremely" or "very" comfortable discussing risks was 57.1% (95% CI 51.1, 63.2%). Patient/family CT request that the physician felt was not indicated was of "very high" or "high" importance for driving risk discussions in 86.4% of respondents. For 75.5%, patient/family query about radiation risks was of "high" or "very high" importance. Among 57.4% of respondents, the patient being elderly and/or having a reduced life expectancy was of "high" or "very high" importance in the decision not to discuss risk.Conclusions: Emergency physicians involved in residency leadership report frequently disclosing potential malignancy risks from CT at frequencies inversely proportional to patient age. About half are comfortable with discussions, and many discussions are driven by patient requests. Opportunities exist to optimize and standardize emergency department CT radiation risk disclosure practices. [ABSTRACT FROM AUTHOR]

Importance: Although concussion treatment guidelines advocate rest in the immediate postinjury period until symptoms resolve, no clear evidence has determined that avoiding physical activity expedites recovery.Objective: To investigate the association between participation in physical activity within 7 days postinjury and incidence of persistent postconcussive symptoms (PPCS).Design, Setting, and Participants: Prospective, multicenter cohort study (August 2013-June 2015) of 3063 children and adolescents aged 5.00-17.99 years with acute concussion from 9 Pediatric Emergency Research Canada network emergency departments (EDs).Exposures: Early physical activity participation within 7 days postinjury.Main Outcomes and Measures: Physical activity participation and postconcussive symptom severity were rated using standardized questionnaires in the ED and at days 7 and 28 postinjury. PPCS (≥3 new or worsening symptoms on the Post-Concussion Symptom Inventory) was assessed at 28 days postenrollment. Early physical activity and PPCS relationships were examined by unadjusted analysis, 1:1 propensity score matching, and inverse probability of treatment weighting (IPTW). Sensitivity analyses examined patients (≥3 symptoms) at day 7.Results: Among 2413 participants who completed the primary outcome and exposure, (mean [SD] age, 11.77 [3.35] years; 1205 [39.3%] females), PPCS at 28 days occurred in 733 (30.4%); 1677 (69.5%) participated in early physical activity including light aerobic exercise (n = 795 [32.9%]), sport-specific exercise (n = 214 [8.9%]), noncontact drills (n = 143 [5.9%]), full-contact practice (n = 106 [4.4%]), or full competition (n = 419 [17.4%]), whereas 736 (30.5%) had no physical activity. On unadjusted analysis, early physical activity participants had lower risk of PPCS than those with no physical activity (24.6% vs 43.5%; Absolute risk difference [ARD], 18.9% [95% CI,14.7%-23.0%]). Early physical activity was associated with lower PPCS risk on propensity score matching (n = 1108 [28.7% for early physical activity vs 40.1% for no physical activity]; ARD, 11.4% [95% CI, 5.8%-16.9%]) and on inverse probability of treatment weighting analysis (n = 2099; relative risk [RR], 0.74 [95% CI, 0.65-0.84]; ARD, 9.7% [95% CI, 5.7%-13.7%]). Among only patients symptomatic at day 7 (n = 803) compared with those who reported no physical activity (n = 584; PPCS, 52.9%), PPCS rates were lower for participants of light aerobic activity (n = 494 [46.4%]; ARD, 6.5% [95% CI, 5.7%-12.5%]), moderate activity (n = 176 [38.6%]; ARD, 14.3% [95% CI, 5.9%-22.2%]), and full-contact activity (n = 133 [36.1%]; ARD, 16.8% [95% CI, 7.5%-25.5%]). No significant group difference was observed on propensity-matched analysis of this subgroup (n = 776 [47.2% vs 51.5%]; ARD, 4.4% [95% CI, -2.6% to 11.3%]).Conclusions and Relevance: Among participants aged 5 to 18 years with acute concussion, physical activity within 7 days of acute injury compared with no physical activity was associated with reduced risk of PPCS at 28 days. A well-designed randomized clinical trial is needed to determine the benefits of early physical activity following concussion. [ABSTRACT FROM AUTHOR]

Objectives: To determine the sensitivity of parental suspicion of concussion relative to paediatric emergency physicians in children who presented to an emergency department (ED) with a head injury. A secondary objective was to examine the variables associated with parental suspicion of concussion concordant with that of a physician. Methods: Parents of children five to 18 years of age presenting to an urban paediatric ED with a nonstructural head injury completed a 24-item questionnaire. Results: Of the 577 eligible parents, 495 (85.8%) consented to participate. The sensitivity of parental suspicion for concussion was 40.0% (95% CI 33.2% to 47.2%), while the specificity was 58.3% (95% CI 52.4% to 64.0%). The variable of child age ≥10 years was associated with an increased odds (OR 3.0) of a parental suspicion of concussion concordant with that of a physician; parent age, parent sex, mechanism of head injury and history of concussion in the child were not. Although 453 (91.5%) parents would stop activity if they believed their child sustained a concussion, only 159 (32.1%) were familiar with return-to-play guidelines. Conclusions: Parents often did not suspect a concussion when it was ultimately diagnosed by a paediatric emergency physician, although they were more likely to do so in older children. Only approximately one-third were aware of return-to-play guidelines. To enhance the potential for parent-driven advocacy in the recognition and management of concussion, these data support the need for increased parental education on this injury. [ABSTRACT FROM AUTHOR]

Importance: Approximately one-third of children experiencing acute concussion experience ongoing somatic, cognitive, and psychological or behavioral symptoms, referred to as persistent postconcussion symptoms (PPCS). However, validated and pragmatic tools enabling clinicians to identify patients at risk for PPCS do not exist.Objective: To derive and validate a clinical risk score for PPCS among children presenting to the emergency department.Design, Setting, and Participants: Prospective, multicenter cohort study (Predicting and Preventing Postconcussive Problems in Pediatrics [5P]) enrolled young patients (aged 5-<18 years) who presented within 48 hours of an acute head injury at 1 of 9 pediatric emergency departments within the Pediatric Emergency Research Canada (PERC) network from August 2013 through September 2014 (derivation cohort) and from October 2014 through June 2015 (validation cohort). Participants completed follow-up 28 days after the injury.Exposures: All eligible patients had concussions consistent with the Zurich consensus diagnostic criteria.Main Outcomes and Measures: The primary outcome was PPCS risk score at 28 days, which was defined as 3 or more new or worsening symptoms using the patient-reported Postconcussion Symptom Inventory compared with recalled state of being prior to the injury.Results: In total, 3063 patients (median age, 12.0 years [interquartile range, 9.2-14.6 years]; 1205 [39.3%] girls) were enrolled (n = 2006 in the derivation cohort; n = 1057 in the validation cohort) and 2584 of whom (n = 1701 [85%] in the derivation cohort; n = 883 [84%] in the validation cohort) completed follow-up at 28 days after the injury. Persistent postconcussion symptoms were present in 801 patients (31.0%) (n = 510 [30.0%] in the derivation cohort and n = 291 [33.0%] in the validation cohort). The 12-point PPCS risk score model for the derivation cohort included the variables of female sex, age of 13 years or older, physician-diagnosed migraine history, prior concussion with symptoms lasting longer than 1 week, headache, sensitivity to noise, fatigue, answering questions slowly, and 4 or more errors on the Balance Error Scoring System tandem stance. The area under the curve was 0.71 (95% CI, 0.69-0.74) for the derivation cohort and 0.68 (95% CI, 0.65-0.72) for the validation cohort.Conclusions and Relevance: A clinical risk score developed among children presenting to the emergency department with concussion and head injury within the previous 48 hours had modest discrimination to stratify PPCS risk at 28 days. Before this score is adopted in clinical practice, further research is needed for external validation, assessment of accuracy in an office setting, and determination of clinical utility. [ABSTRACT FROM AUTHOR]

Context Despite calls for the improvement of self-assessment as a basis for self-directed learning, instructional designs that include reflection in practice are uncommon. Using data from a screen-based simulation for learning radiograph interpretation, we present validity evidence for a simple self-monitoring measure and examine how it can complement skill assessment. Methods Medical students learning ankle radiograph interpretation were given an online learning set of 50 cases which they were asked to classify as 'abnormal' (fractured) or 'normal' and to indicate the degree to which they felt certain about their response ( Definitely or Probably). They received immediate feedback on each case. All students subsequently completed two 20-case post-tests: an immediate post-test ( IPT), and a delayed post-test ( DPT) administered 2 weeks later. We determined the degree to which certainty ( Definitely versus Probably) correlated with accuracy of interpretation and how this relationship changed between the tests. Results Of 988 students approached, 115 completed both tests. Mean ± SD accuracy scores decreased from 59 ± 17% at the IPT to 53 ± 16% at the DPT (95% confidence interval [ CI] for the difference: −2% to −10%). Mean self-assessed certainty did not decrease (rates of Definitely: IPT, 17.6%; DPT, 19.5%; 95% CI for difference: +7.2% to −3.4%). Regression modelling showed that accuracy was positively associated with choosing Definitely over Probably (odds ratio [ OR] 1.63, 95% CI 1.27-2.09) and indicated a statistically significant interaction between test timing and certainty ( OR 0.72, 95% CI 0.52-0.99); thus, the accuracy of self-monitoring decayed over the retention interval, leaving students relatively overconfident in their abilities. Conclusions This study shows that, in medical students learning radiograph interpretation, the development of self-monitoring skills can be measured and should not be assumed to necessarily vary in the same way as the underlying clinical skill. [ABSTRACT FROM AUTHOR]

Background Emergency departments (EDs) have utilized university student volunteers to facilitate enrollment of patients into prospective studies; however, the impact of this experience on participant careers is relatively unknown. Objectives We determined the proportion of successful postgraduate school/research job applications supported by our program reference letter. We also examined participant satisfaction. Methods This was a prospective cohort study of volunteer research assistants in a tertiary care pediatric ED from September 2011 to July 2013. Students volunteered one 5-h shift per week for at least 6 months. They completed three surveys: 1) Entrance – demographics and goals for entering the ED research assistant program; 2) Exit – program satisfaction, reasons for leaving the program, and future career goals; 3) Follow-up – survey and e-mails were sent to record positions secured since leaving the program. Results There were a total of 920 applicants over the study period, and 127 volunteers were selected to participate in the program. Response rates for entrance, exit, and follow-up surveys were 100%, 84.9%, and 96.2%, respectively. Of the participants who left and responded, 89/101 (88.9%) obtained school/research positions supported by our program reference letter. Further, 72.6% ranked their satisfaction with the program at least a 7 on a 10-point categorical scale, and 82.9% reported that they “agreed/strongly agreed” that the program helped with their career goals. Conclusions A volunteer student program is in high demand for university students interested in health sciences/research and potentially has a beneficial career impact for its participants. [ABSTRACT FROM AUTHOR]

Background Emergency Department (ED) student-based research assistant programs have been shown to be effective in enrolling patients when the students receive university course credit or pay. However, the impact on research outcomes when university students act as volunteers in this role is relatively unknown. Objectives The main objective of this study was to determine how often potentially eligible children were accurately identified by volunteer research assistants for enrollment into prospective research in the ED. We also examined the frequency of successful enrollments and the accuracy of data capture. Methods This was a prospective cross-sectional study of university student volunteer research assistant performance in a tertiary care pediatric ED between March 2011 and July 2013. The participant's primary role was to screen and facilitate enrollment of ED patients into clinical research. For each volunteer, we recorded demographics, number of screenings, enrollments, and data capture accuracy. Results Over five 6-month sessions, 151 student volunteers participated. Of these, 77.3% were female, 58.8% were undergraduate students, and 61.1% were interested in medical school. Student volunteers accurately screened 11,362/13,067 (87.0%) children, and they accurately identified 4407/4984 (88.4%) potentially eligible children for study enrollment. Of the 3805 eligible for enrollment exclusively by the students, 3228 (84.8%) families/children consented and completed all study procedures. Furthermore, students correctly entered 11,660/12,567 (92.8%) data points. Conclusions Utilizing university student volunteers to facilitate research enrollment in the ED is effective and allows for the capture of a high percentage of potentially eligible patients into prospective clinical research studies. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine whether there is an association between childhood obesity and severe extremity fractures. Associations between obesity and complications related to the fracture and/or fracture management were also examined. METHODS: The present study was a retrospective, cross-sectional study conducted at a tertiary care children's emergency department. Eligible cases for review were children (two to 17 years of age) with an extremity fracture. Severe extremity fractures were defined as those requiring manipulation under anesthesia, open operative repair and/or admission to hospital. The primary outcome was the proportion of severe extremity fractures and the secondary outcome was the proportion of complications. RESULTS: A total of 1340 charts of children who presented with extremity fracture from January 2008 to December 2010 were reviewed. The mean (± SD) age of the study population was 9.1 ±4.0 years and 62.1% were male. Overall, 19.9% (95% CI 17.8% to 22.0%) were obese and 39.6% (95% CI 36.7% to 39.1%) sustained a severe extremity fracture. The OR of severe extremity fractures among obese versus nonobese children was 1.00 (95% CI 0.76 to 1.32), adjusted for age, sex and mechanism of injury. In addition, the OR of experiencing complications among obese relative to nonobese children was 1.12 (95% CI 0.68 to 1.85). CONCLUSIONS: The results of the present study demonstrated that in children with extremity fractures, obese children were not at increased risk for sustaining more severe extremity fractures or subsequent complications compared with nonobese children. [ABSTRACT FROM AUTHOR]

Medical Education 2012: 46: 289-298 Objectives Using a large image bank, we systematically examined how the use of different ratios of abnormal to normal cases affects trainee learning. Methods This was a prospective, double-blind, randomised, three-arm education trial conducted in six academic training programmes for emergency medicine and paediatric residents in post-licensure years 2-5. We developed a paediatric ankle trauma radiograph case bank. From this bank, we constructed three different 50-case training sets, which varied in their proportions of abnormal cases (30%, 50%, 70%). Levels of difficulty and diagnoses were similar across sets. We randomly assigned residents to complete one of the training sets. Users classified each case as normal or abnormal, specifying the locations of any abnormalities. They received immediate feedback. All participants completed the same 20-case post-test in which 40% of cases were abnormal. We determined participant sensitivity, specificity, likelihood ratio and signal detection parameters. Results A total of 100 residents completed the study. The groups did not differ in accuracy on the post-test (p = 0.20). However, they showed considerable variation in their sensitivity-specificity trade-off. The group that received a training set with a high proportion of abnormal cases achieved the best sensitivity (0.69, standard deviation [SD] = 0.24), whereas the groups that received training sets with medium and low proportions of abnormal cases demonstrated sensitivities of 0.63 (SD = 0.21) and 0.51 (SD = 0.24), respectively (p < 0.01). Conversely, the group with a low proportion of abnormal cases demonstrated the best specificity (0.83, SD = 0.10) compared with the groups with medium (0.70, SD = 0.15) and high (0.66, SD = 0.17) proportions of abnormal cases (p < 0.001). The group with a low proportion of abnormal cases had the highest false negative rate and missed fractures one-third more often than the groups that trained on higher proportions of abnormal cases. Conclusions Manipulating the ratio of abnormal to normal cases in learning banks can have important educational implications. [ABSTRACT FROM AUTHOR]

Objectives: Pediatric fractures suspicious for abuse are often evaluated in emergency departments (ED), although corresponding diagnostic coding for possible abuse may be lacking. Thus, the primary objective of this study was to determine the proportion of fracture cases investigated in the ED for abuse that had corresponding International Classification of Diseases (ICD) codes documenting abuse suspicion. Additional objectives were to determine the proportion of these fractures with admission ICD abuse coding, and physician text diagnoses recording abuse suspicion in the ED and/or admission notes. Factors possibly associated with abuse-related ED ICD codes were also examined. Methods: Children less than three years of age that presented primarily with a fracture to two large academic children's hospitals from 1997 to 2007 and were evaluated for suspicion of abuse by child protective services were included in this retrospective review. The main outcome measure was the proportion of the fracture cases that had abuse suspicion reflected in ED discharge ICD codes. Results: Of the 216 eligible patients, only 23 (11.5%) patients had ED ICD codes that included the possibility of abuse. Forty-nine (22.7%) had the possibility for abuse documented by physicians as an ED discharge diagnosis. In addition, 53/149 (35.6%) of all admitted patients and 34/55 (61.8%) of confirmed abuse cases included abuse-related admission ICD coding. Female gender was found to be a factor associated with ED ICD abuse codes. Conclusion: Current standards of ICD coding result in a significant underestimate of the prevalence of children assessed in the ED and hospital wards for possible and confirmed abusive fracture(s). [Copyright &y& Elsevier]

OBJECTIVES: Because physicians may have difficulty distinguishing accidental fractures from those that are caused by abuse, abusive fractures may be at risk for delayed recognition;therefore,the primary objective of this study was to determine how frequently abusive fractures were missed by physicians during previous examinations. A secondary objective was to determine clinical predictors that are associated with unrecognized abuse. METHODS: Children who were younger than 3 years and presented to a large academic children's hospital from January 1993 to December 2007 and received a diagnosis of abusive fractures by a multidisciplinary child protective team were included in this retrospective review. The main outcome measures included the proportion of children who had abusive fractures and had at least 1 previous physician visit with diagnosis of abuse not identified and predictors that were independently associated with missed abuse. RESULTS: Of 258 patients with abusive fractures, 54 (20.9%) had at least 1 previous physician visit at which abuse was missed. The median time to correct diagnosis from the first visit was 8 days (minimum: 1; maximum: 160). Independent predictors of missed abuse were male gender, extremity versus axially located fracture, and presentation to a primary care setting versus pediatric emergency department or to a general versus pediatric emergency department. CONCLUSIONS: One fifth of children with abuse-related fractures are missed during the initial medical visit. In particular, boys who present to a primary care or a general emergency department setting with an extremity fracture are at a particularly high risk for delayed diagnosis. [ABSTRACT FROM AUTHOR]