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Background Dental infections are frequently encountered in the emergency department (ED), with periapical abscesses being among the most painful. Traditional pain management strategies include local anesthetic injections, oral analgesics, and intravenous opioids. Objectives We sought to identify an alternative pain management strategy with early use of dexamethasone as adjunct to conventional therapies for inflammation and pain at the site of infection. Methods We conducted a prospective, randomized, double-blind, placebo-controlled study comparing the analgesic effect of dexamethasone and placebo in ED patients with periapical abscess during a 2-year timeframe at two urban academic EDs. Adult patients presenting with physical examination findings consistent with a diagnosis of periapical abscess were randomized to receive oral dexamethasone or an identical placebo. Pain was assessed using the verbal numeric scale in person at discharge and via telephone at 12, 24, 48, and 72 h after discharge from the ED. Results Seventy-three patients were enrolled, with 37 receiving dexamethasone and 36 receiving placebo. Follow-up pain scores were obtained for 52 patients at 12, 24, 48, and 72 h. Ten patients from the dexamethasone group and 11 from placebo group were lost to follow-up. Patients who received dexamethasone reported a greater reduction in pain at 12 h compared with the placebo group (p = 0.029). Changes in pain scores from baseline and at 24, 48, and 72 h were not statistically significant. No adverse events were reported. Conclusions Single-dose dexamethasone as adjunct to conventional medical management for pain caused by periapical abscess demonstrated a significant reduction in pain 12 h post treatment compared with placebo.

Author(s): Leetch, Aaron N.; Glasser, Joshua A.; Woolridge, Dale P. | Abstract: Introduction: Three pathways are available to students considering a pediatric emergency medicine(PEM) career: pediatric residency followed by PEM fellowship (Peds-PEM); emergency medicineresidency followed by PEM fellowship (EM-PEM); and combined EM and pediatrics residency(EMaPeds). Questions regarding differences between the training pathways are common amongmedical students. We present a comparative analysis of training pathways highlighting majorcurricular differences to aid in students’ understanding of these training options.Methods: All currently credentialed training programs for each pathway with curricula publishedon their websites were included. We analyzed dedicated educational units (EU) core to all threepathways: emergency department (ED), pediatric-only ED, critical care, and research. Minimumrequirements for primary residencies were assumed for fellowship trainees.Results: Of the 75 Peds-PEM, 34 EM-PEM, and 4 EMaPeds programs screened, 85% of Peds-PEM and EM-PEM and all EMaPeds program curricula were available for analysis. AveragePeds-PEM EUs were 20.4 EM, 20.1 pediatric-only EM, 5.8 critical care, and 9.0 research. AverageEM-PEM EUs were 33.2 EM, 18.3 pediatric-only EM, 6.5 critical care, and 3.3 research. AverageEMaPeds EUs were 26.1 EM, 8.0 pediatric-only EM, 10.0 critical care, and 0.3 research.Conclusion: All three pathways exceed pediatric-focused training required for EM or pediatricresidency. Peds-PEM has the most research EUs, EM-PEM the most EM EUs, and EMaPedsthe most critical care EUs. All prepare graduates for a pediatric emergency medicine career. Understanding the difference in emphasis between pathways can inform students to select the bestpathway for their own careers.

Every year, millions of pediatric patients seek emergency care. Significant barriers limit access to optimal emergency services for large numbers of children. The American Academy of Pediatrics, American College of Emergency Physicians, and Emergency Nurses Association have a strong commitment to identifying these barriers, working to overcome them, and encouraging, through education and system changes, improved access to emergency care for all children.

Rash and skin complaints comprise a common pediatric chief complaint and among the top 20 reasons patients present to the emergency department. For this reason, it is important for emergency physicians to be able to distinguish life-threatening rashes from those that are benign. This chapter reviews common dermatologic conditions seen in pediatrics, such as eczema, erythema multiforme, Henoch–Schonlein purpura, scabies, tinea infections, urticaria, impetigo, and ecthyma. For each presentation, the incidence, epidemiology, typical and atypical presentations, diagnosis, differential diagnosis, treatment, disposition, complications, and clinical algorithms are reviewed. The chapter focuses on topics that are clinically relevant to patients seen in the emergency department, including admission requirements, discharge instructions, return precautions, and subspecialist follow-up.

Background Emergency care in the United States faces notable challenges with regard to children. In some jurisdictions, available resources are not sufficient to meet local needs. Physicians with specialty training in pediatric emergency care are largely concentrated in children's medical centers within larger urban areas. Rural emergency facilities, which are more likely to face ongoing staffing shortages in all specialties, are particularly deficient in pediatric emergency medicine (PEM) physicians. This paper addresses challenges in distribution of pediatric emergency care specialists into suburban and rural health care facilities, and proposes potential local and regional solutions to improve pediatric emergency care capabilities as well as to enhance disaster response in children. Objectives The American College of Emergency Physicians (ACEP) committee on PEM generated the objective to study and explore methods and strategies to address current challenges and shortcomings in the distribution of pediatric emergency physicians and to develop recommendations to improve access to emergency pediatric expertise in all care settings. A sub‐committee was formed to generate a written report followed by full committee input. The content was reviewed by the ACEP Board of Directors. Discussion Pediatric emergency physicians are certified either by the American Board of Emergency Medicine or the American Board of Pediatrics (ABP) depending on whether their training occurred through the emergency medicine or a pediatric residency program. ABP‐certified PEM that account for the majority of PEM physicians, remain largely concentrated in urban tertiary pediatric care centers, primarily children's hospitals. By contrast to the resources, the majority of pediatric patients receive emergency care in emergency departments (EDs) outside this setting. The goal of our recommendations is to help regionalize PEM expertise, allowing sharing of such resources with facilities that have traditionally not had access to PEM expertise. Financial or low number of pediatric cases likely contributed to lack of PEM resources in suburban and rural EDs, although a significant factor for lack of access to ABP‐certified PEM physicians may be local privilege and practice restrictions. Expanding the scope of practice for ABP‐certified PEM physicians beyond traditionally assigned arbitrary age limits to include selective adult patients has the potential to alleviate credentialing barriers and offset the financial and volume concerns while enhancing preparedness efforts, resource utilization, and access to specialized pediatric emergency care. Conclusion Recognition that the training of ABP‐certified PEM physicians allows for these individuals to safely care for selective adult patients with common disease patterns that extend beyond traditionally assigned arbitrary pediatric age limits has the potential to improve resource dissemination and utilization, allowing for greater access to pediatric emergency physicians in currently underserved settings.

Congenital Dermal Melanocytosis (CDM) can be difficult to differentiate from contusions. The need for a prompt and accurate diagnosis is best illustrated in cases where child abuse and maltreatment is of concern. Transcutaneous bilirubin (TCB) spectrophotometry has been well established to measure bilirubin under the skin for jaundice in infants. The use of TCB spectrometry has not been used to identify or differentiate contusions from CDM. We hypothesized that bilirubin, a degradation product of hemoglobin, would be elevated in contusions but not in CDM thus demonstrating the efficacy of a novel diagnostic technique to compliment or improve on physical assessment alone.Pilot study with thirty-seven infants and children noted to have CDM and fifty-six infants, children and adults with contusions underwent measurement of their lesion with TCB spectrometry. In each patient, the affected skin was scanned along with the adjacent unaffected native skin allowing an internal control for individual pigment variation.TCB measurements of CDM resulted in lower transcutaneous bilirubin values that were not significantly different from adjacent native skin pigmentation. This was in contrast to cutaneous contusions, which resulted in a higher measured value (mean 5.01 mg/dL) compared to adjacent native tissue (1.24 mg/dL) demonstrating a four-fold increase in measurement at the lesion site (P 0.001). Direct comparison of a ΔTCB value (lesion measurement minus the adjacent tissue) demonstrated a significantly higher value in contusions compared to CDM with a mean value of 3.77 and 0.12 mg/dL, respectively (P 0.001).TCB Spectrometry as a novel diagnostic technique has the potential to discern contusions from CDM and may therefore have the ability to compliment the use of physical assessment alone.

Background The Emergency Medical Services for Children State Partnership Program, as well as the Institute of Medicine report on pediatric emergency care, encourages recognition of emergency departments (EDs) through categorization and verification systems. Although pediatric verification programs are associated with greater pediatric readiness, clinical outcome data have been lacking to track the effects and patient-centered outcomes by implementing such programs. Objective To describe pediatric mortality rates prior to and after implementation of a pediatric emergency facility verification system in Arizona. Methods This was a cross-sectional study conducted using data from ED visits between 2011 and 2014 recorded in the Arizona Hospital Discharge Database. The primary outcome measure was the mortality rate for ED visits by patients under 18 years old. Rates were compared prior to and after facility certification by the Arizona Pediatric Prepared Emergency Care program. Results The total number of ED visits by children during the study period was 1,928,409. Of these, 1,127,294 were at facilities undergoing certification. For hospitals becoming certified, overall ED mortality rates were 35.2 deaths/100,000 ED visits (95% confidence interval [CI] 29.5–41.7) in the precertification analysis and 34.4 deaths/100,000 ED visits (95% CI 30.4–38.9) in the postcertification analysis. The injury-related ED visit mortality rate for certified hospitals showed a decrease from 40.0 injury-related deaths/100,000 ED visits (95% CI 28.6–54.4) in the precertification analysis to 25.8 injury-related deaths/100,000 ED visits (95% CI 18.7–34.8) in the postcertification analysis. Conclusion The implementation of the Arizona pediatric ED verification system was associated with a trend toward lower mortality. These results offer a platform for further research on pediatric ED preparedness efforts and their effects on improved patient outcomes.

Background Total anomalous pulmonary venous return (TAPVR) is an uncommon congenital heart defect. Obstructed forms are more severe, and typically present earlier in life, usually in the immediate newborn period, with symptoms of severe cyanosis and respiratory failure. Case Report A 13-day-old boy presented to the emergency department (ED) with respiratory extremis. He appeared cyanotic and limp, and was found to have significant hypoxia with oxygen saturation of 40%. He had no improvement of oxygenation with bag-valve-mask ventilation despite a fraction of inspired oxygen near 100%. This gave clear indication that the hypoxia was caused by a shunt and not by hypoventilation, a ventilation/perfusion mismatch, or a barrier to diffusion. Next, the patient was intubated emergently. Broad spectrum antibiotics and fluid resuscitation with normal saline were initiated. A chest radiograph showed evidence of pulmonary edema vs. diffuse interstitial disease. Cardiology was consulted and evaluated the child with an echocardiogram, which revealed TAPVR with infradiaphragmatic obstructed veins. Once stabilized, he was transferred for definitive surgical repair. This is, to our knowledge, the first reported case of TAPVR with infradiaphragmatic obstruction presenting to the ED with hemodynamic and respiratory compromise beyond the first week of life. Why Should an Emergency Physician Be Aware of This? Despite improvements in antenatal and newborn screening, congenital heart disease often remains an elusive diagnosis. Some patients with these critical lesions are discharged home before the manifestation of their disease becomes apparent. Once symptomatic, these patients often present to the ED in extremis. We conclude that it is important to recognize this presentation to ensure proper evaluation and early diagnosis. If misdiagnosed, many of the usual therapies for other diseases could be detrimental.

Pediatric endotracheal intubation is a procedure that can be stress provoking to the emergency physician. Although the need for this core skill is rare, when confronted with this situation, the emergency physician must have knowledge of the anatomic, physiologic, and pathologic components unique to the pediatric airway to optimize success. Furthermore, the emergency physician should be well versed in the various equipment and adjuncts as well as techniques developed to effectively manage the pediatric airway. This review covers the pathophysiology and practice of endotracheal intubation. Figures show a gum elastic bougie; the Mallampati classification; appropriate oropharyngeal, laryngeal, and tracheal axes; advancing the laryngoscope to lift the epiglottis; endotracheal tube position in neonates; and synchronized intermittent mandatory ventilation pressure-regulated volume control mechanical ventilation. Tables list endotracheal tube sizes, neonatal endotracheal tube sizes, pediatric laryngeal mask airway sizes, commonly used induction agents, and endotracheal tube insertion depth guidelines. This review contains 6 figures, 8 tables, and 77 references. Key words: emergent tracheal intubation; endotracheal tube; laryngoscopy; pediatric airway; pediatric airway management; pediatric endotracheal intubation; pediatric laryngeal mask; video laryngoscopy

This article provides recommendations for pediatric readiness, scope of services, competencies, staffing, emergency preparedness, and transfer of care coordination for urgent care centers (UCCs) and retail clinics that provide pediatric care. It also provides general recommendations for the use of telemedicine in these establishments. With continuing increases in wait times and overcrowding in the nation's emergency departments and the mounting challenges in obtaining timely access to primary care providers, a new trend is gaining momentum for the treatment of minor illness and injuries in the form of UCCs and retail clinics. As pediatric visits to these establishments increase, considerations should be made for the type of injury or illnesses that can be safely treated, the required level training and credentials of personnel needed, the proper equipment and resources to specifically care for children, and procedures for safe transfer to a higher level of care, when needed. When used appropriately, UCCs and retail clinics can be valuable and convenient patient care resources.

Background In 1998, emergency medicine–pediatrics (EM-PEDS) graduates were no longer eligible for the pediatric emergency medicine (PEM) sub-board certification examination. There is a paucity of guidance regarding the various training options for medical students who are interested in PEM. Objectives We sought to to determine attitudes and personal satisfaction of graduates from EM-PEDS combined training programs. Methods We surveyed 71 graduates from three EM-PEDS residences in the United States. Results All respondents consider their combined training to be an asset when seeking a job, 92% find it to be an asset to their career, and 88% think it provided added flexibility to job searches. The most commonly reported shortcoming was their ineligibility for the PEM sub-board certification. The lack of this designation was perceived to be a detriment to securing academic positions in dedicated children's hospitals. When surveyed regarding which training offers the better skill set for the practice of PEM, 90% (44/49) stated combined EM-PEDS training. When asked which training track gives them the better professional advancement in PEM, 52% (23/44) chose combined EM-PEDS residency, 27% (12/44) chose a pediatrics residency followed by a PEM fellowship, and 25% (11/44) chose an EM residency then a PEM fellowship. No EM-PEDS respondents considered PEM fellowship training after the completion of the dual training program. Conclusion EM-PEDS graduates found combined training to be an asset in their career. They felt that it provided flexibility in job searches, and that it was ideal training for the skill set required for the practice of PEM. EM-PEDS graduates' practices varied, including mixed settings, free-standing children's hospitals, and community emergency departments.

Background In 2012, a voluntary certification program called Pediatric Prepared Emergency Care (PPEC) was established in Arizona as a system for pediatric emergency preparedness. Emergency medicine and pediatric specialists generated basic, intermediate, and advanced designation criteria. Dedicated medical management by a pediatric emergency specialist is required for advanced centers. Designation follows a site visit, review, and approval by the subcommittee and the Arizona Chapter of the American Academy of Pediatrics. Discussion Arizona has 5 designated pediatric emergency departments, all of which are in the southeast part of the state. Therefore, a designation system was implemented so that all emergency departments statewide can receive more training, support, and supervision of pediatric care. The goal was to create a self-sustaining network with active participation from member institutions while fostering the pediatric commitment. Since its inception, 39 hospitals and 5 tribal facilities have joined PPEC, equating to 51% of Arizona's emergency facilities. Of the hospitals, 7 are advanced, 6 are intermediate, and 17 are basic centers. In 2015, all of the 9 sites due for recertification were recertified. The multiple tiers allow for mutual accountability, sharing of resources, and improved quality of care for pediatrics in emergency departments statewide. Conclusion PPEC enhances the quality of pediatric emergency preparedness by means of voluntary certification. The primary limitations are sustainability and funding, because an Emergency Medical Services for Children grant has offset the cost until now. The number of member facilities in this designation system is continually growing, and universal recertification shows sustainability.

Seizures represent a common neurologic complaint among pediatric patients in the emergency department (ED). They can be classified as generalized or focal. In terms of etiology, seizures are most basically broken down into “acute symptomatic” seizures, which are due to another primary medical cause, and unprovoked seizures which occur as a primary pathology. Febrile seizures are the most common types of seizures in children, which themselves can be simple or complex. The most concerning seizures are those which associate with meningismus, encephalitis, metabolic derangements, intracranial mass, and, of course those which progress to status epilepticus. Significantly, it is appropriate and even critical to assume status epilepticus and intervene accordingly whenever a child arrives to the ED seizing for an unspecified period of time. This review covers the initial evaluation, resuscitation, management, work-up, and disposition of pediatric patients who present to the emergency room with seizures. Figures in this chapter illustrate stepwise and algorithmic approaches to initial management, expanded differential, systematic diagnostic approach, and disposition for pediatric patients presenting with seizures and status epilepticus. Tables list important physical exam components for evaluating children with seizures, classifications of seizures, common seizure look-alikes in children, features of febrile seizures, etiologies of pediatric seizures. Key Words: Pediatric seizures, febrile seizures, pediatric neurologic emergencies, pediatric emergency medicine, status epilepticus

Henoch-Schonlein purpura (HSP) is the most common vasculitis seen in children with 90% of the presentations occurring before the age of 10 years. Pathogenesis involves a systemic, immune-mediated small vessel vasculitis that commonly affects the vessels supplying the skin, GI tract, kidney, and joints. Patient’s symptoms are directly related to the organ systems involved. All patients will have a palpable purpuric rash most commonly involving the lower extremities, more than 75% of patients will have a migratory arthritis of the knees and ankles as well as colicky abdominal pain, and roughly half of all patients diagnosed with HSP will have varying degrees of renal manifestations from mild proteinuria to severe, progressive glomerulonephritis requiring dialysis. Diagnosis may be difficult when patients present with vague symptoms such as abdominal pain before the rash becomes apparent. Treatment is mostly supportive with Tylenol for pain or fever; H2 blockers may be effective in some patients with mild GI symptoms. The role of steroids in the treatment of HSP is somewhat controversial. Steroids may decrease discomfort but does not impact the disease course of HSP or decrease sequelae.

This report highlights a presentation of urinary calculus impacted at the urethral meatus and bedside extraction after evaluation with point-of-care ultrasound (POCUS). Visualization of a stone at the urethral meatus prompted a point-of-care ultrasound of the penile shaft and glans. The ultrasound ruled out anatomic variations such as urethral diverticula and as a result bedside removal was expedited. The stone was successfully removed with traction and intraurethral lidocaine gel without urethral lesions or injury to the meatus. Bedside ultrasound is readily available in the emergency department and can be used to characterize urethral foreign bodies, evaluate urethral anatomy, and assess the likelihood of bedside removal.

Point-of-care ultrasonography is increasingly being used to facilitate accurate and timely diagnoses and to guide procedures. It is important for pediatric emergency physicians caring for patients in the emergency department to receive adequate and continued point-of-care ultrasonography training for those indications used in their practice setting. Emergency departments should have credentialing and quality assurance programs. Pediatric emergency medicine fellowships should provide appropriate training to physician trainees. Hospitals should provide privileges to physicians who demonstrate competency in point-of-care ultrasonography. Ongoing research will provide the necessary measures to define the optimal training and competency assessment standards. Requirements for credentialing and hospital privileges will vary and will be specific to individual departments and hospitals. As more physicians are trained and more research is completed, there should be one national standard for credentialing and privileging in point-of-care ultrasonography for pediatric emergency physicians.

Emergency providers are confronted with medical, social, and legal dilemmas with each case of possible child maltreatment. Keeping a high clinical suspicion is key to diagnosing latent abuse. Child abuse, especially sexual abuse, is best handled by a multidisciplinary team including emergency providers, nurses, social workers, and law enforcement trained in caring for victims and handling forensic evidence. The role of the emergency provider in such cases is to identify abuse, facilitate a thorough investigation, treat medical needs, protect the patient, provide an unbiased medical consultation to law enforcement, and provide an ethical testimony if called to court.

This multiorganizational literature review was undertaken to provide an evidence base for determining whether recommendations for out-of-hospital termination of resuscitation could be made for children who are victims of traumatic cardiopulmonary arrest. Although there is increasing acceptance of out-of-hospital termination of resuscitation for adult traumatic cardiopulmonary arrest when there is no expectation of a good outcome, children are routinely excluded from state termination-of-resuscitation protocols. The decision to withhold resuscitative efforts in a child under specific circumstances (decapitation or dependent lividity, rigor mortis, etc) is reasonable. If there is any doubt as to the circumstances or timing of the traumatic cardiopulmonary arrest, under the current status of limiting termination of resuscitation in the field to persons older than 18 years in most states, resuscitation should be initiated and continued until arrival to the appropriate facility. If the patient has arrested, resuscitation has already exceeded 30 minutes, and the nearest facility is more than 30 minutes away, involvement of parents and family of these children in the decision-making process with assistance and guidance from medical professionals should be considered as part of an emphasis on family-centered care because the evidence suggests that either death or a poor outcome is inevitable.

Copyright © 2016 by the American Academy of Pediatrics. Transitions of care (ToCs), also referred to as handoffs or sign-outs, occur when the responsibility for a patient's care transfers from 1 health care provider to another. Transitions are common in the acute care setting and have been noted to be vulnerable events with opportunities for error. Health care is taking ideas from other high-risk industries, such as aerospace and nuclear power, to create models of structured transition processes. Although little literature currently exists to establish 1 model as superior, multiorganizational consensus groups agree that standardization is warranted and that additional work is needed to establish characteristics of ToCs that are associated with clinical or practice outcomes. The rationale for structuring ToCs, specifically those related to the care of children in the emergency setting, and a description of identified strategies are presented, along with resources for educating health care providers on ToCs. Recommendations for development, education, and implementation of transition models are included.

Child abuse presents commonly to emergency departments. Emergency providers are confronted with medical, social, and legal dilemmas with each case. A solid understanding of the definitions and risk factors of victims and perpetrators aids in identifying abuse cases. Forensic examination should be performed only after the child is medically stable. Emergency providers are mandatory reporters of a reasonable suspicion of abuse. The role of the emergency provider is to identify abuse, facilitate a thorough investigation, treat medical needs, protect the patient, provide an unbiased medical consultation to law enforcement, and to provide an ethical testimony if called to court.

Background Medication errors are a leading cause of increased cost and iatrogenic injury in the pediatric population. In the academic setting, studies have suggested that these increased error rates are related primarily to resident inexperience, thus advocating a higher level of supervision. Study Objective We sought to identify the number of prescription errors in our institution's academic Emergency Department, how this varied between the beginning and end of the academic year and between practitioners at varying levels of training. Methods A retrospective review of computer-based outpatient prescriptions for children aged 0–12 years old was performed. Outpatient prescriptions were reviewed during a 2-week time block at the end of the academic year and beginning of the academic year (109 [June] and 111 [July] data sets, respectively). Prescriptions were retrieved electronically and reviewed for appropriate dosing. Errors were defined as those that varied>10% above or below recommended weight-based dosing. Results Twenty-nine (16.1%) of 180 written prescription orders were determined to be incorrectly written. Error rates were not significantly different between the beginning and end of the academic year. In both sampling periods, a higher percentage were found to be derived from senior level practitioners in both data sets (9/14 and 10/15; respectively), but few of these were considered high-grade prescription errors. Conclusions Overall prescription error rates at our institution are comparable to nationally reported error rates in children. Error rates were not associated with newly matriculated residents. These findings dispute previously held opinion that physician level of training is a factor of prescription errors.

Despite the broad technologic advancements of medicine, screening for illness in infants is highly reliant on a complete physical exam. For this reason it is critical that the examining physician not only have a thorough understanding of abnormal findings but also the normal findings and their variants. The vast majority of infants are healthy and findings predictive of future health problems are subtle and infrequent. Yet, outcomes can be devastating. Therefore it is critical the physician remain diligent when screening for these. It is our hope that this article will assist you in this task and allow for more accurate and timely diagnosis that prevents or minimizes long-term health problems in children.

Appendicitis is uncommon in children6 months old, with few observational studies reporting cases of children younger than 5 years old with the diagnosis. The classic periumbilical pain that migrates to the right lower quadrant, followed by the onset of fever and vomiting, is present in approximately 40% of pediatric patients under 12 years of age with appendicitis.A 4-month-old girl presented to the Emergency Department (ED) with acute onset of grunting, pallor, fussiness, emesis, and diarrhea. The patient was initially afebrile, tachycardic, and tachypneic with a soft, nondistended, nontender abdomen and active bowel sounds. The patient became febrile, with a maximum temperature of 39.3°C (102.7°F), and remained tachycardic despite receiving fluids and antipyretics. Laboratory studies were notable for mild dehydration and sterile pyuria. Chest x-ray study was negative for infectious etiologies. Initial abdominal ultrasound found no clear etiology of the patient's symptoms. The patient was admitted to inpatient pediatrics for dehydration, fever, and presumed pyelonephritis. Twenty-four hours later the patient's abdomen became distended and diffusely tender to palpation, with obstipation and increasing episodes of emesis. Abdominal x-ray study demonstrated mild gaseous distension of multiple bowel loops with repeat abdominal ultrasound notable for a focal 8-mm, noncompressible hyperemic structure in the right lower quadrant. The patient was taken to the operating room for a laparoscopic appendectomy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Appendicitis is a potentially life-threatening condition. In the infant population it frequently presents without the features typically seen in older children.

The pediatric musculoskeletal system differs greatly from that of an adult. Although these differences diminish with age, they present unique injury patterns and challenges in the diagnosis and treatment of pediatric orthopedic problems.

Emergency providers are confronted with medical, social, and legal dilemmas with each case of possible child maltreatment. Keeping a high clinical suspicion is key to diagnosing latent abuse. Child abuse, especially sexual abuse, is best handled by a multidisciplinary team including emergency providers, nurses, social workers, and law enforcement trained in caring for victims and handling forensic evidence. The role of the emergency provider in such cases is to identify abuse, facilitate a thorough investigation, treat medical needs, protect the patient, provide an unbiased medical consultation to law enforcement, and provide an ethical testimony if called to court.

The death of a child in the emergency department (ED) is one of the most challenging problems facing ED clinicians. This revised technical report and accompanying policy statement reaffirm principles of patient- and family-centered care. Recent literature is examined regarding family presence, termination of resuscitation, bereavement responsibilities of ED clinicians, support of child fatality review efforts, and other issues inherent in caring for the patient, family, and staff when a child dies in the ED. Appendices are provided that offer an approach to bereavement activities in the ED, carrying out forensic responsibilities while providing compassionate care, communicating the news of the death of a child in the acute setting, providing a closing ritual at the time of terminating resuscitation efforts, and managing the child with a terminal condition who presents near death in the ED.

The death of a child in the emergency department (ED) is one of the most challenging problems facing ED clinicians. This revised technical report and accompanying policy statement reaffirm principles of patient- and family-centered care. Recent literature is examined regarding family presence, termination of resuscitation, bereavement responsibilities of ED clinicians, support of child fatality review efforts, and other issues inherent in caring for the patient, family, and staff when a child dies in the ED. Appendices are provided that offer an approach to bereavement activities in the ED, carrying out forensic responsibilities while providing compassionate care, communicating the news of the death of a child in the acute setting, providing a closing ritual at the time of terminating resuscitation efforts, and managing the child with a terminal condition who presents near death in the ED.

Overexpression of the BltD gene in Bacillus subtilis causes acetylation of the polyamines spermidine and spermine. BltD is co-regulated with another gene, Blt, which encodes a multidrug export protein whose overexpression facilitates spermidine export [Woolridge, Vazquez-Laslop, Markham, Chevalier, Gerner and Neyfakh (1997) J. Biol. Chem. 272, 8864-8866]. Here we show that BltD acetylates both spermidine and spermine at primary propyl amine moieties, with spermine being the preferred substrate. In the presence of saturating concentrations of acetyl CoA, BltD rapidly acetylates spermine at both the N1 and N12 positions. The Km (app) values for spermine, spermidine and N1-acetylspermine are ≤ 67, 200 and 1200 μM, respectively. Diamines ranging from 1,3-diaminopropane to 1,12-diaminododecane, monoacetylputrescine and N8-acetylspermidine were not substrates for BltD. Putrescine (1,4-diaminobutane) and N8-acetylspermidine were competitive inhibitors of spermidine acetylation by BltD, with Ki values of 0.25 and 5.76 mM, respectively. CoA competitively inhibited both spermidine and acetyl-CoA interactions with BltD. These data and other results indicate that the mechanism of spermidine and spermine acetylation by BltD is a random-order mechanism of bi-molecular kinetics.

Radiologic studies are a vital component in the workup and diagnosis of disease. Although an indispensable adjunct, they should not be used as a substitute for a thorough history and physical examination. Multiple imaging modalities are available for use. Each has its own advantages, disadvantages, and safety profile, and practitioners should be versed in these when selecting how to work up disease. An appropriate radiographic study will accurately rule in or rule out disease with the least possible harm. Harm is often thought of as pain or physical injury, but broader definitions can include time, cost, radiation, and psychological stress to the patient. When compared with outpatient diagnostics, imaging choices within the emergency setting favor sensitivity over specificity to rule out diseases that require emergent intervention. A stepwise radiological approach may be used to identify illness. Accordingly, the time, cost, and potential harm of imaging studies may increase over time as a specific diagnosis is pursued. Special considerations are necessary for the imaging of children. Sedation or anxiolysis may be required for either computed tomography (CT) or magnetic resonance imaging (MRI). The pediatric emergency provider should be trained in techniques for

Purpose To determine whether a correlation exists between the term “good” on the summative, comparative assessment of a student’s Medical Student Performance Evaluation (MSPE) and his or her actual performance in medical school. Method The authors reviewed the MSPEs submitted to three residency programs to determine the presence of the term “good” in either the summary paragraph or the appendices. Next, they noted, for institutions using “good,” the percentile rankings of those students who received “good” as a descriptor. To examine the consistency among institutions regarding the percentile ranking denoted by “good,” they dichotomized the data into students below and above the bottom 25th percentile. They analyzed the data using a nonparametric test because of their nonnormal distribution. Results The authors collected MSPEs from 122 of the 125 Liaison Committee on Medical Education–accredited medical schools that were graduating students in 2008. Of these 122 institutions, 34 (28%) used the term “good.” All 34 institutions used the term to characterize students in the bottom 50% of the graduating class. The authors found a significant difference in the percentile ranking of students described as “good” between institutions using it to describe the bottom 25% and institutions using the term to describe those in the 25th to 50th percentiles (median ranking of 12.5% versus 30%, P .0001). Conclusions Overall, the term “good” in the MSPE describes students in the bottom 50% of the class; therefore, the term “good,” as used to describe performance in medical school, consistently indicates belowaverage performance.

The objective of this study was to evaluate the faculty and graduate training profiles of Pediatric Emergency Medicine (PEM) fellowship training programs. An electronic 10-point questionnaire was sent to 57 PEM fellowship directors, with a 70% response rate. Analysis of the individual certification of faculty members in PEM training programs demonstrated that the largest represented training types were general pediatricians and pediatricians with PEM sub-certification (29% and 62% representation, respectively). The remaining faculty types consistently showed < 5% overall involvement. Reported estimates on faculty delivery of clinical training, didactic training, and procedural skills demonstrated that pediatricians sub-board certified in PEM consistently administered the highest percentage of these skill sets (74%, 68%, and 68%, respectively). Emergency Medicine-trained physicians showed a relative increase of involvement in fellowship programs administered by Emergency Medicine departments and in those programs located within adult hospitals. Yet, this involvement still remained substantially lower than that of the pediatric-type faculty. Program directors of fellowships within pediatric hospitals and those administered by Pediatric programs demonstrated a preference for general pediatricians with sub-board certification in PEM to improve their faculty pools. Program directors of fellowship programs located in adult hospitals and those administered by departments of EM demonstrated no preference in training type. Lastly, program directors report that 95% of past graduates received their primary board certification through Pediatrics and only 5% received their primary board certification through Emergency Medicine. There are currently many more pediatric-trained physicians among PEM fellowship faculty and graduates. This survey has demonstrated that there has been a decline in EM-trained physicians involved in PEM fellowships since 2000.

Many studies have found conflicting evidence over the use of clinical indicators to predict intracranial injury in pediatric mild head injury. Although altered mental status, loss of consciousness, and abnormal neurologic examination have all been found to be more prevalent among head-injured children, studies have observed inconsistent results over their specificity and predictive value. Children older than 2 years have been evaluated, managed, and studied differently than those less than 2 years old. Evidence strongly supports a lower threshold to perform a CT scan in younger children because they have a higher risk of significant brain injury after blunt head trauma.

Multidrug transporters pump structurally dissimilar toxic molecules out of cells. It is not known, however, if detoxification is the primary physiological function of these transporters. The chromosomal organization of the gene encoding the Bacillus subtilis multidrug transporter Blt suggests a specific function for this protein; it forms a single operon with another gene, bltD, whose protein product is identified here as a spermine/spermidine acetyltransferase, an enzyme catalyzing a key step in spermidine degradation. Overexpression of the Blt transporter in B. subtilis leads not only to the multidrug-resistance phenotype but also to the efflux of large amounts of spermidine into the medium; this efflux is supressed by an inhibitor of Blt, reserpine. Taken together, these results strongly suggest that the natural function of the Blt transporter is the efflux of spermidine, whereas multiple drugs may be recognized by Blt merely opportunistically.

A cDNA encoding the human spermidine/spermine N1-acetyltransferase (N1SSAT) was conditionally expressed in a strain of Escherichia coli deficient in spermidine-acetylating activity. Conditional expression of this cDNA was performed under the control of the lac promoter, by addition of the non-hydrolysable lactose analogue isopropyl β-D-thiogalactoside. Expression of the N1SSAT cDNA oriented in the sense direction resulted in the acetylation of spermidine at the N1 but not the N8 position and a decrease in endogenous spermidine contents and growth rates in these bacteria. When this cDNA was expressed in the anti-sense orientation, spermidine acetylation was not detected and endogenous spermidine contents and growth rates were unaffected. Increasing the endogenous N1-acetylspermidine concentration by addition of this amine to the culture medium did not suppress growth, and increasing endogenous spermidine pools by exogenous addition was not sufficient to restore optimal growth in cells expressing the human N1SSAT. Exogenous spermidine, but neither N1- nor N8-acetylspermidine, stimulated cell growth in strains unable to synthesize spermidine. These results suggest that one physiological consequence of spermidine acetylation in E. coli is growth inhibition. The mechanism of this inhibition seems to involve the formation of acetylspermidine, and is not simply due to a decrease in the intracellular concentration of non-acetylated spermidine.

NIH3T3 cells transfected with the yeast plasma membrane H(+)-ATPase (RN1a line) or transfected with a low-activity mutant H(+)-ATPase (N-Mut line) were used to examine the relationship between cytosolic pH (pHcyt) and protein turnover. At an extracellular pH (pHex) of 7.15, NIH3T3 and N-Mut cells have a pHcyt of 7-7.1 and a vacuolar pH (pHvac) of 6.3, whereas in RN1a cells both the pHcyt and the pHvac are 0.3 unit more alkaline. Rates of protein synthesis and degradation are optimum at pHex 7.2 and are much more sensitive to pH changes in RN1a cells than in NIH3T3 cells. However, irrespective of pH, rates of protein degradation in RN1a cells are always less than those measured in NIH3T3 cells. Rates of protein synthesis are the same for sparse cultures of RN1a and NIH3T3 cells and show a density-dependent decline in NIH3T3 cells but remain high in RN1a cells even at high cell densities. These data indicate that the elevation of pHcyt caused by transformation with the H(+)-ATPase has no direct effect on protein synthesis. On the other hand, rates of protein degradation are consistently lower in RN1a cells than in NIH3T3 or N-Mut cells. Basal rates of protein degradation, measured in medium containing 10 mM 3-methyladenine or 10% serum or 1 microM insulin, as well as the autophagic response to serum or insulin withdrawal, are both significantly lower in RN1a cells. These data indicate that transformation with the H(+)-ATPase has a direct effect on rates of protein degradation, possibly through an elevation of pH. The higher pHvac will directly effect lysosomal protein breakdown and the higher pHcyt may be permissive for maintenance of low basal rates of protein breakdown. Overall, we conclude that transformation with the H(+)-ATPase provides a permissive environment for high rates of protein synthesis and low rates of protein degradation that result in high rates of growth and the tumor phenotype.

Unweighting, but not denervation, of muscle reportedly "spares" insulin receptors, increasing insulin sensitivity. Unweighting also increases beta-adrenergic responses of carbohydrate metabolism. These differential characteristics were studied further by comparing cyclic adenosine monophosphate (cAMP) accumulation and beta-adrenergic binding in normal and 3-day unweighted or denervated soleus muscle. Submaximal amounts of isoproterenol, a p-agonist, increased cAMP accumulation in vitro and in vivo (by intramuscular (IM) injection) to a greater degree (P less than .05) in unweighted muscles. Forskolin or maximal isoproterenol had similar in vitro effects in all muscles, suggesting increased beta-adrenergic sensitivity following unweighting. Increased sensitivity was confirmed by a greater receptor density (B(sub max)) for iodo-125(-)-pindolol in particulate preparations of unweighted (420 x 10(exp -18) mol/mg muscle) than of control or denervated muscles (285 x 10(exp-18) mol/mg muscle). The three dissociation constant (Kd) values were similar (20.3 to 25.8 pmol/L). Total binding capacity (11.4 fmol/muscle) did not change during 3 days of unweighting, but diminished by 30% with denervation. This result illustrates the "sparing" and loss of receptors, respectively, in these two atrophy models. In diabetic animals, IM injection of insulin diminished CAMP accumulation in the presence of theophylline in unweighted muscle (-66% +/- 2%) more than in controls (-42% +'- 6%, P less than .001). These results show that insulin affects CAMP formation in muscle, and support a greater in vivo insulin response following unweighting atrophy. These various data support a role for lysosomal proteolysis in denervation, but not in unweighting, atrophy.