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We developed a web-based tool to measure the amount and rate of skill acquisition in pediatric interproximal caries diagnosis among pre- and postdoctoral dental students and identified variables predictive for greater image interpretation difficulty. In this multicenter prospective cohort study, a convenience sample of pre- and postdoctoral dental students participated in computer-assisted learning in the interpretation of bitewing radiographs of 193 children. Participants were asked to identify the presence or absence of interproximal caries and, where applicable, locate the lesions. After every case, participants received specific visual and text feedback on their diagnostic performance. They were requested to complete the 193-case set but could complete enough cases to achieve a competency performance standard of 75% accuracy, sensitivity, and specificity. Of 130 participants, 62 (47.7%) completed all cases. The mean change from initial to maximal diagnostic accuracy was +15.3% (95% CI, 13.0-17.7), sensitivity was +10.8% (95% CI, 9.0-12.7), and specificity was +15.5% (95% CI, 12.9-18.1). The median number of cases completed to achieve competency was 173 (interquartile range, 82-363). Of these 62 participants, 45 (72.6%) showed overall improvement in diagnostic accuracy. Greater numbers of interproximal lesions (P <.001) and the presence of noninterproximal caries (P <.001) predicted greater interpretation difficulty. Computer-assisted learning led to improved diagnosis of interproximal caries on bitewing radiographs among pre- and postdoctoral dental students. [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]

Objectives To compare the proportion of children diagnosed with a concussion by pediatric emergency physicians vs the proportion who met criteria for this injury as recommended by Zurich Fourth International Conference on Concussion consensus statement and to determine clinical variables associated with a physician diagnosis of a concussion. Study design This was a prospective, cross-sectional study conducted at a tertiary care pediatric emergency department. We enrolled children ages 5 through 17 who presented with a head injury and collected data on demographics, mechanism of injury, head injury-related symptoms/signs, physician diagnosis, and discharge advice. Results We identified 495 children whose mean age was 10.1 years (SD 3.4 years); 308 (62.2%) were male. Emergency physicians diagnosed concussion in 200 (40.4%; 95% CI 36.1, 44.7) children, and 443 (89.5%; 95% CI 86.8, 92.2) met criteria for concussion in accordance with the Zurich consensus statement (P < .0001). Age ≥10 years (OR 1.8), presentation ≥1 day after injury (OR 2.4), injury from collision sports (OR 5.6), and symptoms of headache (OR 2.2) or amnesia (OR 3.4) were the variables significantly associated with an emergency physician's diagnosis of concussion. Conclusions Pediatric emergency physicians diagnosed concussion less often relative to international consensus-based guidelines and used a limited number of variables to make this diagnosis compared with current recommendations. Thus, pediatric emergency physicians may be missing cases of concussion and the corresponding opportunity to provide critical advice for cognitive and physical management. [ABSTRACT FROM AUTHOR]

Objective To determine the relationship between body mass index (BMI) and odds of extremity bone fractures in children. Study design This was a prospective cross-sectional study conducted at 2 tertiary care pediatric emergency departments. A convenience sample of children 2-17 years of age with a nonpenetrating extremity injury was enrolled. Demographics, activity level, mechanism of injury, participant BMI, and presence of a fracture were recorded. The main outcome was the odds of an extremity bone fracture based on BMI category; logistic regression was used to estimate the odds of fracture by BMI category. Results We enrolled 2213 children, of whom 1078 (48.7%) sustained a fracture and 316 (14.3%) were classified as obese. The mean (SD) age was 9.5 (4.2) years, and percentage of male children was 56.8%. Compared with children with a normal BMI, the adjusted odds of fracture among obese, overweight, and underweight children were 0.75 (0.58, 0.97), 1.15 (0.89, 1.48), and 1.44 (1.00, 2.07) respectively. Conclusions Obese children had a minor but statistically significant decreased odds of fracture relative to children with a normal BMI, but no association was observed in overweight children. However, underweight children were found to be at an increased odds of fracture. This study suggests that overweight and obese children do not have increased odds of extremity fracture. [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]

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]

Objectives: To characterize symptom burden, school function, and physical activity in youth 1 year following acute concussion and those with subsequent repeat concussion.Study Design: Secondary analysis of Predicting Persistent Postconcussive Problems in Pediatrics prospective, multicenter cohort study conducted in 9 Canadian emergency departments. Participants were children between ages 5 and 18 years who presented consecutively ≤48 hours of concussion and agreed to participate in a post hoc electronic survey 1 year after injury. Outcomes were assessed using a standardized 25-question symptom scale derived from the Post-Concussion Symptom Inventory-Parent; school function and physical activity outcomes were queried. The primary outcome was total symptom score 1 year following concussion, defined as the number of symptoms experienced more than before injury.Results: Of 3052 youth enrolled in the Predicting Persistent Postconcussive Problems in Pediatrics study, 432 (median [IQR] age, 11.5 [9,14] years; 266 [62%] male) completed the 1-year survey; 34 respondents reported a repeat concussion. Following acute concussion, youth were more likely to be symptom-free than following repeat concussion (75% vs 50%; difference = 25% [95% CI 8-41]; P = .002) and to have recovered fully (90% vs 74%; difference = 17% [95% CI 5-34]; P = .002) after 1 year. Although physical symptoms were less 1 year after initial emergency department presentation for both groups (P < .001), youth with a repeat concussion reported greater headache persistence (26% vs 13%; difference = 13% [95% CI 1,31]; P = .024). Both groups returned to their normal school routine (100% vs 95%; difference = 5% [95% CI -5 to 8; P = .618). Youth without repeat concussion more frequently returned to normal physical activities (98% vs 85%; difference = 13% [95% CI 4-28]; P < .0001) and sport (95% vs 82%; difference = 13% [95% CI 3-29]; P = .009).Conclusions: Most youth are symptom-free and fully recovered 1 year following concussion. Some children with repeat concussion have worse outcomes and have delays in returning to normal school routines and sport. [ABSTRACT FROM AUTHOR]

Study Objective: Implementation of the Low Risk Ankle Rule can safely reduce radiographs for children with acute ankle injuries. The main objective of this study is to examine the costs and consequences of implementing the rule. Methods: For children aged 3 to 16 years and with an acute ankle injury, we collected data on health care provider visits, imaging, and treatment at the index emergency department (ED) visit and days 7 and 28 post-ED discharge. This was done during 3 consecutive 6-month phases at 6 EDs. After the baseline phase 1, the Low Risk Ankle Rule was introduced in phases 2 and 3 in 3 intervention EDs, but not in the 3 pair-matched control EDs. We compared the effect of the Low Risk Ankle Rule on health care and patient-paid costs, the proportion of radiographs ordered, the proportion of missed clinically important fractures, and the follow-up use of health care resources. Results: We enrolled 2,151 children with ankle injuries, 1,055 at the intervention and 1,096 at the control EDs. Health care costs were $36.93 less per patient at intervention compared with control sites (P=.02). Out-of-pocket costs to the patients were $2.09 more per patient at intervention sites (P=.30). In intervention versus control sites, the main contributor to cost reduction was the 22.9% reduction in ankle radiography. Furthermore, there were no significant differences in the frequency of missed clinically important fractures (0.1% versus 0.9%) or follow-up use of health care resources. Conclusion: Widespread implementation of the Low Risk Ankle Rule may lead to reduction of unnecessary radiographs for children and result in cost savings. [ABSTRACT FROM AUTHOR]

Study objective: We evaluate the association between triage levels assigned using the Canadian Triage and Acuity Scale and surrogate markers of validity for real-life children triaged in multiple emergency departments (EDs). Methods: This was a retrospective cohort study evaluating the triage assessment and outcomes of all children presenting to 12 pediatric EDs, all of which are members of the Pediatric Emergency Research Canada group, during a 1-year period (2010 to 2011). Anonymous data were retrieved from the ED computerized databases. The primary outcome measure was the proportion of children hospitalized for each triage level. Other outcomes were ICU admission, proportion of patients who left without being seen by a physician, and length of stay in the ED. Evaluation of all children visiting these EDs during 1 year was expected to provide more than 1,000 patients in each triage category. Results: A total of 550,940 children were included. Pooled data demonstrated hospitalization proportions of 61%, 30%, 10%, 2%, and 0.9% for patients in Canadian Triage and Acuity Scale levels 1, 2, 3, 4, and 5, respectively. There was a strong association between triage level and admission to the ICU, probability of leaving without being seen by a physician, and length of stay. Conclusion: The strong association between triage level and multiple markers of severity in 12 Canadian pediatric EDs suggests validity of the Canadian Triage and Acuity Scale for children. [Copyright &y& Elsevier]

Study objective: The aims of the study are to measure both the interrater agreement of nurses using the Canadian Triage and Acuity Scale in children and the validity of the scale as measured by the correlation between triage level and proxy markers of severity. Methods: This was a prospective multicenter study of the reliability and construct validity of the Canadian Triage and Acuity Scale in 9 tertiary care pediatric emergency departments (EDs) across Canada during 2009 to 2010. Participants were a sample of children initially triaged as Canadian Triage and Acuity Scale level 2 (emergency) to level 5 (nonurgent). Participants were recruited immediately after their initial triage to undergo a second triage assessment by the research nurse. Both triages were performed blinded to the other. The primary outcome measures were the interrater agreement between the 2 nurses and the association between triage level and hospitalization. Secondary outcome measures were the association between triage level and health resource use and length of stay in the ED. Results: A total of 1,564 patients were approached and 1,464 consented. The overall interrater agreement was good, as demonstrated by a quadratic weighted κ score of 0.74 (95% confidence interval 0.71 to 0.76). Hospitalization proportions were 30%, 8.3%, 2.3%, and 2.2% for patients triaged at levels 2, 3, 4, and 5, respectively. There was also a strong association between triage levels and use of health care resources and length of stay. Conclusion: The Canadian Triage and Acuity Scale demonstrates a good interrater agreement between nurses across multiple pediatric EDs and is a valid triage tool, as demonstrated by its good association with markers of severity. [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]

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 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: 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]