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Objective: To assess the co-occurrence and clustering of post-concussive symptoms in children, and to identify distinct patient phenotypes based on symptom type and severity., Methods: We performed a secondary analysis of the prospective, multicentre Predicting and Preventing Post-concussive Problems in Pediatrics (5P) cohort study, evaluating children 5-17 years of age presenting within 48 hours of an acute concussion. Our primary outcome was the simultaneous occurrence of two or more persistent post-concussive symptoms on the Post-Concussion Symptom Inventory at 28 days post-injury. Analyses of symptom and patient clusters were performed using hierarchical cluster analyses of symptom severity ratings., Results: 3063 patients from the parent 5P study were included. Median age was 12.1 years (IQR: 9.2-14.6 years), and 1857 (60.6%) were male. Fatigue was the most common persistent symptom (21.7%), with headache the most commonly reported co-occurring symptom among patients with fatigue (55%; 363/662). Headache was common in children reporting any of the 12 other symptoms (range: 54%-72%). Physical symptoms occurred in two distinct clusters: vestibular-ocular and headache. Emotional and cognitive symptoms occurred together more frequently and with higher severity than physical symptoms. Fatigue was more strongly associated with cognitive and emotional symptoms than physical symptoms. We identified five patient groups (resolved/minimal, mild, moderate, severe and profound) based on symptom type and severity., Conclusion: Post-concussive symptoms in children occur in distinct clusters, facilitating the identification of distinct patient phenotypes based on symptom type and severity. Care of children post-concussion must be comprehensive, with systems designed to identify and treat distinct post-concussion phenotypes., Competing Interests: Competing interests: GG is an author of the Post-Concussion Symptom Inventory (PCSI) used in this study. The PCSI is freely available and he receives no financial benefit from its use., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

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.

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 © 2014 Elsevier Inc. All rights reserved.)

Purpose: To demonstrate how learning curves can describe proficiency improvements associated with deliberate practice of radiograph interpretation., Method: This was a prospective, cross-sectional study of pediatric residents in two tertiary care programs. A 234-item digital case bank of pediatric ankle radiographs was developed. The authors gave participants a brief clinical summary of each case and asked them to consider three radiograph views of the ankle. Participants classified each case as either normal or abnormal and, if applicable, specified the location of the abnormality. They received immediate feedback and a radiologist's dictated report. The authors reviewed longitudinal learning curves, which were generated based on calculated test characteristics (e.g., accuracy, sensitivity, specificity)., Results: Eighteen participants (56.3% of those eligible) completed all 234 cases. The form of the participants' learning curves was similar across all test characteristics. The curves showed a period of "noise" until the participants completed an average of 20 cases. The slope of the learning curve was maximal from 21 to 50 cases during which cumulative sensitivity (95% CI) increased from 0.50 (0.45, 0.57) to 0.54 (0.47, 0.58). Then, the curves reached an inflection point after which learning slowed but did not stop even after 234 cases. The final cumulative sensitivity was 0.60 (0.54, 0.63). Applying a reference criterion, the authors classified learners into formative categories., Conclusions: Learning curves describing deliberate practice of radiograph interpretation allow medical educators to define at which point(s) practice is most efficient and how much practice is required to achieve a defined level of mastery.

Objectives: Acute gastroenteritis is a very common emergency department (ED) diagnosis accounting for greater than 1.5 million outpatient visits and 200,000 hospitalizations annually among children in the United States. Although guidelines exist to assist clinicians, they do not clearly address topics for which evidence is new or limited, including the use of antiemetic agents, probiotics, and intravenous (IV) fluid rehydration regimens. This study sought to describe the ED treatments administered to children with acute gastroenteritis and to compare management between Canadian and U.S. physicians practicing pediatric emergency medicine (PEM)., Methods: Members of PEM research networks located in Canada and the United States were invited to participate in a cross-sectional, Internet-based survey. Participants were included if they are attending physicians and provide care to patients <18 years of age in an ED., Results: In total, 235 of 339 (73%) eligible individuals responded. A total of 103 of 136 Canadian physicians (76%) report initiating oral rehydration therapy (ORT) in children with moderate dehydration, compared with 44 of 94 (47%) of their U.S. colleagues (p<0.001). The latter more often administer antiemetic agents to children with vomiting (67% vs. 45%; p=0.001). American physicians administer larger IV fluid bolus volumes (p<0.001) and over shorter time periods (p=0.001) and repeat the fluid boluses more frequently (p<0.001). Probiotics are routinely recommended by only 35 of 230 respondents (15%)., Conclusions: The treatment of pediatric gastroenteritis varies by geographic location and differs significantly between Canadian and American PEM physicians. Oral rehydration continues to be underused, particularly in the United States. Probiotic use remains uncommon, while ondansetron administration has become routine. Children frequently receive IV rehydration, with the rate and volume administered being greater in the United States., (© 2010 by the Society for Academic Emergency Medicine.)

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) drastically 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 department 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 public health emergencies.

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]

Objectives: We determined how often emergency physician pediatric musculoskeletal (MSK) radiograph interpretations were discordant to that of a radiologist and led to an adverse event (AE). We also established the variables independently associated with this outcome. Methods: This prospective cohort study was conducted in an urban, tertiary care children's emergency department (ED). We enrolled children who presented to an ED with an extremity injury and received radiographs. ED physicians documented their radiograph interpretation, which was compared to a radiology reference standard. Patients received telephone follow‐up and had institutional medical records reviewed in 3 weeks. An AE occurred if there were clinical sequelae and/or repeat health care visits due to a delay in correct radiograph interpretation. Results: We enrolled 2,302 children (mean [±SD] age = 9.0 [4.4] years; 1,288 (56.0%) male]. Of these, 180 (7.8%; 95% confidence interval = 6.8 to 9.0) ED physician discordant interpretations resulted in an AE. Specifically, there were no negative clinical outcomes; however, relative to cases diagnosed correctly at the index ED, patients whose fracture was not initially identified encountered 77.2% more subsequent ED visits, while those falsely diagnosed with a fracture experienced 41.5% additional orthopedic clinic visits. Odds of an ED discrepant interpretation was significantly higher if a physician's pretest probability of a fracture was ≤ 20% versus> 20% (adjusted odds ratio [aOR] = 1.6), patient's pain score was ≤ 2 versus> 2 (aOR = 1.6), and injury was located in a joint versus other location (aOR = 1.7). Conclusions: Emergency physician discordant pediatric MSK radiograph interpretations that resulted in an AE occurred with regular frequency in a pediatric ED setting. AEs were primarily an increase in subsequent health care visits. Importantly, a low clinical suspicion for a fracture or injury located in the joint were risk factors for ED physician discordant interpretations. [ABSTRACT FROM AUTHOR]

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]

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]

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]

Objectives: In a practice setting where casting is considered the standard of care, the aim of this study was to assess the cost-effectiveness of wrist splints compared with routine casting in children with acceptably angulated distal radius greenstick or transverse fractures.Methods: A cost-effectiveness analysis was conducted alongside a randomized controlled trial (RCT). One hundred children with acceptably angulated distal radius greenstick or transverse fractures received either a wrist splint or cast. Information on health care provider and patient and family resource use as well as productivity cost was collected. Resource use was costed using unit costs from local administrative data sources and expense diaries. Effectiveness was assessed at 6 weeks using the performance version of the Activities Scale for Kids (ASKp) questionnaire. Cost-effectiveness analysis related differential costs to differential ASKp scores.Results: Mean total cost was $877.58 in the splint group and $950.35 in the cast group, with a mean difference of $−72.76 (standard error [SE] 45.88). Mean total healthcare cost was $670.66 in the splint group and $768.22 in the cast group, with a mean difference of $−97.56 (SE 9.24). Mean (SE) ASKp was 92.8 in the splint group and 91.4 in the cast group, with a mean difference of 1.439 (SE 1.585). Therefore, splint management was more effective and cheaper. After accounting for uncertainty, the probability of splint being cost-effective compared with cast was 94 percent for a willingness-to-pay threshold value of $0 for one-unit gain in ASKp score and exceeded 82 percent for all threshold values.Conclusions: In this RCT, splint management was cost-effective compared with casting in children with acceptably angulated distal radius greenstick or transverse fractures. This study challenges the existing standard of care for children with this type of fracture and provides justification on clinical and economic grounds for a change in routine practice. [ABSTRACT FROM AUTHOR]

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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]