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To validate a computational phenotype that identifies acute brain dysfunction (ABD) based on clinician concern for neurologic or behavioral changes in pediatric sepsis.Retrospective observational study.Single academic children's hospital.Four thousand two hundred eighty-nine index sepsis episodes.None.An existing computational phenotype of ABD was optimized to include routinely collected variables indicative of clinician concern for acute neurologic or behavioral change (completion of CT or MRI, electroencephalogram, or new antipsychotic administration). First, the computational phenotype was compared with an ABD reference standard established from chart review of 527 random sepsis episodes to determine criterion validity. Next, the computational phenotype was compared with a separate validation cohort of 3,762 index sepsis episodes to determine content and construct validity. Criterion validity for the final phenotype had sensitivity 83% (95% CI, 76-89%), specificity 93% (90-95%), positive predictive value 84% (77-89%), and negative predictive value 93% (90-96%). In the validation cohort, the computational phenotype identified ABD in 35% (95% CI 33-36%). Content validity was demonstrated as those with the ABD computational phenotype were more likely to have characteristics of neurologic dysfunction and severe illness than those without the ABD phenotype, including nonreactive pupils (15% vs 1%; p0.001), Glasgow Coma Scale less than 5 (44% vs 12%; p0.001), greater than or equal to two nonneurologic organ dysfunctions (50% vs 25%; p0.001), and need for intensive care (81% vs 65%; p0.001). Construct validity was demonstrated by higher odds for mortality (odds ratio [OR], 6.9; 95% CI, 5.3-9.1) and discharge to rehabilitation (OR, 11.4; 95% CI 7.4-17.5) in patients with, versus without, the ABD computational phenotype.A computational phenotype of ABD indicative of clinician concern for new neurologic or behavioral change offers a valid retrospective measure to identify episodes of sepsis that involved ABD. This computational phenotype provides a feasible and efficient way to study risk factors for and outcomes from ABD using routinely collected clinical data.

To compare outcomes associated with timing-early versus late-of any neurologic dysfunction during pediatric sepsis.Secondary analysis of a cross-sectional point prevalence study.A total of 128 PICUs in 26 countries.Less than 18 years with severe sepsis on 5 separate days (2013-2014).None.Patients were categorized as having either no neurologic dysfunction or neurologic dysfunction (i.e., present at or after sepsis recognition), which was defined as Glasgow Coma Scale score less than 5 and/or fixed dilated pupils. Our primary outcome was death or new moderate disability (i.e., Pediatric Overall [or Cerebral] Performance Category score ≥3 and change ≥1 from baseline) at hospital discharge, and 87 of 567 severe sepsis patients (15%) had neurologic dysfunction within 7 days of sepsis recognition (61 at sepsis recognition and 26 after sepsis recognition). Primary site of infection varied based on presence of neurologic dysfunction. Death or new moderate disability occurred in 161 of 480 (34%) without neurologic dysfunction, 45 of 61 (74%) with neurologic dysfunction at sepsis recognition, and 21 of 26 (81%) with neurologic dysfunction after sepsis recognition (p0.001 across all groups). On multivariable analysis, in comparison with those without neurologic dysfunction, neurologic dysfunction whether at sepsis recognition or after was associated with increased odds of death or new moderate disability (adjusted odds ratio, 4.9 [95% CI, 2.3-10.1] and 10.7 [95% CI, 3.8-30.5], respectively). We failed to identify a difference between these adjusted odds ratios of death or new moderate disability that would indicate a differential risk of outcome based on timing of neurologic dysfunction (p = 0.20).In this severe sepsis international cohort, the presence of neurologic dysfunction during sepsis is associated with worse outcomes at hospital discharge. The impact of early versus late onset of neurologic dysfunction in sepsis on outcome remains unknown, and further work is needed to better understand timing of neurologic dysfunction onset in pediatric sepsis.

Acute-on-chronic liver failure (ACLF) is an acute decompensation of chronic liver disease leading to multiorgan failure and mortality. The objective of this study was to evaluate characteristics and outcomes of children with ACLF who are at the highest priority for liver transplantation (LT) on the United Network for Organ Sharing (UNOS) database-listed as status 1B. The characteristics and outcomes of 478 children with ACLF listed as status 1B on the UNOS LT waiting list from 2007-2019 were compared with children with similar or higher priority listing for transplant: 929 with acute liver failure (ALF) listed as status 1A and 808 with metabolic diseases and malignancies listed as status 1B (termed "non-ACLF"). Children with ACLF had comparable rates of cumulative organ failures compared with ALF (45% vs. 44%; p 0.99) listings, but higher than non-ACLF (45% vs. 1%; p 0.001). ACLF had the lowest LT rate (79%, 84%, 95%; p 0.001), highest pre-LT mortality (20%, 11%, 1%; p 0.001), and longest waitlist time (57, 3, 56 days; p 0.001), and none recovered without LT (0%, 4%, 1%; p 0.001). In survival analyses, ACLF was associated with an increased adjusted hazard ratio (HR) for post-LT mortality (HR, 1.50 vs. ALF [95% confidence interval, CI, 1.02-2.19; p = 0.04] and HR, 1.64 vs. non-ACLF [95% CI, 1.15-2.34; p = 0.01]). ACLF has the least favorable waitlist and post-LT outcomes of all patients who are status 1A/1B. Increased prioritization on the LT waiting list may offer children with ACLF an opportunity for enhanced outcomes.

Purpose of review The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic has overwhelmed the global community, negatively impacting patient health and research efforts; associated neurological manifestations are a significant cause of morbidity. This review outlines the worldwide epidemiology of neurologic manifestations of different SARS-CoV-2 clinical pediatric phenotypes, including acute coronavirus disease 2019 (COVID-19), multisystem inflammatory syndrome in children (MIS-C) and postacute sequelae of COVID-19 (PASC). We discuss strategies to develop adaptive global research platforms for future investigation into emerging pediatric neurologic conditions. Recent findings Multicenter, multinational studies show that neurological manifestations of acute COVID-19, such as smell/taste disorders, headache, and stroke, are common in hospitalized adults (82%) and children (22%), associated with increased mortality in adults. Neurological manifestations of MIS-C are reported in up to 20% of children, including headache, irritability, and encephalopathy. Data on PASC are emerging and include fatigue, cognitive changes, and headache. Reports of neurological manifestations in each phenotype are limited by lack of pediatric-informed case definitions, common data elements, and resources. Summary Coordinated, well resourced, multinational investigation into SARS-CoV-2-related neurological manifestations in children is critical to rapid identification of global and region-specific risk factors, and developing treatment and mitigation strategies for the current pandemic and future health neurologic emergencies.

X-linked myotubular myopathy (XLMTM) is a rare congenital myopathy characterized by profound hypotonia and poor respiratory effort at birth. The condition is associated with multiple morbidities including chronic respiratory insufficiency, feeding tube dependence, and rarely, vitamin K deficiency leading to bleeding and coagulopathy. We report a case of a 6-month-old boy with X-linked myotubular myopathy who experienced a fatal intracranial hemorrhage due to vitamin K deficiency without prior clinical evidence of cholestasis or micronutrient deficiency. We propose clinically non-apparent cholestasis in combination with acute illness and poor weight gain led to his vitamin K deficiency and intracranial hemorrhage. However, the etiology and mechanism of his cholestasis remains unclear. We conclude that children with X-linked myotubular myopathy, especially with gene therapy on the horizon, may benefit from routine hepatic, coagulation, and nutritional screening to prevent potentially catastrophic bleeding.

Targeted temperature management (TTM) is an important treatment modality in pediatric neurocritical care. There are different types of devices available to deliver this therapy, but limited pediatric data exist. This quality improvement study evaluates the use of a surface cooling device that uses gel-adhesive pads for TTM in critically ill pediatric patients. An institutional TTM protocol to use the gel-adhesive pad system was developed with three different temperature goals: normothermia (goal temperature 37°C), mild hypothermia (goal temperature 35°C with rewarming duration of 12 hours to normothermia), and moderate hypothermia (goal temperature 33°C with rewarming duration of 24 hours to normothermia). Protocol and device implementation required several different educational sessions for all members of the critical care team. An exploratory analysis was performed for 19 patients with complete clinical and device temperature data. The most common protocol used was normothermia (73.6%). By protocol, time to goal temperature was 58 minutes (22.0–112.8) for normothermia, 46.5 minutes (44.3–48.8) for mild hypothermia, and 93 minutes (46.5–406.5) for moderate hypothermia. Patients remained within ±0.5°C temperature goal 99% (96.0–99.3) of the time in the normothermia protocol, 99.5% (99–100) in mild hypothermia, and 93% (80–100) for the moderate hypothermia protocol. Shivering was the most common adverse event (35%). Our results show that use of the gel-adhesive pad system for pediatric TTM is feasible, efficacious with regard to achieving both a short time to target temperature and maintaining temperature goal, and, in this limited sample, was free from major adverse events. We also defined several technical aspects of device use in pediatric patients that should be considered in future trial design and/or clinical use. Further studies are needed to determine if this device is superior to other cooling devices for temperature management in the pediatric population.

Our objective was to characterize the frequency, early impact, and risk factors for neurological manifestations in hospitalized children with acute severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection or multisystem inflammatory syndrome in children (MIS-C).Multicenter, cross-sectional study of neurological manifestations in children aged18 years hospitalized with positive SARS-CoV-2 test or clinical diagnosis of a SARS-CoV-2-related condition between January 2020 and April 2021. Multivariable logistic regression to identify risk factors for neurological manifestations was performed.Of 1493 children, 1278 (86%) were diagnosed with acute SARS-CoV-2 and 215 (14%) with MIS-C. Overall, 44% of the cohort (40% acute SARS-CoV-2 and 66% MIS-C) had at least one neurological manifestation. The most common neurological findings in children with acute SARS-CoV-2 and MIS-C diagnosis were headache (16% and 47%) and acute encephalopathy (15% and 22%), both P 0.05. Children with neurological manifestations were more likely to require intensive care unit (ICU) care (51% vs 22%), P 0.001. In multivariable logistic regression, children with neurological manifestations were older (odds ratio [OR] 1.1 and 95% confidence interval [CI] 1.07 to 1.13) and more likely to have MIS-C versus acute SARS-CoV-2 (OR 2.16, 95% CI 1.45 to 3.24), pre-existing neurological and metabolic conditions (OR 3.48, 95% CI 2.37 to 5.15; and OR 1.65, 95% CI 1.04 to 2.66, respectively), and pharyngeal (OR 1.74, 95% CI 1.16 to 2.64) or abdominal pain (OR 1.43, 95% CI 1.03 to 2.00); all P 0.05.In this multicenter study, 44% of children hospitalized with SARS-CoV-2-related conditions experienced neurological manifestations, which were associated with ICU admission and pre-existing neurological condition. Posthospital assessment for, and support of, functional impairment and neuroprotective strategies are vitally needed.

Severe sepsis in immunocompromised children is associated with increased mortality. This paper describes the epidemiology landscape, clinical acuity, and outcomes for severe sepsis in pediatric intestinal (ITx) and multi-visceral (MVTx) transplant recipients requiring admission to the pediatric intensive care unit (PICU). Severe sepsis episodes were retrospectively reviewed in 51 ITx and MVTx patients receiving organs between 2009 and 2015. Twenty-nine (56.8%) patients had at least one sepsis episode (total of 63 episodes) through December 2016. Bacterial etiologies accounted for 66.7% of all episodes (n = 42), occurring a median of 122.5 days following transplant (IQR 59-211.8 days). Multidrug-resistant organisms (MDROs) accounted for 73.8% of bacterial infections; extended spectrum beta-lactamase producers, vancomycin-resistant enterococcus, and highly-resistant Pseudomonas aeruginosa were the most commonly identified. Increased mechanical ventilation and vasoactive requirements were noted in MDRO episodes (OR 3.03, 95% CI 1.09-8.46 and OR 3.07, 95% CI 1.09-8.61, respectively; p

High mobility group box 1 (HMGB1) is a prototypical danger-associated molecular pattern molecule that is considered a late mediator of neuro-inflammation after traumatic brain injury (TBI). Prior studies have suggested that targeting HMGB1 may lead to neuroprotective effects, but none of these studies have reported cognitive outcomes. We hypothesized that loss of HMGB1 before and after TBI would markedly attenuate post-traumatic brain edema, blood–brain barrier (BBB) permeability, improve functional deficits and long-term neuropathology versus control mice. Using the controlled cortical impact model and conditional global HMGB1 knockout (HMGB1 KO) mice, we demonstrate that there was a neuroprotective effect seen in the HMGB1 KO versus wild-type control evidenced by a significant reduction in contusion volume. However, two surprising findings were 1) the lack of benefit on either post-traumatic brain edema or BBB permeability, and 2) that spatial memory performance was impaired in HMGB1 KO naïve mice such that the behavioral effects of HMGB1 deletion in uninjured naïve mice were similar to those observed after TBI. Our data suggest the possibility that the role of HMGB1 in TBI is a “double-edged sword”; that is, despite the benefits on selected aspects of secondary injury, the sustained absence of HMGB1 may impair cognitive function, even in naïve mice. Given the pleiotropic actions of extracellular and intracellular HMGB1, when evaluating the potential use of therapies targeting HMGB1, effects on long-term cognitive outcome should be carefully evaluated. It also may be prudent in future studies to examine cell-specific effects of manipulating the HMGB1 pathway.

Purpose: Sepsis-induced brain injury is associated with an acute deterioration of mental status resulting in cognitive impairment, long-term cognitive deficits, increased functional morbidity, and diminution in the quality of life. The underlying pathophysiology of the septic brain has been suggested to include cerebral edema, blood-brain barrier disruption, microglial activation, increased free radicals, and microvascular injury. In addition to the lack of standard terminology to describe these manifestations, the consequences of sepsis on both acute and …

Multisystem inflammatory syndrome in children (MIS-C) is characterized by fever and multiorgan system dysfunction. Neurologic complications of MIS-C are not well described. We present 4 patients with MIS-C who had intracranial hypertension and discuss the unique management considerations when this occurs concurrently with significant myocardial dysfunction.

Liver disease results in approximately 15,000 pediatric hospitalizations per year in the United States and is a significant burden to child health. Major etiologies of liver failure and indications for transplantation in children include: biliary atresia, metabolic/genetic conditions, toxins, infections, tumors, and immune-mediated liver/biliary injury. Children requiring transplantation are placed on the United Network of Organ Sharing waitlist including those with acute liver failure (ALF) and acute on chronic liver failure (ACLF). ALF is a clinical syndrome in which a previously healthy child develops rapid-onset hepatic dysfunction, and becomes critically ill with multiple organ dysfunction within days. ACLF, by contrast, is generally described as an acute decompensation of pre-existing chronic liver disease (CLD) brought on by a precipitating event, with higher risk of mortality. Children with ALF and ACLF receive multidisciplinary care in pediatric intensive care units (ICUs) due to multiple organ system involvement and high risk of decompensation in these patients. The care of these patients requires a holistic approach that addresses the complex interplay between hepatic and extra-hepatic organ systems. This review will define and describe ALF and ACLF in the pediatric population, and outline the effects of ALF and ACLF on individual organ systems with diagnostic and management considerations in the ICU while awaiting liver transplantation.

OBJECTIVES Neurologic complications occur in up to 40% of adult abdominal solid organ transplant recipients and are associated with increased mortality. Comparable pediatric data are sparse. This study describes the occurrence of neurologic and behavioral complications (neurobehavioral complications) in pediatric abdominal solid organ transplant recipients. We examine the association of these complications with length of stay, mortality, and tacrolimus levels. DESIGN The electronic health record was interrogated for inpatient readmissions of pediatric abdominal solid organ transplant recipients from 2009 to 2017. A computable composite definition of neurobehavioral complication, defined using structured electronic data for neurologic and/or behavioral phenotypes, was created. SETTING Quaternary children's hospital with an active transplant program. PATIENTS Pediatric abdominal solid organ transplant recipients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Computable phenotypes demonstrated a specificity 98.7% and sensitivity of 63.0% for identifying neurobehavioral complications. There were 1,542 readmissions among 318 patients, with 65 (20.4%) having at least one admission with a neurobehavioral complication (total 109 admissions). Median time from transplant to admission with neurobehavioral complication was 1.2 years (interquartile range, 0.52-2.28 yr). Compared to encounters without an identified neurobehavioral complication, encounters with a neurobehavioral complication were more likely to experience ICU admission (odds ratio, 3.9; 2.41-6.64; p < 0.001), have longer ICU length of stay (median 10.3 vs 2.2 d; p < 0.001) and hospital length of stay (8.9 vs 4.3 d; p < 0.001), and demonstrate higher maximum tacrolimus level (12.3 vs 9.8 ng/mL; p = 0.001). Patients with a neurobehavioral complication admission were more likely to die (odds ratio, 5.04; 1.49-17.09; p = 0.009). In a multivariable analysis, type of transplant, ICU admission, and tacrolimus levels were independently associated with the presence of a neurobehavioral complication. CONCLUSIONS Common electronic health record variables can be used to accurately identify neurobehavioral complications in the pediatric abdominal solid organ transplant population. Late neurobehavioral complications are associated with increased hospital resource utilization, mortality, and tacrolimus exposure. Additional studies are required to delineate the relationship between maximum tacrolimus level and neurobehavioral complications to guide therapeutic drug monitoring and dosing.

Although there are some commonalities between pediatric and adult sepsis, there are important differences in pathophysiology, clinical presentation, and therapeutic approaches. The recognition and diagnosis of sepsis is a significant challenge in pediatric patients as vital sign aberrations and examination findings are often subtle as compared to those observed in adults. Gaps in knowledge that have been studied in depth in adult sepsis are still being investigated in pediatric patients such as best practices in ventilation, invasive monitoring, and resuscitation.In this review, we address key differences in the etiology, presentation, resuscitation, and outcomes of sepsis in children compared with adults.

Sepsis-induced brain injury is associated with an acute deterioration of mental status resulting in cognitive impairment and acquisition of new functional limitations in sepsis survivors. However, the exact nature of brain injury in this setting is often subtle and remains to be fully characterized both in pre-clinical studies and at the bedside. Given the translation potential for the use of magnetic resonance imaging (MRI)() to define sepsis-induced brain injury, we sought to determine and correlate the cellular changes with neuroradiographic presentations in a classic murine model of sepsis induced by cecal ligation and puncture (CLP)(). Sepsis was induced in 6–10-week-old male C57/BL6 mice by CLP. We used immunohistochemistry (IHC)() to define neuropathology in a mouse model of sepsis along with parallel studies using MRI, focusing on cerebral edema, blood-brain barrier (BBB)() disruption, and microglial activation on days 1 and 4 days after CLP. We demonstrate that septic mice had evidence of early axonal injury, inflammation and robust microglial activation on day 1 followed by cytotoxic edema on day 4 in the cortex, thalamus, and hippocampus in the absence of BBB disruption. We note the superiority of the MRI to detect subtle brain injury and cytotoxic cerebral edema in comparison to the traditional gold standard assessment, i.e., percent brain water (wet-dry weight method). We conclude that inflammatory changes in the septic brain can be detected in real-time, and further studies are needed to understand axonal injury and the impact of inhibition of microglial activation on the development of cerebral edema.

OBJECTIVE: To describe characteristics of liver transplant patients with severe sepsis in the pediatric intensive care unit (PICU) DESIGN: Retrospective descriptive analysis SETTING: Tertiary children’s hospital PICU PATIENTS: Liver transplant recipients admitted Jan 2010 to Jul 2016 for pediatric severe sepsis INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: Between Jan 2010 – Jul 2016, 173 liver transplants were performed, and 36 of these patients (21%) were admitted with severe sepsis (54 episodes total). Median age at admission was 2 y [1–6.5 y], 47.2% were male. Bacterial infections were the most common (77.8%), followed by culture negative (12.9%) and viral infections (7.4%). Fungal infections accounted for only 1.9%. Median time from transplant for viral and culture negative infections was 18 d [8.25–39.75 d] and 25 d [9–41 d], while 54.5 d [17–131.25 d] for bacterial infections. Bloodstream and intra-abdominal were the most common bacterial sites (45% and 22.5%, respectively). Multidrug-resistant organisms (MDROs) accounted for 47.6% of bacterial sepsis. Vancomycin resistant enterococcus and extended spectrum beta-lactamase producers were the most frequently identified MDROs. Patients with MDRO sepsis demonstrated higher admission PELOD scores (P=0.043) and were noted to have an odds ratio of 3.8 and 3.6 for mechanical ventilation and MODS, respectively (P=0.047 and P=0.044). Overall mortality was 5.5% (n=2 patients), with both deaths occurring in MDRO episodes. CONCLUSIONS: We report that MDROs are increasingly being identified as causative pathogens for sepsis in pediatric liver transplant recipients and are associated with significantly higher odds for mechanical ventilation and higher organ failure. The emergence of MDRO infections in pediatric liver transplant patients has implications for patient outcomes, antibiotic stewardship and infection prevention strategies.

Adenovirus infection is common in childhood and is generally associated with self-limited disease. Cidofovir, a viral DNA polymerase inhibitor, is used to treat adenovirus infection in select populations but is not often recommended for immunocompetent patients because of limited antiviral activity and nephrotoxicity. Here, we report a case of fulminant adenovirus infection associated with lymphopenia and multiple organ failure requiring extracorporeal membrane oxygenation support in a previously healthy child. After 1 week of supportive therapy, the patient had persistent organ failure and continued to have adenoviremia of >560 000 copies per mL. Weekly doses of cidofovir with concurrent probenecid for renal protection was initiated. Adenovirus blood load declined after the first cidofovir dose, becoming undetectable after 3 doses. The patient was successfully decannulated from extracorporeal membrane oxygenation, extubated, and eventually discharged at his functional baseline without need for ongoing respiratory support. Lymphopenia improved after viremia resolved, and a subsequent immunologic workup revealed no evidence of primary immunodeficiency. The viral isolate was genotyped as adenovirus type 7. This case reveals the successful use of cidofovir for management of severe adenovirus infection in a previously healthy child. To date, there are no universally accepted recommendations for the use of cidofovir in this population. Further study is warranted to determine the potential role of cidofovir in treating severe adenovirus infections in immunocompetent children.

The role of dietary fiber in chronic inflammatory disorders has been explored, but very little is known about its benefits in acute inflammation. Previously, we have demonstrated that dietary cellulose supplementation confers protection in a murine model of sepsis by promoting the growth of the gut microbiota that are linked to metabolic health. The survival benefit is associated with a decrease in serum concentration of proinflammatory cytokines, reduced neutrophil infiltration in the lungs, and diminished hepatic inflammation. Here, we aim to understand if the benefit of manipulating the gut microbiome exerts a broader "systemic" influence on the immune system in a lethal murine endotoxemia model. We hypothesize that mice-fed high-fiber cellulose (HF) diet will demonstrate a reduction in activated macrophages and dendritic cells (DCs) and a concomitant increase in the suppressive capacity of T-regulatory cells (Tregs) toward T cells responsiveness. We characterized the immunological profile and activation status of macrophages, DCs, and T cells in mice on HF diet that were then subjected to endotoxemia. Supplementation with HF diet decreased the number and activation of splenic macrophages and DCs in mice after LPS administration. Similarly, HF diet amplified the suppressive function of Tregs and induced anergy in T cells as compared with mice on a regular diet. Our data suggest that the use of HF diet can be a simple, yet effective tool that decreases the hepatic DNA-binding activity of NF-κB leading to a reduction in proinflammatory cytokine response in a murine endotoxemia model.

The incidence of multiple organ dysfunction syndrome (MODS) in sepsis varies from 17 to 73% and furthermore, increases the risk of death by 60% when controlled for the number of dysfunctional organs. Several MODS phenotypes exist, each unique in presentation and pathophysiology. Common to the phenotypes is the stimulation of the immune response by pathogen-associated molecular patterns (PAMPs), or danger-associated molecular patterns (DAMPs) causing an unremitting inflammation. Two of the MODS phenotypes are discussed in detail, thrombocytopenia-associated multiple organ failure (TAMOF) and the hyperinflammatory phenotype–macrophage activating syndrome (MAS) and hemophagocytic lymphohistiocytosis (HLH). In the end, we will briefly review the role of mitochondrial dysfunction as a significant contributor to the pathogenesis of MODS.

Introduction Family-centered rounds (FCR) are a common method for daily communication between families and providers in pediatric hospitals. Traditionally, medical education teaches students fundamental oral presentation skills. However, students frequently struggle with synthesizing pertinent information for communication to patients and families, especially without the use of medical jargon. To address this deficit, we created a workshop for third-year medical students on their pediatric clerkship to provide expectations for FCR presentations and allow for directed practice with immediate feedback. Methods This 1-hour workshop begins with a preworkshop survey and PowerPoint introductory presentation on FCR. Participants then watch videos of both good and bad history and physical (H&P) performances and discuss the differences. The workshop ends with 30 minutes for small-group H&P practice. Results This workshop has increased medical students' perceived comfort with oral presentations on family-centered rounds, as well as their ability to identify and synthesize pertinent information. Discussion The workshop has created a solid foundation for the introduction of medical students to family-centered rounds presentations; however, further development of educational and feedback tools would continue to enhance this learning experience. The creation and maintenance of the workshop relied heavily upon senior resident involvement to serve as small-group facilitators.

Background Recent clinical observations of increased necrotizing enterocolitis (NEC) incidence in some Nasal Continuous Positive Airway Pressure (NCPAP) patients raise concerns whether the related abdominal distension is benign or contributes to NEC. We tested the hypothesis that mechanical strain causes an exaggerated enterocyte inflammatory response and decreased enterocyte growth and proliferation, in the absence and presence of lipopolysaccharide (LPS). Methods First we used a confluent enterocyte (IEC-6) monolayer to investigate effects of strain on inflammatory cytokine production and Toll-like Receptor 4 (TLR4) gene expression. Then we used a low seeding density to measure cell growth and proliferation. 10% mechanical strain was applied. Results Significant increases in IL-8 and in IL-6 were observed after 8 and 24 h of cellular strain respectively, and maintained throughout the study. TLR-4 expression was increased at 48 hours. Mechanical strain led to slower proliferation and division whereas LPS alone had minimal effects. The responses of LPS and strain were supra-additive, suggesting synergistic cellular effects. Conclusion We speculate intestinal distension associated with the use of NCPAP, especially in the presence of abnormal gut colonization, may result in increased inflammatory cytokine production and be a contributing factor to neonatal intestinal morbidities.

Background Medical students use several strategies for United States Medical Licensing Examination (USMLE) Step 1 preparation. At Ohio State University College of Medicine, a yearlong, peer-designed and -led Step 1 review course is a new option for our second-year students. This study aims to ascertain the value of the peer-designed and -led Step 1 review course, to assess the difference in Step 1 scores between participants and nonparticipants, and to understand the course's role in improving preparation for Step 1 among participants. Method Eligible students completed a confidential survey. Scores between participants and nonparticipants were compared, controlling for preexisting differences between groups. Results Course participants had a higher average Step 1 score than nonparticipants (P = .005). The majority of participants felt the course was a valuable use of time and would recommend it to future students. Conclusions A Step 1 review course designed and led by near-peer senior medical students, those who had successfully completed the USMLE Step 1 exam within the previous year, was shown to be valuable to second-year medical students and improved Step 1 score outcomes.

Systemic adenovirus infection in the immunocompromised host is often fatal and therapeutic options are limited. We report an infant with acute lymphoblastic leukemia who developed disseminated adenovirus infection while lymphopenic during maintenance chemotherapy 6 months following a bout of adenoviral diarrhea. His serum adenoviral load peaked at 35 million copies/mL and was associated with pancytopenia and hepatic injury. Treatment with cidofovir was effective although associated with mild renal injury. The patient recovered fully and completed chemotherapy for infant acute lymphoblastic leukemia.

Introduction Social determinants of health (SDH) are emerging as a major barrier to the promotion of child health in the twenty-first century. The effects of poverty, including food insecurity, unsafe housing conditions, inadequate educational interventions, domestic violence, and limited access to medical care, have been linked to poor health and developmental outcomes in children. Many pediatric residents lack competence in identifying families that face social, economic, or environmental difficulties and feel inadequately prepared to counsel and refer patients and families to appropriate community resources due to their limited training during medical school and early residency years. Methods This curriculum was developed following a needs assessment and positive feedback obtained after a brief one-time educational experience with videotaped social history vignettes. Scripts for a series of appropriate and inappropriate video vignettes depicting typical scenarios of resident physicians screening for SDH in continuity clinic were developed, with clinic parents and resident physicians acting in their respective roles. A series of “Day in the Life” videos was also created to allow actual patients and families from the clinic tell their story of how screening, detection, and intervention impacted their family's lives. Residents experience this resource by attending the included didactic PowerPoint presentation, viewing the appropriate/inappropriate vignettes, engaging in group discussion, viewing the “Day in the Life” videos, and participating in a final discussion. Results The vast majority (> 95%) of participating residents strongly agreed/agreed that this education addressed important topics and included a good combination of both didactic and interactive components. Resident selfrated competence in screening for housing, benefits, and educational concerns significantly improved (p < 0.05 for each). Parents seen by residents who received this education reported that the resident was significantly more likely to screen for both domestic violence and depression. Although not significant, parents also recalled being screened more frequently for food insecurity, public benefits issues, housing, and educational needs. Discussion Many pediatric residents lack competence in counseling and referring patients and families to appropriate community resources. Additionally, the majority of pediatric residents were not raised in poverty, so they cannot build upon their past experiences. Through the use of these vignettes, videotaped first-hand accounts, and discussions, residents are better equipped to identify and aid families in need.

Introduction Screening and management of the social determinants of health (SDH) are critical for child health promotion. We sought to evaluate the impact of a facilitated video curriculum on resident SDH screening competence, parental perceptions of resident practice, resident-initiated referrals to a medical–legal partnership (MLP), and formula distribution to food-insecure families. Methods This was a pre–post study with concurrent control performed at a large pediatric residency program. Second- and third-year residents were assigned to control and intervention groups on the basis of their continuity clinic day. The curriculum included videotaped vignettes of screening for SDH and a "day in the life" series of families describing the impact of intervention on their lives. Residents completed self-assessments on screening competence and resource knowledge. After a well-child encounter, families (3 per resident) assessed their level of trust and respect for the resident and the number of SDHs screened for. MLP referral rates and formula distribution were compared. Results The intervention group's self-assessed competence in screening for housing, benefits, and educational concerns was significantly higher compared to controls (each P ≤ .05). Parents' rating of trust and respect was high and did not differ between groups. Screening for each SDH was higher in the intervention group with domestic violence (odds ratio 2.16, 95% confidence interval 1.01–4.63) and depression (odds ratio 2.63, 95% confidence interval 1.15–5.99), reaching statistical significance. MLP referral rates increased ( P = .06), and formula distribution ( P = .02) reached statistical significance in the intervention group. Conclusions This SDH video curriculum improved resident self-assessed screening competence, parental perception of screening, and both MLP referrals and formula distribution.