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Background: The pediatric emergency department is a high-value site for screening and resource referral for health-related social needs. However, best practices for this unique environment remain unclear. This study's objective was to introduce a consensus-based social care training toolkit for the pediatric emergency medicine (PEM) setting., Methods: We conducted a modified Delphi study to establish consensus on social care practice and develop a user-friendly toolkit. Initially, five priority areas (sections) were identified. Participants reviewed literature and shared their expertise to draft preliminary sections of the toolkit. Two rounds of the modified Delphi process were conducted, involving a ranking system, significant qualitative feedback, and a final approval stage, resulting in the finalized toolkit., Results: Seventeen participants were included in the Delphi process, including pediatric and general EM faculty and trainees, as well as a social worker and public health professor. Forty-two content items were ranked in the first Delphi round. Based on a combination of score cut-off and extensiveness of qualitative comments, items were either minorly edited and kept (29%) or sent back to their section for review (71%). The second Delphi round integrated further suggested edits, and all participants in this final round approved the publicly available version of the toolkit., Conclusion: By utilizing diverse sources of information and a consensus-driven process of the modified Delphi, we generated best practice recommendations for the design, implementation, and training of social care programs in the PEM setting., Competing Interests: Declaration of Competing Interest Natalie Tedford’s institution has received grant funding from the American Academy of Pediatrics Community Access to Child Health Program for investigator-initiated research and from the National Institute of Nursing Research of the National Institutes of Health for investigator-collaborative research. This is not related to this study. The remaining authors have no conflicts of interest to report., (Copyright © 2024 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objectives: To assess whether the association of adverse childhood experiences (ACEs) with pediatric health care utilization differs by age., Methods: In this retrospective cohort study, we included patients completing primary care ACEs screening between January 2020 and September 2021. Pediatric ACEs and Related Life Events Screener Part 1 scores were categorized 0, 1 to 3, or ≥4 (none, low, and high, respectively). Two multivariable logistic regression models assessed emergency department (ED) and inpatient utilization across all ages 6 months after screening., Results: Among 37 315 patients, 15.7% visited the ED and 2.5% were hospitalized within 6 months of ACEs screening. Using no ACEs as the reference, infants and toddlers with any ACEs had lower odds of ED and inpatient utilization, whereas older children with any ACEs had higher odds of ED (age-low ACEs: 0.04, P value < .001; age-high ACEs: 0.08, P value < .001) and inpatient (age-low ACEs: 0.06, P value < .001; age-high ACEs: 0.15, P value < .001) utilization and increased each successive year of age., Conclusions: The association of ACEs with health care utilization is dependent on age and is more complex than previously described. These trends may inform specific therapeutic strategies for pediatric patients by age., (Copyright © 2024 by the American Academy of Pediatrics.)

Objective: The aim of the study is to assess the association of social determinants of health (SDOH) education and social needs training on pediatric emergency medicine (PEM) physician perception and practices of social care., Methods: Data were derived from the 2021 National Social Care Practices Survey of PEM program directors (PDs) and fellows. Ordinal and binary logistic regression modeling were completed for educational/training factors and social care perspective and practice outcomes., Results: A national sample of 44 PDs (49% response rate) and 109 fellows (28%) participated. A minority of fellows received SDOH education and social needs training during fellowship. Fellows and PDs with SDOH education had a 3.1 odds (95% confidence interval CI, 1.4-6.9) of screening for social needs, with 4.4 odds among fellows (95% CI, 1.2-20.7). Those with social needs training were more comfortable assessing social risk, with 2.4 odds overall (95% CI, 1.2-4.7) and 3.1 odds among fellows (95% CI, 1.4-6.7). They also had 2.4 odds overall (95% CI, 1.1-4.9) of screening for social needs, with a 2.9 odds among fellows (95% CI, 1.3-6.8)., Conclusions: Social care education and training appear to be associated with comfort assessing social risk and social needs screening tendency among both PEM PDs and fellows. Key areas for educational interventions are identified among PEM fellows, who are uniquely positioned as clinical leaders and patient advocates., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: We aimed to understand family preferences around reporting and receiving health-related social needs (HRSN) information by assessment modality during pediatric emergency department (PED) visits., Methods: Families were randomized into paper (control), cell phone, or tablet modality groups by their child's exam room. Nurses alerted families to complete a single HRSN assessment during routine workflow. We used logistic regression and McNemar's test to assess discordance in modality preference., Results: Forty-seven percent of families disclosed at least one HRSN across a total 611 assessments. Disclosure of HRSN was similar by modality. Twenty-three percent of those assigned tablet preferred cell phone ( p  < 0.001). Two-thirds of families preferred receiving digitally formatted community resources (email or text). There was no difference in preferred timing of HRSN assessment completion., Conclusions: Assessment modality did not appear to influence family HRSN disclosure. Families were generally satisfied with all HRSN assessment modalities but demonstrated a particular preference in using personal cell phones over tablets. Digitally formatted community referrals also pose numerous advantages over conventional paper handouts., Innovation: Use of personal cell phones is a novel, streamlined method of HRSN interventions in the clinical setting, performing similar to more conventional modalities, with a preference among families when compared to tablets., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors. Published by Elsevier B.V.)

Abstract: We present a case of a teenage patient with new-onset cardiac symptoms discovered to have primary pulmonary arterial hypertension. Point-of-care ultrasound used early in the patient's presentation identified significant right-sided heart dilatation and dysfunction despite the patient's relatively unrevealing physical examination. This article emphasizes the utility of performing focused cardiac ultrasound in pediatric patients early in their presentation. We briefly review focused cardiac ultrasound technique and highlight relevant literature., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Social care has become increasingly relevant to the emergency physician and includes activities that address health-related social risk and social needs. The literature has consistently documented substantial health care provider challenges in incorporating social care into routine practice. Yet, interventions on the health care organizational level hold promise to bring about more widespread, sustainable impact., Methods: This study was a subanalysis of the 2021 National Social Care Practices Survey data set among pediatric emergency medicine (PEM) program directors (PDs) and fellows. The purpose was to investigate the association between health care organizational factors and PEM physician social care practices and perceptions among PEM PDs and fellows. We performed binary and ordinal logistic regressions of organizational factors and five specific PEM physician social care perspective and practice outcomes., Results: The sample population included 153 physicians-44 PDs (49% response rate) and 109 fellows (28%). PDs and fellows with access to a social care systematic workflow in their pediatric emergency department (PED) had higher odds of comfort assessing social risk (odds ratio [OR] 2.1%, 95% confidence interval [CI] 1.1-4.0), valuation of social care (OR 3.2, 95% CI 1.3-7.9), preparedness to assist families (OR 2.4, 95% CI 1.1-5.2), screening tendency (OR 2.2, 95% CI 1.1-4.5), and ability to refer to community resources (OR 2.3, 95% CI 1.2-4.6). A similarly directed, but less pronounced pattern was noted with access to a community resource database for referrals and 24-h access to a social worker in the PED., Conclusions: PED organizational factors-particularly access to a social care systematic workflow-appear positively associated with PEM physician practices and perceptions of social care delivery. Further research is under way to advance understanding of PEM training factors in social care., Competing Interests: The authors have no example conflicts of interest to disclose., (© 2022 Society for Academic Emergency Medicine.)

There is a growing body of literature and scientific discovery on pediatric autoimmune encephalitides. This is a heterogenous group of neuroinflammatory conditions leading to often perplexing acute and progressive neurologic and/or neuropsychiatric symptoms. This report demonstrates the evaluation and management of an adolescent with myelin-oligodendrocyte glycoprotein (MOG) antibody-associated fulminant acute disseminated encephalomyelitis (ADEM) in the context of current literature. The featured magnetic resonance imaging uniquely highlights progressive central nervous system lesions detected over the course of the first week of disease., Topics: Encephalitis, encephalopathy, ADEM, MOG., (© 2022 Assaf.)

Background: The emergence of social emergency medicine-the incorporation of social context into the structure and practice of emergency care-has brought forth greater embracement of the social determinants of health by medical professionals, yet workforce practices and training have remained elusive. Academic literature particularly in the field of pediatric emergency medicine (PEM) fellowship training is lacking relative to general pediatrics and adult emergency medicine., Methods: The primary objective of this study was to assess the social care knowledge, perspectives, and training of PEM program directors (PDs) and fellows across a national cross-sectional sample. A secondary aim was to uncover key actionable areas for the development of social care curricula in PEM training programs. A social care practices assessment tool was developed via snowball sampling interviews among clinician researcher experts and disseminated to PEM PDs and fellows nationally in accredited academic PEM training institutions., Results: A total of 153 participants-44 PDs (49% response rate) and 109 fellows (28%)-completed the assessment tool. Responses among PDs and fellows were highly concordant. Only 12% reported regular use of a standardized social needs screening tool. The majority felt unprepared to assist families with social needs and less than half felt comfortable talking to families about social need. At the same time, social care was highly valued by 73% of participants. All participants felt that providing social care training during PEM fellowship would be beneficial. PDs and fellows identified five priority areas for PEM curricular development., Conclusions: PEM PDs and fellows have an overall favorable perception of social care yet report significant deficits in current practice organization and training. This study is part of a larger national collaborative advocacy project to organize and advance social care delivery across academic PEM training institutions through evidence-based approaches, best practices, and expert consensus., Competing Interests: The authors have no potential conflicts to disclose., (© 2022 Society for Academic Emergency Medicine.)

Cellulitis is among the more common conditions diagnosed and treated within pediatric emergency departments. However, unusual distribution, recurrence, and/or poor response to antibiotics may point towards another pathologic process. This case presentation illustrates a teenager with recurrent episodes of painful erythematous and swollen extremities misdiagnosed repeatedly as cellulitis. Careful history, exam, laboratory evaluation and rheumatologist consultation aided in making the correct diagnosis of erythromelalgia, which was successfully treated with supportive measures. This report reviews a rare presentation of erythromelalgia, as well as its pathophysiology, recommended therapies, and common misdiagnoses., Topics: Painful extremities; recurrent swelling; erythromelalgia., (© 2022 Assaf.)

Pediatric neuroblastoma is famously characterized by an abdominal mass in a toddler with "raccoon eyes," Horner syndrome, and/or opsoclonus myoclonus. However, rare cases may present with non-discrete symptoms and signs which create challenges for timely diagnosis. This case depicts a toddler with bulbar symptoms, including bilateral ptosis, dysphagia, drooling, head tilt and ataxia in a post-viral course mimicking other neurologic diagnoses, including myasthenia gravis. Magnetic resonance imaging (MRI) of the brain and spine uncovered a right adrenal mass along with heterogenous enhancement in multiple vertebral bodies and the clivus, consistent with metastatic disease. A diagnosis of neuroblastoma was confirmed with elevated homovanillic acid (HMA) and vanillylmandelic acid (VMA) levels and adrenal biopsy. The patient was treated with plasmapheresis for suspected paraneoplastic neurological syndrome and subsequent chemotherapy. In this case presentation, we review neurologic syndromes causing acute-onset pediatric bulbar weakness along with the patient's key MRI findings., Topics: Toddler weakness, neuroblastoma, paraneoplastic syndrome., (© 2022 Assaf.)

Neonatal adrenal hemorrhage is a rare phenomenon which may occur in utero or in the intrapartum period. This case illustrates ultrasound and subsequent abdominal computed tomography (CT) imaging of a 30-day-old neonate who initially presented with acute vomiting and was found to have an abscess at the site of a previous right-sided adrenal hemorrhage. Ultrasound-guided fine needle aspiration of the abscess was ultimately the key diagnostic and therapeutic intervention, which detected Escherichia coli (E. coli) infection. The discussion addresses the connection between key pathologic features of this case, while reviewing the acute management of clinical sequelae in the emergency department., Topics: Neonatal vomiting, adrenal hemorrhage, retroperitoneal abscess, pseudohypoaldosteronism., (© 2021 Assaf, et al.)

Objective: The objective was to investigate the impact of affective, social, behavioral, and cognitive factors on pediatric emergency department (PED) provider mood changes during clinical shifts, with the introduction of a novel on-shift measure., Methods: The nominal group technique was used to generate the ED experience survey (EDES), encompassing factors that may influence PED provider mood. Providers were alerted via experience sampling method to complete the EDES and positive and negative affect schedule at randomly generated times. Analyses were conducted using multilevel modeling of moods within shifts within persons., Results: Measures were completed 221 times during 137 shifts by 52 PED providers. Positive mood tended to increase with higher self-rated capacity to deal with challenging patient situations (p < 0.001). Having to repeat patient assessments was negatively associated with positive mood during the beginning, but not rest of shift (p = 0.01). Changes in positive mood varied across provider groups (p < 0.001). Negative mood tended to decrease with higher self-rated quality of interactions with patients/families (p < 0.001). Needing a restroom break during any time on duty was associated with negative mood (p < 0.001). Furthermore, negative mood was associated with the need to process emotions during the shift beginning (p = 0.01). Finally, not knowing about patients' outcomes was associated with negative mood during the shift end (p < 0.001)., Conclusions: PED providers' mood during shifts are impacted by ED-specific factors spanning physical, social, behavioral, affective, and cognitive features. Future research may explore potential entry points for mitigation of clinician stress to support provider well-being and ultimately improve patient care., Competing Interests: The authors have no potential conflicts to disclose., (© 2021 by the Society for Academic Emergency Medicine.)

Little is known about the population of caregiving youth in the United States. We sought to describe the participation rates, demographics, and caregiving tasks among sixth graders served by the American Association of Caregiving Youth (AACY) in its Caregiving Youth Project (CYP) in Palm Beach County, FL and evaluate the perceived benefit of AACY services. Sixth grade enrollment data from eight middle schools between 2007 and 2013 were obtained from The School District of Palm Beach County and the AACY. Data were obtained using a retrospective review of AACY program participant files. These files contained responses to evaluative questions from both students and family members. Overall, 2.2 % of sixth graders enrolled and participated in the program. Among the 396 caregiving sixth graders studied, care recipients were predominantly a grandparent (40.6 %) or parent (30.5 %). Common activities included providing company for the care recipient (85.6 %), emotional support (74.5 %), and assistance with mobility (46.7 %). Youth reported a median of 2.5 h caregiving on weekdays and 4 h on weekend days, while families reported fewer hours (1.6 and 2.3, respectively). At the end of the school year, the sixth graders reported improvement in school (85.5 %), caregiving knowledge (88.5 %), and self-esteem (89.5 %). Slightly over 2 % of sixth graders participated in the CYP. While support services may mitigate the negative effects of the time spent by caregiving youth, more prospective research is needed to better define the true prevalence, tasks, and time spent caregiving among this subpopulation.

Trans fats, also known as partially hydrogenated oils, have long been associated with cardiovascular disease. In 2003, the Food and Drug Administration mandated that trans fat content of ≥0.5 g be listed on food labeling; the next year, the World Health Organization released a recommended daily limit on trans fat intake. During the following decade, legislatures in different municipal and state governments moved trans fat regulation forward, whereas many food companies decided to independently phase out trans fat in their products. The advancement of these parallel processes suggests an emerging best practices phenomenon, integrating public health, law, and the food industry. With both legislation and markets seemingly favoring a limitation on trans fat content in foods, attention has once again shifted to the Food and Drug Administration for a ruling on the safety of trans fats., (Copyright © 2014 Elsevier HS Journals, Inc. All rights reserved.)

Background: Therapeutic limitations of griseofulvin in treating onychomycosis have led to a search for alternative antimycotic agents. An optimal dosing regimen for fluconazole has yet to be defined., Objective: Our purpose was to evaluate the intermittent use of fluconazole (either once-weekly or alternate-day dosing) without concurrent nail avulsion in patients with moderate to severe onychomycosis., Methods: Eleven patients with mycologically confirmed onychomycosis of the toenails or fingernails (43 infected nails) were treated with intermittent fluconazole until clinical cure was obtained. Eight patients received fluconazole 300 mg once weekly, one patient received 200 mg once weekly, and two patients received 100 or 200 mg of fluconazole every other day. Eight patients also used an adjunctive topical antimycotic preparation., Results: All six patients with toenails involved (32 infected nails) were clinically cured after a mean treatment duration of 6 months, and all five patients with fingernails involved (11 infected nails) were cured after 3.7 months. There were no significant clinical or laboratory adverse events., Conclusion: Intermittent fluconazole, taken once weekly or on alternate days, is a well-tolerated and efficacious method to treat onychomycosis.

The various agents of the superficial mycoses have been recognized for more than a century as causes of mild diseases affecting humankind. Two of these, Malassezia furfur and Trichosporon beigelii, are ubiquitous organisms now known to be opportunistic pathogens in susceptible patient populations. The clinical manifestation, pathogenesis, and treatment of the common skin presentation of these and the other superficial mycoses are reviewed.