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Objective Adolescents are more likely to seek care and disclose sensitive health information if confidentiality is assured. Little is known regarding the provision of confidential care to adolescents in the hospital setting. We sought to understand confidentiality practices and barriers for adolescents cared for in a tertiary hospital setting. Methods This was a cross-sectional survey of all Emergency Department (ED), hospitalist, and resident physicians at a tertiary paediatric hospital from May/2019 to July/2019. Participants were asked multiple choice questions regarding practices, comfort, and barriers to confidential care. Results Response rate was 91% (n = 72/79; 26 ED, 14 hospitalists, 32 residents). Overall, 47% of respondents doubted that confidential care was being consistently provided to adolescents. Fifty-eight per cent of attendings and 31% of residents reported usually/always offering confidential care. Factors most reported to influence the provision of confidential care were chief complaint (75%), time of visit (45%), and patient age (25%). Barriers to the quantity or quality of confidential care were identified by 89%, most commonly including time constraints (21%), perceived parental resistance (26%), lack of private space (26%), and the belief that confidentiality is not necessary for all adolescent encounters (34%). Forty per cent of respondents reported breaching confidentially and discussing sensitive topics with adolescents in front of family members. Overall, only 45% felt they had received adequate training on how best to deliver confidential care, and 75% reported a desire for additional training. Conclusion Results suggest inadequate provision of confidential care in a tertiary teaching hospital, with several potentially modifiable barriers.

Children frequently present to an Emergency Department (ED) after concussion, and headache is the most commonly associated symptom. Recent guidelines emphasize the importance of analgesia for post-concussion headache (PCH), yet evidence to inform treatment is lacking. We sought to characterize abortive therapies used to manage refractory PCH in the pediatric ED and factors associated with treatment. A scenario-based survey was distributed to ED physicians at all 15 Canadian tertiary pediatric centers. Participants were asked questions regarding ED treatment of acute (48 h) and persistent (1 month) PCH refractory to appropriate doses of acetaminophen/ibuprofen. Logistic regression was used to assess factors associated with treatment. Response rate was 63% (137/219). Nearly all physicians (128/137, 93%) endorsed treatment in the ED for acute PCH of severe intensity, with most selecting intravenous treatments (116/137, 84.7%). Treatments were similar for acute and persistent PCH. The most common treatments were metoclopramide (72%), physiologic saline (47%), and nonsteroidal anti-inflammatory agents (NSAIDS; 35%). Second-line ED treatments were more variable. For acute PCH of moderate intensity, overall treatment was lower (102/137, 74%

The COVID-19 pandemic has had considerable mental health consequences for children and adolescents, including the exacerbation of previously diagnosed eating disorders. Whether the pandemic is a factor associated with the concomitant increase in new-onset anorexia nervosa or atypical anorexia nervosa remains unknown.To assess the incidence and severity of newly diagnosed anorexia nervosa or atypical anorexia nervosa in a national sample of youth before and during the first wave of the COVID-19 pandemic.This repeated cross-sectional study analyzed new eating disorder assessments that were conducted at 6 pediatric tertiary-care hospitals in Canada between January 1, 2015, and November 30, 2020. Patients aged 9 to 18 years with a new anorexia nervosa or atypical anorexia nervosa diagnosis at the index assessment were included.COVID-19-associated public health confinement measures during the first wave of the pandemic (March 1 to November 30, 2020).Primary outcomes were the incidence and hospitalization rates within 7 days of de novo anorexia nervosa or atypical anorexia nervosa diagnosis. Event rate trends during the first wave were compared with trends in the 5-year prepandemic period (January 1, 2015, to February 28, 2020) using an interrupted time series with linear regression models. Demographic and clinical variables were compared using a χ2 test for categorical data and t tests for continuous data.Overall, 1883 children and adolescents with newly diagnosed anorexia nervosa or atypical anorexia nervosa (median [IQR] age, 15.9 [13.8-16.9] years; 1713 female patients [91.0%]) were included. Prepandemic anorexia nervosa or atypical anorexia nervosa diagnoses were stable over time (mean [SD], 24.5 [1.6] cases per month; β coefficient, 0.043; P = .33). New diagnoses increased during the first wave of the pandemic to a mean (SD) of 40.6 (20.1) cases per month with a steep upward trend (β coefficient, 5.97; P .001). Similarly, hospitalizations for newly diagnosed patients increased from a mean (SD) of 7.5 (2.8) to 20.0 (9.8) cases per month, with a significant increase in linear trend (β coefficient, -0.008 vs 3.23; P .001). These trends were more pronounced in Canadian provinces with higher rates of COVID-19 infections. Markers of disease severity were worse among patients who were diagnosed during the first wave rather than before the pandemic, including more rapid progression (mean [SD], 7.0 [4.2] months vs 9.8 [7.4] months; P .001), greater mean (SD) weight loss (19.2% [9.4%] vs 17.5% [9.6%]; P = .01), and more profound bradycardia (mean [SD] heart rate, 57 [15.8] beats per minute vs 63 [15.9] beats per minute; P .001).This cross-sectional study found a higher number of new diagnoses of and hospitalizations for anorexia nervosa or atypical anorexia nervosa in children and adolescents during the first wave of the COVID-19 pandemic in Canada. Research is needed to better understand the drivers and prognosis for these patients and to prepare for their mental health needs in the event of future pandemics or prolonged social isolation.

Introduction There is increasing interest for patient-to-provider telemedicine in pediatric acute care. The suitability of telemedicine (virtualizability) for visits in this setting has not been formally assessed. We estimated the proportion of in-person pediatric emergency department (PED) visits that were potentially virtualizable, and identified factors associated with virtualizable care. Methods This was a retrospective analysis of in-person visits at the PED of a Canadian tertiary pediatric hospital (02/2018–12/2019). Three definitions of virtualizable care were developed: (1) a definition based on “resource use” classifying visits as virtualizable if they resulted in a home discharge, no diagnostic testing, and no return visit within 72 h; (2) a “diagnostic definition” based on primary ED diagnosis; and (3) a stringent “combined definition” by which visits were classified as virtualizable if they met both the resource use and diagnostic definitions. Multivariable logistic regression was used to identify factors associated with telemedicine suitability. Results There were 130,535 eligible visits from 80,727 individual patients during the study period. Using the most stringent combined definition of telemedicine suitability, 37.9% (95% confidence interval (CI) 37.6%–38.2%) of in-person visits were virtualizable. Overnight visits (adjusted odds ratio (aOR) 1.16–1.37), non-Canadian citizenship (aOR 1.10–1.18), ethnocultural vulnerability (aOR 1.14–1.22), and a consultation for head trauma (aOR 3.50–4.60) were associated with higher telemedicine suitability across definitions. Discussion There is a high potential for patient-to-provider telemedicine in the PED setting. Local patient and visit-level characteristics must be considered in the design of safe and inclusive telemedicine models for pediatric acute care.

Approximately 2% of all full-term neonates are evaluated for fever in the first months of life, and there exists significant ongoing variation in their care.1 Although most febrile neonates and infants 90 days or younger (hereafter referred to as young infants) have self-limited viral illnesses, the prevalence of life-threatening serious bacterial infections (SBIs) has remained approximately 10% for more than 30 years.1 On March 11, 2020, the COVID-19 pandemic was declared, and since that time, studies worldwide have reported a 30% to 89% reduction in the number of children brought to emergency care2,3 as well as fewer circulating respiratory viruses owing to widespread COVID-19 public health mitigation strategies.4,5 To our knowledge, the epidemiologic characteristics of SBIs among febrile young infants during the COVID-19 pandemic has not previously been assessed. We sought to assess the prevalence of SBIs among febrile young infants evaluated in the emergency department (ED) for fever during the COVID-19 pandemic.

Ambient air pollution has been associated with adverse neurological health outcomes. Ambient pollutants are thought to trigger oxidative stress and inflammation to which vulnerable populations, such as elderly may be particularly susceptible. Our study investigated the possible association between concentrations of ambient air pollutants and the number of emergency department (ED) visits for nervous system disorders among people residing in a large Canadian city. A time-stratified case-crossover study design combining data from the National Ambulatory Care Reporting System (NACRS) and the National Air Pollution Surveillance (NAPS) between 2004 and 2015 was used. Two air quality health indices were considered in additional to specific pollutants, including carbon monoxide (CO), nitrogen dioxide (NO2), sulfur dioxide (SO2), ozone (O3) and fine particulate matter (PM2.5). Weather condition data were included in the models. ED visits with a discharge diagnosis were identified using ICD-10 codes (G00-G99). The analysis was stratified by sex and age, also by seasons. The associations were investigated in arrays organized as 18 strata and 15 time lags (in days) for each pollutant. Overall, 140,511 ED visits were included for the analysis. Most ED visits were related to episodic and paroxysmal diagnoses (G40-G47, 64%), with a majority of visits for migraines (G43, 39%). Among females, an increase of 0.1ppm ambient CO was associated with an increased risk of paroxysmal diagnoses at day 1 (RR = 1.019 (95%CI 1.004–1.033)), day 6 (1.024 (1.010–1.039)) and day 7 (1.022 (1.007–1.036). PM2.5 and SO2, and air quality indices were similarly associated with ED visits for episodic and paroxysmal disorders in days 6 and 7. Findings highlight that ambient air pollution is associated with an increased number of ED visits for nervous system disorders, particularly visits for paroxysmal diagnoses.

Primary Subject area Emergency Medicine - Paediatric Background Fever in the first months of life is among the most common clinical problems in pediatric healthcare. Nearly 2% of all infants will be evaluated for fever in an Emergency Department (ED) and approximately 10% harbor life-threatening serious bacterial infections (SBIs). The Rochester criteria are most widely used criteria for risk-stratification and predate modern biomarkers including procalcitonin (PCT). Recently, a high-performing prediction rule incorporating PCT was derived by the Pediatric Emergency Care Applied Research Network (PECARN). At present, PCT is not available in all clinical settings, limited largely by test cost. Objectives Compare the medical costs associated with PECARN and Rochester risk-stratification strategies using contemporary price, epidemiologic and test characteristic data. Design/Methods We assessed hospital-level costs associated with the door-to-discharge care of all well-appearing febrile infants aged ≤ 60 days evaluated at an urban tertiary pediatric hospital between April 2016 and March 2019. Direct and indirect ED and inpatient costs were obtained from provincial Ministry of Health data. Real-world costs were then incorporated into a probabilistic model for a cohort of equal size using either Rochester or PECARN risk-stratification, accounting for the added incremental cost of PCT ($24.86CAD). Models used an 8.4% pooled SBI risk, and Sn/Sp for Rochester and PECARN of 94%/49% and 98%/63%, respectively. Modeling was calculated under 4 scenarios; true positive with hospitalization, false negative with return visit and hospitalization, false positive with hospitalization, true negative with ED discharge. All costs were calculated in Canadian dollars. Results During the 3-year study period, 1168 index infant encounters met inclusion and were analyzed for hospital trajectory costs. Median costs per infant were $323 (IQR $286-$393) for infants discharged from the ED with no SBI, $2356 (IQR $1858-$3120) for infants hospitalized with no SBI, $3150 (IQR $2352-$4201) for hospitalized infants treated for a SBI, and $3763 (IQR $2146-$5180) for infants discharged from the ED ultimately requiring hospitalization with a missed SBI. For a cohort of 1168 infants, cost-per-infant using PECARN risk-stratification was $1332 (IQR $1062-$1739), compared to $1515 (IQR $1198-$1992) using Rochester. PECARN criteria would be expected to produce an overall savings of 12.1% for the modeled cohort ($1,556,432 vs $1,769,339). Under pessimistic and optimistic model assumptions, total savings were 4.9% and 18.3%, respectively. Costs borne by families were not considered, nor were the indirect benefits of reduced unnecessary invasive testing, hospitalizations and broad-spectrum antibiotic use. Conclusion Risk-stratification of febrile infants using PECARN prediction rules would produce important cost-savings due to superior test characteristics offsetting upfront PCT-associated costs. Such a strategy would also likely result in unmodeled non-monetary family-centered and healthcare system benefits. Real-world cost-effectiveness studies are needed.

Primary Subject area Emergency Medicine - Paediatric Background Acute gastroenteritis (AGE) is among the most common illnesses for which children are evaluated in the Emergency Department (ED). Among children with AGE, ondansetron has been shown to reduce vomiting, intravenous (IV) fluid administration and hospitalizations when administered in the ED. Objectives To determine whether increasing ondansetron administration is associated with a concomitant decline in IV rehydration and hospitalization among children presenting with AGE in a broad, nationally representative ED sample. Design/Methods This was a cross-sectional analysis of the US Centers for Disease Control and Prevention (CDC) National Hospital Ambulatory Medical Care Survey (NHAMCS) database from 2006 to 2015. Children < 18 years old with a discharge diagnosis of AGE were included for analysis. Survey weighting procedures were applied to generate population-level estimates and to perform multivariable logistic regression to identify factors associated with ondansetron administration. Results There were an estimated 15.1 million (95% CI 13.5-16.7) visits for AGE during the 10-year study period. AGE visits increased as a proportion of all pediatric ED visits over time (4.6% in 2006, 5.7% in 2015; p-trend=0.013). The mean patient age was 4.7 (95% CI 4.5-5.0) years, and most visits were to non-teaching (86.6%, 95% CI 83.3-89.3%) and non-pediatric (83.4%, 95% CI 78.2-87.5%) hospitals. The proportion of patients receiving ondansetron increased over time (11.8% in 2006, 62.5% in 2015; p-trend < 0 .001), both in the ED (10.6% in 2006, 55.5% in 2015; p-trend < 0 .001) and as outpatient prescriptions (3.3% in 2006, 45.3% in 2015; p-trend < 0 .001). Over the same period, there was no change in hospitalizations (2.9% overall, 95% CI 2.2-3.7%; p-trend=0.144). IV hydration for AGE decreased (31.8% in 2006, 24.9% in 2015; p-trend < 0 .048), as did IV fluid administration across all other pediatric ED visits (10.3% in 2006, 7.8% in 2015; p-trend < 0 .023). After adjustment for patient- and hospital-level factors, the odds ratio for IV rehydration among children with AGE was 0.97 (95% CI 0.92-1.01). Multivariable analysis found younger age (aOR 0.94, 95% CI 1.04-1.09), Medicaid/Medicare insurance (aOR 0.74; 95% CI 0.57-0.97), and presentation to a teaching hospital (aOR 0.74; 95% CI 0.54-0.99) were inversely associated with ondansetron administration. Other antiemetics most commonly used were promethazine (7.4%, 95% CI 5.9-9.2%), metoclopramide (1.8%, 95% CI 1.3-2.5%) and trimethobenzamide (1.5%, 95% CI 1.1-2.1%). Antimotility agents, H2-receptor blockers, and probiotics were infrequently used. Conclusion Both ED and outpatient prescribing of ondansetron for children with AGE increased; however, no concomitant decline was observed in hospitalizations or IV rehydration. Guidelines and quality improvement efforts are needed to target ondansetron administration to children most likely to benefit to minimize adverse events and costs associated with overuse.

Objectives Correction factors have been proposed for traumatic lumbar punctures (LPs) in febrile young infants. However, no studies have assessed their diagnostic utility. We sought to determine the proportion of traumatic LPs safely reclassified as low risk for bacterial meningitis using recently derived white blood cell (WBC) and protein correction factors. Methods We retrospectively analyzed traumatic LPs among all febrile infants ≤60 days old at two tertiary paediatric hospitals from 2006 through 2018. Traumatic LPs were defined as ≥10,000 RBCs/mm3. Abnormal cerebrospinal fluid (CSF) WBCs and protein were adjusted downward using a newly derived correction factor (877 red blood cells [RBCs]: 1 WBC), three commonly used correction factors (500 WBCs: 1 RBC; 1,000 WBCs: 1 WBC; peripheral RBCs: WBCs), and a newly derived protein correction factor (1,000 RBCs: 0.011 g/L protein). Results There were 437 traumatic LPs including 357 (82%) with pleocytosis and 4 (0.9%) with bacterial meningitis. Overall, fewer infants were classified as having CSF pleocytosis using 877:1 and 1,000:1 ratios (38% and 43%, respectively), with 100% sensitivity and negative predictive value, and improved specificity (63% for 877:1, 58% for 1,000:1 ratios versus 19% for uncorrected counts). Among infants with pleocytosis, 877:1 and 1,000:1 ratios reclassified 191 (54%) and 171 (48%) as normal with no misclassified bacterial meningitis cases. Ratios of 500:1 and peripheral RBC:WBC misclassified 1 infant that had bacterial meningitis. Corrected CSF protein outperformed uncorrected protein in specificity but did not add diagnostic value following WBC-based correction. Conclusions Correction ratios of 877:1 and 1,000:1 safely reclassified half of all febrile infants ≤60 days. These corrections should be considered when interpreting CSF results of traumatic LPs.

IntroductionMild traumatic brain injury (mTBI) is highly prevalent, especially in children under 6 years. However, little research focuses on the consequences of mTBI early in development. The objective of the Kids’ Outcomes And Long-term Abilities (KOALA) study is to document the impact of early mTBI on children’s motor, cognitive, social and behavioural functioning, as well as on quality of life, stress, sleep and brain integrity.Methods and analysesKOALA is a prospective, multicentre, longitudinal cohort study of children aged 6 months to 6 years at the time of injury/recruitment. Children who sustain mTBI (n=150) or an orthopaedic injury (n=75) will be recruited from three paediatric emergency departments (PEDs), and compared with typically developing children (community controls, n=75). A comprehensive battery of prognostic and outcome measures will be collected in the PED, at 10 days, 1, 3 and 12 months postinjury. Biological measures, including measures of brain structure and function (magnetic resonance imaging, MRI), stress (hair cortisol), sleep (actigraphy) and genetics (saliva), will complement direct testing of function using developmental and neuropsychological measures and parent questionnaires. Group comparisons and predictive models will test the a priori hypotheses that, compared with children from the community or with orthopaedic injuries, children with mTBI will (1) display more postconcussive symptoms and exhibit poorer motor, cognitive, social and behavioural functioning; (2) show evidence of altered brain structure and function, poorer sleep and higher levels of stress hormones. A combination of child, injury, socioenvironmental and psychobiological factors are expected to predict behaviour and quality of life at 1, 3 and 12 months postinjury.Ethics and disseminationThe KOALA study is approved by the Sainte-Justine University Hospital, McGill University Health Centre and University of Calgary Conjoint Health Research Ethics Boards. Parents of participants will provide written consent. Dissemination will occur through peer-reviewed journals and an integrated knowledge translation plan.

This systematic review and meta-analysis assesses the association between experiences of childhood maltreatment and suicide behaviors in children and young adults., Key Points Question What is the association between experiences of childhood maltreatment and suicide behaviors in children and young adults? Findings This systematic review and meta-analysis was based on 79 individual studies with 337 185 unique participants found an association between core types of childhood maltreatment and suicide behaviors in children and young adults. Younger individuals with experiences of sexual abuse who were not under the care of clinicians had higher rates of suicide attempt, and young age was also associated more strongly with suicide ideation. Meaning These findings highlight the need for raising public awareness and incorporating suicide prevention strategies into treatment planning and suggest that a primary focus of psychological treatments should be the amelioration of the effects of adverse childhood experiences., Importance Children and young people’s reports of experiences of adverse childhood events have increased in recent years, and this trend has been associated with an elevated risk for suicide behaviors. However, a systematic review and meta-analysis is needed to confirm the significance of this association in young people. Objective To quantify the association between core types of childhood maltreatment, including sexual, physical, and emotional abuse and/or neglect and suicide behaviors in children and young adults. Data Sources Medline, PsychInfo, Embase, Web of Science, and CINAHL (Cumulative Index to Nursing and Allied Health) databases were searched from January 1, 1980, until December 31, 2019. The reference lists of all the included studies were also checked. Study Selection Quantitative studies that focused on the association between core types of childhood abuse and/or neglect and suicide ideation, plans, and attempts. Data Extraction and Synthesis Data were extracted by 2 independent raters. Publication bias and risk of bias across studies were assessed. Meta-analyses using random-effect models were applied, and heterogeneity was quantified using the I2 statistic. Data were analyzed from January to May 2020 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guidelines. Main Outcomes and Measures The association between core types of childhood maltreatment and suicide behaviors. Results Seventy-nine studies with 337 185 young individuals (mean [SD] age, 15.67 [2.11] years; 63.19% female) were included. The findings demonstrated that sexual abuse (odds ratio [OR], 3.41; 95% CI, 2.90-4.00), physical abuse (OR, 2.18; 95% CI, 1.75-2.71), emotional abuse (OR, 2.21; 95% CI, 1.37-3.57), emotional neglect (OR, 1.93; 95% CI, 1.36-2.74), physical neglect (OR, 1.79; 95% CI, 1.27-2.53), and combined abuse (OR, 3.38; 95% CI, 2.09-5.47) were significantly associated with higher rates of suicide attempts. Core types of childhood maltreatment were also associated with as much as 2.5-fold greater odds for suicide ideation, and sexual abuse with a 4.0-fold increase for suicide plans. Studies based on community samples (β [SE] = −1.68 [0.79]; P = .04) or with lower methodological quality (β [SE] = −2.86 [1.30]; P = .03) were associated more strongly with suicide attempts in those reporting experiences of sexual abuse, whereas young age was associated with both suicide attempts (β [SE] = −0.59 [0.27]; P = .03) and ideation (β [SE] = −0.41 [0.18]; P = .03). Conclusions and Relevance These findings suggest that policy actions should focus on raising public awareness and offering proactive suicide prevention therapies for children and young adults who have experienced abuse and/or neglect.

Background A cornerstone of quality adolescent health care is assuring confidential time for adolescent patients. Adolescents are more likely to seek care and disclose sensitive health information if confidentiality is assured. Several national societies endorse the need for confidential care at all health-related encounters with adolescents. Many adolescents have infrequent contact with the medical system other than unscheduled urgent care in pediatric hospitals. Little is known regarding the effectiveness and feasibility of providing confidential care to adolescents in a tertiary pediatric hospital setting. Objectives We hypothesized that significant variation exists in the frequency and quality of confidential care delivery for adolescents. This study sought to characterize clinician comfort with confidentiality provision as well as identification of potential predicators and barriers to providing confidential care for adolescents in a tertiary, pediatric hospital setting. Design/Methods We undertook a cross-sectional survey among Emergency Department (ED), Hospitalist and Resident physicians at an urban, academic pediatric center. Data was collected using a standardized, self-administered electronic questionnaire. Survey participants responded to multiple-choice questions to characterize their comfort and self-identified barriers to providing confidential care to adolescents. Results Response rate was 91% (n=72/79; 26 ED, 14 Hospitalists, 32 Residents). A majority of respondents were female (69%), under the age of 50 (60%) and within their first 10 years of practice (51%). Forty-seven percent of respondents reported being somewhat/very doubtful that confidential care was being consistently provided to adolescents. Eighty-nine percent of respondents identified barriers to the quantity or quality of confidential care provided. Factors most commonly reported to influence physician decision to provide confidential care were diagnosis (75%), time of visit (45%), and patient age (25%). Among attending physicians 60% reported that they usually/always provide confidential care to adolescents, and 83% ensure that their trainees offer confidential care; whereas only 31% of trainees reported usually/always providing confidential care themselves (p=0.01). Limits of confidentiality were more likely to be explained to adolescent patients compared to their parents (83% vs. 33%; p Conclusion Survey results suggest inadequate provision of confidential care in an academic pediatric hospital, with several potentially modifiable barriers. Confidentiality-specific education likely represents an important intervention to optimize physician comfort and improve the delivery of appropriate confidential care for adolescents.

Background The incidence of children presenting to an Emergency Department (ED) following concussion has increased markedly in recent decades. Headache is the most commonly associated symptom and recent guidelines emphasize the importance of analgesia, yet evidence to inform treatment of post-concussive headache (PCH) is completely lacking. Objectives This study sought to characterize abortive therapies used to treat PCH among physicians in academic pediatric EDs and to determine whether duration of symptoms and/or headache intensity influence treatment strategies. Design/Methods A scenario-based electronic survey was sent to physician members of the Pediatric Emergency Research Canada (PERC) database. Participants were asked questions regarding management when presented with cases of an adolescent presenting to the ED with PCH refractory to appropriate doses of acetaminophen and ibuprofen. Scenarios differed only by duration of symptoms (48-hours versus 1-month post-injury), as well as headache intensity (moderate versus severe). Descriptive statistics are reported. Results Survey response rate was 63% (n/N=137/219). At 48 hours post-injury, 93% of physicians reported that they would initiate treatment for a headache rated as severe. The most commonly selected medications to treat PCH were metoclopramide (72%), an intravenous bolus of normal saline (47%) and non-steroidal anti-inflammatories (NSAIDS; 35%). There was wide variability among second line strategies for refractory pain following first-line treatment. When presented with PTH pain rated moderate in severity, 63% of respondents would change their management compared to severe pain, with 66% no longer offering pharmacologic treatment in the ED and most frequently selecting oral NSAIDS (58%) when electing to initiate treatment. Medication selection was unchanged when presented with a patient reporting severe PCH at 1 month compared to 48-hours post-injury. Conclusion Most physicians would treat pediatric PCH in the ED for a patient reporting severe pain, however, pain rated as moderate was less likely to receive abortive treatment. Metoclopramide was the most frequently selected medication for analgesia for severe pain. Future research should aim to establish the efficacy of this and comparative treatments for PTH in children.

OBJECTIVES Forearm fractures are among the most common pediatric injuries. Procedural sedation is frequently used for analgesia during fracture reduction but requires a prolonged recovery period and can be associated with adverse events. Bier block is a safe alternative for fracture reduction analgesia. This study sought to compare Bier block and procedural sedation for forearm fracture reduction. METHODS We performed a retrospective study of patients aged 6 to 18 years, presenting with forearm fractures requiring closed reduction from June 2012 to March 2014. Outcomes assessed were emergency department length of stay, reduction success rates, adverse events, and unscheduled return visits. RESULTS Overall, 274 patients were included (Bier block, n = 109; procedural sedation, n = 165). Mean length of stay was 82 minutes shorter for Bier block patients (279 vs 361 minutes, P < 0.001). Subanalysis revealed a reduced length of stay among Bier block patients with forearm fractures involving a single bone (286 vs 388 minutes, P < 0.001) and both bones (259 vs 321 minutes, P < 0.05). Reduction success did not differ between Bier block and procedural sedation (98.2% vs 97.6%, P = 0.74). There were no major adverse events in either group, but Bier block patients experienced fewer minor adverse events (2.7% vs 14.5%, P < 0.001). Return visit rates were similar between Bier block and procedural sedation (17.6% vs 16.9%, P = 0.92). CONCLUSIONS Compared with procedural sedation, forearm fracture reduction performed with Bier block was associated with a reduced emergency department length of stay and fewer adverse events, with no differences in reduction success or return visits.

OBJECTIVES: With no nationally-endorsed guidelines and the emergence of newer diagnostic tools, there exists significant variation in the management of febrile infants

Primary Subject area Adolescent Medicine Background The coronavirus (COVID-19) pandemic has had profound effects on adolescent mental health. Beginning in mid-March 2020, public health measures were implemented throughout the province of Quebec, including full school closure and confinement. Previous studies have demonstrated the association between stressful events and the exacerbation of anorexia nervosa (AN), however the association of the COVID-19 pandemic on new AN diagnoses remains unknown. Objectives To assess the incidence and severity of newly diagnosed AN or atypical AN (AAN) cases among adolescents during the COVID-19 pandemic compared to the five preceding years. Design/Methods We performed a retrospective analysis from Jan 1 2015 to Nov 15 2020 of new eating disorder assessments at an urban tertiary pediatric hospital. Baseline demographic information and clinical assessment variables were collected. The primary outcomes were the incidence of de novo AN or AAN diagnoses and hospitalization within 7 days of diagnosis. Event rate time trends were compared during the period of pandemic public health measures (March 2020 to November 2020) to the proceeding 5-years (January 2015 to February 2020) using an interrupted time series and logistic mixed modeling. Results Overall, 353 patients met inclusion criteria during the study period. Median patient age was 15.9 (IQR 13.8-16.9) years, 93% were female, and 65% of patients were diagnosed with atypical AN. For the full cohort at diagnosis, %mBMI was 92% (SD ±15%) and mean weight loss was 11 Kg (SD ±7Kg). In the 5 years preceding the pandemic, there were 4.5 new AN/AAN cases per month with a modest downward trend (ßcoeff=-0.016). During confinement, new diagnoses rose to 8.0/month with a steep upward trend (ßcoeff=1.417, p < 0 .001). Similarly, hospitalizations for new cases increased from 0.8 to 2.6/month with a significant increase in linear tend (ßcoeff -0.012 vs. 0.500, p < 0 .001). Moreover, patients diagnosed during COVID-19 confinement had a shorter duration of symptoms (6 months vs. 10 months, p=0.001), with a higher percentage of body weight loss (19% vs. 16%, p=0.03) at a faster rate (2.3kg/mo vs. 1.5Kg/mo, p=0.001). Bradycardia was more pronounced at diagnosis during the pandemic (55 bpm vs. 62 bpm, p=0.001) with a greater proportion meeting threshold for admission (38% vs. 19%, p=0.001). Conclusion During the COVID-19 confinement, new diagnoses of AN and AAN nearly doubled and hospitalizations for these patients more than tripled. Markers for disease severity were more pronounced and evolved more rapidly. Findings highlight the urgent need for increased community resources during the pandemic, as well as prospective research to understand drivers and prognosis for these patients more effectively.

Exposure to ambient air pollutants may cause adverse health effects. This study sought to assess the association of five major air pollutants concentration levels and number of Emergency Department (ED) visits for ear and mastoid pathology in the large Canadian urban city, Toronto. A time-stratified case-crossover study design was used for the period between April 1, 2004 and December 31, 2015. Daily air pollution data were collected from the National Air Pollution Surveillance Database for carbon monoxide (CO), nitrogen dioxide (NO2), sulfur dioxide (SO2), ground-level ozone (O3) and fine particulate matter (PM2.5). Data were also collected for weather variables. ED visit data were extracted from the National Ambulatory Care Reporting System database. Conditional Poisson models were applied using daily counts of the ED visits. Temperature and relative humidity in the models were represented by natural splines. Independent variables (air pollutants and weather conditions) were lagged by the same number of exposure days, from 0 to 14. The analyses were grouped by strata according to patients’ sex and age, also by seasons. For each studied pollutant, 270 models were derived (15 lags × 18 strata). There were 188,997 ED visits during the 140-month study period. Children under 10 years represented 31.7% of all visits, compared to 53.8% for patients aged 11–60 years, and 14.5% for those above 60 years. Short-term (time lags 4 and 5 days) NO2 exposure was positively associated with number of ED visits for ear and mastoid pathology for children independent of sex. Boys had relative risks (RR) of 1.030 (95% confidence intervals: 1.009–1.053) and 1.033 (1.011–1.055) for ED visits on days 4 and 5 after exposure to NO2 by one interquartile range (IQR = 8.8 ppb), respectively. Girls had RR of 1.046 (1.021–1.071) and 1.039 (1.014–1.064) on days 4 and 5 after exposure to NO2 by the same IQR, respectively. For lag 4, a one unit increase in the calculated air quality health index results in a 1.038 (1.020–1.057), 1.042 (1.017–1.067), and 1.036 (1.014–1.058), for all children, girls, and boys, respectively. In this large urban cohort, number of ED visits for ear and/or mastoid process infections peaked in the acute period following elevated overall air pollution and NO2 specifically, especially among young children.

Background Fever among infants in the first months of life remains among the most common pediatric problems in the Emergency Department (ED) setting. These infants are at increased risk of potentially life-threatening serious bacterial infection (SBI), specifically urinary tract infections (UTIs), bacteremia and bacterial meningitis. Infants with UTIs have historically been considered at increased risk of bacterial meningitis. A presumptive diagnosis of UTI relies entirely upon abnormal urinalysis results in the ED, prompting further invasive testing by lumbar puncture, broad-spectrum antibiotic exposure and hospitalization. However, the necessity of lumbar puncture for infants older than 28 days on the basis of an abnormal urinalysis has been questioned for over a decade and remains controversial. Objectives The objective of this study was to estimate the prevalence of meningitis among well-appearing, febrile infants aged 29-60 days with a positive urinalysis, to inform whether routine CSF testing is required in these patients. Design/Methods We searched MEDLINE and Embase for articles published from January 1, 2000 to July 25, 2018, deliberately limiting the search to recent studies to account for: 1) changing SBI epidemiology; 2) evolving clinical definitions of UTI; and, 3) improvements in urinalysis diagnostic accuracy for febrile young infants. Studies were eligible for inclusion if they reported urinalysis results and SBI prevalence. In the case of studies reporting UTI prevalence but not UA results, or aggregate data only, the corresponding authors were contacted for details. The primary outcome was the prevalence of culture-proven bacterial meningitis among infants with a positive urinalysis. The secondary outcome was the prevalence of bacterial meningitis among infants with a positive urinalysis, defined by either a positive CSF culture or a suggestive history at 1-month post-discharge if CSF testing was not undertaken in the ED. Studies were assessed for bias using the Critical Appraisal Skills Programme (CASP) tool, and prevalence estimates for bacterial meningitis were pooled in a random effects meta-analysis. Results The parent search yielded 2334 unique citations, of which screening by title and abstract identified 106 for full text review. Eleven studies met inclusion and were ultimately included in the final meta-analysis. Seven studies did not have significant risk of bias for the primary outcome of interest. Among 1430 febrile infants with a positive urinalysis and CSF testing performed, 5 infants had culture-proven bacterial meningitis (primary outcome; prevalence 0.33%, 95% CI: 0.1% to 0.79%). Only these same 5 infants were considered to have bacterial meningitis among 2311 infants with a positive urinalysis and meningitis status ascertained by either CSF testing or clinical follow-up (secondary outcome; prevalence 0.24%, 95% CI: 0.08 to 0.54%). Conclusion The prevalence of bacterial meningitis in well appearing febrile infants aged 29-60 days with a positive urinalysis is low. The practice of lumbar puncture in this subgroup of infants should not be guided by urinalysis results alone, but rather on the basis of other clinical criteria. Results should inform decisions regarding invasive testing and aid in shared decision-making.

* Abbreviations: CT — : computed tomography ED — : emergency department TBI — : traumatic brain injury Traumatic brain injuries (TBIs) are among the most common causes of pediatric morbidity and mortality globally. After acute head trauma, children at risk for clinical deterioration must be identified rapidly and accurately, usually in the emergency department (ED) setting. Neuroimaging by computed tomography (CT) for pediatric head trauma proliferated rapidly in the late 1990s1 and remains the diagnostic gold standard for the identification of clinically important TBIs. Therein lies the problem: the risk of missing significant intracranial pathology must be weighted against the risks of radiation-induced malignancy associated with CT imaging.2–4 Reducing CT scans for head-injured children has been the focus of international research5–8 and educational campaigns for nearly 2 decades.9–11 Despite these long-standing efforts, neuroimaging of head-injured children by CT remains elevated.12 MRI presents a potentially attractive alternative to CT that would not expose children to the harmful effects of ionizing radiation. However, the use of MRI for pediatric head trauma has traditionally been limited by the need to remain motionless for a prolonged period and frequently necessitates procedural sedation with its additional inherent risks. A fast MRI protocol that is motion tolerant and sensitive for brain injury would curtail the limitations of conventional MRI. Previous … Address correspondence to Brett Burstein, MDCM, PhD, MPH, Division of Pediatric Emergency Medicine, Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Center, 1001 Decarie Blvd, Montreal, QC H4C 3J1, Canada. E-mail: brett.burstein{at}mail.mcgill.ca

Given the lack of evidence regarding effective pharmacological and non-pharmacological interventions for pediatric mild traumatic brain injury (mTBI) and the resultant lack of treatment recommendations reflected in consensus guidelines, variation in the management of pediatric mTBI is to be expected. We therefore surveyed practitioners across 15 centers in the United States and Canada who care for children with pediatric mTBI to evaluate common-practice variation in the management of pediatric mTBI. The survey, developed by a panel of pediatric mTBI experts, consisted of a 10-item survey instrument regarding providers' perception of common pediatric mTBI symptoms and mTBI interventions. Surveys were distributed electronically to a convenience sample of local experts at each center. Frequencies and percentages (with confidence intervals [CI]) were determined for survey responses. One hundred and seven respondents (71% response rate) included specialists in pediatric Emergency Medicine, Sports Medicine, Neurology, Neurosurgery, Neuropsychology, Neuropsychiatry, Physical and Occupational Therapy, Physiatry/Rehabilitation, and General Pediatrics. Respondents rated headache as the most prevalently reported symptom after pediatric mTBI, followed by cognitive problems, dizziness, and irritability. Of the 65 (61%; [95% CI: 51,70]) respondents able to prescribe medications, non-steroidal anti-inflammatory medications (55%; [95% CI: 42,68]) and acetaminophen (59%; [95% CI: 46,71]) were most commonly recommended. One in five respondents reported prescribing amitriptyline for headache management after pediatric mTBI, whereas topiramate (8%; [95% CI: 3,17]) was less commonly reported. For cognitive problems, methylphenidate (11%; [95% CI: 4,21]) was used more commonly than amantadine (2%; [95% CI: 0,8]). The most common non-pharmacological interventions were rest ("always" or "often" recommended by 83% [95% CI: 63,92] of the 107 respondents), exercise (59%; [95%CI: 49,69]), vestibular therapy (42% [95%CI: 33,53]) and cervical spine exercises (29% [95%CI: 21,39]). Self-reported utilization for common pediatric mTBI interventions varied widely across our Canadian and United States consortium. Future effectiveness studies for pediatric mTBI are urgently needed to advance the evidence-based care.

This cross-sectional analysis of the National Hospital Ambulatory Medical Care Survey studies emergency department visits for suicide attempts and suicidal ideation among US youth between 2007 and 2015.

Importance Fever in the first months of life remains one of the most common pediatric problems. Urinary tract infections are the most frequent serious bacterial infections in this population. All published guidelines and quality initiatives for febrile young infants recommend lumbar puncture (LP) and cerebrospinal fluid (CSF) testing on the basis of a positive urinalysis result to exclude bacterial meningitis as a cause. For well infants older than 28 days with an abnormal urinalysis result, LP remains controversial. Objective To assess the prevalence of bacterial meningitis among febrile infants 29 to 60 days of age with a positive urinalysis result to evaluate whether LP is routinely required. Data sources MEDLINE and Embase were searched for articles published from January 1, 2000, to July 25, 2018, with deliberate limitation to recent studies. Before analysis, the search was repeated (October 6, 2019) to ensure that new studies were included. Study selection Studies that reported on healthy, full-term, well-appearing febrile infants 29 to 60 days of age for whom patient-level data could be ascertained for urinalysis results and meningitis status were included. Data extraction and synthesis Data were extracted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and used the Newcastle-Ottawa Scale to assess bias. Pooled prevalences and odds ratios (ORs) were estimated using random-effect models. Main outcomes and measures The primary outcome was the prevalence of culture-proven bacterial meningitis among infants with positive urinalysis results. The secondary outcome was the prevalence of bacterial meningitis, defined by CSF testing or suggestive history at clinical follow-up. Results The parent search yielded 3227 records; 48 studies were included (17 distinct data sets of 25 374 infants). The prevalence of culture-proven meningitis was 0.44% (95% CI, 0.25%-0.78%) among 2703 infants with positive urinalysis results compared with 0.50% (95% CI, 0.33%-0.76%) among 10 032 infants with negative urinalysis results (OR, 0.74; 95% CI, 0.39-1.38). The prevalence of bacterial meningitis was 0.25% (95% CI, 0.14%-0.45%) among 4737 infants with meningitis status ascertained by CSF testing or clinical follow-up and 0.28% (95% CI, 0.21%-0.36%) among 20 637 infants with positive and negative urinalysis results (OR, 0.89; 95% CI, 0.48-1.68). Conclusions and relevance In this systematic review and meta-analysis, the prevalence of bacterial meningitis in well-appearing febrile infants 29 to 60 days of age with positive urinalysis results ranged from 0.25% to 0.44% and was not higher than that in infants with negative urinalysis results. These results suggest that for these infants, the decision to use LP should not be guided by urinalysis results alone.

Correction factors have been proposed for traumatic lumbar punctures (LPs) in febrile young infants. However, no studies have assessed their diagnostic utility. We sought to determine the proportion of traumatic LPs safely reclassified as low risk for bacterial meningitis using recently derived white blood cell (WBC) and protein correction factors.We retrospectively analyzed traumatic LPs among all febrile infants ≤60 days old at two tertiary paediatric hospitals from 2006 through 2018. Traumatic LPs were defined as ≥10,000 RBCs/mmThere were 437 traumatic LPs including 357 (82%) with pleocytosis and 4 (0.9%) with bacterial meningitis. Overall, fewer infants were classified as having CSF pleocytosis using 877:1 and 1,000:1 ratios (38% and 43%, respectively), with 100% sensitivity and negative predictive value, and improved specificity (63% for 877:1, 58% for 1,000:1 ratios versus 19% for uncorrected counts). Among infants with pleocytosis, 877:1 and 1,000:1 ratios reclassified 191 (54%) and 171 (48%) as normal with no misclassified bacterial meningitis cases. Ratios of 500:1 and peripheral RBC:WBC misclassified 1 infant that had bacterial meningitis. Corrected CSF protein outperformed uncorrected protein in specificity but did not add diagnostic value following WBC-based correction.Correction ratios of 877:1 and 1,000:1 safely reclassified half of all febrile infants ≤60 days. These corrections should be considered when interpreting CSF results of traumatic LPs.

OBJECTIVE:Well-appearing febrile infants with viral illnesses cannot be distinguished from those with occult life-threatening infections. Infants with respiratory viruses are less likely to have serious bacterial infections; however, current risk-stratification criteria predate widespread viral testing and there are limited data to safely inform physician management with this now common diagnostic tool. This study sought to explore the possible impact of respiratory virus testing on clinical decision-making for the management of febrile young infants METHODS:A scenario-based survey was sent to emergency department (ED) and inpatient physicians at all 16 Canadian tertiary pediatric centers. Participants were asked questions regarding management decisions with and without results of respiratory virus testing.RESULTS:Response rate was 78% (n = 330; 190 ED, 140 inpatient). Detection of a respiratory virus reduced admission rates among 3-week-old (83% vs 95%, P < .001) and 5-week-old infants (36% vs 52%, P < .001). Similarly, empirical antibiotic treatment was decreased by detection of a respiratory virus for 3-week-old (65% vs 92%, P < .001) and 5-week-old infants (25% vs 39%, P < .001). Management of 5-week-old infants differed between ED and inpatient physicians, both in the presence and absence of a respiratory virus. There was no consensus among inpatient physicians regarding admission duration for well infants with a detectable respiratory virus and otherwise negative workup.CONCLUSIONS:Respiratory virus testing appears to influence clinical decision-making for febrile infants

Background The evaluation of fever among infants in the first months of life remains one of the most common problems in pediatric healthcare. Approximately 10% harbor potentially life-threatening infections including bacterial meningitis, frequently necessitating invasive cerebrospinal fluid (CSF) testing by lumbar puncture (LP). LPs are often traumatic leading to uninterpretable results and consequently, broad-spectrum antibiotic exposure and prolonged hospitalization. Several strategies have been proposed to identify low-risk infants with traumatic LPs, including recently-derived correction factors, however studies validating the safety and diagnostic utility of such approaches are lacking. Objectives To evaluate the test characteristics and misclassification rates of recently described ratio-based correction methods for the interpretation of CSF results among young infants with traumatic LPs. Design/Methods We undertook a multicenter cohort study of infants aged ≤60 days with a traumatic LP performed at two urban tertiary Pediatric hospitals from 2006 to 2018. Traumatic LPs were defined as CSF specimens with ≥10,000 RBCs/mm3, and for infants aged ≤28 days and 29-60 days, pleocytosis was defined as ≥20 and ≥10 WBC/mm3, respectively, and abnormal protein ≥1.15 and ≥0.89 g/L, respectively. CSF WBCs and protein were adjusted downward for traumatic LPs using RBC ratio-based correction methods (newly derived 877:1, commonly used 500 and 1000:1, peripheral RBC:WBC ratio, and newly derived 1000 RBCs:0.011g/L protein). Descriptive statistics are presented with sensitivity, specificity, and negative predictive values of unadjusted and adjusted CSF for predicting culture-proven bacterial meningitis. Results Of 4,912 LPs meeting inclusion criteria, 437 (8.9%) were traumatic, among which 4 (0.9%) were positive for bacterial meningitis. Compared to uncorrected CSF WBC counts, both 877 and 1000 correction factors classified fewer infants with pleocytosis (38.0% and 42.6% vs 81.7%). These correction factors both maintained 100% sensitivity and 100% negative predictive value, and performed with greater specificity for bacterial meningitis than the uncorrected WBC count (62.6% and 58.0% vs 18.5%). No infants with bacterial meningitis were misclassified using either 877 or 1000:1 correction factors. CSF 500:1 and peripheral RBC:WBC correction ratios performed with the lowest sensitivity and negative predictive values and both misclassified 1 infant with bacterial meningitis. Corrected CSF protein outperformed uncorrected protein in specificity (66.8% vs 33.9%), but did not add diagnostic value when used in combination with WBC correction ratios. Conclusion Correction of the CSF WBC count substantially reduced the number of infants classified with CSF pleocytosis. The newly-derived 877:1 correction factor performed with the best test characteristics, safely reclassifying nearly half of all infants with a traumatic LP. It may be appropriate to use a correction factor in the evaluation of CSF cell counts in traumatic LPs in order to more effectively risk-stratify febrile young infants, reduce antibiotic exposure and admission duration.

Objective To estimate the proportion of pediatric patients with a concussion who received analgesia when presenting with pain to US emergency departments, and to describe the analgesics used. Study design This was a repeated cross-sectional analysis study using the National Hospital Ambulatory Medical Care Survey database of nationally representative emergency department visits from 2007 to 2015. We included children under 18 years old with isolated concussions. Survey weighting procedures were applied to generate population-level estimates and to perform multivariable logistic regression to identify factors associated with analgesic administration. Results There were an estimated 1.54 million isolated concussion visits during the 9-year study period. Pain at presentation was reported frequently (78%), with the majority rated as moderate (36%) or severe (27%). Among all children reporting pain, 42% received no analgesics, including 40% with moderate-to-severe pain intensity. Multivariable analysis found younger age, male sex, and treatment in a nonacademic hospital were all negatively associated with analgesic administration. The medications most frequently administered were acetaminophen (54%), nonsteroidal anti-inflammatories (44%), and opioids (13%). Conclusions Analgesic medications seem to be underused in the treatment of pediatric concussion-related pain. Following acetaminophen and nonsteroidal anti-inflammatories, opioids, which are not recommended for this condition, were the most frequently prescribed analgesics. Further research should establish optimal, consistent, and responsible pain management strategies for pediatric concussions.

BACKGROUND AND OBJECTIVES: International efforts have been focused on identifying children at low risk of clinically important traumatic brain injury in whom computed tomography (CT) neuroimaging can be avoided. We sought to determine if CT use for pediatric head trauma has decreased among US emergency departments (EDs). METHODS: This was a cross-sectional analysis of the National Hospital Ambulatory Care Medical Survey database of nationally representative ED visits from 2007 to 2015. We included children RESULTS: There were an estimated 14.3 million pediatric head trauma visits during the 9-year study period. Overall, 32% (95% confidence interval [CI]: 29%–35%) of children underwent CT neuroimaging with no significant annual linear trend (P trend = .50). Multivariate analysis similarly revealed no difference by year (adjusted odds ratio [aOR]: 1.02; 95% CI: 0.97–1.07) after adjustment for patient- and ED-level covariates. CT use was associated with age ≥2 years (aOR: 1.51; 95% CI: 1.13–2.01), white race (aOR: 1.43; 95% CI: 1.10–1.86), highest triage acuity (aOR: 8.24 [95% CI: 4.00–16.95]; P < .001), and presentation to a nonteaching (aOR: 1.47; 95% CI: 1.05–2.06) or nonpediatric (aOR: 1.53; 95% CI: 1.05–2.23) hospital. CONCLUSIONS: CT neuroimaging did not decrease from 2007 to 2015. Findings suggest an important need for quality improvement initiatives to decrease CT use among children with head injuries.

One-fourth of patients with bronchiolitis seen in US emergency departments between 2007 and 2015 received antibiotics; 70% of them had no documented bacterial coinfection. Macrolides were prescribed in 38% of the cases. Antibiotic use did not decrease after national recommendations against routine prescribing. Efforts are needed to reduce unnecessary and inappropriate antibiotic use for bronchiolitis.

BACKGROUND Distal forearm fractures are among the most common injuries presenting to the pediatric emergency department (PED). Bier block (BB), or intravenous regional anesthesia, is a safe and effective alternative to procedural sedation for closed reduction of forearm fractures; it is associated with fewer adverse events, a shorter length of stay, and reduced costs. BB has long remained relatively underutilized; however, with an increasing emphasis on efficient resource use and patient-centered care, there is renewed interest in this technique. OBJECTIVE Our tertiary PED recently became the first in Canada to successfully implement an active BB program. Subsequently, we developed a mobile BB smartphone app designed to support the sustained departmental use of BB. The app can be used for training and maintenance of competency and incorporates instructional material, as well as our institutional BB protocol, printable medication order sheets, and monitoring forms. The present report describes the development and functionality of the BB smartphone app. METHODS We have described app development and content. App dissemination metrics will be tracked, and user feedback will be analyzed using a self-administered electronic survey. Additionally, app utilization in our PED will be compared with real-world clinical use of BB for fracture reductions. RESULTS The first iteration of the BB app was launched in 2015, with the most recent update in September 2018. App metric tracking is planned for January 2020 until December 2021. CONCLUSIONS We have highlighted how the BB app serves as a paradigm of an educational tool designed not only for individual users but also for supporting the department-wide implementation and dissemination of a new technique. App dissemination and use metrics will be tracked and correlated with clinical use of BB in the PED. INTERNATIONAL REGISTERED REPOR PRR1-10.2196/10363

BACKGROUND The Pediatric Emergency Care Applied Research Network (PECARN) clinical prediction rules identify children at low risk of clinically important traumatic brain injury in whom computed tomography (CT) neuro-imaging can safely be avoided. Since publication in 2009, these rules have been externally validated and are widely used in the Emergency Department (ED) assessment of children with acute head trauma. OBJECTIVES This study sought to determine if the proportion of children receiving CT-imaging in US EDs following head trauma has decreased following the development of PECARN rules. DESIGN/METHODS This study was a cross-sectional study using the National Hospital Ambulatory Care Survey (NHAMCS) database from 2007–2014. NHAMCS collects data on approximately 30,000 nationally representative visits annually to 300 randomly selected U.S EDs. We included all children RESULTS There were 55,253 paediatric visits during the 8-year study period. Among these, 2,783 (5.3% 95%CI 5.0%-5.6%) met inclusion criteria, representing 12,417,725 paediatric head trauma visits. Median patient age was 6 years (IQR 2–13 years), 62% were male, and a majority were evaluated in non-teaching and non-paediatric hospitals (88% and 90%, respectively). Overall, 32% (95%CI 29%-35%) underwent CT neuroimaging. There was no significant difference in CT use after 2009 (31% after vs. 33% before, p=0.41). Multivariate analysis similarly demonstrated no difference after adjustment for patient age, gender, race, insurance provider, paediatric or teaching hospital, admission status and triage acuity (AOR 1.02 after vs. before, 95%CI 0.79–1.32, p=0.85). Factors associated with increased CT use were age ≥2 years (AOR 1.4, 95%CI 1.1–1.9, p=0.02), admission (AOR 5.3, 95%CI 2.2–12.4, p CONCLUSION The use of CT neuro-imaging did not decrease in the 5-year period following derivation of PECARN rules. Findings suggest an important need for quality improvement initiatives to ensure appropriate CT utilization among head injured children.

Paraphimosis is an acute urologic emergency requiring urgent manual reduction, frequently necessitating procedural sedation (PS) in the pediatric population. The present study sought to compare outcomes among pediatric patients undergoing paraphimosis reduction using a novel topical anesthetic (TA) technique versus PS.We performed a retrospective analysis of all patients18years old, presenting to a tertiary pediatric ED requiring analgesia for paraphimosis reduction between October 2013 and September 2016. The primary outcome was reduction first attempt success; secondary outcomes included Emergency Department length of stay (ED LOS), adverse events and return visits. Dichotomous outcomes were analyzed by Chi-square testing and multivariate linear regression was used to compare continuous variables.Forty-six patients were included; 35 underwent reduction using TA, 11 by PS. Patient age and duration of paraphimosis at ED presentation did not differ between groups. There was no difference in first attempt success between TA (32/35, 91.4%) and PS groups (9/11, 81.8%; p=0.37). Mean ED LOS was 209min shorter for TA patients (148min vs. 357min, p=0.001) and remained significantly shorter after controlling for age and duration of paraphimosis (adjusted mean difference -198min, p=0.003). There were no return visits or major adverse events in either group, however, among successful reduction attempts, PS patients more frequently experienced minor adverse events (7/9 vs. 0/32, p0.001).Paraphimosis reduction using TA was safe and effective. Compared to PS, TA was associated with a reduced ED LOS and fewer adverse events. TA could potentially allow more timely reduction with improved patient experience and resource utilization.

Objectives Bier block (BB) is a safe and effective alternative to procedural sedation for analgesia during forearm fracture reductions, yet remains infrequently used in the pediatric emergency department (PED). No standardized methods of BB training have previously been described. The objective of this study was to determine whether a multimodal instructional course increases comfort with BB and translates to increased use of this technique. Methods A novel interdisciplinary simulation and Web-based training course was developed to teach the use of BB for forearm fracture reduction at a tertiary PED. Participants were surveyed pre-/post-training, and at 2 and 6 months regarding their comfort with BB. In parallel, we prospectively assessed the clinical use of BB for children ages 6 to 18 years requiring closed reduction of forearm fractures during the 24-month post-course period. Results Course participation included 26 physicians and 12 nurses. Survey response rate was 100%. Course participation increased both comfort (10% pre-training v. 89% post-training, ppp Conclusions A novel combined simulation and Web-based training course increased comfort and willingness to use BB and was associated with increased use of this technique for forearm fracture reduction in the PED.

This epidemiology study uses National Hospital Ambulatory Medical Care Survey data to characterize trends in use of radiography to diagnose bronchiolitis in children younger than 24 months evaluated in emergency departments between 2007 and 2015.

Rationale: Although connexin changes are important for the ventricular arrhythmic substrate in congestive heart failure (CHF), connexin alterations during CHF-related atrial arrhythmogenic remodeling have received limited attention. Objective: To analyze connexin changes and their potential contribution to the atrial fibrillation (AF) substrate during the development and reversal of CHF. Methods and Results: Three groups of dogs were studied: CHF induced by 2-week ventricular tachypacing (240 bpm, n=15); CHF dogs allowed a 4-week nonpaced recovery interval after 2-week tachypacing (n=16); and nonpaced sham controls (n=19). Left ventricular (LV) end-diastolic pressure and atrial refractory periods increased with CHF and normalized on CHF recovery. CHF caused abnormalities in atrial conduction indexes and increased the duration of burst pacing-induced AF (DAF, from 22±7 seconds in control to 1100±171 seconds, P P P Conclusions: CHF causes atrial connexin changes, but these are not essential for CHF-related conduction disturbances and AF promotion, which are rather related primarily to fibrotic interruption of muscle bundle continuity.

There are many similarities between atrial effects of atrial tachycardia remodeling (ATR) and vagal nerve stimulation (VS): both promote atrial fibrillation (AF), reduce atrial effective refractory period (AERP) and AERP rate accommodation, enhance AERP heterogeneity, and increase inward-rectifier K+ current.This study sought to compare the consequences of ATR and VS at similar levels of AERP abbreviation in dogs.ATR dogs (n = 6) were subjected to 7-day atrial tachypacing at 400 beats/min, with radiofrequency-induced atrioventricular block and ventricular demand pacing (80 beats/min) to control ventricular response. VS was applied in 6 matched dogs with stimulation parameters selected to produce similar mean AERP values to ATR dogs.ATR and VS produced similarly short AERPs (79 +/- 12 and 80 +/- 12 ms, respectively), AERP rate-adaptation loss, and AERP heterogeneity increases. Although both ATR and VS increased AF duration, VS was significantly more effective in AF promotion, with mean AF duration of 992 +/- 134 seconds, versus 440 +/- 240 seconds (P.05) under ATR. The greater AF-promoting effect of VS was associated with greater mean dominant frequency values during AF (11.7 +/- 1.8 versus 10.0 +/- 1.3 Hz ATR, P.05). VS greatly enhanced the spatial dominant frequency variability, increasing the coefficient of variation to 15.2 +/- 1.9 Hz, versus 8.9 +/- 1.5 Hz for ATR (P.05), primarily by increasing the per-dog maximum dominant frequency (15.4 +/- 0.6 Hz versus 12.5 +/- 0.6 for ATR, P.01).For matched AERP values, VS promotes AF more strongly than ATR. Despite similar AERP changes, VS produces considerably greater increases in dominant frequencies, particularly maximum values, consistent with previous suggestions that inward-rectifier K+ current enhancement is particularly effective at accelerating and stabilizing spiral wave rotors that maintain AF.