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Generalized bullous fixed drug eruptions (GBFDEs) are rare in the paediatric population. We present the case of a 7-year-old girl with GBFDE believed to be secondary to oral ibuprofen, who experienced rapid resolution of lesions and cessation of blistering with a 3-week course of oral cyclosporine. To the best of our knowledge, this is the first report of a paediatric case of GBFDE treated with cyclosporine. In our report, we review published cases of GBFDE in children, and all adult cases managed with cyclosporine.

Objectives The transfer of children from community emergency departments (EDs) to tertiary care pediatric EDs for investigations, interventions, or a second opinion is common. In order to improve health care system efficiency, we must have a better understanding of this population and identify areas for education and capacity building. Methods We conducted a retrospective chart review of all patients (aged 0-17 years) who were transferred from community ED to a pediatric ED from November 2013 to November 2014. The primary outcome was the frequency of referred patients who were discharged home from the pediatric ED. Results Two hundred four patients were transferred from community EDs in the study period. One hundred thirteen children (55.4%) were discharged home from the pediatric ED. Presence of inpatient pediatric services (P = 0.04) at the referral hospital and a respiratory diagnosis (P = 0.03) were independently associated with admission to the children's hospital. In addition, 74 patients (36.5%) had no critically abnormal vital signs at the referral hospital and did not require any special tests, interventions, consultations, or admission to the children's hospital. Younger age (P = 0.03), lack of inpatient pediatric services (P = 0.04), and a diagnosis change (P = 0.03) were independently associated with this outcome. Conclusions More than half of patients transferred to the pediatric tertiary care ED did not require admission, and more than one third did not require special tests, interventions, consults, or admission. Many of these patients were likely transferred for a second opinion from a pediatric emergency medicine specialist. Education and real-time videoconferencing consultations using telemedicine may help to reduce the frequency of transfers for a second opinion and contribute to cost savings over the long term.

Education during the clinical clerkship years requires active learning. Students cannot be bystanders, but rather they must discover, apply, and integrate new information in a clinical context. We present a novel model of case-based learning that encourages active learning, focusing on problem-solving skills for the clinical environment.

IntroductionTechnological and medical advances have led to a growing population of children with medical complexity (CMC) defined by substantial medical needs, healthcare utilisation and morbidity. These children are at a high risk of missed, fragmented and/or inappropriate care, and families bear extraordinary financial burden and stress. While small in number (Methods and analysisOur primary objective is to evaluate the CCKO intervention using a randomised waitlist control design. The waitlist approach involves rolling out an intervention over time, whereby all participants are randomised into two groups (A and B) to receive the intervention at different time points determined at random. Baseline measurements are collected at month 0, and groups A and B are compared at months 6 and 12. The primary outcome is the family-prioritized Family Experiences with Coordination of Care (FECC) survey at 12 months. The FECC will be compared between groups using an analysis of covariance with the corresponding baseline score as the covariate. Secondary outcomes include reports of child and parent health outcomes, health system utilisation and process outcomes.Ethics and disseminationResearch ethics approval has been obtained for this multicentre RCT. This trial will assess the effect of a large population-level complex care intervention to determine whether dedicated key workers and coordinated care plans have an impact on improving service delivery and quality of life for CMC and their families.Trial registration numberNCT02928757.

BACKGROUND Resident continuity clinics (RCCs) provide an opportunity for residents to gain experience with longitudinal care in an outpatient setting. RCCs have become a part of almost all recognized residency training programs across specialties in North America. However, the structure, function, and effectiveness of RCCs vary widely. OBJECTIVES To determine resident perspective on the structure and function of paediatric RCCs and investigate which factors were associated with resident satisfaction with paediatric RCCs. DESIGN/METHODS A qualitative survey of Canadian paediatric resident trainees was conducted to assess their RCC experience. The survey was administered through the REDCap© database and distributed through the Canadian Pediatric Program Directors Consortium in June-July 2016. RESULTS There were 127 respondents. Approximately 40% participated in RCCs. The majority of respondents were likely to recommend RCCs to other programs. The most common structure reported was a monthly half-day clinic overseen by an academic paediatrician. Referrals were mainly from inpatient wards, emergency department or family physicians. The majority of residents were satisfied with their experience (n=33, 71.7%). Participants in resident-run RCCs had more positive views compared to participants in staff-run RCCs (all U≥25.0, p≤0.009). Contributing factors to a positive RCC experience included patient-resident continuity, being viewed as the main care provider, and learning to make independent management decisions. CONCLUSION Almost all respondents felt that RCCs should be part of paediatric residency training. Further research is needed to determine the optimal structure for paediatric RCCs. Understanding our current training environment is an important precursor for informing program leadership and national policymakers who wish to improve ambulatory care training

1. Erin R. Peebles, MD, FRCPC* 2. Tamara A. VanHooren, MD, FRCPC* 3. Anna C. Gunz, MD, FRCPC* 4. Marina I. Salvadori, MD, FRCPC* 1. *Western University, London, Ontario, Canada A 32-day-old boy presents to the emergency department with a 12-hour history of poor feeding and lethargy. The child was born at 34+1 weeks and spent 2 weeks in the NICU, where he was fed infant ready-made formula by gavage feeding as he gradually increased his suckling. He was discharged 5 days before his presentation. On assessment, he is noted to be pale, hypotonic, and irritable. He is hypothermic, with a rectal temperature of 97.0°F (36.1°C). His heart rate is 150 beats/min, and capillary refill is noted to be appropriate. A full sepsis evaluation is performed. White blood cell count is 20,000/μL (20×109/L), hemoglobin is 9.3 g/dL (93 g/L), and platelet count is 63×103/μL (63×109/L). Cerebrospinal fluid analysis shows a white blood cell count of 10,000/μL (10×109/L), a protein level of 1,650 g/dL (16,500 g/L), and a glucose level of 5.6 mg/dL (0.31 mmol/L). He is started on ampicillin, cefotaxime, and acyclovir. Within 5 hours of admission, he becomes mottled and tachycardic (190 beats/min), with intermittent apneas requiring PICU admission. Gram-negative bacilli are identified on gram stain in the cerebrospinal fluid (CSF) 6 hours after presentation; the acyclovir is stopped, and the …

First-generation cephalosporins and antistaphylococcal penicillins are typically the first choice for treating skin and soft tissue infections (SSTI), but are not effective for infections caused by methicillin-resistant Staphylococcus aureus (MRSA). It is currently unclear what percentage of SSTIs is caused by community-associated MRSA in different regions in Canada.To determine the incidence of MRSA in children presenting to a pediatric emergency department with SSTI, and to determine which antibiotics were used to treat these infections.All visits to a pediatric emergency department were reviewed from April 15, 2010 to April 14, 2011. Diagnoses of cellulitis, abscess, impetigo, folliculitis and skin infection (not otherwise specified) were reviewed in detail to determine whether a culture was taken and which antibiotic was prescribed.There were 367 cases of SSTI diagnosed over the study period. Forty-five (12.3%) patients had lesions that were swabbed for culture and sensitivity. S aureus was the most common organism found, with 14 (66%) methicillin-sensitive cases and seven (33%) methicillin-resistant cases. Of the seven cases of MRSA identified, only one patient had clear risk factors for hospital-acquired MRSA. First-generation cephalosporins were initially prescribed for 280 (76%) patients.The overall incidence of MRSA in the population presenting to a pediatric emergency department in Newfoundland and Labrador appeared to be low, although only a small percentage of infections were cultured. At this time, there appears to be no need to change empirical antibiotic coverage, which remains a first-generation cephalosporin.Les céphalosporines de première génération et les pénicillines antistaphylococciques sont généralement le traitement de première intention des infections des tissus cutanés et des tissus mous (ITCM), mais ne sont pas efficaces contre les infections causées par leDéterminer l’incidence de SARM chez les enfants qui consultent à une salle d’urgence pédiatrique en raison d’une ITCM, ainsi que les antibiotiques utilisés pour traiter ces infections.Les chercheurs ont analysé toutes les visites à la salle d’urgence effectuées entre le 15 avril 2010 et le 14 avril 2011. Ils ont examiné attentivement les diagnostics de cellulite, d’abcès, d’impétigo, de folliculite et d’infection cutanée (non autrement spécifiée) pour déterminer si une culture avait été effectuée et quel antibiotique avait été prescrit.Au total, 367 cas d’ITCM ont été diagnostiqués pendant la période de l’étude. Quarante-cinq patients (12,3 %) avaient des lésions qui avaient fait l’objet d’une analyse de culture et de sensibilité. LeL’incidence globale de SARM au sein de la population qui consulte à une salle d’urgence pédiatrique de Terre-Neuve-et-Labrador semble faible, même si seulement un petit pourcentage de ces infections a fait l’objet d’une culture. À l’heure actuelle, il ne semble pas nécessaire de modifier la couverture antibiotique empirique, soit une céphalosporine de première génération.

In recent years, the term ‘cyberbullying’ has become relatively common in the media, often cited as a contributor to several high-profile suicides of young adolescents. A review of the literature published in 2010 (1) showed that no articles referenced ‘cyberbullying’ before 2004, confirming its recent emergence. There is no universally accepted definition; however, most definitions describe a repeated activity conducted via electronic means with an intent to cause psychological torment. Cyberbullying can take many forms. It can include harassment (insults or threats), spreading rumours, impersonation, outing and trickery (gaining an individual’s trust and then using online media to distribute their secrets) or exclusion (excluding an individual from activities). These activities can be performed via e-mail, instant messaging, text message, social networking sites such as Facebook or Tumblr, and other websites (2). The prevalence of cyberbullying and cyberbullying victimization is difficult to accurately determine. The variable definitions and the typical challenges of accounting for self-reported activities contribute to this difficulty. A study conducted in the United States involving nearly 4000 students in grades 6 to 8 showed that in the preceding two months, 11% of the students had been cyberbully victims, 4% reported acting as cyberbullies, and 7% had been both a cyberbully and a cyberbully victim (3). In a Canadian study published in 2010 involving >2000 students in grades 6, 7, 10 and 11, 25% reported experiencing a cyberbullying event in the previous three months. Eight percent reported acting as a cyberbully, and 25% reported being both a cyberbully and cyberbully victim. The authors postulated that the rates were higher in their study because they did not describe the activity as ‘cyberbullying’, but instead asked about specific behaviours (name calling, threatening, spreading rumours, etc) (4). Cyberbullying differs from traditional bullying in several key ways. Perhaps the most obvious is that it requires some degree of technical expertise – children who are not ‘plugged in’, either through computer, cell phone or video games, do not partake in cyberbullying, either as bullies or victims. Cyberbullying also provides anonymity to the bully not possible with traditional bullying. Because of this, bullies cannot see the reactions of their victims and studies have shown that they feel less remorse (5). Cyberbullying is opportunistic because it causes harm with no physical interaction, little planning and small chance of being caught. Despite this, 40% to 50% of cyberbully victims report knowing who their tormentor is (3). Cyberbullying can be more pervasive than traditional bullying. While traditional bullying is generally limited to school and home is a reprieve, victims of cyberbullying can be reached anywhere, anytime, and the potential audience is huge. This is compounded by the fact that there is a lack of supervision. With traditional bullying, teachers are regarded as enforcers. With cyberbullying, there is no clear authority, and children express reluctance to tell adults for fear of losing computer privileges or being labelled as an informer (6). Studies have also shown that there is a large amount of overlap among traditional bullying and cyberbullying behaviours. Children who act as cyberbullies report high rates of being a traditional bully, and are also traditional and cyberbully victims. Cyberbully victims report high rates of traditional victimization, but are also involved in traditional bullying and cyberbullying activities (3,7). The relationship between traditional bullying and cyberbullying is not well understood, but what is clear about children involved in cyberbullying is that they report high rates of Internet use. Juvonen and Gross (8) found that cyberbully victims were significantly more likely to be heavy Internet users (>3 h/day) than noncyberbully victims (OR 1.45). A study by Mishna et al (4) published in 2012 found that cyberbullies, cyberbully victims and cyberbully/victims were significantly more likely to use the computer for >2 h/day versus students who were not involved in cyberbullying activities.

Scleredema adultorum is a rare condition characterised by progressive collagen and mucin deposition in the skin. While the aetiology has not been clearly delineated, the condition is often associated with common infections. The current report describes a previously healthy 16-year-old boy who presented with 3 weeks of progressive neck swelling and skin induration. He had evidence of both active streptococcal and Ebstein-Barr virus (EBV) infections. Skin biopsy confirmed the diagnosis of scleredema. The patient was treated for his streptococcal infection, but otherwise managed conservatively. Clear improvement in the signs and symptoms was seen at a 3-month follow-up appointment. Scleredema can be a complication of streptococcal infection but to our knowledge has not been reported in association with EBV. It should be considered in the differential diagnosis of any patient presenting with cutaneous/subcutaneous induration and swelling of the face and/or neck.