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Point-of-care ultrasonography is increasingly being used to facilitate accurate abstract and timely diagnoses and to guide procedures. It is important for pediatric emergency medicine (PEM) physicians caring for patients in the emergency department to receive adequate and continued point-of-care ultrasonography training for those indications used in their practice setting. Emergency departments should have credentialing and quality assurance programs. PEM fellowships should provide appropriate training to physician trainees. Hospitals should provide privileges to physicians who demonstrate competency in point-of-care ultrasonography. Ongoing research will provide the necessary measures to define the optimal training and competency assessment standards. Requirements for credentialing and hospital privileges will vary and will be specific to individual departments and hospitals. As more physicians are trained and more research is completed, there should be one national standard for credentialing and privileging in point-of-care ultrasonography for PEM physicians.

Introduction: Bile duct involvement is a key finding of primary biliary cholangitis (PBC). The aim of this study was to evaluate baseline ductopenia and disease progression., Methods: Retrospective longitudinal histological follow-up of treatment-naive patients with PBC., Results: Eighty-three patients were included, with ductopenia correlated to fibrosis stage at baseline. The cumulative incidence of severe ductopenia remained stable after 5 years, whereas fibrosis continually increased over time. Baseline AST-to-Platelet Ratio Index and elevated alkaline phosphatase >2 times the normal with abnormal bilirubin were associated with ductopenia progression., Discussion: Bile duct injury does not seem to follow the same course as fibrosis in PBC., (Copyright © 2022 Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.)

Background: Dental infections are frequently encountered in the emergency department (ED), with periapical abscesses being among the most painful. Traditional pain management strategies include local anesthetic injections, oral analgesics, and intravenous opioids., Objectives: We sought to identify an alternative pain management strategy with early use of dexamethasone as adjunct to conventional therapies for inflammation and pain at the site of infection., Methods: We conducted a prospective, randomized, double-blind, placebo-controlled study comparing the analgesic effect of dexamethasone and placebo in ED patients with periapical abscess during a 2-year timeframe at two urban academic EDs. Adult patients presenting with physical examination findings consistent with a diagnosis of periapical abscess were randomized to receive oral dexamethasone or an identical placebo. Pain was assessed using the verbal numeric scale in person at discharge and via telephone at 12, 24, 48, and 72 h after discharge from the ED., Results: Seventy-three patients were enrolled, with 37 receiving dexamethasone and 36 receiving placebo. Follow-up pain scores were obtained for 52 patients at 12, 24, 48, and 72 h. Ten patients from the dexamethasone group and 11 from placebo group were lost to follow-up. Patients who received dexamethasone reported a greater reduction in pain at 12 h compared with the placebo group (p = 0.029). Changes in pain scores from baseline and at 24, 48, and 72 h were not statistically significant. No adverse events were reported., Conclusions: Single-dose dexamethasone as adjunct to conventional medical management for pain caused by periapical abscess demonstrated a significant reduction in pain 12 h post treatment compared with placebo., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: To evaluate the prospective association between eating disorders, disordered eating behaviors, and sleep disturbances in young adults., Methods: We used prospective cohort data of young adults aged 18-26 from the National Longitudinal Study of Adolescent to Adult Health (N = 12,082). Self-reported exposures of interest (at 18-26 years) included (1) an eating disorder diagnosis proxy; disordered eating behaviors such as (2) restrictive eating behaviors including fasting/skipping meals, (3) compensatory behaviors including vomiting, laxatives/diuretics, or weight loss pills; and (4) loss of control/overeating. Self-reported sleep disturbances at 7-year follow-up included trouble falling or staying asleep., Results: In negative binomial regression models, all four exposures predicted both sleep disturbance outcomes at 7-year follow-up, when adjusting for demographic covariates and baseline sleep disturbances. When additionally adjusting for baseline depressive symptoms, the associations between eating disorder diagnosis proxies and trouble falling (incidence rate ratio [IRR] 1.24; 95% CI 1.05-1.46) and staying (IRR 1.16; 95% CI 1.01-1.35) asleep remained statistically significant; however, the associations between eating behaviors and sleep disturbances were attenuated., Conclusions: Eating disorders in young adulthood predict sleep disturbances at 7-year follow-up. Young adults with eating disorders or who engage in disordered eating behaviors may be assessed for sleep disturbances., Level Iii: Evidence obtained from well-designed cohort or case-control analytic studies.

Background: Emergency care in the United States faces notable challenges with regard to children. In some jurisdictions, available resources are not sufficient to meet local needs. Physicians with specialty training in pediatric emergency care are largely concentrated in children's medical centers within larger urban areas. Rural emergency facilities, which are more likely to face ongoing staffing shortages in all specialties, are particularly deficient in pediatric emergency medicine (PEM) physicians. This paper addresses challenges in distribution of pediatric emergency care specialists into suburban and rural health care facilities, and proposes potential local and regional solutions to improve pediatric emergency care capabilities as well as to enhance disaster response in children., Objectives: The American College of Emergency Physicians (ACEP) committee on PEM generated the objective to study and explore methods and strategies to address current challenges and shortcomings in the distribution of pediatric emergency physicians and to develop recommendations to improve access to emergency pediatric expertise in all care settings. A sub-committee was formed to generate a written report followed by full committee input. The content was reviewed by the ACEP Board of Directors., Discussion: Pediatric emergency physicians are certified either by the American Board of Emergency Medicine or the American Board of Pediatrics (ABP) depending on whether their training occurred through the emergency medicine or a pediatric residency program. ABP-certified PEM that account for the majority of PEM physicians, remain largely concentrated in urban tertiary pediatric care centers, primarily children's hospitals. By contrast to the resources, the majority of pediatric patients receive emergency care in emergency departments (EDs) outside this setting. The goal of our recommendations is to help regionalize PEM expertise, allowing sharing of such resources with facilities that have traditionally not had access to PEM expertise. Financial or low number of pediatric cases likely contributed to lack of PEM resources in suburban and rural EDs, although a significant factor for lack of access to ABP-certified PEM physicians may be local privilege and practice restrictions. Expanding the scope of practice for ABP-certified PEM physicians beyond traditionally assigned arbitrary age limits to include selective adult patients has the potential to alleviate credentialing barriers and offset the financial and volume concerns while enhancing preparedness efforts, resource utilization, and access to specialized pediatric emergency care., Conclusion: Recognition that the training of ABP-certified PEM physicians allows for these individuals to safely care for selective adult patients with common disease patterns that extend beyond traditionally assigned arbitrary pediatric age limits has the potential to improve resource dissemination and utilization, allowing for greater access to pediatric emergency physicians in currently underserved settings., Competing Interests: The authors have no conflict of interest., (© 2020 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of the American College of Emergency Physicians.)

This article provides recommendations for pediatric readiness, scope of services, competencies, staffing, emergency preparedness, and transfer of care coordination for urgent care centers (UCCs) and retail clinics that provide pediatric care. It also provides general recommendations for the use of telemedicine in these establishments. With continuing increases in wait times and overcrowding in the nation's emergency departments and the mounting challenges in obtaining timely access to primary care providers, a new trend is gaining momentum for the treatment of minor illness and injuries in the form of UCCs and retail clinics. As pediatric visits to these establishments increase, considerations should be made for the type of injury or illnesses that can be safely treated, the required level training and credentials of personnel needed, the proper equipment and resources to specifically care for children, and procedures for safe transfer to a higher level of care, when needed. When used appropriately, UCCs and retail clinics can be valuable and convenient patient care resources.

Objective: Congenital Dermal Melanocytosis (CDM) can be difficult to differentiate from contusions. The need for a prompt and accurate diagnosis is best illustrated in cases where child abuse and maltreatment is of concern. Transcutaneous bilirubin (TCB) spectrophotometry has been well established to measure bilirubin under the skin for jaundice in infants. The use of TCB spectrometry has not been used to identify or differentiate contusions from CDM. We hypothesized that bilirubin, a degradation product of hemoglobin, would be elevated in contusions but not in CDM thus demonstrating the efficacy of a novel diagnostic technique to compliment or improve on physical assessment alone., Methods: Pilot study with thirty-seven infants and children noted to have CDM and fifty-six infants, children and adults with contusions underwent measurement of their lesion with TCB spectrometry. In each patient, the affected skin was scanned along with the adjacent unaffected native skin allowing an internal control for individual pigment variation., Results: TCB measurements of CDM resulted in lower transcutaneous bilirubin values that were not significantly different from adjacent native skin pigmentation. This was in contrast to cutaneous contusions, which resulted in a higher measured value (mean 5.01 mg/dL) compared to adjacent native tissue (1.24 mg/dL) demonstrating a four-fold increase in measurement at the lesion site (P < 0.001). Direct comparison of a ΔTCB value (lesion measurement minus the adjacent tissue) demonstrated a significantly higher value in contusions compared to CDM with a mean value of 3.77 and 0.12 mg/dL, respectively (P < 0.001)., Conclusions: TCB Spectrometry as a novel diagnostic technique has the potential to discern contusions from CDM and may therefore have the ability to compliment the use of physical assessment alone., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objective: There is a growing demand for interpreters in the cancer setting. Interpreters, the link to quality care for limited English proficiency patients, face many psychosocial stressors in their work. This project assessed interpreters' experiences of stress and piloted a resiliency program to help interpreters cope with stressors., Methods: From 2013 to 2014, we pilot tested a targeted resiliency program with interpreters from three Boston-based hospitals. In Phase 1, we conducted five focus groups (n = 31) to identify interpreters' psychosocial needs. In Phase 2, we developed and tested a 4-h group program with 29 interpreters (response rate = 90%; 69% female, 54% Hispanic, 85% born outside of the U.S.)., Results: Phase 1. Stressors were patient-based (seeing young patients decline), interactions with medical team (unsure of role), and systems-based (appointment unpredictability). Phase 2. At baseline interpreters reported low abilities to cope with stress (measured by the Measure of Current Status (MOCS-A)). At 4-week follow-up we found improvements in job satisfaction (p = .02; Cohen's d = .41) and declines in sick days (p = .08; Cohen's d = .38). Stress reactivity (MOCS-A) improved; specifically participants reported feeling more assertive about their needs (p = .10; Cohen's d = .30) and more able to relax at will (p = .10; Cohen's d = .35)-important mechanisms to lower distress., Conclusions: We piloted a resiliency program for medical interpreters in cancer care. We found that interpreters experience distress and have low coping skills. This program resulted in improved work factors and stress reactivity. Future research should include further implementation and testing in a larger, randomized trial.Copyright © 2016 John Wiley & Sons, Ltd., (Copyright © 2016 John Wiley & Sons, Ltd.)

Background: The Emergency Medical Services for Children State Partnership Program, as well as the Institute of Medicine report on pediatric emergency care, encourages recognition of emergency departments (EDs) through categorization and verification systems. Although pediatric verification programs are associated with greater pediatric readiness, clinical outcome data have been lacking to track the effects and patient-centered outcomes by implementing such programs., Objective: To describe pediatric mortality rates prior to and after implementation of a pediatric emergency facility verification system in Arizona., Methods: This was a cross-sectional study conducted using data from ED visits between 2011 and 2014 recorded in the Arizona Hospital Discharge Database. The primary outcome measure was the mortality rate for ED visits by patients under 18 years old. Rates were compared prior to and after facility certification by the Arizona Pediatric Prepared Emergency Care program., Results: The total number of ED visits by children during the study period was 1,928,409. Of these, 1,127,294 were at facilities undergoing certification. For hospitals becoming certified, overall ED mortality rates were 35.2 deaths/100,000 ED visits (95% confidence interval [CI] 29.5-41.7) in the precertification analysis and 34.4 deaths/100,000 ED visits (95% CI 30.4-38.9) in the postcertification analysis. The injury-related ED visit mortality rate for certified hospitals showed a decrease from 40.0 injury-related deaths/100,000 ED visits (95% CI 28.6-54.4) in the precertification analysis to 25.8 injury-related deaths/100,000 ED visits (95% CI 18.7-34.8) in the postcertification analysis., Conclusion: The implementation of the Arizona pediatric ED verification system was associated with a trend toward lower mortality. These results offer a platform for further research on pediatric ED preparedness efforts and their effects on improved patient outcomes., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: In 2012, a voluntary certification program called Pediatric Prepared Emergency Care (PPEC) was established in Arizona as a system for pediatric emergency preparedness. Emergency medicine and pediatric specialists generated basic, intermediate, and advanced designation criteria. Dedicated medical management by a pediatric emergency specialist is required for advanced centers. Designation follows a site visit, review, and approval by the subcommittee and the Arizona Chapter of the American Academy of Pediatrics., Discussion: Arizona has 5 designated pediatric emergency departments, all of which are in the southeast part of the state. Therefore, a designation system was implemented so that all emergency departments statewide can receive more training, support, and supervision of pediatric care. The goal was to create a self-sustaining network with active participation from member institutions while fostering the pediatric commitment. Since its inception, 39 hospitals and 5 tribal facilities have joined PPEC, equating to 51% of Arizona's emergency facilities. Of the hospitals, 7 are advanced, 6 are intermediate, and 17 are basic centers. In 2015, all of the 9 sites due for recertification were recertified. The multiple tiers allow for mutual accountability, sharing of resources, and improved quality of care for pediatrics in emergency departments statewide., Conclusion: PPEC enhances the quality of pediatric emergency preparedness by means of voluntary certification. The primary limitations are sustainability and funding, because an Emergency Medical Services for Children grant has offset the cost until now. The number of member facilities in this designation system is continually growing, and universal recertification shows sustainability., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Appendicitis is uncommon in children <6 months old, with few observational studies reporting cases of children younger than 5 years old with the diagnosis. The classic periumbilical pain that migrates to the right lower quadrant, followed by the onset of fever and vomiting, is present in approximately 40% of pediatric patients under 12 years of age with appendicitis., Case Report: A 4-month-old girl presented to the Emergency Department (ED) with acute onset of grunting, pallor, fussiness, emesis, and diarrhea. The patient was initially afebrile, tachycardic, and tachypneic with a soft, nondistended, nontender abdomen and active bowel sounds. The patient became febrile, with a maximum temperature of 39.3°C (102.7°F), and remained tachycardic despite receiving fluids and antipyretics. Laboratory studies were notable for mild dehydration and sterile pyuria. Chest x-ray study was negative for infectious etiologies. Initial abdominal ultrasound found no clear etiology of the patient's symptoms. The patient was admitted to inpatient pediatrics for dehydration, fever, and presumed pyelonephritis. Twenty-four hours later the patient's abdomen became distended and diffusely tender to palpation, with obstipation and increasing episodes of emesis. Abdominal x-ray study demonstrated mild gaseous distension of multiple bowel loops with repeat abdominal ultrasound notable for a focal 8-mm, noncompressible hyperemic structure in the right lower quadrant. The patient was taken to the operating room for a laparoscopic appendectomy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Appendicitis is a potentially life-threatening condition. In the infant population it frequently presents without the features typically seen in older children., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Radiologic studies are a vital component in the workup and diagnosis of disease. An appropriate radiographic study will accurately rule in or rule out disease with the least possible harm. Special considerations are necessary for the imaging of children. Current trends in pediatric imaging support the increased use of ultrasound and magnetic resonance imaging to decrease radiation exposure. In this review, we highlight some of the emerging concepts in the radiographic workup of pediatric disease, with a focus on decreasing ionizing radiation, increasing ultrasound use, and using clinical decision rules to identify children who do not need imaging., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Child abuse presents commonly to emergency departments. Emergency providers are confronted with medical, social, and legal dilemmas with each case. A solid understanding of the definitions and risk factors of victims and perpetrators aids in identifying abuse cases. Forensic examination should be performed only after the child is medically stable. Emergency providers are mandatory reporters of a reasonable suspicion of abuse. The role of the emergency provider is to identify abuse, facilitate a thorough investigation, treat medical needs, protect the patient, provide an unbiased medical consultation to law enforcement, and to provide an ethical testimony if called to court., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Susac syndrome is a rare condition involving the brain, retina, and cochlea. Electroencephalogram (EEG) findings from published case reports show mainly generalized slowing., Case Report: A 30-year-old man presented with acute onset of superior vision loss, unsteady gait, and hearing loss. This was accompanied by short-term memory loss and behavioral and mood changes. MRI showed multiple white matter hyperintensities. The EEG showed frontal intermittent rhythmic delta activity. A diagnosis of Susac syndrome was made and treatment with methylprednisolone, ASA, and Nimodipine was instituted. At one-year follow-up, bilateral hearing loss, mild visual impairment, and mood changes were still apparent., Conclusions: Frontal intermittent rhythmic delta activity can be seen in Susac syndrome.

Overexpression of the BltD gene in Bacillus subtilis causes acetylation of the polyamines spermidine and spermine. BltD is co-regulated with another gene, Blt, which encodes a multidrug export protein whose overexpression facilitates spermidine export [Woolridge, Vazquez-Laslop, Markham, Chevalier, Gerner and Neyfakh (1997) J. Biol. Chem. 272, 8864-8866]. Here we show that BltD acetylates both spermidine and spermine at primary propyl amine moieties, with spermine being the preferred substrate. In the presence of saturating concentrations of acetyl CoA, BltD rapidly acetylates spermine at both the N1 and N12 positions. The Km (app) values for spermine, spermidine and N1-acetylspermine are

A cDNA encoding the human spermidine/spermine N1-acetyltransferase (N1SSAT) was conditionally expressed in a strain of Escherichia coli deficient in spermidine-acetylating activity. Conditional expression of this cDNA was performed under the control of the lac promoter, by addition of the non-hydrolysable lactose analogue isopropyl beta-D-thiogalactoside. Expression of the N1SSAT cDNA oriented in the sense direction resulted in the acetylation of spermidine at the N1 but not the N8 position and a decrease in endogenous spermidine contents and growth rates in these bacteria. When this cDNA was expressed in the antisense orientation, spermidine acetylation was not detected and endogenous spermidine contents and growth rates were unaffected. Increasing the endogenous N1-acetylspermidine concentration by addition of this amine to the culture medium did not suppress growth, and increasing endogenous spermidine pools by exogenous addition was not sufficient to restore optimal growth in cells expressing the human N1SSAT. Exogenous spermidine, but neither N1- nor N8-acetylspermidine, stimulated cell growth in strains unable to synthesize spermidine. These results suggest that one physiological consequence of spermidine acetylation in E. coli is growth inhibition. The mechanism of this inhibition seems to involve the formation of acetylspermidine, and is not simply due to a decrease in the intracellular concentration of non-acetylated spermidine.

Unweighting, but not denervation, of muscle reportedly "spares" insulin receptors, increasing insulin sensitivity. Unweighting also increases beta-adrenergic responses of carbohydrate metabolism. These differential characteristics were studied further by comparing cyclic adenosine monophosphate (cAMP) accumulation and beta-adrenergic binding in normal and 3-day unweighted or denervated soleus muscle. Submaximal amounts of isoproterenol, a beta-agonist, increased cAMP accumulation in vitro and in vivo (by intramuscular [IM] injection) to a greater degree (P less than .05) in unweighted muscles. Forskolin or maximal isoproterenol had similar in vitro effects in all muscles, suggesting increased beta-adrenergic sensitivity following unweighting. Increased sensitivity was confirmed by a greater receptor density (Bmax) for [125I]iodo-(-)-pindolol in particulate preparations of unweighted (420.10(-18) mol/mg muscle) than of control or denervated muscles (285.10(-18) mol/mg muscle). The three dissociation constant (Kd) values were similar (20.3 to 25.8 pmol/L). Total binding capacity (11.4 fmol/muscle) did not change during 3 days of unweighting, but diminished by 30% with denervation. This result illustrates the "sparing" and loss of receptors, respectively, in these two atrophy models. In diabetic animals, IM injection of insulin diminished cAMP accumulation in the presence of theophylline in unweighted muscle (-66% +/- 2%) more than in controls (-42% +/- 6%, P less than .001). These results show that insulin affects cAMP formation in muscle, and support a greater in vivo insulin response following unweighting atrophy. These various data support a role for lysosomal proteolysis in denervation, but not in unweighting, atrophy.