Diagnostic Value of Lactate Dehydrogenase and Uric Acid as Screening Tools for Malignancies in Children.

OBJECTIVE: The aim of this study was to determine the diagnostic value of lactate dehydrogenase (LDH) and uric acid (UA) in children undergoing evaluation for possible malignancies. METHODS: This was a retrospective chart review of patients aged 0 to 18 years presenting to an urban, tertiary care, pediatric hospital between July 1, 2011, and July 1, 2016. Patients were included if they had an LDH and/or UA level drawn, and they were excluded if they had a known cancer diagnosis. Sensitivity, specificity, and receiver operating characteristic curves were calculated for each biomarker. RESULTS: Six hundred five subjects were included in this study; 579 and 384 subjects had LDH and UA levels drawn, respectively; 15.7% had a final diagnosis of malignancy (49 leukemia, 46 nonleukemia). CONCLUSION: The specificities of both biomarkers for all types of malignancies were lower than their respective sensitivities. Comparing leukemic versus nonleukemic malignancies, the areas under the curve were 0.848 and 0.719, respectively, for LDH and 0.681 and 0.555, respectively, for UA.

Repeat Intravenous Ketamine Dosing in Children Undergoing Emergency Department Procedural Sedation.

BACKGROUND: Patients undergoing procedural sedation with intravenous ketamine often receive repeat doses to maintain dissociation; however, data between doses are lacking. OBJECTIVES: The purpose of this study was to characterize the frequency, time interval, and dosages of ketamine received by children undergoing procedural sedation and to explore the effects of age and body mass index on these parameters. METHODS: This was a retrospective study of patients 1 to 18 years of age undergoing procedural sedation with intravenous ketamine in a pediatric emergency department between October 2016 and June 2017. Total repeat ketamine dosages were standardized to a 1-h sedation. RESULTS: Four hundred nineteen patients were included in the analysis. The median sedation time was 33.0 minutes (interquartile range [IQR] 25.0-45.0). Three hundred sixty-three patients (86.6%) received at least 1 repeat ketamine dose. The median time between doses was 7.0 minutes (IQR 5.0-12.0). Children <6 years of age, compared with older children, received higher hourly doses of ketamine in mg/kg/h (2.8 [IQR 1.8-3.9] vs. 1.8 [IQR 1.2-2.6], pc < 0.01). Children <3 years of age, compared with older children, received the highest hourly dose of ketamine in mg/kg/h (3.7 [IQR 2.3-5.0] vs. 1.9 [IQR 1.4-2.8], pc < 0.01). Ketamine repeat and hourly dosing does not appear to be significantly different in children of differing body mass index classes. CONCLUSIONS: Patients undergoing ketamine sedation often receive repeat doses to maintain dissociation. Patients <3 years of age received the highest total repeat ketamine dosages.

Simulation training for pediatric residents on central venous catheter placement: a pilot study.

OBJECTIVE: To assess the effect of simulation training on pediatric residents' acquisition and retention of central venous catheter insertion skills. A secondary objective was to assess the effect of simulation training on self-confidence to perform the procedure. DESIGN: Prospective observational pilot study. SETTING: Single university clinical simulation center. SUBJECTS: Pediatric residents, postgraduate years 1-3. INTERVENTIONS: Residents participated in a 60- to 90-minute ultrasound-guided central venous catheter simulation training session. Video recordings of residents performing simulated femoral central venous catheter insertions were made before (baseline), after, and at 3-month following training. Three blinded expert raters independently scored the performances using a 24-item checklist and 100-mm global rating scale. At each time point, residents rated their confidence to perform the procedure on a 100-mm scale. MEASUREMENTS AND MAIN RESULTS: Twenty-six residents completed the study. Compared with baseline, immediately following training, median checklist score (54.2% [interquartile range, 40.8-68.8%] vs 83.3% [interquartile range, 70.0-91.7%]), global rating score (8.0 mm [interquartile range, 0.0-64.3 mm] vs 79.5 mm [interquartile range, 16.3-91.7 mm]), success rate (38.5% vs 80.8%), and self-confidence (8.0 mm [interquartile range, 3.8-19.0 mm] vs 52.0 mm [interquartile range, 43.5-66.5 mm]) all improved (p < 0.05 for all variables). Compared with baseline, median checklist score (54.2% [interquartile range, 40.8-68.8%] vs 54.2% [interquartile range, 45.8-80.4%], p = 0.47), global rating score (8.0 mm [interquartile range, 0.0-64.3 mm] vs 35.5 mm [interquartile range, 5.3-77.0], p = 0.62), and success rate (38.5% vs 65.4%, p = 0.35) were similar at 3-month follow-up. Self-confidence, however, remained above baseline at 3-month follow-up (8.0 mm [interquartile range, 3.8-19.0 mm] vs 61.0 mm [interquartile range, 31.5-71.8 mm], p < 0.01). CONCLUSIONS: Simulation training improved pediatric residents' central venous catheter insertion procedural skills. Decay in skills was found at 3-month follow-up. This suggests that simulation training for this procedure should occur in close temporal proximity to times when these skills would most likely be used clinically and that frequent refresher training might be beneficial to prevent skills decay.

Rapid bedside triage does not affect the delivery of pain medication for extremity pain in the pediatric emergency department.

OBJECTIVE: Rapid bedside triage (RBT), rather than traditional waiting room triage (WRT), is becoming a "best practice" in managing emergency department (ED) patient flow, yet little is known about the impact of this process on other aspects of patient care. This study was designed to compare overall adherence to an existing nurse-driven ED pain protocol after changing from a WRT to an RBT process. METHODS: On November 1, 2011, the triage process at our institution changed from a traditional WRT system to an in-department RBT allowing for comparison of the 2 groups. A retrospective chart review assessing compliance with the department's pain protocol was performed on all patients presenting to the ED during October and November 2011, representing the immediate time periods before and after the implementation of the change in triage process. Patients younger than 19 years, with complaint of isolated extremity pain or injury, were included in this analysis. Compliance was defined as patients having a pain score assessed and pain medication given for scores of 4 or more within 30 minutes of arrival. RESULTS: In total, 546 patients were identified for inclusion in the study; 306 received traditional WRT, and 240 received RBT. Compliance with the pain protocol was seen in 54.6% of patients receiving WRT versus 57.5% receiving RBT (P = 0.50). CONCLUSIONS: Changing from a traditional WRT process to an in-department RBT process resulted in no change in the compliance with the existing pain protocol.

Twenty-five years of leadership: a look at trends in tenure and appointments of chairs of ophthalmology.

OBJECTIVE: To assess trends in tenure for chairs of academic departments of ophthalmology and to assess characteristics that may be correlated with longevity. DESIGN: Cross-sectional study. PARTICIPANTS: Current chairs from 136 institutions were surveyed. METHODS: Questionnaires mailed to ophthalmology chairs. MAIN OUTCOME MEASURES: Questionnaires assessed demographics along with duration of tenure for current and previous chairs. RESULTS: From 1983 through 2007, 415 individuals (404 men and 11 women) held the position of chair at the 127 responding institutions. The mean duration of tenure for chairs whose tenure included 1980 was 20.3 years, and the mean duration decreased to 14.7 years for chairs whose tenure included 2000. Mean annual turnover changed from 4.8% during the first 5 years of the study to 6.7% during the last 5 years of the study. Departments had an average of 3.3 chairs during this period, with 25 departments having 5 or more new chairs. The number of female chairs increased from 4 in 1983 to 6 in 2007. Length of tenure was not found to correlate with a department's national ranking. CONCLUSIONS: The average turnover rate for chairs of departments of ophthalmology has shown a slight upward trend over the last 25 years with a corresponding decrease in mean tenure length. Although this trend is not particularly alarming compared with those of other disciplines, academic leaders must be aware of this trend to estimate future leadership needs and to take steps to ensure tenure length does not decrease in such a way that it hinders the field.

Burnout in chairs of academic departments of ophthalmology.

PURPOSE: To evaluate the incidence of burnout in chairs of academic departments of ophthalmology, identify stressors, and propose methods for reducing and preventing burnout in our academic leaders. DESIGN: Cross-sectional study. PARTICIPANTS: One-hundred thirty-one chairs of academic departments of ophthalmology in the United States and Canada. METHODS: Confidential surveys mailed to ophthalmology chairs. MAIN OUTCOME MEASURES: Questionnaires assessed demographics, potential stressors, satisfaction with personal life, self-efficacy, burnout as measured by the Maslach Burnout Inventory-Human Services Survey (MBI-HSS), and quality of life. RESULTS: Questionnaires were returned from 101 chairs, a response rate of 77%. Each chair had served an average of 9.4 years. They worked an average of 62 hours each week, spending 41% on patient care, 36% on administrative duties, 13% on teaching, and 9% on research. There was no difference in hours worked each week in chairs who had served >10 years from those who had been chair <5 years. The most frequently identified stressors were faculty retention, Residency Review Committee/Accreditation Council for Graduate Medical Education issues, department or hospital budgets, and compliance issues. Seventy percent of chairs reported they are currently satisfied with their positions compared with 79% who reported feeling that way 5 years ago. Nine chairs (9%) were considered to have burnout based on their MBI-HSS surveys, and 9 (9%) chair's scores showed no characteristics of burnout. Fifty-six percent had scores consistent with low personal achievement, the highest risk factor for burnout. Overall, the MBI-HSS revealed moderate subscale scores for emotional exhaustion, low for depersonalization, and low for personal accomplishment. CONCLUSIONS: The overall prevalence of burnout in chairs of academic departments of ophthalmology is similar to burnout rates seen in chairs of other academic departments. The MBI-HSS scores for ophthalmology chairs showed high levels of emotional exhaustion, moderate levels of depersonalization, and moderate levels of personal accomplishment. Because the cost of burnout can be high, both in terms of a chair's psychological well-being and the actual cost associated with replacing a chair, it is important that strategies are put in place to reduce burnout in our academic leaders.

Comparison of two different surgical techniques for the treatment of strabismus in dysthyroid ophthalmopathy.

BACKGROUND: Surgical management of strabismus caused by dysthyroid ophthalmopathy has a history of variable success outcomes ranging from 43% to 82%. Previous studies showed that correcting the restricted duction seen in thyroid eye disease, rather than the deviation as is done in other types of strabismus surgery, resulted in markedly improved success rates. Other investigators have recommended a change in the approach to the surgical management of dysthyroid ophthalmopathy. METHODS: Retrospective comparison of sequential case series. RESULTS: The data of 86 patients were retrospectively reviewed, including 52 in the deviation correction group and 34 in the duction correction group, with 74 deviation correction operations and 47 duction correction operations. A successful outcome, defined as postoperative deviation less than or equal to 5(Delta), was seen in 72% of deviation corrections operations and 66% of duction correction operations (p = 0.55). CONCLUSIONS: In our study, no difference in outcome between surgical corrections of restricted duction versus deviation was demonstrated.

The effect of simulation training on PALS skills among family medicine residents.

BACKGROUND AND OBJECTIVES: The Accreditation Council for Graduate Medical Education requires that family medicine residents receive structured skills training on pediatric advanced life support (PALS) and should learn procedures for medical emergencies in patients of all ages. Traditional methods of training family medicine residents in PALS is challenging given their limited clinical exposure to critically ill patients. The primary objective of this study was to assess the effect of a 2-hour PALS training session utilizing high-fidelity mannequins on residents' psychomotor skills performances. METHODS: Between February and June 2009, residents from two urban family medicine residency programs received training on four PALS procedures (bag-mask ventilation, tracheal intubation, intraosseous line placement, and cardiac rhythm assessment/defibrillation) at a university simulation center. Residents completed questionnaires to provide data on previous resuscitation training and experience. We collected self-confidence data and video recordings of residents performing the procedures before and after training. To assess retention at 6 months, we collected self-confidence data and video recordings of PGY-1 and PGY-2 residents performing the procedures. A blinded reviewer scored the video recordings. RESULTS: Forty-seven residents completed the study. The majority of residents (53.2%) had never performed any of the procedures on a real patient. Immediately following skills training, mean overall performance improved from 39.5% (± 11.5%) to 76.5% (± 10.4%), difference 37.0% (95% CI, 33.5%--40.6%). Bag-mask ventilation and intraosseous insertion skills remained above baseline at 6-month follow-up. CONCLUSIONS: Simulation training is beneficial for teaching PALS procedures to family medicine residents.

Orbital desmoid tumor in a pediatric patient.

A 3-year-old girl with desmoid tumor of the right orbit initially presented with a 4-month history of unilateral ptosis and was subsequentially found to have fullness of the right upper eyelid. Computed tomography of the orbit revealed a soft tissue density in the superolateral quadrant of the right orbit. Histopathology from a biopsy revealed a desmoid tumor with positive margins. The patient subsequently underwent compete excision of the tumor and is presently doing well.