Caregiver Intent and Willingness to Accept COVID-19 Vaccine in the Pediatric Emergency Department.

BACKGROUND: While COVID-19 vaccine (CV) acceptance is improving, little is known about parental acceptance of CV in the pediatric emergency department (PED). OBJECTIVES: The aims of the study are to assess rates of CV uptake among eligible children presenting to the PED, describe caregiver willingness to accept CV in the PED, and assess potential ED-based interventions to increase CV acceptance. METHODS: We surveyed caregivers of 384 children aged ≥6 months presenting to the PED for minor illness/injury. Demographics, COVID-19/other vaccine history, and intent/willingness to receive CV were recorded. Participants were recontacted by phone 6-12 months after vaccine eligibility to assess CV status, barriers to CV, willingness to receive CV in the ED, and preferences for ED-based vaccine-related interventions. Data were analyzed using standard descriptive statistics. RESULTS: In initial surveys, 31.6% of caregivers planned to vaccinate their child; 32.2% would likely accept CV in the PED. Follow-up data was available for 302 (78.6%) previously unvaccinated participants; only 59 (19.5%) had received CV at follow-up. Of those unvaccinated at follow-up, 27 (28.7%) intended to vaccinate, nearly all of whom would accept CV in the PED. Factors associated with increased likelihood of vaccination included initial intent to vaccinate (P = 0.004), definite/probable acceptance of CV in the PED (P = 0.035), and child age 5+ (P = 0.005). Nearly one-fourth of unvaccinated families reported barriers to CV access. Interventions most likely to persuade families to vaccinate included: discussing CV with a provider (25.5%), receiving an information sheet (23.4%), and offering CV without an ED visit (22.3%). CONCLUSIONS: CV acceptance was low in this cohort. A gap population of unvaccinated children whose caregivers intend to vaccinate exists, and many of these would accept CV in the ED. This data supports the presence of CV programs in the ED to close this gap.

Use of the Child Opportunity Index to Examine Racial Variations in Outpatient Antibiotic Prescribing to Children.

To examine further racial and ethnic variations in antibiotic prescribing to children, we used the Child Opportunity Index. Black children were less likely to be prescribed an antibiotic. Low- and moderate-opportunity areas were associated with greater rates of antibiotic prescribing, after adjusting for race and other factors.

Serum periostin among infants with severe bronchiolitis and risk of developing asthma: A prospective multicenter cohort study.

BACKGROUND: Infants hospitalized for bronchiolitis (severe bronchiolitis) are at high risk for developing childhood asthma. However, the pathobiological link between these conditions remains unclear. We examined the longitudinal relationship of periostin (an extracellular matrix protein upregulated in response to type 2 inflammation) during bronchiolitis with the subsequent development of asthma. METHODS: In a 17-center prospective cohort study of infants (aged <1 year) with severe bronchiolitis, we measured the serum periostin level at hospitalization and grouped infants into 3 groups: low, intermediate, and high levels. We examined their association with asthma development by age 6 years and investigated effect modification by allergic predisposition (eg, infant's IgE sensitization). RESULTS: The analytic cohort consists of 847 infants with severe bronchiolitis (median age, 3 months). Overall, 28% developed asthma by age 6 years. In the multivariable model adjusting for nine patient-level factors, compared to the low periostin group, the asthma risk was significantly higher among infants in the intermediate group (23% vs. 32%, OR 1.68, 95%CI 1.12-2.51, p = .01) and non-significantly higher in the high-level group (28%, OR 1.29, 95%CI 0.86-1.95, p = .22). In the stratified analysis, infants with IgE sensitization had a significantly higher risk for developing asthma (intermediate group, OR 4.76, 95%CI 1.70-13.3, p = .002; high group, OR 3.19, 95%CI 1.08-9.36, p = .04). By contrast, infants without IgE sensitization did not have a significantly higher risk (p > .15). CONCLUSIONS: In infants with severe bronchiolitis, serum periostin level at bronchiolitis hospitalization was associated with asthma risk by age 6 years, particularly among infants with an allergic predisposition.

Parent Intent and Willingness to Immunize Children Against Influenza in the Pediatric Emergency Department.

OBJECTIVES: To determine rates of influenza immunization among children treated in a pediatric emergency department (ED) and to ascertain parent willingness for children to receive influenza vaccine (IV) in the ED. METHODS: Interviews were conducted with parents of children 6 months or older evaluated in the ED for minor illness or injury. Demographic data, IV history, and intent and willingness to receive future IV were recorded during the summer of 2013. Participants were contacted in March 2014 to assess IV status, barriers to obtaining IV, and willingness to obtain IV in the ED. Chart review determined number of patients who were at high risk. RESULTS: Of 457 families approached, 285 (62%) were enrolled. Two hundred forty-two (85%) intended to vaccinate; 83% reported willingness to receive IV at a future ED visit. Common reasons for not receiving IV were concerns about adverse effects (31%) and lack of time or interest (24%). Of the 224 participants (79%) reached in follow-up, 112 (50%) had received IV in the prior season. Among those who did not receive IV, 65 (66%) had intended to vaccinate, and 54 (55%) indicated they would have accepted IV in the ED. Fifty-three (54%) of unvaccinated patients at follow-up had high risk of influenza complications. CONCLUSIONS: Our data support an IV program in the pediatric ED as a means of increasing vaccination rates, particularly among high-risk patients. Parents are often concerned about adverse effects of IV, and providers should target education in this area.

Changes in blood pressure and heart rate during sedation with ketamine in the pediatric ED.

BACKGROUND: Ketamine is commonly used in the emergency department for short, painful procedures. We describe changes in blood pressure (BP) and heart rate (HR) during procedural sedation with ketamine, as these changes have not been well described in children. METHODS: We performed a secondary analysis of a prospective, observational study involving children aged 8 to 18 years who received procedural sedation with ketamine in a pediatric emergency department. Serial vital signs and sedation scores were recorded from baseline until recovery from ketamine procedural sedation. Time of orthopedic manipulation was also recorded. Linear mixed-effect models were used to evaluate changes in systolic BP (SBP), diastolic BP (DBP), and HR using 3 sedation strata: presedation (baseline), sedated (ketamine administered and patient deeply sedated), and recovery (ketamine administered with patient minimally sedated), controlling for age and weight. RESULTS: Sixty children were enrolled; 10 were excluded due to missing manipulation time. A total of 394 observations were recorded. Mean sedated SBP, DBP, and HR were 8 mm Hg, 4 mm Hg, and 13 beats/min higher than presedation SBP (P<.001), DBP (P<.01), and HR (P<.001), respectively. Mean sedated SBP and DBP were 3 and 4 mm Hg higher than SBP (P=.006) and DBP (P<.01) during recovery. Manipulation increased mean SBP by 5 mm Hg (P<.001), mean DBP by 7 mm Hg (P<.001), and mean HR by 1 beat/min (P=.35). CONCLUSIONS: Ketamine administered during procedural sedation for painful procedures causes a statistically significant but modest increase in SBP, DBP, and HR. Orthopedic manipulation further increases BP.

Outpatient Emergency Preparedness: A Survey of Pediatricians.

OBJECTIVE: To determine outpatient pediatricians' self-reported experience with and preparation for patient emergencies, and their awareness of the American Academy of Pediatrics (AAP) policy statement on outpatient emergency preparedness. METHODS: A 34-question cross-sectional survey of outpatient pediatric faculty and gratis faculty from the sole medical school in a metropolitan area was used to assess demographic information, training, and equipment for patient emergencies and familiarity with the AAP policy. RESULTS: Of the 57 responses from 123 surveyed physicians (46% response rate), 23% worked in academics and 70% in private practice. At least 1 emergency per month was reported by 39%; 75% referred a patient to the emergency department or hospital at least monthly. Current Pediatric Advanced Life Support (PALS) certification was maintained by 21%, and 42% had current Basic Life Support (BLS). The majority (79%) agreed that respiratory emergencies were most common. Almost all had bag-valve mask (96%) in the office; however, only 65% had oropharyngeal airways. All reported feeling comfortable performing bag-valve mask ventilation, but only 68% reported the same comfort level with oropharyngeal airways. About half (44%) had intubation equipment, and about half (47%) had automated external defibrillators. Only 25% performed mock emergencies. About half of pediatricians (53%) reported awareness of the 2007 AAP policy guideline, and one quarter (23%) thought their office met guideline recommendations. CONCLUSIONS: Although emergencies occur frequently in general pediatric offices, pediatricians may not have adequate emergency equipment and training. Variable preparedness reflects the need for greater awareness of and compliance with the AAP policy.

Effect of Hispanic ethnicity and language barriers on appendiceal perforation rates and imaging in children.

OBJECTIVE: To determine the association between Hispanic ethnicity and limited English proficiency (LEP) and the rates of appendiceal perforation and advanced radiologic imaging (computed tomography and ultrasound) in children with abdominal pain. STUDY DESIGN: We performed a secondary analysis of a prospective, cross-sectional, multicenter study of children aged 3-18 years presenting with abdominal pain concerning for appendicitis between March 2009 and April 2010 at 10 tertiary care pediatric emergency departments in the US. Appendiceal perforation and advanced imaging rates were compared between ethnic and language proficiency groups using simple and multivariate regression models. RESULTS: Of 2590 patients enrolled, 1001 (38%) had appendicitis, including 36% of non-Hispanics and 44% of Hispanics. In multivariate modeling, Hispanics with LEP had a significantly greater odds of appendiceal perforation (OR, 1.44; 95% CI, 1.20-1.74). Hispanics with LEP with appendiceal perforation of moderate clinical severity were less likely to undergo advanced imaging compared with English-speaking non-Hispanics (OR, 0.64; 95% CI, 0.43-0.95). CONCLUSION: Hispanic ethnicity with LEP is an important risk factor for appendiceal perforation in pediatric patients brought to the emergency department with possible appendicitis. Among patients with moderate clinical severity, Hispanic ethnicity with LEP appears to be associated with lower imaging rates. This effect of English proficiency and Hispanic ethnicity warrants further investigation to understand and overcome barriers, which may lead to increased appendiceal perforation rates and differential diagnostic evaluation.

Impact of ultrasound-guided femoral nerve blocks in the pediatric emergency department.

OBJECTIVE: The objective of this study was to compare the duration of analgesia, need for analgesic medications, and pain-related nursing interventions in patients who did and did not receive ultrasound-guided femoral nerve blocks for femur fracture pain. METHODS: This is a retrospective, preimplementation and postimplementation cohort study. An emergency department log of patients receiving femoral nerve blocks for femur fracture pain was compared with a similar cohort of patients with femur fractures who did not receive nerve blocks. The primary outcome is time from initial pain treatment until the next dose of analgesic. Data were analyzed using Kaplan-Meier methods. Secondary outcomes include number of doses of pain medication, total amount of morphine given, and number of pain-related nursing interventions. Data were analyzed with the Mann-Whitney U test. RESULTS: Eighty-one patients met inclusion/exclusion criteria: 50 in the preimplementation cohort and 31 in the postimplementation group. The median times until next dose of analgesic medication were 2.2 hours (interquartile range [IQR], 1.2-3.4 hours) in the preimplementation group and 6.1 hours (IQR, 3.8-9.5 hours) in the postimplementation group (P < 0.001). The median numbers of doses of pain medication were 0.3 per hour (IQR, 0.25-0.5 per hour) in the preimplementation group and 0.15 per hour (IQR, 0.07-0.3 per hour) in the postimplementation group. The median total doses of morphine were 14.8 µg/kg per hour (IQR, 9.4-19.2 µg/kg per hour) in the preimplementation group and 6.5 µg/kg per hour (IQR, 0-12.2 µg/kg per hour) in the postimplementation group (P = 0.01). The median numbers of nursing interventions were 0.4 per hour (IQR, 0.25-0.5 per hour) in the preimplementation group and 0.15 per hour (IQR, 0.1-0.2 per hour) in the postimplementation group (P < 0.001). CONCLUSIONS: Patients who received ultrasound-guided femoral nerve block for femur fracture pain had longer duration of analgesia, required fewer doses of analgesic medications, and needed fewer nursing interventions than those receiving systemic analgesic medication alone.

COVID-19 Pandemic Impact on Pediatricians Entering the Pediatric Workforce.

OBJECTIVE: Determine extent of impact of coronavirus disease 2019 (COVID-19) pandemic on career choice and employment of pediatricians entering pediatric workforce. METHODS: A national, cross-sectional electronic survey of pediatricians registering for the 2021 American Board of Pediatrics initial general certifying examination on the impact of the COVID-19 pandemic on 3 aspects of career (career choice, employment search, employment offers) was performed. Data were analyzed using descriptive statistics and multivariate logistic regression to determine factors associated with the pandemic's impact on career. Thematic analysis was used to generate themes for open-ended survey questions. RESULTS: Over half (52.3%, 1767 of 3380) of pediatricians responded. Overall, 29.1% reported that the pandemic impacted their career (career choice [10.4%], employment search [15.6%], or employment offers [19.0%]); applicants to general pediatrics (GP) (52.9%) or pediatric hospitalist (PH) positions (49.3%) were most affected. Multivariate logistic regression modeling found those applying to GP (odds ratio [OR]: 3.83, 95% confidence interval [CI]: 2.22-6.60), PH (OR: 9.02, 95% CI: 5.60-14.52), and International Medical Graduates (IMGs) (OR: 1.90; 95% CI: 1.39-2.59) most likely to experience any career impact. CONCLUSIONS: Almost one third of pediatricians registering for the initial general pediatrics certifying examination reported their careers were impacted by the COVID-19 pandemic, with 10% of respondents reporting the pandemic impacted their career choice. Half of new pediatricians seeking employment reported being impacted by the pandemic, particularly IMGs. As the pandemic evolves, career advising will continue to be critical to support trainees in their career choices and employment.

The Early Effects of the Coronavirus Disease-19 Pandemic on Pediatric Resident Education: A National Assessment.

PURPOSE: Residency programs must ensure resident competence for independent practice. The coronavirus disease-19 (COVID-19) pandemic disrupted health care delivery, impacting pediatric residencies. This study examines the impact on pediatric resident education. METHODS: The authors conducted a mixed methods national survey of pediatric residency program directors (PDs) from May 2020 to July 2020. Data analysis included descriptive statistics, chi-square, and Wilcoxon rank sum tests. Multivariable modeling identified factors associated with resident preparation for more senior roles. Thematic analysis was performed on open-ended questions about PD COVID-19 pandemic recommendations to peers, Accreditation Council for Graduate Medical Education and American Board of Pediatrics. RESULTS: Response rate was 55% (110/199). PDs reported the COVID-19 pandemic negatively affected inpatient (n = 86, 78.2%), and outpatient education (n = 104, 94.5%), procedural competence (n = 64; 58.2%), and resident preparation for more senior roles (n = 50, 45.5%). In bivariate analyses, increasingly negative impacts on inpatient and outpatient education were associated with an increasingly negative impact on resident preparation for more senior roles (P = .03, P = .008), these relationships held true in multivariable analysis. Qualitative analysis identified 4 themes from PD recommendations: 1) Clear communication from governing bodies and other leaders; 2) Flexibility within programs and from governing bodies; 3) Clinical exposure is key for competency development; 4) Online platforms are important for education, communication, and support. CONCLUSIONS: The COVID-19 pandemic negatively impacted inpatient and outpatient education. When these were more negatively impacted, resident preparation for more senior roles was worse, highlighting the importance of competency based medical education to tailor experiences ensuring each resident is competent for independent practice.

The effect of abdominal pain duration on the accuracy of diagnostic imaging for pediatric appendicitis.

STUDY OBJECTIVE: Advanced imaging with computed tomography (CT) or ultrasonography is frequently used to evaluate for appendicitis. The duration of the abdominal pain may be related to the stage of disease and therefore the interpretability of radiologic studies. Here, we investigate the influence of the duration of pain on the diagnostic accuracy of advanced imaging in children being evaluated for acute appendicitis. METHODS: A secondary analysis of a prospective multicenter observational cohort of children aged 3 to 18 years with suspected appendicitis who underwent CT or ultrasonography was studied. Outcome was based on histopathology or telephone follow-up. Treating physicians recorded the duration of pain. Imaging was coded as positive, negative, or equivocal according to an attending radiologist's interpretation. RESULTS: A total of 1,810 children were analyzed (49% boys, mean age 10.9 years [SD 3.8 years]); 1,216 (68%) were assessed by CT and 832 (46%) by ultrasonography (238 [13%] had both). The sensitivity of ultrasonography increased linearly with increasing pain duration (test for trend: odds ratio=1.39; 95% confidence interval 1.14 to 1.71). There was no association between the sensitivity of CT or specificity of either modality with pain duration. The proportion of equivocal CT readings significantly decreased with increasing pain duration (test for trend: odds ratio=0.76; 95% confidence interval 0.65 to 0.90). CONCLUSION: The sensitivity of ultrasonography for appendicitis improves with a longer duration of abdominal pain, whereas CT demonstrated high sensitivity regardless of pain duration. Additionally, CT results (but not ultrasonographic results) were less likely to be equivocal with longer duration of abdominal pain.

Cutaneous abscesses in children: epidemiology in the era of methicillin-resistant Staphylococcus aureus in a pediatric emergency department.

OBJECTIVE: Skin and soft tissue infections are a major public health issue. Previous literature suggests a recurrence rate of 4% in children. The purpose of this study was to examine the epidemiology, body location, and history of previous infections among children in the emergency department setting. METHODS: A retrospective study was performed using electronic medical records from all subjects treated in a large pediatric emergency department with attending physician diagnosis and billing codes indicative of a cutaneous abscess from July 1, 2007, to December 31, 2007. Descriptive statistics were used to evaluate abscess location, prior history of infection, bacterial etiology, and patient disposition. RESULTS: Three hundred eighteen abscess visits occurred in 308 individual subjects; 79% were due to methicillin-resistant Staphylococcus aureus. Approximately 14% of subjects presented with more than 1 abscess. Those 2 years or younger were more likely to have buttock abscesses (P < 0.001). Of the 192 subjects for whom responses were documented, 82 (43%) had a history of a prior abscess. Children 2 years or younger were significantly more likely to be hospitalized or go to the operating room: 49% versus 15% (P < 0.001). CONCLUSIONS: Many children with a cutaneous abscess have a prior history of infection. Multiple abscesses are common. Young children are more likely to have abscesses in the diaper area or be hospitalized. Studies of effective hygiene practices and interventions to reduce recurrence are urgently needed.

Quality of antibiotic prescribing to children through the coronavirus disease 2019 (COVID-19) pandemic.

Objective: To describe pediatric outpatient visits and antibiotic prescribing during the coronavirus disease 2019 (COVID-19) pandemic. Design: An observational, retrospective control study from January 2019 to October 2021. Setting: Outpatient clinics, including 27 family medicine clinics, 27 pediatric clinics, and 26 urgent or prompt care clinics. Patients: Children aged 0-19 years receiving care in an outpatient setting. Methods: Data were extracted from the electronic health record. The COVID-19 era was defined as April 1, 2020, to October 31, 2021. Virtual visits were identified by coded encounter or visit type variables. Visit diagnoses were assigned using a 3-tier classification system based on appropriateness of antibiotic prescribing and a subanalysis of respiratory visits was performed to compare changes in the COVID-19 era compared to baseline. Results: Through October 2021, we detected an overall sustained reduction of 18.2% in antibiotic prescribing to children. Disproportionate changes occurred in the percentages of antibiotic visits in respiratory visits for children by age, race or ethnicity, practice setting, and prescriber type. Virtual visits were minimal during the study period but did not result in higher rates of antibiotic visits or in-person follow-up visits. Conclusions: These findings suggest that reductions in antibiotic prescribing have been sustained despite increases in outpatient visits. However, additional studies are warranted to better understand disproportionate rates of antibiotic visits.

Inappropriate outpatient antibiotic use in children insured by Kentucky Medicaid.

OBJECTIVE: To describe risk factors associated with inappropriate antibiotic prescribing to children. DESIGN: Cross-sectional, retrospective analysis of antibiotic prescribing to children, using Kentucky Medicaid medical and pharmacy claims data, 2017. PARTICIPANTS: Population-based sample of pediatric Medicaid patients and providers. METHODS: Antibiotic prescriptions were identified from pharmacy claims and used to describe patient and provider characteristics. Associated medical claims were identified and linked to assign diagnoses. An existing classification scheme was applied to determine appropriateness of antibiotic prescriptions. RESULTS: Overall, 10,787 providers wrote 779,813 antibiotic prescriptions for 328,515 children insured by Kentucky Medicaid in 2017. Moreover, 154,546 (19.8%) of these antibiotic prescriptions were appropriate, 358,026 (45.9%) were potentially appropriate, 163,654 (21.0%) were inappropriate, and 103,587 (13.3%) were not associated with a diagnosis. Half of all providers wrote 12 prescriptions or less to Medicaid children. The following child characteristics were associated with inappropriate antibiotic prescribing: residence in a rural area (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.07-1.1), having a visit with an inappropriate prescriber (OR, 4.15; 95% CI, 4.1-4.2), age 0-2 years (OR, 1.39; 95% CI, 1.37-1.41), and presence of a chronic condition (OR, 1.31; 95% CI, 1.28-1.33). CONCLUSIONS: Inappropriate antibiotic prescribing to Kentucky Medicaid children is common. Provider and patient characteristics associated with inappropriate prescribing differ from those associated with higher volume. Claims data are useful to describe inappropriate use and could be a valuable metric for provider feedback reports. Policies are needed to support analysis and dissemination of antibiotic prescribing reports and should include all provider types and geographic areas.

Examination of U.S. national rates of emergency department visits and hospitalizations for depression and suicidal behaviors after the release of the 13 Reasons Why Netflix series by demographic characteristics.

BACKGROUND: To evaluate the impact of the series 13Reasons Why on depression and suicidal behaviors in children and adolescents. METHODS: Data from the 2016 to 2018 Nationwide Inpatient Sample (NIS) and the Nationwide Emergency Department Sample (NEDS) of the Healthcare Cost and Utilization Project (HCUP) from 2016 to 2018 was used to determine the presentation in both settings for depression and suicidal thoughts and behavior. This was compared to predictive modeling for presentations in the same time frame. RESULTS: Following the release of 13 Reasons Why both hospital admissions and presentations to the Emergency Department (ED) increased for complaints of worsening depression or suicidal thoughts and behavior. This was more pronounced for youth aged 10-17 years, Black race, and female sex. There were no significant findings, overall, for females 6-9 years, but in-patient visits for depression increased in May 2017 for Black females 6-9 years. Males 6-9 years had higher rates of ED visits for depression and both ED and in-patient visits for suicidal behaviors. LIMITATIONS: Secondary data analyses have known limitations including inability to track over time, inclusion of only visit-level data, and failure to collect variables of interest. CONCLUSIONS: The series 13 Reasons Why was likely associated with exacerbations of both depressive illnesses and suicidal behavior in youth, particularly for female and Black youth from 10 to 17 years. This study adds to known concerns regarding the role of media in influencing suicidal behavioral in vulnerable children and has important implications for youth monitoring and parent and youth education. More research is needed to identify specific targets for prevention.

Scholarly activity training in pediatric pulmonology fellowship programs.

BACKGROUND: Scholarly activity training is a required component of pediatric pulmonology fellowship programs. However, there are no data on resources and barriers to training and factors associated with fellow productivity. METHODS: We surveyed US pediatric pulmonology fellowship program directors (FPDs) between March and October 2019. Our primary outcome was fellow productivity (>75% of fellows in the past 5 years had a manuscript accepted in a peer-reviewed journal). Analyses included descriptive statistics, χ2 and Fisher's exact tests for categorical values, and t-test or Wilcoxon rank-sum test for numerical values. RESULTS: Sixty-one percent (33/54) of FPDs completed the survey. Seventy-nine percent reported that most fellows completed clinical, basic science, or translational research. However, only 21% reported that most fellows pursued research positions after graduation; academic clinical positions were more common. For 21%, lack of funding and competing clinical responsibilities were barriers to completing the scholarly activity. Only 39% had highly productive programs; those FPDs were more likely to be highly satisfied with fellow scholarly activity products (p = 0.049) and have >6 publications in the previous 3 years (p = 0.03). Fifty-two percent of FPDs believed that pediatric pulmonary training should be shortened to 2 years for those pursuing clinical or clinician-educator careers. CONCLUSIONS: Barriers to scholarly activity training in pediatric pulmonology programs threaten the pipeline of academic pediatric pulmonologists and physician-investigators. Aligning fellow scholarly activity and clinical training with the skills required in their postgraduate positions could optimize the utilization of limited resources and better support career development.

Scholarly Activity During Pediatric Fellowship.

BACKGROUND AND OBJECTIVES: The educational requirements for pediatric fellows include at least 12 months of scholarly activity and generation of a work product. Yet there lacks detailed guidance on how programs can best integrate scholarly activity training into fellowships. Our objectives were to understand the resources and barriers to training and identify factors associated with productivity. METHODS: We surveyed pediatric fellowship program directors (FPDs) nationally in 2019. Data analysis included descriptive statistics, χ2 and Fisher's exact tests, and multivariable modeling to identify factors associated with high productivity (>75% of fellows in the past 5 years had an article from their fellowship accepted). RESULTS: A total of 499 of 770 FPDs responded (65%). A total of 174 programs (35%) were highly productive. The most frequent major barriers were a lack of funding for fellows to conduct scholarship (21%, n = 105) and lack of sufficient divisional faculty mentorship (16%, n = 79). The median number of months for scholarship with reduced clinical obligations scholarship was 17. A total of 40% (n = 202) of FPDs believed training should be shortened to 2 years for clinically oriented fellows. Programs with a T32 and a FPD with >5 publications in the past 3 years were twice as likely to be productive. Not endorsing lack of adequate Scholarship Oversight Committee expertise and a research curriculum as barriers was associated with increased productivity (odds ratio = 1.83-1.65). CONCLUSIONS: Despite significant protected fellow research time, most fellows do not publish. Ensuring a program culture of research may provide the support needed to take projects to publication. The fellowship community may consider reevaluating the fellowship duration, particularly for those pursing nonresearch focused careers.

Premature departure from the pediatric emergency department: a cohort analysis of process- and patient-related factors.

OBJECTIVE: Previous literature suggests that process-related factors (eg, time of day, patient volume) and patient-related factors (eg, acuity, socioeconomic status) are associated with premature departure from emergency departments. We sought to evaluate the relationship of these and other factors with premature departure in a large, unselected cohort of pediatric emergency department patients. METHODS: This study was a retrospective cohort analysis of visits to a single tertiary site during a 1-year period. Patients' zip codes determined assignment of census-based socioeconomic metrics. Multivariate regression identified factors associated with premature departure. Sensitivity and subset analyses were performed. Return visits within 48 hours after premature departure were also reviewed. RESULTS: There were 46,417 visits, of which 2164 were premature departures. In multivariate analysis, independent predictors of premature departures were arrival time, arrival month, arrival day of week, patient acuity, concurrent premature departures, arrival rate, arrival period average length of stay, and poverty rate. Aside from patient acuity and poverty rate, no patient-related factors were significant in multivariate analysis. These results were robust in sensitivity analysis across different multivariate models. Among premature departures, there were 120 return visits (5.5%), of which 15 were admitted (0.7%). There were no deaths. Acuity was similar between initial and subsequent visits. CONCLUSIONS: Process-related factors and individual patient acuity have the strongest influence on premature departure from the pediatric emergency department. Health care organizations concerned with premature departure should focus efforts on improving pediatric emergency process flow.

Scholarly Activity Training During Pediatric Residency: How Well Aligned Are Program Directors and Residents?

OBJECTIVE: Training residents to be scholars is endorsed by leading medical education organizations. Our previous research suggests that the scholarly activity (SA) training experience is highly variable across pediatric residency programs, and residents and program directors (PDs) are generally dissatisfied. Understanding how PD and resident views align can help programs better guide resource allocation and improvement efforts. METHODS: We conducted cross-sectional surveys of second and third year pediatric residents and PDs at 22 diverse US categorical programs. We compared resident and PD responses to SA training beliefs, barriers, and satisfaction by 2-proportion z tests. We used descriptive statistics to describe resident responses in relation to same-institution PD responses. RESULTS: About 464 of 771 residents (60.2%) and 22 PDs (100%) responded. Across programs, PDs more strongly agreed that all residents should participate in SA (59% of PDs [n = 13] versus 27% of residents [n = 127], P = .002). Residents more strongly believed all residents should have protected SA time (91% of residents [n = 424] versus 68% of PDs [n = 15], P = .001). PDs more strongly perceived gaps in other resources as barriers, including lack of funding to conduct or present SA (P < .001, P = .02), lack of statistical support (P = .03), and lack of faculty mentorship (P < .001). Within program concordance was low. CONCLUSIONS: Discordance exists between PDs and residents with respect to SA participation and necessary resources, particularly, protected time. Programs must help residents identify when SA can be accomplished. Clearer national guidelines around SA training may also be necessary to reduce discordance and improve perceptions.

Intrinsically defective skin barrier function in children with atopic dermatitis correlates with disease severity.

BACKGROUND: Recent genetic evidence supports that an underlying defect in skin barrier function contributes to the pathogenesis of atopic dermatitis (AD). The integrity of the skin barrier can be assessed objectively by measuring transepidermal water loss (TEWL). Previous investigations of TEWL as a biomarker of skin barrier function have been limited by small sample size, and studies including African American subjects are lacking. OBJECTIVE: We sought to determine whether children with AD have inherently altered skin barrier function by comparing TEWL as a measure of skin barrier function in African American and white children with AD with that in control subjects without AD. METHODS: TEWL was measured on nonlesional normal-appearing skin at 4 sites (the volar forearm, dorsal arm, lower leg, and cheek) in (1) children with AD (cases), (2) children with asthma or allergic rhinitis but without AD (allergic control subjects), and (3) nonatopic control subjects. AD severity was assessed by using the objective SCORAD index. RESULTS: TEWL was increased in children with AD compared with that seen in both control groups at most of the anatomic sites tested (P < .05). TEWL also correlated with objective SCORAD score. The presence of allergic sensitization or other allergic conditions did not affect TEWL among children with AD. TEWL was higher in white than in African American children. CONCLUSION: Skin barrier function as assessed by TEWL is intrinsically compromised in children with AD but not in children with other allergic conditions. The magnitude of skin barrier dysfunction correlates with AD disease severity.