Clinical Characteristics, Etiology, and Outcomes of Hypothermia in Well-appearing Children Referred to the Emergency Department.

BACKGROUND: Hypothermia, as a sign of serious bacterial infection (SBI) in children and infants older than 90 days is poorly characterized, especially in the post-pneumococcal vaccine era. OBJECTIVES: To assess the prevalence of SBI in children and infants presenting to the pediatric emergency department (PED) with reported or documented hypothermia. METHODS: Retrospective data analysis was conducted of all well-appearing children aged 0-16 years who presented with a diagnosis of hypothermia at two tertiary PEDs from 2010 to 2019. RESULTS: The study comprised 99 children, 15 (15.2%) age 0-3 months, 71 (71.7%) 3-36 months, and 13 (13.1%) > 36 months. The youngest age group had increased length of stay in the hospital (P < 0.001) and increased rates of pediatric intensive care unit admissions (P < 0.001). Empirical antibiotic coverage was initiated in 80% of the children in the 0-3 months group, 21.1% in the 3-36 months group, and 15.4% in > 36 months (P < 0.001). Only one case of SBI was recorded and no bacteremia or meningitis. Hypothermia of unknown origin was the most common diagnosis in all age groups (34%, 42%, 46%), respectively, followed by bronchiolitis (26%) and hypoglycemia (13.3%) for 0-3 month-old children, unspecified viral infection (20%) and otitis media (7%) for 3-36-month old, and unspecified viral infection (23%) and alcohol intoxication (15.2%) in > 36 months. CONCLUSIONS: There is a low incidence of SBI in well-appearing children presenting to the PED with hypothermia and a benign course and outcome in those older than 3 months.

Return Visits in Infants Younger Than 90 Days Presenting to the Pediatric Emergency Department for Fever.

Fever in infants presenting to pediatric emergency departments (PEDs) often results in significant return visits (RVs). This retrospective study aimed to identify factors associated with RVs in febrile infants aged 0 to 90 days. Data from infants presenting to PED between 2018 and 2021 and returning within 7 days (RV group) were compared to age-matched febrile infants without RVs (control group). Each group had 95 infants with similar demographics and medical history. RVs were primarily due to positive cultures and persistent fever. The control group had higher initial hospitalization rates, longer PED stays, and increased antibiotic treatment. Prevalence of serious bacterial infections (SBIs) did not significantly differ. Higher hospitalization, prolonged PED stays, and initial antibiotic treatment were associated with reduced RV incidence despite similar SBI rates. Return visits in infants <90 days were primarily driven by persistent fever and positive cultures. Addressing these factors through targeted parental education and improved care protocols may reduce RVs.

The Impact of Parental Presence on Invasive Procedures in the Pediatric Emergency Department: A Prospective Study.

Parental presence during invasive pediatric procedures is controversial, and its benefits are under-researched. The objective of this study was to assess the effects of parental presence during invasive procedures on the parents themselves and the physician performing the procedure. This prospective study was conducted at a single tertiary center in Jerusalem, Israel. During 10 shifts, all physicians and the families of patients who underwent invasive procedures in the pediatric emergency department (PED) were asked to fill in questionnaires related to their experiences. A total of 98 parental questionnaires and 101 physician questionnaires were collected. The most commonly performed procedures were laceration repair (65%) and abscess drainage (18%). Sedation was required in 75% of cases. In total, 73% of the cited family members were present during these procedures. The main reason for refusing to allow family members access was the physicians' concern that the procedure would be hard for parents to watch. However, in more than 85% of cases, the physicians felt that the presence of a family member contributed to the success of the procedure, augmented the child's sense of safety and lessened the family members' feelings of anxiety. All parents who opted to be present during the procedure felt very satisfied, compared to 67% of parents who were not present (p < 0.0001). When asked if, in retrospect, they would have made the same decision, 100% of the parents who were present during the procedure indicated that they would have made the same decision, compared to only 68% of the parents who were not present (p < 0.001). Overall, these findings highlight the positive effects of parental presence during invasive procedures performed in the PED, even when procedures were performed under sedation. Encouraging parental attendance during invasive procedures may, thus, enhance family-centered practices in the PED.

Clinical Characteristics and Management of Snake Bite Injuries in the Jerusalem Area.

Venomous snake bites can constitute medical emergencies, and without immediate care may be life-threatening. This study describes the characteristics and management of patients suffering from snake bite injuries (SNIs) in the Jerusalem area. A retrospective analysis of all patients who were admitted to the Hadassah Medical Center emergency departments (EDs) due to SNIs between 1 January 2004 and 31 March 2018 was conducted. During this period, 104 patients were diagnosed with SNIs, of whom 32 (30.7%) were children. Overall, 74 (71.1%) patients were treated with antivenom, 43 (41.3%) were admitted to intensive care units, and 9 (8.6%) required treatment with vasopressors. No mortality was recorded. On ED admission, none of the adult patients presented with an altered mental state compared to 15.6% of the children (p < 0.00001). Cardiovascular symptoms were observed in 18.8% and 5.5% of the children and adults, respectively. Fang marks appeared in all of the children. These findings underscore the severity of SNIs and the differences in clinical presentation between children and adults in the Jerusalem region.

Serious Bacterial Infections in Preterm Infants: Should Their Age Be "Corrected"?

Adjusting the chronological age of preterm infants according to their gestational age is a widely accepted practice in the field of neurodevelopment. It has been suggested for the assessment of preterm infants with suspected infection, but has been poorly validated. Correcting for chronological age is especially critical in infants with a chronological age above 3 months, but a corrected age below 3 months due to the differences in assessment protocols. This study assessed the difference in incidence of serious bacterial infection (SBI) according to chronological and corrected age in preterm infants. A retrospective analysis of pediatric emergency department (PED) presentations was conducted for all 448 preterm infants born in between January 2010 and August 2019. Of the 448 preterm infants, 204 (46%) presented at one of 3 PEDs in Jerusalem, Israel, during their first year of life. Overall, 141 (31.4%) presented with fever and were included in the study. The infants were divided into 3 age groups: 1-corrected age >3 months; 2-chronological age >3 months, but corrected age <3 months; 3-chronological and corrected age <3 months. SBI was diagnosed in 2.6%, 16.7%, and 33.3% of the infants in groups 1, 2 and 3, respectively; (p < 0.01, p = 0.17, p < 0.001). The incidence of SBI in the control group of 300 term infants <3 months presenting to the PED due to fever was 15.3%. Preterm infants with a corrected age <3 months are at increased risk for SBI, similarly to term infants <3 months of age. Age correction should thus be considered for preterm infants presenting with fever.

Severe Acute Respiratory Syndrome Coronavirus 2 in Infants Younger Than 90 Days Presenting to the Pediatric Emergency Department: Clinical Characteristics and Risk of Serious Bacterial Infection.

OBJECTIVES: There are scant data on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in infants younger than 90 days. This study was designed to characterize COVID-19 presentation and clinical course in this age group and evaluate the risk of serious bacterial infection. METHODS: Data on all SARS-CoV-2-polymerase chain reaction-positive infants presenting to the pediatric emergency department (PED) were retrospectively collected, followed by a case-control study comparing those infants presenting with fever (COVID group) to febrile infants presenting to the PED and found to be SARS-CoV-2 negative (control group). RESULTS: Of the 96 PCR-positive SARS-CoV-2 infants who met the inclusion criteria, the most common presenting symptom was fever (74/96, 77.1%) followed by upper respiratory tract infection symptoms (42/96, 43.8%). Four (4.2%) presented with symptoms consistent with brief resolved unexplained event (4.2%).Among the febrile infants, the presenting symptoms and vital signs were similar in the COVID and control groups, with the exception of irritability, which was more common in the control group (8% and 26%; P < 0.01). The SARS-CoV-2-positive infants had decreased inflammatory markers including: C-reactive protein (0.6 ± 1 mg/dL vs 2.1 ± 2.7 mg/dL; P < 0.0001), white blood cell count (9.3 ± 3.4 × 10 9 /L vs 11.8 ± 5.1 × 10 9 /L; P < 0.001), and absolute neutrophils count (3.4 ± 2.4 × 10 9 /L vs 5.1 ± 3.7 × 10 9 /L; P < 0.001). The rate of invasive bacterial infection was similar between groups (1.4% and 0%; P = 0.31). No mortality was recorded. Although not significantly different, urinary tract infections were less common in the COVID group (7% and 16%; P = 0.07). CONCLUSIONS: The SARS-CoV-2 infection in infants aged 0 to 90 days who present to the PED seems to be mostly mild and self-limiting, with no increased risk of serious bacterial infection.

Changes in pediatric major trauma epidemiology, injury patterns, and outcome during COVID-19-associated lockdown.

Introduction: The COVID-19 pandemic and its associated preventive measures such as national and regional lockdowns have dramatically changed the epidemiology of pediatric admissions to the emergency department. Nevertheless, there are scant data on the epidemiology and injury patterns of major pediatric trauma injuries during these lockdown periods. Methods: A single-center retrospective study of data obtained from a tertiary level 1 trauma hospital trauma registry. The data included demographics, injury mechanisms, injury severity and type, treatment, and resource utilization in children aged 0-18 years who required trauma team activation upon arrival. The analysis compares the data from the 5-week lockdown period from March to May 2020 in Jerusalem, Israel, to its parallel periods in 2018-2019. Results: A total of 187 trauma visits that required trauma team activation (TTA) were analyzed: 48 visits during the lockdown period vs. 139 in 2018-2019, corresponding to a 40% drop in TTA. There was a significant decrease of 34% in MVA-related injuries (p = 0.0001) but a significant increase of 14% in burns (p = 0.01) and a 16% increase in bicycle-related injuries (p = 0.001). No changes in ISS, injury patterns, admission rate, PICU utilization, or need for interventions were observed. Conclusion: There was a significant decrease in the number of overall pediatric trauma visits during the 2020 lockdown, mainly in MVA-associated trauma, but an increase in burns and bicycle injuries. These findings can thus inform policy makers as to the need to formulate prevention awareness programs alerting the public to indoor hazards and the dangers of activities outside the home. Furthermore, it can inform hospital policy decision-making in future lockdowns. The fact that PICU admissions and the need for operating rooms stayed unchanged suggests that it is vital to maintain trauma team capabilities even during lockdowns.

Bronchiolitis Due to RSV and HMPV-Epidemiology, Clinical Course, and Prognosis: Experience of a Single Tertiary Center.

Acute bronchiolitis is a leading cause of hospitalization in infants. In this retrospective study, 645 patients with acute bronchiolitis diagnosed as respiratory syncytial virus (RSV; n = 538) or human metapneumovirus (HMPV; n = 107) were compared in terms of demographic, clinical, and laboratory findings. The HMPV patients presented later in the winter, were older (20 vs 7.55 months; P < .001)), had higher levels of C-reactive protein (4.55 vs 3.03 mg/dL; P = .007), and a higher prevalence of complications (43.9% vs 32.7%; P = .03). This study highlights the similarities and differences between these 2 common respiratory viral pathogens and shows that HMPV has a slightly more severe disease course than RSV. These findings can help guide approaches to these 2 common viruses that cause bronchiolitis.

The yield of ophthalmoscopy as a screening tool for intracranial pathology in pediatric headache.

Headache is a common complaint in children who present at the pediatric emergency department (PED). Serious conditions such as intracranial tumors and idiopathic intracranial hypertension (IIH) should be rapidly ruled out. Ophthalmoscopy for the presence of papilledema has long been considered critical to the assessment of headaches in children; however, the yield of this procedure is poorly validated. This retrospective study implemented a computerized search of the medical records of a single tertiary center to identify all children aged 2-18 years who presented at the PED complaining of headache between 2007 and 2017. The clinical, demographic, radiographic, and laboratory data were analyzed. Of the 948 children aged 2-18 years who presented at the PED complaining of headache, 536 had an ophthalmoscopy examination carried out by an ophthalmologist. Forty-one had papilledema, of whom 7 had an intracranial tumor, 15 had IIH, and 9 had optic nerve head drusen. Of the 495 children without papilledema, 3 had intracranial tumor, and 11 had IIH. The sensitivity and specificity of papilledema for the diagnosis of intracranial tumor were 70% and 93.5%, respectively, with an NPV and PPV of 99.4% and 17.1%, respectively. The sensitivity and specificity of papilledema for the diagnosis of intracranial pathology in general were 61.1% and 96.2%, respectively, with an NPV and PPV of 97.2% and 53.7%, respectively.  Conclusion: Assessment by ophthalmoscopy for papilledema in children presenting to the PED with headache had high sensitivity and high specificity, thus reinforcing the importance of ophthalmoscopy as a screening tool in these children. What is Known: • Headache is a common complaint in children. Serious intracranial pathologies need to be rapidly excluded. • Ophthalmoscopy for the presence of papilledema is commonly used as a screening tool for intracranial pathology, but this procedure is poorly validated. What is New: • Ophthalmoscopy for the assessment of papilledema in children who present with headache to the pediatric emergency department is shown to exhibit sensitivity and specificity for the diagnosis of intracranial pathology.

Orthotic hip brace as an alternative for treatment of femoral fractures in children under the age of 3 years: a retrospective study.

Femoral fractures are among the most common reasons for orthopedic-related hospital admissions in children. While spica cast is recommended for most children younger than 5 years, in the last decades, Pavlik harness was proven to be a safe alternative for young children. The objective is to assess the safety, outcomes and complications of a hip abduction brace (HAB) for the treatment of femoral fractures in children under the age of 3 years. This 7-year retrospective study was conducted in a single tertiary hospital. Children aged 6-36 months diagnosed with a femoral fracture, which did not necessitate operative treatment, were included. HAB has been used as the treatment of choice for nondisplaced or minimally displaced fractures of the proximal femur as well as for both displaced and nondisplaced femoral shaft fractures. The database was composed of a total of 102 children under the age of 3 with femoral fractures. Twenty-nine (28.4%) patients were treated with HAB and the others with a spica cast. The average age (±SD) at presentation was 21.5 ± 6.1 months. The length of stay was 0.96 ± 1 day. The complication rate was 6.9%. A satisfactory outcome in terms of fracture alignment and union was reported in 100% of the patients treated with HAB. When compared with patients treated with a spica cast, the HAB group were younger, had less severe injuries, shorter lengths of stay, lower complication rates and no need for surgical intervention. HAB can be considered a safe and comfortable alternative in selected children aged 6-36 months with nondisplaced/mildly displaced proximal and diaphyseal femoral fractures.

Parents' Adherence to Follow-up Testing Instructions Following Hospital Discharge.

The adherence to follow-up testing instructions post-hospitalization is influenced by a variety of factors. Our aim was to assess the parental adherence to follow-up instructions and identify the factors that influence it. Parents of 200 children were asked about their adherence with these instructions; responses were obtained from 184 of 200. Parents did not adhere in 20 of 194 (10.9%) of cases. Families of infants under 12 months and children older than 10 years had lower adherence rates. Test completion was more frequent for children discharged with a test appointment compared with those discharged without an appointment (96% vs 86.6%; P = .07). The main reasons for non-adherence were disagreement as to the value of the testing (45%) or parental misunderstanding (30%). In conclusion, in order to increase adherence with post-hospitalization follow-up testing, physicians should focus on explaining the need and importance of the test and schedule an appointment prior to discharge.

Audit of ultrasound usage in emergency departments in greater metropolitan Brisbane.

OBJECTIVE: The Australasian College for Emergency Medicine identifies five ultrasound applications which the College deem core to the practice of emergency medicine but there is scant information as to the uptake of ultrasound or the qualification of users. This study aims to determine the percentage of ED physicians in one metropolitan area who utilise ultrasound for core diagnostic and procedural applications in participating hospitals and the percentage of users who have been formally assessed in any ultrasound application. METHODS: The EDs of eight major public hospitals in greater metropolitan Brisbane area participated in this audit. Data-collectors at each participating ED approached every senior house officer, registrar and senior medical officer in the department and, after obtaining informed consent, asked the participant six questions pertaining to their use of ultrasound for five core applications and about ultrasound training and recorded the answers without information as to the identity of the participant. RESULTS: 94.4% of the physicians participated. Of those participating, 90% used ultrasound for venous access, with progressively fewer using E-FAST (69%), AAA (51%), Lung (40%) and BELS (29%) for diagnostic purposes. Ninety-eight percent of participants were in favour of enhanced departmental training. Only 33% of participants had their ultrasound skills assessed by a qualified person for even one application. CONCLUSION: While use of ultrasound in some applications is widespread, few users have had their skills assessed. Assessment being a routine part of structured training, it cannot be assumed that these users can competently use ultrasound for procedural or diagnostic applications.

The role of Staphylococcus lugdunensis as a pathogen in children: a multicentre retrospective study.

Introduction: Staphylococcus lugdunensis (SL), a tube coagulase negative Staphylococcus, is known to be pathogenic in adults, causing mainly skin infections.Gap Statement: Previous studies assessing SL's role in paediatric populations are sparse and are mainly limited to case reports.Aim: Present the clinical characteristics consistent with SL infections and its putative role as a pathogen in the paediatric population.Methodology: A retrospective multicentre study was conducted in four paediatric medical centres in Israel. Patients with isolates of SL presenting between 2009-2019 were included.Results: SL was isolated from 40 patients. Average (±SD) age at presentation was 5.9 (±6.2) years, with 22 (55 %) being female. Skin, soft tissue and musculoskeletal infections were the most common (n=20, 50%) followed by ear infections (n=13, 32.5%). Five cases of urine isolates and two isolates from blood culture samples were also reported. Skin abscess was the most common infection among skin and soft tissue isolates, reported in 17 children (85%) with SL being the only pathogen in 15 (75%). Otitis media was the most common ear infection accounting for 12 (92%) of all cases with SL as the only isolate reported in 6 (46%). Five cases of SL isolates from urine specimens were reported, all of which with poor growth of bacteria and normal urinalysis. Two cases of SL growth in blood culture were found in children presenting with signs and symptoms consistent with invasive blood stream infection.Conclusions: In the paediatric population, studied infections caused by SL are increasingly observed. The results of this study highlight its role as a pathogen in soft tissue infections and its putative role in otitis media and invasive blood stream infections. However, the role of SL as an uropathogen was not established.

Microhematuria as an Indicator of Significant Abdominal Injury.

BACKGROUND AND OBJECTIVES: Trauma is one of the leading causes of morbidity and mortality in the pediatric population. In many centers, microhematuria is used as a screening tool for the presence of significant abdominal injury and as an indication for further imaging. Our objective was to evaluate the role of microhematuria by dipstick as an indicator of significant abdominal injury in children. METHODS: A retrospective review of children aged 0 to 16 years admitted for a motor vehicle accident or a fall from 2007 to 2017 who had urinalyses performed. RESULTS: The charts of 655 children were reviewed. Microhematuria was found in 100 children, of whom 49 (49%), 28 (28%), and 23 (23%) had small, moderate, and large amounts of hematuria, respectively. Of the children who had microhematuria, 41 underwent a computed tomography scan. Positive findings were recorded in 16 (39%) of these patients. There was a clear association between microhematuria as detected by the urine dipstick and a significant finding on the computed tomography scan (P = 0.002). The sensitivity of microhematuria for significant abdominal pathology on imaging was 66.6% and the specificity was 68.3% (positive predictive value, 39%; negative predictive value, 87.1%). Microhematuria was associated with increased length of stay in the hospital (P < 0.001), surgical interventions (P = 0.036), and admission to the pediatric intensive care unit (P < 0.001). CONCLUSIONS: The diagnostic role of dipstick urine analysis in the assessment of intra-abdominal injury has low sensitivity and specificity. Nevertheless, it is still a valuable screening tool for the evaluation of the severity of injury.

Factors Associated With Increased Risk of Pediatric Orbital Cellulitis-Who Should Be Scanned?

BACKGROUND: Evaluation of a child with POC/OC is complicated due difficulties in physical examination and risks of imaging by computed tomography. METHOD: Retrospective review of children 0-16 years admitted to the pediatric emergency department for POC/OC from 2009 to 2019. RESULTS: Ten years study period, 243 children younger than 16 years presented to the pediatric emergency department with a diagnosis of POC/OC. OC was documented in 51 (20.6%) patients. The mean age was 7.8 years (±4.3 years). Fever (80.4%), upper respiratory tract infection (43%), swelling of both eyelids (96%), proptosis (33.3%), and tenderness on percussion (24.5%) were more common in comparison to POC (P = 0.0001, 0.03, 0.0001, 0.0001, 0.0001 respectively). All children with suspected diagnosis of OC underwent computed tomography scan. POC accounted for 196 patients. Mean age was 4.6 (±4.3) years. Twenty percent of the cases were recorded as local trauma or insect bite in the infected eye.Mean leukocyte count in the OC group had higher mean of 15.2 (109/L) versus 13.4(109/L) (P = 0.05), absolute neutrophil count was significantly higher in the OC 11.3(109/L) versus 7.2(109/L) (P = 0.0001) whereas the lymphocyte count was higher in the POC 4.5(109/L) versus 2.4(109/L) (P = 0.0001), NLR of 0.318 correlates with orbital cellulitis with sensitivity of 75.5% and specificity of 77.4%.Patients with OC had mean C-reactive protein levels of 11.7 (mg/dL) versus 4.9(mg/dL) (P = 0.0001), erythrocyte sedimentation rate was elevated in the OC 53.6 (cm/h) versus 36.4 (cm/h) (P = 0.02).Based on the aforementioned study a risk calculator for OC was formulated with 6 major variables. CONCLUSIONS: Differentiation between POC/OC is cardinal. This study highlights the importance of ancillary laboratory tests especially C-reactive protein in the assessment of infections of the eye.

Pediatricians as Case Managers Reduce the Exposure to Computerized Tomography in Children Experiencing Minor Head Trauma.

BACKGROUND: Head trauma is one of the most common reasons for pediatric emergency medicine department (PED) visits. Computerized tomography (CT) scan is considered the criterion standard for the diagnosis of traumatic brain injury but was shown to increases the risk of malignancies. METHODS: We retrospectively analyzed collected data of all children (ages 0-16 years) experiencing mild head trauma who were admitted to a single center, from January 1, 2010, to December 31, 2015. Comparison between patients treated by pediatricians/pediatric emergency medicine physicians (PEMP) with those treated by surgeons regarding CT rates and prognosis was done. RESULTS: During the previously mentioned period, 4232 children presented to the PED after minor head trauma, the average age was 5.4 (±4) years and 67.1% were male. Head CT was done in 7.7%, of which 30.7% had positive findings. Younger children tended to have higher percentage of positive findings on CT scan (60%, 43.8%, 26.6%, P = 0.003, for children up to 5 months, 5-24 months, and older than 24 months, respectively). Pediatricians ordered less CT scans when compared with surgeons (5.4% vs 8.5%, P < 0.001). Moreover, they had higher rates of positive findings on CT scan (52.5% vs 25.8%, P < 0.001). When all other characteristics were similar, if the case manager was a pediatrician, the patient's chances to undergo a CT scan were 4.3 times lower than if the case manager was a surgeon (odds ratio, 4.277; confidence interval, 2.274-7.104). No difference in readmissions or other complications were found between the 2 groups. DISCUSSION: This study highlights that when the case manager of children with minor head trauma is a pediatrician/PEMP, CT scan rates and thus exposure to radiation are diminished without a failure to detect clinically important traumatic brain injury.In conclusion, our findings suggest that when possible, all children experiencing minor head trauma should be treated by a pediatrician/PEMP in the PED.

Predicting factors for complications in peripheral intravenous catheters in the pediatric population.

AIM: To characterise the association between peripheral intravenous catheter (PIVC) gauge (G), the patient's age, insertion site and complication incidence. METHODS: This prospective study was performed in Hadassah Medical Center, Jerusalem, Israel, between June 2018 and March 2019. Children with PIVC admitted to the paediatric departments were included. PIVCs were evaluated daily. RESULTS: A total of 113 children with 132 PIVCs were included in the study. The most common site of insertion was the antecubital fossa (43.9%). PIVCs were most commonly used for intravenous (IV) antibiotics (46.6%). Complications were observed for 40.9% PIVCs. Dislodgement was the most common complication. The complication rate was higher for the lower limbs (60%) and external jugular veins (100%) p = 0.002. In infants younger than 12 months, the complication rate was higher for 22 G PIVCs or larger (58.7% versus 27.5%; p = 0.05). In contrast, for the 1-6 years age group, PIVCs smaller than 24 G had a higher complication rate (p = 0.004). Patients with comorbidities had a higher complication rate (p = 0.003). CONCLUSION: Risk factors for complications are comorbidities and sites of insertion other than the upper limbs. In infants, 24 G PIVC or smaller should be inserted, whereas 22 G PIVC or larger are superior for 1- to 6-year-old children.

The use of bacterial DNA from saliva for the detection of GAS pharyngitis.

BACKGROUND: Acute tonsillitis is a very common medical condition. Despite different methods of detection, all tests are based on GAS sampling using a throat swab. However, obtaining the swab can elicit vomiting and is often accompanied by fear and apprehension in children. The aim of this study was to find a non-invasive method for the detection of GAS pharyngitis. METHODS: A classic throat swab was obtained for culture, and a saliva sample was taken from 100 subjects recruited from Meuhedet Health Care Organization clinic. Real time PCR was performed to detect GAS dnaseB specific gene in the saliva samples. RESULTS: 56% of the throat cultures and 48% of the PCR samples were positive for GAS. The overall sensitivity and specificity of the saliva PCR method was 79% and 91% respectively; NPV and PPV were 77% and 92% respectively. When excluding patients who presented on the first day of fever, sensitivity and specificity increased to 90% and 100% respectively. No other anamnestic or clinical findings increased the yield of the test. CONCLUSION: Saliva-based PCR amplification of GAS DNA method is effective in detection of GAS pharyngitis. Further studies are needed to achieve detection rates to replace the traditional throat swab-based approach.

Tickborne Relapsing Fever, Jerusalem, Israel, 2004-2018.

To compare tickborne relapsing fever (TBRF) in children and adults in Jerusalem, Israel, we collected data from the medical records of all 92 patients with TBRF during 2004-2018. The 30 children with TBRF had more episodes of fever and lower inflammatory markers than adult patients.

Arum palaestinum poisoning: revenge of the witch.

The Arum palaestinum plant is one of the 26 species of the Arum genus of the Araceae family. This plant species is found through the Mediterranean region, Western Asia, and Europe. The leaves and seeds of the plant contain needle-shaped oxalate crystals that can irritate the affected tissue (skin, oral cavity, or GI tract) upon exposure. Up to this date, there is no available literature supporting the epidemiology or the clinical manifestations of poisoning by this plant. We retrospectively reviewed all Arum palaestinum exposures to children younger than 18 years of age reported to the Israel National Poison Information Center during 2017 from the IPIC computerized data system. We extracted demographic data and clinical data from those digital files. We reviewed the files of 53 patients' files and found slight male predominance (58% vs. 42%), and the age of exposure ranged from 9 month to 15 years. The main site of exposure was at home in most cases (47%) followed by outdoor exposure in 40% of the cases. In 66% of the cases, minor clinical manifestations were reported, mainly erythema and mouth irritation, agitation, and drooling. Asymptomatic patients composed 34% of the cases. In 17% of the cases, patients were recommended to visit an ambulatory facility, and other 15% of the cases were referred to the emergency department. There were no cases of severe poisoning, upper airways compromise, or death.Conclusion: Poisoning by Arum palaestinum is one of the most common pediatric plant poisoning in Israel. Our study supports with clinical data for the first time that this poisoning is self-limited, confined to the affected mucosa, and most likely does not necessitate any intervention. What is Known • A. palaestinum poisoning is one of the most common pediatric plant poisoning in Israel. • The leaves and seeds of the plant contain needle-shaped oxalates crystals. What is New • Pediatric exposure to A. palaestinum usually causes only mild and self-limited poisoning. • Expectant observation is the preferred management of such exposure.