The Association Between C-Reactive Protein Levels and Pediatric Appendicitis Score and the Severity of Appendicitis in Children.

BACKGROUND: Acute appendicitis is a common cause of abdominal pain leading to emergent abdominal surgery in children. C-reactive protein (CRP), an inflammatory marker typically elevated in acute appendicitis, and Pediatric Appendicitis Score (PAS), a clinical scoring system used for the diagnosis of appendicitis, have the potential to predict the severity of inflammation of the appendix. This may be useful in helping the physician make a treatment plan prior to surgery. OBJECTIVE: The purpose of this study was to assess whether CRP value and PAS differ with the extent of inflammation of the appendix seen on histologic examination. METHODS: This was a prospective observational study of patients diagnosed with acute appendicitis via computed tomography or ultrasound. Enrolled patients had CRP levels drawn, PAS calculated, and appendix pathology reviewed. Appendix pathology was categorized by the pathologist on the basis of the level of inflammation: simple, suppurative, gangrenous, and perforated. RESULTS: One hundred sixty-three patients were enrolled. CRP levels and PAS were statistically different (p < 0.002) among the four pathology classifications. Patients with simple appendicitis (n = 3) had a mean CRP of 2.95 mg/L and PAS of 3.9, patients with suppurative appendicitis (n = 99) had a mean CRP of 26.89 mg/L and PAS of 6.5, patients with gangrenous appendicitis (n = 56) had a mean CRP of 91.11 mg/L and PAS of 7.5, and patients with perforated appendicitis (n = 6) had a mean CRP of 154.17 mg/L and PAS of 7. The results remained statistically significant (p < 0.002) after adjusting for age, race, and sex. When combined-PAS ≥ 8 and CRP level > 40 mg/L-the specificity of complicated appendicitis was 91.2% and positive predictive value was 72.7%. CONCLUSIONS: Higher CRP levels and PAS were associated with increased histologic inflammation of the appendix. This study provides preliminary evidence that CRP and PAS could potentially assist in treatment decisions for appendicitis.

Validation of the Survey of Sleep Quality in the Pediatric Intensive Care Unit (SSqPICU).

STUDY OBJECTIVES: Observational data suggest pediatric intensive care unit-related sleep and circadian disruption (PICU-SCD) affects many critically ill children. Multi-center trials exploring PICU-SCD have been impractical as measuring sleep in this setting is challenging. This study validates a questionnaire for caregivers to describe children's sleep in the PICU. METHODS: This prospective, multi-center, case-control study enrolled caregivers of children in four PICUs or in a hospital-based sleep lab (controls). Survey items were compiled from validated adult ICU and pediatric in- and outpatient sleep questionnaires. Control responses were compared to polysomnography to determine accuracy. A score was calculated by summing the level of disruption of sleep timing, duration, efficiency, quality, and daytime sleepiness and irritability. RESULTS: In 152 PICU and 61 sleep lab caregivers, sleep survey items had acceptable internal reliability (α=0.75) and reproducibility on re-test surveys (ICC>0.600). Caregivers could not assess sleep of sedated children. Factor analysis identified three sub-scales of PICU-SCD. Control parents had good agreement with polysomnography sleep onset time (κ=0.823) and sleep onset latency (κ=0.707). There was a strong correlation between sleep scores derived by parental reporting to those by polysomnography (r=0.844, p<0.001). Scores had a linear association with caregiver-reported child sleep quality. There were no site-specific differences in sleep quality. Nearly all respondents found the survey easy to understand and of appropriate length. CONCLUSIONS: The SSqPICU provides a reliable, accurate description of inpatient sleep disruption in non-sedated children, generalizable across PICUs. It offers practical means to quantify PICU-SCD daily in future investigations.

Necrotizing Enterocolitis Complicating Severe RSV Bronchiolitis in PICU Settings.

This retrospective study aims to analyze the baseline characteristics and factors associated with poor outcomes in patients with necrotizing enterocolitis (NEC) complicating respiratory syncytial virus (RSV) infection. Using the Virtual Pediatric Systems data registry, patients under 2 years admitted to the pediatric intensive care unit (PICU) were screened. Patients with documented RSV infection and NEC, intestinal perforation, noninfectious gastroenteritis/colitis, or pneumatosis intestinalis occurring around the timing of RSV bronchiolitis diagnosis were included. Out of the screened patients, 41 were analyzed. Most patients (93%) were aged 30 days to 2 years, one-third had baseline anatomical cardiac defects, and 20% history of prematurity. Median PICU length of stay was 11.7 days. Seven patients died before hospital discharge. While not statistically significant, nonsurvivors tended to exhibit higher PRISM-3 scores, more acidemia, and lower systolic blood pressure. These findings emphasize the need for cautious assessment of gastrointestinal symptoms in critically ill patients with RSV infection.

Role of Dual-Contingency Management in Family-Based Obesity Therapy and the Effects of Weight Loss on Liver Transient Elastography Parameters in Youth: A Pilot Study.

The pilot study evaluated contingency management (CM) for family-based obesity therapy (FBT). The secondary outcome assessed the association of the hepatic transient electrography (TE) parameters, including the controlled attenuation parameter (CAP) and liver stiffness (LSM), and changes in liver function blood tests and BMI changes in youth involved in intensive FBT. It included youth-parent dyads from an urban pediatric center randomized to weekly behavioral therapy (BT, n= 4) who received fixed financial compensation for attendance, or BT+CM (n= 5) who received an escalating monetary reward for weight loss. At week 30, all youth and parents had weight-loss trends without significant differences between groups. While the TE measures and blood tests were normal in the youth at baseline and week 30, the CAP changes correlated with BMI changes (R2= 0.86, P< 0.001) and LSM changes with alanine aminotransferase changes (R2= 0.79, P=0.005). In conclusion, BT+CM did not significantly add to the BMI improvement seen with BT alone in youth and their parents. However, in youth with obesity and normal liver blood tests, TE may be useful for monitoring changes in fatty liver disease.

Asthma Cases Treated With Inhaled Anesthetics or Extracorporeal Membrane Oxygenation: A Virtual Pediatric Systems Database Study of Outcomes.

OBJECTIVES: Extracorporeal membrane oxygenation (ECMO) and/or inhaled anesthetics (IAs) are considered in the management of asthma when refractory to conventional therapy. We aimed to compare the outcomes of these two modalities in asthma PICU care and determine associated survival to hospital discharge among patients in a United States database. DESIGN: Retrospective analysis using the Virtual Pediatric Systems (VPS, LLC) database. SETTING: PICUs participating in the VPS database. PATIENTS: Patients less than 18 years old with diagnosis of asthma treated with IA and/or ECMO from January 2010 to December 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 221 patients were included; 149 (67%) received ECMO, 62 (28%) received IA, and 10 (5%) received both interventions. We failed to identify any difference between the ECMO and IA groups in demographics, Pediatric Index of Mortality 2 percentage, Pediatric Risk of Mortality 3 score, Pediatric Logistic Organ Dysfunction score, or pre-intervention pH and Pa co2 levels. Use of ECMO versus IA was associated with lower pre-intervention Pa o2 (60 torr [7.99 kPa] vs 78 torr [10.39 kPa]; p < 0.001) and higher utilization of high-frequency oscillatory ventilation. We failed to identify an association between type of intervention (IA vs ECMO) and greater odds of survival (57/62 [92%] vs 128/149 [86%]; odds ratio [OR], 1.87; 95% CI, 0.67-5.21; p = 0.23). However, these data do not exclude the possibility that IA use is associated with more than five-fold greater odds of survival. ECMO use was associated with longer duration of intervention (5 vs 1.3 d; p < 0.001) and PICU length of stay (LOS) (13 vs 7 d; p < 0.001). As expected, ECMO versus IA was also associated with greater odds of undergoing bronchoscopy (34% vs 11%; OR, 3.7; 95% CI, 1.5-9.4; p = 0.004). CONCLUSIONS: In the VPS database of asthma management cases, we failed to identify an association between ECMO versus IA use and survival to hospital discharge. However, ECMO was associated with longer duration of intervention and PICU LOS.

Ondansetron Safety Regarding Prolong QTc for Children with Head Trauma.

BACKGROUND: There have been recent reports of increased QT interval after head trauma in concussed athletes and adult patients. Ondansetron, which is widely used in treatment of nausea and vomiting symptoms in head injuries, was issued a safety warning from the U.S. Food and Drug Administration regarding QT prolongation and risk of fatal dysrhythmias. OBJECTIVE: The purpose of this study was to evaluate the safety of ondansetron regarding QT prolongation for patients experiencing nausea or vomiting after head trauma. METHODS: Patients aged 1-20 years presenting to a pediatric emergency department with head trauma and who required a dose of ondansetron for nausea or vomiting were enrolled in the study. Patients received a baseline 12-lead electrocardiogram (ECG) prior to administration of either oral or IV ondansetron. A second post-ondansetron 12-lead ECG was performed after administration of ondansetron. All ECGs were reviewed and the QTc calculated manually by a board-certified pediatric cardiologist. RESULTS: Forty-two patients met enrollment criteria. Five patients received IV ondansetron and 37 received oral ondansetron. Mean QTc pre ondansetron was 387.5 ms and mean QTc post ondansetron was 400.9 ms (p = 0.120). We found no statistically significant difference in other ECG parameters pre and post ondansetron. CONCLUSIONS: Ondansetron is safe in regard to QTc prolongation in patients with head trauma. Based on this research, ondansetron should continue to be used for the treatment of nausea and vomiting in emergency department patients who present with head injury.

Cervical spine flexion-extension radiography versus magnetic resonance imaging in pediatric patients following blunt traumatic injury.

Background: In pediatric trauma patients, 60-80% of spinal cord injuries involve the cervical vertebrae. While the American College of Radiology offers guidelines for best imaging practices in the setting of acute pediatric trauma, there is a lack of uniformity in imaging-decision protocols across institutions. MRI has been shown to demonstrate high sensitivity for both bony and ligamentous injuries while also avoiding unnecessary radiation exposure in the pediatric patient population. However, the efficacy of flexion-extension (FE) radiography following initial MRI has not been evaluated in children. Our hypothesis is that FE radiography conducted following an initial MRI does not contribute significant diagnostic information or reduce time to cervical collar removal and thus can be removed from institutional protocols in order to avoid unnecessary testing and reduce pediatric radiation exposure. Methods: Trauma data were collected for pediatric patients presenting with suspected acute cervical spine injury from 2014 to 2021. A total of 108 patients were subdivided into 41 patients who received "MRI Only" and 67 patients who received both "MRI and FE" diagnostic cervical spine imaging. Chi-square testing and t-tests were performed to determine differences between MRI and FE radiographic detection rates of bony and ligamentous injuries in the subgroups. Results: In patients for whom FE did not find any injury, MRI detected bony and ligamentous injuries in 9/63 and 12/65 cases, respectively. In 3/21 (14.3%) cases in which MRI detected a bony and/or ligamentous injury and FE did not, patients eventually required surgical intervention for c-spine stabilization. No patients required surgical fixation when FE radiography showed an abnormality and MRI was normal. Addition of follow-up FE radiography after initial MRI did not have a significant effect on overall hospital length of stay (MRI Only vs MRI+FE: 9.2±12.0 days vs 8.6±13.5 days, p=0.816) or on rates of collar removal at discharge or greater than 48 hours after imaging (MRI Only vs MRI+FE: 41.5% vs 56.7%, p=0.124). Conclusions: FE radiography following initial MRI did not have a significant effect on reducing time to cervical collar removal or overall hospital length of stay. In addition, in 3 of 6 cases (50.0%) in which surgical fixation was required, MRI detected ligamentous and/or bony injury while FE radiography was normal. Level of Evidence: This study contributes Level 2b scientific evidence consistent with a well-designed cohort or case-control analytic study.

Antibody dependent cell cytotoxicity is maintained by the unmutated common ancestor of 6F5, a Gp41 conformational epitope targeting antibody that utilizes heavy chain VH1-2.

In studies on monoclonal IgG antibodies (mAbs) from long-term non-progressors (LTNPs), our laboratory has previously described highly mutated Abs against a complex conformational epitope with contributions from both gp41 the N terminal and C terminal heptad repeat helices. Despite using the VH1-2 gene segment, known to contribute to some of the broadest neutralizing Abs against HIV, members of these Abs, termed group 76C Abs, did not exhibit broad neutralization. Because of the high number of mutations and use of VH1-2, our goal was to characterize the non-neutralizing functions of Abs of group 76C, to assess if targeting of the epitope correlates with LTNP, and to assess the maturation of these Abs by comparison to their predicted common ancestor. Serum competition assays showed group 76C Abs were enriched in LTNPs, in comparison to VRC-01. Specific group 76C clones 6F5 and 6F11, expressed as recombinant Abs, both have robust ADCC activity, despite their sequence disparity. Sequence analysis predicted the common ancestor of this clonal group would utilize the germline non-mutated variable gene. We produced a recombinant ancestor Ab (76Canc) with a heavy chain utilizing the germline variable gene sequence paired to the 6F5 light chain. Competition with group 76C recombinant Ab 6F5 confirms 76Canc binds HIV envelope constructs near the original group C epitope. 76Canc demonstrates comparable ADCC to 6F5 and 6F11 when using gp41 constructs of both clade B and clade C. The functional capability of Abs utilizing germline VH1-2 has implications for disease control and vaccine development.

Pediatric Antibiotic Prescribing and Utilization Practices for RTIs at Private Urgent Care Centers.

Data on pediatric antibiotic prescribing and utilization practices at urgent care centers (UCC) remain limited. In this study, an electronic medical record-based review of UCC encounters for respiratory tract infections (RTI) of patients belonging to one mid-sized pediatric practice was performed. Antibiotic prescribing and guideline adherence were compared between UCCs that were staffed exclusively by pediatric-trained providers to those staffed otherwise. Of a total of 457 RTI visits, 330 (72%) occurred at the pediatric UCC. Across all bacterial RTIs, 82% of encounters at the pediatric UCC were guideline-adherent versus 59% at nonpediatric UCCs (P < .001). At nonpediatric UCCs, pharyngitis was the most common RTI encounter diagnosis (40%), and full streptococcal management guideline adherence was 41%. While 93% of RTI-UCC encounters for <2 years were at pediatric UCCs, the majority of children >10 presented to nonpediatric UCCs. RTI guideline education to UCCs should be a focus of ambulatory stewardship efforts.

Single-Dose Dexamethasone Is Not Inferior to 2 Doses in Mild to Moderate Pediatric Asthma Exacerbations in the Emergency Department.

OBJECTIVE: The purpose of this study was to compare the efficacy of a single dose of dexamethasone to 2 doses of dexamethasone in treating mild to moderate asthma exacerbations in pediatric patients. We anticipated that there would not be a difference in the rate of return visits to the emergency department (ED), urgent care, or primary care physician for continued asthma symptoms. METHODS: This was a prospective, randomized, single-center, unblinded, parallel-group randomized clinical trial of patients 2 to 20 years old presenting to a pediatric ED with mild to moderate asthma exacerbations. The patients were randomized to receive 1 or 2 doses of dexamethasone (0.6 mg/kg per dose, maximum of 16 mg). Telephone follow-up interviews were performed on the sixth day after ED visit. The primary outcome measures were return visits to either primary care physician or ED for continued asthma symptoms. Secondary outcomes were days of symptoms, missed school days, and adverse effects. RESULTS: Of the 318 children initially enrolled, 308 patients met the enrollment criteria. These patients were randomized into 2 groups. There were 116 patients in group 1 and 116 patients in group 2. There was no significant difference between groups regarding return visits (group 1, 12.1%; group 2, 10.3%; odds ratio [OR], 0.892 [95% confidence interval {CI}, 0.377-2.110]), days to symptom resolution (group 1, 2.4; group 2, 2.5; OR, 0.974 [95% 95% CI, 0.838-1.132]), missed school days (group 1, 47%; group 2, 51%; OR, 1.114 [95% CI, 0.613-2.023]), or vomiting (group 1, 8.6%; group 2, 3.4%; OR, 2.424 [95% CI, 0.637-9.228]). CONCLUSIONS: In this single-center, unblinded randomized trial of children and adolescents with mild to moderate acute exacerbations of asthma, there was no difference in the rate of return visits for continued or worsened symptoms between patients randomized to 1 or 2 doses of dexamethasone.

Trichomonas Infection Rates in Males Presenting to the Emergency Department for Sexually Transmitted Infections.

BACKGROUND: Trichomonas vaginalis (TV) is one of the most common sexually transmitted infections (STIs). Overall prevalence is reported to be 3.1%, with rates approaching 12.9-14.4% in high-risk female populations. Although there is a plethora of data on TV in the female population, the corresponding data for the male population are limited. OBJECTIVE: Our aim was to determine the infection rate of TV in male patients seeking care for STIs in the emergency department (ED) and determine the symptoms associated with TV infection in male patients. METHODS: We conducted a retrospective study of male patients aged 13 years or older who presented to the ED for STI evaluation. Male patients included had nucleic acid amplification test (NAAT) TV testing as part of standard STI evaluation. RESULTS: Of the 2137 male patients included, 95 (4.4%) were positive for TV. Male patients who tested positive were significantly older (mean age 38.9 years vs. 30.7 years for male patients who tested negative; p < 0.05). Black male patients were more likely than White male patients to be positive for TV (6.3% prevalence vs. 1.8%; p < 0.05). TV-positive male patients were more likely to have discharge, specifically clear penile discharge, on examination (p < 0.05), and were less likely to have testicular pain or testicular tenderness (p < 0.05). Higher rates of TV were seen in an urban (4.9%) compared with suburban ED (1.6%; p < 0.05). CONCLUSIONS: Rates of TV in male patients who receive STI testing in the ED are similar to rates published previously for female patients. We found higher rates among older and African-American male patients. TV among male patients is prevalent and testing should continue when evaluating for STIs.

Do Your Kids Vape?: Investigating Parent Knowledge of Adolescent e-Cigarette Use.

OBJECTIVE: This study aimed to evaluate parental knowledge of their adolescent's e-cigarette use and their awareness of negative effects. METHODS: Participants were English-speaking 12- to 18-year-old patients and their guardians presenting to a pediatric emergency department. Patients and guardians were invited to complete a survey detailing e-cigarette use, parental awareness, and the understanding of risks. Participants were given separate surveys. They were monitored by research assistants in the room to ensure that answers were kept private. χ2 Analysis was used to interpret the data. RESULTS: A total of 309 paired surveys were obtained over an 8-month period. Of adolescents surveyed, 85 (27.5%) admitted to having ever used an e-cigarette and 33 (10.7%) admitted to regular use. Regular usage was defined as use within the last 30 days. Of the adolescents who used e-cigarettes, the majority (77.8%) had never smoked a traditional cigarette before. For teens who used e-cigarettes, 71.8% of their respective guardians were aware. When the adolescent reported that they did not use e-cigarettes, 91.3% of guardians responded that they did not believe their child was using the device. Guardians were somewhat worse at knowing if their child regularly used e-cigarettes, with only 54.8% of parents reporting to think that their child regularly uses. Finally, both adolescents and guardians reported to know that e-cigarette use was harmful. On a scale of 1 to 5, with 5 being the worst, 83.5% and 88.3% of patients and guardians, respectively, rated e-cigarette usage harm at 4 or 5. CONCLUSIONS: It seems guardians are generally aware of their adolescent's e-cigarette use, and both parents and adolescents are aware of the negative side effects of e-cigarettes on health. We did not investigate whether guardians discussed their concerns on e-cigarette usage with their adolescents. It is also unclear what specific health consequences guardians and adolescents are aware of. These may be points of further investigation and intervention.

The Importance of Differentiating Oligoarticular Juvenile Idiopathic Arthritis From Lyme Arthritis in Pediatric Patients.

Objective This study aims to compare clinical and laboratory features between Lyme arthritis (LA) and oligoarticular juvenile idiopathic arthritis (oligoarticular JIA) by examining several potential predictors in pediatric patients. This study also aims to improve and increase awareness of ways to detect LA and oligoarticular JIA in pediatric patients who present with clinical features of joint pain. Methods A medical chart review was conducted among pediatric patients diagnosed with LA or oligoarticular JIA at John R. Oishei Children's Hospital of Buffalo between January 2014 and September 2018. Patients' diagnoses were identified using the International Classification of Disease 10th Revision code for LA (ICD 10 code A69.23) and oligoarticular JIA (ICD 10 code M08.40). Patients with LA were only included in this study if they (1) exhibited arthritis, (2) tested positive for Lyme antibodies, (3) indicated a positive western blot (WB) of five or more out of 10 Borrelia burgdorferi proteins by IgG antibodies or at least two of three B. burgdorferi proteins by IgM antibodies, and (4) at the age of 16 or below at the time of diagnosis. Patients with oligoarticular JIA were included in this study if they (1) exhibited arthritis affecting one to four joints for at least six weeks in the first six months of diagnosis and (2) are at the age of 16 or below at the time of diagnosis after ruling out LA and reactive arthritis. In this study, clinical presentations, physical exam findings during initial healthcare visits, and demographics including age, sex, and race of patients were obtained. In addition, laboratory results including white blood cells (WBCs), hemoglobin (Hgb), platelet count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, Lyme antibodies through enzyme-linked immunosorbent assay (ELISA) and WB, synovial fluid analysis for red blood cells (RBCs), nucleated cells, and polymerase chain reaction (PCR) for B. burgdorferi DNA were also collected and analyzed. Results In our data, ESR and CRP were significantly higher in LA compared to oligoarticular JIA (P=0.0053 and 0.0005, respectively). The mean WBC in the synovial joint fluid was significantly higher in LA compared to oligoarticular JIA (P=0.002). Conclusion LA shares features with oligoarticular JIA. This overlap prevents the creation of a clinically useful predictive model for LA. Therefore, Lyme testing should be performed on all patients presenting with monoarticular and oligoarticular arthritis. In addition, ESR, CRP, and WBC in the synovial joint fluid were significantly higher in LA compared to oligoarticular JIA in our findings. While this difference is not definitive by any means, it may help distinguish between the two in cases where the diagnosis is not clear-cut, and the values of ESR, CRP, and WBC in the joint aspirate may help guide clinical judgment in cases that lack a definitive diagnosis.

Follow-up and management of serologically active clinically quiescent cases in pediatric systemic lupus erythematosus.

OBJECTIVES: Our aim is to identify the presence of serologically active clinically quiescent (SACQ) episodes in pediatric systemic lupus erythematosus (SLE) patients. We aim to identify serologic biomarkers associated with SACQ episodes and discuss risks and benefits of escalating treatments. MATERIAL AND METHODS: We evaluated 25 pediatric SLE patients, 13 of whom experienced SACQ episodes. Serologically active clinically quiescent was defined as two consecutive clinic visits without any clinical symptoms or clinical examination findings of a lupus flare with a clinical Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) score of zero, but either elevated anti-ds-DNA antibodies or low complement (C3 and/or C4) levels. RESULTS: Among the 13 patients who experienced a SACQ episode, there were a total of 24 episodes, with each patient experiencing 1-4 SACQ episodes. Erythrocyte sedimentation rate (ESR) was the most commonly elevated laboratory marker in a SACQ episode, followed by low hemoglobin levels, and then elevated anti-dsDNA antibodies. Of the 17 episodes treated during a SACQ episode, 15 (88%) did not progress to a clinical flare within six months, while two did. Furthermore, of the 7 patients who were not treated during their SACQ episode, 2 (29%) continued to be SACQ without flare, whereas 5 led to a clinical flare within six months. CONCLUSIONS: Serologically active clinically quiescent episodes were identified in pediatric SLE patients, suggesting that the presence of SACQ is not limited to adults with SLE. Serologic markers such as increased ESR, hemoglobin, and elevated anti-dsDNA antibodies are preliminarily associated with pediatric SACQ episodes. Treating these SACQ episodes in pediatric SLE patients was less likely to lead to a clinical flare within six months when compared to not treating (p < 0.05). More research with a larger sample size is needed to define SACQ episodes, determine the prevalence in pediatric SLE patients, and establish SACQ treatment guidelines.

Response to treatment with intra-articular triamcinolone hexacetonide and triamcinolone acetonide in oligo articular juvenile idiopathic arthritis.

BACKGROUND: Oligo-articular juvenile idiopathic arthritis (Oligo JIA) is the most common subtype of juvenile idiopathic arthritis. Intra-articular corticosteroid (IAC) injection is a mainstay treatment of oligo JIA providing pain relief, improving mobility and preventing further joint destruction in the majority of patients. In 2015, production of triamcinolone hexacetonide (TH) an intra-articular corticosteroid was discontinued in the United States leading to use of triamcinolone acetonide (TA) as an alternative. In this study, we compared response to treatment in children with oligo JIA who underwent therapy with intra-articular TA and TH injection. METHODS: Our study is a retrospective chart review of children with oligo JIA who were treated with IAC injections with TH between January 2012 and June 2015 and TA between J uly 2015 and December 2018. The two groups were followed at John R. Oishei Children's Hospital of Buffalo and were evaluated for response to treatment, side effects and predictors of response including duration of disease before treatment, erythrocyte sedimentation rate (ESR), and c-reactive protein (CRP). Response to treatment was defined as at least 6 months follow up without evidence of active arthritis in injected joints. Patients were considered to be non-responders if they continued to show active arthritis during their first follow up after joint injection. The primary objective was to evaluate whether there was a significant difference in rate of response between TH and TA. RESULTS: Forty-nine patients, 38 female and 11 male with oligo JIA were included in the study. The average age was 6.7 years. A total of 111 joints were injected includin g 78 knees, 13 ankles, 9 wrists, 4 hips, 4 elbows, 2 TMJ and one subtalar joint. In the TA group, 49% (29/59) did not show response to injection compared to 27% (14/52) in the TH group. After 6 months, response rates were better for individuals injected with TH compared to TA (73% vs. 51%). In general, response to intra-articular TH was superior to TA with P = .016 using chi-square test of independence. This difference in outcome was not influenced by other variables such as duration of illness before treatment (P value 0.784) or elevated ESR and CRP. No difference in side effects between the two groups were noted. CONCLUSION: Our results in conjunction with prior published data suggests that TH intra-articular joint injection in oligo JIA is superior to TA, although future controlled trials are necessary for confirmation. An effective, long lasting treatment can have a great impact on the outcome of these children.

Using Low-Cost Models for Training First-Year Pediatric Residents on 4 Accreditation Council for Graduate Medical Education-Required Procedures: A Pilot Study.

OBJECTIVES: The aims of the study were to assess the feasibility of using low-cost models to train first-year pediatric residents and to examine whether residents who receive such training will be as competent as their experienced colleagues in performing 4 American College of Graduate Education-required procedures, including suturing, splinting, lumbar puncture, and venipuncture. METHODS: We performed a pilot study with postgraduate year (PGY) 1 to 3 residents. Postgraduate year 1 residents completed a self-assessment questionnaire before the onset of training. A lecture was given to all PGY levels residents about procedural techniques. The PGY-1 residents practiced these techniques on low-fidelity models immediately after the lecture. One and 9 months after the initial lecture, all residents were assessed on these models using a 10-point checklist for each skill. RESULTS: Thirteen PGY-1 residents, 10 PGY-2 residents, and 10 PGY-3 residents completed the study. There was no statistically significant difference in performance of PGY-1 residents when compared with PGY-2 and PGY-3 residents in performing lumbar puncture, venipuncture, and suturing on models in the initial assessment that was performed 1 month after the lecture. Postgraduate year 1 residents performed equally well to PGY-3 residents and significantly (P < 0.05) better than PGY-2 residents, in splinting.There was no statistically significant difference between groups at final follow-up, supporting that training on models could help enhance proficiency among residents. CONCLUSIONS: This pilot study supports the feasibility of using low-cost models to train residents on invasive and painful procedures. Furthermore, residents trained on models showed maintenance of skills for a 9-month period.

Antibiotic Treatments and Patient Outcomes in Necrotizing Enterocolitis.

OBJECTIVE: This study aimed to examine the impact of different antibiotic treatments on necrotizing enterocolitis (NEC) outcomes. STUDY DESIGN: Patient outcomes, including total parenteral nutrition and hospitalization durations, abdominal surgeries, intestinal strictures, and mortality data, were analyzed and compared by various antibiotic groups and treatment durations for 160 NEC patients managed at the Women and Children's Hospital of Buffalo between 2008 and 2016. RESULTS: Fourteen different antibiotics were used for NEC, most commonly ampicillin, gentamicin, and metronidazole (AGM). Medical (vs. surgical) NEC patients more likely received AGM (37 vs. 6%, p < 0.001). Surgical (vs. medical) NEC patients more likely received vancomycin (80 vs. 30%, p < 0.001) and antipseudomonal agents (69 vs. 15%, p < 0.001). For medical NEC there were no outcome differences between patients receiving only AGM versus those receiving other treatments; in patients receiving AGM, there were no outcome differences in durations of ≤10 days versus longer courses. CONCLUSION: Antibiotic use for NEC varies substantially without definite outcome differences. Particularly with medical NEC, AGM for ≤10 days had comparable outcomes to other treatments. In light of growing concern for short and longer term adverse effects with early-life antibiotic exposure, narrow-spectrum and shorter course NEC treatment may be preferred.

Lyme Arthritis in Children on the Uptick in Western New York Area.

OBJECTIVE: This study explores a suspected increasing incidence of Lyme arthritis in the Western New York pediatric population. In addition, we aim to describe a clinical picture of Lyme arthritis and the clinical features that distinguish it from other forms of arthritis. METHODS: Patients diagnosed with Lyme arthritis between January 2014 and September 2018 were identified using International Classification of Diseases-10th Revision (ICD 10) codes for Lyme disease and Lyme arthritis. Patients were included in the study if they (1) exhibited arthritis, (2) tested positive for Lyme antibodies, and (3) exhibited a positive Western blot. RESULTS: A total of 22 patients were included in the study. There was a general trend toward an increasing number of cases of Lyme arthritis over the 45-month observation period. We identified 1 case in each 2014 and 2015, 4 cases in 2016, 7 in 2017, and 9 in the first 9 months of 2018. In total, 17 patients had arthritis as their only symptom at the time of diagnosis and 10 patients had a rash or a history that prompted suspicion of Lyme disease. The knee was the most frequent joint (86.4% of patients), and patients typically had 2 or fewer joints affected (86.4% of patients). CONCLUSIONS: A significant increase (P = .02) in Lyme arthritis cases was observed at Oishei Children's Hospital of Buffalo. Lyme arthritis may clinically present similarly to other forms of arthritis, such as oligoarticular juvenile idiopathic arthritis, so health care providers should be aware of distinguishing clinical features, which include rapid onset of swelling and patient age. Because the geographic area of endemic Lyme disease is expanding, all health care providers need to be aware of Lyme arthritis as a possible diagnosis.

Occult Head Injury in Children Less Than 2 Years With Suspected Child Abuse in the Emergency Department.

OBJECTIVE: This study aims to determine the frequency of clinically significant findings requiring emergent neurosurgical intervention on computed tomography (CT) in neurologically intact children admitted to the hospital with suspected abuse. METHODS: This was a retrospective review of neurologically stable children (0-24 months) in whom both skeletal survey and CT head were performed for child abuse evaluation from 2000 to 2011. RESULTS: A total of 132 patients met inclusion criteria (mean age, 7.6 mo; 55% male, 52% Caucasian, and 34% African-American). Computed tomography scans demonstrated occult head injury in 5%; none required neurosurgical intervention or had any neurological deterioration. Average length of stay was 4 days, with average time to CT scan being 12.8 hours from triage, and average time to magnetic resonance imaging (MRI) scan of 70.5 hours. Five MRIs were performed, and 4 had identical results on CT scan. CONCLUSIONS: No clinically significant brain injury (requiring intervention) was seen in this cohort. These findings support delaying imaging in neurologically intact children to obtain MRI after hospital admission, thus, limiting radiation exposure.