Pediatric Residency Preparedness for Pediatric Emergency Medicine Fellowship.

OBJECTIVE: The aim of the study was to examine the perception of pediatric emergency medicine (PEM) program directors (PDs), associate PDs (APDs) and first-year fellows regarding the preparedness of new PEM fellows who have graduated from pediatric residency programs. METHODS: Unique surveys were created and electronically distributed to PEM PDs/APDs and first-year PEM fellows. Individual and institutional demographic information was collected. Using a 5-point Likert scale, survey items centered the perceived preparedness of first-year PEM fellows within 5 domains: professionalism, independence/autonomy, psychomotor skills, clinical evaluation and management, and academia/scholarship. RESULTS: Forty percent (48/119) of eligible PDs and APDs and 56% (82/147) of eligible first-year PEM fellows responded. Most PDs/APDs strongly agreed or agreed that incoming fellows perform adequately in areas of professionalism, independence/autonomy, and clinical evaluation and management. The PDs/APDs perceived fellows to be less prepared in the academia/scholarship domain and several psychomotor skills. Most first-year PEM fellows perceived themselves as prepared in areas of professionalism and clinical evaluation and management. Fellows had varied feelings of preparedness in the domains of independence/autonomy, psychomotor skills, and academia/scholarship. Overall, most PDs/APDs (54%) and fellows (84%) feel that pediatric residency training was strong or very strong. CONCLUSIONS: Most respondents in both groups felt that in general, pediatric residency programs adequately train residents for PEM fellowship. Both groups felt that the strengths of general pediatric training were among the domains of professionalism and clinical evaluation and management, whereas psychomotor skills and academia and scholarship were areas of improvement. These findings may be used by general pediatric residency and PEM fellowship programs to guide curriculum development.

Agreement With Pediatric Suprapatellar Bursa Effusion Assessments by Point-of-Care Ultrasound After Remote Training.

BACKGROUND: The ease of instruction for point-of-care ultrasound (POCUS) to detect suprapatellar bursa (SPB) effusions in pediatric patients is unknown. Considering in person limitations because of the coronavirus pandemic, strategies for POCUS education by remote learning are necessary. METHODS: We crafted a 90-minute didactic training that was presented via a remote learning format. The main outcome of interest was the interobserver reliability of SPB effusion assessment by novice sonologists compared with POCUS faculty. Novice sonologists were pediatric emergency medicine (PEM) fellows. Pediatric emergency medicine fellows interpreted longitudinal SPB examinations obtained in our pediatric emergency department from July 2013 to June 2020. Assessments were performed 2 months after the remote training. Pediatric emergency medicine fellows had a limited experience performing these musculoskeletal scans and were blinded to POCUS faculty and each other's assessments. Interobserver reliability was assessed with Cohen κ coefficient. Second, we calculated test characteristics of knee radiography compared with PEM POCUS faculty determination of SPB effusion by ultrasound. We further explored how effusion size measured by POCUS impacted the diagnosis by knee radiography. A receiver operator characteristic curve of knee radiography diagnosis of SPB effusion was created using the maximal height of SPB effusion by POCUS as the predictor variable. RESULTS: A total of 116 SPB scans in 71 patients were assessed. From this group, 70 scans were of affected knees and 46 scans were of contralateral, asymptomatic knees. The mean age of patients was 10 years and 46% were girl. The prevalence of SPB effusions was 42%. The κ coefficients between the 3 novice sonologists and POCUS faculty were 0.75 (0.62-0.87), 0.77 (0.65-0.89), and 0.83 (0.72-0.93) with 88%, 89%, and 91% agreement. Knee radiography exhibited an overall sensitivity of 65% (95% confidence interval [CI], 46-79%), specificity of 84% (95% CI, 60-97%), negative predictive value of 55% (95% CI, 43-66%), and positive predictive value of 88% (95% CI, 73-96%) to diagnose SPB effusions. The area under the receiver operator characteristic curve was 0.850. With an SPB height cutoff of 4 mm as true positives, radiography had a sensitivity of 81% and a specificity of 83%. CONCLUSIONS: After a remote teleconference didactic session, PEM fellows were able to successfully diagnose SPB effusions using a longitudinal view with substantial interobserver reliability. Knee radiography exhibited limited sensitivity to rule out SPB effusions.

A Workplace Procedure Training Cart to Augment Pediatric Resident Procedural Learning.

OBJECTIVE: Our primary aim was to describe pediatric residents' use of a workplace procedural training cart. An exploratory aim was to examine if the cart associated with increased resident procedural experiences with real patients. METHODS: Guided by the procedural training construct of "Learn, See, Practice, Prove, Do, Maintain," we created a novel workplace procedural training cart with videos (learn and see) and simulation equipment (practice and prove). An electronic logbook recorded resident use data, and a brief survey solicited residents' perceptions of the cart's educational impact. We queried our electronic medical record to compare the proportion of real procedures completed by residents before and after the intervention. RESULTS: From August 1 to December 31, 2019, 24 pediatric residents (10 interns and 14 seniors) rotated in the pediatric emergency department. Twenty-one cart encounters were logged, mostly by interns (67% [14/21]). The 21 cart encounters yielded 32 learning activities (8 videos watched and 24 procedures practiced), reflecting the residents' interest in laceration repair (50% [4/8], 54% [13/24]) and lumbar puncture (38% [3/8], 33% [8/24]). All users agreed (29% [6/21]) or strongly agreed (71% [15/21]) the cart encouraged practice and improved confidence in independently performing procedures. No changes were observed in the proportion of actual procedures completed by residents. CONCLUSIONS: A workplace procedural training cart was used mostly by pediatric interns. The cart cultivated residents' perceived confidence in real procedures but was not used by all residents or influenced residents' procedural behaviors in the pediatric emergency department.

Evaluation of Hip Pain and Management of Toxic Synovitis in the Ultrasound Era.

ABSTRACT: The cause of acute onset hip pain in children can be difficult to determine. Once trauma is excluded, the workup revolves around determining whether there is a hip effusion and eliminating orthopedic emergencies. Point-of-care-ultrasound can be used as an adjunct in the workup. In this article, we review (1) differential diagnosis of hip pain, with a focus on toxic synovitis; (2) the evaluation of a hip for the presence of effusion, including the point-of-care ultrasound technique; and (3) the management of toxic synovitis.

Analytical Evaluation of Vitamin D Measurements in Routine Laboratories.

BACKGROUND: Its increasing clinical importance has turned 25-hydroxy-Vitamin D (25(OH)D) into an indispensable test in clinical laboratories. In this study, we aimed to analyze the analytical performances of two widely used immunoassays, namely new restandardized Abbott product Architect 25-OH Vitamin D test and the Beckman Coulter product Access 25(OH) Vitamin D Total Test by making comparisons with the reference method liquid chromatography tandem mass spectrometry (LC-MS/MS). METHODS: The new restandardized Architect I2000SR System (Abbott Laboratories, IL, USA; ref 5P02) and Access2 (Beckman Coulter, Brea, CA, USA; ref B24838) immunoassay were compared with LC-MS/MS (Shimadzu LCMS-8030, Kyoto, Japan) method 25(OH)D test for precision and reproducibility in 90 serum samples. In comparison with reference method, Deming Regression analysis and Bland Altman graphs were used. RESULTS: Within run coefficient of variation (CV%) for Architect was found to be lower than 3.1%. Within run coefficient of variation (CV%) for Access2 was lower than 7.04%. When compared with LC-MS/MS, R value of Architect 25-OH Vitamin D kit was 0.911 (intercept 1.62, slope 1.06), mean bias was -0.04% and for Access 25(OH) Vitamin D Total kit, R value was 0.841 (intercept 9.43, slope 0.92) and mean bias of 6.9%. CONCLUSIONS: When renewed 5P02 Abbott Architect 25(OH)D and Beckman Coulter Access2 25(OH)D Total tests were compared with LC-MS/MS method in our study, they were found to have appropriate analytical values.

A specific folate activates serotonergic neurons to control C. elegans behavior.

Folates are B-group vitamins that function in one-carbon metabolism. Here we show that a specific folate can activate serotonergic neurons in C. elegans to modulate behavior through a pathway that requires the folate receptor FOLR-1 and the GON-2 calcium channel. FOLR-1 and GON-2 physically interact in a heterologous system, and both are expressed in the HSN and NSM serotonergic neurons. Both the folate 10-formyl-THF and a non-metabolic pteroate induce increases in the number of Ca2+ transients in the HSN neurons and egg laying in an FOLR-1- and GON-2-dependent manner. FOLR-1 and GON-2 are required for the activation of the NSM neurons in response to 10-formyl-THF, and for full NSM-mediated stoppage of movement when starved animals encounter bacteria. Our results demonstrate that FOLR-1 acts independently of one-carbon metabolism and suggest that 10-formyl-THF acts as a dietary signal that activates serotonergic neurons to impact behavior through a pathway that involves calcium entry.

Histological Investigation of the Cleaning Effectiveness of Different Biomechanic Processes of Isthmus in Lower Molars.

OBJECTIVES: This study aimed to evaluate the efficacy of different instruments (Hyflex, ROTATE, and hand files) and irrigation methods (EndoUltra, EndoActivator, and side-perforated syringe) in the mesial root canal of a mandibular first molar with isthmuses. MATERIALS AND METHODS: Sixty-three mandibular molar teeth with isthmus were selected using cone beam computed tomography (CBCT) images. The root canals were instrumented with Hyflex, ROTATE, or hand files (21 of each) and three of each as control group and the specimens were embedded in silicone blocks. Final irrigation was performed with the perforated syringe or ultrasonic (EndoUltra) or sonic irrigation (EndoActivator). All canals were irrigated using 5.25% NaOCl solution (15 mL). Then, the roots were stained with hematoxylin-eosin, and specimens were sliced for histologic evaluation. The isthmus regions (2.7, 3, 4.7, and 5 mm from the apex) were analyzed, and the percentage of debris was calculated. STATISTICAL ANALYSIS: All data were statistically analyzed using one-way analysis of variance and Tukey's tests. RESULTS: Both Hyflex and ROTATE groups showed less debris compared with the hand instrument group (P < 0.05). When irrigation methods were compared, EndoUltra showed the least, followed by EndoActivator and perforated needle irrigation having the maximum debris (p < 0.05). When sections were compared, the maximum debris was found in the apical section and the least in the coronal section (p < 0.05). CONCLUSION: Although none of the methods cleaned the isthmus completely, nickel-titanium (NiTi) systems and ultrasonic and sonic systems removed more debris than the side-perforated needle syringe irrigation.

Preparedness for Pediatric Office Emergencies: A Multicenter, Simulation-Based Study.

OBJECTIVES: Pediatric emergencies can occur in pediatric primary care offices. However, few studies have measured emergency preparedness, or the processes of emergency care, provided in the pediatric office setting. In this study, we aimed to measure emergency preparedness and care in a national cohort of pediatric offices. METHODS: This was a multicenter study conducted over 15 months. Emergency preparedness scores were calculated as a percentage adherence to 2 checklists on the basis of the American Academy of Pediatrics guidelines (essential equipment and supplies and policies and protocols checklists). To measure the quality of emergency care, we recruited office teams for simulation sessions consisting of 2 patients: a child with respiratory distress and a child with a seizure. An unweighted percentage of adherence to checklists for each case was calculated. RESULTS: Forty-eight teams from 42 offices across 9 states participated. The mean emergency preparedness score was 74.7% (SD: 12.9). The mean essential equipment and supplies subscore was 82.2% (SD: 15.1), and the mean policies and protocols subscore was 57.1% (SD: 25.6). Multivariable analyses revealed that independent practices and smaller total staff size were associated with lower preparedness. The median asthma case performance score was 63.6% (interquartile range: 43.2-81.2), whereas the median seizure case score was 69.2% (interquartile range: 46.2-80.8). Offices that had a standardized process of contacting emergency medical services (EMS) had a higher rate of activating EMS during the simulations. CONCLUSIONS: Pediatric office preparedness remains suboptimal in a multicenter cohort, especially in smaller, independent practices. Academic and community partnerships using simulation can help address gaps and implement important processes like contacting EMS.

Analytical performance evaluation of Sysmex CS-2500 and Stago STA Compact.

: The Sysmex Coagulation System-2500 (CS-2500) is a fully automated coagulation analyzer that uses the optical reaction method. In this study, we aimed to evaluate performance characteristics of the CS-2500 in two coagulation tests [prothrombin time (PT) and activated partial thromboplastin time (aPTT)] at our hospital laboratory. PT and aPTT measurements were performed using the CS-2500 and STA-Compact Diagnostica Stago coagulometers (STA-Compact). Then, precision, accuracy, reference range verification, and method comparison statistics were performed. In the precision study, which was performed with normal and pathologic controls for the PT-international normalized ratio (INR) and aPTT tests, all coefficient of variation% were found less than 3.5%. In the comparison study, the Passing-Bablok regression analysis demonstrated the good agreement between each analyzer for PT-INR (y = -0.081 + 1.07x and r = 0.962) and for aPTT (y = 5.498 + 0.86x and r = 0.944). Both analyzers exhibited less than 9.9% bias in the accuracy study. The reference range verification analyses revealed that the manufacturer ranges were acceptable. The verification studies of the CS-2500 coagulation system were acceptable; however, in the comparison studies, there were small differences between STA-Compact. Overall, we propose that these differences could be eliminated in future standardization studies performed to use the same reference ranges for all systems.

[Non traumatic high flow priapism: arterial embolization treatment]. / Priapisme à haut débit non traumatique: traitement par embolisation artérielle.

PURPOSE: To report cases of non traumatic high flow priapism treated by arterial embolization. MATERIAL AND METHODS: Six men presented with non traumatic high flow priapism, the diagnosis was based on colour Doppler ultrasound, cavernous blood gas analysis with arterial blood saturation levels and failed medical or surgical therapy. Four patients had sickle cell disease. The embolization was performed with Gelfoam and was unilateral in one case, bilateral in the other cases. RESULTS: Detumescence occurred in a few hours in all cases. One patient had recurrent priapism two years after and was treated by embolization. Transient erectile dysfunction was observed in five cases, permanent in one case. CONCLUSION: Arterial embolization is the treatment of choice in high flow priapism with low rate of permanent erectile dysfunction.

Behavioral Interventions to Improve Asthma Outcomes for Adolescents: A Systematic Review.

BACKGROUND: Factors at multiple ecological levels, including the child, family, home, medical care, and community, impact adolescent asthma outcomes. OBJECTIVE: This systematic review characterizes behavioral interventions at the child, family, home, medical system, and community level to improve asthma management among adolescents. METHODS: A systematic search of PubMed, SCOPUS, OVID, PsycINFO, CINAHL, and reference review databases was conducted from January 1, 2000, through August 10, 2014. Articles were included if the title or abstract included asthma AND intervention AND (education OR self-management OR behavioral OR technology OR trigger reduction), and the mean and/or median age of participants was between 11 and 16 years. We compared populations, intervention characteristics, study designs, outcomes, settings, and intervention levels across studies to evaluate behavioral interventions to improve asthma management for adolescents. RESULTS: Of 1230 articles identified and reviewed, 24 articles (21 unique studies) met inclusion criteria. Promising approaches to improving adherence to daily controller medications include objective monitoring of inhaled corticosteroid adherence with allergist and/or immunologist feedback on medication-taking behavior and school nurse directly observed therapy. Efficacy at increasing asthma self-management skills was demonstrated using group interactive learning in the school setting. This systematic review is not a meta-analysis, thus limiting its quantitative assessment of studies. Publication bias may also limit our findings. CONCLUSIONS: Novel strategies to objectively increase controller medication adherence for adolescents include allergist and/or immunologist feedback and school nurse directly observed therapy. Schools, the most common setting across studies in this review, provide the opportunity for group interactive learning to improve asthma knowledge and self-management skills.

Prostate-specific antigen bounce after curative brachytherapy for early-stage prostate cancer: A study of 274 African-Caribbean patients.

BACKGROUND: Prostate cancer incidence in the African-Caribbean population ranks among the highest worldwide. We aim to evaluate the prostate-specific antigen (PSA) kinetics after brachytherapy, which so far remains unknown in this population. METHODS AND MATERIALS: From 2005 to 2013, 371 patients received (125)I brachytherapy of 145 Gy for early-stage prostate cancer. Eligibility criteria were cTNM ≤T2c, Gleason score ≤7, and initial PSA ≤15 ng/mL. Pretreatment androgen deprivation therapy was allowed. PSA bounce was defined as an increase of ≥0.4 ng/mL, lasting ≥6 months, followed by a decrease without any anticancer therapy. We examined PSA kinetics during followup. RESULTS: For the 274 patients with at least 24 months followup, median age was 62 years old (range, 45-76). Initial PSA was <10 ng/mL in 244 and 10-15 ng/mL in 30 patients; 40 received androgen deprivation therapy. With a median followup of 50 months (range, 24-125), PSA declined continuously in 168 (61%) patients, bounced in 87 (31%), and initially declined and then rose in 22 (8%) patients. Among these latter patients, 18 presented clinical recurrence. Mean bounce intensity was 2.0 ng/mL (median, 1.2; range, 0.4-12.4). Bounces occurred in average 12 months after brachytherapy. Patients with bounce were significantly younger: mean age 59 vs. 63 years old in patients without bounce, p <0.001. Bounce was also significantly associated with the immediate post-brachytherapy PSA, mean 4.0 among bounce cases vs. 2.9 among non-bounce cases, p < 0.001. Bounce was not associated with recurrence. CONCLUSIONS: PSA bounce in our African-Caribbean population seemed earlier and was more intense than described in other populations. Early increase of PSA should not be ascribed to treatment failure.

Visual object detection, categorization, and identification tasks are associated with different time courses and sensitivities.

Recent evidence suggests that the recognition of an object's presence and its explicit recognition are temporally closely related. Here we re-examined the time course (using a fine and a coarse temporal resolution) and the sensitivity of three possible component processes of visual object recognition. In particular, participants saw briefly presented (Experiment I to III) or noise masked (Experiment IV) static images of objects and non-object textures. Participants reported the presence of an object, its basic level category, and its subordinate category while we measured recognition performance by means of accuracy and reaction times. All three recognition tasks were clearly separable in terms of their time course and sensitivity. Finally, the use of a coarser temporal sampling of presentation times decreased performance differences between the detection and basic level categorization task suggesting that a fine temporal sampling for the dissociation of recognition performances is important. Overall the three probed recognition processes were associated with different time courses and sensitivities.

Why pesticides could be a common cause of prostate and breast cancers in the French Caribbean Island, Martinique. An overview on key mechanisms of pesticide-induced cancer.

Prostate and breast cancers have become very frequent in Martinique. We previously conducted a multifactorial analysis in the French Caribbean Island, Martinique, in order to elucidate the aetiology of prostate cancer. Using a linear regression analysis, we found that the growth curves of incidence rates for Martinique and metropolitan France have been significantly diverging since 1983. Although a Caribbean genetic susceptibility factor may be involved in prostate carcinogenesis: this factor, because it could not have changed during the observation period, cannot per se account for the growing incidence of this cancer in the island. We therefore suggested that among possible environmental factors, the intensive and prolonged exposure to Carcinogenic, Mutagenic and/or Reprotoxic (CMR) or presumed CMR pesticides may account for the observed growing incidence of prostate cancer and thus may be involved in prostate carcinogenesis. In this study, we further attempt to show that due to their carcinogenic properties, pesticides and especially organochlorine pesticides may in fact be causally implicated in the growing incidence of prostate cancer in Martinique. Also, we suggest that CMR or presumed CMR pesticides may be causally involved in the growing incidence of breast cancer through a common endocrine disruption mechanism. We therefore propose that protective medical recommendations should be immediately set up and carried out by general practitioners, paediatricians, obstetricians, gynaecologists and urologists; and that public health measures of primary precaution and prevention should be urgently taken in close collaboration with health professionals in order to protect population, more especially pregnant women and children, with the final objective perhaps that these medical recommendations and public health measures will stop Martinique's cancer epidemic.

Involution of the rat thymus in experimentally induced hypothyroidism.

The thymus, as part of the immune-neuroendocrine axis, is greatly influenced by factors from most endocrine glands, especially the thyroid. Antithyroid drugs (carbimazole and methimazole) were used to induce hypothyroidism in rats. Histological and ultrastructural examination of the thymus showed progressive thymic involution after 4 weeks of drug treatment to the end of observations (7 weeks). The involution was characterised by increased thymocyte apoptosis and thymocyte phagocytosis by macrophages. This resulted in thymocyte depopulation, increases in numbers of interdigitating cells, alterations to mainly subcapsular and medullary epithelial cells, an apparent increase of mast cells and collagen in the capsule and septa, and increased numbers of B cells and plasma cells. Lymphoid cells immuno-reactive with MRC OX12 (which detects B cells) were observed within blood vessel walls, suggesting that they may have been moving in and out of the thymus. The administration of drugs causing hypothyroidism, therefore, also caused marked involution of the thymus.