Retinal Hemorrhages: Abusive Head Trauma or Not?

Abusive head trauma is an important cause of morbidity and mortality in infants and young children. Retinal hemorrhages (RHs) are frequently seen, particularly during dilated eye examination of these children. This review focuses on the evaluation of children with RH, with emphasis on the differential diagnosis, pathophysiology, and distinguishing features of RHs due to abusive head trauma. Many causes exist for RHs in infants and children. Most medical and accidental traumatic causes result in a pattern of RH that is nonspecific and not typical of the pattern and distribution of RHs seen in children with abusive head trauma. In children with intracranial hemorrhage and concerns for abuse, the finding of severe, multilayered RHs extending to the periphery of the retina is very specific for abuse as the cause of the findings, especially if retinoschisis is present. There are few other accidental traumatic mechanisms associated with retinoschisis, and the history of such a traumatic event is readily apparent. The indications for ophthalmologic consult, optimal timing of the eye examination, and significance of the findings are specifically discussed.

Two Year Old With Water Bead Ingestion.

Foreign body ingestion is a common pediatric complaint. Two case reports describe intestinal obstruction in children from an ingestion of a single superabsorbent water ball, requiring surgical removal. We describe nonsurgical management of an asymptomatic child who ingested approximately 100 superabsorbent water beads.Because of the risk for subsequent intestinal obstruction, the patient was admitted for whole bowel irrigation. This case report is the first describing use of whole bowel irrigation in the management of an asymptomatic patient with multiple water beads ingestion.

Does active dissemination of evidence result in faster knowledge transfer than passive diffusion?: An analysis of trends of the management of pediatric asthma and croup in US emergency departments from 1995 to 2009.

OBJECTIVE: This study aimed to compare knowledge transfer (KT) in the emergency department (ED) management of pediatric asthma and croup by measuring trends in corticosteroid use for both conditions in EDs. METHODS: A retrospective, cross-sectional study of the National Hospital Ambulatory Medical Care Survey data between 1995 and 2009 of corticosteroid use at ED visits for asthma or croup was conducted. Odds ratios (OR) were calculated using logistic regression. Trends over time were compared using an interaction term between disease and year and were adjusted for all other covariates in the model. We included children aged 2 to 18 years with asthma who received albuterol and were triaged emergent/urgent. Children aged between 3 months to 6 years with croup were included. The main outcome measure was the administration of corticosteroids in the ED or as a prescription at the ED visit. RESULTS: The corticosteroid use in asthma visits increased from 44% to 67% and from 32% to 56% for croup. After adjusting for patient and hospital factors, this trend was significant both for asthma (OR, 1.07; 95% confidence interval [CI], 1.04-1.10) and croup (OR, 1.07; 95% CI, 1.03-1.12). There was no statistical difference between the 2 trends (P = 0.69). Hospital location in a metropolitan statistical area was associated with increased corticosteroid use in asthma (OR, 1.76; 95% CI, 1.10-2.82). Factors including sex, ethnicity, insurance, or region of the country were not significantly associated with corticosteroid use. CONCLUSIONS: During a 15-year period, knowledge transfer by passive diffusion or active guideline dissemination resulted in similar trends of corticosteroid use for the management of pediatric asthma and croup.

Pediatric blast lung injury from a fireworks-related explosion.

Blast injuries related to explosions have been described in the literature but are uncommon in children. We describe a multisystem blast injury in a child resulting from a commercial firework-related explosion in her home. She presented with respiratory failure, shock, altered level of consciousness, and multiple orthopedic injuries. The patient required immediate stabilization and resuscitation in the emergency department and a prolonged hospitalization. This report reviews the spectrum of injuries that are seen in blast-related trauma and the emergency measures needed for rapid stabilization of these critical patients.

Case records of the Children's Mercy Hospital: A 12-year-old girl with a straddle injury.

Straddle injuries are common in children. At the end of this case presentation, you should be able to describe the approach to the evaluation and treatment of a straddle injury, list indications for gynecologic consultation and/or sedation, plan disposition, and discuss pitfalls to avoid in evaluating patients with straddle injuries.

Current Milestones Assessment Practices, Needs, and Challenges of Program Directors: A Collective Case Study in a Pediatric Hospital Setting.

Introduction Accreditation Council for Graduate Medical Education's (ACGME's) Milestones assessment requirement has placed new demands on Program Directors (PDs), especially those with limited knowledge of assessment and evaluation activities. There is a lack of clarity on how Program Director (PDs)/Associate PDs (APDs) are effectively implementing milestones assessment and evaluation practices in the Graduate Medical Education programs. The purpose of this study was to investigate current assessment practices, needs, and challenges of PDs in implementing milestones assessment within their residency and fellowship programs in a pediatric hospital setting. Methods This study used a collective case study approach to obtain information from PDs, APDs, and Clinical Competency Committee (CCC) Chairs in 19 graduate programs at a pediatric hospital. We used structured meetings with planned agendas and a pre-formatted template to itemize program needs/difficulties/challenges in the milestone assessment. We used cross-case thematic content anal-ysis to identify categories and themes to compare differences and commonalities across programs. Results A total of 38 PDs, APDs, and CCC Chairs from 19 different specialties/subspe-cialties participated in this study. Thirteen types of assessment and evaluation tools were consistently used across programs. Three categories emerged in relation to those assessment and evaluation types (direct, indirect, and multi-source). Rotation evaluation (84.2%), direct observation (73.2%), and 360-degree assessment (68.4%) were primarily used for measuring patient care among the six core competencies. Programs' needs varied from curriculum and assessment tool development to alignment of milestones items, and to creating a sys-tematic assessment management plan. The most common challenges were difficulties related to logistics and tracking of evaluation in the survey management system (52.6%), challenges with time management (47.3%), and difficulty in determining and interpret-ing the milestones' numbers and levels (31.5%). Conclusions Milestones assessment and evaluation in medical education can be a challenge, but a priority for many training programs. Our study indicated that milestones assessment and evaluation in medical education are far more com-plex than we expect. Multiple assessment methods must be utilized to evaluate all essential competencies for accurate measurement of trainees' performance abilities. Our study uncovered several issues PDs faced during the implementation of milestones assessment and needs and challenges.

Benchmarks for the emergency department care of children with asthma, bronchiolitis, and croup.

OBJECTIVES: The objectives of this study were (1) to measure the 2005 performance of freestanding children's hospital emergency departments (EDs) in the care of children with asthma, bronchiolitis, and croup (ABC) using 5 clinical quality indicators and (2) to construct achievable benchmarks for 7 clinical quality indicators of ED care for children with ABC for 2005. METHODS: This was a retrospective review using the Pediatric Health Information System database containing information on 1,468,607 (2005) discharges. Performance on 5 established clinical quality indicators for ABC was determined in patients younger than 19 years at 27 hospital EDs in the United States. Benchmarks were computed for 7 clinical quality indicators. RESULTS: Corticosteroids were administered in 65.8% (95% confidence interval [CI], 65.2%-66.2%) of visits for moderate to severe asthma and in 82.5% (95% CI, 82.0%-83.0%) of visits for croup. Physicians ordered an x-ray in 28.6% (95% CI, 28.1%-29.0%) of asthma visits, 37.3% (95% CI, 36.7%-37.9%) of bronchiolitis visits, and in 9.1% (95% CI, 8.7%-9.5%) of croup visits. Benchmarks for corticosteroid administration were 79% and 92% for asthma and croup, respectively; benchmarks for ordering x-rays were 17% for both asthma and bronchiolitis and 2% for croup. Additional benchmarks for antibiotic administration in the ED for asthma and bronchiolitis were 1% and 2%, respectively. CONCLUSIONS: Variation exists among freestanding children's hospitals in the ED care for ABC, but the performance is better than previously reported national averages. We report achievable benchmarks for ED care based on objective clinical quality indicators.

Final evaluation of the 2005 to 2007 National Pediatric Emergency Medicine Fellows' Conferences.

OBJECTIVE: Evaluate the effectiveness of the 2005 to 2007 National Pediatric Emergency Medicine (PEM) Fellows Conference series in achieving predefined objectives in the domains of scholarship, leadership, and partnership. METHODS: Conference attendees included fellows in the existing PEM fellowship programs. Self-administered preconference and postconference questionnaires measured knowledge, research-related confidence, beliefs about institutional support for Emergency Medical Services for Children (EMSC) research, and intentions to engage in 7 specific behaviors relating to scholarship, leadership, and partnership. Pearson product-moment correlations measured relationships among continuous variables. Repeated-measures analysis of variance measured change between preconference and postconference measures. Hierarchical multiple linear regression models identified predictors of postconference intentions to engage in each of the 7 specific behaviors, controlling for preconference intention. RESULTS: Approximately one third of all PEM fellows attended the conference each year. Preconference and postconference questionnaires were completed by at least 70% of attendees each year. Because several fellows attended more than one conference, data were analyzed from the first conference that a fellow attended. In each year, we observed significant increases in attendees' conference-specific knowledge, confidence, and intentions to continue in EMSC research, join national collaborative research networks, and establish national mentoring relationships. CONCLUSIONS: The National PEM Fellows' Conference is an effective means to increasing fellows' knowledge about scholarship, leadership, and partnership in EMSC and increasing their confidence and intentions to conduct research in EMSC.

Outcomes evaluation of the 2005 National Pediatric Emergency Medicine Fellows' Conference.

OBJECTIVE: Evaluate the effectiveness of the 2005 National Pediatric Emergency Medicine Fellows' Conference in achieving predefined objectives in scholarship, leadership, and partnership. METHODS: Preconference and postconference questionnaires measured knowledge, research-related confidence, beliefs about institutional support for emergency medical services for children (EMSC) research, and intentions to engage in 7 specific behaviors relating to scholarship, leadership, and partnership. Bivariate correlations among the variables were assessed. Repeated-measures analysis of variance measured change between preconference and postconference measures. Hierarchical multiple linear regression models identified predictors of postconference intentions to engage in each of the 7 specific behaviors controlling for preconference intentions. RESULTS: Ninety-two pediatric emergency medicine fellows attended; more than 90% completed preconference and postconference questionnaires, and 88% completed both. Knowledge (P < 0.001) and confidence (P < 0.001) improved after the conference. Increases were observed in fellows' intentions to establish national mentoring relationships (P < 0.001), continue in EMSC research (P = 0.003), and participate in national collaborations (P = 0.022). Confidence and subjective norms correlated significantly (P < 0.05) with each of the behavioral intentions in bivariate tests. In the multivariable regression models, confidence correlated with 4 behavioral intentions (P < 0.02), and subjective norms correlated with one (P < 0.001). Forty-eight percent established a mentoring relationship with a faculty member; 25% planned to collaborate on research with other attendees. CONCLUSIONS: The 2005 National Pediatric Emergency Medicine Fellows' Conference resulted in positive, measurable outcomes relating to the professional development of attendees, including increased conference-specific knowledge, confidence, and intentions to continue in EMSC research, join national collaborative research networks, and establish national mentoring relationships.

Enhanced phosphorus nutrition in monocots and dicots over-expressing a phosphorus-responsive type I H+-pyrophosphatase.

Plants challenged by limited phosphorus undergo dramatic morphological and architectural changes in their root systems in order to increase their absorptive surface area. In this paper, it is shown that phosphorus deficiency results in increased expression of the type I H+-pyrophosphatase AVP1 (AVP, Arabidopsis vacuolar pyrophosphatase), subsequent increased P-type adenosine triphosphatase (P-ATPase)-mediated rhizosphere acidification and root proliferation. Molecular genetic manipulation of AVP1 expression in Arabidopsis, tomato and rice results in plants that outperform controls when challenged with limited phosphorus. However, AVP1 over-expression and the resulting rhizosphere acidification do not result in increased sensitivity to AlPO4, apparently because of the enhancement of potassium uptake and the release of organic acids. Thus, the over-expression of type I H+-pyrophosphatases appears to be a generally applicable technology to help alleviate agricultural losses in low-phosphorus tropical/subtropical soils and to reduce phosphorus runoff pollution of aquatic and marine environments resulting from fertilizer application.

Report of the National Consensus Conference on Family Presence During Pediatric Cardiopulmonary Resuscitation and Procedures.

Representatives from 18 national organizations were convened for a conference to develop recommendations regarding family presence (FP) during pediatric procedures and cardiopulmonary resuscitation. Before the conference, invitees were given a questionnaire and provided with current literature regarding FP. A modified Delphi process was used to develop consensus, including use of multiple questionnaires and breakouts for discussion of specific issues. Participants were encouraged to develop consensus recommendations based on the literature and discussions. Changes in attitude were tracked with repeat questionnaires. Results of the conference were circulated to participants for review and revision. Consensus recommendations include (1) consider FP as an option for families during pediatric procedures and cardiopulmonary resuscitation, (2) offer FP as an option after assessing factors that could adversely affect the interaction, (3) if family is not offered the option for FP, document the reasons why, (4) always consider the safety of the health care team, (5) develop in-hospital transport and transfer policies and procedures for FP, such as family member definition, preparation of the family, handling disagreements, and providing support for the staff, (6) obtain legal review of policies, (7) include education in FP in all core curricula and orientation for health care providers, (8) promote research into best methods for education; effects of FP on patients, family, and staff; best practices for FP; and legal issues regarding FP, among others. These recommendations were approved in concept by the American Academy of Pediatrics and the Ambulatory Pediatrics Association.

Mothers' and health care providers' perspectives on screening for intimate partner violence in a pediatric emergency department.

OBJECTIVE: To determine the attitudes, feelings, and beliefs of mothers and pediatric emergency department health care providers toward routine intimate partner violence screening. METHODS: This qualitative project employed focus groups of mothers who brought their children to a children's hospital emergency department for care, and physicians and nurses who staffed the same department. We held 6 ethnically homogeneous mother focus groups (2 white, 2 African American, and 2 Latina) and 4 provider focus groups (2 predominately female nurse focus groups and 2 physician groups: 1 male and 1 female). Professional moderators conducted the sessions using a semistructured discussion guide. All groups were audiotaped and videotaped, and tapes were reviewed for recurring themes. RESULTS: A total of 59 mothers, 21 nurses, and 17 physicians participated. Mothers identified intimate partner violence as a common problem in their communities, and most remarked that routine screening for adult intimate partner violence is an appropriate activity for a pediatric emergency department. However, many expressed concern that willingness to disclose might be affected by a fear of being reported to child protective services. They stressed the importance of addressing the child's health problem first, that screening be done in an empathetic way, and that immediate assistance be available if needed. Themes identified in the provider groups included concerns about time constraints, fear of offending, and concerns that unless immediate intervention was available, the victim could be placed in jeopardy. Many said they would feel obligated to notify child protective services on disclosure of intimate partner violence. CONCLUSIONS: Intimate partner violence screening protocols in the pediatric emergency department should take into consideration the beliefs and attitudes of both those doing the screening and those being screened. Those developing screening protocols for a pediatric emergency department should consider the following: (1) that those assigned to screen must demonstrate empathy, warmth, and a helping attitude; (2) the importance of addressing the child's medical needs first, and a screening process that is minimally disruptive to the emergency department; (3) a defined, organized approach to assessing danger to the child, and how and when it is appropriate to notify child protective services when a caregiver screens positive for intimate partner violence; and (4) that resources must be available immediately to a victim who requests them.

Handgun safety: what do consumers learn from gun dealers?

OBJECTIVE: To explore the type and quality of handgun safety information a typical consumer would obtain from a licensed gun dealer. METHODS: Semistructured, interactional on-site interviews were conducted with licensed handgun dealers in 2 metropolitan areas. A variety of dealers (gun shops, pawnshops, general merchandise stores, and sporting goods stores) were visited. Investigators posed as customers interested in buying a handgun. During the interview, investigators expressed concern that as the parent of a 4-year-old child, they needed suggestions about keeping their child safe with a gun in the home. Information collected included basic dealer demographics, opinions on whether a 4-year-old child could pull a handgun trigger, handgun safety advice and recommendations, and the type of safety devices and handgun safety educational materials that were available in the store. RESULTS: There were 96 visits made to gun dealers. The typical salesperson was a man who appeared to be older than 40 years. Trigger locks were the most common safety devices available. When asked what a consumer should know about purchasing a handgun, 85% of salespeople did not mention safe storage. Only 9 (9%) offered advice that included all of the following: keeping the gun securely locked, keeping the gun unloaded, and storing the gun separately from the ammunition. One third answered "no" or "don't know" or "uncertain" when asked if a 4-year-old could pull the trigger. The majority (92%) did not have any handgun safe storage educational materials on site. CONCLUSIONS: Salespeople offered potential buyers little or no education about safe storage of handguns. The information provided was often inconsistent with the recommendations of the American Academy of Pediatrics.

Variation and trends in ED use of radiographs for asthma, bronchiolitis, and croup in children.

OBJECTIVES: The objectives were (1) to determine trends in radiograph use in emergency department (ED) care of children with asthma, bronchiolitis, and croup; and (2) to examine the association of patient and hospital factors with variation in radiograph use. METHODS: A retrospective, cross-sectional study of National Hospital Ambulatory Medical Care Survey data between 1995 and 2009 on radiograph use at ED visits in children aged 2 to 18 years with asthma, aged 3 months to 1 year with bronchiolitis, and aged 3 months to 6 years with croup. Odds ratios (ORs) were calculated and adjusted for all factors studied. RESULTS: The use of radiographs for asthma increased significantly over time (OR: 1.06; 95% confidence interval [CI]: 1.03-1.09; P < .001 for trend) but were unchanged for bronchiolitis and croup. Pediatric-focused EDs had lower use for asthma (OR: 0.44; 95% CI: 0.29-0.68), bronchiolitis (OR: 0.37; 95% CI: 0.23-0.59), and croup (OR: 0.34; 95% CI: 0.17-0.68). Compared with the Northeast region, the Midwest and South had statistically higher use of radiographs for all 3 conditions. The Western region had higher use only for asthma (OR: 1.67; 95% CI: 1.07-2.60), and bronchiolitis (OR: 2.94; 95% CI: 1.48-5.87). No associations were seen for metropolitan statistical area or hospital ownership status. CONCLUSIONS: The ED use of radiographs for children with asthma increased significantly from 1995 to 2009. Reversing this trend could result in substantial cost savings and reduced radiation. Pediatric-focused EDs used significantly fewer radiographs for asthma, bronchiolitis, and croup. The translation of practices from pediatric-focused EDs to all EDs could improve performance.

Can incorporating inpatient overnight work hours into a pediatric clerkship improve the clerkship experience for students?

PURPOSE: After incorporating medical students into pediatric resident night-float teams, the authors studied the effects of the new schedule on (1) cognitive performance, (2) number of new admissions, (3) clerkship satisfaction, and (4) amount and quality of resident teaching. METHOD: Part 1 was a retrospective historical controls study. The intervention was a schedule change that eliminated inpatient call. The historical control group had a four-week inpatient schedule of daytime hours plus five calls (DT+C). The comparison group had a schedule of three weeks of daytime hours plus five consecutive overnight shifts (DT+OS). National Board of Medical Examiners (NBME) Pediatrics Subject Exam scores, number of admission history and physicals (HPEs), and clerkship satisfaction data from both groups were compared. Part 2 was a two-item survey with open-ended comments that measured perceptions of resident teaching time and quality of resident teaching (QRT) from students on the DT+OS schedule. RESULTS: DT+OS students had a significantly increased number of HPEs (t=2.17; P=.03) compared with the DT+C group (mean=7.49, standard deviation [SD]=3.34 in DT+OS versus mean=6.11, SD=2.95 in DT+C). The paired samples t test showed that students rated QRT significantly higher when on overnights than when they were on daytime hours (t=2.47; P=.02). There were no differences in satisfaction or NBME scores. CONCLUSION: Overnight work hours for medical students increased clerkship capacity while maintaining student satisfaction and cognitive performance. Added benefits included increased clinical experience and improved QRT.