Advances in pediatric emergency from 2023.

Most children receive emergency care by general emergency physicians and not in designated children's hospitals. There are unique considerations in the care of children that differ from the care of adults. Many management principles can be extrapolated from adult studies, but the unique pathophysiology of pediatric disease requires specialized attention and management updates. This article highlights ten impactful articles from the year 2023 whose findings can improve the care of children in the Emergency Department (ED). These studies address pediatric resuscitation, traumatic arrest, septic shock, airway management, nailbed injuries, bronchiolitis, infant fever, cervical spine injuries, and cancer risk from radiation (Table 1). The findings in these articles have the potential to impact the evaluation and management of children (Table 2).

Industry 5 and the Human in Human-Centric Manufacturing.

Industry 4 (I4) was a revolutionary new stage for technological progress in manufacturing which promised a new level of interconnectedness between a diverse range of technologies. Sensors, as a point technology, play an important role in these developments, facilitating human-machine interaction and enabling data collection for system-level technologies. Concerns for human labour working in I4 environments (e.g., health and safety, data generation and extraction) are acknowledged by Industry 5 (I5), an update of I4 which promises greater attention to human-machine relations through a values-driven approach to collaboration and co-design. This article explores how engineering experts integrate values promoted by policy-makers into both their thinking about the human in their work and in their writing. This paper demonstrates a novel interdisciplinary approach in which an awareness of different disciplinary epistemic values associated with humans and work guides a systematic literature review and interpretive coding of practice-focussed engineering papers. Findings demonstrate evidence of an I5 human-centric approach: a high value for employees as "end-users" of innovative systems in manufacturing; and an increase in output addressing human activity in modelling and the technologies available to address this concern. However, epistemic publishing practices show that efforts to increase the effectiveness of manufacturing systems often neglect worker voice.

Seroconversion among rituximab-treated patients following SARS-CoV-2 vaccine supplemental dose.

Rituximab (RTX) is a very effective treatment for autoimmune rheumatic diseases (AIRD), but it increases infection risk and impairs vaccine responses. Herein we evaluated the antibody response of RTX-treated patients to the supplemental COVID-19 vaccine. After the supplemental dose, 53.1% of patients had detectable antibody titers. Only 36% of patients who did not mount an antibody response after the original vaccine series did have detectable antibodies after the supplemental dose (seroconversion). Patients with undetectable CD20+ cell levels did not seroconvert while hypogammaglobulinemia was associated with a 15-times decrease in the likelihood of seroconversion. Although we noted 11 COVID-19 infections after the supplemental dose, no patients who received monoclonal antibodies pre-exposure prophylaxis had COVID-19 afterwards. We propose that patients receiving RTX should continue to be prioritized for prophylaxis measures and that vaccination should be timed after B cell recovery wherever possible.

Discordance in patient and physician global assessment in relapsing polychondritis.

OBJECTIVES: Relapsing polychondritis (RP) is a rare, heterogeneous, systemic inflammatory disease that targets cartilage. Patient-reported outcome measures may differ from physician assessment. This study compared patient global assessment (PtGA) and physician global assessment (PhGA) scores in a prospective cohort of patients with RP. METHODS: Adult patients with RP underwent a standardized comprehensive evaluation at ∼6 month intervals. At each visit, three physicians scored PhGA by consensus. The patient independently completed four patient-reported outcomes: PtGA, 36-item Short Form Health Survey (SF-36), Brief Illness Perception Questionnaire (BIPQ) and Multidimensional Fatigue Inventory (MFI). Patient-physician discordance was defined as a difference between PtGA and PhGA of ≥3 on a 0-10 scale. RESULTS: A total of 76 patients were evaluated over 154 visits. The median PhGA was 3 [interquartile range (IQR) 2-3] and the median PtGA was 5 (IQR 4-7). PtGA and PhGA were concordant in 66 visits (42.9%) and patients scored disease severity ≥3 points higher than physicians scored disease activity (positive discordance) in 84 visits (54.5%). Compared with visits with concordance, visits with positive discordance were associated with significantly worse scores on the MFI, BIPQ, SF-36 physical component score and SF-36 mental component score. CONCLUSION: Patients with RP typically self-report high PtGA that does not align with PhGA. Discordance is likely driven by the high physical and psychological burden of illness experienced by patients. Multifaceted treatment approaches that address the burden of disease in RP from the patient perspective are needed.

Use of 18F-fluorodeoxyglucose positron emission tomography to standardize clinical trial recruitment in Takayasu's arteritis.

OBJECTIVES: To assess whether data from 18F-fluorodeoxyglucose (FDG) PET should be incorporated into eligibility criteria for clinical trials in Takayasu's arteritis (TAK). METHODS: The study was conducted in two parts. Part one was an international online survey among physicians with experience managing TAK to determine, using clinical vignettes, whether FDG-PET data influence decisions about enrolment in trials. Part two used patient data from an observational cohort study in TAK to assess agreement regarding decisions about enrolment into trials, based on clinical assessment with and without incorporation of FDG-PET data. RESULTS: In part one, 68 physicians responded to the survey. Most physicians had used FDG-PET to diagnose TAK (82%) or monitor disease activity (66%). In vignettes representing active clinical disease, FDG-PET findings increased physician confidence in disease assessment and reduced outlier assessments. The greatest variability in decisions regarding enrolment into trials was observed in vignettes representing constitutional symptoms alone and elevated acute-phase reactants. In these cases, FDG-PET findings influenced decisions about enrolment and improved physician confidence. In multivariable models, FDG-PET findings were 1.29 times more strongly associated with enrolment decisions compared with levels of acute-phase reactants. In part two, incorporation of FDG-PET data significantly improved agreement about enrolment decisions between raters [inter-rater reliability (IRR) = 0.68 (95% CI 0.67, 0.69) to IRR = 0.88 (95% CI 0.87, 0.89); P < 0.01]. CONCLUSIONS: Incorporation of FDG-PET data into assessment of TAK influences decisions about enrolment of patients into trials, improves physician confidence about clinical assessment and could help reduce variability in study populations. Future trials in TAK should consider incorporating FDG-PET data into eligibility criteria.

Anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase antibodies: incidence using different testing criteria, and case series.

OBJECTIVES: To estimate the incidence of anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR) antibodies utilising different testing criteria, and review the clinical details of a series of patients with associated autoimmune myopathy. METHODS: The incidence of anti-HMGCR antibodies in 2019 from 3 groups, South West London, Berkshire/Surrey and Southampton, were compared in the adult population. Anti-HMGCR antibodies were measured by commercial chemiluminescent and immunodot assays. The case notes of patients with anti-HMGCR antibodies were reviewed for the case series. RESULTS: The estimated incidence of anti-HMGCR antibodies in the first 2 groups was 1.94 per million adults per year, and in the third group 10.3 per million adults per year. In the first 2 groups the test criteria restricted analysis to specific clinician request for anti-HMGCR. In the third group test criteria included cases with less specific clinical features or a cytoplasmic indirect immunofluorescence anti-nuclear antibody pattern. The latter strategy had a positive predictive value of 66.1% for anti-HMGCR associated myopathy. A case series of 27 patients with anti-HMGCR antibodies revealed 19 with myopathy, oesophageal involvement in 26% and median peak CK 8000 IU/L. Response to treatment, including intravenous immunoglobulin, was good with CK normalising after median 5.5 months. In 8 cases there was no evidence of autoimmune muscle disease, 7 not statin exposed. CONCLUSIONS: Varying criteria result in a 5-fold difference in estimated incidence of anti-HMGCR antibodies, revealing positive cases without evidence of myopathy. Patients with anti-HMGCR myopathy respond well to immune suppression, supporting wider testing for these antibodies amongst patients with myopathy.

The population genomics of repeated freshwater colonizations by Gulf pipefish.

How organisms adapt to the novel challenges imposed by the colonization of a new habitat has long been a central question in evolutionary biology. When multiple populations of the same species independently adapt to similar environmental challenges, the question becomes whether the populations have arrived at their adaptations through the same genetic mechanisms. In recent years, genetic techniques have been used to tackle these questions by investigating the genome-level changes underlying local adaptation. Here, we present a genomic analysis of colonization of freshwater habitats by a primarily marine fish, the Gulf pipefish (Syngnathus scovelli). We sample pipefish from four geographically distinct freshwater locations and use double-digest restriction site associated DNA sequencing to compare them to 12 previously studied saltwater populations. The two most geographically distant and isolated freshwater populations are the most genetically distinct, although demographic analysis suggests that these populations are experiencing ongoing migration with their saltwater neighbours. Additionally, outlier regions were found genome-wide, showing parallelism across ecotype pairs. We conclude that these multiple freshwater colonizations involve similar genomic regions, despite the large geographical distances and different underlying mechanisms. These similar patterns are probably facilitated by the interacting effects of intrinsic barriers, gene flow among populations and ecological selection in the Gulf pipefish.

Paramedic Identification of Pediatric Seizures: A Prospective Cohort Study.

OBJECTIVE: Pediatric seizures commonly trigger emergency medical services (EMS) activation and account for approximately 5-15% of all pediatric 911-EMS calls. More than 50% of children with active seizure activity do not receive prehospital antiepileptic drugs, potentially because they are not recognized by EMS. The purpose of this study is to evaluate specificity and sensitivity of paramedic identification of pediatric seizures and to describe the characteristics of unrecognized seizures. METHODS: This is an 18-month prospective cohort study at a single, pediatric emergency department (ED). EMS patients ≤15 years old with a prehospital provider impression of seizure were included. Upon ED arrival, a data collection form, which included the EMS verbal report and patient's clinical status, was completed by the attending emergency physician. The primary outcome was sensitivity and specificity of paramedic identification of active seizure. Secondary outcomes included characteristics of missed seizures, ED interventions, and disposition. Descriptive statistics, sensitivity, and specificity were computed. Patient characteristics and clinical outcomes were compared. RESULTS: Surveys were completed for 349 patients (Median 3, IQR = 3.4). Fifty-two of the patients (15%) were actively seizing upon arrival at the ED. Sensitivity was 54% and specificity was 96% for paramedic identification of active seizure. Common features of missed cases were abnormal vital signs (75%), gaze deviation (50%) and clenched jaw (33%). Of these, 37% required intubation and 53% were admitted to the intensive care unit. CONCLUSION: Paramedics were highly specific, but not sensitive in identifying active seizures on ED arrival. Patients with unrecognized seizures presented most commonly with abnormal vital signs and gaze deviation.

Clinical management of Lupus patients during the COVID-19 pandemic.

Severe acute respiratory syndrome coronavirus (SARS-CoV-2), the virus causing Coronavirus disease 2019 (COVID-19), has had a huge impact on health services with a high mortality associated with complications including pneumonia and acute respiratory distress syndrome. Historical evidence suggests that Lupus patients have a higher incidence of several viral infections. This is likely due to a combination of immune dysfunction, immunosuppressive therapy and excess co-morbidities. In this context there has been concern that Lupus patients may be at a higher risk of developing COVID-19 and suffering a severe disease course. As a result, many Lupus patients have been advised to 'shield' by isolating from social contact in the hope that this will reduce the likelihood of infection. Early clinical data does not appear to show that the incidence of COVID-19 is higher in Lupus patients. Reassuringly, the clinical course of COVID-19 in Lupus does not generally seem to be more severe than in the general population. There has been huge interest in repurposing existing drugs as potential treatments, including several used to treat Lupus. Of these, corticosteroids and hydroxychloroquine are the most well researched so far. The current evidence suggests that the corticosteroid dexamethasone improves outcome for the sickest COVID-19 patients requiring respiratory support. Initial reports suggested that hydroxychloroquine could have a positive impact on the course of COVID-19, however larger prospective studies have not supported this. Janus kinase inhibitors, currently being investigated for efficacy in lupus, have been shown to have anti-viral effects in vitro and inhibiting the JAK-STAT pathway may dampen down the host hyper-inflammatory response. Several trials are ongoing to assess the outcome of the use of JAK inhibitors in COVID-19 positive patients. For most patients continuing with their existing therapies to prevent a lupus flare or adverse events associated with sudden corticosteroid withdrawal is important whilst an Individualised risk assessment remains vital.

The Estrogen-Responsive Transcriptome of Female Secondary Sexual Traits in the Gulf Pipefish.

Sexual dimorphism often results from hormonally regulated trait differences between the sexes. In sex-role-reversed vertebrates, females often have ornaments used in mating competition that are expected to be under hormonal control. Males of the sex-role-reversed Gulf pipefish (Syngnathus scovelli) develop female-typical traits when they are exposed to estrogens. We aimed to identify genes whose expression levels changed during the development and maintenance of female-specific ornaments. We performed RNA-sequencing on skin and muscle tissue in male Gulf pipefish with and without exposure to estrogen to investigate the transcriptome of the sexually dimorphic ornament of vertical iridescent bands found in females and estrogen-exposed males. We further compared differential gene expression patterns between males and females to generate a list of genes putatively involved in the female secondary sex traits of bands and body depth. A detailed analysis of estrogen-receptor binding sites demonstrates that estrogen-regulated genes tend to have nearby cis-regulatory elements. Our results identified a number of genes that differed between the sexes and confirmed that many of these were estrogen-responsive. These estrogen-regulated genes may be involved in the arrangement of chromatophores for color patterning, as well as in the growth of muscles to achieve the greater body depth typical of females in this species. In addition, anaerobic respiration and adipose tissue could be involved in the rigors of female courtship and mating competition. Overall, this study generates a number of interesting hypotheses regarding the genetic basis of a female ornament in a sex-role-reversed pipefish.

Local and Topical Anesthetics for Pediatric Patients in the Emergency Department.

Painful diagnostic and therapeutic procedures are common in the emergency department. Adequately treating pain, including the pain of procedures is an essential component of the practice of emergency medicine. Pain management is also part of the core competency for emergency medicine residencies and pediatric emergency medicine fellowships. There are many benefits to providing local and/or topical anesthesia before performing a medical procedure, including better patient and family satisfaction and increased procedural success rates. Local and topical anesthetics when used appropriately, generally, have few, if any, systemic side effects, such as hypotension or respiratory depression, which is an advantage over procedural sedation. Use of local and topical anesthetics can do much toward alleviating the pain and anxiety of pediatric patients undergoing procedures in the emergency department.

Endoscopic guided PCNL in the prone split-leg position versus supine PCNL: a comparative analysis stratified by Guy's stone score.

INTRODUCTION: The optimal patient positioning for percutaneous nephrolithotomy (PCNL) based on the complexity of stone burden is not yet defined. Thus, we aimed to evaluate the intraoperative parameters, effectiveness and complications of patients undergoing PCNL between the endoscopic-guided prone split-leg PCNL (ePSL) and the supine PCNL by stratifying patients according to Guy's stone score (GSS). MATERIALS AND METHODS: A retrospective chart review was conducted of patients undergoing PCNL at two high-volume tertiary referral centers. At one center, patients underwent PCNL using the ePSL technique, while at the second center, patients underwent PCNL in supine. Patient demographics and stone characteristics, operative details, complications and effectiveness were compared between groups. The impact of obesity was also investigated. RESULTS: Of 830 subjects, a total of 449 (54%) underwent PCNL in ePSL and 381 (46%) in supine. The ePSL group had a greater mean age and body mass index. No statistical differences were found in gender, serum chemistry and Charlson comorbidity index. After stratifying patients by GSS, the differences in baseline stone burden between PSL and supine lost significance and both groups could be compared. Complications were not statistically different between both groups. Univariate analysis demonstrated that multiple tracts and lower pole access were more prevalent in supine. In addition, for GSS1-3, ePSL was correlated with reduced operative time, radiation exposure, length of hospital stay and need for secondary procedure. Multivariate analysis correlated ePSL with lower radiation exposure and need for secondary procedures (p = 0.01). In comparison to the whole trial population, the same tendencies were appreciated for obese cohort. CONCLUSIONS: This is the first report focusing on the performance differences between ePSL and supine PCNL stratified by GSS. Both techniques are safe, with a low rate of complications. For GSS1-3, ePSL reduces radiation exposure and requires less need for both multiple access and secondary procedure.

Carotid Dissection and Cerebral Infarction From Posterior Oropharyngeal Trauma: The Diagnostic and Therapeutic Challenges.

Posterior oropharyngeal trauma commonly occurs in children and frequently presents to the emergency department (ED). Rarely, serious infectious and neurologic sequelae result. Emergency providers are tasked with the challenge of diagnosing the minority with life-threatening complications while maintaining thoughtful stewardship regarding radiation exposure. A previously healthy 2-year-old girl sustained trauma to her posterior oropharynx with a toothbrush that resulted in a left carotid dissection. This dissection was diagnosed in the ED via computed tomography angiogram, Otolaryngology and neurosurgery were consulted in the ED, and anticoagulation therapy was initiated with aspirin. The child did initially well and was without neurologic deficit and no brain ischemia on magnetic resonance imaging. She was discharged home on aspirin therapy. Four days after initial injury, the child returned to the ED after a seizure. Computed tomography scan of the head demonstrated infarction at the junction of the left parietal and temporal areas. Although neurologic complications are rare, posterior oropharyngeal trauma in children is not. There are many diagnostic and therapeutic challenges in its management. This case is, to the authors' awareness, the first case report in the English literature of a known and treated carotid dissection in a child after posterior oropharyngeal trauma that resulted in stroke despite diagnosis and initiation of treatment. The diagnostic and therapeutic challenges of posterior oropharyngeal trauma in children are discussed in this article.

Active Seizures in Children Are Often Subtle and Unrecognized by Prehospital Providers.

Early recognition and treatment of seizures is essential for optimal patient outcomes. Seizure activity, particularly in young children, can be subtle and often go unrecognized by providers. This case series retrospectively identified 7 cases of pediatric patients (14 years and younger) who presented to the emergency department with active seizure activity that was unrecognized by the prehospital care providers. The presentation of these patients, their clinical signs of seizure, and emergency department disposition are highlighted in this series.

Seasonal and spatial variation in the reproductive biology of the dwarf seahorse Hippocampus zosterae.

Factors associated with the reproductive ecology of the dwarf seahorse Hippocampus zosterae were investigated. Fish from a Tampa Bay (FL, USA) seagrass ecosystem were collected, photographed and returned to the wild, with photos analysed to determine patterns of body size, density, sex ratio and reproductive state across site and season to understand the population dynamics of H. zosterae over time. Animal density did not vary significantly with site and season, indicating there is little evidence of seasonal migration in this species. Densities reported in this study were higher than the mean density for all seahorse species Hippocampus spp. There was no sexual dimorphism in body length and both sexes reached sexual maturity at the same size. The ratio of gravid to non-gravid males was found to shift by season but not by site, with breeding detected year-round in this population compared with populations further north in their range. Peak breeding (70% gravid males) was observed in the late summer-autumn (August-October) in the site furthest from shore. The largest fish for both sexes were recorded during the summer and autumn months in the mid-shore, deepest site. Sex ratio shifted by site with even sex ratios near the shore but significantly female-biased sex ratios detected at sites near open water. Lastly, an increase in marking dates with decreased time intervals between collections did not yield a higher recapture rate, compared with sampling in 2010. However, the Tampa Bay population of dwarf seahorses demonstrated stable densities across 3 years with year-round breeding, indicating that it is a robust population worthy of long-term monitoring for conservation efforts.

Pregnancy-Related Spontaneous Coronary Artery Dissection: A Case Series and Literature Review.

BACKGROUND: Cardiac emergencies during pregnancy are rare but have significant associated morbidity and mortality when they do occur. The emergency physician must not only be aware of potentially life-threatening conditions in the pregnant woman, but also know the emergent management and treatment of these conditions to avoid worsening of the underlying condition. Pregnancy-related spontaneous coronary artery dissection has been described in the cardiology literature, but is not well-known in emergency medicine literature. CASE SERIES: We present a case series of six previously healthy women ages 27 to 39 years who presented 1 to 75 days after delivery with spontaneous coronary artery dissection. The left main coronary was involved in 5 of 6 cases. One patient died, 5 survived. Two survivors maintained significant long-term disability. The patient that died had the diagnosis made on autopsy, the others were diagnosed with coronary angiography. Two patients were treated with stents, 2 with coronary artery bypass surgery, and 2 with medical management. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergent coronary catheterization is indicated if this diagnosis is suspected. However, emergency care teams must also understand how and why management including coronary artery catheterization can exacerbate the underlying condition. The role of coronary artery computed tomography remains unknown, although it exposes the fetus to significant radiation if the woman is still pregnant at presentation. Medical management is indicated with diffuse or distal disease as pregnancy-related coronary artery dissections often resolve with time. Localized discrete lesions may be stented. Coronary artery bypass graft surgery may be considered if the left main artery is involved or there are multiple proximal lesions. Cardiac transplantation is indicated rarely.

Population genomics reveals multiple drivers of population differentiation in a sex-role-reversed pipefish.

A major goal of molecular ecology is to identify the causes of genetic and phenotypic differentiation among populations. Population genomics is suitably poised to tackle these key questions by diagnosing the evolutionary mechanisms driving divergence in nature. Here, we set out to investigate the evolutionary processes underlying population differentiation in the Gulf pipefish, Syngnathus scovelli. We sampled approximately 50 fish from each of 12 populations distributed from the Gulf coast of Texas to the Atlantic coast of Florida and performed restriction-site-associated DNA sequencing to identify SNPs throughout the genome. After imposing quality and stringency filters, we selected a panel of 6348 SNPs present in all 12 populations, 1753 of which were not physically linked. We identified a genome-wide pattern of isolation by distance, in addition to a more substantial genetic break separating populations in the Gulf of Mexico from those in the Atlantic. We also used several divergence outlier approaches and tests for genotype-environment correlations to identify 400 SNPs putatively involved in local adaptation. Patterns of phenotypic differentiation and variation diverged from the overall genomic pattern, suggesting that selection, phenotypic plasticity or demographic factors may be shaping phenotypes in distinct populations. Overall, our results suggest that population divergence is driven by a variety of factors in S. scovelli, including neutral processes and selection on multiple traits.

A DNA-Based Assessment of the Phylogenetic Position of a Morphologically Distinct, Anchialine-Lake-Restricted Seahorse.

Isolated populations provide special opportunities to study local adaptation and incipient speciation. In some cases, however, morphological evolution can obscure the taxonomic status of recently founded populations. Here, we use molecular markers to show that an anchialine-lake-restricted population of seahorses, originally identified as Hippocampus reidi, appears on the basis of DNA data to be Hippocampus erectus We collected seahorses from Sweetings Pond, on Eleuthera Island, Bahamas, during the summer of 2014. We measured morphological traits and sequenced 2 genes, cytochrome b and ribosomal protein S7, from 19 seahorses in our sample. On the basis of morphology, Sweetings Pond seahorses could not be assigned definitively to either of the 2 species of seahorse, H. reidi and H. erectus, that occur in marine waters surrounding the Bahamas. However, our DNA-based phylogenetic analysis showed that the Sweetings Pond fish were firmly nested within the H. erectus clade with a Bayesian posterior probability greater than 0.99. Thus, Sweetings Pond seahorses most recently shared a common ancestor with H. erectus populations from the Western Atlantic. Interestingly, the seahorses from Sweetings Pond differ morphologically from other marine populations of H. erectus in having a more even torso to tail length ratio. The substantial habitat differences between Sweetings Pond and the surrounding coastal habitat make Sweetings Pond seahorses particularly interesting from the perspectives of conservation, local adaptation, and incipient speciation.

Pelvic Free Fluid in Asymptomatic Pediatric Blunt Abdominal Trauma Patients: A Case Series and Review of the Literature.

BACKGROUND: With focused assessment with sonography in trauma (FAST) examinations being performed more commonly on pediatric trauma patients, emergency providers will encounter a positive FAST examination in patients with benign abdominal examinations. This poses a diagnostic dilemma for the provider when deciding whether to obtain a computed tomography (CT) scan of the abdomen/pelvis, observe the patient, or admit the patient. CASE REPORT: We report a series of pediatric patients involved in blunt abdominal trauma who had small pelvic free fluid on FAST but a benign abdominal examination. Three patients were managed without CT scan and 2 with CT scan. All patients did well and were discharged home. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Free intra-abdominal fluid may be physiologic in both male and female pediatric patients. Clinical examination and hemodynamic stability should be taken into account when deciding to order a CT scan. We review the literature and highlight new protocols that may decrease CT utilization and ionizing radiation exposure, though further studies in this specific population are needed.

The Flipped Classroom in Emergency Medicine Using Online Videos with Interpolated Questions.

BACKGROUND: Utilizing the flipped classroom is an opportunity for a more engaged classroom session. This educational approach is theorized to improve learner engagement and retention and allows for more complex learning during class. No studies to date have been conducted in the postgraduate medical education setting investigating the effects of interactive, interpolated questions in preclassroom online video material. OBJECTIVES: We created a flipped classroom for core pediatric emergency medicine (PEM) topics using recorded online video lectures for preclassroom material and interactive simulations for the in-classroom session. METHODS: Lectures were filmed and edited to include integrated questions on an online platform called Zaption. One-half of the residents viewed the lectures uninterrupted (Group A) and the remainder (Group B) viewed with integrated questions (2-6 per 5-15-min segment). Residents were expected to view the lectures prior to in-class time (total viewing time of approximately 2½ h). The 2½-h in-class session included four simulation and three procedure stations, with six PEM faculty available for higher-level management discussion throughout the stations. Total educational time of home preparation and in-class time was approximately 5 h. RESULTS: Residents performed better on the posttest as compared to the pretest, and their satisfaction was high with this educational innovation. In 2014, performance on the posttest between the two groups was similar. However, in 2015, the group with integrated questions performed better on the posttest. CONCLUSION: An online format combined with face-to-face interaction is an effective educational model for teaching core PEM topics.