The effect of environmental noise isolation on bronchiolitis severity in hospitalised children.

AIM: Bronchiolitis is an infectious disease, with no effective treatment. Music and Mozart's works specifically are known to have a positive effect on physiological parameters, while noise is considered harmful. We aim to evaluate the short-term effect of environmental noise detachment and/or music listening on the course of bronchiolitis in hospitalised children. METHODS: This is a prospective, double-blinded randomised controlled trial. Patients were divided into three intervention groups: 1-Mozart's Sonata, 2-instrumental music, 3-silence. Music was heard via media players and soundproof headphones. Disease severity was evaluated before and after intervention using the Modified Tal score. RESULTS: Seventy music sessions were included in the analysis (Mozart n = 23, instrumental n = 22, silence n = 25). A one-point drop in the average bronchiolitis severity score was observed in all three groups from 7.1 (CI 95%, 5 to 9.2) to 6.1 (CI 95%, 4.3 to 7.9), p < 0.001. No significant difference was found between the three groups with respect to change in the severity score before and after the intervention. CONCLUSION: Isolation from disturbing sounds heard in paediatric departments could be considered a simple non-invasive intervention in children hospitalised with bronchiolitis. Further studies are warranted to evaluate long-term effects of this intervention and the specific effect of music.

Physician and nurses' perception of paediatric trauma care in Israeli emergency departments.

BACKGROUND: Treatment of paediatric trauma requires specialized infrastructure, medical equipment, medical staff and ancillary support personnel that have been specifically trained for such tasks. AIMS AND OBJECTIVES: To examine the perceptions and attitudes of physicians and nurses in general and paediatric emergency departments (PEDs) on training, confidence, and management of paediatric trauma in order to facilitate the establishment of an optimal model for admitting and treating paediatric trauma patients. DESIGN: Drawing on published literature and a previously conducted qualitative study that explored the provision of medical care to paediatric trauma patients, we conducted an attitude survey. METHODS: A 26-item paper-based questionnaire was distributed by nurse managers to all staff working within general EDs and PEDs of 22 medical centres across Israel. RESULTS: Of 843 physicians and nurses who completed the survey, 61.1% considered PEDs the most appropriate facility for treating both minor and severe paediatric trauma, 88.5% believed that minor paediatric trauma should be treated in designated paediatric trauma centres, and 53.6% deemed that paediatric emergency medicine specialists are the most suitable primary decision makers in paediatric trauma. PED teams expressed greater professional confidence for treating paediatric trauma and multiple casualty incident patients. Greater professional confidence was positively correlated with paediatric trauma training, greater exposure to paediatric trauma cases, and working in larger medical centres. CONCLUSIONS: The results of the current study suggest that PEDs are perceived to be more appropriate for dealing with paediatric trauma. Also, treatment of severe trauma may be more appropriate in centres that admit large numbers of paediatric trauma cases. RELEVANCE TO CLINICAL PRACTICE: Emergency medicine teams should undergo training for dealing with paediatric trauma. Such training would develop their skills, increase their confidence, and enhance their emotional abilities to cope with paediatric trauma.

Severe abrupt (thunderclap) non-traumatic headache at the pediatric emergency department - a retrospective study.

BACKGROUND: Adult abrupt severe non-traumatic headache (thunderclap) is often related to serious underlying etiologies such as subarachnoid hemorrhage. However, data are sparse regarding thunderclap headache in the pediatric population. OBJECTIVE: The aim of the study was to evaluate the prevalence, characteristics and causes of thunderclap headache in the pediatric and adolescent population, aged 6-18 years, presenting to a pediatric emergency department. METHODS: The electronic database of a tertiary care pediatric emergency department was searched for children presenting with acute headache during 2016-2018. Headache severity was defined by pain scales, either a visual analogue scale or by the Faces Pain Scale-Revised. RESULTS: Thunderclap headache was diagnosed in 19/2290 (0.8%) of the included patients, all of them with a pain score of 10/10. All the patients had a benign course. Primary headache was diagnosed in 15/19 (78.9%), six patients had migraine and eight were diagnosed with primary thunderclap headache. Four of the 19 patients were diagnosed with secondary headache: three with infectious causes and one with malignant hypertension. CONCLUSIONS: Thunderclap headache is rare among children and adolescents presenting to the emergency department. This headache is generally of a primary origin. Extensive evaluation is still needed to rule out severe diagnosis problems.

Pediatric Preparedness of European Emergency Departments: A Multicenter International Survey.

INTRODUCTION: Children and adolescents often lack optimal emergency care. The objective of the study was to assess the level of preparedness of European emergency departments (EDs) for pediatric patients. METHODS: This was an international multicenter Internet-based survey of EDs with attending children and adolescents younger than 18 years in 101 EDs from 21 countries. Questionnaires were based on the recommendations in the consensus document published by the International Federation for Emergency Medicine, which defines quality of care standards for children aged 0 to 18 years in the ED. A multivariate binary logistic regression was performed to identify independent factors that are related to the expected standards of care provided by the EDs. RESULTS: Most (95.0%) of the EDs fulfilled more than 50% of the International Federation for Emergency Medicine essential standards of care, and 24 (23.7%) EDs fulfilled more than 80%. Best results were obtained in the standards that related to equipment, departmental policies, procedures, and protocols, and being able to stabilize an ill or injured child. Worst results were associated with inadequate staffing levels, quality, and safety; adolescents, mental health, and substance misuse delivery issues; and major incidents. Being included in a multicenter international research network was the unique independent factor associated with a good level of preparedness of the EDs for pediatric cases. CONCLUSIONS: Overall, surveyed European EDs fit well the essential standards of pediatric emergency care. Certain improvement actions are required to guarantee that essential standards of care for pediatric emergency care are always fulfilled in European EDs.

Performance of Two Head Injury Decision Rules Evaluated on an External Cohort of 18,913 Children.

BACKGROUND: The Pediatric Emergency Care Applied Research Network (PECARN) decision rule demonstrates high sensitivity for identifying children at low risk for clinically important traumatic brain injury (ciTBI). As with the PECARN rule, the Israeli Decision Algorithm for Identifying TBI in Children (IDITBIC) recommends proceeding directly to computed tomography (CT) in children with Glasgow Coma Score (GCS) <15. The aim was to assess the diagnostic accuracy of two clinical rules that assign children with GCS <15 at presentation directly to CT. MATERIALS AND METHODS: Accuracy analysis for detecting ciTBI was performed on a multicenter cohort of children used in the Australasian Pediatric Head Injury Rules Study. RESULTS: The external cohort included 18,913 children; 1691 (8.9%) had CT scan, 160 had ciTBI, and 24 (0.13%) had neurosurgery. Applying IDITBIC and PECARN rules would have missed 11 and 1 ciTBI patients; respectively. All patients with missed injuries were classified as such based on a hospital stay of >2 d. None of these patients died, needed neurosurgery, or required ventilatory support. In children aged <2 y, sensitivity, specificity, positive predictive value and negative predictive value of IDITBIC and PECARN rule were 95.2%, 79.5%, 3.8%, and 99.9% and 100.0%, 59.1%, 2.0%, and 100.0%, respectively. In children ≥2 y, sensitivity, specificity, positive predictive value and negative predictive value of IDITBIC and PECARN rule were 92.4%, 75.3%, 3.1%, and 99.9% and 99.2%, 52.9%, 1.7%, and 100.0%, respectively. CONCLUSIONS: The two decision rules demonstrated high accuracy in identifying ciTBI. As a screening tool, the PECARN rule outperformed IDITBIC. The findings suggest that clinicians should strongly consider directing children with GCS <15 at presentation to CT scan.

Assessing patient safety in a pediatric telemedicine setting: a multi-methods study.

BACKGROUND: Telemedicine and telephone-triage may compromise patient safety, particularly if urgency is underestimated. We aimed to explore the level of safety of a pediatric telemedicine service, with particular reference to the appropriateness of the medical diagnoses made by the online physicians and the reasonableness of their decisions. METHODS: This retrospective multi-method study investigated the decision-making process of physicians in a pediatric tele-triage service provided in Israel. The first section of the study investigates several measures relating to patient safety in the telemedicine setting. Two physicians reviewed a random sample of 339 parent-physician consultations conducted via a pediatric telemedicine service provided by a healthcare organization during 2014-2017. The consultations were analyzed for factors that may have affected the online physicians' decisions, with an emphasis on the appropriateness of the diagnoses and the reasonableness of the decisions. The online physicians' decisions were also compared to the subsequent outcomes (i.e., parental compliance with the recommendations and medical follow-ups within the healthcare system) after each consultation. The second section of the study (using a qualitative approach) consisted of interviews with 15 physicians who work in the pediatric telemedicine service, in order to explore their subjective experiences and efforts for assuring patient safety. The physicians were asked about factors that may have affected their reaching an appropriate diagnosis and a reasonable decision while maintaining patient safety. RESULTS: The first section of the study demonstrates high levels of diagnosis appropriateness (98.5%) and decision reasonableness (92%), as well as low levels of false-positive (2.65%) and false-negative (5.3%), good sensitivity (82.85%), and high specificity (96.15%). A high association between the online decisions and the subsequent outcomes was also observed. The second section of the study presents physicians' means for ensuring high patient safety - by implementing a range of factors that helped them reach appropriate diagnoses and reasonable decisions. CONCLUSIONS: The results show overall high patient safety in the pediatric tele-triage service that was examined. However, decision makers must strive to implement additional means for further enhancing the clinicians' ability to reach accurate diagnoses and provide optimal treatments within the tele-triage settings - with the aim of ensuring patient safety.

Physicians' experiences, attitudes and challenges in a Pediatric Telemedicine Service.

BACKGROUND: Telemedicine in general, and telephone triage, in particular, is considered a high-stress clinical activity and involves decision making under conditions of uncertainty and urgency. AIM: We wanted to explore the experiences, attitudes, and challenges of the physicians in a Pediatric Telemedicine Service operated in Israel, and to explore whether the doctors are using non-medical factors (not related to the medical problem), when making the clinical decisions in this setting. METHODS: We used a qualitative methodology in order to obtain rich data that would reflect the participants' subjective experiences. Fifteen physicians who worked during the last 5 years in the "Pediatrician Online of Clalit" service were interviewed. Data were analyzed thematically. FINDINGS: Seven main themes concerning the physicians' challenges during their work at this service were revealed, including difficulties diagnosing from a distance, treating unfamiliar patients, working alone, urgency and load of calls, technological obstacles, and a "moral conflict" between the desire to meet parents' expectations and maintain standards of care. The physicians stated that non-medical factors also affect their decisions. CONCLUSIONS: In telemedicine setting, physicians face various difficulties and challenges, requiring special expertise, qualities and skills. Special measures are needed to obtain proper diagnosis and decisions.

Pediatric Diabetic Ketoacidosis With Hypotensive Shock and Rash-An Unusual Presentation.

We describe a previously healthy adolescent boy who presented with respiratory distress, hypotensive shock, and a diffuse erythematous rash. The final diagnosis was diabetic ketoacidosis. Caregivers should be alert to this unusual combination of symptoms in the emergency department setting in order to improve the recognition and management of children with new-onset diabetes.

Evidence of a link between fever and microscopic hematuria in children.

Despite the common conception that febrile illnesses are associated with microscopic hematuria in children, a review of the literature failed to disclose supportive evidence. The aim of this study was to evaluate this relationship. Background data were collected for a convenience sample of children aged 4-18 years who presented to the emergency department (ED) of a tertiary pediatric medical center. Vital signs were measured and a midstream urine specimen was collected. Specimens positive for the presence of blood (>5 erythrocytes/µl; Combur 10 Test Strips) were examined microscopically. Patients found to have microscopic hematuria (>5 erythrocytes/high power field) were asked to undergo repeated urine testing within 3 weeks or at least 1 week after the fever (if present) resolved. A telephone interview was conducted 9-10 years after the ED visit, for all children with microscopic hematuria. Data were coded and transferred to Microsoft Excel 2007 (Raymond Wa), and then analyzed using SPSS 15 (SPSS Inc., Chicago, IL). Six hundred sixty patients were enrolled in the study; 161 were febrile (mean temperature 39.2 ± .08 °C), and 499 were afebrile (mean temperature 36.7 ± 0.4 °C) (p < 0.001). The febrile group was significantly younger than the afebrile group (mean age 8 ± 3.6 years versus 9.4 ± 3.7 years, respectively, p < 0.001). There was no significant between-group difference in sex distribution (55 and 60% boys, respectively, p = 0.199). Microscopic hematuria was found in 12 children, 9 febrile (5.6%), and 3 afebrile (0.6%) (p < 0.001). All repeated urine tests (n = 12) were negative for microscopic hematuria. CONCLUSION: The findings suggest that fever is associated with transient microscopic hematuria in children. The study is limited by its single-center setting and relatively small sample. What is known: • It is commonly believed that fever increases the incidence of microscopic hematuria. • However, to the best of our knowledge, this assumption has not been proven. What is new: • This study demonstrates a significant association between fever and transient microscopic hematuria in children. • The transient nature of the hematuria may be reassuring for both parents and healthcare providers.

[Telemedicine: a novel service in pediatric emergency care].

INTRODUCTION: Telemedicine is a field that deals with monitoring and caring for patients who are physically apart from the caregivers, so they cannot communicate without technological means. The use of telemedicine has been recognized by a number of official organizations worldwide. This article reviews a unique service, "pediatrician online", provided by Clalit HMO, through Medtrix Ltd, with Schneider Children's Hospital specialists' supervision. With this service, parents can receive medical consultation from pediatricians beyond community clinic hours. The service is provided by telephone, computer or a mobile application, and when possible video calls are made. AIMS: To describe and analyze four years of telemedicine experience of the "pediatrician online" service. METHODS: A retrospective study was performed including analysis of all consultation calls conducted between November 2009 (the beginning of the project) and December 2013. Every call to the service was recorded and documented. Furthermore, analysis was conducted of follow-up calls to 4% of the applicants in order to monitor medical outcome and satisfaction. RESULTS: During the first four years approximately half a million consultation calls were provided. The average time from referral to obtaining medical advice was eight minutes. The duration of the consultation was four and a half minutes on average. Most of the calls were related to young children under 4 years (74%), dealing with common pediatric problems - fever (23%), respiratory complaints (17%), and gastrointestinal problems (12%). One-third of the applicants intended to go to the emergency department before they called the service, but only about one-sixth were referred at the end of the consultation. Among those referred, only about 60% actually went to the emergency department. The use of video-calls has been increasing, and reached an average of 30% of the applications. Satisfaction with the service was very high according to surveys, scoring 9.8 out of ten. Eighty-two percent of patients sampled reported medical improvement on the next day. CONCLUSIONS: There is a very high demand for consulting pediatricians beyond clinic hours. The use of telemedicine, as provided by the "pediatrician online" service, addresses this need safely and effectively with high patient satisfaction. Discussion: The use of telemedicine is expected to expand. In order to ensure its proper use while recognizing the capabilities and limitations, controlled studies should be conducted, exploring the outcome of different approaches in various situations.

Extracorporeal Membrane Oxygenation as a Resuscitation Measure in the Pediatric Emergency Department.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) may serve as a bridge to regain cardiac function in refractory resuscitation. However, its use has so far been limited owing to low availability, especially in emergency departments. OBJECTIVES: To describe two children with acute myocarditis successfully treated with ECMO in the emergency department of a tertiary pediatric medical center. DESCRIPTION: The children presented with vomiting, followed by rapid deterioration to cardiogenic shock that failed to respond to conservative treatment. Given the urgency of their condition and its presumably reversible (viral) etiology, treatment with ECMO was initiated in the department's resuscitation room. RESULTS: Outcome was excellent, and cardiac function remained normal throughout 6 and 10 months follow-up. CONCLUSIONS: Extracorporeal life support has enormous potential in the emergency department and warrants further assessment.

Adoption and utilization of device-assisted telemedicine.

We estimate the effect of adopting a digital device for performing medical exams at home during telehealth visits. We match visits of adopters and non-adopters who used the same virtual care clinic but without the device and compare healthcare utilization after the matched visits. We find that device adoption, partially offset by decreased use of other primary care modalities, results in a 12% higher utilization rate of primary care and increased use of antibiotics. But - particularly among adults - adoption lowers the use of urgent care, the emergency room, and hospital care, resulting in no increase in total cost.

Bacterial vs viral etiology of fever: A prospective study of a host score for supporting etiologic accuracy of emergency department physicians.

BACKGROUND: A host-protein score (BV score) that combines the circulating levels of TNF-related apoptosis-inducing ligand (TRAIL), interferon gamma-induced protein 10 (IP-10) and C-reactive protein (CRP) was developed for distinguishing bacterial from viral infection. This study assessed the potential of the BV score to impact decision making and antibiotic stewardship at the emergency department (ED), by comparing BV score's performance to physician's etiological suspicion at patient presentation. METHODS: Rosetta study participants, aged 3 months to 18 years with febrile respiratory tract infection or fever without source, were prospectively recruited in a tertiary care pediatric ED. 465 patients were recruited, 298 met eligibility criteria and 287 were enrolled. ED physician's etiological suspicion was recorded in a questionnaire. BV score was measured retrospectively with results interpreted as viral, bacterial or equivocal and compared to reference standard etiology, which was adjudicated by three independent experts based on all available data. Experts were blinded to BV scores. RESULTS: Median age was 1.3 years (interquartile range 1.7), 39.7% females. 196 cases were reference standard viral and 18 cases were reference standard bacterial. BV score attained sensitivity of 88.9% (95% confidence interval: 74.4-100), specificity 92.1% (88.1-96.0), positive predictive value 53.3% (35.5-71.2) and negative predictive value 98.8% (97.1-100). Positive likelihood ratio was 11.18 (6.59-18.97) and negative likelihood ratio was 0.12 (0.03-0.45). The rate of BV equivocal scores was 9.4%. Comparing physician's suspicion to BV score and to the reference standard, and assuming full adoption, BV score could potentially correct the physician's diagnosis and reduce error ~2-fold, from 15.9% to 8.2%. CONCLUSIONS: BV score has potential to aid the diagnostic process. Future studies are warranted to assess the impact of real-time BV results on ED practice.

Diagnoses and Health Care Utilization for After-Hours Telemedicine Versus Primary Care Visits.

OBJECTIVE: The use of a nation-wide, pediatricians online (PO) after-hours telemedicine service has been offered in Israel for more than a decade. We sought to compare PO visits with those to the primary care pediatrician (PCP). METHODS: This is a retrospective cross-sectional study using Israel's largest health care provider database. We included children aged 0 to 18 years using either PO or PCP between 2015 and 2018. We compared the baseline characteristics, matching by socioeconomic status, chronic illness, and diagnosis, and compared their admission rates, laboratory testing, and medication prescription. RESULTS: During this study period there were 262,541 PO visits and a random 10% sample of PCP visits which yielded 1,813,103 visits. Users of PO were more likely to have a higher socioeconomic status (43% vs 28.9%), fever (13.3% vs 4.4%) and less likely to have acute respiratory conditions (8.8% vs 16.7%). Users of PO had higher rates of emergency department admissions (2.9% vs 0.4%), hospital admissions (0.9% vs 0.2%), and lower rates of laboratory testing (3.7% vs 7.4%) and medication prescription (42.0% vs 52.0%) within 24 hours. All differences were statistically significant (P < .005). CONCLUSIONS: Our pediatric telemedicine service operating after-hours has been found to be feasible, and widely used, for a myriad of clinical conditions. Significant differences exist between PO and PCP visit characteristics and outcomes. However, it remained unclear whether these differences reflect the difference in the patient population or whether they are the result of the different clinical services. Further research is warranted to clarify this matter.

A management model for admission and treatment of pediatric trauma cases.

BACKGROUND: Pediatric trauma, particularly major trauma cases, are often treated in less than optimal facilities by providers who lack training and experience in treating severely injured children. We aimed to develop a management model for admission and treatment of pediatric trauma using the Theory of Constraints (TOC). METHODS: We conducted interviews with 17 highly experienced policy makers, senior nursing managers and medical managers in pediatrics and trauma. The interviews were analyzed by qualitative methods. The TOC was utilized to identify undesirable effects (UDEs) and core challenges, and to design a focused current reality tree (CRT). Subsequently, a management model for optimal admission and treatment of pediatric trauma was constructed. RESULTS: The CRT was illustrated according to 4 identified UDEs focusing on lack of: (1) clear definitions of case manager in pediatric trauma; (2) uniform criteria regarding the appropriate site for admitting pediatric trauma, (3) standard guidelines and protocols for treatment of trauma cases and for training of trauma medical teams; and (4) standard guidelines for evacuating pediatric trauma patients. The management model for treatment and admission of pediatric trauma is based on 3 major elements: human resources, hospital policy concerning the appropriate emergency department (ED) for pediatric trauma patients and clear definitions regarding children and trauma levels. Each of the elements contains components that should be clearly defined in order for a medical center to be designated for admitting and treating pediatric trauma patients. CONCLUSIONS: Our analysis suggests that the optimal ED for pediatric trauma cases is one with available operating rooms, intensive care beds, an imaging unit, laboratories and equipment suitable for treating children as well as with staff trained to treat children with trauma. To achieve optimal outcomes, medical centers in Israel should be classified according to their trauma treatment capabilities and their ability to treat varied severities of pediatric trauma cases.

Pediatric emergency research networks: a global initiative in pediatric emergency medicine.

OBJECTIVES: Objectives of the Pediatric Emergency Research Network's (PERN's) meeting included (1) learn about each of the participating network's missions, goals, and infrastructure; (2) share important contributions each network has made to the creation of new knowledge; (3) discuss "best practices" to improve each network's effectiveness; and (4) explore the potential for a collaborative research project as proof of concept that would help us promote quality of care of the acutely ill and injured child/youth globally. METHODS: In October 2009, a multiday meeting was attended by 18 delegates representing the following pediatric emergency medicine research networks: Pediatric Emergency Medicine Collaborative Research Committee (United States), Pediatric Emergency Care Applied Research Network (United States), Pediatric Emergency Research of Canada (Canada), Paediatric Research in Emergency Departments International Collaborative (Australia and New Zealand), and Research in European Pediatric Emergency Medicine (15 countries in Europe and the Middle East). RESULTS: The inaugural meeting of PERN demonstrated that there is a common desire for high-quality research and the dissemination of this research to improve health and outcomes of acutely ill and injured children and youths throughout the world. Presently, the PERN group is in the final stages of developing a protocol to assess H1N1 risk factors with the collection of retrospective data. CONCLUSIONS: Several members of PERN will be gathering at the International Conference on Emergency Medicine in Singapore, where the group will be presenting information about the H1N1 initiative. The PERN group is planning to bring together all 5 networks later in 2010 to discuss future global collaborations.

[Pediatric injuries from mass casualty events in Israel: a ten-year summary].

BACKGROUND: Children are the most vulnerable sub-population in mass casualty events (MCEs), however, characteristics of MCE related injuries among children have not been well described. AIM: The aim of our study was to characterize childhood injuries resulting from MCEs in Israel including parameters such as magnitude, injury mechanism and severity and use of hospital resources. METHODS: We conducted a descriptive study of MCE related injuries among hospitalized children (0-17 years) between the years 1998-2007 and recorded in the Israel Trauma Registry (ITR). The main outcome measures included: body region, injury severity (ISS) and mortality rates. RESULTS: A total of 267 children (mean age 11.3 years, 52% girls) were hospitalized for injuries caused by 75 (47%) of the 158 MCEs recorded during the study period. The mechanisms of MCE related injury were as follows: terror-related (63%); motor vehicle collision (buses or train) (32%); a collapsed building (3%); and other mechanisms (2%). Injuries among teenagers (ages 10-17 years) were twice as high as those of younger children [ages 0-9 years), (67% and 33%, respectively (p < 0.05). Head and neck (67%) were the most common body regions to be injured, followed by upper and Lower extremities (62%). Most children sustained mild injuries (55% ISS 1-8), however, a significant percentage had severe to fatal injuries (29% ISS > or =16). Severe injuries were significantly more frequent among children injured in MCEs compared to non-MCE injuries: ISS 16 (29% vs. 8%, respectively p < 0.0001), in-hospital mortaLity (3.4% vs. 0.4%, respectively, p < 0.0001), underwent surgical procedures (50% vs. 20%, respectively, p < 0.05), ICU admission rate (31% vs. 6%, p < 0.0001), and longer hospital stay (median LOS 8.9 vs. 3.5 days, respectively p < 0.0001). CONCLUSIONS: Morbidity and mortality are significantly higher among children who are injured in MCEs than by other mechanisms. Improved pediatric pre-hospital care and hospital resources as well may enhance future pediatric MCE-related injury outcomes.

The role of non-medical factors in physicians' decision-making process in a pediatric telemedicine service.

The complex process of medical decision-making is prone also to medically extraneous influences or "non-medical" factors. We aimed to investigate the possible role of non-medical factors in doctors' decision-making process in a telemedicine setting. Interviews with 15 physicians who work in a pediatric telemedicine service were conducted. Those included a qualitative section, in which the physicians were asked about the role of non-medical factors in their decisions. Their responses to three clinical scenarios were also analyzed. In an additional quantitative section, a random sample of 339 parent -physician consultations, held during 2014-2017, was analyzed retrospectively. Various non-medical factors were identified with respect to their possible effect on primary and secondary decisions, the accuracy of diagnosis, and "reasonability" of the decisions. Various non-medical factors were found to influence physicians' decisions. Those factors were related to the child, the applying parent, the physician, the interaction between the doctor and parents, the shift, and to demographic considerations, and were also found to influence the ability to make an accurate diagnosis and "reasonable" decisions. Our conclusion was that non-medical factors have an impact on doctor's decisions, even in the setting of telemedicine, and should be considered for improving medical decisions in this milieu.

Acute appendicitis after a blunt perineal trauma: an illustrative case.

Acute appendicitis after abdominal trauma, although rare, has been described in the past. We herein report, for the first time, a case of acute appendicitis after a blunt trauma to the perineum in a boy. Clinicians taking care of children with injuries to the abdomen or perineal area should be aware of the possibility that they can develop posttraumatic acute appendicitis.

Bilateral primary spontaneous pneumothorax: buffalo chest.

A case of bilateral primary spontaneous pneumothorax ("buffalo chest") in a previously healthy man is described. The clinical presentation and treatment options are discussed.