Virtual Interviews and the Pediatric Emergency Medicine Match Geography: A National Survey.

Introduction: Virtual interviews (VI) are now a permanent part of pediatric emergency medicine (PEM) recruitment, especially given the cost and equity advantages. Yet inability to visit programs in person can impact decision-making, leading applicants to apply to more programs. Moreover, the cost advantages of VI may encourage applicants to apply to programs farther away than they might otherwise have been willing or able to travel. This could create unnecessary strain on programs. We conducted this study to determine whether PEM fellowship applicants would apply to a larger number of programs and in different geographic patterns with VI (2020 and 2021) as compared to in-person interviews (2018 and 2019). Methods: We conducted an anonymous national survey of all PEM fellows comparing two cohorts: current fellows who interviewed inperson (applied in 2018/2019) and fellows who underwent VIs in 2020/2021 (current fellows and those recently matched in 2021). The study took place in March-April 2022. Questions focused on geographic considerations during interviews and the match. We used descriptive statistics, chi-square and t-tests for analysis. Results: Overall response rate was 42% (231/550); 32% (n = 74) interviewed in person and 68% (n = 157) virtually. Fellows applied to a median of 4/6 geographic regions (interquartile range 2, 5). Most applied for fellowship both in the same region as residency (216, 93%) and outside (192, 83%). Only the Pacific region saw a statistically significant increase in applicants during VI (59.9% vs 43.2%, P = 0.02). There was no statistical difference in the number of programs applied to during in-person vs VI (mean difference (95% confidence interval 0.72, -2.8 - 4.2). A majority matched in their preferred state both during VI (60.4%) and in-person interviews (65.7%). The difference was not statistically significant (P = 0.45). Conclusion: While more PEM fellowship applicants applied outside the geographic area where their residency was and to the Pacific region, there was no overall increase in the number of programs or geographic areas PEM applicants applied to during VI as compared to in-person interview seasons. As this was the first two years of VI, ongoing data collection will further identify trends and the impactof VI.

Retrospective Review of the Efficacy of Droperidol Compared to Prochlorperazine for Headache Management in the Emergency Department.

Introduction Headaches are a common presentation to the emergency department, representing approximately 3% of visits. The standard treatment of headaches has consisted of either monotherapy with an antidopaminergic agent or combination therapy with an antidopaminergic agent, a non-steroidal anti-inflammatory drug (NSAID), and diphenhydramine. Although droperidol is an antidopaminergic medication, it previously was not widely used in the treatment of headaches due to safety concerns. Given its pharmacokinetics, droperidol may provide faster relief in migrainous headaches compared to more commonly used antidopaminergic agents. Methods We conducted a single-center retrospective chart review to examine the impact of droperidol compared to other standard migraine therapies on pain scores. The study consisted of three treatment arms: droperidol monotherapy, a droperidol bundle (droperidol and ketorolac), and a prochlorperazine bundle (prochlorperazine and ketorolac). Patients who received medications in treatment arms and who had an encounter diagnosis including either "headache" or "migraine" were included. Patients were excluded if under 18 years of age, imprisoned, pregnant, or received potentially migraine-altering medications prior to the first documented pain score. The primary outcome was a mean reduction in pain scores. Secondary outcomes included length of emergency department stay, rates of inpatient admission, need for rescue therapies, and adverse events. Results A total of 361 droperidol orders were reviewed, of which 79 met the inclusion criteria. Of those included, 30 orders were within the droperidol monotherapy arm, 19 were within the droperidol bundle arm, and 30 were within the prochlorperazine bundle arm. There were no significant differences in reduction of pain scores, emergency department length of stay, rates of inpatient admission, rates of rescue therapy, or adverse events between the three treatment arms. Conclusion In this study, we found no statistical difference in migraine treatment efficacy between droperidol monotherapy and droperidol and prochlorperazine-based bundle therapies. Further studies are needed with larger sample sizes and predefined timing between pain score charting and medication administration.

Computed tomography rates in pediatric trauma patients among emergency medicine and pediatric emergency medicine physicians.

BACKGROUND: Pediatric trauma patients undergo fewer computed tomography (CT) scans when evaluated at pediatric trauma centers (PTC) versus adult trauma centers (ATC) with no change in clinical outcome. Factors contributing to this difference are unclear. We sought to identify whether the training background of physicians, specifically emergency medicine (EM) versus pediatric emergency medicine (PEM), affected the CT rate of pediatric trauma patients within one institution. METHODS: A single-center retrospective study of CT utilization based on attending physicians' training in trauma patients <18 years between November 2018 and November 2020. Attendings were categorized into two groups: EM residency with no PEM fellowship, or pediatrics/EM residency with PEM fellowship. Primary outcomes measured were the proportion of patients receiving a CT and CT positivity rate. RESULTS: Of 463 study patients, CTs were obtained in 145/228 (64%) patients by EM, and 130/235 (55%) by PEM (p=.07). CT positivity rate was 21% and 19% in EM and PEM, respectively (p=.46). The mean number of CTs per patient in EM was 2.8 compared to 2.1 in PEM (p<.01), and for patients with an injury severity score (ISS) >15, mean number of CTs per patient increased to 4.9 in EM versus 2.4 in PEM (p=.01). CONCLUSIONS: The mean number of CTs ordered per patient was statistically higher for EM attendings. The differences between CT rates highlight future opportunities for ongoing development of pediatric trauma imaging guidelines and radiation exposure reduction. LEVELS OF EVIDENCE: Retrospective Study, Level III.

Diversity of leadership in academic emergency medicine: Are we making progress?

BACKGROUND: Faculty who identify as women or racial/ethnic groups underrepresented in medicine (URiM) are less likely to occupy senior leadership positions or be promoted. Recent attention has focused on interventions to decrease this gap; thus, we aim to evaluate changes in leadership and academic promotion for these populations over time. METHODS: Successive cross-sectional observational study of six years (2015 to 2020) of data from the Academy of Administrators/Association of Academic Chairs of Emergency Medicine- Benchmark Survey. Primary analyses focused on gender/URiM differences in leadership roles and academic rank. Secondary analysis focused on disparities during the first 10 years of practice. Statistical modeling was conducted to address the primary aim of assessing differences in gender/URiM representation in EM leadership roles/rank over time. RESULTS: 12,967 responses were included (4589 women, 8378 men). Women had less median years as faculty (7 vs 11). Women and URiM were less likely to hold a leadership role and had lower academic rank with no change over the study period. More women were consistently in the early career cohort (within 10 years or less as faculty) : 2015 =-75.0% [95% CI:± 3.8%] v 61.4% [95% CI:± 3.0%]; 2020 =-75.1% [95% CI: ± 2.9%] v 63.3%, [95% CI:: ± 2.5%]. Men were significantly more likely to have any leadership role compared to women in 2015 and 2020 (2015 = 54.3% [95% CI: ± 3.1%] v 44.8%, [95% CI: ± 4.3%]; 2020 = 43.1% [95% CI:± 2.5%] v 34.8 [95% CI:± 3.1%]). Higher academic rank (associate/professor) was significantly more frequent among early career men than women in 2015 (21.1% [95% CI:± 2.58%] v 12.9%; [95% CI:± 3.0%]) and 2020 (23.1% [95% CI:± 2.2%] v 17.4%; [95% CI:± 2.5%]). CONCLUSIONS: Disparities in women and URiM faculty leadership and academic rank persist, with no change over a six-year time span. Men early career faculty are more likely to hold leadership positions and be promoted to higher academic rank, suggesting early career inequities must be a target for future interventions.

"Could we have predicted this?" The association of a future mental health need in young people with a non-specific complaint and frequent emergency department visits.

OBJECTIVE: Mental health emergencies among young people are increasing. There is growing pressure for emergency departments to screen patients for mental health needs even when it is not their chief complaint. We hypothesized that young people with an initial non-specific condition and emergency department (ED) revisits have increased mental health needs. METHODS: Retrospective, observational study of the California Office of Statewide Health Planning and Development Emergency Department Discharge Dataset (2010-2014) of young people (11-24 years) with an index visit for International Classification of Diseases, Ninth Revision diagnostic codes of "Symptoms, signs, and ill-defined conditions" (Non-Specific); "Diseases of the respiratory system" (Respiratory) and "Unintentional injury" (Trauma) who were discharged from a California ED. Patients were excluded if they had a prior mental health visit, chronic disease, or were pregnant. ED visit frequency was counted over 12 months. Regression models were created to analyze characteristics associated with a mental health visit. RESULTS: Patients in the Non-Specific category compared to the Respiratory category had 1.2 times the odds of a future mental health visit (OR 1.20; 95% CI 1.17-1.24). Patients with ≥1 ED revisit, regardless of diagnostic category, had 1.3 times the odds of a future mental health visit. Patients with both a Non-Specific index visit and 1, 2, and 3 or more revisits with non-specific diagnoses had increasing odds of a mental health visit (OR 1.38; 95% CI 1.29-1.47; OR 1.70; 95% CI 1.46-1.98; OR 2.20; 95% CI 1.70-2.87, respectively.). CONCLUSIONS: Young people who go to the ED for non-specific conditions and revisits may benefit from targeted ED mental health screening.

National Awards and Female Emergency Physicians in the United States: Is the "Recognition Gap" Closing?

BACKGROUND: Gender inequities in recognition, compensation, promotion, and leadership roles exist in emergency medicine. Formal recognition in the workplace and opportunities for advancement are vulnerable to bias. OBJECTIVE: To examine the gender distribution of national awards in emergency medicine, to analyze whether there is a gap, and to highlight notable trends. METHODS: Recipients of the major award categories between 2001 and 2020 were examined for the 3 main national emergency medicine organizations. The gender distribution of award winners by year was compared with the gender distribution of female faculty in emergency medicine departments using data from the Association of American Medical Colleges and a chi-squared analysis. RESULTS: The gender gap in award winners has decreased over time, but men are still disproportionately given national awards over women. In all 3 organizations, women represented a smaller proportion of award winners than men when compared with the national proportion of women in academic emergency medicine. Advocacy awards were the one category where women were more likely to be recognized. Women were notably least likely to receive clinical and leadership awards. CONCLUSIONS: The gender gap in emergency medicine awards has narrowed in the last 20 years but still exists. This discrepancy is an example of how bias can compound over time to generate gaps in recognition, career advancement, and promotion. The pipeline to award nominations should be addressed at the individual, departmental, awards committee, and organizational levels. © 2021 Elsevier Inc.

A Four-Week-Old Infant With Respiratory Distress: An Emergency Department Case Presentation of Congenital Lobar Emphysema.

Congenital lobar emphysema (CLE) and congenital pulmonary lymphangiectasis (CPL) are rare conditions that are most often identified with prenatal ultrasonography. Occasionally, this disease process is first identified in the emergency department (ED), where the physician should avoid common pitfalls in order to prevent acute decompensation. To the best of our knowledge, there are no prior reports in the emergency medicine literature of CLE or CPL presenting to the ED as undifferentiated respiratory distress in an infant. Here, we describe one such case and then discuss the importance of differentiating these congenital anomalies from more commonly encountered emergency diagnoses, such as pneumothorax and pneumonia. Management differs radically, and the use of chest tubes and positive pressure ventilation in CLE may precipitate acute cardiovascular decompensation.

Protecting the emergency physician workforce during the coronavirus disease 2019 pandemic through precision scheduling at an academic tertiary care trauma center.

The coronavirus disease 2019 (COVID-19) pandemic created new emergency physician staffing challenges. Emergency physicians may be taken out of the workforce because of respiratory symptoms or pending severe acute respiratory syndrome coronavirus 2 test results. Vulnerable emergency physician populations with increased risk of serious disease and death from COVID-19 include physicians at older ages; those with chronic medical conditions, including cardiac and pulmonary diseases and immunosuppression; and potentially pregnancy. We present our approach to planning for staffing issues through precision scheduling. We describe the actions taken to protect our vulnerable physicians and maximize our physician coverage. Measures include optimizing workforce; increasing backup call system; adjusting shifts based on patient arrival times, volume, and surge predictions; minimizing exposure to COVID-19 and reduce personal protective equipment use through telemedicine, huddles, and, creating lower risk emergency department care areas; and standardizing intubations to limit exposure.

Here to chair: Gender differences in the path to leadership.

OBJECTIVE: Career paths leading to department chair positions are elusive. Women represent only 11% of academic emergency department (ED) chairs. It is unclear whether the pathway to chair is different for men and women; the characteristics, achievements, and qualifications among those who become ED chairs is unknown. METHODS: This study is a cross-sectional analysis of curriculum vitae (CV) of current ED chairs in departments with Accreditation Council for Graduate Medical Education (ACGME)-accredited residency programs. Former women chairs were included due to paucity of current women chairs. Statistics were calculated using bivariate and multivariate analysis. RESULTS: Of 163 eligible chairs, 88 CV (54%) were obtained, including six former women chairs. A majority (86.4%) self-identified as White/Caucasian, 21.5% were women, 46% were chief residents, 28.4% completed additional postgraduate degrees, and 21.8% were fellowship trained. At time of chair appointment, 58% were professor rank, 53.5% held ED operations roles, and 32% served as vice chair. Women were more likely to be in educational (53% vs. 22%) versus operational (26% vs. 61%, p = 0.02) roles. Women obtained more advanced degrees (47% vs. 25%, p = 0.02), were awarded more nonfederal grants (median = 7 vs. 3, p = 0.04), and achieved more national committee leadership (median = 4 vs. 1, p = 0.02). There were no gender differences in fellowship training, awards, leadership training programs, publications, federal grants, or national/international lectures after adjusting for years in practice. CONCLUSION: While the majority of chairs held prior leadership roles in ED operations, only one in five women chairs did, suggesting gender differences in the path to chair attainment. These differences in paths may contribute to persistent gender disparities in ED chairs and may be influenced by career path choices, implicit bias, and structural barriers.

Implementation of Targeted Temperature Management After Out-of-Hospital Cardiac Arrest: Observations From the Los Angeles County Regional System.

Background Despite the benefits of targeted temperature management (TTM) for out-of-hospital cardiac arrest), implementation within the United States remains low. The objective of this study was to evaluate the prevalence and factors associated with TTM use in a large, urban-suburban regional system of care. Methods and Results This was a retrospective analysis from the Los Angeles County regional cardiac system of care serving a population of >10 million residents. All adult patients aged ≥18 years with non-traumatic out-of-hospital cardiac arrest transported to a cardiac arrest center from April 2011 to August 2017 were included. Patients awake and alert in the emergency department and patients who died in the emergency department before consideration for TTM were excluded. The primary outcome measure was prevalence of TTM use. The secondary analysis were annual trends in TTM use over the study period and factors associated with TTM use. The study population included 8072 patients; 4154 patients (51.5%) received TTM and 3767 patients (46.7%) did not receive TTM. Median age was 67 years, 4780 patients (59.2%) were men, 4645 patients (57.5%) were non-White, and the most common arrest location was personal residence in 4841 patients (60.0%). In the adjusted analysis, younger age, male sex, an initial shockable rhythm, witnessed arrest, and receiving coronary angiography were associated with receiving TTM. Conclusions Within this regional system of care, use of TTM was higher than previously reported in the literature at just over 50%. Use of integrated systems of care may be a novel method to increase TTM use within the United States.

Emergency department implementation of abbreviated magnetic resonance imaging for pediatric traumatic brain injury.

Pediatric head injury is a common presenting complaint in the emergency department (ED), often requiring neuroimaging or ED observation for diagnosis. However, the traditional diagnostic neuroimaging modality, head computed tomography (CT), is associated with radiation exposure while prolonged ED observation impacts patient flow and resource utilization. Recent scientific literature supports abbreviated, or focused and shorter, brain magnetic resonance imaging (MRI) as a feasible and accurate diagnostic alternative to CT for traumatic brain injury. However, this is a relatively new application and its use is not widespread. The aims of this review are to describe the science and applications of abbreviated brain MRI and report a model protocol's development and ED implementation in the evaluation of children with head injury for replication in other institutions.

Racial and ethnic differences in outcomes after out-of-hospital cardiac arrest: Hispanics and Blacks may fare worse than non-Hispanic Whites.

BACKGROUND: This study evaluates differences in out-of-hospital cardiac arrest (OHCA) characteristics, interventions, and outcomes by race/ethnicity. METHODS: This is a retrospective analysis from a regionalized cardiac system. Outcomes for all adult patients treated for OHCA with return of spontaneous circulation (ROSC) were identified from 2011-2014. Stratifying by race/ethnicity with White as the reference group, patient characteristics, treatment, and outcomes were evaluated. The adjusted odds ratios (OR) for survival with good neurologic outcome (cerebral performance category 1 or 2) were calculated. RESULTS: There were 5178 patients with OHCA; 290 patients excluded for unknown race, leaving 4888 patients: 50% White, 14% Black, 12% Asian, 23% Hispanic. In univariate analysis, compared with Whites, Blacks had fewer witnessed arrests (83% vs 86%, p = 0.03) and less bystander CPR (37% vs 44%, p = 0.005), were less likely to undergo coronary angiography (14% vs 22%, p < 0.0001), and less likely to receive PCI (32% vs 54%, p < 0.0001). Asians presented less often with a shockable rhythm (27% vs 34%, p = 0.001) and were less likely to undergo angiography (15% vs 22%, p < 0.0001). Hispanics presented less often with a shockable rhythm (31% vs 34%, p = 0.03), had fewer witnessed arrests (82% vs 86%, p = 0.001) and less bystander CPR (37% vs 44%, p = 0.0001). In multivariable analysis, Hispanic ethnicity was associated with decreased favorable neurologic outcome (OR 0.78 [95%CI 0.63-0.96]). Outcomes for Asians and Blacks did not differ from Whites. When accounting for clustering by hospital, race was no longer statistically significantly associated with survival with good neurologic outcome. CONCLUSION: We identified important differences in patients with OHCA according to race/ethnicity. Such differences may have implications for interventions; for example, emphasis on bystander CPR instruction in Black and Hispanic communities.

2018 Academic Emergency Medicine Consensus Conference: Advancing Pediatric Emergency Medicine Education Through Research and Scholarship.

To achieve high-quality emergency care for pediatric patients nationwide, it is necessary to define the key elements for pediatric emergency medicine (PEM) education and scholarship that would: 1) close the gaps in fundamental PEM education and 2) promote systems and standards that assure an ongoing communication of best practices between tertiary pediatric institutions, general (nonchildren's) hospital emergency departments, and urgent care centers. A working group of medical educators was formed to review the literature, develop a framework for consensus discussion at the breakout session, and then translate their findings into recommendations for future research and scholarship. The breakout session consensus discussion yielded many recommendations. The group concluded that future progress depends on multicenter collaborations as a PEM education research network and a unified vision for PEM education that bridges organizations, providers, and institutions to assure the best possible outcomes for acutely ill or injured children.

Regional "Call 911" Emergency Department Protocol to Reduce Interfacility Transfer Delay for Patients With ST-Segment-Elevation Myocardial Infarction.

BACKGROUND: We evaluated the first-medical-contact-to-balloon (FMC2B) time after implementation of a "Call 911" protocol for ST-segment-elevation myocardial infarction (STEMI) interfacility transfers in a regional system. METHODS AND RESULTS: This is a retrospective cohort study of consecutive patients with STEMI requiring interfacility transfer from a STEMI referring hospital, to one of 35 percutaneous coronary intervention-capable STEMI receiving centers (SRCs). The Call 911 protocol allows the referring physician to activate 911 to transport a patient with STEMI to the nearest SRC for primary percutaneous coronary intervention. Patients with interfacility transfers were identified over a 4-year period (2011-2014) from a registry to which SRCs report treatment and outcomes for all patients with STEMI transported via 911. The primary outcomes were median FMC2B time and the proportion of patients achieving the 120-minute goal. FMC2B for primary 911 transports were calculated to serve as a system reference. There were 2471 patients with STEMI transferred to SRCs by 911 transport during the study period, of whom 1942 (79%) had emergent coronary angiography and 1410 (73%) received percutaneous coronary intervention. The median age was 61 years (interquartile range [IQR] 52-71) and 73% were men. The median FMC2B time was 111 minutes (IQR 88-153) with 56% of patients meeting the 120-minute goal. The median STEMI referring hospital door-in-door-out time was 53 minutes (IQR 37-89), emergency medical services transport time was 9 minutes (IQR 7-12), and SRC door-to-balloon time was 44 minutes (IQR 32-60). For primary 911 patients (N=4827), the median FMC2B time was 81 minutes (IQR 67-97). CONCLUSIONS: Using a Call 911 protocol in this regional cardiac care system, patients with STEMI requiring interfacility transfers had a median FMC2B time of 111 minutes, with 56% meeting the 120-minute goal.

Sex Differences in Survival From Out-of-Hospital Cardiac Arrest in the Era of Regionalized Systems and Advanced Post-Resuscitation Care.

BACKGROUND: The purpose of this study was to evaluate sex differences in out-of-hospital cardiac arrest (OHCA) characteristics, interventions, and outcomes. METHODS AND RESULTS: This is a retrospective analysis from a regionalized cardiac arrest system. Data on patients treated for OHCA are reported to a single registry, from which all adult patients were identified from 2011 through 2014. Characteristics, treatment, and outcomes were evaluated with stratification by sex. The adjusted odds ratio (OR) for survival with good neurological outcome (cerebral performance category 1 or 2) was calculated for women compared to men. There were 5174 out-of-hospital cardiac arrests (OHCAs; 3080 males and 2094 females). Women were older, median 71 (interquartile range [IQR], 59-82) versus 66 years (IQR, 55-78). Despite similar frequency of witnessed arrest, women were less likely to present with a shockable rhythm (22% vs 35%; risk difference [RD], 13%; 95% CI, 11-15), have ST-segment elevation myocardial infarction (23% vs 32%; RD, 13%; 95% CI, 7-11), or receive coronary angiography (11% vs 25%; RD, 14%; 95% CI, 12-16), percutaneous coronary intervention (5% vs 14%; RD, 9%; 95% CI, 7-11), or targeted temperature management (33% vs 40%; RD, 7%; 95% CI, 4-10). Women had decreased survival to discharge (33% vs 40%; RD, 7%; 95% CI, 4-10) and a lower proportion of good neurological outcome (16% vs 24%; RD, 8%; 95% CI, 6-10). In multivariable modeling, female sex was not associated with decreased survival with good neurological outcome (OR, 0.9; 95% CI, 0.8-1.1). CONCLUSIONS: Sex-related differences in OHCA characteristics and treatment are predictors of survival outcome disparities. With adjustment for these factors, sex was not associated with survival or neurological outcome after OHCA.

Pediatric Acute Bacterial Sinusitis: Diagnostic and Treatment Dilemmas.

Acute bacterial sinusitis (ABS) is a common complication of a simple upper respiratory infection. Acute bacterial sinusitis and an upper respiratory infection, however, have different management plans. This article will help clinicians establish when a diagnosis of ABS can be made based on the latest guidelines from the American Academy of Pediatrics. Also covered will be the pathophysiology of ABS, the role of diagnostic imaging, the recognition of complications of ABS, and treatment options.

Risk factors for apnea in pediatric patients transported by paramedics for out-of-hospital seizure.

STUDY OBJECTIVE: Apnea is a known complication of pediatric seizures, but patient factors that predispose children are unclear. We seek to quantify the risk of apnea attributable to midazolam and identify additional risk factors for apnea in children transported by paramedics for out-of-hospital seizure. METHODS: This is a 2-year retrospective study of pediatric patients transported by paramedics to 2 tertiary care centers. Patients were younger than 15 years and transported by paramedics to the pediatric emergency department (ED) for seizure. Patients with trauma and those with another pediatric ED diagnosis were excluded. Investigators abstracted charts for patient characteristics and predefined risk factors: developmental delay, treatment with antiepileptic medications, and seizure on pediatric ED arrival. Primary outcome was apnea defined as bag-mask ventilation or intubation for apnea by paramedics or by pediatric ED staff within 30 minutes of arrival. RESULTS: There were 1,584 patients who met inclusion criteria, with a median age of 2.3 years (Interquartile range 1.4 to 5.2 years). Paramedics treated 214 patients (13%) with midazolam. Seventy-one patients had apnea (4.5%): 44 patients were treated with midazolam and 27 patients were not treated with midazolam. After simultaneous evaluation of midazolam administration, age, fever, developmental delay, antiepileptic medication use, and seizure on pediatric ED arrival, 2 independent risk factors for apnea were identified: persistent seizure on arrival (odds ratio [OR]=15; 95% confidence interval [CI] 8 to 27) and administration of field midazolam (OR=4; 95% CI 2 to 7). CONCLUSION: We identified 2 risk factors for apnea in children transported for seizure: seizure on arrival to the pediatric ED and out-of-hospital administration of midazolam.

Constipation in a 7-year-old boy: congenital band causing a strangulated small bowel and pulseless electrical activity.

BACKGROUND: Constipation in pediatric patients is a common diagnosis in the emergency department (ED) and may occasionally arise from a significant underlying illness. OBJECTIVE: To discuss a rare cause of constipation that led to a strangulated small bowel and cardiac arrest. CASE REPORT: A 7-year-old boy presented in pulseless electrical activity. The patient had been seen in the ED 2 days prior with the complaint of abdominal pain, which was diagnosed as constipation. The boy had emigrated from Mexico 18 months earlier. The patient was resuscitated in the ED and taken emergently to the operating room. During surgery he was discovered to have a congenital abdominal adhesive band that led to a strangulated small bowel. He suffered subsequent multi-organ failure, including hypoxic ischemic encephalopathy, and was hospitalized for 5 months. One month after discharge he was improving and being followed by multiple providers. CONCLUSION: Congenital adhesive bands, although rare, may be life-threatening anomalies. We present this case to increase awareness of this condition among emergency physicians.

Effect of a minimum lymph node policy in radical cystectomy and pelvic lymphadenectomy on lymph node yields, lymph node positivity rates, lymph node density, and survivorship in patients with bladder cancer.

BACKGROUND: Extended pelvic lymphadenectomy (PLND) during radical cystectomy (RC) reportedly improves bladder cancer-specific survival. Lymph node counts are often a proxy for the extensiveness of a dissection. In the current study, the impact of an institutional policy requiring a minimum number of lymph nodes was assessed. METHODS: Patients undergoing RC and PLND for invasive bladder cancer between March 2000 and February 2008 were retrospectively reviewed at the study institution. Beginning March 1, 2004, a policy was established that at least 16 lymph nodes had to be examined. Specimens with <16 lymph nodes were resubmitted (including any fat) to detect additional lymph nodes. Lymph node yields, lymph node positivity, lymph node density (LND), and survivorship before and after policy implementation were compared. RESULTS: A total of 147 patients underwent surgery 4 years before policy implementation and 202 underwent surgery 4 years after. The median number of lymph nodes increased from 15 to 20. Percentage of cases with >or=16 lymph nodes increased from 42.9% to 69.3% (P <.01). The lymph node positivity rates did not change significantly, but the proportion of patients with LND <20% increased from 43.9% to 65.5% (P = .04). Overall survival increased from 41.5% to 72.3% (P <.01). Univariate and multivariate regression demonstrated that policy implementation, and subsequent increase in median lymph node yield, decreased mortality risk by 30% (hazards ratio [HR], 0.70; P = .04) and 48% (HR, 0.52; P = .01), respectively. CONCLUSIONS: Thorough evaluation of PLND specimens obtained at RC can be influenced by an institutional policy mandating a minimum number of lymph nodes. This could lead to greater confidence in pathologic staging and reliability of LND as a predictor of prognosis. Survival can improve due to increased awareness to perform a more thorough PLND.