A Survey of Graduates of Combined Emergency Medicine-Pediatrics Residency Programs: An Update.

BACKGROUND: In 1998, emergency medicine-pediatrics (EM-PEDS) graduates were no longer eligible for the pediatric emergency medicine (PEM) sub-board certification examination. There is a paucity of guidance regarding the various training options for medical students who are interested in PEM. OBJECTIVES: We sought to to determine attitudes and personal satisfaction of graduates from EM-PEDS combined training programs. METHODS: We surveyed 71 graduates from three EM-PEDS residences in the United States. RESULTS: All respondents consider their combined training to be an asset when seeking a job, 92% find it to be an asset to their career, and 88% think it provided added flexibility to job searches. The most commonly reported shortcoming was their ineligibility for the PEM sub-board certification. The lack of this designation was perceived to be a detriment to securing academic positions in dedicated children's hospitals. When surveyed regarding which training offers the better skill set for the practice of PEM, 90% (44/49) stated combined EM-PEDS training. When asked which training track gives them the better professional advancement in PEM, 52% (23/44) chose combined EM-PEDS residency, 27% (12/44) chose a pediatrics residency followed by a PEM fellowship, and 25% (11/44) chose an EM residency then a PEM fellowship. No EM-PEDS respondents considered PEM fellowship training after the completion of the dual training program. CONCLUSION: EM-PEDS graduates found combined training to be an asset in their career. They felt that it provided flexibility in job searches, and that it was ideal training for the skill set required for the practice of PEM. EM-PEDS graduates' practices varied, including mixed settings, free-standing children's hospitals, and community emergency departments.

NICU admission hypothermia, chorioamnionitis, and cytokines.

OBJECTIVE: To determine whether neonatal intensive care unit (NICU) admission hypothermia is associated with an intrauterine inflammatory response. METHODS: We analyzed a cohort of 309 very low birthweight infants to determine relationships between admission hypothermia, chorioamnionitis, and serum and cerebrospinal fluid (CSF) interleukin (IL)-1ß, IL-6, and tumor necrosis factor-α. RESULTS: Admission hypothermia <36°C occurred in 72% of patients <26 weeks and 44% of patients ≥26 weeks gestational age. NICU admission hypothermia was not associated with histologic chorioamnionitis or with elevated serum cytokine concentrations. CSF IL-6 concentrations ≥6.3 pg/mL were associated with admission hypothermia in infants <26 weeks' gestation. Clinical chorioamnionitis was associated with a lower risk of admission hypothermia, while cesarean section delivery was associated with increased risk. CONCLUSIONS: NICU admission hypothermia is common among preterm infants and is not associated with the fetal inflammatory response syndrome. Hypothermia is less common in the setting of clinical chorioamnionitis and more common in cesarean section deliveries, identifying two groups in whom extra attention to appropriate thermoregulation is warranted.

Patients leaving against medical advice (AMA) from the emergency department--disease prevalence and willingness to return.

BACKGROUND: How patients fare once they leave the emergency department (ED) against medical advice (AMA), and the extent of illness burden that accompanies them, remains unstudied. OBJECTIVE: To determine the fate of patients leaving the ED AMA for a defined period of time post-discharge. METHODS: This was a prospective follow-up study of a convenience sample of patients leaving the ED AMA during two 6-month periods in consecutive calendar years at an urban academic ED with 32,000 annual patient visits. RESULTS: A total of 199 patients were identified, with 194 enrolled. Categories of discharge diagnoses included cardiovascular, undifferentiated abdominal pain, respiratory, and cellulitis. Of the 194 patients studied, 126 patients (64.9%, 95% confidence interval [CI] 57.6-71.5%) stated that their symptoms had improved or resolved. Of these 126 patients, 109 (86.5%, 95% CI 78.9-91.7%) had their original AMA discharge diagnoses referable to cardiovascular pathology. Ninety-five patients (75.4%, 95% CI 66.7-82.4%) with improved or abated symptoms did not plan to return. Of those with improved or abated symptoms, 31 patients (24.6%, 95% CI 17.6-33.2%) did return, and with further evaluation, 15 of them were found to have significant clinical findings. Of the 68 patients with continuing symptoms, 36 (52.9%, 95% CI 40.5-64.9%) returned for further evaluation. A total of 127 patients did not return. Twenty-five patients (19.7%, 95% CI 15.9-25.4%) expressed a reluctance to return to the same ED for fear of embarrassment. Seven patients (5.5%, 95% CI 4.8-8.7%) who did not seek alternative care but were still having symptoms did not return due to job or family commitments or because they would follow-up with a personal physician. CONCLUSION: Patients who leave the ED AMA have significant pathology.

Pediatric orthopedic emergencies.

Many well seasoned emergency physicians often find it challenging to assess and treat pediatric patients regardless of the complaint. Because of anatomic and physiologic differences, pediatric patients experience orthopedic injuries that are both unique and specific to this subset of the population. Emergency physicians must be aware of these nuances to properly diagnose and treat these injuries. An understanding of fractures unique to growing bone, such as buckle/torus and greenstick types, will provoke clinicians to have a keener eye when reviewing pediatric radiographs. The Salter-Harris classification provides a proven, generally accepted stratification of injury to describe and properly disposition pediatric fractures. Emergency physicians must also recognize a distal radial fracture, because it is the most common pediatric fracture, and the many complications of the supracondylar fracture. Nursemaid's elbow and ankle injuries are further common presenting complaints that are discussed. Recognition of child abuse and the work-up of the child presenting with a limp are additional areas that the Emergency physician should feel comfortable evaluating.

Emergency physician ability to predict methicillin-resistant Staphylococcus aureus skin and soft tissue infections.

Methicillin-resistant Staphylococcus aureus (MRSA) has a high prevalence in Emergency Departments (EDs). The objective of this study was to determine the ability of emergency physicians to predict MRSA infection in purulent wounds. A prospective observational study was conducted in an urban, tertiary academic center in ED patients presenting with purulent wounds and abscesses that received wound culture. Physicians completed a questionnaire with patient demographic data and their own suspicion for MRSA infection in eligible patients. For emergency physician ability to predict positive culture for MRSA, sensitivities, specificities, and positive and negative likelihood ratios (LRs) were calculated. Risk factors were assessed for statistical significance using a chi-squared test with p < 0.05. There were 176 patients enrolled, and 19 were eliminated for incomplete data. Physician suspicion of MRSA had a sensitivity of 80% (95% confidence interval [CI] 71%-87%) and a specificity of 23.6% (95% CI 14%-37%) for the presence of MRSA on wound culture with a positive LR of 1.0 (95% CI 0.9-1.3) and a negative LR of 0.8 (95% CI 0.5-1.3). Prevalence was 64%. Only intravenous drug use was significantly associated with MRSA. Emergency physician's suspicion of MRSA infection is a poor predictor of MRSA infection.