Increasing Chlamydia and Gonorrhea Testing for Adolescents in the Pediatric Emergency Department.

OBJECTIVE: Adolescents who use the emergency department are more likely to engage in high-risk sexual activity and are at an increased risk of sexually transmitted infections. We aimed to increase testing for Chlamydia and gonorrhea from 12% to 50% among adolescents presenting to our pediatric emergency department with at-risk chief complaints over 12 months. METHODS: Plan-Do-Study-Act cycles were initiated in July 2020. A multidisciplinary team reviewed preexisting data and developed interventions to increase Chlamydia and gonorrhea testing in teens with at-risk complaints, including genitourinary and behavioral health complaints, and females with abdominal pain. Two categories of interventions were implemented: education and electronic medical record optimization. Process measures were the proportion of patients with a documented sexual history and the proportion of patients tested with a documented confidential phone number. Secondary outcome measures included the weekly number of positive test results and the proportion of patients testing positive who were contacted to arrange treatment. Statistical process control charts were used to examine changes in measures over time. RESULTS: Within 14 months of project initiation, the proportion of at-risk patients tested increased from 12% to 59%. Teen phone number documentation remained unchanged from 23%. Sexual history documentation remained unchanged from 46%. The number of positive test results increased from 1.8 to 3.4 per month, and the proportion of patients testing positive who were contacted to arrange treatment remained unchanged at 83%. CONCLUSIONS: We surpassed our goal and increased the proportion of at-risk patients tested for Chlamydia and gonorrhea to 59%, sustained for 4 months from the last intervention.

Developing an innovative pediatric integrated mental health care program: interdisciplinary team successes and challenges.

Introduction: Children and adolescents often do not receive mental healthcare when they need it. By 2021, the complex impact of the COVID-19 pandemic, structural racism, inequality in access to healthcare, and a growing shortage of mental health providers led to a national emergency in child and adolescent mental health in the United States. The need for effective, accessible treatment is more pressing than ever. Interdisciplinary, team-based pediatric integrated mental healthcare has been shown to be efficacious, accessible, and cost-effective. Methods: In response to the youth mental health crisis, Rady Children's Hospital-San Diego's Transforming Mental Health Initiative aimed to increase early identification of mental illness and improve access to effective treatment for children and adolescents. A stakeholder engagement process was established with affiliated pediatric clinics, community mental health organizations, and existing pediatric integrated care programs, leading to the development of the Primary Care Mental Health Integration program and drawing from established models of integrated care: Primary Care Behavioral Health and Collaborative Care. Results: As of 2023, the Primary Care Mental Health Integration program established integrated care teams in 10 primary care clinics across San Diego and Riverside counties in California. Measurement-based care has been implemented and preliminary results indicate that patient response to therapy has resulted in a 44% reduction in anxiety symptoms and a 62% decrease in depression symptoms. The program works toward fiscal sustainability via fee-for-service reimbursement and more comprehensive payor contracts. The impact on patients, primary care provider satisfaction, measurement-based care, funding strategies, as well as challenges faced and changes made will be discussed using the lens of the Reach, Effectiveness, Adoption, Implementation and Maintenance framework. Discussion: Preliminary results suggest that the Primary Care Mental Health Integration is a highly collaborative integrated care model that identifies the needs of children and adolescents and delivers brief, evidence informed treatment. The successful integration of this model into 10 primary care clinics over 3 years has laid the groundwork for future program expansion. This model of care can play a role addressing youth mental health and increasing access to care. Challenges, successes, and lessons learned will be reviewed.

First-Person Point-of-View Instructional Video on Lumbar Puncture Procedure.

OBJECTIVES: Tutorial videos filmed from a first-person point of view (FP-POV) are generally well received. Pediatric residents are expected to be competent in performing the lumbar puncture (LP). The educational effectiveness of a FP-POV in lumbar puncture procedure training for resident physicians has yet to be evaluated. We compared a FPPOV LP video with a standard in-person demonstration of the LP. METHODS: We designed an assigned cohort study to compare a FP-POV procedural instructional video of a simulated pediatric LP to the standard in-person procedure demonstration.After the intervention, residents completed an LP observed by one of two blinded reviewers who assessed the procedure using a modified, published assessment tool.Participants completed preintervention and postintervention surveys to rate self-confidence and usefulness of the FP-POV educational method. The data was analyzed using a Wilcoxon Rank sum test. z Scores were calculated on the raw assessment scores. RESULTS: Eighteen first year pediatric residents participated, nine in each group. The median modified assessment tool score was 17 in the FP-POV group (min, 14; max, 17; IQR:, 1.5) and 14 in the standard demonstration group (min, 6; max, 17; IQR, 4.5), with the higher score being more successful. There was a statistical difference between the assessment scores between the 2 groups (z score = 2.18, P = 0.04). Postintervention survey data demonstrated relative satisfaction with the FPPOV educational method. CONCLUSIONS: This study supports the educational effectiveness of a FP-POV procedure tutorial.Future studies with a larger sample size are needed.

Optimizing Education During Pediatric Resident Mock Code Sessions.

INTRODUCTION: Most pediatric residents have limited opportunities to manage cardiac arrest. We used simulation to fill that educational void. Given work hours and other obligations, resident education sessions must be high-yield. We examined the effectiveness of adding varying amounts of formal education to a mock code session on resident knowledge and confidence in managing pediatric cardiac arrest compared with participation alone. METHODS: Convenient groups of 3 to 8 pediatric residents completed a simulation session with the identical scenario: a 3-month-old infant with pulseless ventricular tachycardia and then pulseless electrical activity. All residents completed pretests and posttests, which consisted of open-ended knowledge questions from the American Heart Association Pediatric Advanced Life Support guidelines and confidence Likert scale assessments. Resident groups were assigned to 1 of 3 educational models: experiential-only: participation in the mock, traditional: mock code participation with standardized education after the mock code, or reinforced: standardized education before and after mock code participation. RESULTS: Ninety-five residents participated. Collectively, residents demonstrated a median 2-point (interquartile range, 1-4) increase in knowledge (test maximum score, 10) after they attended a mock code simulation session ( P < 0.0001); however, there were no statistically significant differences noted between educational modalities. All residents also demonstrated a 4-point median increase in confidence (test maximum score, 25) after completing their simulation session (interquartile range, 3-6) ( P < 0.001), but no differences were seen by type or amount of accompanying education. CONCLUSIONS: Residents had gains in confidence and knowledge of pediatric cardiac arrest management after participation in the mock code. Formal educational sessions and reinforced formal education sessions accompanying the mock code did not significantly increase knowledge or confidence.

Efficacy of a digital mental health intervention embedded in routine care compared with treatment as usual in adolescents and young adults with moderate depressive symptoms: protocol for randomised controlled trial.

INTRODUCTION: There are unmet mental health needs of depressed adolescents and young adults (AYAs) across the USA. Behavioural technology adequately integrated into clinical care delivery has potential to improve care access and efficiency. This multisite randomised controlled trial evaluates how a coach-enhanced digital cognitive behavioural intervention (dCBI) enhances usual care for depressed AYAs in paediatric practices with minority enriched samples. METHODS AND ANALYSIS: Participants (n=750) ages 16-22 who meet threshold criteria for depressive severity (Patient Health Questionnaire-9; PHQ-9 score 10-24) will be recruited through paediatric practices across three academic institutions (Boston, Pittsburgh and San Diego). Participants will be randomised to 12 weeks of dCBI+treatment as usual (TAU) (n=450) or TAU alone (n=300) in outpatient paediatric practices. Assessments will be completed at baseline, 6 weeks and 12 weeks with the primary outcome being improvement in clinician-rated and self-reported depressive severity (Children's Depression Rating Scale-Revised and PHQ-9) and secondary outcomes being self-reported suicidal ideation (item 9 on PHQ-9), anxiety severity (Generalised Anxiety Disorder), general quality of life (Satisfaction with Life Scale) and general functioning (Children's Global Assessment Scale). The study design is an intent-to-treat mixed effects regression with group, and covariates nested within the sites. ETHICS AND DISSEMINATION: All participants or their parent/guardian (under 18 years or unemancipated) will give informed consent to a study team member. All data are expected to be collected over 18 months. The Institutional Review Board (IRB) is a board at each institution in the United States that reviews and monitors research involving human subjects. IRB approval from the University of Pittsburgh was obtained on 30 November 2021 (STUDY21080150), from the University of California San Diego's Human Research Protection Program IRB on 14 July 2022 (802047), and from the Boston Children's Hospital IRB on 25 October 2022 (P00040987). Full study results are planned to be published within 2 years of initial study recruitment (October 2024). Dissemination of findings will occur in peer-reviewed journals, professional conferences and through reports to participating entities and stakeholders. TRIAL REGISTRATION NUMBER: NCT05159713; ClinicalTrials.gov.

Predictive Factors for Delayed Surgical Intervention in Children With Epidural Hematomas.

BACKGROUND: Optimal treatment of children with traumatic intracranial epidural hematomas (EDHs) is unknown. We sought to identify clinical and radiographic predictors of delayed surgical intervention among children with EDH admitted for observation. METHODS: We retrospectively identified patients younger than 15 years with acute traumatic EDHs evaluated at our level 1 pediatric trauma center. We excluded patients with penetrating head injuries, recent surgical evacuation of EDH, or depressed skull fracture requiring surgical repair and assigned the remaining subjects to the immediate surgery group if they underwent immediate surgical evacuation, to the supportive-therapy-only group if they underwent observation only, and to the delayed surgery group if they underwent surgery after observation. We abstracted clinical and laboratory findings, surgical interventions, and neurological outcome and measured EDH dimensions and volumes, adjusting for cranial size. We compared clinical and radiographic characteristics among groups and performed receiver-operator characteristic analyses of predictors of delayed surgery. RESULTS: Of 172 patients with EDH, 103 patients met the inclusion criteria, with 6 (6%) in the immediate surgery group, 87 (84%) in the supportive-therapy-only group, and 10 (10%) in the delayed surgery group. Headache, prothrombin time of >14 seconds, EDH maximal thickness of ≥1.1 cm, volume of ≥14 mL, EDH thickness/cranial width index of ≥0.08 and EDH volume/cranial volume index of ≥0.18, and mass effect were associated with delayed surgical intervention. There was no difference in length of stay or functional impairment between the immediate and delayed surgery groups. However, patients in delayed surgery group were more likely to have subjective symptoms at discharge than those in immediate surgery group. CONCLUSIONS: Among patients with EDH admitted for observation, larger EDH, mass effect, headaches, and prothrombin time of >14 seconds were associated with delayed surgical intervention. A larger-scale study is warranted to identify independent predictors of delayed surgery in children under observation for EDH.

Sexual History Documentation and Screening in Adolescent Females with Suicidal Ideation in the Emergency Department.

Adolescents with mental illness often seek care in the emergency department (ED) and are more likely to engage in risky behaviors such as substance abuse and unprotected sex, increasing their risk of sexually transmitted infections (STI), unintended pregnancy, and non-consensual sex. This was a retrospective study of 312 females, aged 13-17 years, presenting to the pediatric ED with the chief complaint of suicidal ideation from February to May 2018. Electronic medical records were reviewed for demographics, psychiatric history, sexual history, and testing for pregnancy or STI. The primary outcome was the documentation of the presence or absence of prior sexual activity. Secondary outcomes included documented aspects of sexual history and pregnancy or STI testing performed in the ED. Of the 312 eligible patients, 144 (46.2%) had a documented sexual history, and of those 50 (34.7%) reported being sexually active. Sexual history documentation was not associated with patient age, race, ethnicity, insurance, or the gender of the ED provider. A history of anxiety and a recent suicide attempt were associated with a lack of sexual history documentation (p = 0.03). Of the sexually active patients, 28 (56%) had documentation of contraception use. Pregnancy testing was performed in 67.3% of all patients and 80% of sexually active patients. Only 10 patients had STI testing in the ED, with most testing occurring in those with sexual history documentation (p = 0.007). In conclusion, more than half of females with suicidal ideation in our ED had no documentation of sexual history, and when documentation was completed, it was often missing important elements, including screening for pregnancy, STI, non-consensual sex, and contraception use. Since the ED visit provides an important opportunity to address the reproductive health needs of this high-risk population, further work is needed to determine ways to improve provider documentation and sexual health screening.

Disappearing Help Text: Implementing a Note-Based Tool for In-Line Clinical Decision Support and Note Bloat Reduction.

OBJECTIVE: The authors describe a novel solution to the challenges of lengthy notes and poor note readability by creating an unobtrusive clinical decision support tool named "disappearing help text." METHODS: We designed this tool in Pediatric Hospital Medicine (PHM) note templates to provide in-line decision support on best documentation practices, note bloat reduction, billing compliance, and provider workflow enhancement. RESULTS: After template changes that utilized disappearing help text, we reduced the percent of notes utilizing any laboratory SmartLink from 90.2 to 15.3% for admission notes (p <0.001), 92.6 to 17.8% for progress notes (p <0.001), and 14 to 7.2% for discharge summaries (p <0.001). In admission and progress notes, this correlated with a significant reduction in the median note length as a proxy of note bloat reduction, with a 18.7% character count reduction in progress notes (p <0.001) and a 6.4% reduction in admission notes (p <0.001). PHM coding queries decreased from an average of 42 per month to 36 per month, and there was no change in PHM attending billing compliance audit performance. DISCUSSION: Note template changes that utilized disappearing help text significantly reduced the length of both progress and admission notes, a proxy for note bloat reduction, without negatively impacting coding query frequency or internal billing audit performance. One factor that likely contributed to this reduction in note length is the reduced usage of laboratory SmartLinks prompted by disappearing help text. CONCLUSION: We present the use of in-line disappearing help text embedded into note templates as a clinical decision support tool to improve note readability, educate trainees on note documentation, and protect confidential teen information. Help text implementation correlated with a reduction in the automatic insertion of laboratories into notes and a decrease in note character count.

The Effect of COVID-19 Lockdown on PHQ Depression Screening Scores for High School Athletes.

Adolescent behavioral health was in crisis before COVID-19. The shutdown and reopening of in-person learning and extracurricular activities may have worsened this crisis. We examined high school athletes' depression before and during the pandemic. Data were collected as part of a pilot program incorporating Patient Health Questionnaire (PHQ) screenings during high school sports physicals before the COVID-19 lockdown and three timepoints after. Statistical comparisons were made using logistic regression. A total of 927 individual scores were analyzed: 385 from spring 2020; 145 from fall 2020; 163 from fall 2021; and 234 from spring 2022. Fall 2020 students were 3.7 times more likely to have elevated PHQ-2 scores than spring 2020 students (95% CI = 1.8, 7.6). Fall 2021 and spring 2022 scores did not differ significantly from pre-pandemic, although trends of elevated scores persisted (OR = 1.6; 95% CI = 0.7, 3.5, and OR = 1.2; 95% CI = 0.6, 2.4, respectively). A significant difference in PHQ-9 depression severity classification was detected over time (p < 0.01). Elevated PHQ scores were found after the onset of the COVID-19 pandemic. After the initial peak in fall 2020, scores decreased but did not reach pre-pandemic levels.

Emergence of Extended-Spectrum ß-Lactamase-Producing Pathogens in Community-Acquired Urinary Tract Infections Among Infants at a Pediatric Emergency Department.

BACKGROUND: Extended-spectrum ß-lactamase (ESBL)-producing pathogens are common among adults and are associated with extended and multiple hospitalizations. They cause urinary tract infections (UTIs) among children with known risk factors such as urinary tract abnormalities and antimicrobial prophylaxis. The emergence of UTIs caused by ESBL-producing organisms among infants has not been well characterized. OBJECTIVE: We sought to describe the incidence and current clinical management of infants who were diagnosed with UTIs caused by ESBL-producing organisms at a pediatric emergency department (ED). In addition, we sought to describe risk factors associated with inpatient hospitalization for UTIs caused by ESBL-producing organisms. METHODS: We retrospectively identified infants who were treated in the ED from 2013 to 2017 and who had positive urinalyses and urine cultures positive for greater than 50,000 colony-forming unit per milliliter of a single ESBL-producing urinary pathogen. We abstracted details of clinical management and known previous risk factors, including prior neonatal intensive care unit hospitalization stay, prior UTI caused by an ESBL-producing organism, and known urologic abnormalities. RESULTS: Forty-five UTIs caused by ESBL-producing organisms occurred in 43 patients (mean age of 5.9 months and 59% female)-ESBL Escherichia coli represented the majority (42/45). The incidence of UTIs caused by ESBL-producing organisms ranged from 0.9% to 4.5% during the 5-year study period. The 13 patients (26%) admitted from the ED were significantly younger than discharged patients (1.9 vs 6.7 months, P = 0.016) and more likely to have had prior neonatal intensive care unit hospitalizations (50% vs 15.6%, P = 0.0456). Of the 33 visits (77%) resulting in initial outpatient management, 5 were followed by readmission for parenteral antibiotic treatment. Of those who were readmitted, 40% (n = 2) were afebrile at the time of admission. The remainder (28/33) completed outpatient oral antibiotic courses guided by susceptibilities. Two patients (4%) had negative repeat urine cultures despite in vitro resistance to initial antibiotic coverage. CONCLUSIONS: Extended spectrum ß-lactamase-producing organisms are an increasing cause of UTIs in infants presenting at a pediatric ED, and outpatient management may be reasonable for infants older than 2 months.

Risk Factors for Peri-intubation Cardiac Arrest in a Pediatric Emergency Department.

OBJECTIVES: Cardiac arrest is a significant complication of emergent endotracheal intubation (ETI) within the pediatric population. No studies have evaluated risk factors for peri-intubation cardiac arrest (PICA) in a pediatric emergency department (ED) setting. This study identified risk factors for PICA among patients undergoing emergent ETI in a pediatric ED. METHODS: We performed a nested case-control study within the cohort of children who underwent emergent ETI in our pediatric ED during a 9-year period. Cases were children with PICA within 20 minutes of ETI. Controls (4 per case) were randomly selected children without PICA after ETI. We analyzed potential risk factors based on published data and physiologic plausibility and created a simple risk model using univariate results, model fit statistics, and clinical judgment. RESULTS: In the cohort of patients undergoing ETI, PICA occurred in 21 of 543 subjects (3.9%; 95% confidence interval [CI], 2.2-5.9%), with return of spontaneous circulation in 16 of 21 (76.2%; 95% CI, 52.8-91.8%) and survival to discharge in 12 of 21 (57.1%; 95% CI, 34.0-78.2%). On univariate analysis, cases were more likely to be younger, have delayed capillary refill time, systolic or diastolic hypotension, hypoxia, greater than one intubation attempt, no sedative or paralytic used, and pulmonary disease compared with controls. Our 4-category risk model for PICA combined preintubation hypoxia (or an unobtainable pulse oximetry value) and younger than 1 year. The area under the receiver operating characteristic curve for this model was 0.87 (95% CI, 0.77-0.97). CONCLUSIONS: Hypoxia (or an unobtainable pulse oximetry value) was the strongest predictor for PICA among children after emergent ETI in our sample. A simple risk model combining pre-ETI hypoxia and younger than 1 year showed excellent discrimination in this sample. Our results require independent validation.

The Effectiveness of a Pediatric Emergency Medicine Block Education Session for Pediatric Residents.

BACKGROUND AND OBJECTIVE: There exists no standardized curriculum for pediatric residents to develop procedural skills during residency training. Many pediatric residency programs are transitioning to block education sessions; the effectiveness of this format for delivering pediatric emergency medicine (PEM) procedural curriculum has not been evaluated. The objective is to determine if a PEM block education session improved pediatric residents' knowledge and confidence in 4 domains: laceration repair, splinting of extremities, resuscitation/airway management, and point-of-care ultrasound. METHODS: Pediatric residents at the University of California at San Diego participated in a 4-hour PEM block education session during which they rotated through 4 interactive stations: laceration repair, splinting of extremities, resuscitation/airway management, and point-of-care ultrasound. Residents' knowledge was assessed using 2 distinct multiple-choice tests, each consisting of 20 questions (5 questions per domain). Residents were block randomized to take one version of the test as the pretest and the other version as the posttest. Residents' confidence was assessed for each domain using a standardized 5-point confidence tool before and after the block education session. RESULTS: Forty-five residents attended the PEM block education session. Forty-three residents completed both the preknowledge and postknowledge tests. The PEM block education session resulted in an almost 14% increase in knowledge test when comparing preknowledge and postknowledge scores (P < 0.0001). Significant improvement in resident confidence was seen in all 4 domains (P < 0.0001). CONCLUSIONS: The PEM block educational session improved both pediatric residents' knowledge and confidence in domains frequently encountered in the pediatric emergency department.

Reducing Opioid Doses Prescribed From a Pediatric Emergency Department.

BACKGROUND: Opioid overdose and abuse have reached epidemic rates in the United States. Medical prescriptions are a large source of opioid misuse. Our quality improvement initiative aimed to reduce opioid exposure from the pediatric emergency department (ED). Objective was to reduce opioid doses prescribed weekly from our ED by 50% within 4 months. METHODS: Three categories of interventions were implemented in Plan-Do-Study-Act cycles: guidelines and education, electronic medical record optimization, and provider-specific feedback. Primary measures were opioid doses prescribed weekly from the ED and opioid doses per 100 ED visits. Process measures were opioid prescriptions, opioid doses per prescription, and opioid prescriptions for unspecified abdominal pain, headache, and viral upper respiratory infection. Balancing measures were phone calls and return visits for poor pain control in patients prescribed opioids and reports of poor pain control in call backs to orthopedic reduction patients. We used statistical process control to examine changes in measures over time. RESULTS: Opioid doses decreased from 153 to 14 per week and from 8 to 0.7 doses per 100 ED visits in 10 months, sustained for 9 months. Opioid prescriptions, opioid doses per prescription, and prescriptions for unspecified abdominal pain, headache, and viral upper respiratory infection decreased. Phone calls and return visits in patients prescribed opioids did not increase. There were 2 reports of poor pain control among 152 orthopedic reduction patients called back. CONCLUSIONS: We decreased opioid doses prescribed weekly from the pediatric ED by 91% while minimizing return visits and reports of poor pain control.

Tablet Computer as a Distraction Tool During Facial Laceration Repair: A Randomized Trial.

OBJECTIVES: Child life interventions reduce the anxiety of medical procedures but are not always available in emergency departments. In this study, we determined the effect of parent-directed tablet computer use without child life direction on patient anxiety and on parent and suturing clinician experience during pediatric facial laceration repair. METHODS: In a children's hospital emergency department, we enrolled children 2 to 12 years of age undergoing unsedated facial laceration repairs and randomized them to parent-directed tablet computer distraction or standard supportive care. We measured anxiety using the Observational Scale of Behavioral Distress-Revised (OSBD-R) for 5 procedure phases from videotaped laceration repairs. We compared OSBD-R scores for 5 phases and weighted averages between the tablet and standard care groups. Parents and suturing clinicians completed surveys about their experiences after the procedures. RESULTS: From April 2014 to July 2015, 77 patients (39 tablet, 38 standard) underwent repairs. Age, use of restraint, procedure duration, and number of sutures were similar between the 2 groups. The groups did not differ in procedure phase or weighted-average OSBD-R scores. Parents in the tablet group reported less personal anxiety compared with parents in the standard group (P = 0.01). In a post hoc subgroup analysis, subjects in the unrestrained tablet group had lower OSBD-R scores during the anesthetic injection phase than did subjects in the unrestrained standard group (P = 0.04). If restrained, subjects in the tablet group had higher OSBD-R scores during the anesthetic injection phase than did subjects in the standard group (P = 0.048). CONCLUSIONS: Unrestrained children may benefit from parent-directed tablet computer distraction. Parents who operate the device are less anxious during their children's procedures.

Hold the Phone! Cell Phone-Related Injuries in Children, Teens, and Young Adults Are On the Rise.

We describe trends in cell phone-related injuries in patients 21 years of age and under presenting to United States Emergency Departments. We calculated age-adjusted rates of cell phone-related injury per 100 000 individuals using data from the National Electronic Injury Surveillance System (NEISS) database and United States Census Bureau. From 2002 to 2015, an estimated 38 063 patients 21 years old and younger sustained a cell phone-related injury. The overall rate of injuries for all ages increased from 17.1 injuries per 100 000 in 2002 to 138 injuries per 100 000 in 2015, an increase of over 700%. The incidence of cell phone-related injuries increased across all age groups, with children 2 years of age and under experiencing the highest single incidence rate of 159 injuries per 100 000 in 2014. These findings highlight an important and relatively under-reported pediatric safety issue. Anticipatory guidance and injury prevention plans should be updated accordingly.

Patterns of Stress, Coping and Health-Related Quality of Life in Doctor of Pharmacy Students.

Objective. To examine perceived stress, coping strategies, and health-related quality of life in Doctor of Pharmacy students across the first three years (pre-clinical portion) of the curriculum. Methods. Three instruments, the Perceived Stress Scale, Brief COPE, and Short Form-36, were administered to students three times a year over a five-year period. Median annual scores were compared using Skillings-Mack tests and correlations were assessed using Spearman correlation. Results. One hundred forty-five students (approximately 46% of the school's enrollment) participated. A significant increase in scores on the PSS, increase in students' maladaptive coping behaviors, and worsening mental health-related quality of life were detected in students across the first three years of the pre-clinical curriculum. The PSS scores of first- and second-year pharmacy students had a moderate to large positive correlation with maladaptive coping behaviors (rho = 0.43 and 0.58, respectively) and PSS scores exhibited a large negative correlation with maladaptive coping behaviors in all three years of the pre-clinical curriculum (rho ranged from -0.69 to -0.78). Conclusion. Increasing levels of stress, increasing use of maladaptive coping strategies, and declining mental health-related quality of life among pharmacy students across the first three years of the four-year curriculum were very similar to findings in the cohort of pharmacy students observed in the preceding five years.

Associations between Dietary Acid Load and Biomarkers of Inflammation and Hyperglycemia in Breast Cancer Survivors.

Metabolic acidosis can lead to inflammation, tissue damage, and cancer metastasis. Dietary acid load contributes to metabolic acidosis if endogenous acid-base balance is not properly regulated. Breast cancer survivors have reduced capacities to adjust their acid-base balance; yet, the associations between dietary acid load and inflammation and hyperglycemia have not been examined among them. We analyzed data collected from 3042 breast cancer survivors enrolled in the Women's Healthy Eating and Living (WHEL) Study who had provided detailed dietary intakes and measurements of plasma C-reactive protein (CRP) and hemoglobin A1c (HbA1c). Using a cross-sectional design, we found positive associations between dietary acid load and plasma CRP and HbA1c. In the multivariable-adjusted models, compared to women with the lowest quartile, the intakes of dietary acid load among women with the highest quartile showed 30-33% increases of CRP and 6-9% increases of HbA1c. Our study is the first to demonstrate positive associations between dietary acid load and CRP and HbA1c in breast cancer survivors. Our study identifies a novel dietary factor that may lead to inflammation and hyperglycemia, both of which are strong risk factors for breast cancer recurrence and comorbidities.

A Specialized Pediatric Emergency Medicine Track Decreases Computed Tomography in Head Injured Patients.

BACKGROUND: There is an increased emphasis on reducing exposure to ionizing radiation in pediatric patients. Guidelines from the Pediatric Emergency Care Applied Research Network help practitioners identify patients at low risk for clinically important traumatic brain injury after head injury. OBJECTIVES: We seek to determine whether the institution of a pediatric track staffed by pediatric emergency medicine physicians (PEMs) within a community emergency department (ED) impacts the overall utilization of head computed tomography (CT) on children younger than 15 years with head injury. METHODS: We used a retrospective cohort analysis of patients under the age of 15 years presenting to a community ED in the year before and the year of institution of a pediatric emergency track. Relative risk estimates were used to determine the risk of CT use associated with nonpediatric-trained emergency providers. RESULTS: The community ED saw 11,094 patients and 14,639 patients younger than 15 years in fiscal years 2014-2015 and 2015-2016, respectively. In the year before PEMs, there were 312 children younger than 15 years seen for head injury; 47.09% received head CTs. After PEM coverage, there were 396 children younger than 15 years seen for head injury; 17.17% received head CTs. Pediatric patients with head injury were 2.2 times more likely to receive CTs before the institution of the pediatric track (95% confidence interval, 1.8-2.6). CONCLUSION: The implementation of a pediatric emergency track demonstrated a significant decrease in CT utilization for head injury. Continued development of pediatric tracks in community EDs can lead to reduction of CTs.

A Retrospective Review of Antipsychotic Medications Administered to Psychiatric Patients in a Tertiary Care Pediatric Emergency Department.

OBJECTIVES: An increasing number of pediatric patients with psychiatric chief complaints present to emergency departments (EDs) nationwide. Many of these patients require treatment with antipsychotic medications to treat agitation. We sought to examine the use of antipsychotic medications in pediatric patients presenting to a tertiary care pediatric ED. METHODS: We performed a retrospective electronic medical record review of patients presenting to a tertiary care pediatric hospital from January 2009 through February 2016 with a psychiatric chief complaint who received an antipsychotic medication in the ED. RESULTS: A total of 229 patients were identified, 54.1% of whom were male. Mean age was 14.4 ± 2.6 years. Commonly administered medications included olanzapine (51.1%), aripiprazole (26.6%), haloperidol (24.0%), and risperidone (11.8%). Eighty-seven patients (38.0%) were given at least 1 intravenous or intramuscular dose of antipsychotic medication. A total of 113 patients (49.3%) received only 1 antipsychotic medication, 65 (28.4%) received 2, 30 (13.1%) received 3, and 21 (9.2%) received 4 or more antipsychotics. Median length of stay (minutes) increased significantly with increasing number of medications administered (p < 0.001). Length of stay was significantly shorter in patients given only oral medications (675.6 minutes, IQR 418-1194) compared to those given at least one intramuscular or intravenous dose (951 minutes, IQR 454-1652) (p = 0.014). CONCLUSIONS: In this retrospective series, the majority of patients were treated with newer oral antipsychotics. Administration of multiple medications was associated with a significantly longer length of stay in the ED, as was parenteral administration of antipsychotics.

Comparison of pediatric post-reduction fluoroscopic- and ultrasound forearm fracture images.

OBJECTIVE: Emergency department (ED) reduction of pediatric fractures occurs most commonly in the forearm and can be challenging if fluoroscopy is not available. We sought to assess the ability of point of-care ultrasonography (POCUS) to predict adequacy of reduction by fluoroscopy. METHODS: We prospectively enrolled ED patients 0-17 years of age with radial and/or ulnar fractures requiring reduction under fluoroscopic guidance. Post-reduction POCUS (probe dorsal, volar, and coronal) and fluoroscopic (AP and lateral) fracture images were recorded. Fracture angles were compared between blinded POCUS and fluoroscopic measurements and between POCUS measurements by a blinded emergency physician and a blinded radiologist, reporting mean differences and 95% confidence intervals. We calculated sensitivity, specificity, and likelihood ratios of POCUS in the prediction of fluoroscopically detected post-reduction malalignment, as interpreted by a blinded pediatric orthopaedist. RESULTS: The 58 patients were 7.9 ±â€¯3.5 years of age and had 21 radial (36%), 1 ulnar (2%), and 36 radioulnar (62%) fractures. Fluoroscopy and POCUS angles were within a mean of 0.1°-3.2°, depending on the site and surface measured. Radiologist- and emergency physician-interpreted POCUS measurements were within a mean of 1° in all dimensions. POCUS identified inadequate reductions with 100% sensitivity and 92-93% specificity. CONCLUSIONS: Blinded emergency medicine and radiology interpretations of post-reduction POCUS fracture images agree closely. Post-reduction POCUS measurements are comparable to those obtained by fluoroscopy and accurately predict adequacy of reduction. POCUS can be used to guide pediatric fracture reduction when bedside fluoroscopy is not available in the ED.