Statewide Physician Survey Regarding Pediatric Muslim Fasting.

During Ramadan, Muslims fast from dawn to dusk for the duration of the month. The current literature focuses on adults who fast, with little attention to pediatric practices. An anonymous, digital survey was conducted using Qualtrics software and distributed to residents, fellows, or attendings in Michigan in 2019. Overall, 278 participants were included in the analysis, with 87% (242/278) identifying as pediatric trained physicians. In all, 82% (228/278) of physicians identified as non-Muslim and 76% (211/278) had never partaken in the Muslim fast. About 52% (141/273) of participants had at least a moderate amount of exposure to Muslim pediatric patients in their clinical practice. Most physicians (66%; 175/265) reported they never asked their pediatric patients or their families about fasting. About 61% (167/273) of participants rated their understanding of fasting as minimal to none. Another 52% (142/273) of participants reported feeling somewhat or extremely uncomfortable discussing fasting recommendations with their pediatric patients and their families. Our study is the first of its kind in assessing current knowledge and practice regarding pediatric Muslim fasting among physicians in the United States. In addition, it highlights a gap in physicians' understanding and comfort in providing anticipatory guidance for their Muslim patients.

Minor head injury transfers: Trends and outcomes.

BACKGROUND: Children with traumatic head injury are often transferred from community Emergency Departments (ED) to a Pediatric Emergency Department (PED). The primary objective of this study was to describe the outcomes of minor head injury (MHI) transfers to a PED. The secondary objective was to report Computed Tomography (CT) utilization rates for MHI. METHODS: We conducted a retrospective study of children aged ≤18 years transferred to our PED for MHI from 2013 to 2018. Patients with Glasgow Coma Scale (GCS) < 14, coagulopathies, history of brain mass/shunt and suspected non-accidental trauma were excluded. Data collected included demographics, interventions performed, and disposition. MHI risk stratification and clinically important traumatic brain injury (ciTBI) were defined per the Pediatric Emergency Care Applied Research Network (PECARN) head injury guidelines. Descriptive statistics were reported using general measures of frequency and central tendency. RESULTS: A total of 1078 children with MHI were analyzed based on eligibility criteria. The majority of patients were male (62%) and ≥ 2 years of age (69.3%). Subspecialist consultation (57.2%) and neuroimaging (27.4%) were the most commonly performed interventions in the PED. Only 14 children (1.3%) required neurosurgical intervention. One-third of the transferred patients required no additional work-up. Two-thirds of the patients (66.6%) were directly discharged from the PED. Though the total number of MHI transfers per year declined steadily during the study period (from 271/year to 119/year), CT head utilization remained relatively similar across the study years (60.3% to 70.8%). A higher proportion of children received CT in the ED when compared to the PED for low-risk (28.9% vs 15.8%) and intermediate-risk groups (42.8% vs 29.4%). CONCLUSIONS: The majority of pediatric MHI transfers are discharged home following a subspecialty consultation and/or neuroimaging. Despite guidelines and a low incidence of ciTBI, CT utilization remains high in the intermediate and low risk MHI groups, especially in the community settings. Targeted interventions are needed to reduce the potentially avoidable transfers and low-value performance of CT in children with MHI.

Factors associated with avoidable interhospital transfers for children with a minor head injury.

INTRODUCTION: Children with minor head injuries (MHI) are routinely transferred to a pediatric trauma center for definitive care. Unwarranted transfers result in minimal benefit to the patient and add substantially to healthcare costs. The purpose of this study is to explore the factors associated with avoidable interhospital transfers of children with MHI. METHODS: We conducted a retrospective cohort study of children <18 years of age transferred to our pediatric emergency department (PED) for MHI between January 2013 and December 2018. Patients transferred for non-accidental trauma, and those with a history of coagulopathies, underlying neurological conditions, intraventricular shunts and developmental delay were excluded. Transfers were categorized as avoidable if none of the following interventions were required at our PED: procedural sedation, anticonvulsant initiation, subspecialty consultation, intensive care unit admission or hospital admission for ≥2 nights, intubation or operative intervention. We collected demographics, injury mechanism, neuroimaging results, interventions performed and PED disposition. Binary logistic regression was conducted to provide adjusted associations between patient characteristics and the risk of avoidable interhospital transfers. RESULTS: We analyzed 1078 transfers for MHI, of which 450 (42%) transfers were classified as avoidable. Children in the avoidable transfer group tended to be younger, less likely to have experienced loss of consciousness, and more likely to belong to the the group at lowest risk for a clinically important traumatic brain injury (ciTBI). Our multivariable model determined that children less than 2 years of age (OR = 1.75; 95% CI = 1.3-2.37), low-risk group for ciTBI (OR = 1.66; 95% CI = 1.22-0.1), and a positive head CT at the transferring hospital (OR = 0.06; 95% CI = 0.02-0.1) were all significantly associated with avoidable transfers. CONCLUSION: There is a high rate of avoidable transfers in children with MHI. Focused interventions targeting risk factors associated with avoidable transfers may reduce unwarranted interhospital transfers.

Parietal Arteriovenous Malformation Mimicking Carotid-cavernous Fistula in Context of Sinus Thrombosis: Bidirectional or Unidirectional Relationship? Literature Review.

Cortically located arteriovenous malformations (AVMs) constitute majority of brain AVMs. A common drainage is through respective cortical veins into superior sagittal or transverse sinuses. Through a case report and literature review, we discuss three issues: first, the anomalous drainage of a cortical AVM into an anterior orbital venous drainage system; second, the impact of this drainage on the clinical picture; and third, importantly, the bidirectional versus unidirectional relationship of AVM and old venous sinus thrombosis.

Perinatal HIV Transmission: Missed Opportunities and Proposed Solutions.

Much progress has been made in the elimination of perinatal human immunodeficiency virus (HIV). Since the 1980s, the transmission rate from pregnant women to their children has dropped from approximately 25% to less than 1% in resource-rich areas. Routine HIV testing in pregnancy, the introduction of multidrug antiretroviral therapy for pregnant women, and the recognition that HIV viral load directly correlates with viral transmission have all led to the elimination of perinatal HIV. However, there are still missed opportunities that could further minimize transmission.