Pediatric and emergency medicine resident comfort assessing and treating pediatric pain across pediatric age groups.

Aim: Assess pediatric and emergency medicine (EM) resident comfort treating and assessing pediatric pain. Materials & methods: Pediatric and EM residents at a single institution (SIUH Northwell Health in New York) completed an anonymous survey 6 months into the academic year regarding comfort assessing and treating pediatric pain. Results: A total of 40 (16/24 EM and 24/24 pediatric) residents completed this survey: 20% (8/24) pediatric first year residents, 40% (16/40) pediatric second year and above, 20% (8/40) EM first year and 20% (8/40) EM second year and above. A 46% (11/24) pediatric and 12% (2/16) EM residents were comfortable assessing neonatal pain (p < 0.05). A 38% (9/24) pediatric residents were comfortable treating neonatal pain compared with 12% (2/16) EM residents (p < 0.05). Both resident groups reported increasing comfort assessing and treating pain with increasing patient age. Conclusion: Both residents groups reported limitations in comfort assessing and treating pediatric pain, especially in younger patients. Education for both groups is important to optimize pediatric pain management.

Pediatric pain is common, and often underassessed and undertreated. Pediatric and emergency medicine (EM) residents care for pediatric patients with pain and must be able to appropriately assess and treat this pain. For this study, pediatric and EM residents at a single institution (SIUH Northwell Health in New York) completed an anonymous survey 6 months into the academic year regarding comfort assessing and treating pain and comfort prescribing pain medications across pediatric age ranges. In this study, 40 (16/24 EM and 24/24 pediatric) residents completed this anonymous survey. Of the 40 residents, 20% (8/24) were pediatric first year residents, 40% (16/40) were second or third year pediatric residents, 20% (8/40) were EM first year residents and 20% (8/40) were second, third or fourth year residents. About 46% (11/24) of pediatric residents and 12% (2/16) of EM residents were comfortable assessing neonatal pain. With increasing patient age, pediatric residents and EM residents comfort in assessing pediatric pain trended up (93.3% EM residents comfortable assessing pain in teenage patients). About 38% (9/24) of pediatric residents were comfortable treating neonatal pain as compared with 12% (2/16) of EM residents. While pediatric residents were significantly more comfortable treating pain in age categories from neonate to adolescents as compared with EM residents, both pediatric and EM residents reported increasing comfort in treating pediatric pain with increasing patient age. Limitations in comfort assessing and treating pediatric pain exist for both specialties. Education for both groups is important to optimize pediatric pain management.

Invasive Salmonella Typhimurium ST313 with naturally attenuated flagellin elicits reduced inflammation and replicates within macrophages.

Invasive non-typhoidal Salmonella (iNTS) are an important cause of septicemia in children under the age of five years in sub-Saharan Africa. A novel genotype of Salmonella enterica subsp. enterica serovar Typhimurium (multi-locus sequence type [ST] 313) circulating in this geographic region is genetically different to from S. Typhimurium ST19 strains that are common throughout the rest of the world. S. Typhimurium ST313 strains have acquired pseudogenes and genetic deletions and appear to be evolving to become more like the typhoidal serovars S. Typhi and S. Paratyphi A. Epidemiological and clinical data show that S. Typhimurium ST313 strains are clinically associated with invasive systemic disease (bacteremia, septicemia, meningitis) rather than with gastroenteritis. The current work summarizes investigations of the broad hypothesis that S. Typhimurium ST313 isolates from Mali, West Africa, will behave differently from ST19 isolates in various in vitro assays. Here, we show that strains of the ST313 genotype are phagocytosed more efficiently and are highly resistant to killing by macrophage cell lines and primary mouse and human macrophages compared to ST19 strains. S. Typhimurium ST313 strains survived and replicated within different macrophages. Infection of macrophages with S. Typhimurium ST19 strains resulted in increased apoptosis and higher production of proinflammatory cytokines, as measured by gene expression and protein production, compared to S. Typhimurium ST313 strains. This difference in proinflammatory cytokine production and cell death between S. Typhimurium ST19 and ST313 strains could be explained, in part, by an increased production of flagellin by ST19 strains. These observations provide further evidence that S. Typhimurium ST313 strains are phenotypically different to ST19 strains and instead share similar pathogenic characteristics with typhoidal Salmonella serovars.

Salmonella enterica serovar enteritidis core O polysaccharide conjugated to H:g,m flagellin as a candidate vaccine for protection against invasive infection with S. enteritidis.

Nontyphoidal Salmonella enterica serovars Enteritidis and Typhimurium are a common cause of gastroenteritis but also cause invasive infections and enteric fever in certain hosts (young children in sub-Saharan Africa, the elderly, and immunocompromised individuals). Salmonella O polysaccharides (OPS) and flagellar proteins are virulence factors and protective antigens. The surface polysaccharides of Salmonella are poorly immunogenic and do not confer immunologic memory, limitations overcome by covalently attaching them to carrier proteins. We conjugated core polysaccharide-OPS (COPS) of Salmonella Enteritidis lipopolysaccharide (LPS) to flagellin protein from the homologous strain. COPS and flagellin were purified from a genetically attenuated (ΔguaBA) "reagent strain" (derived from an isolate from a patient with clinical bacteremia) engineered for increased flagellin production (ΔclpPX). Conjugates were constructed by linking flagellin monomers or polymers at random COPS hydroxyls with various polysaccharide/protein ratios by 1-cyano-4-dimethylaminopyridinium tetrafluoroborate (CDAP) or at the 3-deoxy-d-manno-octulosonic acid (KDO) terminus by thioether chemistry. Mice immunized on days 0, 28, and 56 with COPS-flagellin conjugates mounted higher anti-LPS IgG levels than mice receiving unconjugated COPS and exhibited high antiflagellin IgG; anti-LPS and antiflagellin IgG levels increased following booster doses. Antibodies generated by COPS-flagellin conjugates mediated opsonophagocytosis of S. Enteritidis cells into mouse macrophages. Mice immunized with flagellin alone, COPS-CRM197, or COPS-flagellin conjugates were significantly protected from lethal challenge with wild-type S. Enteritidis (80 to 100% vaccine efficacy).