Impacts of a University Research Assistant Program: The First Decade.

Purpose: There is a declining number of physician-scientists. Little is published about the potential for university student experiences to contribute to the pipeline of future researchers. The purpose of this study was to describe a unique university research program and report the outcomes of the first 10 years. Method: The University Research Assistant Program (URAP) was described including course content, research experiences, and student composition. Outcomes of URAP student contributions to the literature and research presentations was reported. URAP students were also surveyed to assess their perspectives on the impact of the URAP program on career choices after graduation. Results: URAP began as an independent study course and grew into for-credit university courses. A total of 212 students have taken at least one semester and 88 responded to the survey. All students who participated in URAP have graduated, and 77% (n = 68) reported the URAP program prepared them to reach their career goals. Most graduates pursued health care careers including medical school (55%), Master's programs in health care (29%), or PhD in health care (5%). URAP students participated in research involving 11 different pediatric subspecialties. Many attained co-authorship of abstracts and publications, 53 first-authored an abstract presentation and 7 manuscripts. Conclusions: URAP significantly influenced university students who overwhelmingly entered health care fields. While difficult to assess if these early experiences will influence participation as future physician -scientists, these students made meaningful research contributions while enrolled in these courses. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-023-01852-6.

Online Behavioral Screener with Tailored Obesity Prevention Messages: Application to a Pediatric Clinical Setting.

Obesity prevention involves promoting healthy eating and physical activity across all children. Can we leverage technology to feasibly survey children's health behaviors and deliver theory-based and user-tailored messages for brief clinical encounters? We assessed the acceptability and utility of an online pediatric-adapted liking survey (PALS) and tailored messages among children receiving non-urgent care in a pediatric emergency department (PED). Two hundred and forty-five children (average age = 10 years, racially/ethnically diverse, 34% overweight/obese from measured indices, 25% of families reporting food insecurity) and their parents/caregivers participated. Each reported the child's activity and behaviors using the online PALS and received two to three messages tailored to the responses (aligned with elaboration likelihood and transtheoretical models) to motivate behavioral improvements or reinforce healthy behaviors. Most children and parents (>90%) agreed the PALS was easy to complete, encouraging thought about their own/child's behaviors. The child's PALS responses appeared reasonable (fair-to-good child-parent intraclass correlations). Most children and parents (≥75%) reported the tailored messages to be helpful and favorable for improving or maintaining the targeted behavior. Neither message type (motivating/reinforcing) nor favorability responses varied significantly by the child's weight or family's food security status. In summary, children and parents found the PALS with tailored messages acceptable and useful. The message types and responses could help focus brief clinical encounters.

Predictors for Acute Appendicitis in Children.

BACKGROUND: Acute appendicitis in children is the most common condition requiring urgent evaluation and surgery in the emergency department. At times, despite the appendix being seen on ultrasound (US), there can be discrepancy as to whether a patient has clinical appendicitis. Secondary findings suggestive of appendicitis can be helpful in identifying and evaluating these children. OBJECTIVE: The aim of this study was to determine if specific US findings and/or laboratory results are predictive of appendicitis in children with a visualized appendix on US. METHODS: A prospective study was conducted on children (birth to 18 years) presenting to the pediatric emergency department with suspected appendicitis who underwent right-lower-quadrant US. Ultrasound findings analyzed appendix diameter, compressibility, increased vascularity, presence of appendicolith, inflammatory changes, right-lower-quadrant fluid near the appendix, lower abdominal fluid, tenderness during US, and lymph nodes. Diagnosis was confirmed via surgical pathology. RESULTS: There were 1252 patients who enrolled, 60.8 (762) had their appendix visualized, and 39.1 (490) did not. In children where the appendix was seen, 35.2% (268) were diagnosed with appendicitis. Among patients with a visualized appendix, the likelihood of appendicitis was significantly greater if the appendix diameter was 7 mm or greater (odds ratio [OR], 12.4; 95% confidence interval [CI], 4.7-32.7), an appendicolith was present (OR, 3.9; 95% CI, 1.5-10.3), inflammatory changes were seen (OR, 10.2; 95% CI, 3.9-26.1), or the white blood cell (WBC) count was 10,000/µL (OR, 4.8; 95% CI, 2.4-9.7). A duration of abdominal pain of 3 days or more was significantly less likely to be associated with appendicitis (OR, 0.3; 95% CI, 0.08-0.99). The absence of inflammatory changes, WBC count of less than 10,000/µL, and appendix diameter of 7 mm or less had a negative predictive value of 100%. CONCLUSIONS: When the appendix is seen on US but diagnosis of appendicitis is questioned, the absence of inflammatory changes, WBC count of less than 10,000/µL, and appendix diameter of 7 mm or less should decrease suspicion for appendicitis.

Pediatric-Adapted Liking Survey (PALS): A Diet and Activity Screener in Pediatric Care.

Clinical settings need rapid yet useful methods to screen for diet and activity behaviors for brief interventions and to guide obesity prevention efforts. In an urban pediatric emergency department, these behaviors were screened in children and parents with the 33-item Pediatric-Adapted Liking Survey (PALS) to assess the reliability and validity of a Healthy Behavior Index (HBI) generated from the PALS responses. The PALS was completed by 925 children (average age = 11 ± 4 years, 55% publicly insured, 37% overweight/obese by Body Mass Index Percentile, BMI-P) and 925 parents. Child-parent dyads differed most in liking of vegetables, sweets, sweet drinks, and screen time. Across the sample, child and parent HBIs were variable, normally distributed with adequate internal reliability and construct validity, revealing two dimensions (less healthy-sweet drinks, sweets, sedentary behaviors; healthy-vegetables, fruits, proteins). The HBI showed criterion validity, detecting healthier indexes in parents vs. children, females vs. males, privately- vs. publicly-health insured, and residence in higher- vs. lower-income communities. Parent's HBI explained some variability in child BMI percentile. Greater liking of sweets/carbohydrates partially mediated the association between low family income and higher BMI percentile. These findings support the utility of PALS as a dietary behavior and activity screener for children and their parents in a clinical setting.

Role of Patients and Parents in Pediatric Drug Development.

Patient engagement in health care has been an emerging priority in the global effort and move toward the consideration of patients as experts of their own conditions. However, the input of pediatric patients and their families have not been consistently requested nor regarded as valuable when deriving protocols for, as well as assessing the outcomes of, pediatric clinical trials. Extending this mutual collaboration further upstream is important, especially in the area of pediatric drug development where the lack of formalized trials for children and adolescents result in the increased use of off-label prescribing and risk of adverse effects. While recent changes to European and North American legislation contributed to the inclusion of children and youth in pediatric drug development, the lack of systematic guidelines and methodologies in literature serve as barriers for practical application. When combined with the work of external pediatric advocacy and patient advisory groups, the hope is that pediatric patient voices can be brought forward for the future. This article brings together international experts to review current best practices, progress from regulatory agencies, as well as global advocacy efforts to involve patients and families in the pursuit of drug development processes that value the voice of children and youth.

Diagnostic accuracy of laboratory and ultrasound findings in patients with a non-visualized appendix.

Ultrasound (US) and laboratory testing are initial diagnostic tests for acute appendicitis. A diagnostic dilemma develops when the appendix is not visualized on US. Objective: To determine if specific US findings and/or laboratory results predict acute appendicitis when the appendix is not visualized. Methods: A prospective study was conducted on children (birth-18 yrs) presenting to the pediatric emergency department with suspected acute appendicitis who underwent right lower quadrant US. Children with previous appendectomy, US at another facility, or eloped were excluded. US findings analyzed: inflammatory changes, right lower quadrant and lower abdominal fluid, tenderness during US exam and lymph nodes. Diagnoses were confirmed via surgical pathology. Results 1252 subjects were enrolled, 60.8% (762) had appendix visualized and 39.1% (490) did not. In children where the appendix was not seen, 6.7% [33] were diagnosed with appendicitis. Among patients with a non-visualized appendix, the likelihood of appendicitis was significantly greater if: inflammatory changes in the RLQ (OR 18.0, 95% CI 4.5-72.1), CRP >0.5 mg/dL (OR 2.64, 95% CI 1.0-6.8), or WBC > 10 (OR 4.36, 95% CI 1.66-11.58). Duration of abdominal pain >3 days was significantly less likely associated with appendicitis in this model (OR 0.34, 95% CI 0.003-0.395). Combined, the absence inflammatory changes, CRP < 0.5 mg/dL, WBC < 10, and pain, ≤3 days had a NPV of 94.0%. Conclusion When the appendix is not visualized on US, predictors for appendicitis include the presence of inflammatory changes in the RLQ, an elevated WBC/CRP and abdominal pain <3 days.

Pediatric Adapted Liking Survey: A Novel, Feasible and Reliable Dietary Screening in Clinical Practice.

PURPOSE: Rapid yet useful methods are needed to screen for dietary behaviors in clinical settings. We tested the feasibility and reliability of a pediatric adapted liking survey (PALS) to screen for dietary behaviors and suggest tailored caries and obesity prevention messages. METHODS: In an observational study, children admitted to a pediatric emergency department (PED) for nonurgent care were approached to complete the PALS (33 foods, 4 nonfoods including brushing teeth). Measured height/weight were used for body mass index (BMI) percentile determination. Feasibility was assessed by response rate and PALS completion time. Reliability was assessed by internal consistency of food groups and test-retest reliability for PED-home reported PALS. RESULTS: PALS was completed by 144 children (96% of approached) - 54% male (average age = 11 ± 3 years) with diversity in family income (43% publicly insured), race/ethnicity (15% African American, 33% Hispanic, 44% Caucasian) and adiposity (3% underweight, 50% normal, 31% overweight, 17% obese, 8% extremely obese). The average completion time was 3: 52 min, and conceptual food groups had reasonable internal reliability. From 57% (n = 82) with PED-home completion, PALS had a good/excellent test-retest reliability. Relative preferences for sweets versus brushing teeth identified unique groups of children for tailored prevention messages (high sweet/brushing preference, sweets > brushing, brushing > sweets). Females with higher adiposity reported significantly greater preference for sweet/high-fat foods, independently of demographic variables; the relationship was nonsignificant in males and with the other food groups. CONCLUSION: The PALS appears to be a fast, feasible and reliable dietary screener in a clinical setting to assist in forming tailored diet-related messages for dental caries and obesity prevention.

Predictors of abnormal electrocardiograms in the pediatric emergency department.

BACKGROUND: Electrocardiograms (ECGs) are ordered in the pediatric emergency room for a wide variety of chief complaints. OBJECTIVES: Criteria are lacking as to when physicians should obtain ECGs. This study uses a large retrospective cohort of 880 pediatric emergency department (ED) patients to highlight objective criteria including significant medical history and specific vital sign abnormalities to guide clinicians as to which patients might have an abnormal ECG. METHODS: Retrospective review of Pediatric ED charts in all patients aged < 18 years who had ECG performed during ED stay. Pediatric ED physician interpretation of the ECG, clinical data on vital signs and past medical history was collected from the medical record for analysis. RESULTS: Of 880 ECGs performed in the ED, 17.4% were abnormal. When controlled for medical history and demographic differences, abnormal ECGs were associated with age-adjusted abnormal ED vital signs including increased heart rate (odds ratio [OR] 1.85, 95% confidence interval [CI] 1.1-3.09) and increased respiratory rate (OR 1.74, CI 1.42-2.62). In a logistic regression analysis, certain chief complaints and history components were less likely to have abnormal ECGs including complaints of chest pain (OR 0.38, CI 0.18-0.80) and known history of gastrointestinal or respiratory condition (i.e., asthma) (OR 0.48, CI 0.29-0.79). CONCLUSIONS: In this cohort of patients, those with a chief complaint of chest pain or known respiratory conditions and normal age-adjusted vital signs in the ED have low likelihood of an abnormal ECG.

Revisiting the Appendiceal Diameter via Ultrasound for the Diagnosis of Acute Appendicitis.

OBJECTIVES: This study aims to investigate the optimal outer appendiceal diameter via ultrasound for the diagnosis of acute appendicitis. METHODS: A retrospective chart review was conducted on patients (ages, 2-18 years) presenting to an urban pediatric emergency department between January 1, 2009 and December 31, 2010 with suspected acute appendicitis. Children were considered as having "suspected acute appendicitis" if they (1) presented with acute abdominal pain and had either a surgical consult or an abdominal ultrasound, or (2) presented or transferred with the stated suspicion of acute appendicitis. Pathology reports were used to confirm the diagnosis of appendicitis. The appendiceal diameters were determined by board-certified pediatric radiologists. RESULTS: A total of 320 patient charts were reviewed (females, 57%; mean age, 10.9; SD, 3.9). Seventy-two percent (N = 230) of the patients screened positive for acute appendicitis via ultrasound, 69% (N = 222) had confirmed acute appendicitis, 75% (N = 239) of the ultrasound reports included an outer appendiceal diameter. Overall, ultrasound was found to be highly sensitive (91%) and moderately specific (74%). With an outer appendiceal diameter of 6 mm as a cutoff, ultrasound had an excellent sensitivity (100%) but poor specificity (43%). With an outer diameter of 7 mm as a cutoff, sensitivity decreased to 94% but specificity increased to 71%. With increasing cutoff size, the sensitivity decreased and specificity increased. CONCLUSIONS: Our data suggest that the optimal outer appendiceal diameter for the diagnosis of acute appendicitis should be 7 mm instead of the currently used 6 mm.

Asthmonia: A clinical definition of a commonly used colloquial term.

OBJECTIVE: To describe the clinical characteristics of pediatric asthmonia, a syndrome in which children have both an acute asthma exacerbation and a concomitant diagnosis of community acquired pneumonia. METHODS: A retrospective chart review was conducted on children admitted to Connecticut Children's Medical Center in the pediatric emergency department from January 1, 2012 to December 31, 2012. Children with asthma and pneumonia were identified using ICD-9 codes 493 (asthma) or 482 (pneumonia). In this study, we defined asthmonia, a third group, based on the following criteria: (1) history of asthma based on documentation in the past medical history section of the chart, (2) documented wheezing on presentation, (3) administration of bronchodilator(s), and (4) new focal infiltrate on chest radiograph during ED visit. The three nonoverlapping groups (asthma, pneumonia, and asthmonia) were described. RESULTS: Three hundred and sixty-eight children were identified for our study population. In the study population, 66.0% (N = 243) had asthma, 20.4% (N = 75) pneumonia, and 13.6% (N = 50) met our definition of asthmonia. We found that 84.0% (N = 42) of children who met asthmonia criteria in our study were treated with antibiotic therapies. Also, 28.0% (N = 14) of children who met asthmonia criteria had documented fever during admission or by parent report. CONCLUSIONS: This study defined clinical features of the coexistence of pneumonia in children with asthma. Overall, these children frequently presented with fever and were treated with antibiotics. More studies are needed to better elucidate this clinical entity and its ramifications.

Symptom-Guided Emergency Department Discharge Instructions for Children With Concussion.

OBJECTIVES: The objective was to evaluate the use and utility of a novel set of emergency department discharge instructions (DIs) for concussion based on a child's ongoing symptoms: symptom-guided DIs (symptom DIs). Differences in clinical outcomes were also assessed. METHODS: A convenience sample of 114 children aged 7 to 17 years presenting to an urban pediatric emergency department with a complaint of concussion was assembled. Children were randomized to standard DIs or symptom DIs. Children completed a graded symptom checklist (GSC) and completed daily the GSC for 1 week. Telephone follow-up was performed at 7 days after enrollment using a standardized survey. RESULTS: Fifty-eight children received the symptom DIs, and 56 received the standard DIs. Rates of use were similar with reported rates of 92% for symptom DIs and 84% for standard DIs. Caregivers with symptom DIs reported that the DIs were more helpful in determining when their child could return to school and physical activity (P < 0.05) than caregivers with standard DIs. Children continued to have postconcussive symptoms days and weeks after their injury with 44% of children with symptom DIs and 51% of children with standard DIs reporting symptoms on the GSC at 1 week. CONCLUSIONS: Both study groups reported frequent use of the DIs. Caregivers with symptom DIs found them particularly helpful in determining when their child could return to school and physical activity. Larger-scale investigations are needed to further develop instructions that are easy to use and that may decrease the postconcussive period.

CARES: improving the care and disposition of psychiatric patients in the pediatric emergency department.

OBJECTIVES: Pediatric psychiatric emergencies are a nationwide crisis and have contributed to an increase in behavioral health emergency department (ED) visits. A collaborative response to this crisis was the creation of the Child & Adolescent Rapid Emergency Stabilization (CARES) program. The objective of this study is to determine how the CARES unit influenced length of stay (LOS) and costs for psychiatric patients in the pediatric ED. METHODS: A retrospective review of ED patients was conducted. Children presenting 1 year before CARES, October 13, 2006, to October 13, 2007 (pre-CARES), were compared with 1 year after, October 15, 2007, to October 15, 2008 (post-CARES). The study population includes all patients presenting to the ED with psychiatric illnesses. The primary outcome is mean LOS in hours. Supplemental analyses of total charges, payments, and costs were performed. RESULTS: There were 1719 visits before and 1867 visits after CARES, with 1190 and 1273 unique patient visits, respectively. Children in both groups had similar age, gender, and ethnicity. Pre-CARES had a mean LOS of 19.7 hours (SD, 32.6), whereas post-CARES had 10.8 hours (SD, 19.9) (P < 0.0001). Evaluating only unique visits, the difference remained highly significant. Post-CARES, compared with pre-CARES, the average charge per patient decreased by $905 (P < 0.0001), average payment decreased by $111 (P < 0.06), and average total cost decreased by $569 or 38.7% (P < 0.0001). The total cost savings the year after CARES opened was $1,019,168.55.

Abdominal CT Does Not Improve Outcome for Children with Suspected Acute Appendicitis.

INTRODUCTION: Acute appendicitis in children is a clinical diagnosis, which often requires preoperative confirmation with either ultrasound (US) or computed tomography (CT) studies. CTs expose children to radiation, which may increase the lifetime risk of developing malignancy. US in the pediatric population with appropriate clinical follow up and serial exam may be an effective diagnostic modality for many children without incurring the risk of radiation. The objective of the study was to compare the rate of appendiceal rupture and negative appendectomies between children with and without abdominal CTs; and to evaluate the same outcomes for children with and without USs to determine if there were any associations between imaging modalities and outcomes. METHODS: We conducted a retrospective chart review including emergency department (ED) and inpatient records from 1/1/2009-2/31/2010 and included patients with suspected acute appendicitis. RESULTS: 1,493 children, aged less than one year to 20 years, were identified in the ED with suspected appendicitis. These patients presented with abdominal pain who had either a surgical consult or an abdominal imaging study to evaluate for appendicitis, or were transferred from an outside hospital or primary care physician office with the stated suspicion of acute appendicitis. Of these patients, 739 were sent home following evaluation in the ED and did not return within the subsequent two weeks and were therefore presumed not to have appendicitis. A total of 754 were admitted and form the study population, of which 20% received a CT, 53% US, and 8% received both. Of these 57%, 95% CI [53.5,60.5] had pathology-proven appendicitis. Appendicitis rates were similar for children with a CT (57%, 95% CI [49.6,64.4]) compared to those without (57%, 95% CI [52.9,61.0]). Children with perforation were similar between those with a CT (18%, 95% CI [12.3,23.7]) and those without (13%, 95% CI [10.3,15.7]). The proportion of children with a negative appendectomy was similar in both groups: CT (7%, 95% CI [2.1,11.9]), US (8%, 95% CI [4.7,11.3]) and neither (12%, 95% CI [5.9,18.1]). CONCLUSION: In this uncontrolled study, the accuracy of preoperative diagnosis of appendicitis and the incidence of pathology-proven perforation appendix were similar for children with suspected acute appendicitis whether they had CT, US or neither imaging, in conjunction with surgical consult. The imaging modality of CT was not associated with better outcomes for children presenting to the ED with suspected appendicitis.

iCAN: Providing a Voice for Children and Families in Pediatric Research.

Research and innovation are critical to improving the health and well-being of the world's children; clinical trials yield important information on a medical product's safety, dosing, and effectiveness. While the prescribing information available to pediatric providers has substantially improved, approximately 50% of medicines still do not have data on their labels to guide their appropriate use in children. Regulatory bodies have recently taken measures to ensure, if drugs have a potential pediatric indication, that the safety and efficacy clinical trials include the pediatric population. However, there are significant challenges with pediatric trials, including study design and feasibility, suitable formulations, and patient recruitment and retention. The authors propose that these challenges can be addressed by actively involving young people and families in study design so their insights can inform successful trial implementation. As the volume of pediatric research increases, there needs to be a concomitant effort for researchers and providers to seek input from patients and families in the development of their work, which can lead to a transformation of the cultural and regulatory environment of pediatric medicine. The benefits of patient and public involvement in research have been well documented. In 2006, the National Institute for Health Research Clinical Research Network: Children started its first Young Persons' Advisory Group in an effort to include young people in the design and delivery of pediatric research. Since their initial efforts, the youth advisory concept has grown into a global effort known as the International Children's Advisory Network (iCAN). This article describes the foundational building blocks of iCAN and provides tools to investigators and practitioners in an effort to increase the instances of children and families being invited to share their unique point of view in medicine.

The feasibility of screening for violence in the pediatric emergency department.

BACKGROUND: Youth violence is a significant public health concern. The objective of this study was to evaluate the feasibility of violence screening tools in a pediatric emergency department (PED). METHODS: Children between eight and 17 years presenting to the PED were prospectively enrolled. Two questionnaires were administered: Violence Prevention Emergency Tool (VPET) and Violence Exposure Scale for Children (VEX). RESULTS: One hundred children were enrolled: mean age was 12.9 years (SD 2.8), 42% girls, 48% Hispanic, and 13% African-American. Mean time to complete VPET was 9.0 minutes and VEX 4.9 minutes. Ease of understanding between VPET and VEX were 74% vs 92% (interviewer) and 74% vs 93%, (subjects) both P < 0.05. The number of repeated items was significantly less for VEX compared to VPET, 1% vs 6% (P < 0.01). CONCLUSION: It may be feasible to screen for exposure to violence in the PED. VEX is a more feasible screening tool compared to VPET.

Corticosteroid timing and length of stay for children with asthma in the Emergency Department.

OBJECTIVE: The aim of this study was to evaluate the relationship between time of corticosteroid administration to children with asthma exacerbations in the Emergency Department (ED) and length of stay (LOS). We hypothesized administration within 60 minutes would be associated with a 10- minute or greater decrease in mean LOS. METHODS: A retrospective chart review of 882 patients was conducted. Children between the ages of 2 and 18 years presented to the Connecticut Children's Medical Center's (CCMC's) ED with an acute asthma exacerbation were included. Children were excluded if they did not receive oral corticosteroids in the ED, had significant co-morbidities, were currently taking corticosteroids, or had taken them within the past 7 days. Children receiving corticosteroids within 60 minutes of triage were compared with children receiving corticosteroids for 61 minutes or later. The primary outcome was mean LOS. RESULTS: Children treated with corticosteroids within 60 and 61 minutes or later had similar age, gender, insurance, and disposition. Children treated with corticosteroids within 60 minutes had a 25-minute decrease in LOS compared with children treated for 61-minute or later (95% CI: 15-35), p < .0001. CONCLUSIONS: Administering corticosteroids to pediatric asthma patients in the ED within an hour of triage is associated with a 25-minute mean decrease in LOS. With large numbers of asthma visits, a 25-minute decrease in LOS for each child could have a significant impact on patient throughput in the ED.

Factors associated with attaining coaching goals during an intervention to improve child asthma care.

PURPOSE: To examine parent and child characteristics associated with engagement in a coaching intervention to improve pediatric asthma care and factors associated with readiness to adopt and maintain targeted asthma management behaviors. METHODS: Using methods based on the Transtheoretical Model, trained lay coaches worked with 120 parents of children with asthma promoting adoption and maintenance of asthma management strategies (behaviors). Coaches assigned stage-of-change (on continuum: pre-contemplation, contemplation, preparation, action, maintenance) for each behavior every time it was discussed. Improvement in stage-of-change was analyzed for association with characteristics of the participants (parents and children) and coaching processes. RESULTS: Having more coach contacts was associated with earlier first contact (p<0.001), fewer attempts per successful contact (p<0.001), prior asthma hospitalization (p=0.021), more intruding events (p<0.001), and less social support (p=0.048). In univariable models, three factors were associated with forward movement at least one stage for all three behaviors: more coach contacts overall, fewer attempts per successful contact, and more discussion/staging episodes for the particular behavior. In multivariable models adjusting for characteristics of participants and coaching process, the strongest predictor of any forward stage movement for each behavior was having more contacts (p<0.05). CONCLUSIONS: Improvement in readiness to adopt and maintain asthma management behaviors was mostly associated with factors reflecting more engagement of participants in the program. Similar coaching interventions should focus on early and frequent contacts to achieve intervention goals, recognizing that parents of children with less severe disease and who have more social support may be more difficult to engage.

A randomized controlled trial of parental asthma coaching to improve outcomes among urban minority children.

OBJECTIVES: To investigate whether asthma coaching decreases emergency department (ED) visits and hospitalizations and increases outpatient asthma monitoring visits. DESIGN: Randomized controlled trial. SETTING: Urban tertiary care children's hospital. PARTICIPANTS: Primary caregivers (hereafter referred to as parents) of children aged 2 to 10 years with asthma who have Medicaid insurance coverage and are urban residents who were attending the ED for acute asthma care. INTERVENTION: Eighteen months of participating in usual care (control group) vs receiving coaching focused on asthma home management, completion of periodic outpatient asthma monitoring visits, and development of a collaborative relationship with a primary care provider (intervention group). MAIN OUTCOME MEASURES: The primary outcome was ED visits. Secondary outcomes were hospitalizations and asthma monitoring visits (nonacute visits focused on asthma care). Outcomes were measured during the year before and 2 years after enrollment. RESULTS: We included 120 intervention parents and 121 control parents. More children of coached parents had at least 1 asthma monitoring visit after enrollment (relative risk [RR], 1.21; 95% confidence interval [CI], 1.04-1.41), but proportions with at least 4 asthma monitoring visits during 2 years were low (20.0% in the intervention group vs 9.9% in the control group). Similar proportions of children in both study groups had at least 1 ED visit (59.2% in the intervention group vs 62.8% in the control group; RR, 0.94; 95% CI, 0.77-1.15) and at least 1 hospitalization (24.2% in the intervention group vs 26.4% in the control group; 0.91; 0.59-1.41) after enrollment. An ED visit after enrollment was more likely if an ED visit had occurred before enrollment (RR, 1.46; 95% CI, 1.16-1.86; adjusted for study group), but risk was similar in both study groups when adjusted for previous ED visits (1.02; 0.82-1.27). CONCLUSION: This parental asthma coaching intervention increased outpatient asthma monitoring visits (although infrequent) but did not decrease ED visits. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00149500.

"Be quick": a systems response to overcrowding in the pediatric emergency department.

OBJECTIVE: The purpose of this study was to evaluate the combined effects of focused system changes on several key measures of emergency department (ED) quality (length of stay, waiting time, rate of leaving without being seen, and patient satisfaction) in a children's hospital ED. METHODS: System-wide ED changes were made and implemented during a 6-month period. The combined changes are called "be quick"--BEQK. The components were bedside registration, the Bed-ahead program, electronic medical records and tracking board, quick triage, and Kids Express. Three study periods were evaluated: before BEQK (2005) and the 2 periods after BEQK (2006 and 2007). RESULTS: The primary outcome measures, namely wait time, length of stay, and leaving without being seen rates, were all decreased during the 2 post-BEQK periods compared with the pre-BEQK period (2005). The mean waiting time was 46 minutes (95% confidence interval [CI], 39-53 minutes) in 2005 and this decreased to 22 minutes (95% CI, 21-23 minutes) and 14 minutes (95% CI, 13-15 minutes) in 2006 and 2007, respectively. The mean length of stay was 151 minutes (95% CI, 139-163 minutes) in 2005 and this decreased to 136 minutes (95% CI, 135-137 minutes) and 115 minutes (95% CI, 114-116 minutes) in 2006 and 2007, respectively. The rate of leaving without being seen was 2.45% of patient visits per month in 2005 and this decreased to 1.67% in 2006 and to 0.92% in 2007. CONCLUSIONS: In our pediatric ED, focused system changes significantly decreased wait time, leaving without being seen, and length of stay and improved patient satisfaction.

A fever of unknown origin workup in the emergency department reveals an unusual pathogen.

The cause of a fever of unknown origin (FUO, fever of >21 days without an identified etiology) may be a common illness, an atypical presentation of a common illness, or an unusual illness. A patient with an FUO occasionally presents to the emergency department (ED). The differential diagnosis of an FUO is extensive. A primary goal for the ED physician is to determine if the patient with an FUO has a disorder that needs immediate recognition and treatment. We describe a case of a teenage boy who presented to our ED with 2 weeks of high fever and back pain. We describe this teenage boy with FUO and a surprising diagnosis.