Characteristics of Sports-Related Injuries Presenting to a Pediatric Emergency Department.

OBJECTIVE: Pediatric injuries associated with participation in sports are common. Understanding the epidemiology and trends of sports-related injuries is an important component of injury prevention efforts and is the objective of this study. METHODS: A retrospective review of sports injuries presenting during the course of 1 year (2019) to the emergency department (ED) of Benjamin Russell Hospital for Children, a large academic children's hospital, was performed. Inclusion criteria focused on patients 18 years old and younger whose ED visit resulted from active participation in a sport. Cases were identified using International Classification of Diseases, Tenth Revision codes. Demographic data were collected and included sex, age, race, injury specifics (sport, location, type, and mechanism). Descriptive statistics were performed and categorical variables were analyzed using the χ2 test. RESULTS: A total of 1333 injuries seen by the ED during 2019 were sports injuries. Most commonly, these injuries were associated with football (43%), basketball (36%), soccer (11%), or baseball (8%). Considering sports-related injuries, 428 (32%) patients were 12 years and younger and 905 (68%) were 12 years old and older. The median age was 13 years (interquartile range 4 years). Other demographic findings included male sex 1143/1333 (86%) and Black race 835/1333 (63%). School was the most common location for sports injuries (28%). When comparing injuries by age groups (younger than 12 vs 12 and older), football and baseball injuries were more common in those younger than 12 years (53% vs 38%, z = 5.2, P < 0.00001; and 14.0% vs. 5.6%, z = 4.9, P < 0.00001, respectively), whereas basketball and soccer injuries were more common in those 12 years and older (43% vs 22%, z = 7.4, P < 0.00001; and 11.4% vs 9.3%, z = 5.9, P < 0.00001, respectively). When comparing injuries by sex, football and baseball injuries were more common in males (49% vs 6%, z = 11.1, P < 0.00001; and 9.4% vs. 2.1%, z = 3.3, P < 0.00001, respectively), whereas basketball and soccer injuries were more common in females (59% vs 32%, z = 7.2, P < 0.00001; and 27% vs 8%, z = 7.8, P < 0.00001, respectively. CONCLUSIONS: Sports injuries that are commonly encountered in the ED differ in age and sex. Basketball and soccer injuries were more likely to be encountered in older females, whereas baseball and football injuries were more likely seen in younger males. This may reflect efforts that have been previously focused on the sports considered to be higher risk, especially for concussive injuries. This information can help guide future preventive efforts provided by primary physicians, schools, and coaches.

Pharmacogenomic Profiling of Pediatric Patients on Psychotropic Medications in an Emergency Department.

OBJECTIVE: The aim of the study was to evaluate the ability of a combinatorial pharmacogenomic test to predict medication blood levels and relative clinical improvements in a selected pediatric population. METHODS: This study enrolled patients between ages 3 to 18 years who presented to a pediatric emergency department with acute psychiatric, behavioral, or mental health crisis and/or concerns, and had previously been prescribed psychotropic medications. Patients received combinatorial pharmacogenomic testing with medications categorized according to gene-drug interactions (GDIs); medications with a GDI were considered "incongruent," and medications without a GDI were considered "congruent." Blood levels for escitalopram, fluoxetine, aripiprazole, and clonidine were evaluated according to level of GDI. Relative clinical improvements in response to the prescribed psychotropic medications were measured using a parent-rated Clinical Global Impression of Improvement (CGI-I) assessment, where lower scores corresponded with greater improvement. RESULTS: Of the 100 patients enrolled, 73% reported taking ≥1 incongruent medication. There was no significant difference in CGI-I scores between patients prescribed congruent versus incongruent medications (3.37 vs 3.68, P = 0.343). Among patients who presented for depression or suicidal ideation, those prescribed congruent medications had significantly lower CGI-I scores compared with those taking incongruent medications ( P = 0.036 for depression, P = 0.018 for suicidal ideation). There was a significant association between medication GDI and blood levels for aripiprazole (n = 15, P = 0.01) and escitalopram (n = 10, P = 0.01). CONCLUSIONS: Our preliminary findings suggest that combinatorial pharmacogenomic testing can predict medication blood levels and relative outcomes based on medication congruency in children presenting to an emergency department with acute psychiatric/behavioral crises. Additional studies will be needed to confirm these findings.

Belimumab for systemic lupus erythematosus.

BACKGROUND: Belimumab, the first biologic approved for the treatment of systemic lupus erythematosus (SLE), has been shown to reduce autoantibody levels in people with SLE and help control disease activity. OBJECTIVES: To assess the benefits and harms of belimumab (alone or in combination) in systematic lupus erythematosus. SEARCH METHODS: An Information Specialist carried out the searches of CENTRAL, MEDLINE, Embase, CINAHL, Web of Science, the World Health Organization (WHO) International Clinical Trials Registry Platform, and clinicaltrials.gov from inception to 25 September 2019. There were no language or date restrictions. SELECTION CRITERIA: We included randomized controlled trials (RCTs) or controlled clinical trials (CCTs) of belimumab (alone or in combination) compared to placebo/control treatment (immunosuppressive drugs, such as azathioprine, cyclosporine, mycophenolate mofetil or another biologic), in adults with SLE. DATA COLLECTION AND ANALYSIS: We used standard methodologic procedures expected by Cochrane. MAIN RESULTS: Six RCTs (2917 participants) qualified for quantitative analyses. All included studies were multicenter, international or US-based. The age range of the included participants was 22 to 80 years; most were women; and study duration ranged from 84 days to 76 weeks. The risk of bias was generally low except for attrition bias, which was high in 67% of studies. Compared to placebo, more participants on belimumab 10 mg/kg (Food and Drug Administration (FDA)-approved dose) showed at least a 4-point improvement (reduction) in Safety of Estrogen in Lupus National Assessment (SELENA) - Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) score, a validated SLE disease activity index: (risk ratio (RR) 1.33, 95% confidence interval (CI) 1.22 to 1.45; 829/1589 in belimumab group and 424/1077 in placebo; I2= 0%; 4 RCTs; high-certainty evidence). Change in health-related quality of life (HRQOL), assessed by Short Form-36 Physical Component Summary score improvement (range 0 to 100), showed there was probably little or no difference between groups (mean difference 1.6 points, 95% CI 0.30 to 2.90; 401 in belimumab group and 400 in placebo; I2= 0%; 2 RCTs; moderate-certainty evidence). The belimumab 10 mg/kg group showed greater improvement in glucocorticoid dose, with a higher proportion of participants reducing their dose by at least 50% compared to placebo (RR 1.59, 95% CI 1.17 to 2.15; 81/269 in belimumab group and 52/268 in placebo; I2= 0%; 2 RCTs; high-certainty evidence). The proportion of participants experiencing harm may not differ meaningfully between the belimumab 10 mg/kg and placebo groups: one or more serious adverse event (RR 0.87, 95% CI: 0.68 to 1.11; 238/1700 in belimumab group and 199/1190 in placebo; I2= 48%; 5 RCTs; low-certainty evidence; ); one or more serious infection (RR 1.01, 95% CI: 0.66 to 1.54; 44/1230 in belimumab group and 40/955 in placebo; I2= 0%; 4 RCTs; moderate-certainty evidence); and withdrawals due to adverse events (RR 0.82, 95% CI: 0.63 to 1.07; 113/1700 in belimumab group and 94/1190 in placebo; I2= 0%; 5 RCTs; moderate-certainty evidence). Mortality was rare, and may not differ between belimumab 10 mg/kg and placebo (Peto odds ratio 1.15, 95% CI 0.41 to 3.25; 9/1714 in belimumab group and 6/1203 in placebo; I2= 4%; 6 RCTs; low-certainty evidence). AUTHORS' CONCLUSIONS: The six studies that provided evidence for benefits and harms of belimumab were well-designed, high-quality RCTs. At the FDA-approved dose of 10 mg/kg, based on moderate to high-certainty data, belimumab was probably associated with a clinically meaningful efficacy benefit compared to placebo in participants with SLE at 52 weeks. Evidence related to harms is inconclusive and mostly of moderate to low-certainty evidence. More data are needed for the longer-term efficacy of belimumab.

Examining Pediatric Residency Voting Practices.

OBJECTIVE: Voting is one of our civic duties, yet many Americans do not vote, and physician voter participation is even lower than that of the general public. We aimed to explore pediatric residents' attitudes and behaviors in regard to voting and assess the impact of interventions aimed at increasing resident participation. METHODS: Pediatric residents were given preelection surveys regarding interest in voting, plans to vote in the November 2016 national election, and barriers to participation. Voting registration, election dates, and registration deadlines were disseminated before the election. Postelection surveys were distributed after the 2016 national election to pediatric residents regarding their voter participation, barriers to voting, and the effectiveness of our interventions. RESULTS: Fifty-one residents completed the presurvey and 49 completed the postsurvey (61% and 59% of total residents, respectively). Eighty-nine percent of residents surveyed planned to vote and 83% were registered to vote. The postsurveys indicated that only 69% of responding residents voted in the national election, far fewer than the 89% who planned to vote (z = 2.5, P < 0.05). The most common reasons for not voting were "no time off," "didn't get absentee ballot," and "not registered in state of residence." In total, 19 of 33 (58%) respondents indicated that interventions encouraged them to vote. CONCLUSIONS: Intention to vote among participants was higher than voting participation; however, participants in this study voted at higher rates (69%) than the average citizen rates (61.4%). More than half of the residents who did vote indicated that the study interventions encouraged them to vote.

Descriptive Epidemiology of Pediatric Drowning Patients Presenting to a Large Southern US Children's Hospital.

OBJECTIVES: Drowning is the leading cause of death for children ages 1 to 4, and it is among the leading causes of death for children of all ages. National data show disparities in drowning risk for certain racial groups. This study aimed to describe characteristics of patients presenting after a drowning event to guide focused drowning prevention outreach efforts. METHODS: This was a retrospective chart review study designed to analyze the epidemiologic and demographic characteristics of drowning-related injuries and deaths that presented to a large, urban, southern US pediatric hospital from 2016 to 2019. All patients aged 0 to 19 years were identified using International Classification of Diseases, Ninth Revision and Tenth Revision codes for drowning or submersion injuries. RESULTS: One hundred sixty-two patients met the inclusion criteria for the study. Submersion injuries were most common in the 1- to 5-year-old age group. Fifty-eight percent of patients were male. The analysis of race showed that 65% of patients were White and 33% of patients were Black. Pools were the setting for 78% of drowning events. Fifty-four percent of patients received cardiopulmonary resuscitation. Sixty-four percent of patients required hospitalization after the injury. CONCLUSIONS: Characteristics of drowning victims may vary significantly from national data, depending on the area involved. This finding highlights the need for assessing local data to better inform local outreach. Further research is necessary to understand why such variance exists. Drowning prevention education, tailored toward pool safety and preschool-age children, should be a focus of injury prevention efforts.

Using a Resident-Led School Outreach Program to Improve Knowledge of All-Terrain Vehicle Safety.

BACKGROUND: During the past decade, all-terrain vehicle (ATV)-related injuries treated in US emergency departments decreased by 33%, down to approximately 100,000 injuries in 2016. In comparison, the number of children evaluated for ATV injuries in the Children's of Alabama emergency department more than doubled between 2006 and 2016, counter to the national trend. The American Academy of Pediatrics guidelines state that ATV operators should be at least 16 years old; however, children younger than 16 continue to represent almost one-third of all ATV-related injuries nationwide, and nearly all of the injuries to children in Alabama. METHODS: Using surveillance data from the Children's of Alabama hospital electronic medical record database, several Alabama counties near Birmingham were identified as having an increased number of children with ATV-related injuries in 2016. The Safety Tips for ATV Riders (STARs) program, developed in Iowa, was provided to middle school students in these counties by pediatric residents. Surveys were anonymously administered to children before and after the program and included information about demographics, knowledge of safe ATV practices, and the likelihood of using the education afterward. RESULTS: In total, 525 students participated in January 2019; their ages ranged from 11 to 15 years and the proportion of males and females was equivalent. More than 50% of the children reported riding ATVs in the last 12 months, and of these riders, 47% reported never wearing a helmet when riding. Initially, only 20% of the overall participants knew ATVs were not intended for passengers, 20% knew the recommended engine size for their age, and 57% knew that Alabama law prohibits riding on public roads. After education, this increased to 91%, 90%, and 89%, respectively. Before the STARs program, only 6% knew all three correct answers, whereas 80% answered all of the questions correctly on the postprogram survey. After the program, 34% reported they were very likely/likely to use this information in the future. CONCLUSIONS: The STARs program dramatically improved short-term ATV safety knowledge, and many participants reported they were likely to subsequently use the safe practices presented. School-based programs, such as STARs, may help increase ATV safety awareness and change behaviors in high-risk age groups. This training may be successfully provided by various motivated individuals, including medical residents.

Unintentional Opioid Ingestions Presenting to a Pediatric Emergency Department.

OBJECTIVES: The purpose of this study was to describe unintentional opioid exposures in young children, including demographics, medical interventions, and clinical outcomes. METHODS: This was a retrospective, cross-sectional study of children 0 to 6 years of age with possible opioid exposure over a 3-year period (July 2010 to June 2013). Data collected included sex, age, specific drug, whether they were referred to the emergency department (ED) by the Regional Poison Control Center, presence of symptoms, therapeutic interventions, ED disposition, and clinical outcomes for admitted patients. RESULTS: Median age of patients included in the study was 2 years, and 64% of these children were male. The most common drug of exposure was buprenorphine/naloxone. Of the 429 charts screened, 140 patients were reported to be symptomatic and referred to the ED, of which 113 patients actually presented to the ED. An additional 122 patients presented to the ED without Regional Poison Control Center referral. Of the total 235 patients presenting to ED, 76 (32%) received a therapeutic intervention. Of 231 total opioid exposures, 31 exposures were administered naloxone. Three children underwent endotracheal intubation. Sixty-five patients were hospitalized, with a median length of stay of 1 day. Although there were no fatalities, 1 child suffered severe morbidity (anoxic brain injury). CONCLUSIONS: While opioid exposures in young children are a common and potentially life-threatening problem, most children remain asymptomatic. The majority of patients are able to be discharged from the ED after observation, and of those who are admitted, most have favorable outcomes and brief hospital stays. A small number of these patients require considerable medical interventions.

Pain Assessment in Pediatric Emergency Departments: A National Survey.

OBJECTIVE: Accurate and consistent assessment of pain is essential in the pediatric emergency setting. Despite recommendations for formal assessment protocols, current data are lacking on pain assessment in pediatric emergency departments (EDs) and, specifically, whether appropriate tools are being used for different age groups. Our aim was to determine the status of pain assessment in US pediatric EDs. METHODS: We disseminated an online cross-sectional survey (after piloting) to pediatric EDs within the Children's Hospital Association. Responses were analyzed for each question owing to incomplete responders. We report descriptive statistics, with categorical variables compared with χ2 (P < 0.05 considered statistically significant). RESULTS: From 120 pediatric EDs, we received 57 responses (48%). Most respondents (28/49, 57%) were from freestanding pediatric centers. All 57 EDs (100%) performed formal pain assessments, with 31 (63%) of 49 using an ED-specific protocol. Freestanding children's hospitals were more likely to have ED-specific protocols (21/31, 68%) than nonfreestanding (10/31, 32%) (P = 0.04). Among 56 responders, 100% stated that nurses are tasked with assessing pain. For children 0 to 2 years, 29 (54%) of 54 used the Face, Legs, Activity, Cry, Consolability scale. Numerical scales were increasingly used with older ages: 3 to 4 years, 40 (80%) of 50; 5 to 10 years, 49 (98%) of 50; and 11 to 21 years, 50 (100%) of 50. CONCLUSIONS: In contrast to prior research, US pediatric EDs are routinely assessing pain with scales that are mostly appropriate for their respective age groups. Further research is needed to explore barriers to implementing appropriate pain ratings for all children and, ultimately, how these assessments impact the care of children in the emergency setting.

Increasing Comfort with Sensory Processing Difficulties in the Prehospital Setting: Pre-Post Study of Education and Sensory Tools in EMS Providers.

OBJECTIVES: Interfacing with patients with sensory processing difficulties is challenging to healthcare providers and even more problematic for emergency medical services (EMS) personnel in the acute care setting. Sensory training may be an effective nonpharmacologic method to deal with these patient populations. The purpose of this study was to evaluate whether an educational session and placement sensory tools would improve the comfort of EMS providers in the prehospital setting. METHODS: EMS providers from two agencies in the Alabama Gulf EMS System were selected for this study. Preeducation questionnaires were administered to EMS providers to assess their frequency and comfort level in taking care of patients with sensory processing difficulties. The educational session included a video presentation of various topics related to sensory processing difficulties and education on sensory tools. Posteducation questionnaires were administered to EMS providers 3 months posteducational session to assess the use of sensory tools and their comfort in patient care. Comfort level was assessed on a Likert scale of 1 to 10, with 1 being not comfortable at all and 10 being extremely comfortable. We performed descriptive statistics and the nonparametric Wilcoxon signed rank test to compare medians. RESULTS: A total of 177 of 225 (78.6%) EMS providers completed the preeducation questionnaire. In the preeducation period, 159 (89.8%) EMS providers transported patients with sensory processing difficulties. The preeducation median comfort level was 7.5 (range 1-10). At postsurvey, 135 of 177 (76.3%) EMS providers received educational training; 37 (27.4%) used the sensory tools within the previous 3 months. The posteducation median comfort level was 8 (range 3-10). Pre- and post median comfort levels were significantly different using the Wilcoxon signed rank test (P = 0.006). CONCLUSIONS: Sensory training can be an effective method for EMS providers to increase comfort levels in taking care of patients with sensory difficulties. Further research with larger sample sizes is needed to confirm/refute these findings.

Characteristics of Pediatric Patients With Retained Bullet Fragments and Need for Follow-Up Blood Lead Monitoring.

OBJECTIVES: Multiple case reports of lead toxicity related to retained bullet fragments in pediatric patients sustaining gunshot wound have been published. The purpose of the present study was to determine whether the demographic and clinical characteristics of gunshot wounds (GSWs) could be classified high/low risk and whether routine blood lead monitoring is necessary in these patients. METHODS: A single-center prospective case series of pediatric GSW patients presenting to the emergency department (ED). The data points that were collected and analyzed included age, sex, race, wound location, disposition, and baseline and follow-up lead levels within 6 months post-injury. RESULTS: Twenty patients were enrolled in the study and the median age was 7.5 years (interquartile range 5.25-10.75); 75% of the patients were African American. A total of 15 patients (75%) had injuries in either a lower or upper extremity, 9 of whom required admission. Almost all of the injuries involving the head, chest, or abdomen required admission. Of the patients, 65% were admitted and 35% were discharged. All of the patients had an initial blood lead level taken, and follow-up lead levels were determined at 6 months post-injury to be <5 µg/dL. Twelve of 20 patients were lost to follow-up. CONCLUSIONS: Pediatric GSW is common in male African Americans and these patients had baseline and follow-up lead levels below the reference level. These patients were difficult to follow up. Based on the available data, follow-up lead monitoring may not be indicated.

Does Point-of-Care Ultrasound Affect Outcomes in Pediatric Patients with Skin and Soft Tissue Infections?

OBJECTIVE: There is increasing evidence for the use of point-of-care ultrasound (POCUS) in pediatric patients with skin and soft tissue infections (SSTI), but there is a lack of sufficient data on its impact on SSTI outcomes. The objective of this study was to determine whether POCUS use is associated with fewer complications after discharge from the pediatric emergency department. METHODS: This was a prospective cohort study in patients presenting to the emergency department with SSTI between the ages of 2 months and 19 years old. Adverse outcomes included hospitalization after discharge, change in antibiotics, subsequent procedures, or reevaluation by a medical professional. Outcome information was obtained 1 week later. Descriptive statistics and χ2 tests were used. RESULTS: Of 456 patients screened, 250 were enrolled. POCUS was performed on 113 (45%) patients. The median age was 5 years, with more females in the non-POCUS group compared with the POCUS group (58% vs. 52%). Cellulitis without abscess was more commonly diagnosed in the POCUS group than in the non-POCUS group (26% vs 14%, P = 0.02.) The patients in the non-POCUS group were more likely to undergo incision and drainage than those in the POCUS group (62% vs 45%, P = 0.008). Overall, a greater number of patients in the POCUS group did not undergo any procedure (45% vs 27%, P = 0.003). The outcomes at 1 week did not differ significantly between the two groups. CONCLUSIONS: POCUS use may lead to fewer procedures, but it does not lead to significantly better outcomes. Large randomized controlled trials are needed to confirm or refute our findings.

Travel Histories in Children: How Well Do Interns and Medical Students Do?

OBJECTIVE: To evaluate the knowledge of obtaining travel histories in medical students and interns. METHODS: Medical students and interns participated in a high-fidelity pediatric simulation with two cases (malaria or typhoid fever) that hinged on travel history. After the simulation, appropriate methods of obtaining travel histories were discussed. Participants completed surveys regarding their previous education and comfort with obtaining travel histories. If and how a travel history was obtained was derived from simulation observation. RESULTS: From June 2016 to July 2017, 145 medical trainees participated in 24 simulation sessions; 45% reported no prior training in obtaining travel histories. Participants asked for a travel history in all but 2 simulations; however, in 9 of 24 simulations (38%), they required prompting by either a simulation confederate or laboratory results. Participants were more comfortable diagnosing/treating conditions acquired from US domestic travel than from international travel (32.9% vs 22.4%, P < 0.001). Previous education in obtaining travel histories and past international travel did not significantly influence the level of comfort that participants felt with travel histories. CONCLUSIONS: This study highlights the lack of knowledge regarding the importance of travel histories as part of basic history taking. Medical students and interns had low levels of comfort in obtaining adequate travel histories and diagnosing conditions acquired from international travel.

Individualized patient decision-aid for immunosuppressive drugs in women with lupus nephritis: study protocol of a randomized, controlled trial.

BACKGROUND: Systemic Lupus erythematosus (SLE), also commonly referred to as lupus, is a rare, but sometimes, fatal disease, that primarily affects young women. Lupus nephritis, a common manifestation of lupus, is more common and more devastating in patients of minority race/ethnicity. Patients have negative views of immunosuppressive drugs for lupus nephritis due to a concern about side effects and under-appreciation of its benefit. We designed a study to assess the effectiveness of individualized, computerized patient decision-aid for immunosuppressive drugs for lupus nephritis compared to a standard pamphlet for patient decision-making. METHODS: Adult women with lupus nephritis, with a current lupus nephritis flare or at risk of a future lupus nephritis flare will be randomized to individualized, computerized patient decision-aid for immunosuppressive drugs vs. standard pamphlet with information about lupus and its treatment including immunosuppressive drugs and outcomes. Patients will complete outcome assessments immediately after the intervention has been administered. Patients will be followed at 3-months with a brief survey, either in person or on the phone, and at 6-months with medical record review for exploratory outcomes. Co-primary outcomes are decisional conflict and informed choice regarding immunosuppressive drugs (combines values, knowledge and choice). Secondary outcomes include: (1) assessment of patient-physician communication by assessing audio-taped physician-patient communication after intervention administration; (2) concordance between patient's desired and actual role in immunosuppressive drugs decision-making using the control preference scale (CPS); and (3) patient perception of physician interaction using the interpersonal process of care- short form (IPC-SF). DISCUSSION: This is one of the first studies to evaluate the effectiveness of an educational intervention targeting minorities with lupus nephritis. This patient-centered lupus nephritis decision-aid will be available in the public domain in English and Spanish. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02319525 ; registered on November 5, 2014.

Biologics or tofacitinib for rheumatoid arthritis in incomplete responders to methotrexate or other traditional disease-modifying anti-rheumatic drugs: a systematic review and network meta-analysis.

BACKGROUND: This is an update of the 2009 Cochrane overview and network meta-analysis (NMA) of biologics for rheumatoid arthritis (RA). OBJECTIVES: To assess the benefits and harms of nine biologics (abatacept, adalimumab, anakinra, certolizumab pegol, etanercept, golimumab, infliximab, rituximab, tocilizumab) and small molecule tofacitinib, versus comparator (MTX, DMARD, placebo (PL), or a combination) in adults with rheumatoid arthritis who have failed to respond to methotrexate (MTX) or other disease-modifying anti-rheumatic drugs (DMARDs), i.e., MTX/DMARD incomplete responders (MTX/DMARD-IR). METHODS: We searched for randomized controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL) (via The Cochrane Library Issue 6, June 2015), MEDLINE (via OVID 1946 to June 2015), and EMBASE (via OVID 1947 to June 2015). Data extraction, risk of bias and GRADE assessments were done in duplicate. We calculated both direct estimates using standard meta-analysis and used Bayesian mixed treatment comparisons approach for NMA estimates to calculate odds ratios (OR) and 95% credible intervals (CrI). We converted OR to risk ratios (RR) which are reported in the abstract for the ease of interpretation. MAIN RESULTS: This update included 73 new RCTs for a total of 90 RCTs; 79 RCTs with 32,874 participants provided usable data. Few trials were at high risk of bias for blinding of assessors/participants (13% to 21%), selective reporting (4%) or major baseline imbalance (8%); a large number had unclear risk of bias for random sequence generation (68%) or allocation concealment (74%).Based on direct evidence of moderate quality (downgraded for inconsistency), biologic+MTX/DMARD was associated with a statistically significant and clinically meaningful improvement in ACR50 versus comparator (RR 2.71 (95% confidence interval (CI) 2.36 to 3.10); absolute benefit 24% more patients (95% CI 19% to 29%), number needed to treat for an additional beneficial outcome (NNTB) = 5 (4 to 6). NMA estimates for ACR50 in tumor necrosis factor (TNF) biologic+MTX/DMARD (RR 3.23 (95% credible interval (Crl) 2.75 to 3.79), non-TNF biologic+MTX/DMARD (RR 2.99; 95% Crl 2.36 to 3.74), and anakinra + MTX/DMARD (RR 2.37 (95% Crl 1.00 to 4.70) were similar to the direct estimates.Based on direct evidence of moderate quality (downgraded for inconsistency), biologic+MTX/DMARD was associated with a clinically and statistically important improvement in function measured by the Health Assessment Questionnaire (0 to 3 scale, higher = worse function) with a mean difference (MD) based on direct evidence of -0.25 (95% CI -0.28 to -0.22); absolute benefit of -8.3% (95% CI -9.3% to -7.3%), NNTB = 3 (95% CI 2 to 4). NMA estimates for TNF biologic+MTX/DMARD (absolute benefit, -10.3% (95% Crl -14% to -6.7%) and non-TNF biologic+MTX/DMARD (absolute benefit, -7.3% (95% Crl -13.6% to -0.67%) were similar to respective direct estimates.Based on direct evidence of moderate quality (downgraded for inconsistency), biologic+MTX/DMARD was associated with clinically and statistically significantly greater proportion of participants achieving remission in RA (defined by disease activity score DAS < 1.6 or DAS28 < 2.6) versus comparator (RR 2.81 (95% CI, 2.23 to 3.53); absolute benefit 18% more patients (95% CI 12% to 25%), NNTB = 6 (4 to 9)). NMA estimates for TNF biologic+MTX/DMARD (absolute improvement 17% (95% Crl 11% to 23%)) and non-TNF biologic+MTX/DMARD (absolute improvement 19% (95% Crl 12% to 28%) were similar to respective direct estimates.Based on direct evidence of moderate quality (downgraded for inconsistency), radiographic progression (scale 0 to 448) was statistically significantly reduced in those on biologics + MTX/DMARDs versus comparator, MD -2.61 (95% CI -4.08 to -1.14). The absolute reduction was small, -0.58% (95% CI -0.91% to -0.25%) and we are unsure of the clinical relevance of this reduction. NMA estimates of TNF biologic+MTX/DMARD (absolute reduction -0.67% (95% Crl -1.4% to -0.12%) and non-TNF biologic+MTX/DMARD (absolute reduction, -0.68% (95% Crl -2.36% to 0.92%)) were similar to respective direct estimates.Based on direct evidence of moderate quality (downgraded for imprecision), results for withdrawals due to adverse events were inconclusive, with wide confidence intervals encompassing the null effect and evidence of an important increase in withdrawals, RR 1.11 (95% CI 0.96 to 1.30). The NMA estimates of TNF biologic+MTX/DMARD (RR 1.24 (95% Crl 0.99 to 1.57)) and non-TNF biologic+MTX/DMARD (RR 1.20 (95% Crl 0.87 to 1.67)) were similarly inconclusive and downgraded to low for both imprecision and indirectness.Based on direct evidence of high quality, biologic+MTX/DMARD was associated with clinically significantly increased risk (statistically borderline significant) of serious adverse events on biologic+MTX/DMARD (Peto OR [can be interpreted as RR due to low event rate] 1.12 (95% CI 0.99 to 1.27); absolute risk 1% (0% to 2%), As well, the NMA estimate for TNF biologic+MTX/DMARD (Peto OR 1.20 (95% Crl 1.01 to 1.43)) showed moderate quality evidence of an increase in the risk of serious adverse events. The other two NMA estimates were downgraded to low quality due to imprecision and indirectness and had wide confidence intervals resulting in uncertainty around the estimates: non-TNF biologics + MTX/DMARD: 1.07 (95% Crl 0.89 to 1.29) and anakinra: RR 1.06 (95% Crl 0.65 to 1.75).Based on direct evidence of low quality (downgraded for serious imprecision), results were inconclusive for cancer (Peto OR 1.07 (95% CI 0.68 to 1.68) for all biologic+MTX/DMARD combinations. The NMA estimates of TNF biologic+MTX/DMARD (Peto OR 1.21 (95% Crl 0.63 to 2.38) and non-TNF biologic+MTX/DMARD (Peto OR 0.99 (95% Crl 0.58 to 1.78)) were similarly inconclusive and downgraded to low quality for both imprecision and indirectness.Main results text shows the results for tofacitinib and differences between medications. AUTHORS' CONCLUSIONS: Based primarily on RCTs of 6 months' to 12 months' duration, there is moderate quality evidence that the use of biologic+MTX/DMARD in people with rheumatoid arthritis who have failed to respond to MTX or other DMARDs results in clinically important improvement in function and higher ACR50 and remission rates, and increased risk of serious adverse events than the comparator (MTX/DMARD/PL; high quality evidence). Radiographic progression is slowed but its clinical relevance is uncertain. Results were inconclusive for whether biologics + MTX/DMARDs are associated with an increased risk of cancer or withdrawals due to adverse events.

A cross-sectional internet-based patient survey of the management strategies for gout.

BACKGROUND: Almost half of the patients with gout are not prescribed urate-lowering therapy (ULT) by their health care provider and >50 % use complementary and alternative therapies. Diet modification is popular among gout patients due to known associations of certain foods with gout flares. The interplay of the use of dietary supplements, diet modification, and ULT adherence in gout patients is not known. Despite the recent interest in diet and supplements, there are limited data on their use. Our objective was to assess ULT use and adherence and patient preference for non-pharmacological interventions by patients with gout, using a cross-sectional survey. METHODS: People who self-reported physician-diagnosed gout during their visit to a gout website ( http://gouteducation.org ) were invited to participate in a brief anonymous cross-sectional Internet survey between 08/11/2014 to 04/14/2015 about the management of their gout. The survey queried ULT prescription, ULT adherence, the use of non-pharmacological interventions (cherry extract, diet modification) and the likelihood of making a lifelong diet modification for gout management. RESULTS: A total of 499 respondents with a mean age 56.3 years were included; 74% were males and 74% were White. Of these, 57% (285/499) participants were prescribed a ULT for gout, of whom 88% (251/285) were currently taking ULT. Of those using ULT, 78% (97/251) reported ULT adherence >80%. Gender, race, and age were not significantly associated with the likelihood of receiving a ULT prescription or ULT adherence >80%. Fifty-six percent of patients with gout preferred ULT as a lifelong treatment for gout, 24% preferred cherry extract and 16% preferred diet modification (4% preferred none). Men had significantly lower odds of preferring ULT as the lifelong treatment choice for gout vs. other choices (p = 0.03). We found that 38.3% participants were highly motivated to make a lifelong dietary modification to improve their gout (score of 9-10 on a 0-10 likelihood scale). Older age was significantly associated with high level of willingness to modify diet (p = 0.02). CONCLUSION: We found that only 57% of gout patients reported being prescribed ULT. 40% of gout patients preferred non- pharmacological interventions such as cherry extract and diet modification for gout management. The latter finding requires further investigation.

Outcome of highly active antiretroviral therapy in HIV-infected Indian children.

BACKGROUND: With the advent of highly active antiretroviral therapy (HAART), HIV infection has become a chronic condition in children with improved survival and quality of life. Reports on long term effectiveness of non-nucleoside reverse transcriptase inhibitor based HAART in HIV-infected children in developing countries are limited. METHODS: A chart review was conducted and children who received at least six months of HAART between 2004-2011 at All India Institute of Medical Sciences (AIIMS), Delhi were included. The clinical, immunological and virological responses to HAART were documented. Factors predicting non-adherence and non-response to treatment were described. RESULTS: One seventy five children (boys: 74.9%) were included in the study, with a median follow up of 43 (IQR: 17, 68) months. The median age at diagnosis was 119 (IQR: 75, 156) months. The median CD4 count at start of HAART was 340 cells/µL (IQR: 185,704), which increased to 924 cells/µL (IQR: 591,1278) at 48 months after HAART and plateaued at 749 (IQR: 542,1056) cells/ µL after 90 months of therapy. The weight for age (WAZ) and height for age (HAZ) z score both showed improvement with time after HAART initiation [baseline: WAZ -2.8 (IQR: -4,-1.6), HAZ -2.1 (IQR: -3.4,-0.69); at 42 months of therapy: WAZ -1.2 (IQR: -2.1, 0.01), HAZ -0.75(IQR: -1.6,-0.37)]. Adverse events were reported in 21 (12%) children. Non-adherence to therapy, treatment failure and death were noted in 35 (20%), 9 (5.1%) and 6 (3.4%) children respectively. CONCLUSIONS: Our experience shows that HAART in HIV-infected children is effective, safe and is associated with good immunological and virological response as well as improvement in growth parameters.

Impact of SARS-CoV-2 Infection on the Association Between Laboratory Tests and Severe Outcomes Among Hospitalized Children.

Background: To assist clinicians with identifying children at risk of severe outcomes, we assessed the association between laboratory findings and severe outcomes among severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected children and determined if SARS-CoV-2 test result status modified the associations. Methods: We conducted a cross-sectional analysis of participants tested for SARS-CoV-2 infection in 41 pediatric emergency departments in 10 countries. Participants were hospitalized, had laboratory testing performed, and completed 14-day follow-up. The primary objective was to assess the associations between laboratory findings and severe outcomes. The secondary objective was to determine if the SARS-CoV-2 test result modified the associations. Results: We included 1817 participants; 522 (28.7%) SARS-CoV-2 test-positive and 1295 (71.3%) test-negative. Seventy-five (14.4%) test-positive and 174 (13.4%) test-negative children experienced severe outcomes. In regression analysis, we found that among SARS-CoV-2-positive children, procalcitonin ≥0.5 ng/mL (adjusted odds ratio [aOR], 9.14; 95% CI, 2.90-28.80), ferritin >500 ng/mL (aOR, 7.95; 95% CI, 1.89-33.44), D-dimer ≥1500 ng/mL (aOR, 4.57; 95% CI, 1.12-18.68), serum glucose ≥120 mg/dL (aOR, 2.01; 95% CI, 1.06-3.81), lymphocyte count <1.0 × 109/L (aOR, 3.21; 95% CI, 1.34-7.69), and platelet count <150 × 109/L (aOR, 2.82; 95% CI, 1.31-6.07) were associated with severe outcomes. Evaluation of the interaction term revealed that a positive SARS-CoV-2 result increased the associations with severe outcomes for elevated procalcitonin, C-reactive protein (CRP), D-dimer, and for reduced lymphocyte and platelet counts. Conclusions: Specific laboratory parameters are associated with severe outcomes in SARS-CoV-2-infected children, and elevated serum procalcitonin, CRP, and D-dimer and low absolute lymphocyte and platelet counts were more strongly associated with severe outcomes in children testing positive compared with those testing negative.

Early versus delayed initiation of antiretroviral therapy for Indian HIV-Infected individuals with tuberculosis on antituberculosis treatment.

BACKGROUND: For antiretroviral therapy (ART) naive human immunodeficiency virus (HIV) infected adults suffering from tuberculosis (TB), there is uncertainty about the optimal time to initiate highly active antiretroviral therapy (HAART) after starting antituberculosis treatment (ATT), in order to minimize mortality, HIV disease progression, and adverse events. METHODS: In a randomized, open label trial at All India Institute of Medical Sciences, New Delhi, India, eligible HIV positive individuals with a diagnosis of TB were randomly assigned to receive HAART after 2-4 or 8-12 weeks of starting ATT, and were followed for 12 months after HAART initiation. Participants received directly observed therapy short course (DOTS) for TB, and an antiretroviral regimen comprising stavudine or zidovudine, lamivudine, and efavirenz. Primary end points were death from any cause, and progression of HIV disease marked by failure of ART. FINDINGS: A total of 150 patients with HIV and TB were initiated on HAART: 88 received it after 2-4 weeks (early ART) and 62 after 8-12 weeks (delayed ART) of starting ATT. There was no significant difference in mortality between the groups after the introduction of HAART. However, incidence of ART failure was 31% in delayed versus 16% in early ART arm (p = 0.045). Kaplan Meier disease progression free survival at 12 months was 79% for early versus 64% for the delayed ART arm (p = 0.05). Rates of adverse events were similar. INTERPRETATION: Early initiation of HAART for patients with HIV and TB significantly decreases incidence of HIV disease progression and has good tolerability. TRIAL REGISTRATION: CTRI/2011/12/002260.

Effects of the COVID-19 pandemic on the pediatric emergency department: a single institution experience.

BACKGROUND: The COVID-19 pandemic resulted in drastic decreases in volume for most pediatric emergency departments (ED). Injuries have persisted and there is concern that injuries may have increased during the pandemic. This study evaluates the impact of the COVID-19 pandemic on ED patient trends at a freestanding children's hospital. RESULTS: Despite an average annual increase of 1100 patients per year between 2017 and 2019, this ED saw a decrease of over 25,000 patients in 2020. The number of trauma alerts increased from 341 in 2017 to 571 in 2020 and those numbers remained stable (568-571) in 2020 compared to 2019. The percent of total volume accounted for by trauma alerts increased from 0.65 to 1.2% between 2019 and 2020 (following the trend of 0.48% in 2017 to 0.56% in 2018). Historically, motor vehicle crashes account for the majority of the trauma alerts, though the number of trauma alerts from firearm-related injuries increased from 36 per year in 2018 to 44 in 2019 to 66 (12% of total trauma alerts) in 2020. CONCLUSIONS: While total volumes of patients being seen decreased, the number of trauma alerts remained stable resulting in an increased percentage of trauma alert patients. This indicates that severe injuries requiring trauma alert activation did not diminish during the pandemic. These trends have implications for prevention as well as implications for ED staffing. Changing trends in types of severe injuries are noted.

Assessment of Pediatric Residents' Comfort Level With CellScope Oto to Examine Pediatric Ear Exams.

Examining a child's tympanic membrane (TM) is challenging, but crucial for proper management of acute otitis media (AOM). CellScope Oto (CSO) is an attachment that turns a smartphone into an otoscope. We aimed to assess pediatric resident comfort level with ear exams using CSO to see whether comfort level and accuracy of diagnosis of AOM improved. A pre-post study of pediatric residents in a freestanding Pediatric Emergency Department was conducted to assess their comfort level of traditional otoscope and CSO via a Likert scale. Ear exams were recorded and rated by 2 faculty for accuracy of AOM diagnosis. A total of 18 pediatric residents participated, and 308 exams were collected, with 2% diagnosed as AOM. The median change in comfort level increased by +1.0 for interns and third years but remained unchanged for second years. There was substantial agreement by faculty raters of video ear exams. Overall, comfort level increased with accuracy of diagnosis of AOM.