An Atypical Case of Idiopathic Purpura Fulminans.

Idiopathic purpura fulminans (PF) is rare but has been reported in pediatric patients, commonly following infections. We present a case of a 5-year-old boy, heterozygous for factor V Leiden, with no history of recent infections, who presented with PF secondary to acquired protein S deficiency. Despite initial supportive treatment, the patient required surgical fasciotomy and extensive skin grafts. The protein S level normalized 4 months following the presentation. In this context, an autoimmune component with transient anti-protein S antibodies was believed to be involved. This case report highlights the course of idiopathic PF due to noninfectious acquired protein S deficiency.

ST-elevation in an adolescent with COVID-19: Myopericarditis or myocardial infarction?

Myocardial infarctions (MI) have been reported in adults with COVID-19. Although MIs are rare in children with COVID-19, cardiac involvement is still possible. In this case report, we present an adolescent with recent COVID-19 infection who presented with an ECG initially suggestive of myocardial infarction (MI). We describe how to differentiate between myocardial infarctions and myopericarditis. A 15-year-old boy, with a history of COVID-19 infection a month prior, presented to the emergency department with fever, abdominal pain, diarrhea, and chest pain. On ECG, he was found to have focal ST-segment elevations in V3 through V6. Given the immediate concern for MI, an emergent echocardiogram was done and showed normal left ventricular systolic function with no regional dyskinesia and normal coronary artery diameters. A repeat ECG showed diffuse ST elevations in the inferior leads and T-wave inversions on V5 and V6, confirming the diagnosis of myopericarditis. In conclusion, multisystem-inflammatory syndrome in children associated with COVID-19 (MIS-C) is a new entity describing a post-infectious inflammatory response in children with prior COVID-19 exposure. Cardiac involvement can include myopericarditis. Initial ECGs may show ST-changes suggestive of MI. However, serial ECGs and echocardiograms can differentiate between MI and myocarditis/myopericarditis. Even with COVID-19, MIs are extremely rare in children, and it is important to be aware of MIS-C and its cardiac complications.

The Use of Ultrasound Simulators to Strengthen Scanning Skills in Medical Students: A Randomized Controlled Trial.

OBJECTIVES: This study evaluates the use of ultrasound simulators for retaining and improving ultrasound skills acquired in undergraduate ultrasound training. METHODS: Fourth-year medical students (n = 19) with prior training in point-of-care sonography for shock assessment were recruited for this study. Students were randomly assigned to a study group (n = 10) that followed an undergraduate ultrasound training curriculum, then used a simulator to complete 2 self-directed practice ultrasound sessions over 4 weeks. The control group (n = 9) followed the same undergraduate ultrasound training curriculum and received no additional access to a simulator or ultrasound training. A blinded assessment of the students was performed before and after the 4-week study period to evaluate their image acquisition skills on standardized patients (practical examination). To evaluate the student's clinical understanding of pathological ultrasound images, students watched short videos of prerecorded ultrasound scans and were asked to complete a 22-point questionnaire to identify their findings (visual examination). RESULTS: All results were adjusted to pretest performance. The students in the study group performed better than those in the control group on the visual examination (80.1% versus 58.9%; P = .003) and on the practical examination (77.7% versus 57.0%; P = .105) after the 4-week study period. The score difference on the postintervention practical examinations was significantly better for the study group compared to the control group (11.6% versus -9.9%; P = .0007). CONCLUSION: The use of ultrasound simulators may be a useful tool to help previously trained medical students retain and improve point-of-care ultrasound skills and knowledge.

Ocular Point-of-Care Ultrasound in the Pediatric Emergency Department.

OBJECTIVE: Point-of-care ultrasound has become an important adjunct for diagnostic assessment in pediatric emergency medicine. In this case series, we demonstrate how ocular point-of-care ultrasound is used to correctly diagnose ocular pathologies and to expedite care. METHODS/RESULTS: We present a series of cases in which the point-of-care ultrasound ocular examination proved valuable in the timely diagnosis of pathologies involving the lens, vitreous, retina, and retrobulbar segment of the eye. CONCLUSION: Point-of-care ultrasound may facilitate diagnosis in children with ocular complaints, even in young and uncooperative patients, and should be considered in children of all ages.

Point-of-Care Ultrasound Use to Differentiate Hematoma and Sarcoma of the Thigh in the Pediatric Emergency Department.

Hematomas and soft tissue sarcomas can be difficult to differentiate clinically, even with the addition of traditional imaging modalities. There are several case reports of sarcomas being misdiagnosed as hematomas, most commonly with a history of mild trauma. In this case report, we described a sarcoma initially misinterpreted as a hematoma on ultrasound. Key clinical features and sonographic findings that may assist clinicians using point-of-care ultrasound to correctly differentiate sarcomas from hematomas are reviewed. A soft tissue mass larger than 5 cm, with internal vascular Doppler flow, presenting without a clear mechanism of injury or with constitutional symptoms should be considered as suspicious for malignancy.

Parents' perspective on pediatric emergency department visits for low-acuity conditions before and during the COVID-19 pandemic: a cross-sectional bicentric study.

OBJECTIVES: The primary objective of this study was to describe and compare the motivation of parents/guardians to bring children with low-acuity conditions to a tertiary-care pediatric emergency department (ED) versus a clinic before and after the pandemic. The secondary objectives were to describe and compare the demographic and clinical characteristics of the population studied and the impact of the pandemic on their access to primary care services. METHODS: This is a cross-sectional study based on a survey administered to parents/guardians of patients presenting with low-acuity conditions at one of two EDs. RESULTS: The respondents numbered 659. Children were brought to a pediatric ED generally because of the perceived urgency of the condition, the presumed resource availability in the pediatric ED and the unavailability of the primary care physician. However, most respondents (n = 438, 66.5%) indicated preference for a clinic. More respondents before than during the pandemic reported they had been unable to find a doctor outside the ED (48.6% before COVID vs 26.8% during COVID, p < 0.001) but patients during the pandemic were less likely to seek care in a primary care practice or walk-in clinic (30.0% during COVID vs 48.6% before COVID, p < 0.001). In addition, the number of respondents presenting with symptoms of infection decreased by more than half after the pandemic began while the proportion of musculoskeletal and psychiatric complaints doubled. CONCLUSION: Although the pandemic has altered the landscape of presenting complaints and pediatric healthcare-seeking behaviors, most respondents indicated they would prefer to receive care in a clinic. This finding contradicts the view that most pediatric ED visits for low-acuity conditions are by choice rather than perceived necessity. Prioritizing improved access to primary care resources would better address the preferences and expectations of parents/guardians.

ABSTRAIT: OBJECTIFS: L'objectif principal de cette étude était de décrire et de comparer la motivation des parents/tuteurs à amener des enfants présentant des troubles de faible sévérité à un service d'urgence (SU) pédiatrique de soins tertiaires par rapport à une clinique avant et après la pandémie. Les objectifs secondaires étaient de décrire et de comparer les caractéristiques démographiques et cliniques de la population étudiée et l'impact de la pandémie sur leur accès aux services de soins primaires. MéTHODES: Il s'agit d'une étude transversale fondée sur une enquête menée auprès de parents/tuteurs de patients présentant des problèmes de faible sévérité à l'un des deux SU. RéSULTATS: Les répondants étaient au nombre de 659. Les enfants ont été amenés à un SU pédiatrique généralement en raison de l'urgence perçue de la condition, de la disponibilité présumée des ressources dans le SU pédiatrique et de l'indisponibilité du médecin de soins primaires. Cependant, la plupart des répondants (n = 438, 66,5%) ont indiqué une préférence pour une clinique. Plus de répondants avant que pendant la pandémie ont déclaré qu'ils avaient été incapables de trouver un médecin à l'extérieur de l'urgence (48,6% avant la COVID-19 contre 26,8% pendant la COVID-19, p < 0,001), mais les patients pendant la pandémie étaient moins susceptibles de solliciter des soins dans une clinique de soins primaires ou une clinique sans rendez-vous. (30,0% pendant la COVID-19 contre 48,6% avant la COVID-19, p < 0,001). De plus, le nombre de répondants présentant des symptômes d'infection a diminué de plus de la moitié après le début de la pandémie, tandis que la proportion de plaintes musculosquelettiques et psychiatriques a doublé. CONCLUSION: Bien que la pandémie ait modifié le portrait des raisons et des habitudes de consultation dans les urgences pédiatriques, la plupart des répondants ont indiqué qu'ils préféreraient recevoir des soins dans une clinique. Cette constatation contredit le point de vue selon lequel la plupart des visites aux urgences pédiatriques pour des problèmes de faible sévérité se font par choix plutôt que par nécessité perçue. Donner la priorité à l'amélioration de l'accès aux ressources de soins primaires permettrait de mieux répondre aux préférences et aux attentes des parents/tuteurs.

Value-Based Care for Healthy Children With First Episode of Febrile Neutropenia.

OBJECTIVES: There is a lack of guidance on the management of febrile neutropenia in otherwise healthy children, including the need for hospitalization and antibiotic administration, leading to significant practice variation in management. The aim of this initiative was to decrease the number of unnecessary hospitalizations and empirical antibiotics prescribed by 50% over a 24-month period for well-appearing, previously healthy patients older than 6 months presenting to the emergency department with a first episode of febrile neutropenia. METHODS: A multidisciplinary team of stakeholders was assembled to develop a multipronged intervention strategy using the Model for Improvement. A guideline for the management of healthy children with febrile neutropenia was created, coupled with education, targeted audit and feedback, and reminders. Statistical control process methods were used to analyze the primary outcome of the percentage of low-risk patients receiving empirical antibiotics and/or hospitalization. Balancing measures included missed serious bacterial infection, emergency department (ED) return visit, and a new hematologic diagnosis. RESULTS: Over the 44-month study period, the mean percentage of low-risk patients hospitalized and/or who received antibiotics decreased from 73.3% to 12.9%. Importantly, there were no missed serious bacterial infections, no new hematologic diagnoses after ED discharge, and only 2 ED return visits within 72 hours without adverse outcomes. CONCLUSIONS: A guideline for the standardized management of febrile neutropenia in low-risk patients increases value-based care through reduced hospitalizations and antibiotics. Education, targeted audit and feedback, and reminders supported sustainability of these improvements.

Profile of resistance to IVIG treatment in patients with Kawasaki disease and concomitant infection.

INTRODUCTION: Kawasaki disease (KD) can be associated with concomitant viral or bacterial infections. Children with persistent or recurrent fever 36 hours after the end of intravenous immunoglobulin (IVIG) are considered to be resistant to treatment and are at increased risk for coronary complications. Although concomitant infection does not affect coronary outcome, it is unknown how it influences the response to IVIG treatment. METHODOLOGY: Retrospective cohort study between 2008 and 2016 in a tertiary pediatric university hospital, including 154 children, of which 59 (38%) had concomitant infection. RESULTS: Children with concomitant infection were more likely to have fever 48 hours after initial IVIG treatment (36% vs 20%, p = 0.05) and to be treated with a second dose (33% vs 18%, p = 0.04). Children with infection had higher C-reactive protein at the time of diagnosis (148 vs 112 mg/L, p = 0.04), and 48 hours after IVIG administration (111 vs 59 mg/L, p = 0.003). Nevertheless, there was no statistically significant difference in the prevalence of coronary complications (Z-score > 2.5) between children with and without concomitant infection (36% vs 39%, p = 0.68). CONCLUSION: Children with KD and concomitant infection are more likely to have persistent fever and elevated inflammatory markers after treatment. This association increases the likelihood of receiving a second dose of IVIG but not the risk of coronary complication. Accordingly, prospective studies to distinguish true IVIG resistance from infection induced persistent fever is warranted.