Work-Life Integration for Women in Pediatric Emergency Medicine: Themes Identified Through Group Level Assessment.

OBJECTIVE: Women in medicine generally have higher burnout and lower career satisfaction and work-life integration compared with men. This study identifies factors that contribute to burnout, career satisfaction, and work-life integration in women pediatric emergency medicine (PEM) physicians. METHODS: Self-identified women PEM physicians in the United States participated in a virtual focus group using Group Level Assessment methodology. Participants completed Group Level Assessment process steps of climate setting, generating, appreciating, reflecting, understanding, selecting, and action to (1) identify themes that contribute to burnout, career satisfaction, and work-life integration and (2) determine actionable factors based on these themes. Data were collected and thematically analyzed in real time through iterative processing. The group prioritized identified themes through rounds of distillation. RESULTS: Seventeen women participated, representing 10 institutions (ages 30s-70s, 69% employed full-time). Participants identified 3 main themes contributing to burnout, career satisfaction, and work-life integration: (1) gender inequities, (2) supportive leadership, and (3) balance with family life. Actionable items identified were as follows: (1) development of initiatives to equalize pay, opportunity, and career advancement among genders; (2) implementation of an institutional focus on supportive and collaborative leadership; and (3) improvement of resources and supports for physicians with family responsibilities. CONCLUSIONS: Women PEM physicians identified gender inequities, leadership, and balance with family life as major themes affecting their burnout, career satisfaction, and work-life integration. Several action steps were identified and can be used by individuals and institutions to improve work-life integration for women PEM physicians.

Patient Characteristics Associated with Hospital Admission or Antiarrhythmic Medication Changes After Emergency Department Evaluation of Supraventricular Tachycardia.

BACKGROUND: Supraventricular tachycardia (SVT) is a relatively frequent diagnosis in the pediatric emergency department (ED). However, there are no consensus guidelines for ED disposition, and there are limited data on ED outcomes. Better understanding of those who are admitted or have antiarrhythmic medication changes may avoid potentially unnecessary transfers or admissions. Our objective was to identify patient factors associated with discharge from the emergency department without medication initiation or modification after management of SVT in the pediatric ED. DESIGN/METHODS: A retrospective review of children aged 0-18 years seen in the emergency department for SVT was conducted using electronic medical record data over a ten-year period at a single academic tertiary children's hospital. Patients with congenital cardiac disease or prior cardiac surgeries were excluded. Multivariable logistic regression analysis was used to determine association between patient factors of interest and the primary outcome of admission and secondary outcome of change to antiarrhythmic medications. RESULTS: We analyzed 197 patients encounters. The mean age was 7 years. Of these 104 (52.8%) were admitted to the hospital or discharged with antiarrhythmic medication changes. This primary outcome was associated with younger age (aOR 0.77, 95% CI 0.67-0.86), history of pre-excitation (aOR 5.82, 95% CI 2.01-18.8), intercurrent illness (aOR 3.75, 95% CI 1.27-12.1), number of adenosine doses prior to arrival (aOR 5.45, 95% CI 1.55-22.3), and in-person cardiology consultation (aOR 6.42, 95% CI 2.43-19.4). CONCLUSIONS: Nearly half of children treated in a pediatric ED for SVT are discharged without changes in medications. We identified patient factors associated with hospital admission or antiarrhythmic medication changes. These factors represent high value care and can be assessed when considering transfer from a referring facility. Risk stratification using these patient characteristics may reduce potentially avoidable transfers and admissions.

Gender Differences in Work-Life Integration, Career Satisfaction, and Burnout in Pediatric Emergency Medicine Physicians: A Cross-Sectional Analysis.

OBJECTIVE: Women physicians report worse work-life integration, career satisfaction, and burnout than men. No studies have evaluated work-life integration and career satisfaction in pediatric emergency medicine (PEM) or explored gender differences for these outcomes. This study aims to (1) compare work-life integration, career satisfaction, and burnout in women and men PEM physicians and (2) compare associated individual and occupational factors to distinguish modifiable factors. METHODS: We distributed an electronic survey to assess well-being parameters in PEM physicians. We assessed career satisfaction and work-life integration with single-item measures. We used a 2-item screen to measure burnout. We performed descriptive analyses, univariate analysis to compare gender differences, and multivariate logistic regression analysis for each outcome. RESULTS: Two hundred thirty-nine PEM physicians participated, yielding a response rate of 50% (57% women; age range, 30-80 years). Overall satisfaction with work-life integration was 42.9%, with 34.3% of women reporting appropriate work-life integration, compared with 55.4% of men (P = 0.001). Career satisfaction rate was 77.8%, with 71.6% of women reporting career satisfaction, compared with 86.1% of men (P = 0.008). Burnout rate was 44.5%, with 53.7% of women reporting burnout compared with 33.7% of men (P = 0.002). Modifiable factors identified include perception of unfair compensation, inadequate physical and mental health support provided by organization, feeling unappreciated, inadequate provider staffing, inadequate resources for patient care, lack of advance notice or control of work schedule, and inadequate sleep. CONCLUSIONS: Of PEM physicians, women have worse work-life integration, less career satisfaction, and more burnout than men. The PEM community should devote resources to modifiable occupational factors to improve gender disparities in well-being parameters.

Ascorbate deficiency confers resistance to hippocampal neurodegeneration after asphyxial cardiac arrest in juvenile rats.

BACKGROUND: Asphyxial cardiac arrest (CA) is a significant cause of death and disability in children. Using juvenile Osteogenic disorder Shionogi (ODS) rats that, like humans, do not synthesize ascorbate, we tested the effect of ascorbate deficiency on functional and histological outcome after CA. METHODS: Postnatal day 16-18 milk-fed ODS and wild-type Wistar rats underwent 9-min asphyxial CA (n = 8/group) or sham surgery (n = 4/group). ODS mothers received ascorbate in drinking water to prevent scurvy. Levels of ascorbate and glutathione (GSH) were measured in plasma and hippocampus at baseline and after CA. Neurologic deficit score (NDS) was measured at 3, 24, and 48 h and hippocampal neuronal counts, neurodegeneration, and microglial activation were assessed at day 7. RESULTS: ODS rats showed depletion of plasma and hippocampal ascorbate, attenuated hippocampal neurodegeneration and microglial activation, and increased CA1 hippocampal neuron survival vs. Wistar rats while NDS were similar. Hippocampal GSH levels were higher in ODS vs. Wistar rats at baseline and 10 min, whereas hypoxia-inducible factor-1α levels were higher in Wistar vs. ODS rats at 24 , after CA. CONCLUSION: Ascorbate-deficient juvenile ODS rats appear resistant to neurodegeneration produced by asphyxia CA, possibly related to upregulation of the endogenous antioxidant GSH in brain. IMPACT: Like humans and unlike other rodents, osteogenic disorder Shionogi (ODS) rats do not synthesize ascorbate, and thus may serve as a useful model for studying the role of ascorbate in human disease. Conflicting evidence exists regarding ascorbate's protective versus detrimental effects in animal models and clinical studies. Ascorbate-deficient ODS rats are resistant to neurodegeneration after experimental cardiac arrest.

Management and Outcome of Pediatric Patients With Transient Small Bowel-Small Bowel Intussusception.

OBJECTIVE: The aim of this study was to assess the management and outcomes of healthy pediatric patients diagnosed radiologically with transient and benign small bowel-small bowel intussusception (SB-SBI). METHODS: Retrospective cohort study of healthy patients 0 to 18 years of age who presented to a children's hospital emergency department from January 1, 2005, to June 30, 2015, and had transient and benign SB-SBI characterized by spontaneous resolution (ie, transient), diameter of less than 2.5 cm, no lead point, normal bowel wall thickness, nondilated proximal small bowel, and no colonic involvement (ie, benign radiographic features). Charts were reviewed for demographics, clinical presentation, radiologic studies obtained, outcomes, and further management. Medical and radiologic records were also reviewed for 1 year after presentation for any subsequent pathologic diagnoses. RESULTS: Sixty-eight patients were included in our study, with a total of 87 episodes of transient and benign SB-SBI on initial or follow-up examination. Overall, 39 patients (57%) were admitted to the hospital, and 38 patients (56%) had a surgical consultation. Twenty-four patients (35%) had further radiologic studies obtained, including computed tomography scans, esophagogastroduodenoscopy, Meckel's scan, barium swallow studies, and magnetic resonance imaging. All studies were negative for concerning pathology including apparent lead points. None of the patients required surgical intervention or had any complications. CONCLUSIONS: Transient and benign SB-SBIs with reassuring radiologic and clinical features diagnosed in healthy pediatric patients are likely incidentally found and are unlikely to be associated with a pathologic lead point.

Management and Outcomes of Spontaneous Pneumomediastinum in Children.

OBJECTIVES: Management of spontaneous pneumomediastinum in the pediatric population is highly variable. There are limited data on the use of diagnostic tests and the need for admission. Our objectives were to characterize the management of pediatric spontaneous pneumomediastinum, determine the diagnostic yield of advanced imaging, and describe the patients' outcomes. METHODS: This is a retrospective cohort study of all patients presenting to a single tertiary pediatric emergency department between January 2008 and February 2015 diagnosed with pneumomediastinum. Patients were identified using 2 complementary strategies: International Classification of Diseases, Ninth Revision billing codes and a keyword search of the hospital radiology database. RESULTS: We identified 183 patients with spontaneous pneumomediastinum. The mean age was 12.8 ± 4.8 years. Diagnosis was established by chest radiograph (CXR) in 165 (90%) patients, chest computed tomography in 15 (8%), neck imaging in 2 (1%), and abdominal imaging in 1. After diagnosis, many patients underwent additional studies: repeat CXR (99, 54%), chest computed tomography (53, 29%), esophagram (45, 25%), and laryngoscopy (15, 8%). Seventy-eight percent of patients (n = 142) were admitted with a median length of stay of 27 hours (18.4-45.6 hours). Six patients returned to the emergency department within 96 hours for persistent chest pain; 2 were admitted, and 1 was found to have worsening pneumomediastinum on CXR. We performed a secondary analysis on 3 key subgroups: primary spontaneous pneumomediastinum (64, 35%), secondary gastrointestinal-associated pneumomediastinum (31, 17%), and secondary respiratory-associated pneumomediastinum (88, 48%). No patients in the study received an invasive intervention for pneumomediastinum. In all patients, further studies did not yield additional diagnostic information. CONCLUSIONS: Our data suggest that patients with spontaneous pneumomediastinum who are clinically well appearing can be managed conservatively with clinical observation, avoiding exposure to radiation and invasive procedures.

Success of Pediatric Intubations Performed by a Critical Care Transport Service.

Background: Prehospital pediatric endotracheal intubation (ETI) is rarely performed. Previous research has suggested that pediatric prehospital ETI, when performed by ground advanced life support crews, is associated with poor outcomes. In this study, we aim to evaluate the first-attempt success rate, overall success rate and complications of pediatric prehospital ETI performed by critical care transport (CCT) personnel.Methods: We conducted a retrospective observational study in a multi-state CCT service performing rotor wing, ground, and fixed wing missions. We included pediatric patients (<18 years) for whom ETI was performed by CCT personnel (flight nurse or flight paramedic).Our primary outcome of interest was rate of first-attempt ETI. Secondary outcomes were overall rates of successful ETI, complications encountered, and outcomes of patients with unsuccessful intubation.Results: 993 patients were included (63.2% male, median age 12 years, IQR 4-16 years). 807/993 (81.3%) patients were intubated on the first attempt. Lower rates of successful first-attempt intubation were seen in younger ages (42.9% in infants ≤30 days of age). In multivariable logistic regression, lower odds (adjusted odds ratio, 95% confidence interval) of successful first-attempt ETI were associated with ages >30 days to <1 year (0.33, 0.18-0.61) and 2 to <6 years (0.60, 0.39-0.94) compared to patients 12 to <18 years. Patients given an induction agent and neuromuscular blockade (NMB) had a higher odds of first-attempt ETI success (1.53, 1.06-2.15). 13 (1.3%) had immediately recognized esophageal intubation and 33 (3.3%) had vomiting. No episodes of pneumothorax were reported. 962/993 (96.9%) patients were successfully intubated after all attempts. In patients without successful ETI (n = 31), supraglottic airways were used in 24, bag-valve mask ventilation in 5, and surgical cricothyroidotomy in 2, with an overall advanced airway success rate of 988/993 (99.5%).Conclusion: Critical care flight nurses and paramedics performed successful intubations in pediatric patients at a high rate of success. Younger age was associated with lower success rates. Improved ETI training for younger patients and use of an induction agent and NMB may improve airway management in critically ill children.

Cardiac Arrest Secondary to Lightning Strike: Case Report and Review of the Literature.

Lightning strike injuries, although less common than electrical injuries, have a higher morbidity rate because of critical alterations of the circulatory system, respiratory system, and central nervous system. Most lightning-related deaths occur immediately after injury because of arrhythmia or respiratory failure. We describe the case of a pediatric patient who experienced cardiorespiratory arrest secondary to a lightning strike, where the Advanced Cardiac Life Support and Basic Life Support chain of survival was well executed, leading to return of spontaneous circulation and intact neurological survival. We review the pathophysiology of lightning injuries, prognostic factors of favorable outcome after cardiac arrest, including bystander cardiopulmonary resuscitation, shockable rhythm, and automatic external defibrillator use, and the importance of temperature management after cardiac arrest.

The aquaporin-4 inhibitor AER-271 blocks acute cerebral edema and improves early outcome in a pediatric model of asphyxial cardiac arrest.

BACKGROUND: Cerebral edema after cardiac arrest (CA) is associated with increased mortality and unfavorable outcome in children and adults. Aquaporin-4 mediates cerebral water movement and its absence in models of ischemia improves outcome. We investigated early and selective pharmacologic inhibition of aquaporin-4 in a clinically relevant asphyxial CA model in immature rats in a threshold CA insult that produces primarily cytotoxic edema in the absence of blood-brain barrier permeability. METHODS: Postnatal day 16-18 Sprague-Dawley rats were studied in our established 9-min asphyxial CA model. Rats were randomized to aquaporin-4 inhibitor (AER-271) vs vehicle treatment, initiated at return of spontaneous circulation. Cerebral edema (% brain water) was the primary outcome with secondary assessments of the Neurologic Deficit Score (NDS), hippocampal neuronal death, and neuroinflammation. RESULTS: Treatment with AER-271 ameliorated early cerebral edema measured at 3 h after CA vs vehicle treated rats. This treatment also attenuated early NDS. In contrast to rats treated with vehicle after CA, rats treated with AER-271 did not develop significant neuronal death or neuroinflammation as compared to sham. CONCLUSION: Early post-resuscitation aquaporin-4 inhibition blocks the development of early cerebral edema, reduces early neurologic deficit, and blunts neuronal death and neuroinflammation post-CA.

Expansile Superabsorbent Polymer Ball Foreign Body in the Ear.

BACKGROUND: Superabsorbent polymers (SAPs) are materials that can absorb large quantities of water. Small spherical SAPs are commonly marketed as toys for children. CASE REPORT: We report the case of a 4-year-old female who presented to a pediatric emergency department with a small, marble-sized SAP that was placed in her ear by herself during the course of play at daycare. On examination, the object was translucent and difficult to visualize. After multiple attempts at removal, the object was partially removed using an ear curette. The patient sustained a small tympanic membrane perforation. During a follow-up operative intervention by otorhinolaryngology, the remainder of the object was removed using a suction device and the tympanic membrane was repaired. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: While large SAPs associated with intestinal obstruction have been removed from the market, smaller SAPs can present a health risk when placed in orifices such as the ear or nose. Cases of foreign body SAPs have been misdiagnosed as ear infections and treated with topical antibiotics, which can lead to enlargement of the foreign body. Irrigation techniques and topical medications should not be used. SAPs are friable and can break into multiple pieces during removal attempts. Blunt tools, such as ear curettes, may be best suited for their removal. If the item breaks up during removal or if removal fails, urgent consultation with an otorhinolaryngologist is recommended.

Difficult Intubation and Ventilation in an Infant With Retropharyngeal Abscess With Mediastinal Extension.

A previously healthy 7-month-old male infant presented for evaluation of fever, deceased oral intake, and intermittent noisy breathing. Physical examination revealed neck tenderness. Soft tissue neck radiographs and computed tomography (CT) scan supported a diagnosis of retropharyngeal swelling with extension to the superior mediastinum. Surgical exploration was planned, and endotracheal intubation was performed in the operating room. Significant cardiorespiratory derangements developed immediately after the tracheal tube was inserted, including hypotension, hypoxia, and bradycardia with signs of cardiac ischemia. The patient was resuscitated with intravenous fluids, vasopressors, and bronchodilators; his condition improved after resuscitation and surgical evacuation of purulent material. A combination of mediastinal mass effect, aspiration, and bronchospasm likely contributed to the patient's deterioration. The subsequent clinical course was uneventful. The patient was extubated in a delayed fashion and discharged on the fourth postoperative day. This case highlights the importance of preparing for a difficult airway in cases of retropharyngeal abscesses that necessitate tracheal intubation. A multidisciplinary approach is best suited to manage the airway, preferably in the operating room.

Adenosine Administration With a Stopcock Technique Delivers Lower-Than-Intended Drug Doses.

STUDY OBJECTIVE: Adenosine administration with a stopcock is the recommended treatment for pediatric patients with acute supraventricular tachycardia. Recent reports suggest that many infants do not respond to the first dose of adenosine administered. Our aim is to determine whether administration of adenosine with a stopcock delivers lower-than-expected drug doses in patients weighing less than 10 kg, corresponding to weights of infants. METHODS: We developed an in vitro model of adenosine delivery. Doses of adenosine corresponding to weights 2 to 25 kg were calculated, using a dose of 0.1 mg/kg, and administered through one port of a stopcock. Distilled water was administered through the second port. The adenosine concentration of the output was measured with mass spectrometry and results were confirmed with spectrophotometry of Evans blue. RESULTS: The mean doses of adenosine delivered through the stopcock increased as weight increased. The mean dose of adenosine delivered was 0.08 mg/kg for weights 2 to 9 kg and 0.1 mg/kg for weights 10 to 25 kg (95% confidence interval for difference of means -0.03 to -0.009). The median dose of adenosine delivered was 0.07 mg/kg (interquartile range [IQR] 0.06 to 0.07 mg/kg), 0.09 mg/kg (IQR 0.08 to 0.09 mg/kg), and 0.1 mg/kg (IQR 0.09 to 0.1 mg/kg) for weights 2 to 5, 6 to 9, and 10 to 25 kg, respectively (rank difference=100; P<.05 for 2 to 5 kg versus 10 to 25 kg). Similar results were obtained with spectrophotometry. CONCLUSION: Administration of adenosine through a stopcock delivers doses lower than intended in patients weighing less than 10 kg, which may account for the decreased response of infants to the first dose of adenosine.

Primary Omental Torsion in a Pediatric Patient: Case Report and Review of the Literature.

Primary omental torsion is a rare cause of acute abdominal pain with a clinical presentation resembling acute appendicitis. Here, we report the case of a 7-year-old child presenting with right lower quadrant pain. Primary omental torsion was discovered upon laparoscopy, and the torsed omentum was excised without postoperative complications. Potential causes, contributing factors, diagnosis, and treatment are discussed.

A Case of Lenticulostriate Stroke Due to Minor Closed Head Injury in a 2-Year-Old Child: Role of Mineralizing Angiopathy.

OBJECTIVE: Cerebral infarction due to minor head injury is rare. Mineralizing angiopathy is considered a predisposing factor for lenticulostriate stroke after minor closed head injury. This entity is characterized by infarction of the basal ganglia and most often occurs in young children, from infancy to 2 years of age. Symptoms usually occur immediately after the injury. METHODS AND RESULTS: We present the case of a previously healthy 2-year-old female child presenting with right facial hemiparesis and aphasia, along with right arm and leg weakness that occurred immediately after a fall from the couch onto a carpeted floor. A brain computed tomography scan revealed small and linear calcifications of the basal ganglia and subcortical frontoparietal area, in the absence of signs of intracranial hemorrhage. Brain magnetic resonance imaging with stroke protocol revealed restriction of water diffusion in the left basal ganglia on diffusion-weighted imaging sequences as well as apparent diffusion coefficient sequences, suggesting an acute infarct of the left basal ganglia within the distribution of the lenticulostriate vessels. The patient was treated with aspirin and conservative management and had gradual improvement over the next few days, with full recovery of the aphasia, facial nerve function, and arm and leg mobility, within 2 months. CONCLUSIONS: Some infants can present with the onset of stroke-like symptoms after minor head injuries. Presence of linear calcifications of the basal ganglia noticed on brain computed tomography in many of these patients suggests that mineralizing angiopathy may be a predisposing factor for lenticulostriate stroke after minor closed head injury in infants. Brain magnetic resonance imaging to further delineate possible cerebral infarction is indicated.

Acute Management of Refractory and Unstable Pediatric Supraventricular Tachycardia.

OBJECTIVE: To characterize the management of acute pediatric supraventricular tachycardia (SVT), placing special emphasis on infants, patients refractory to adenosine (refractory SVT), and patients with hypotension, poor perfusion, or altered mental status (unstable SVT). STUDY DESIGN: Retrospective cohort study of patients 0-18 years of age without congenital heart disease who presented to our pediatric hospital from January 2003 to December 2012 for the treatment of acute SVT. Multiple logistic regression was applied to identify whether age was a risk factor for different SVT therapies. Model fit and residuals also were examined. RESULTS: We identified 179 episodes for SVT. First dose of adenosine was effective in 72 (56%) episodes, and a second dose was effective in 27 of 54 (50%) episodes, leaving 27 (15%) episodes with refractory SVT. The response to the first dose of adenosine increased proportionally with age (OR 1.13, 95% CI 1.05-1.2). Only 1 of 17 episodes in infants responded to the first dose of adenosine. Refractory SVT was more frequent in infants vs older children (χ2 = 5.9 [1 df], P = .01). Unstable SVT was present in 13 episodes and was treated with adenosine and antiarrhythmics. Synchronized cardioversion was performed on 3 patients, 2 patients with unstable SVT, and 1 with refractory SVT. CONCLUSION: In children with SVT, young age is associated with decreased response to the first dose of adenosine and increased odds of adenosine-refractory SVT. In the treatment of unstable SVT, medical management with various antiarrhythmics before cardioversion may have a role in a subset of patients. Synchronized cardioversion rarely is performed for acute SVT.

Monitoring microvascular perfusion variations with laser speckle contrast imaging using a view-based temporal template method.

PURPOSE: Laser speckle contrast imaging (LSCI) continues to gain an increased interest in clinical and research studies to monitor microvascular perfusion. Due to its high spatial and temporal resolutions, LSCI may lead to a large amount of data. The analysis of such data, as well as the determination of the regions where the perfusion varies, can become a lengthy and tedious task. We propose here to analyze if a view-based temporal template method, the motion history image (MHI) algorithm, may be of use in detecting the perfusion variations locations. METHODS: LSCI data recorded during three different kinds of perfusion variations are considered: (i) cerebral blood flow during spreading depolarization (SD) in a mouse; (ii) cerebral blood flow during SD in a rat; (iii) cerebral blood flow during cardiac arrest in a rat. Each of these recordings was processed with MHI. RESULTS: We show that, for the three pathophysiological situations, MHI identifies the area in which perfusion evolves with time. The results are more easily obtained compared with a visual inspection of all of the frames constituting the recordings. MHI also has the advantage of relying on a rather simple algorithm. CONCLUSIONS: MHI can be tested in clinical and research studies to aid the user in perfusion analyses.

Enduring disturbances in regional cerebral blood flow and brain oxygenation at 24 h after asphyxial cardiac arrest in developing rats.

BACKGROUND: Disturbances in cerebral blood flow (CBF) and brain oxygenation (PbO2) are present early after pediatric cardiac arrest (CA). CBF-targeted therapies improved neurological outcome in our CA model. To assess the therapeutic window for CBF- and PbO2-targeted therapies, we propose to determine if CBF and PbO2 disturbances persist at 24 h after experimental pediatric CA. METHODS: Regional CBF and PbO2 were measured at 24 h after asphyxial CA in immature rats (n = 26, 6-8/group) using arterial spin label MRI and tissue electrodes, respectively. RESULTS: In all regions but the thalamus, CBF recovered to sham values by 24 h; thalamic CBF was >32% higher after CA vs. sham. PbO2 values at 24 h after CA in the cortex and thalamus were similar to shams in rats who received supplemental oxygen, however, on room air, cortical PbO2 was lower after CA vs. shams. CONCLUSION: CBF remains increased in the thalamus at 24 h after CA and PbO2 is decreased to hypoxic levels in cortex at 24 h after CA in rats who do not receive supplemental oxygen. Given the enduring disturbances in this model and the lack of routine CBF or PbO2 monitoring in patients, our data suggest the need for clinical correlation.

Ischemia-induced autophagy contributes to neurodegeneration in cerebellar Purkinje cells in the developing rat brain and in primary cortical neurons in vitro.

Increased autophagy/mitophagy is thought to contribute to cerebellar dysfunction in Purkinje cell degeneration mice. Intriguingly, cerebellar Purkinje cells are highly vulnerable to hypoxia-ischemia (HI), related at least in part to their high metabolic activity. Whether or not excessive or supraphysiologic autophagy plays a role in Purkinje cell susceptibility to HI is unknown. Accordingly, we evaluated the role of autophagy in the cerebellum after global ischemia produced by asphyxial cardiac arrest in postnatal day (PND) 16-18 rats, using siRNA-targeted inhibition of Atg7, necessary for microtubule-associated protein light chain 3-II (LC3-II) and Atg12-Atg5 complex formation. Two days before a 9min asphyxial cardiac arrest or sham surgery, Atg7 or control siRNA was injected intracisternally to target the cerebellum. Treatment with Atg7 siRNA: 1) reduced Atg7 protein expression in the cerebellum by 56%; 2) prevented the typical ischemia-induced formation of LC3-II in the cerebellum 24h after asphyxial cardiac arrest; 3) improved performance on the beam-balance apparatus on days 1-5; and 4) increased calbindin-labeled Purkinje cell survival assessed on day 14. Improved Purkinje cell survival was more consistent in female vs. male rats, and improved beam-balance performance was only seen in female rats. Similar responses to Atg7 siRNA i.e. reduced autophagy and neurodegeneration vs. control siRNA were seen when exposing sex-segregated green fluorescent protein-LC3 tagged mouse primary cortical neurons to oxygen glucose deprivation in vitro. Thus, inhibition of autophagy after global ischemia in PND 16-18 rats leads to increased survival of Purkinje cells and improved motor performance in a sex-dependent manner.

Neck Pain in a 12-Year-Old Female: An Unusual Diagnosis.

BACKGROUND: Neck pain in the pediatric population has a broad differential diagnosis, ranging from benign to imminently life-threatening causes. Trauma and infection represent the most common etiologies of pediatric neck pain in the pediatric emergency department (PED) setting. Malignancy, though a rare cause of pediatric neck pain, is important to consider in patients with acquired torticollis or focal neurologic signs. CASE REPORT: We describe the case of a previously healthy 12-year-old female who presented to the PED with neck pain radiating down her upper extremities. The physical examination revealed diminished strength in her upper extremities compared to her lower extremities. Further evaluation revealed lymphadenopathy in the cervical and mediastinal areas and an epidural tumor in the cervical spinal column. The ultimate diagnosis was Hodgkin lymphoma presenting in an unusual manner with cervical spinal cord compression. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Neck pain is a common chief complaint among pediatric patients in the emergency setting. This case of spinal cord compression caused by malignancy illustrates the necessity of detailed spinal imaging in patients with neck pain and "red flag" signs, including but not limited to an abnormal neurologic examination.