Faculty Bibliography

BACKGROUND: : Infant lumbar puncture (LP) is mandated by the Accreditation Council for Graduate Medical Education for all pediatric trainees. Current training usually involves the apprenticeship model of 'see one, do one, teach one' where a trainee's first LP attempt occurs in a high-stakes environment. Simulation training promotes skill development in a safe environment before patient contact. OBJECTIVE: : To demonstrate that deliberate practice simulation-based training after audiovisual training (AV) improves infant LP skills compared with a control group receiving AV training only. DESIGN/METHODS: : This was a randomized trial of simulation-based training + AV versus AV only for pediatric residents. On enrollment, the subjects' infant LP skills were evaluated through their performance on a simulator. A questionnaire and brief quiz were administered to collect information on the subjects' infant LP experience, knowledge, and confidence. All subjects viewed an educational AV presentation. The intervention group went on to participate in a simulation-based deliberate practice session on the infant LP simulator while the control group did not. Our primary outcome was self-reported clinical success on the first infant LP after training. Secondary outcomes were rates of traumatic clinical LPs, infant LP skills (measured via observed structured clinical examinations on the simulator 6 months after training), and change in participants' knowledge and confidence. RESULTS: : Fifty-one residents reported 32 clinical encounters. Sixteen of 17 subjects (94%) in the intervention group who performed a clinical infant LP obtained cerebrospinal fluid compared with 7 of 15 subjects (47%) in the control group (difference = 47%; 95% CI = 16%-70%). There was no difference between groups at 6 months on observed structured clinical examination performance, knowledge, or confidence. CONCLUSIONS: : Participation in a simulation-based deliberate practice intervention can improve infant LP skill

Background: The emergency department (ED) evaluation of children with blunt torso trauma and normal abdominal computed tomography (CT) scans is often complicated by concerns of occult intra-abdominal injury (IAI), such that many children are hospitalized for observation despite a normal CT scan. Objectives: To determine the risk of IAI in children with blunt torso trauma after a normal abdominal CT scan. Methods: We conducted a prospective, multicenter study of children < 18 years with blunt torso trauma evaluated in EDs, through the Pediatric Emergency Care Applied Research Network (PECARN). We conducted a planned sub-group analysis of those patients with normal abdominal CT scans in the ED, as interpreted by a faculty radiologist. Normal CT scans were defined as the lack of any evidence of IAI, including no intraperitoneal fluid. IAIs included injuries to a solid organ, hollow viscous, pancreas, urinary bladder, connective tissue, or vascular structure. To determine the presence of an occult IAI and any associated therapies for that IAI, patients were followed during hospitalization or received telephone follow-up if discharged from the ED. Data are presented with descriptive statistics. Results: of the 12,044 patients enrolled into the main study, 3,391 (28%) had normal abdominal CT scans in the ED and were included in this analysis. of these 3,391 patients, 1,480 (44%) were discharged home and 1,911 (56%) were admitted to the hospital. Twelve of 3,391 patients (0.4%, 95% CI 0.2, 0.6%) with a normal ED CT scan were later identified with an IAI: one of the 1,480 discharged patients (0.07%) and eleven of the 1,911 admitted patients (0.6%). Specific IAIs included pancreas (6), gastrointestinal (5), liver (1), and adrenal gland (1). Treatment in these 12 patients included therapeutic laparotomy in three, blood transfusion for abdominal hemorrhage in two, and bowel rest for more than two days in five. There were no deaths due to an IAI in those patients with a normal abdominal CT scan. The negative predictive value (NPV) for IAI of a normal abdominal CT scan was 99.6% (95% CI 99.5, 99.9%). Conclusion: Children with normal abdominal CT scans in the ED following blunt torso trauma, and no other injuries requiring hospitalization, may be safely discharged home. Appropriate discharge instructions are required, as rarely, an IAI may subsequently become evident

Background: Use of abdominal computed tomography (CT) in children with blunt abdominal trauma is highly variable due to limited evidence available to clinicians. Objectives: To derive a clinical prediction rule to identify children with blunt abdominal trauma who are at very low risk for intra-abdominal injuries (IAIs) undergoing acute intervention. Methods: We prospectively enrolled children (< 18 years old) with blunt torso trauma in 20 emergency departments (EDs) and documented history and physical examination findings onto data forms prior to abdominal CT, if obtained. Patients discharged from the ED were contacted by telephone and hospitalized patients were followed for IAI outcomes. We used binary recursive partitioning to create a prediction rule to identify patients at very low risk for IAI undergoing an acute intervention (therapeutic laparot- omy, angiographic embolization, blood transfusion for abdominal hemorrhage, or IV fluid administration for > 2 days in those with pancreatic/duodenal injuries). We considered only historical and physical examination variables with acceptable inter-rater reliability for possible inclusion into the rule. Results: We enrolled 12,044 patients with a mean age of 9.8 +/- 5.4 years; 5,179 (43%) underwent abdominal CT in the ED. of the 761 patients with IAIs, 203 (27%; 95% CI 24, 30%) had IAI undergoing acute intervention. The derived clinical prediction rule for IAI undergoing acute intervention consisted of: complaints of abdominal pain, history of vomiting, evidence of abdominal wall trauma (including seat belt sign), Glasgow Coma Scale score < 14, abdominal tenderness, evidence of thoracic wall trauma, and decreased breath sounds. The rule identified 197/203 (97%; 95% CI 95, 99%) patients with IAI undergoing acute intervention and had a negative predictive value of 5,028/5,034 (99.9%; 95% CI 99.8, 100%). Conclusion: We derived a clinical prediction rule consisting of simple clinical variables, which identifies almost all children with IAI undergoing acute intervention. Patients lacking these variables are at very low risk of IAI requiring therapeutic intervention. CT scanning is typically not warranted for these patients

Background: In NYC, pediatric pedestrians struck by motor vehicles account for thousands of visits to pediatric emergency departments. In 2007, approximately 60 children were killed due to this mechanism of injury. Currently, NY State collects retrospective information of admitted pediatric pedestrians injured. Objectives: Our goal is to collect comprehensive information prospectively of all children injured as a pedestrian or cyclist vs. motor vehicle. This novel project will allow better delineation of risk factors to target injury prevention. Methods: We have developed a prospective database of all pedestrians/cyclists injured or killed by motor vehicles from December 22, 2008 until present. A pediatric patient is defined as age < 18 years. Information regarding circumstances of incident, injury information, and hospital course were obtained from patient, guardian, emergency responders (paramedics, police, fire officers), and other sources (witnesses and medical record). Results: of 1000 patients, 116 (12%) were pediatric patients. The mean age was 11 years, with 40% of patients in the 6-12 age range. There was a male predominance. Eighty-five percent were pedestrians. One quarter of the cyclists were wearing a helmet. Fifty-two percent did not have adult supervision at the time of the incident. Five percent of incidents occurred within two blocks of school. Forty-two percent of patients were struck mid-block, 25% were darting out into the street, and two patients were boarding a bus. Eleven percent of patients were using an electronic device at time of injury. One patient reported cocaine and one patient was ethanol intoxicated. Twenty percent of patients had loss of consciousness and 6% had a GCS < 15 upon arrival. The injury severity score was greater than 10 in 9% of patients. Twenty-eight percent of patients were admitted. There were no mortalities. Conclusion: Pediatric pedestrians and cyclists struck by motor vehicles are a public health hazard. The majority of injuries are low acuity and result in few hospitalizations. Injury prevention strategies should focus on improving traffic safety knowledge and safety gear wearing in children. (Table Presented)

Agents of opportunity (AO) in academic medical centers (AMC) are defined as unregulated or lightly regulated substances used for medical research or patient care that can be used as 'dual purpose' substances by terrorists to inflict damage upon populations. Most of these agents are used routinely throughout AMC either during research or for general clinical practice. To date, the lack of careful regulations for AOs creates uncertain security conditions and increased malicious potential. Using a consensus-based approach, we collected information and opinions from staff working in an AMC and 4 AMC-affiliated hospitals concerning identification of AO, AO attributes, and AMC risk and preparedness, focusing on AO security and dissemination mechanisms and likely hospital response. The goal was to develop a risk profile and framework for AO in the institution. Agents of opportunity in 4 classes were identified and an AO profile was developed, comprising 16 attributes denoting information critical to preparedness for AO misuse. Agents of opportunity found in AMC present a unique and vital gap in public health preparedness. Findings of this project may provide a foundation for a discussion and consensus efforts to determine a nationally accepted risk profile framework for AO. This foundation may further lead to the implementation of appropriate regulatory policies to improve public health preparedness. Agents of opportunity modeling of dissemination properties should be developed to better predict AO risk

BACKGROUND: Agents of opportunity (AO) are potentially harmful biological, chemical, radiological, and pharmaceutical substances commonly used for health care delivery and research. AOs are present in all academic medical centers (AMC), creating vulnerability in the health care sector; AO attributes and dissemination methods likely predict risk; and AMCs are inadequately secured against a purposeful AO dissemination, with limited budgets and competing priorities. We explored health care workers' perceptions of AMC security and the impact of those perceptions on AO risk. METHODS: Qualitative methods (survey, interviews, and workshops) were used to collect opinions from staff working in a medical school and 4 AMC-affiliated hospitals concerning AOs and the risk to hospital infrastructure associated with their uncontrolled presence. Secondary to this goal, staff perception concerning security, or opinions about security behaviors of others, were extracted, analyzed, and grouped into themes. RESULTS: We provide a framework for depicting the interaction of staff behavior and access control engineering, including the tendency of staff to 'defeat' inconvenient access controls. In addition, 8 security themes emerged: staff security behavior is a significant source of AO risk; the wide range of opinions about 'open' front-door policies among AMC staff illustrates a disparity of perceptions about the need for security; interviewees expressed profound skepticism concerning the effectiveness of front-door access controls; an AO risk assessment requires reconsideration of the security levels historically assigned to areas such as the loading dock and central distribution sites, where many AOs are delivered and may remain unattended for substantial periods of time; researchers' view of AMC security is influenced by the ongoing debate within the scientific community about the wisdom of engaging in bioterrorism research; there was no agreement about which areas of the AMC should be subject to stronger access controls; security personnel play dual roles of security and customer service, creating the negative perception that neither role is done well; and budget was described as an important factor in explaining the state of security controls. CONCLUSIONS: We determined that AMCs seeking to reduce AO risk should assess their institutionally unique AO risks, understand staff security perceptions, and install access controls that are responsive to the staff's tendency to defeat them. The development of AO attribute fact sheets is desirable for AO risk assessment; new funding and administrative or legislative tools to improve AMC security are required; and security practices and methods that are convenient and effective should be engineered

OBJECTIVE:: To determine whether screening children in an urban pediatric emergency department (PED) would lead to identification of previously undiagnosed developmental delay. METHODS:: This was a cross-sectional study of families presenting to an urban public hospital PED with children 6 to 36 months and no history of developmental delay. Children were screened for possible developmental delay using the Ages and Stages Questionnaire; parents completed an instrument that assesses 5 domains: communication, gross motor, fine motor, problem solving, and personal-social. Sociodemographic data were also obtained. RESULTS:: One hundred thirty-eight children were enrolled, all accompanied by their mothers. Mean age of the children was 18.9 months; 51.5% were female; 56.8% of the mothers were high-school graduates; 59.9% were immigrants; 75.4% were Latino. Twenty-one percent did not have a regular source of primary care; 26.8% (95% confidence interval, 20.1%-34.8%) screened positive in at least 1 domain, with a trend toward the highest percentage of positive screens on the communication domain (z = 1.89, P = 0.059). In a simultaneous multiple logistic regression model including all predictor variables, child age of 12 to 30 months was associated with increased adjusted odds of positive screen (adjusted odds ratio, 8.4; 95% confidence interval, 1.4-48.9). Having a primary caregiver born in the United States was statistically significant for screening positive in at least 1 Ages and Stages Questionnaire domain (P = 0.03). CONCLUSIONS:: Almost 30% of 6- to 36-month-old children presenting to an urban PED without prior developmental concerns screened positive for possible delay, suggesting the utility of performing routine developmental screening in the PED. Pediatric emergency department use alone may be an indication for screening. Further study is needed for feasibility of screening for delay in the PED

Up to 3 million US children are cared for by emergency medical services (EMSs) annually. Limited research exists on pediatric prehospital care. The Pediatric Emergency Care Applied Research Network (PECARN) mission is to perform high-quality research for children, including prehospital research. Our objective was to develop a pediatric-specific prehospital research agenda. METHODS: Representatives from all 4 PECARN nodes and from EMS agency partners participated in a 3-step process. First, participants ranked potential research priorities and suggested others. Second, participants reranked the list in order of importance and scored each priority using a modified Hanlon method (prevalence, seriousness, and practicality of each research area were assessed). Finally, the revised priority list was presented at a PECARN EMS summit, and consensus was sought. RESULTS: Forty-two representatives participated, including PECARN representatives, EMS agency leaders, and nationally recognized prehospital researchers. Consensus was reached on the priority ranking. The prioritization processes resulted in 2 ranked lists: 15 clinical topics and 5 EMS system topics. The top 10 clinical priorities included (1) airway management, (2) respiratory distress, (3) trauma, (4) asthma, (5) head trauma, (6) shock, (7) pain, (8) seizures, (9) respiratory arrest, and (10) C-spine immobilization. The 5 EMS system topics identify methods to improve prehospital care on the system level. CONCLUSIONS: PECARN has identified high-priority EMS research topics for children using a consensus-derived method. These research priorities include novel EMS system topics. The PECARN EMS pediatric research priority list will help focus future pediatric prehospital research both within and outside the network

INTRODUCTION: Injury is a major cause of death and disability in children and young adults worldwide. X-rays are routinely performed to evaluate injuries with suspected fractures. However, the World Health Organisation estimates that up to 75% of the world population has no access to any diagnostic imaging services. Use of clinician-performed point-of-care ultrasound to diagnose fractures is not only feasible in traditional healthcare settings, but also in underserved or remote settings. Our objective was to determine the accuracy of clinician-performed point-of-care ultrasound for the diagnosis of fractures in children and young adults presenting to an acute care setting. METHODS: We conducted a prospective cohort study of patients aged <25 years that presented to emergency departments with injuries requiring X-rays or CT for suspected fracture. Paediatric emergency physicians with a 1h training session diagnosed fractures by point-of-care ultrasound. X-rays or CT were used as the reference standard to determine test performance characteristics. RESULTS: Point-of-care ultrasound was performed on 212 children and young adults with 348 suspected fractures. Forty-two percent of all bones imaged were non-long bones. The prevalence rate of fracture was 24%. Overall: sensitivity-73% (95% CI: 62-82%), specificity-92% (95% CI: 88-95%); long bones: sensitivity-73% (58-84%), specificity-92% (86-95%); non-long bones: sensitivity-77% (58-90%); specificity-93% (87-97%); age> or =18 years: sensitivity-60% (39-78%), specificity-92% (87-96%); age<18: sensitivity-78 (65-87%), specificity-93% (87-95)%. Majority of errors in diagnosis (>85%) occurred at the ends-of-bones. CONCLUSIONS: Clinicians with focused ultrasound training were able to diagnose fractures using point-of-care ultrasound with a high specificity rate. Specificity rates to rule-in fracture were similar for non-long bone and long bone fractures, as well as in skeletally mature young adults and children with open growth plates. Clinician-performed point-of-care ultrasound accuracy was highest at the diaphyses of long bones, while most diagnostic errors were committed at the ends-of-bones or near joints. Point-of-care ultrasound may serve as a rapid alternative means to diagnose midshaft fractures in settings with limited or no access to X-ray