INTRODUCTION:Pediatric sepsis is a leading cause of death among children. Electronic alert systems may improve early recognition but do not consistently result in timely interventions given the multitude of clinical presentations, lack of treatment consensus, standardized order sets, and inadequate interdisciplinary team-based communication. We conducted a quality improvement project to improve timely critical treatment of patients at risk for infection-related decompensation (IRD) through team-based communication and standardized treatment workflow.METHODS:We evaluated children at risk for IRD as evidenced by the activation of an electronic alert system (Children at High Risk Alert Tool [CAHR-AT]) in the emergency department. Outcomes were assessed after multiple improvements including CAHR-AT implementation, clinical coassessment, visual cues for situational awareness, huddles, and standardized order sets.RESULTS:With visual cue activation, initial huddle compliance increased from 7.8% to 65.3% ( p < .001). Children receiving antibiotics by 3 hours postactivation increased from 37.9% pre-CAHR-AT to 50.7% posthuddle implementation ( p < .0001); patients who received a fluid bolus by 3 hours post-CAHR activation increased from 49.0% to 55.2% ( p = .001).CONCLUSIONS:Implementing a well-validated electronic alert tool did not improve quality measures of timely treatment for high-risk patients until combined with team-based communication, standardized reassessment, and treatment workflow.

We describe three previously healthy children, admitted from our emergency department (ED) to our free-standing children's hospital, as the first documented cases of croup as a manifestation of SARS-CoV-2 infection. All three cases (ages 11 months, 2 years, and 9 years old) presented with non-specific upper-respiratory-tract symptoms that developed into a barky cough with associated stridor at rest and respiratory distress. All were diagnosed with SARS-CoV-2 by polymerase chain reaction testing from nasopharyngeal samples that were negative for all other pathogens including the most common etiologies for croup. Each received multiple (≥3) doses of nebulized racemic epinephrine with minimal to no improvement shortly after medication. All had a prolonged period of time from ED presentation until the resolution of their stridor at rest (13, 19, and 21 h). All received dexamethasone early in their ED treatment and all were admitted. All three received at least one additional dose of dexamethasone, an atypical treatment occurrence in our hospital, due to each patient's prolonged duration of symptoms. One child required heliox therapy and admission to intensive care. All patients were eventually discharged. Pathogen testing is usually not indicated in croup, but with “COVID-19 croup,” SARS-CoV-2 testing should be considered given the prognostic significance and prolonged quarantine implications. Our limited experience with this newly described COVID-19 croup condition suggests that cases can present with significant pathology and might not improve as rapidly as those with typical croup.

Background Missing signs of early sepsis can result in delayed diagnosis and treatment, complications, and death. We have introduced a pediatric ED assessment tool to improve recognition of sepsis in critically-ill children, team critical thinking, and patient outcomes. Delayed recognition and poor nurse-provider communication were identified as common challenges in timely treatment of children at high risk for infection-related etiologies. Objectives This stand-alone urban children’s hospital ED aims to improve team-based care, situational awareness, and patient outcomes …

Objectives: Frequently, infants and children require sedation to facilitate noninvasive procedures and imaging studies. Propofol and dexmedetomidine are used to achieve deep procedural sedation in children. The objective of this study was to compare the clinical safety and efficacy of propofol versus dexmedetomidine in pediatric patients undergoing sedation in a pediatric sedation unit. Methods: Aretrospective analysis of patients sedated with either propofol or dexmedetomidine in a pediatric sedation unit by pediatric emergency physicians was performed. Both medications were dosed per protocol with propofol 2 mg/kg induction and 150 mu g center dot kg(-1) center dot min(-1) maintenance and dexmedetomidine 3 mu g/kg induction for 10 minutes and 2 mu g center dot kg(-1) center dot h(-1)maintenance. The variables collected included drug dose, sedation time (time that the drug was given to the completion of the procedure), recovery time (end of the study to the return to the presedation sedation score for 15 minutes), need for dose rate changes, airway management, and adverse events. Results: A total of 2432 children were included-1503 who received propofol and 929 who received dexmedetomidine. Propofol and dexmedetomidine resulted in successful completion of the study in 98.8% and 99.7%, respectively (P = 0.02). The mean recovery time for propofol was 34.3 minutes, compared with 65.6 minutes for dexmedetomidine (P < 0.001). The need for unexpected airway management was 9.7% for propofol and 2.2% for dexmedetomidine (P < 0.001). Adverse events occurred in 8.6% and 6% of patients in the propofol and dexmedetomidine groups, respectively (P = 0.02). Conclusions: Propofol use led to significantly shorter recovery times, with an increased need for airway management, but rates of bag-mask ventilation (2.3%), airway obstruction (1.1%), and desaturation (1.6%) were low. No patients required intubation. Propofol is a reasonable alternative to dexmedetomidine, with a clinically acceptable safety profile.

OBJECTIVES The purpose of this study was to determine the prevalence, clinical signs and radiological features of breast lymphoma. METHODS This is a retrospective review of 36 patients with breast lymphoma (22 primary and 14 secondary). 35 patients were female and 1 was male; their median age was 65 years (range 24-88 years). In all patients, the diagnosis was confirmed histopathologically. RESULTS The prevalence of breast lymphoma was 1.6% of all identified cases with non-Hodgkin lymphoma and 0.5% of cases with breast cancer. B-cell lymphoma was found in 94% and T-cell lymphoma in 6%. 96 lesions were identified (2.7 per patient). The mean size was 15.8 ± 8.3 mm. The number of intramammary lesions was higher in secondary than in primary lymphoma. The size of the identified intramammary lesions was larger in primary than in secondary lymphoma. Clinically, 86% of the patients presented with solitary or multiple breast lumps. In 14%, breast involvement was diagnosed incidentally during staging examinations. CONCLUSION On mammography, intramammary masses were the most commonly seen (27 patients, 82%). Architectural distortion occurred in three patients (9%). In three patients (9%), no abnormalities were found on mammography. On ultrasound, the identified lesions were homogeneously hypoechoic or heterogeneously mixed hypo- to hyperechoic. On MRI, the morphology of the lesions was variable. After intravenous administration of contrast medium, a marked inhomogeneous contrast enhancement was seen in most cases. On CT, most lesions presented as circumscribed round or oval masses with moderate or high enhancement.

Ziele: Die Häufigkeit von intramuskulären Metastasen (IM) anhand eines großen onkologischen Patientenkollektivs zu beurteilen und ihre radiologischen Zeichen von zu identifizieren. Methode: Retrospektive Suche in der statistischen Datenbank der Martin-Luther-Universität vom Januar 2000 bis zum Dezember 2007 ergab 5.170 Patienten mit metastasierenden soliden Tumoren, die an unserer Einrichtung untersucht und behandelt wurden. Außerdem durchsuchten wir retrospektiv die radiologische Datenbank nach Muskelbefall bei onkologischen Erkrankungen. Ein Staging-CT war bei all diesen Patienten vorhanden und die CT-Bilder jedes Patienten wurden erneut analysiert. IM wurden in 61 (1,2%) Fällen diagnostiziert, darunter 27 Frauen und 34Männer mit einem medianen Alter von 65 Jahren. Ergebnis: 80 Metastasen wurden in den Skelettmuskeln von diesen 61 onkologischen Patienten gefunden. Die Skelettmuskelmetastasen stammten von folgenden malignen Tumoren: genitale Tumoren (24,6%), gastrointestinale Tumoren (21,3%), urologische Tumoren (16,4%) und malignes Melanom (13,1%). Andere Neoplasien waren selten. In 8,2% der Fälle konnte kein Primärtumor identifiziert werden.

This study was conducted to determine the baseline fund of knowledge of pediatric and emergency medicine residents at a single institution in the medical management of pediatric victims of biologic and chemical terrorism. A test covering essential content was developed and validated by experts. The test was given anonymously to volunteer pediatric and emergency medicine residents at a single institution. The test was readministered 5 months after a lecture on the content. The 34 pediatric residents and 15 emergency medicine residents scored a median of 65% and 73%, respectively (P = .03). Residents from both specialties combined scored a median of 70% correct versus those residents who did not attend the lecture. Pediatric and emergency medicine residents are significantly unprepared to manage pediatric victims of biologic and chemical terrorism. Education curriculums on this topic must be incorporated into these residencies. The traditional lecture format may not be the most effective technique.

Purpose Biological and chemical terrorism is a legitimate threat to children in the United States, and it is incumbent upon both pediatricians and emergency medicine physicians to be knowledgeable in this area. The AAP has recently recommended the integration of biological and chemical terrorism education into residency curricula. Currently, the extent of such education in emergency medicine and pediatric residencies is program dependent. The objectives of this study include developing a tool for assessing residents9 knowledge on essential aspects of evaluating and treating pediatric victims of biological and chemical terrorism, comparing the baseline fund of knowledge of pediatric and emergency medicine residents at a single institution, and assessing the effect of an educational intervention. Methods Using information from the Centers for Disease Control (CDC) and Department of Defense (DOD), a written, validated, multiple-choice test was created to evaluate knowledge of identification, isolation, and treatment of pediatric victims of biological and chemical terrorism. The examination covered all agents on the CDC “A” list of bioterror agents, as well as chemical agents highlighted by the DOD. The test was then administered to pediatric and emergency medicine residents prior to any formal educational on terrorism in either residency9s curriculum (“pretest”). A 1-hour lecture covering all essential material was delivered to all available residents. The identical written test was administered 5 months after the lectures (“post-test”) to all available residents, including those who had been unavailable for the lecture. Results Thirty-four pediatric and 16 emergency medicine residents took the pretest. Pediatric residents scored a median of 65% correct and emergency medicine residents scored a median of 70% correct (p = .03). Twenty-five pediatric and 10 emergency medicine residents took the post-test. Residents who took both tests and attended the lecture improved from a pretest median score of 66% correct to a post-test median score of 70% (p = .11). Conclusions This pilot study suggests that emergency medicine residents may demonstrate a higher baseline fund of knowledge as to the identification, treatment, and isolation requirements of pediatric biological and chemical terrorism patients than do pediatric residents. Pediatric residents may be in particular need of education on these topics. It is unclear whether traditional lecture-based education will be effective in producing lasting gains in knowledge or if more rigorous educational interventions are required.

Purpose of review A new Fab fragment antivenom (CroFab) for the treatment of crotaline envenomation, the predominant venomous snakebite in the United States, has drastically changed snakebite management since its release in December 2000. This review examines the evidence supporting the use of CroFab, with particular attention on the pediatric population. Recent findings The published experience with CroFab in humans consists of six studies and some case reports. These publications demonstrate that CroFab is highly efficacious in treating both the local and systemic toxic effects of crotaline envenomation. They identify an important phenomenon of recurrent or delayed toxicity in some patients. The studies report a very low incidence of acute or delayed hypersensitivity reactions to the antivenom. They suggest comparable efficacy and safety of CroFab in the pediatric population as in adults. Summary Based on limited data, CroFab has been shown to be a safe and efficacious antivenom for use in children as well as adults. Further studies are needed to refine our understanding of its efficacy, safety, indications, and dosing.

Background: Idiopathic intussusception is a leading cause of intestinal obstruction in young children. Although the etiology remains obscure, lymphoid hyperplasia is found in a majority of cases. Antibiotics, the most frequently prescribed medication class in the pediatric population, have been recently associated with intussusception. The authors sought to determine whether enteral antibiotic exposure influences the development of mesenteric adenopathy, bowel dilation or intussusception in an animal model. Materials and Methods: The authors conducted a randomized, controlled animal trial using a previously described intussusception model. Mice were gavaged with normal saline, amoxicillin-clavulanate or azithromycin twice daily for 5 days to assess the influence of enteral antibiotic exposure on intussusception, mesenteric adenopathy and bowel dilation. One pediatric surgeon performed all laparotomies and was blinded to group designation. χ2 and Fisher exact tests were used to evaluate differences between antibiotic exposed and control groups. Results: Mesenteric adenopathy was identified in 4.1% of the normal saline controls compared with 54.1% (P < 0.01) and 38.9% (P < 0.01) of the amoxicillin-clavulanate and azithromycin exposed animals, respectively. A total of four intussusceptions were observed in the antibiotic-exposed groups combined whereas no intussusception cases were identified in the control group (P = 0.30). Conclusions: This is the first study to describe a significant association between antibiotic use and mesenteric adenopathy in any animal species.

During perinatal development, avian and mammalian skeletal muscles express a novel set of troponin T (TnT) isoforms with higher M(r)s and more acidic pIs than their adult counterparts. In mammals, these TnTs result from the incorporation of a developmentally regulated 5'-fetal exon into fast TnT mRNAs. To determine whether chicken perinatal TnTs are generated by a similar mechanism, we sequenced 40 chicken TnT 5'-cDNAs from perinatal and adult pectoralis. Evidence for five 5'-exons not present in the mammalian gene was found, including one, y, whose splicing is developmentally regulated. Although none of these new exons are homologous with the mammalian fetal exon, their alternative splicing, superimposed on three conserved splicing patterns of the phylogenetically shared 5'-exons, generates the chicken perinatal TnT isoforms. These observations indicate that chicken, and most likely other avian species, evolved an independent 5'-alternative splicing mechanism to generate perinatal TnTs that have the same biophysical, and presumably functional, properties as their mammalian homologs.

A developmentally regulated exon has been identified in the 5'-alternatively spliced region of the human fast Troponin T (TnT) gene. Expressed in fetal (but not adult) muscle, this exon is homologous with the fetal exons recently described in the rabbit and rat fast TnT genes. They all exhibit a split codon organization and encode a highly acidic peptide. To determine if the splicing pathways, including the human fetal exon, are also conserved, we defined the major TnT splicing patterns in fetal muscle. They generate fetal TnT 1, fetal TnT 3, and TnT1f, and TnT3f, species previously described in rabbit and rat skeletal muscles.