Viral infections and seasonality are linked with trends in new pediatric leukemia and lymphoma cases. The COVID-19 pandemic disrupted this norm, and subsequently the international medical community observed a decrease in new diagnoses of hematologic cancers in children. However, this was not the trend observed at Cohen Children’s Medical Center where, despite examining fifteen months during the COVID-19 pandemic, we did not see a statistically significant decrease in monthly cases. Rather, cases remained constant as compared to pre-COVID-19 periods. This warrants further study at a multi-institutional level to investigate the association between COVID-19 and rates of pediatric leukemia and lymphoma.

BACKGROUND: Diagnostic guidelines for pediatric ARDS (PARDS) were developed at the 2015 Pediatric Acute Lung Injury Consensus Conference (PALICC). Although this was an improvement in creating pediatric-specific diagnostic criteria, there remains potential for variability in identification of PARDS.RESEARCH QUESTION: What is the interrater reliability of the 2015 PALICC criteria for diagnosing moderate to severe PARDS? What clinical criteria and patient factors are associated with diagnostic disagreements?STUDY DESIGN AND METHODS: Patients with acute hypoxic respiratory failure admitted from 2016 to 2021 who received invasive mechanical ventilation were retrospectively reviewed by two pediatric ICU physicians. Reviewers evaluated whether the patient met the 2015 PALICC definition of moderate to severe PARDS and rated their diagnostic confidence. Interrater reliability was measured using Gwet's agreement coefficient.RESULTS: Thirty-seven of 191 encounters had a diagnostic disagreement. Interrater reliability was substantial (Gwet's agreement coefficient, 0.74; 95% CI, 0.65-0.83). Disagreements were caused by different interpretations of chest radiographs (56.8%), ambiguity in origin of pulmonary edema (37.8%), or lack of clarity if patient's current condition was significantly different from baseline (27.0%). Disagreement was more likely in patients who were chronically ventilated (OR, 4.66; 95% CI, 2.16-10.08; P < .001), had a primary cardiac admission diagnosis (OR, 3.36; 95% CI, 1.18-9.53; P = .02), or underwent cardiothoracic surgery during the admission (OR, 4.90; 95% CI, 1.60-15.00; P = .005). Reviewers were at least moderately confident in their decision 73% of the time; however, they were less likely to be confident if the patient had cardiac disease or chronic respiratory failure.INTERPRETATION: The interrater reliability of the 2015 PALICC criteria for diagnosing moderate to severe PARDS in this cohort was substantial, with diagnostic disagreements commonly caused by differences in chest radiograph interpretations. Patients with cardiac disease or chronic respiratory failure were more vulnerable to diagnostic disagreements. More guidance is needed on interpreting chest radiographs and diagnosing PARDS in these subgroups.

IntroductionTo assess the prevalence of hyponatremia among pediatric patients with coronavirus disease 2019 (COVID-19) and Multisystem Inflammatory Syndrome in Children (MIS-C) and determine if pediatric hyponatremia was associated with an increased length of stay, higher rates of mechanical ventilation, and/or elevated inflammatory markers on admission as compared to eunatremic patients.MethodsElectronic health records were retrospectively analyzed for 168 children less than 18 years old with COVID-19 or MIS-C who were admitted to pediatric units within the Northwell Health system. The primary exposure was hyponatremic status (serum sodium <135 mEq/L) and the primary outcomes were length of stay, mechanical ventilation usage and increased inflammatory markers.ResultsOf the 168 children in the study cohort, 95 (56%) were admitted for COVID-19 and 73 (43.5%) for MIS-C. Overall, 60 (35.7%) patients presented with hyponatremia on admission. Patients with hyponatremia had higher rates of intensive care unit admission when compared to eunatremic patients (32/60 [53.3%] vs. 39/108 [36.1%], p = 0.030). In regression models, hyponatremia was not significantly associated with increased length of stay or mechanical ventilation rates. After adjustment for relevant confounders, hyponatremia remained associated with an increased square root CRP (β = 1.79: 95% CI: 0.22–3.36) and lower albumin levels (β = −0.22: 95% CI: −0.42–−0.01).ConclusionHyponatremia is common in pediatric COVID-19 and MIS-C. Hyponatremia was associated with a lower albumin and higher square root CRP levels. This may suggest an association of inflammation with lower serum sodium levels.

Introduction: The current guidelines for diagnosing pediatric acute respiratory distress syndrome (PARDS) were developed at the Pediatric Acute Lung Injury Consensus Conference (PALICC) in 2015, however there remains potential for variability in provider identification of PARDS. In this study we examined the inter-rater reliability of the PALICC criteria for diagnosing PARDS and investigated the patient factors and clinical criteria that led to diagnostic disagreements. Methods: Patients with acute respiratory failure admitted to our PICU from 2016-2021 who received invasive mechanical ventilation for >48 hours and had an oxygen saturation index >/=7.5 for 24 hours (moderate to severe PARDS) were retrospectively reviewed by two pediatric critical care physicians. Clinicians evaluated whether the patient met PARDS criteria based on the PALICC definition and rated their diagnostic confidence. Inter-rater reliability was measured using Gwet’s Agreement Coefficient (AC1). Results: Of the 191 encounters, 145 met PARDS criteria by both reviewers, 9 by neither, and there were 37 diagnostic disagreements. Inter-rater reliability was “substantial” (AC1 = 0.74 [0.65 – 0.83]). Cardiothoracic surgery patients (OR 4.9, p=0.005) and children with tracheostomies (OR 3.5, p=0.001) were more likely to have diagnostic disagreements. Disagreements were due to different interpretations of qualifying chest x-ray (CXR) findings 56.8% of the time, origin of edema 37.8%, and whether the condition was significantly different from the patient’s baseline 27.0%. Reviewers rated their confidence level as very confident 73% of the time, but were less likely to be confident if the patient had a tracheostomy compared to those without (60.8% vs 77.5%, p = 0.001). Conclusions: The inter-rater reliability of the PALICC criteria for diagnosing moderate to severe PARDS in this retrospective cohort was substantial, with diagnostic disagreements commonly due to differences in CXR interpretations. However, patients who underwent cardiothoracic surgery and those with tracheostomies were more vulnerable to diagnostic disagreements. More guidance is needed on diagnosing PARDS in these subgroups and on interpreting CXRs in order to more reliably identify these patients, as well as to better study how treatment interventions may impact outcomes.

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Objective: To assess the impact of the coronavirus-2019 (COVID-19) pandemic on pediatric critical care medicine (PCCM) fellowship training through a cross-sectional survey of both program directors (PDs) and fellows. Design: Cross-sectional internet-based survey. Setting: Accreditation Council for Graduate Medical Education (ACGME)-accredited PCCM fellowship programs in the United States. Subjects: PCCM PDs and fellows. Results: A total of 34 PDs and 92 fellows responded to the national survey (rate of 47% and 17%, respectively). The majority (69%) of respondents agreed that medical education has been negatively impacted by the COVID-19 pandemic. When PDs were surveyed, 91% noted a significant decrease in the patient census since March 2020, with 59% citing a >15% decrease. Further, 65% reported trainees had less procedural experience. All respondents reported that education was at least in part provided through virtual learning platforms, with nearly half having exclusive remote learning without in-person sessions. Fifty percent of PDs and 62% of fellows reported decreased learner engagement during virtual didactics when compared to in-person education. The majority of PDs reported specific decreases in simulation, procedural skills training, and ultrasound training. Few PDs (15%) and fellows (13-16%) reported redeployment to adult patient care, with northeastern programs having the highest rates. In univariate analyses, decreased PDs confidence in trainee procedural skills was associated with reported decreases in number of procedures performed (P = .0006) and number of procedural skills didactic sessions (P = .0245). Change in the unit census was associated with less PDs confidence in fellows' medical knowledge (P = .0004), fellows' management skills (P = .0232), and fellows' procedural skills (P = .0003), with larger decreases in patient census correlating with larger decreases in confidence. Conclusions: The COVID-19 pandemic has significantly impacted the education and clinical training of PCCM fellows. More knowledge on this topic can assist PDs in curriculum changes for the future to address any gaps in learning that have occurred.

1Cohen Children’s Medical Center, New Hyde Park, NY 2Cohen Children’s Medical Center 3Cohen Children’s Hospital, New Hyde Park, NY

The majority of PDs reported decreases in simulation, procedural skills training, and ultrasound training. B Introduction: b The COVID-19 pandemic has had a significant impact on medical education. In univariate analyses, decreased PD confidence in trainee procedural skills was associated with reported decreases in number of procedures (p=0.0006) and procedural skills didactics (p=0.0245). [Extracted from the article] Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Journal of Hospital MedicineVolume 15, Issue 12 p. 763-764 Perspectives in Hospital Medicine Deployed: Pediatric Residents Caring for Adults During COVID-19's First Wave in New York City Danna Biala MD, MS, RD, MBA, Danna Biala MD, MS, RD, MBA Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New YorkSearch for more papers by this authorElana J Siegel MD, Elana J Siegel MD Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York Now with the Departments of Emergency Medicine and Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New YorkSearch for more papers by this authorLayne Silver MD, Layne Silver MD Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York Now with Pediatric Critical Care Medicine, Steven and Alexandra Cohen Children's Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New YorkSearch for more papers by this authorBenjamin Schindel MD, MPH, Benjamin Schindel MD, MPH Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York Now with Neurodevelopmental Disabilities, Kennedy Krieger Institute and Johns Hopkins School of Medicine, Baltimore, MarylandSearch for more papers by this authorKelly M Smith MD, Corresponding Author Kelly M Smith MD [email protected] Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York Now with General Pediatrics, Kaiser Permanente Napa-Solano, Vallejo, CaliforniaCorresponding Author: Kelly M Smith, MD; Email: [email protected]; Telephone: 707-651-3392; Twitter: @mountsinaipeds.Search for more papers by this author Danna Biala MD, MS, RD, MBA, Danna Biala MD, MS, RD, MBA Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New YorkSearch for more papers by this authorElana J Siegel MD, Elana J Siegel MD Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York Now with the Departments of Emergency Medicine and Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New YorkSearch for more papers by this authorLayne Silver MD, Layne Silver MD Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York Now with Pediatric Critical Care Medicine, Steven and Alexandra Cohen Children's Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New YorkSearch for more papers by this authorBenjamin Schindel MD, MPH, Benjamin Schindel MD, MPH Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York Now with Neurodevelopmental Disabilities, Kennedy Krieger Institute and Johns Hopkins School of Medicine, Baltimore, MarylandSearch for more papers by this authorKelly M Smith MD, Corresponding Author Kelly M Smith MD [email protected] Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York Now with General Pediatrics, Kaiser Permanente Napa-Solano, Vallejo, CaliforniaCorresponding Author: Kelly M Smith, MD; Email: [email protected]; Telephone: 707-651-3392; Twitter: @mountsinaipeds.Search for more papers by this author First published: 18 November 2020 https://doi.org/10.12788/jhm.3527Citations: 9Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. References 1Lasagna L. Hippocratic oath—modern version. Published 1964. Accessed September 14, 2020. http://www.pbs.org/wgbh/nova/doctors/oath_modern.html Google Scholar 2Cram P, Anderson ML, Shaughnessy EE. All hands on deck: learning to "un-specialize" in the COVID-19 pandemic. J Hosp Med. 2020; 15(5): 314–315. https://doi.org/10.12788/jhm.3426 10.12788/jhm.3426 PubMedWeb of Science®Google Scholar 3Cunningham CO, Diaz C, Slawek DE. COVID-19: the worst days of our careers. Ann Intern Med. 2020; 172(11): 764–765. https://doi.org/10.7326/M20-1715 10.7326/M20?1715 PubMedWeb of Science®Google Scholar 4Gallagher TH, Schleyer AM. "We signed up for this!"—student and trainee responses to the COVID-19 pandemic. N Engl J Med. 2020; 382(25):e96. https://doi.org/10.1056/NEJMp2005234 10.1056/NEJMp2005234 CASPubMedWeb of Science®Google Scholar Citing Literature Volume15, Issue12December 2020Pages 763-764 ReferencesRelatedInformation