BACKGROUND:Whether treatment with balanced crystalloid fluid leads to better outcomes than 0.9% saline in children treated for septic shock is debated. METHODS:In this pragmatic clinical trial conducted at 47 emergency departments in five countries, patients (2 months to <18 years of age) with suspected septic shock and abnormal perfusion were randomly assigned to receive fluid resuscitation with either balanced fluid or 0.9% saline for up to 48 hours. The primary outcome was a major adverse kidney event (a composite of death, new renal-replacement therapy, or persistent kidney dysfunction) at 30 days after enrollment or hospital discharge, whichever occurred first. RESULTS:Of 9041 enrolled patients, 277 (6.1%) in the balanced-fluid group and 282 (6.2%) in the 0.9%-saline group withdrew from the trial, leaving 4235 and 4247 patients, respectively, for analysis. A primary-outcome event occurred in 137 patients (3.4%) in the balanced-fluid group and in 124 (3.0%) in the 0.9%-saline group (difference, 0.4 percentage points; 95% confidence interval [CI], -0.5 to 1.3; risk ratio, 1.10; 95% CI, 0.88 to 1.40; P = 0.85). The median number of hospital-free days during 28 days after enrollment was 23 (interquartile range, 19 to 25) in both groups. Hyperchloremia occurred in 868 patients (31.4%) in the balanced-fluid group and in 1383 (49.0%) in the 0.9%-saline group; hypernatremia in 52 (1.8%) and 89 (3.1%), respectively; and hyperlactatemia in 260 (19.8%) and 228 (16.7%). No differences in other safety outcomes or adverse events were seen. CONCLUSIONS:Among children treated for septic shock, no significant difference was seen in the incidence of death, new renal-replacement therapy, or persistent kidney dysfunction when fluid resuscitation was administered with balanced fluid as compared with 0.9% saline. (Funded by Eunice Kennedy Shriver National Institute of Child Health and Human Development and others; PRoMPT BOLUS ClinicalTrials.gov number, NCT04102371.).

Objectives: To determine if end-tidal carbon dioxide (ETCO2) is associated with chest compression (CC) quality in pediatric patients presenting with out-of-hospital cardiac arrest (OHCA). Methods: We conducted a retrospective, observational, video review-based study in a pediatric emergency department. Children <18 years with OHCA from March 2021 to August 2022 were included. We collected ETCO2 values every 5 seconds via video review and CC data from an audiovisual defibrillator (Zoll R Series). CC data were evaluated in 1-minute epochs for compliance with American Heart Association (AHA) high-quality compression metrics for rate, depth, and CC fraction and categorized as low, marginal, adequate, or optimal. ETCO2 was averaged over each minute, aligned with CC epochs, and analyzed using a linear mixed model. Results: Fifty patients presented with OHCA, and 30 were included yielding 380 total epochs. Compression quality was low in 35 epochs, marginal in 196 epochs, adequate in 139 epochs, and optimal in 10 epochs. There was no significant association between ETCO2 and CC quality when comparing epoch categories. ETCO2 had a weak positive correlation with target compression rate (r = 0.113, 95% CI [0.011, 0.213]) but no significant correlation with target depth (r = -0.102, 95% CI [-0.202, 0.000]) or chest compression fraction (CCF) (r = 0.055, 95% [-0.046, 0.155]). Conclusion: In our small, single-center study, we found ETCO2 was minimally associated with compression rate but not depth or CCF and overall may be of limited utility in evaluating CC quality in pediatric OHCA. Our study was limited by the lack of optimal CC quality and unknown downtime.

Background:Clinicians caring for children in emergency departments have variable pediatric training. This study aimed to identify practicing emergency clinicians' perceptions on pediatric topic prioritization, information seeking behaviors, and preferred learning modalities. Methods:A survey was iteratively developed by experts in general and pediatric emergency medicine utilizing survey science best practices. The final survey contained sections on demographics, pediatric topic prioritization, information seeking behaviors, and preferred learning modalities. The survey was disseminated via publication as a link on the WikEM website, the WikEM application, and via e-mails to registered WikEM users. Results:Five-hundred and forty-two surveys were completed by 397 attending physicians (APs) and 145 advanced practice providers (APPs). The top three priority topics among APs were neonatal emergencies, airway and respiratory emergencies, and pediatric-specific procedures, and among APPs were abdominal emergencies, airway and respiratory emergencies, and bronchiolitis. Both APs and APPs indicated that they currently receive most of their pediatric information through online medical resources and communication with colleagues. The least used methods included webinars, social media, courses, and academic journals. APs preferred education modalities included clinical evidence-based pathways, podcasts, and websites/blogs. APPs preferences were clinical evidence-based pathways, podcasts, and online didactic experiences. Both APs and APPs reported that insufficient time and not knowing where to find resources were the largest barriers to pediatric education. Conclusions:Attending physicians and advanced practice emergency providers identified airway and respiratory emergencies as priority topics. Information was most often accessed using online resources and through discussions with colleagues. Evidence-based pathways and podcasts were identified as the preferred modality. These data can inform priority topics for content development and best practices for dissemination of content to practicing clinicians.

OBJECTIVE:Severe acute kidney injury (AKI) portends poor outcomes in pediatric sepsis. We evaluated the trajectory and prognostic utility of AKI biomarkers in pediatric septic shock using a subset of participants in the ongoing Pragmatic Pediatric Trial of Balanced vs. Normal Saline Fluid in Sepsis (PRoMPT BOLUS) trial, NCT04102371. We tested whether fluid volume is associated with persistent elevation of urine neutrophil gelatinase-associated lipocalin (Ur-NGAL). DESIGN:Prospective, non-prespecified cohort study within the PRoMPT BOLUS trial. SETTING:Three children's hospitals in the United States. PATIENTS:Four hundred seventy-eight patients aged 2 months to younger than 18 years old with septic shock. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:Ur-NGAL, kidney injury molecule-1, liver fatty acid binding protein, and interleukin-18 and plasma cystatin C were collected at presentation (T1), days 2-3 (T2), and before discharge/death (T3). At presentation, 418 (88%) had no or only stage 1 AKI and 60 (12%) had stage 2/3 AKI defined using Kidney Disease Improving Global Outcomes creatinine thresholds. All biomarkers were higher with stage 2/3 compared with no/stage 1 AKI at T1 and T2, but only cystatin C remained higher at T3. Among patients with no/stage 1 AKI at presentation, those with Ur-NGAL greater than or equal to 150 vs. less than 150 ng/mL had fewer hospital-free days (21 [interquartile range (IQR) 15-24] vs. 23 d [IQR 19-25], p = 0.05). After applying inverse probability treatment weighting to balance covariates, 14% of patients who received greater than 100 mL/kg within 48 hours had persistently elevated Ur-NGAL over time compared with 6% who received 40-100 mL/kg (odds ratio 2.7 [95% CI, 1.1-6.2]). Hospital-free days were no different across fluid volume groups. CONCLUSIONS:Although kidney injury biomarkers mirrored serum creatinine in children with septic shock, elevated Ur-NGAL identified a subset with subclinical AKI with fewer hospital-free days despite no/stage 1 AKI by creatinine. Children receiving greater than 100 mL/kg fluid had greater odds of early and persistently elevated Ur-NGAL, suggesting high fluid volumes may perpetuate initial kidney damage.

Objectives:Uncontrolled hemorrhage is the most preventable cause of death following traumatic injury; children may be called to act as bystanders when hemorrhage control is necessary. The earliest age that children can learn hemorrhage control remains undetermined. We aimed to identify whether children aged 8 to 12 years can identify when and how to use a combat application tourniquet (CAT) and can appropriately place and tighten it to achieve hemorrhage control. Methods:We conducted a prospective study of children aged 8 to 12 years old. A trained facilitator taught hemorrhage control and CAT placement on manikins in small group sessions. After each session, we assessed the comprehension and application skills of each participant using a standardized 4-question tool. If at least 60% of children within each age group correctly performed both comprehension (cognitive) and skills (psychomotor) assessments, the group was considered successful. We compared success rates between age groups and analyzed the association between performance and participant age, sex, and body mass index (BMI). Results:Of 326 eligible children, 322 completed the training and assessment (99%). Overall, 70% (225/322) of participants completed all 4 assessment questions correctly, 88% (284/322) of participants were able to answer both comprehension (cognitive) questions correctly, and 76% (246/322) of participants were able to accurately demonstrate both CAT placement skills (psychomotor) correctly. All age groups exceeded the 60% success rate in both assessments. Age, sex, and BMI were not significantly associated with assessment performance. Conclusion:Children as young as 8 years old can successfully learn hemorrhage control techniques and combat application tourniquet application, suggesting this training can begin as early as third grade.

BACKGROUND:Risk stratification tools for paediatric community-acquired pneumonia (CAP) in well-resourced settings are scarce. We prospectively developed models to predict CAP severity within a multinational cohort of paediatric emergency departments (EDs). Our primary objective was to develop a risk prediction model to discriminate between mild CAP and moderate or severe CAP to assist clinicians in determining the need for hospitalisation. METHODS:This prospective cohort study was conducted from Feb 6, 2019, to June 30, 2021, at 73 EDs in 14 countries. Children aged 3 months to <14 years with clinical diagnoses of CAP were included. Children were excluded if they were recently hospitalised or had a chronic complex condition (eg, immunodeficiency). The primary outcome was severity, defined as mild (CAP treated in the outpatient setting or hospitalisation <24 h with no use of oxygen or intravenous fluids during that time), moderate (hospitalisation <24 h with oxygen or fluids, or hospitalisation ≥24 h regardless of interventions but without an outcome qualifying as severe CAP), or severe (chest drainage, intensive care unit admission >24 h, positive-pressure ventilation, septic shock, vasoactive infusions, extracorporeal membrane oxygenation, or death) occurring within 7 days of the ED visit. Models were developed using logistic regression with bootstrap validation. FINDINGS:Of 2222 children in the overall study population (1103 [49·7%] female, 1119 [50·3%] male; median age 3 years [IQR 1-5]), 1290 (58·1%) had mild CAP, 812 (36·5%) moderate, and 120 (5·4%) severe. Primary analyses were performed in 1901 patients with complete data: 1011 (53·2%) mild, 772 (40·6%) moderate, and 118 (6·2%) severe CAP. Congestion or rhinorrhoea was negatively associated with moderate or severe CAP (adjusted odds ratio 0·59 [95% CI 0·46-0·76]), while abdominal pain (1·52 [1·17-1·97]), refusal to drink (1·57 [1·24-2·00]), antibiotics before ED visit (1·64 [1·29-2·10]), chest retractions (2·86 [2·24-3·65]), respiratory rate above the 95th percentile for age (1·63 [1·29-2·06]), heart rate above the 95th percentile for age (1·64 [1·27-2·12]), and hypoxaemia (oxygen saturation 90-92%, 3·24 [2·46-4·27]; <90%, 13·39 [8·64-20·73]) were positively associated. The model accurately discriminated between mild CAP and moderate or severe CAP (c-statistic 0·82 [95% CI 0·80-0·84]). Similar results were found in those with radiographic CAP, with decreased breath sounds and multifocal opacities on radiography as additional predictors (c-statistic 0·82 [0·80-0·85]). INTERPRETATION:We developed accurate, pragmatic severity risk prediction models among children with CAP. After future external validation, these models have the potential to provide individualised risk assessments that can be incorporated into clinical judgement in well-resourced health systems to improve management. FUNDING:Division of Emergency Medicine at Cincinnati Children's Hospital Medical Center, Division of Emergency Medicine at Ann & Robert H. Lurie Children's Hospital of Chicago, and Department of Emergency Medicine at University of California, Davis.

Introduction: Virtual interviews (VI) are now a permanent part of pediatric emergency medicine (PEM) recruitment, especially given the cost and equity advantages. Yet inability to visit programs in person can impact decision-making, leading applicants to apply to more programs. Moreover, the cost advantages of VI may encourage applicants to apply to programs farther away than they might otherwise have been willing or able to travel. This could create unnecessary strain on programs. We conducted this study to determine whether PEM fellowship applicants would apply to a larger number of programs and in different geographic patterns with VI (2020 and 2021) as compared to in-person interviews (2018 and 2019).Methods: We conducted an anonymous national survey of all PEM fellows comparing two cohorts: current fellows who interviewed in-person (applied in 2018/2019) and fellows who underwent VIs in 2020/ 2021 (current fellows and those recently matched in 2021). The study took place in March–April 2022. Questions focused on geographic considerations during interviews and the match. We used descriptive statistics, chi-square and t-tests for analysis.Results: Overall response rate was 42% (231/550); 32% (n = 74) interviewed in person and 68% (n = 157) virtually. Fellows applied to a median of 4/6 geographic regions (interquartile range 2, 5). Most applied for fellowship both in the same region as residency (216, 93%) and outside (192, 83%). Only the Pacific region saw a statistically significant increase in applicants during VI (59.9% vs 43.2%, P = 0.02). There was no statistical difference in the number of programs applied to during in-person vs VI (mean difference (95% confidence interval 0.72, −2.8 – 4.2). A majority matched in their preferred state both during VI (60.4%) and in-person interviews (65.7%). The difference was not statistically significant (P = 0.45).Conclusion: While more PEM fellowship applicants applied outside the geographic area where their residency was and to the Pacific region, there was no overall increase in the number of programs or geographic areas PEM applicants applied to during VI as compared to in-person interview seasons. As this was the first two years of VI, ongoing data collection will further identify trends and the impactof VI.

Objective: Among children treated for sepsis in a pediatric emergency department (ED), compare clinical features and outcomes between those with blood cultures positive versus negative for a bacterial pathogen.Design: Single-center retrospective cohort study.Setting: Pediatric emergency department (ED) at a quaternary pediatric care center.Patients: Children aged 0-18 years treated for sepsis defined by the Children's Hospital Association's Improving Pediatric Sepsis Outcomes (IPSO) definition.Interventions: None.Measurements and main results: We analyzed 1307 patients treated for sepsis during the study period, of which 117 (9.0%) had blood cultures positive for a bacterial pathogen. Of children with blood culture positive sepsis, 62 (53.0%) had organ dysfunction compared to 514 (43.2%) with culture negative sepsis (adjusted odds ratio 1.56, 95% confidence interval (CI) 1.04-2.34, adjusting for age, high risk medical conditions, and time to antibiotics). Children with blood culture positive sepsis had a larger base deficit, -4 vs -1 (p < 0.01), and higher procalcitonin, 3.84 vs 0.56 ng/mL (p < 0.01).Conclusions: Children meeting the IPSO Sepsis definition with blood culture positive for a bacterial pathogen have higher rates of organ dysfunction than those who are culture negative, although our 9% rate of blood culture positivity is lower than previously cited literature from the pediatric intensive care unit.(c) 2023 Elsevier Inc. All rights reserved.

14% of children with SARS-CoV-2 infections had radiographic pneumonia. Hypoxemia, cough, higher temperature, and older age were associated with pneumonias. In children tested, SARS-CoV-2 test results were not associated with radiographic pneumonia.

BACKGROUND AND OBJECTIVE:Serum procalcitonin (PCT) is a highly accurate biomarker for stratifying the risk of invasive bacterial infections (IBIs) in febrile infants ≤60 days old. However, PCT is unavailable in some settings. We explored the association of leukopenia and neutropenia with IBIs in non-critically ill febrile infants ≤60 days old, with and without PCT. METHODS:We conducted a secondary analysis of a prospective observational cohort consisting of 7407 non-critically ill infants ≤60 days old with temperatures ≥38°C. We focused on the risk of IBIs in patients with leukopenia (white blood cell [WBC] count <5000 cells/μL) or neutropenia (absolute neutrophil count [ANC] <1000 cells/μL), categorized to extremes of lower values, and the impact of PCT on these associations. Multiple logistic regression was used to identify independent predictors of IBIs. RESULTS:Final analysis included 6865 infants with complete data; 45% (3098) had PCT data available. Of the 6865, a total of 111 (1.6%) had bacteremia without bacterial meningitis, 18 (0.3%) had bacterial meningitis without bacteremia, and 19 (0.3%) had both bacteremia and bacterial meningitis. IBI was present in four of 20 (20%) infants with WBC counts ≤2500 cells/μL and four of 311 (1.3%) with ANC ≤1000 cells/μL. In multivariable logistic regression analysis not including PCT, a WBC count ≤2500 cells/μL was significantly associated with IBI (OR 13.48, 95% CI 2.92-45.35). However, no patients with leukopenia or neutropenia and PCT ≤0.5 ng/mL had IBIs. CONCLUSIONS:Leukopenia ≤2500 cells/μL in febrile infants ≤60 days old is associated with IBIs. However, in the presence of normal PCT levels, no patients with leukopenia had IBIs. While this suggests leukopenia ≤2500 cells/μL is a risk factor for IBIs in non-critically ill young febrile infants only when PCT is unavailable or elevated, the overall low frequency of leukopenia in this cohort warrants caution in interpretation, with future validation required.

Background Despite the reduction in global under-5 mortality over the last decade, childhood deaths remain high. To combat this, there has been a shift in focus from disease-specific interventions to use of healthcare data for resource allocation, evaluation of performance and impact, and accountability. This is a descriptive analysis of data derived from a prospective cohort study describing paediatric admissions to a tertiary referral hospital in Malawi for the purpose of process evaluation and quality improvement.Methods Using a REDCap database, we collected data for patients admitted acutely to Kamuzu Central Hospital, a tertiary referral centre in the central region. Data were collected from 17 123 paediatric inpatients from 2017 to 2020.Results Approximately 6% of patients presented with either two or more danger signs or severely abnormal vital signs. Infants less than 6 months, who had the highest mortality rate, were also the most critically ill on arrival to the hospital. Sepsis was diagnosed in about 20% of children across all age groups. Protocols for the management of high-volume, lower-acuity conditions such as uncomplicated malaria and pneumonia were generally well adhered to, but there was a low rate of completion for labs, radiology studies and subspecialty consultations required to provide care for high acuity or complex conditions. The overall mortality rate was 4%, and 60% of deaths occurred within the first 48 hours of admission.Conclusion Our data highlight the need to improve the quality of care provided at this tertiary-level centre by focusing on the initial stabilisation of high-acuity patients and augmenting resources to provide comprehensive care. This may include capacity building through the training of specialists, implementation of clinical processes, provision of specialised equipment and increasing access to and reliability of ancillary services. Data collection, analysis and routine use in policy and decision-making must be a pillar on which improvement is built.

ABSTRACT. Diagnosis-specific mortality is a measure of pediatric healthcare quality that has been incompletely studied in sub-Saharan African hospitals. Identifying the mortality rates of multiple conditions at the same hospital may allow leaders to better target areas for intervention. In this secondary analysis of routinely collected data, we investigated hospital mortality by admission diagnosis in children aged 1–60 months admitted to a tertiary care government referral hospital in Malawi between October 2017 and June 2020. The mortality rate by diagnosis was calculated as the number of deaths among children admitted with a diagnosis divided by the number of children admitted with the same diagnosis. There were 24,452 admitted children eligible for analysis. Discharge disposition was recorded in 94.2% of patients, and 4.0% (N = 977) died in the hospital. The most frequent diagnoses among admissions and deaths were pneumonia/bronchiolitis, malaria, and sepsis. The highest mortality rates by diagnosis were found in surgical conditions (16.1%; 95% CI: 12.0–20.3), malnutrition (15.8%; 95% CI: 13.6–18.0), and congenital heart disease (14.5%; 95% CI: 9.9–19.2). Diagnoses with the highest mortality rates were alike in their need for significant human and material resources for medical care. Improving mortality in this population will require sustained capacity building in conjunction with targeted quality improvement initiatives against both common and deadly diseases.

Background:To assist clinicians with identifying children at risk of severe outcomes, we assessed the association between laboratory findings and severe outcomes among severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected children and determined if SARS-CoV-2 test result status modified the associations. Methods:We conducted a cross-sectional analysis of participants tested for SARS-CoV-2 infection in 41 pediatric emergency departments in 10 countries. Participants were hospitalized, had laboratory testing performed, and completed 14-day follow-up. The primary objective was to assess the associations between laboratory findings and severe outcomes. The secondary objective was to determine if the SARS-CoV-2 test result modified the associations. Results:We included 1817 participants; 522 (28.7%) SARS-CoV-2 test-positive and 1295 (71.3%) test-negative. Seventy-five (14.4%) test-positive and 174 (13.4%) test-negative children experienced severe outcomes. In regression analysis, we found that among SARS-CoV-2-positive children, procalcitonin ≥0.5 ng/mL (adjusted odds ratio [aOR], 9.14; 95% CI, 2.90-28.80), ferritin >500 ng/mL (aOR, 7.95; 95% CI, 1.89-33.44), D-dimer ≥1500 ng/mL (aOR, 4.57; 95% CI, 1.12-18.68), serum glucose ≥120 mg/dL (aOR, 2.01; 95% CI, 1.06-3.81), lymphocyte count <1.0 × 109/L (aOR, 3.21; 95% CI, 1.34-7.69), and platelet count <150 × 109/L (aOR, 2.82; 95% CI, 1.31-6.07) were associated with severe outcomes. Evaluation of the interaction term revealed that a positive SARS-CoV-2 result increased the associations with severe outcomes for elevated procalcitonin, C-reactive protein (CRP), D-dimer, and for reduced lymphocyte and platelet counts. Conclusions:Specific laboratory parameters are associated with severe outcomes in SARS-CoV-2-infected children, and elevated serum procalcitonin, CRP, and D-dimer and low absolute lymphocyte and platelet counts were more strongly associated with severe outcomes in children testing positive compared with those testing negative.

As more medical students are applying to residency and fellowship programs, the burden of reviewing applications and discriminating among individuals is increasing. In addition, studies highlight the need to intentionally target gender and other biases, which may affect underrepresented in medicine (UIM) applicants.1-3 Integrating standardized letters into the application process may mitigate biases and improve the efficiency of the selection process.4 Standardized letters have been implemented in several medicine and surgery specialties, with a growing body of literature supporting their advantages over narrative letters of recommendation (LORs).5,6 We pose a call to action to graduate medical education (GME) program leaders to collaborate in the process of developing and implementing residency- and fellowship-specific standardized letters across training programs.In 1997, the Council of Residency Directors in Emergency Medicine (CORD) reported on the development and implementation of a standardized letter of recommendation (SLOR) by emergency medicine (EM) residency programs.7 Subsequently, other specialties including orthopedics and otolaryngology developed and implemented their own SLORs.8,9 In 2014, the EM SLOR was updated and renamed the CORD Standardized Letter of Evaluation (SLOE) to better reflect its purpose in providing a summative evaluation of a candidate. Now considered the gold standard by CORD for evaluating potential candidates, the EM SLOE has 4 sections: Background Information, Qualifications for EM, Global Assessment, and Written Comments. Background Information includes the length of the evaluator-student relationship, the nature of their contact, and the student's end-of-rotation grade on a 5-point scale: Honors, High Pass, Pass, Low Pass, and Fail. The Qualifications for EM section asks the evaluator to compare students to their peers on 7 criteria: commitment to EM, work ethic, differential development and treatment plan, teamwork, communication skills, guidance needed during residency, and likelihood of success. The Global Assessment section asks evaluators to rank students in comparison to others they recommended in the prior academic year: top 10%, top third, middle third, and lower third. Finally, the Written Comments section allows evaluators to expand on students' noncognitive attributes.10 Students must obtain a SLOE, completed by faculty trained in writing SLOEs, for each EM rotation they complete and submit it with their residency applications. Like narrative LORs, students may opt to waive their right to view the SLOE. In 2020, the Association of Professors of Gynecology and Obstetrics piloted the obstetrics and gynecology (OB/GYN) SLOE followed by full implementation in 2022; the sections of the OB/GYN SLOE include Competency Assessment Rubric, Most Outstanding Feature, Areas of Focus, and Narrative.11While SLOEs have been adopted by several specialties, most letters submitted for GME applicants use narrative approaches. Program directors identify narrative LORs as critical to the selection process; however, narrative LORs have not been found to reliably provide substantial information on applicants' competencies required by the Accreditation Council for Graduate Medical Education, discriminate between candidates, or predict future performance.12-20 While there are guidelines on how to write narrative LORs, a paucity of literature exists to address the optimal content for narrative LORs to assist faculty who often have little or no training in writing narrative LORs.21,22The number of applicants to GME programs across the United States has been steadily rising.23-34 Performing a thoughtful, holistic review of each candidate's application and selecting who to invite for interviews is a challenging task. Studies performed in various specialties have identified significant linguistic differences in narrative LORs, including infrequent use of language describing strong leadership traits for women and UIM candidates, suggesting that implicit biases related to both candidates and letter writers exist.25-34 Several studies have demonstrated that SLOEs may be better than narrative LORs at mitigating implicit biases that adversely affect women and UIM candidates.33,35-41 Additionally, the SLOE represents a potential tool to better differentiate applicants; Jackson et al demonstrated that the electronic EM SLOE provided more discrimination, even above the original SLOR, with improved spread of rank categorization.42-44 While SLOE implementation may standardize applications and enable candidate comparison in a more objective and unbiased manner, the potential remains for inflation of applicants' qualifications by authors; medical schools and training programs have an interest in helping their graduates secure preferred positions.38-40 It will be imperative to invest time and resources to provide faculty development related to the writing and interpretation of SLOEs for selection committees.To develop and adopt SLOEs across more specialties, it is important to learn from the prior experience of GME programs where implementation has been successful.41,45-47 The Table suggests an action plan with concrete steps that program leaders can take. The total number of applications that selection committees must review within a short time frame has risen sharply. For example, in 2022, 7 of the 17 pediatric subspecialties received, on average, over 100 applications per program, with pediatric emergency medicine (PEM) being one of the most competitive subspecialties. PEM program directors from across the country meet semiannually. During the most recent meeting, we polled attendees, and the overwhelming majority were interested in the development of a subspecialty-specific SLOE. Other discussion points included ensuring the SLOE encourages holistic review of candidates, is designed to meet the needs of institutions where PEM specialists are not present, and is prefaced by faculty development and training. The authors plan to continue this process and hope the effort will be expanded to engage members of the broader GME community.

CONTEXT Cardiovascular dysfunction is associated with poor outcomes in critically ill children. OBJECTIVE We aim to derive an evidence-informed, consensus-based definition of cardiovascular dysfunction in critically ill children. DATA SOURCES Electronic searches of PubMed and Embase were conducted from January 1992 to January 2020 using medical subject heading terms and text words to define concepts of cardiovascular dysfunction, pediatric critical illness, and outcomes of interest. STUDY SELECTION Studies were included if they evaluated critically ill children with cardiovascular dysfunction and assessment and/or scoring tools to screen for cardiovascular dysfunction and assessed mortality, functional status, organ-specific, or other patient-centered outcomes. Studies of adults, premature infants (≤36 weeks gestational age), animals, reviews and/or commentaries, case series (sample size ≤10), and non-English-language studies were excluded. Studies of children with cyanotic congenital heart disease or cardiovascular dysfunction after cardiopulmonary bypass were excluded. DATA EXTRACTION Data were abstracted from each eligible study into a standard data extraction form, along with risk-of-bias assessment by a task force member. RESULTS Cardiovascular dysfunction was defined by 9 elements, including 4 which indicate severe cardiovascular dysfunction. Cardiopulmonary arrest (>5 minutes) or mechanical circulatory support independently define severe cardiovascular dysfunction, whereas tachycardia, hypotension, vasoactive-inotropic score, lactate, troponin I, central venous oxygen saturation, and echocardiographic estimation of left ventricular ejection fraction were included in any combination. There was expert agreement (>80%) on the definition. LIMITATIONS All included studies were observational and many were retrospective. CONCLUSIONS The Pediatric Organ Dysfunction Information Update Mandate panel propose this evidence-informed definition of cardiovascular dysfunction.

IMPORTANCE Little is known about the risk factors for, and the risk of, developing post-COVID-19 conditions (PCCs) among children. OBJECTIVES To estimate the proportion of SARS-CoV-2-positive children with PCCs 90 days after a positive test result, to compare this proportion with SARS-CoV-2-negative children, and to assess factors associated with PCCs. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study, conducted in 36 emergency departments (EDs) in 8 countries between March 7, 2020, and January 20, 2021, included 1884 SARS-CoV-2-positive children who completed 90-day follow-up; 1686 of these children were frequency matched by hospitalization status, country, and recruitment date with 1701 SARS-CoV-2-negative controls. EXPOSURE SARS-CoV-2 detected via nucleic acid testing. MAIN OUTCOMES AND MEASURES Post-COVID-19 conditions, defined as any persistent, new, or recurrent health problems reported in the 90-day follow-up survey. RESULTS Of 8642 enrolled children, 2368 (27.4%) were SARS-CoV-2 positive, among whom 2365 (99.9%) had index ED visit disposition data available; among the 1884 children (79.7%) who completed follow-up, the median age was 3 years (IQR, 0-10 years) and 994 (52.8%) were boys. A total of 110 SARS-CoV-2-positive children (5.8%; 95% CI, 4.8%-7.0%) reported PCCs, including 44 of 447 children (9.8%; 95% CI, 7.4%-13.0%) hospitalized during the acute illness and 66 of 1437 children (4.6%; 95% CI, 3.6%-5.8%) not hospitalized during the acute illness (difference. 5.3%; 95% CI, 2.5%-8.5%). Among SARS-CoV-2-positive children, the most common symptom was fatigue or weakness (21 [1.1%]). Characteristics associated with reporting at least 1 PCC at 90 days included being hospitalized 48 hours or more compared with no hospitalization (adjusted odds ratio [aOR], 2.67 [95% CI, 1.63-4.38]); having 4 or more symptoms reported at the index ED visit compared with 1 to 3 symptoms (4-6 symptoms: aOR, 2.35 [95% CI, 1.28-4.31]; >= 7 symptoms: aOR, 4.59 [95% CI, 2.50 8.44]); and being 14 years of age or older compared with younger than 1 year (aOR, 2.67 [95% CI, 1.43-4.99]). SARS-CoV-2-positive children were more likely to report PCCs at 90 days compared with those who tested negative, both among those who were not hospitalized (55 of 1295 [4.2%; 95% CI, 3.2%-5.5%] vs 35 of 1321[2.7%; 95% CI, 1.9%-3.7%]; difference, 1.6% [95% CI, 0.2%-3.0%]) and those who were hospitalized (40 of 391[10.2%; 95% CI, 7.4%-13.7%] vs 19 of 380 [5.0%; 95% CI, 3.0%-7.7%]; difference, 5.2% [95% CI, 1.5%-9.1%]). In addition, SARS-CoV-2 positivity was associated with reporting PCCs 90 days after the index ED visit (aOR, 1.63 [95% CI, 1.14-2.35]), specifically systemic health problems (eg, fatigue, weakness, fever; aOR, 2.44 [95% CI, 1.19-5.00]). CONCLUSIONS AND RELEVANCE In this cohort study, SARS-CoV-2 infection was associated with reporting PCCs at 90 days in children. Guidance and follow-up are particularly necessary for hospitalized children who have numerous acute symptoms and are older.

OBJECTIVES: To investigate the prevalence of left ventricular systolic dysfunction (LVSD) in Malawian children with severe febrile illness and to explore associations between LVSD and mortality and lactate levels. DESIGN: Prospective observational study. SETTING: Pediatric ward of a tertiary government referral hospital in Malawi. PATIENTS: Children between 60 days and 10 years old with severe febrile illness (fever with at least one sign of impaired perfusion plus altered mentation or respiratory distress) were enrolled at admission from October 2017 to February 2018. INTERVENTIONS: Focused cardiac ultrasound (FoCUS) was performed, and serum lactate was measured for each child at enrollment, with repeat FoCUS the following day. LV systolic function was later categorized as normal, reduced, severely reduced, or hyperdynamic by two pediatric cardiologists blinded to clinical course and outcomes. MEASUREMENTS AND MAIN RESULTS: Fifty-four children were enrolled. LVSD was present in 14 children (25.9%; 95% CI, 15.4–40.3%), of whom three had severely reduced function. Thirty patients (60%) had a lactate greater than 2.5 mmol/L, of which 20 (40%) were markedly elevated (>5 mmol/L). Ten children died during admission (18.5%). Of children who survived, 22.7% had decreased LV systolic function versus 40% of those who died. Dysfunction was not associated with mortality or elevated lactate. CONCLUSIONS: Cardiac dysfunction may be present in one in four Malawian children with severe febrile illness, and mortality in these patients is especially high. Larger studies are needed to further clarify the role cardiac dysfunction plays in mortality and integrate practical bedside assessments for decision support around individualized resuscitation strategies.

ObjectiveAlthough HIV infection, severe malnutrition and hypoxaemia are associated with high mortality in children with WHO-defined severe pneumonia in sub-Saharan Africa, many do not have these conditions and yet mortality remains elevated compared with high-resource settings. Further stratifying mortality risk for children without these conditions could permit more strategic resource utilisation and improved outcomes. We therefore evaluated associations between mortality and clinical characteristics not currently recognised by the WHO as high risk among children in Malawi with severe pneumonia but without HIV (including exposure), severe malnutrition and hypoxaemia.MethodsBetween May 2016 and March 2018, we conducted a prospective observational study alongside a randomised controlled trial (CPAP IMPACT) at Salima District Hospital in Malawi. Children aged 1–59 months hospitalised with WHO-defined severe pneumonia without severe malnutrition, HIV and hypoxaemia were enrolled. Study staff assessed children at admission and ascertained hospital outcomes. We compared group characteristics using Student’s t-test, rank-sum test, χ2 test or Fisher’s exact test as appropriate.ResultsAmong 884 participants, grunting (10/112 (8.9%) vs 11/771 (1.4%)), stridor (2/14 (14.2%) vs 19/870 (2.1%)), haemoglobin <50 g/L (3/27 (11.1%) vs 18/857 (2.1%)) and malaria (11/204 (5.3%) vs 10/673 (1.4%)) were associated with mortality compared with children without these characteristics. Children who survived had a 22 g/L higher mean haemoglobin and 0.7 cm higher mean mid-upper arm circumference (MUAC) than those who died.ConclusionIn this single-centre study, our analysis identifies potentially modifiable risk factors for mortality among hospitalised Malawian children with severe pneumonia: specific signs of respiratory distress (grunting, stridor), haemoglobin <50 g/L and malaria infection. Significant differences in mean haemoglobin and MUAC were observed between those who survived and those who died. These factors could further stratify mortality risk among hospitalised Malawian children with severe pneumonia lacking recognised high-risk conditions.