An Unusual Diagnosis for an Infant Presenting with Olive-Shaped Abdominal Mass.

A 3-month-old male infant was bought to the emergency department with almost 3 weeks of projectile, bilious emesis after each feed. On presentation, he was cachectic and severely dehydrated and had a palpable olive in the epigastric region. Hypertrophic pyloric stenosis was excluded by abdominal ultrasound. The barium meal demonstrated a massively distended stomach, absence of distal gas, and triple bubble sign. Given the radiological findings, the patient underwent an emergency exploratory laparotomy and a congenital duodenal web (CDW) was discovered. While the clinical picture suggested the diagnosis of HPS, barium meal eventually revealed congenital duodenal web. To our knowledge, no other cases of palpable olive mass as the presenting sign of proximal bowel obstruction have been published.

Impact of COVID-19 on pediatric emergency fellowship training in Saudi Arabia.

OBJECTIVES: To assess the impact of the COVID-19 pandemic on the academic and clinical processes of pediatric emergency medicine (PEM) fellowship training held by the Saudi Commission for Health Specialties (SCHS). METHODS: A cross-sectional, nationwide, survey-based study was conducted between June and December 2020. PEM program directors as well as fellowship trainees were eligible. The collected data were under the following domains: (1) sociodemographic and work-related characteristics; (2) impact of the COVID-19 pandemic on patient flow and PEM procedures; (3) impact on emergency skills and competence; (4) impact on academic performance; and (5) attitudes toward PEM practice and potential solutions. Monthly reports of PEM visits and procedures were also collected from program directors. RESULTS: A total of 11 PEM program directors and 42 fellows responded. During the pandemic, the number of total ED visits decreased by 70.1%, ED inpatient admissions fell by 57.3%, and the number of intraosseous need insertion and lumbar puncture procedures fell by 76.7% and 62.3%, respectively; the temporal differences in the median frequencies were statistically significant. The pandemic has influenced the knowledge acquisition and leadership skills of one-third of program directors (36.4% and 27.3%, respectively) and the skills and competence of fellows (31.0%). The majority of directors and fellows showed that online classes/webinars were useful (100% and 95.2%, respectively), and there was no need to extend the current fellowship training to compensate for learning deficits (62.7% and 78.6%, respectively). The importance of dedicated modalities to fill in the training gap increased by 62.5% of program directors and 35.7% of fellows. CONCLUSION: The COVID-19 pandemic had significant effects on clinical procedures and academic activities in the PEM fellowship program. The impact was consistently perceived across PEM program directors and fellows. Technology-driven solutions are warranted to mitigate the expected learning and clinical deficits due to reduced clinical exposure.

Initial Pain Assessment and Management in Pediatric Burn Patients Presenting to a Major Trauma Center in Saudi Arabia.

BACKGROUND: Pediatric burn injury is a traumatic experience for affected children and their families. Burn pain is frequently undertreated and may adversely affect patient experience and outcomes. The aim of this study was to investigate the current practice of initial pediatric burn pain assessment and management at a major trauma center in Riyadh, Kingdom of Saudi Arabia. METHODS: We conducted a retrospective cohort study that included children 14 years and younger who visited King Saud Medical City in the Kingdom of Saudi Arabia with a presenting complaint of burn injury from January 01, 2017 to August 30, 2018. Variables were reported using descriptive statistics as appropriate. RESULTS: The 309 patients who were analyzed were classified into 3 age groups ranging from 0 to younger than 3 years (61%), 3 to 7 years (24%), and older than 7 years (15%). They included 145 (47%) female and 164 (53%) male patients. Pain levels of 182 patients (59%) were documented using an age-appropriate tool. In 75 children (24%), pain levels were documented using an alternate tool, and the tool used was not defined for 44 children (14%). Pain assessment was not documented for 8 children. Of those with an age-appropriate tool, the median initial pain score was 4 (interquartile range [IQR], 2-4). Analgesia was recorded to have been administered to 139 patients (45%), within a median time of 50 minutes (IQR, 17-154 minutes) to first analgesia. Among patients who had appropriate assessment of pain, 92 (50.3%) received analgesia compared with 52 (41.3%) who did not have appropriate assessment (P = 0.12). Among patients who had appropriate pain assessment, time to analgesia was 42 minutes (IQR, 15-132 minutes) compared with 53 minutes (IQR, 17-189 minutes) among patients who did not have appropriate assessment (P = 0.48). DISCUSSION: Most pediatric patients presenting with burns had pain assessment, but a substantial proportion of children were not managed using recommended age-specific tools. The use of age-specific tools was not necessarily associated with delivery of analgesia. For pediatric burns, prompt delivery of analgesia should be prioritized with pain assessment using age-appropriate tools being recommended, but optional.

Improving pediatric emergency department physicians' adherence to clinical practice guidelines on the diagnosis and management of group A beta-hemolytic streptococcal pharyngitis-a cross-sectional study.

INTRODUCTION: Pharyngitis is one of the major and commonly seen presentations in pediatric emergency departments. While it could be caused by both bacterial and viral pathogens, antibiotics are improperly prescribed regardless of the pathogen. Inappropriate usage of antibiotics has risen the concern of microbial resistance and the need for stricter guidelines. Many guidelines have been validated for this reason, and the Centor score (Modified/McIsaac) is most commonly implemented. This study aims to assess the adherence and enumerate the reasons behind the suboptimal adherence to guidelines (Centor/McIsaac score) of pediatric emergency department physicians in the diagnosis and management of GABHS pharyngitis to lay the groundwork for future actions and to employ educational programs and implement local guidelines for the prevention of the development of multi-drug resistant microorganisms. METHODOLOGY: We surveyed pediatric emergency department physicians of ten teaching hospitals of Riyadh, Saudi Arabia. We used convenient sampling and estimated a sample size of 170 physicians, and interns and medical centers without pediatric emergency department were excluded from the study. Elements of the Centor score (Modified/McIsaac) were used as a part of the assessment of physicians' knowledge of the guidelines. Adherence was assessed by requiring the participants to answer questions regarding their usage of diagnostic means when they suspect a bacterial cause of pharyngitis, as recommended by the guidelines. RESULTS: A total of 243 physicians answered the questionnaire, 43 consultants (17.6%) and 200 non-consultants (82.4%). On the knowledge score, 9.1% scored 0, and the majority of both groups, 46.5%, earned a score of 1. The remainder 44.4%, earned a score of 2. Adherence to guidelines was defined as when diagnostic tests (throat culture or rapid antigen detection test) were always requested prior to prescribing antibiotics when acute bacterial pharyngitis was suspected. Only 27.3% (n = 67) of our sample are adherent to guidelines, whereas the majority, 72.7% (n = 175), are non-adherent. Several factors were assessed as reasons for lack of adherence. CONCLUSION: Lack of knowledge and adherence to guidelines is prevalent in our setting, with awareness, knowledge, and behavior of physicians playing as major factors behind this low adherence. Studies should aim towards the assessment of adherence towards locally developed guidelines.

Decreased hydration status of emergency department physicians and nurses by the end of their shift.

BACKGROUND: Typical emergency department (ED) shifts are physically demanding. The aim of this study was to assess the hydration status of ED physicians and nurses by the end of their shifts. METHODS: A prospective cross-sectional clinical study of ED physicians and nurses assessing fluid intake, activities, vital signs, weight, urine specific gravity and ketones at the end of the shift. Forty-three participants were tested over 172 shifts distributed over 48% in the morning, 20% in the evening and 32% at night. Fifty-eight percent were females, and 51% were physicians. RESULTS: Overall, participants lost 0.3% of their body weight by the end of the shift. While physicians lost a mean of 0.57 kg (± SD 0.28; P < 0.0001, 95% CI 0.16-0.28), nurses lost 0.12 kg (± SD 0.25; P < 0.0001, 95% CI 0.07-1.7). While nurses drank more fluid (P < 0.0001), physicians had a higher specific gravity of 1.025 (P < 0.01), visited the washroom less often (P < 0.0001) and reported less workload and stress (P = 0.01 and 0.008, respectively). There were no major changes in vital signs or urinary ketones (OR.0.41, 95% CI 0.1-2.1). In a multivariate analysis, being male (OR 13.5, 95% CI 1.6-112.5), being of younger age (OR 4.1, 95% CI 1.7-10.2), being Middle Eastern (OR 5.3, 95% CI 1.1-26.2), working the morning shift (OR 2.7, 95% CI 0.7-10.5) and having less fluid intake (OR 5.7, 95% CI 1.2-26.6) were significant predictors of decreased hydration. CONCLUSIONS: The majority of physicians and to a lesser extent nurses working in a tertiary care emergency department have decreased hydration status at the end of the shift. Therefore, awareness of the hydration status by emergency department staff is needed. A further study in a similar setting with more subjects and a better balance among the variables is recommended.