Pediatric Emergency Physicians' Knowledge, Attitudes, and Behaviors Regarding Confidential Adolescent Care.

OBJECTIVES: More than 19 million adolescents seek care in the emergency department (ED) annually. We aimed to describe the knowledge, attitudes, and behaviors related to confidential adolescent care among pediatric ED physicians. METHODS: We conducted a cross-sectional questionnaire of US physician members of the Pediatric Emergency Medicine Collaborative Research Committee survey listserv. The 24-item questionnaire assessed familiarity with adolescent confidentiality laws, attitudes toward providing confidential care, frequency of discussing behavioral health topics confidentially, and factors influencing the decision to provide confidential care. We dichotomized Likert responses and used χ2 to compare subgroups. RESULTS: Of 476 eligible physicians, 151 (32%) participated. Most (91. 4%) had completed pediatric emergency medicine fellowship. More participants reported familiarity with all sexual health-related laws compared with all mental health-related laws (64% vs 49%, P < 0.001). The median age at which participants thought it was important to begin routinely providing confidential care was 12 years; 9% thought confidential interviews should not be routinely conducted until older adolescence or at all. Their decision to provide confidential care was influenced by the following: chief complaint (97%), time (43%), language (24%), presence of family (23%) or friends (14%), and space (22%). CONCLUSIONS: Respondents reported moderate familiarity with adolescent confidentiality laws. Although they viewed confidential care as something they were comfortable providing, the likelihood of doing so varied. Barriers to confidential care were influenced by their assessment of adolescents' behavioral health risk, which may contribute to health inequity. Future efforts are needed to develop strategies that augment confidential ED care for adolescents.

Establishing a Permanent Food Pantry in a Pediatric Emergency Department.

Childhood food insecurity is associated with adverse health outcomes. Food pantries housed within healthcare facilities have the potential to reduce childhood food insecurity. An interdisciplinary team established a permanent food pantry in the pediatric emergency department of a metropolitan children's hospital. Members of the team included attending and resident physicians, nurse practitioners, nurses, patient care technicians, a volunteer coordinator, Prevention and Wellness staff, and environmental services staff. The development process, formative evaluation, and impact of the pantry during the first 15 months of use is described. Families presenting to the emergency department were notified of the food pantry and offered a bag of groceries. Data collected included number of adult and children in the household, age ranges of family members, and whether food was accepted. The food pantry provided aid to 2199 households from January 2021 to April 2022. Recipients of food assistance included 4698 children, 3565 adults, and 140 seniors. In addition, the interdisciplinary approach to the development process elucidated barriers to and facilitators of the project's success, thereby maximizing the food assistance outcome.

Impact of Rapid Testing for Gonorrhea and Chlamydia in an Urban Pediatric Emergency Department.

PURPOSE: To determine the impact of rapid testing for gonorrhea (NG) and chlamydia (CT) on accuracy of treatment in adolescents in the pediatric emergency department (ED). METHODS: Retrospective study of adolescents tested for NG and CT in the pediatric ED before and after implementation of rapid testing. Treatment during initial visit, availability of test results prior to discharge, and number of follow-up phone calls made with test results were compared. Appropriate treatment was defined per Centers for Disease Control and Prevention 2015 guidelines as monotherapy for CT and dual therapy for NG. Descriptive statistics were used to compare groups. RESULTS: Rapid testing improved treatment accuracy with 522 (79.3%) patients treated appropriately in the rapid testing group compared to 478 (64.7%) patients in the batched testing group (p < .001). Inaccurate treatment was more common in the batch testing group among those who tested negative (p < .001). Among those who tested positive for NG and/or CT, phone calls were made to 54 (47.8%) patients in the rapid testing group and 129 (84.3%) patients in the batched testing group to discuss positive test results (p < .001). CONCLUSION: Compared to batched testing, rapid testing is associated with improved accuracy of treatment of NG and CT in the pediatric ED setting. Additionally, rapid testing is associated with decreased number of phone calls to discuss positive test results.

Crohn Disease Presenting as the Cutaneous Rash of Pyoderma Gangrenosum.

Pyoderma gangrenosum (PG) is a rare pediatric diagnosis, occurring in 3 to 10 patients per million per year, and most commonly seen in individuals between ages 20 and 50 years. This severe ulcerating skin rash is typically associated with an underlying systemic inflammatory condition. The appearance of PG often coincides with exacerbation of the underlying disease. In the absence of systemic symptoms, misdiagnosis of PG can occur, resulting in delay of appropriate treatment. The disease's visual similarity to soft tissue infections, which have dramatically increased in recent years (Ann Emerg Med. 2008;51,3:291-98), makes isolated dermatologic presentations particularly problematic. We present a case of Crohn disease presenting as the inflammatory rash of PG in the absence of significant bowel symptoms. This case highlights the importance of keeping PG in the differential for inflammatory lesions presenting to the emergency department.

A qualitative assessment of pediatric cardiology core content: Comments from Kentucky trainees, pediatricians, and pediatric cardiologists.

OBJECTIVE: The 2016 American Board of Pediatrics (ABP) content outline is comprehensive, including more than 50 cardiology-specific objectives within eight content areas. This study complements the quantitative analysis of a Kentucky-wide survey of trainees, pediatricians, and pediatric cardiologists asking them to identify "most important" cardiology content by analyzing their open-ended comments about "what should be added" and "why?" within these eight categories. DESIGN, METHODS, OUTCOME MEASURES: This cross-sectional study used an original, online survey instrument based on the 2016 ABP cardiology-specific objectives. We began an initial analysis of the qualitative data using Pandit's version of Glaser and Strauss Grounded theory (constant comparison). However, upon finding an abundance of comments focused on Diagnosis, we proceeded with a secondary analysis that further categorized Diagnosis comments into three themes aligned with Bloom's taxonomy. Additional comments focused on Management and clustered into Emergent/Acute Care (Resuscitation); Short-term Care (Inpatient); and Longitudinal Care (Outpatient). RESULTS: Of the 136 respondents, 23 (17%) were residents, 15 (11%) fellows, 85 (62%) pediatricians, and 13 (10%) pediatric cardiologists with 80% of attendings having faculty/gratis faculty status. The open-ended questions "what needs to be added" and "why" generated 93 comments; 60 of which focused on Diagnosis; further classified as Recognize (16), Differentiate (12), and Evaluate (32). Management comments were related to acuity and care setting, grouped as Emergent/Acute Care (Resuscitation) [10]; Short-term Care (Inpatient) [6]; and Longitudinal Care (Outpatient) [17]. CONCLUSIONS: The 93 comments analyzed for this article showed a distinct preference for all respondents, trainees, pediatricians, and cardiologists alike, to value the addition of diagnostic skills with emphasis in the "evaluate" skill set as important cardiology curricular content beyond that included in the 2016 ABP cardiology-specific objectives. Responses could be used to provide practical guidance for curriculum design and reform.

An unusual case of anemia in a cardiac transplant recipient.

Anemia is a well-described comorbidity in patients with heart failure and has been associated with decreased survival rates after heart transplant. The causes of anemia are broad, and identification of the underlying etiology is critical for management. Herein, we report an unusual case of severe anemia complicating cardiac transplantation.

Using a statewide survey methodology to prioritize pediatric cardiology core content.

OBJECTIVE: Although pediatrician-reported relevance of Canadian cardiology-specific objectives has been studied, similar data are not available for the 2016 American Board of Pediatrics (ABP) cardiology-specific objectives. This study asked Kentucky trainees, pediatricians, and pediatric cardiologists to identify "most important" content within these objectives. DESIGN, METHODS, OUTCOME MEASURES: This cross-sectional study used an original, online survey instrument based on the 2016 ABP cardiology-specific objectives. We collected quantitative data (numerical indications of importance) and qualitative data (open-ended replies regarding missing content and difficulty in teaching and learning). Respondents indicated the top two choices of most important items within eight content areas. Descriptive statistics (frequencies and percentages) and chi-square analysis were calculated. Content within categories was organized using naturally occurring "clusters" and "gaps" in scores. Common themes among open-ended qualitative responses were identified using Pandit's version of Glaser and Strauss Grounded theory (constant comparison). RESULTS: Of the 136 respondents, 23 (17%) were residents, 15 (11%) fellows, 85 (62%) pediatricians, and 13 (10%) pediatric cardiologists. Of attendings, 80% reported faculty/gratis faculty status. Naturally occurring clusters in respondent-designated importance resulted in ≤3 "most selected" objectives per content area. Objectives in "most selected" content pertained to initial diagnosis (recognition of abnormality/disease) (n = 16), possible emergent/urgent intervention required (n = 14), building a differential (n = 8), and planning a workup (n = 4). Conversely, themes for "least selected" content included comanagement with subspecialist (n = 15), knowledge useful in patient-family communication (n = 9), knowledge that can be referenced (as needed) (n = 7), and longitudinal/follow-up concerns (n = 5). CONCLUSIONS: This study demonstrated the utility of an online survey methodology to identify pediatric cardiology content perceived most important. Learners and faculty generally provided concordant responses regarding most important content within the cardiology-specific ABP objectives. Medical educators could apply this methodology to inform curriculum revision.

Catalytic domain of the diversified Pseudomonas syringae type III effector HopZ1 determines the allelic specificity in plant hosts.

The type III secretion systems (T3SS) and secreted effectors (T3SEs) are essential virulence factors in Gram-negative bacteria. During the arms race, plants have evolved resistance (R) genes to detect specific T3SEs and activate defence responses. However, this immunity can be efficiently defeated by the pathogens through effector evolution. HopZ1 of the plant pathogen Pseudomonas syringae is a member of the widely distributed YopJ T3SE family. Three alleles are known to be present in P. syringae, with HopZ1a most resembling the ancestral allelic form. In this study, molecular mechanisms underlying the sequence diversification-enabled HopZ1 allelic specificity is investigated. Using domain shuffling experiments, we present evidence showing that a central domain upstream of the conserved catalytic cysteine residue determines HopZ1 recognition specificity. Random and targeted mutagenesis identified three amino acids involved in HopZ1 allelic specificity. Particularly, the exchange of cysteine141 in HopZ1a with lysine137 at the corresponding position in HopZ1b abolished HopZ1a recognition in soybean. This position is under strong positive selection, suggesting that the cysteine/lysine mutation might be a key step driving the evolution of HopZ1. Our data support a model in which sequence diversification imposed by the plant R gene-associated immunity has driven HopZ1 evolution by allowing allele-specific substrate-binding.