The Gender Landscape of Academic Pediatric Emergency Medicine: An Observational Study of Leadership Positions as Described by Fellowship Programs' Online Presence.

OBJECTIVES: Although many areas of medicine are male dominated, pediatric emergency medicine (PEM) is a female-dominated subspecialty. Despite this, executive leadership within PEM remains male dominated. The aim of this study was to describe the gender landscape of the key positions within academic PEM fellowship programs within the United States, as described by PEM fellowships' online presence. METHODS: Using the 2021-2022 Electronic Residency Application Service American Association of Medical Colleges Pediatric Fellowships ( services.aamc.org/eras/erasstats/par/ ) application service, we were able to identify published information from 84 academic PEM fellowship programs in the United States. Each program's Web site was evaluated to determine which individuals held the position of chief or chair, medical director, and fellowship director. These individuals' genders were then cross-referenced with the National Provider Inventory database. RESULTS: There were 154 executive leadership roles (division chief or medical director) in total. The executive leadership role was significantly different by gender ( z score: 2.54, P < 0.01), with greater male representation (n = 61; 62.9%) among identified executive leadership roles (n = 97). There were significantly more men for the medical director role ( z score: 2.06, P < 0.05). Female representation was greater than male in the fellowship program director role (n = 53; 67.9%) among listed roles ( z score: -3.17, P < 0.001). This gender landscape among key leadership positions was not influenced by the geographic location of the PEM fellowship program. CONCLUSIONS: Although PEM is a female-dominated specialty, executive leadership positions continue to be male dominated. To promote improved gender representation within leadership positions in PEM, PEM fellowship programs must provide consistent and easily accessible executive leadership descriptions within their online storefront.

Ultrasonographic Evaluation of Physiologic Free Intraperitoneal Fluid in Healthy Children: A Prospective Observational Study.

OBJECTIVES: The detection of intraperitoneal free fluid (FF) is an important finding in the sonographic evaluation of the pediatric abdomen, especially in the context of blunt abdominal trauma. One specific challenge is differentiating physiologic from pathologic FF. The purpose of this study was to determine with ultrasound the prevalence, location, and volume of intraperitoneal FF in healthy pediatric patients and its relation to pubertal status and gender. METHODS: Healthy children between the ages of 1 and 17 years who presented to the emergency department with non-abdominal complaints were evaluated for physiologic intra-abdominal fluid. Point-of-Care Ultrasound (POCUS) was performed, utilizing the Focused Assessment with Sonography in Trauma (FAST) examination. RESULTS: A total of 325 pediatric patients were analyzed. Intraperitoneal FF was found in 52 children (16.0%, 95% CI: 12.0-20.0%). The pelvis was the only region where FF was located. The prevalence of FF was nearly equivalent between male and female children (15.4% vs 16.7%, P = .76). There was a higher prevalence of FF identified in the prepubertal subgroup compared to the pubertal group (20.0% vs 11.3%, P = .03). Seventy-seven percent of children with FF had a fluid volume of less than 1 mL. CONCLUSIONS: Physiologic FF of less than 1 mL within the pelvis is a common finding in the pediatric population. There was no difference in the rate of FF identified by gender, but there was a higher prevalence of FF among prepubertal children.

Interpretation Accuracy and Interrater Agreement of Pediatric Skin and Soft Tissue Point-of-Care Ultrasound Images among Residents and Faculty.

BACKGROUND: Point-of-care ultrasound (POCUS) is commonly used to facilitate care in the emergency department. Acquired images are often reviewed by local experts for educational and quality assurance purposes. However, no published study has examined the accuracy and reliability of POCUS image interpretation by multiple reviewers. OBJECTIVES: We studied the accuracy and interrater agreement among expert and trainee reviewers of prerecorded pediatric skin and soft tissue (SST) POCUS images. METHODS: POCUS faculty and emergency medicine (EM) residents blindly reviewed deidentified pediatric SST POCUS images and indicated whether a drainable fluid collection was present, absent, or indeterminate. This was then compared with the gold standard based on discharge diagnoses and telephone follow-up. Images rated as indeterminate were excluded from the initial analysis. Sensitivity analysis assuming indeterminate answers were inaccurate was subsequently conducted. RESULTS: In phase 1, 6 pediatric EM POCUS directors reviewed 168 images. The overall accuracy was 79.7% (range 66.1-86.0%). The mean Cohen's kappa was 0.58 (range 0.24-0.84). Sensitivity analysis yielded an overall accuracy of 71.3% (range 56.5-76.9%) and a Cohen's kappa of 0.43 (range 0.20-0.59). In phase 2, 6 general EM POCUS faculty and 20 EM residents reviewed 120 images. The overall accuracy among residents was 72.2% (range 51.4-84.7%) and among faculty was 83.6% (range 77.9-88.8%). Sensitivity analysis yielded an overall resident accuracy of 63.0% (range 49.5-80.7) and an overall faculty accuracy of 73.9% (range 67.0-79.8%). Fleiss' kappa was 0.322 for residents and 0.461 for faculty. CONCLUSIONS: We found moderate accuracy and fair to good interrater agreement among POCUS faculty and EM residents reviewing pediatric SST POCUS images.

The use of point of care ultrasound in the evaluation of pediatric soft tissue neck masses.

OBJECTIVE: Most soft tissue neck masses represent benign inflammatory or infectious processes; however, in some cases the diagnosis is not clear and a broader differential must be considered. The aim of this study was to compare point-of-care ultrasound (POCUS) to radiology department imaging (RDI) in the diagnosis of soft tissue neck masses. METHODS: This prospective pilot study involved a convenience sample of patients ranging in age from 1 month to 18 years of age presenting to the Pediatric Emergency Department (PED) with a soft tissue neck mass. All children who presented to the PED with soft tissue neck mass at times when an investigator was in the department, and who were candidates for enrollment, underwent a POCUS. The managing pediatric emergency medicine (PEM) provider determined whether RDI was indicated. The results of the POCUS sonologist and radiologist were compared. The kappa statistic was used to analyze agreement with p < 0.05 denoting statistical significance. RESULTS: Twenty-seven patients were enrolled into the study. Twenty-two received radiology ultrasound (RUS), 3 patients received CT, and 2 patients received both RUS and CT. There was agreement between POCUS and RDI diagnoses in 21/27 cases (78%). Accordingly, overall concordance between POCUS and RDI diagnoses was good: the kappa statistic comparing diagnoses obtained by POCUS versus RDI was 0.69 (p < 0.001). CONCLUSION: This prospective pilot study describes the reliability of POCUS as an imaging modality in the management of patients with undifferentiated soft tissue neck masses. POCUS demonstrated good agreement with RDI as a bedside imaging tool in the evaluation of pediatric soft tissue neck masses.

When Fever, Leukocytosis, and Right Lower Quadrant Pain Is Not Appendicitis.

Mesenteric cystic lymphangioma (MCL) is an uncommon, benign, slow-growing abdominal tumor that is derived from the lymphatic vessels (World J Gastroenterol. 2012;18:6328-6332, Radiographics. 1994;14:729-737). It is most often diagnosed in the head and neck of affected children. Rarely, a lymphangioma can develop within the small bowel (Pan Afr Med J. 2012;12:7). The clinical presentation of patients with an abdominal MCL can range from asymptomatic to acute abdominal pain (J Korean Surg Soc. 2012;83:102-106). We report a case of small bowel volvulus caused by an MCL in a 3-year-old child who presented to the pediatric emergency department with right lower quadrant pain. The child was thought to have a perforated appendicitis and was taken to the operating room where an MCL was identified and resected. This case illustrates the need to consider MCL when a patient presents to the emergency department with right lower quadrant pain.

Pediatric emergency medicine point-of-care ultrasound: summary of the evidence.

The utility of point-of-care ultrasound is well supported by the medical literature. Consequently, pediatric emergency medicine providers have embraced this technology in everyday practice. Recently, the American Academy of Pediatrics published a policy statement endorsing the use of point-of-care ultrasound by pediatric emergency medicine providers.  To date, there is no standard guideline for the practice of point-of-care ultrasound for this specialty. This document serves as an initial step in the detailed "how to" and description of individual point-of-care ultrasound examinations.  Pediatric emergency medicine providers should refer to this paper as reference for published research, objectives for learners, and standardized reporting guidelines.

Cerebral Abscess Presenting as a Complex Febrile Seizure.

Currently, there is no standardized approach to the management of complex febrile seizures in children and there are no published practice guidelines for the procurement of neuroimaging. Presented is a 2-year-old female patient who experienced a 3- to 5-minute episode of staring and unilateral mouth twitching associated with high fever. On initial presentation, the patient appeared well and had a normal neurological examination. No focus of infection was identified, and she was diagnosed with complex febrile seizure. The patient was discharged home with close neurology and primary care follow-up but returned the following day with altered mental status, toxic appearance, and right lower extremity weakness. Magnetic resonance imaging of the brain revealed left-sided cranial empyema and the patient was managed with antibiotics and surgical drainage. A literature review to answer the question "Do children with complex febrile seizures require emergent neuroimaging?" yielded a small number of retrospective reviews describing the utility of computed tomography, magnetic resonance imaging and lumbar puncture in the work-up of febrile seizures. Current evidence indicates that neuroimaging is not indicated in an otherwise healthy child who presents with complex febrile seizure if the patient is well appearing and has no evidence of focal neurological deficit on examination. As this case demonstrates, however, serious conditions such as meningitis and brain abscess (though rare) should be considered in the differential diagnosis of complex febrile seizure and physicians should remain aware that the need for neuroimaging and/or lumbar puncture may arise in the appropriate clinical setting.

Update on myocarditis in children.

PURPOSE OF REVIEW: Myocarditis is an uncommon pediatric illness, and it is frequently missed by medical personnel. It often masquerades as more common pediatric illnesses such as respiratory distress or gastrointestinal disease. Given that myocarditis accounts for 12% of sudden cardiac death among adolescents and young adults, the suspicion of this illness in the differential diagnosis of children presenting with nonspecific symptomatology and disease progression can be lifesaving. RECENT FINDINGS: Historically, the diagnosis of myocarditis required endomyocardial biopsy. More recently ancillary diagnostic modalities have been used to help make the diagnosis less invasively. The use of laboratory testing, echocardiography, and cardiac MRI can now make the diagnosis in the absence of invasive biopsy and can help improve the diagnostic yield when biopsy is performed. Additionally, with an improved understanding of the pathophysiology of this disease, research has focused on novel therapeutic interventions such as immunoglobulin therapy and immunosuppressive therapy in the care of the patient with myocarditis. SUMMARY: Myocarditis is a challenging diagnosis to make. With advent of newer diagnostic modalities and an improved understanding of the disease and its progression, there is a genuine hope that outcomes of pediatric myocarditis will be improved. The first step, however, is for medical providers to consider this entity in the differential diagnosis of patients with concerning presentation or illness history.