Performance of Febrile Infant Decision Tools on Hypothermic Infants Evaluated for Infection.

BACKGROUND: Given the lack of evidence-based guidelines for hypothermic infants, providers may be inclined to use febrile infant decision-making tools to guide management decisions. Our objective was to assess the diagnostic performance of febrile infant decision tools for identifying hypothermic infants at low risk of bacterial infection. METHODS: We conducted a secondary analysis of a retrospective cohort study of hypothermic (≤36.0 C) infants ≤90 days of age presenting to the emergency department or inpatient unit among 9 participating sites between September 1, 2016 and May 5, 2021. Well-appearing infants evaluated for bacterial infections via laboratory testing were included. Infants with complex chronic conditions or premature birth were excluded. Performance characteristics for detecting serious bacterial infection (SBI; urinary tract infection, bacteremia, bacterial meningitis) and invasive bacterial infection (IBI; bacteremia, bacterial meningitis) were calculated for each tool. RESULTS: Overall, 314 infants met the general inclusion criteria, including 14 cases of SBI (4.5%) and 7 cases of IBI (2.2%). The median age was 5 days, and 68.1% of the infants (214/314) underwent a full sepsis evaluation. The Philadelphia, Boston, IBI Score, and American Academy of Pediatrics Clinical Practice Guideline did not misclassify any SBI or IBI as low risk; however, they had low specificity and positive predictive value. Rochester and Pediatric Emergency Care Applied Research Network tools misclassified infants with bacterial infections. CONCLUSIONS: Several febrile infant decision tools were highly sensitive, minimizing missed SBIs and IBIs in hypothermic infants. However, the low specificity of these decision tools may lead to unnecessary testing, antimicrobial exposure, and hospitalization.

Time to Positive Blood and Cerebrospinal Fluid Cultures in Hypothermic Young Infants.

BACKGROUND AND OBJECTIVE: Hypothermia in young infants may be secondary to an invasive bacterial infection. No studies have explored culture time-to-positivity (TTP) in hypothermic infants. Our objective was to compare TTP of blood and cerebrospinal fluid (CSF) cultures between pathogenic and contaminant bacteria in hypothermic infants ≤90 days of age. METHODS: Secondary analysis of a retrospective cohort of 9 children's hospitals. Infants ≤90 days of age presenting to the emergency department or inpatient setting with hypothermia from September 1, 2017, to May 5, 2021, with positive blood or CSF cultures were included. Differences in continuous variables between pathogenic and contaminant organism groups were tested using a 2-sample t test and 95% confidence intervals for the mean differences reported. RESULTS: Seventy-seven infants met inclusion criteria. Seventy-one blood cultures were positive, with 20 (28.2%) treated as pathogenic organisms. Five (50%) of 10 positive CSF cultures were treated as pathogenic. The median (interquartile range [IQR]) TTP for pathogenic blood cultures was 16.8 (IQR 12.7-19.2) hours compared with 26.11 (IQR 20.5-48.1) hours for contaminant organisms (P < .001). The median TTP for pathogenic organisms on CSF cultures was 34.3 (IQR 2.0-53.7) hours, compared with 58.1 (IQR 52-72) hours for contaminant CSF organisms (P < .186). CONCLUSIONS: Our study is the first to compare the TTP of blood and CSF cultures between pathogenic and contaminant bacteria in hypothermic infants. All pathogenic bacteria in the blood grew within 36 hours. No difference in TTP of CSF cultures between pathogenic and contaminant bacteria was detected.

Variation in Care of Well-Appearing Hypothermic Young Infants: A Multisite Study.

BACKGROUND AND OBJECTIVES: Numerous decision tools have emerged to guide management of febrile infants, but limited data exist to guide the care of young infants presenting with hypothermia. We evaluated the variation in care for well-appearing hypothermic young infants in the hospital and/or emergency department setting between participating sites. METHODS: This is a retrospective cohort study of well-appearing infants ≤90 days old across 9 academic medical centers from September 1, 2016 to May 5, 2021. Infants were identified via billing codes for hypothermia or an initial temperature ≤36.0°C with manual chart review performed. Primary outcomes included assessment of variation in diagnostic evaluation, disposition, empirical antimicrobial therapy, and length of stay. RESULTS: Of 14 278 infants originally identified, 739 met inclusion criteria. Significant interhospital variation occurred across all primary outcomes. Across sites, a full serious bacterial illness evaluation was done in 12% to 76% of hypothermic infants. Empirical antibiotics were administered 20% to 87% of the time. Performance of herpes simplex viral testing ranged from 7% to 84%, and acyclovir was empirically started 8% to 82% of the time. Hospital admission rates ranged from 45% to 100% of patients. CONCLUSIONS: Considerable variation across multiple aspects of care exists for well-appearing young infants presenting with hypothermia. An improved understanding of hypothermic young infants and their risk of infection can lead to the development of clinical decision tools to guide appropriate evaluation and management.

Prevalence of Invasive Bacterial Infection in Hypothermic Young Infants: A Multisite Study.

OBJECTIVE: To determine the prevalence of bacteremia and meningitis (invasive bacterial infection [IBI]) in hypothermic young infants, and also to determine the prevalence of serious bacterial infections (SBI) and neonatal herpes simplex virus and to identify characteristics associated with IBI. STUDY DESIGN: We conducted a retrospective cohort study of infants ≤90 days of age who presented to 1 of 9 hospitals with historical or documented hypothermia (temperature ≤36.0°C) from September 1, 2017, to May 5, 2021. Infants were identified by billing codes or electronic medical record search of hypothermic temperatures. All charts were manually reviewed. Infants with hypothermia during birth hospitalization, and febrile infants were excluded. IBI was defined as positive blood culture and/or cerebrospinal fluid culture treated as a pathogenic organism, whereas SBI also included urinary tract infection. We used multivariable mixed-effects logistic regression to identify associations between exposure variables and IBI. RESULTS: Overall, 1098 young infants met the inclusion criteria. IBI prevalence was 2.1% (95% CI, 1.3-2.9) (bacteremia 1.8%; bacterial meningitis 0.5%). SBI prevalence was 4.4% (95% CI, 3.2-5.6), and neonatal herpes simplex virus prevalence was 1.3% (95% CI, 0.6-1.9). Significant associations were found between IBI and repeated temperature instability (OR, 4.9; 95% CI, 1.3-18.1), white blood cell count abnormalities (OR, 4.8; 95% CI, 1.8-13.1), and thrombocytopenia (OR, 5.0; 95% CI, 1.4-17.0). CONCLUSIONS: IBI prevalence in hypothermic young infants is 2.1%. Further understanding of characteristics associated with IBI can guide the development decision tools for management of hypothermic young infants.

Diagnosis of Bacterial Tracheostomy-Associated Respiratory Tract Infections in Pediatric Patients.

OBJECTIVES: To identify demographic and clinical characteristics of children with fever and/or respiratory illness associated with a diagnosis of bacterial tracheostomy-associated respiratory tract infections (bTARTI). Secondary objectives included comparison of diagnostic testing, length of stay (LOS), and readmission rates between children diagnosed with bTARTI and others. METHODS: We performed a retrospective chart review of encounters over 1 year for fever and/or respiratory illness at a single academic children's hospital for children with tracheostomy dependence. Patient characteristics, features of presenting illness, and laboratory and imaging results were collected. Generalized linear mixed models were employed to study associations between patient characteristics, diagnosis of bTARTI, and impact on LOS or readmission rates. RESULTS: Among 145 children with tracheostomies identified, 79 children contributed 208 encounters. bTARTI was diagnosed in 66 (31.7%) encounters. Significant associations with bTARTI diagnosis included chest radiograph consistent with bacterial pneumonia (odds ratio [OR], 1.77; 95% confidence interval [CI], 1.50-2.08), positive tracheal aspirate culture (OR, 1.3; 95% CI, 1.05-1.61), higher white blood cell count (16.4 vs 13.1 × 103/µ; P = .03), change in oxygen requirement (OR, 1.14; 95% CI, 1.00-1.31), telephone encounter (OR, 1.41; 95% CI, 1.09-1.81), and living at home with family (OR, 1.42; 95% CI, 1.06-1.92). LOS for admitted patients with bTARTI was 2.19 times longer (CI, 1.23-3.88). CONCLUSIONS: In our single-center study, we identified several clinical and nonclinical factors associated with a diagnosis of bTARTI. Despite widespread use, few laboratory tests were predictive of a diagnosis of bTARTI. There is need for standardization in diagnosis.

A Narrative Review of Key Studies in Medical Education in 2021: Applying Current Literature to Educational Practice and Scholarship.

To remain at the forefront of clinical practice and pedagogy, pediatric medical educators must stay informed of the latest research. Yet familiarization with the growing body of literature in both pediatrics and medical education is a near-impossible task for the busy medical educator. The purpose of this annotated bibliography is to summarize key manuscripts in medical education published in 2021 that have the potential to significantly influence a pediatric medical educator's practice. Using a 2-staged iterative process, discrete author pairs reviewed 1599 abstracts from 16 medical education and specialty journals. In summary, 16 manuscripts were selected and grouped into the following 6 domains: assessment and feedback, USMLE Step 1 changes, communication, wellness, diversity and inclusion, and professional development. The authors provide abridged summaries and high-yield take-aways from these manuscripts that may impact educational practices in pediatrics. This year, we also provide a 6-year retrospective review of the journals that have had selected articles for this annotated bibliography since inception.

An Annotated Bibliography of Key Studies in Medical Education in 2020: Applying the Current Literature to Educational Practice and Scholarship.

Pediatric medical educators, with their multitude of responsibilities, may have difficulty staying abreast with both medical education and specialty specific medical literature. The body of medical literature is growing at an exponential rate. This annotated bibliography serves as a summary of highlighted medical education literature in the year 2020. The purpose was to identify manuscripts which have the potential to significantly influence a pediatric medical educator's practice. The authors reviewed abstracts from 14 medical education and specialty journals using a two-staged review process. Each stage of review was completed by 2 different authors. A total of 1861 abstracts were reviewed and ultimately 15 key manuscripts were identified. The authors grouped the manuscripts into 6 core domains: diversity and inclusion, faculty development, feedback, learner development, mentorship, and teaching skills. Condensed summaries of each medical education manuscript likely to influence educational practice are provided by the authors in this annotated bibliography.

Effect of Perceived Level of Interaction on Faculty Evaluations of 3rd Year Medical Students.

INTRODUCTION: Several factors are known to affect the way clinical performance evaluations (CPEs) of medical students are completed by supervising physicians. We sought to explore the effect of faculty perceived "level of interaction" (LOI) on these evaluations. METHODS: Our third-year CPE requires evaluators to identify perceived LOI with each student as low, moderate, or high. We examined CPEs completed during the academic year 2018-2019 for differences in (1) clinical and professionalism ratings, (2) quality of narrative comments, (3) quantity of narrative comments, and (4) percentage of evaluation questions left unrated. RESULTS: A total of 3682 CPEs were included in the analysis. ANOVA revealed statistically significant differences between LOI and clinical ratings (p ≤ .001), with mean ratings from faculty with a high LOI significantly higher than from faculty with a moderate or low LOI (p ≤ .001). Chi-squared analysis demonstrated differences based on faculty LOI and whether questions were left unrated (p ≤ .001), quantity of narrative comments (p ≤ .001), and specificity of narrative comments (p ≤ .001). CONCLUSIONS: Faculty who perceive higher LOI were more likely to assign that student higher ratings, complete more of the clinical evaluation and were more likely to provide narrative feedback with more specific, higher-quality comments. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s40670-021-01307-w.

Unremitting Pain and Fever in a 15-Year-Old Boy With Osteomyelitis.

A previously healthy 15-year-old boy from a rural county in the southeastern United States was evaluated in the emergency department with fever and worsening toe pain in the absence of trauma. He initially presented to his primary care physician 4 weeks before with upper respiratory symptoms and was treated with corticosteroids for presumed reactive airway disease. His respiratory symptoms resolved. One week after this presentation, he developed fever and right great toe pain and presented to an outside hospital. Inflammatory markers were elevated. MRI confirmed a diagnosis of osteomyelitis with associated periosteal abscess. He was treated with intravenous antibiotics and drainage of the abscess. Ten days after his discharge from the outside hospital, he developed fever and had increasing drainage of the toe and pain refractory to oral pain medications. He presented to our facility for further evaluation. Repeat MRI and inflammatory markers corroborated his worsening disease, and he was admitted to the hospital for intravenous antibiotics and underwent serial surgical debridement. He developed painful subcutaneous nodules on his lower extremities and was found to have lung abnormalities on chest radiograph. A multispecialty team collaborated in the management of this patient and unveiled a surprising diagnosis.

An Annotated Bibliography of Key Studies in Medical Education in 2019: Applying the Current Literature to Educational Practice and Scholarship.

Pediatric medical educators have the dual challenge of remaining up-to-date in the field of pediatrics and in the field of medical education. Due to the volume of information published in these 2 fields it can be nearly impossible to remain current in both fields of practice. To facilitate interpretation of the most recent medical education research, the authors conducted an annotated bibliography of medical education literature published in 2019. The purpose of this annotated bibliography was to identify manuscripts which had the potential to significantly influence a pediatric educator's practice. Using a 2-staged review process, the authors reviewed abstracts from 13 medical education and specialty journals. All reviews were independently completed by 2 different reviewers for each journal in both stages. A total of 4700 abstracts were reviewed and 17 key manuscripts were identified. The authors grouped the key manuscripts into 6 core themes: bedside teaching, learning climate, bias, learner autonomy, learner in trouble, and resident competency. This annotated bibliography provides the authors' condensed summary of the medical education manuscripts most likely to influence educational practices for the busy pediatric medical educator.

An Annotated Bibliography of Key Studies in Medical Education in 2018: Applying the Current Literature to Pediatric Educational Practice and Scholarship.

Pediatric educators desire to and should strive to incorporate current educational methods and ideas into their professional practices. The overwhelming volume of medical education literature makes this difficult. This article provides an overview of 18 key articles from the 2018 literature that the authors considered impactful for the field of pediatric medical education. The author group has extensive combined leadership experience and expertise across the continuum of pediatric medical education and used an iterative, staged process to review 2270 abstracts from 13 medical education-related journals. This process aimed to identify a subset of articles that were most relevant to educational practice and scholarship and most applicable to pediatric medical education. Author pairs independently reviewed and scored abstracts and reached consensus to identify the abstracts that best met these criteria. Selected abstracts were discussed using different author pairs to determine the final articles included in this review. The 18 articles selected are summarized. The results showed a cluster of studies related to assessment, learner education and teaching, communication, and culture and climate. This review offers a summary for educators interested in remaining knowledgeable and current regarding the most relevant and valuable information in the field of medical education.

Practical Application of Assessment Principles in the Development of an Innovative Clinical Performance Evaluation in the Entrustable Professional Activity Era.

Educators have been challenged to create assessments that are competency-based and grounded in accepted standards such as the entrustable professional activities (EPAs). The clinical performance evaluation (CPE) is a commonly utilized assessment modality, which allows multiple evaluators to provide feedback on a learner's performance in the clinical workplace. In this paper, we describe the relevant principles that served as a guide as we developed a new CPE for medical students that fully incorporate EPAs. This may help ease the transition for other institutions looking to introduce a new student CPE.

Faculty and Resident Perspectives on Teaching Pediatric Evidence-Based Medicine in the Clinical Setting: A Qualitative Study.

PURPOSE: To describe how pediatric educators effectively teach evidence-based medicine (EBM) in the clinical setting. Secondarily, to identify barriers hindering effective practice and teaching of EBM and strategies to overcome these barriers. METHODS: The authors conducted a cross-sectional multi-institutional qualitative study from July 2016 to December 2017 in which they interviewed pediatric educators across many subspecialties who were identified as exemplary teachers of EBM at 3 academic pediatric residency programs. Pediatric residents who had recently worked with these faculty members were also interviewed to allow triangulation between participants. Qualitative analysis was complete once saturation was achieved. RESULTS: Twenty-six pediatric educators identified as exemplary teachers of EBM and 10 residents who worked with those educators participated in the study. Thirteen explicit teaching strategies and 2 implicit teaching strategies, namely disclosure of uncertainty and role modeling, were identified. Barriers to practicing clinical EBM included balancing patient responsibilities, inadequate time, and personal knowledge. Barriers to teaching clinical EBM were inadequate time and learner engagement. To overcome these barriers, faculty limit and focus teaching points, attempt to make EBM relevant to patient care, and incorporate follow-up strategies. CONCLUSIONS: Numerous teaching strategies are available to faculty to improve the clinical teaching of EBM and to overcome commonly encountered clinical EBM barriers. Familiarity with these clinical EBM teaching strategies can be used for faculty development and to enhance the teaching of EBM to learners.

The Association Between Pediatric Faculty Factors and Resident Physician Ratings of Teaching Effectiveness.

Background. Faculty factors not inherently related to teaching effectiveness can influence teaching ratings. No studies have focused on pediatric faculty who possess unique differences from general medical faculty. Methods. We designed a retrospective observational study to compare faculty teaching ratings with measured factors across 3 academic pediatric institutions. Results. Our study included 196 faculty members. The majority (76%) of variation in teaching effectiveness ratings was not accounted for by any measured variable, but 24% was attributed to measurable factors. Increased resident exposure (sequential r 2 = .10, P < .0001) significantly affected teaching effectiveness. Variation between resident ratings of pediatric faculty teaching can be partially explained by measured factors not necessarily related to teaching effectiveness. Conclusions. The identification of faculty factors that significantly contribute to rating variation can enhance interpretation of these rating.

A young girl with a painful rash.

The speed with which this rash spread and the fact that the patient's skin sloughed off when pressure was applied made the diagnosis clear.