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 χ 2 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.

Breastfeeding Among Pediatric Emergency Physicians: Rates, Barriers, and Support.

OBJECTIVES: Physician mothers are at risk for early cessation of breastfeeding, in part because of challenges associated with returning to work. Given the inherent unpredictability of emergency medicine practice, we hypothesized that pediatric emergency medicine (PEM) physicians would face unique challenges in continuing breastfeeding while working in their field. The aims of this study were to determine the 6-month breastfeeding rates of PEM physicians, gain insight into their experiences expressing breast milk while working in pediatric emergency departments, and determine factors that support or discourage successful breastfeeding. METHODS: This study was a cross-sectional survey of members of the American Academy of Pediatrics Section on Emergency Medicine via its quarterly membership survey program. Separate survey pathways were developed for respondents who had ever breastfed and those who had not. RESULTS: One hundred ninety-three responded; 91 had breastfed, and 102 had not. Of those who breastfed, 90% did so for 6 months or longer. Mean (SD) duration was 12.5 (7.1) months (range, 2-48 months). Of those who expressed milk at work, only 7.6% felt they "always" had sufficient time to pump; 32% felt they "always" had what they considered to be an appropriate location to pump. Breastfeeding duration rate of at least 6 months was higher for those (66%) who "sometimes" to "always" had access to what they felt were appropriate locations to pump than for those (34%) who "never" or "occasionally" did (98 vs 85%, P = 0.048). Eighty-six percent of respondents who had never breastfed reported being "very supportive" of expressing milk at work. CONCLUSIONS: Breastfeeding PEM physicians have high 6-month breastfeeding rates, and many express milk at work. Although colleagues report being supportive, barriers of perceived lack of sufficient time to pump and appropriate pumping locations remain.

Sexual History Documentation and Sexually Transmitted Infection Screening for Mental Health Patients in a Pediatric Emergency Department.

OBJECTIVES: Adolescents with psychiatric conditions more commonly engage in high-risk sexual behaviors and are at increased risk of sexually transmitted infections (STIs) and when presenting to pediatric emergency departments (PEDs) may be an important population in which to target screening efforts. This study aimed to determine frequency of physician-documented sexual history and STI screening in adolescents presenting to a PED with mental health-related complaints. METHODS: Retrospective study of patients aged 14 to 18 years presenting to a PED February 2015 to September 2016. Electronic records were reviewed for demographics, chief complaint, sexual history documentation, STI screening, resident involvement in patient care, and disposition. Proportions were calculated for frequencies, whereas χ2 and Fisher exact tests evaluated factors associated with documentation of sexual history and STI screening. RESULTS: Two hundred eighty-five patient encounters were identified. Age range was 15 to 18 years with an average of 16 years, and 58% were girls. The most common chief complaint was "intentional ingestion/overdose" (169 encounters, 59%) followed by "suicidal/attempted suicide" (59, 21%). Seventy-seven patients (27%) had sexual history documented. Girls were more likely to have sexual history documented (75% vs 52%, P = 0.0004). Forty-five (59%) patients were noted to be sexually active, and 17 (38%) of these were screened for STI. There was no relationship between screening and race, sex, or involvement of a resident in patient care. CONCLUSIONS: In a high-risk PED population, physicians documented sexual history only 27% of the time. Female patients were more likely to have a sexual history documented. In patients with sexual history indicating risk for STI, less than half were screened.

Adolescent Pride Festival Attendees-Assessing Their Interactions With Primary Care Physicians.

PURPOSE: Pride festivals celebrate the lesbian, gay, bisexual, transgender (LGBT) community. This study aimed to describe adolescent Pride festival attendees, determine rates of accessing health care via their primary care physician (PCP), and assess if providers are discussing sex and offering screening for sexually transmitted infections (STIs) to these adolescents. METHODS: Adolescents, aged 13-17 years, attending the 2017 Minnesota Pride Festival were invited to complete an 18-question survey regarding gender identity, sexual orientation, access to a physician the preceding year, and whether sexual activity was discussed and/or STI screening provided at these encounters. RESULTS: A total of 490 surveys were evaluated. Sixty-nine percent of respondents identified as having nonheterosexual orientation. Rural participants were significantly more likely to identify as LGBT than urban or suburban participants. The majority (90%) of adolescents had been seen in the past year by a physician. Of these, 68% had been asked a sexual history, and 29% were offered STI testing. Older adolescents were more likely to be asked about sex and offered STI testing by a physician. Identifying as LGBT was not associated with rate of sexual history taken or STI screening offered but was associated with perceived need for STI testing. CONCLUSIONS: LGBT youth attending Minnesota Pride are accessing a PCP with the same regularity as cisgender, heterosexual peers but are infrequently offered STI testing, despite knowledge of increased STI rates in this population. Taking a sexual history and screening for STIs is something all physicians can do and represents an important first step in any STI reduction initiative.

Ocular Injury Presenting to a Level-III Pediatric Trauma Center.

The purpose of this study is to describe pediatric ocular injuries presenting to a level-III pediatric trauma center and emergency department. METHODS: We performed a retrospective study and identified children from January 1, 2011, to January 1, 2016. Charts were reviewed for any subject, age from newborn to younger than 18 years, based on International Classification of Diseases, ninth and tenth revision, codes for any ocular injury. Data abstraction included age, sex, means of arrival, eye involved, mechanism of injury, type of ocular injury, imaging studies obtained, procedures performed, location of definitive repair (in the operating room or emergency department), and subspecialty services involved. RESULTS: In the 5-year period, we describe 356 injuries among 278 children. Males had a slightly higher rate of presentation than females (156 and 122, respectively). Forty-three children (15.46%) required repair in the operating room. Dog bites comprised of 7.19% children with outpatient follow-up, one patient (0.36%) eventually developed anophthalmia, and 30 children (10.79%) had long-term ophthalmological sequelae (ie, glaucoma and blindness). CONCLUSIONS: At our institution, a level-III trauma center, we evaluated and managed approximately 1 ocular injury case per week and children required surgical repair in the operating room at a higher rate than higher-level trauma centers. Injuries secondary to dog bites remain a clinically significant etiology.

Streptococcus constellatus Tubo-ovarian Abscess in a Non-Sexually Active Adolescent Female.

Tubo-ovarian abscess (TOA) in non-sexually active female adolescents is a rare presentation to the pediatric emergency department. In the following case, bilateral TOA secondary to Streptococcus constellatus was diagnosed in a 13-year-old virginal female. The patient was seen 4 months before presentation for interventional radiology-guided drainage and antibiotic treatment for an intra-abdominal abscess due to suspected appendiceal rupture. Exploratory laparotomy on the most recent presentation demonstrated an appendix with inflammation and serositis on pathology report, a concern for chronic appendicitis with microperforation and subsequent bacterial translocation of the bilateral ovaries. This case report identifies a rare cause, pathogen, and the patient's demographics presenting with bilateral TOA. Most importantly, this case demonstrates the need for emergency medicine physicians to have a high index of suspicion for TOA in patients with a significant medical history of intra-abdominal pathology to promptly diagnose and treat high-morbidity pathology.

Screening for Asymptomatic Gonorrhea and Chlamydia in the Pediatric Emergency Department.

BACKGROUND: Because adolescents rely heavily on emergency services for health care, a pediatric emergency department (PED) visit may be their only opportunity for sexually transmitted infection (STI) screening. The primary objectives of this study were to determine the proportion of Neisseria gonorrheae (GC) and Chlamydia trachomatis (CT) infections in asymptomatic PED adolescents and patient-perceived barriers to STI screening. METHODS: A convenience sample of patients aged 14 to 21 years presenting to an urban PED with nongenitourinary complaints was offered screening for GC and CT. Regardless of declining or accepting screening, all were asked to complete a questionnaire designed to identify barriers to screening. RESULTS: Sixty-eight percent of those approached participated (n = 719). Those who agreed to STI screening were more likely to be nonwhite (61.4% vs. 38.6%, P = 0.001) and publically insured (63.3%) versus privately insured (29.3%) or no insurance (7.58%). Four hundred three (56%) participants provided urine samples, and of those, 40 (9.9%) were positive for an STI. Controlling for other demographics, race was a significant predictor, with the odds of testing positive for nonwhite participants 5.90 times that of white participants. Patients who refused testing were more likely to report not engaging in sexual activity (54.3% vs. 42.4%, P = 0.009) and less likely to perceive that they were at risk for STIs. CONCLUSIONS: There are high proportions of GC and CT among asymptomatic adolescents visiting an academic urban PED. A universal PED STI screening program may be an important component of STI reduction initiatives, especially among adolescents who do not perceive that they are at risk and may not receive testing elsewhere.

Hair tourniquet of the circumvallate papillae: a potentially "hairy" situation.

Oral foreign bodies and hair-thread tourniquets are fairly common findings. The combination of the two, however, is rarer. In this article, we present a case involving a hair-thread tourniquet of a circumvallate papillae (more commonly known as a "taste bud"). We discuss methods for removal of hair-thread tourniquets as well as techniques for examining children for oral foreign bodies.