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Refugees face barriers to accessing healthcare despite provision of short-term services after arrival. Limited access to sustained primary care may lead to increased emergency department (ED) utilization and little is known regarding how refugee children access emergency care. To compare the proportion of ED claims and median level of service (LOS) between refugee children and general population controls in a statewide claims database. We conducted a retrospective cohort study of medical claims for patients aged 0 to 18 years old in a statewide claims database from 2014-2019. Refugee claims were identified using deterministic linkage of children with known refugee status. Procedure and diagnosis ICD9/10, Healthcare Common Procedure Coding System, and Current Procedural Terminology codes were obtained from the statewide database to indicate type of claim (ED vs outpatient) and LOS. Demographics were extracted from a data warehouse. Primary outcome was the number of ED claims per 1000 combined ED and outpatient claims. LOS was measured as a proxy for ED visit complexity. We compared demographics, frequency of claims, and median LOS using chi-square. There were 5,590,808 total claims with 1,235,476 ED claims. Median number of ED claims per individual patient was the same between groups, however the proportion of claims related to an ED visit was significantly higher in the refugee population than the general population controls (244 vs 221, p = 0.001). Median LOS for ED claims was Level 3 (99283) and there was no difference between groups. Proportion of ED claims was higher in a refugee population compared to controls with no differences in LOS, indicating higher ED utilization among refugees for all acuity levels. Further study is needed to determine if healthcare disparities account for this difference and if population specific services may support the care of the refugee children.

Electrolyte imbalances are common among patients with traumatic brain injury (TBI). Cerebral salt wasting (CSW) is an electrolyte imbalance characterized by hyponatremia and hypovolemia. Differentiating the syndrome of inappropriate antidiuretic hormone and CSW remains difficult and the pathophysiological mechanisms underlying CSW are unclear. Our intent was to review the literature on CSW within the TBI population, in order to report the incidence and timing of CSW after TBI, examine outcomes, and summarize the biochemical changes in patients who developed CSW. We searched MEDLINE through 2014, hand-reviewed citations, and searched abstracts from the American Association for the Surgery of Trauma (2003–2014). Publications were included if they were conducted within a TBI population, presented original data, and diagnosed CSW. Publications were excluded if they were review articles, discussed hyponatremia but did not differentiate the etiology causing hyponatremia, or presented cases with chronic disease. Fifteen of the 47 publications reviewed met the selection criteria; nine (60 %) were case reports, five (33 %) were prospective and 1 (7 %) was a retrospective study. Incidence of CSW varied between 0.8 - 34.6 %. The populations studied were heterogeneous and the criteria used to define hyponatremia and CSW varied. Though believed to play a role in the development of CSW, increased levels of natriuretic peptides in patients diagnosed with CSW were not consistently reported. These findings reinforce the elusiveness of the CSW diagnosis and the need for strict and consistent diagnostic criteria.

BackgroundDiagnostic errors (DxEs) are an understudied source of patient harm in children rarely captured in current adverse event reporting systems. Applying electronic triggers (e-triggers) to electronic health records shows promise in identifying DxEs but has not been used in the emergency department (ED) setting.ObjectivesTo assess the performance of an e-trigger and subsequent manual screening for identifying probable DxEs among children with unplanned admission following a prior ED visit and to compare performance to existing incident reporting systems.Design/methodsRetrospective single-centre cohort study of children ages 0–22 admitted within 14 days of a previous ED visit between 1 January 2018 and 31 December 2019. Subjects were identified by e-trigger, screened to identify cases where index visit and hospital discharge diagnoses were potentially related but pathophysiologically distinct, and then these screened-in cases were reviewed for DxE using the SaferDx Instrument. Cases of DxE identified by e-trigger were cross-referenced against existing institutional incident reporting systems.ResultsAn e-trigger identified 1915 unplanned admissions (7.7% of 24 849 total admissions) with a preceding index visit. 453 (23.7%) were screened in and underwent review using SaferDx. 92 cases were classified as likely DxEs, representing 0.4% of all hospital admissions, 4.8% among those selected by e-trigger and 20.3% among those screened in for review. Half of cases were reviewed by two reviewers using SaferDx with substantial inter-rater reliability (Cohen’s κ=0.65 (95% CI 0.54 to 0.75)). Six (6.5%) cases had been reported elsewhere: two to the hospital’s incident reporting system and five to the ED case review team (one reported to both).ConclusionAn e-trigger coupled with manual screening enriched a cohort of patients at risk for DxEs. Fewer than 10% of DxEs were identified through existing surveillance systems, suggesting that they miss a large proportion of DxEs. Further study is required to identify specific clinical presentations at risk of DxEs.

BackgroundTibial plateau fractures (TPFs) are frequently associated with motor vehicle accidents, auto-pedestrian crashes and falls. However, hospitals near ski resorts commonly treat TPF resulting from skiing. The soft tissue envelope and original mechanism of injury are important determinants in the decision to proceed with immediate or delayed fixation of the fracture. Our objective was to assess whether immediate (≤24 hours) versus delayed (>24 hours) open reduction internal fixation (ORIF) affected in-hospital outcomes among snow sport participants.MethodsThis was a retrospective study of patients with isolated TPF who were injured while skiing or snowboarding and treated at a Level III Trauma Center that serves four major ski resorts between 2010 and 2013. Clinical characteristics and in-hospital outcomes were obtained from an existing trauma database. Imaging was reviewed to classify the fracture as high (Schatzker IV–VI) or low (Schatzker I–III) energy. Differences in clinical characteristics and outcomes between immediate and delayed ORIF patients were analyzed with χ2 and Wilcoxon two-sample tests. These analyses were also performed in the high-energy and low-energy fracture populations.ResultsORIF was performed on 119 snow sport patients, 93 (78%) immediately. Patients had a median age of 49 years (range 19–70) and were predominantly male (66%). Forty percent sustained a high-energy TPF. No differences were observed between the demographic characteristics, injury severity, Schatzker scores or time from injury to hospital arrival for patients treated immediately versus delayed treatment. Compared with delayed fixation, patients treated immediately had less compartment syndrome (3% vs 27%), needed fewer fasciotomies (6% vs 31%) and had a shorter length of stay (3 vs 6.5 days), p<0.05 for all. These results persisted in the stratified analysis of high-energy fracture patients.DiscussionTreating patients immediately led to more favorable in-hospital outcomes compared with delayed treatment, even among the patients with a high-energy fracture.Level of evidenceLevel IV, Therapeutic/Care Management.

BackgroundEasy firearm access increases injury risk among adolescents. We evaluated the acceptability and feasibility of improving knowledge of a 3 min safe firearm storage education video in the paediatric emergency department.MethodsWe conducted a single-centre block trial in a large paediatric emergency department (August 2020–2022). Participants were caregivers of adolescents (10–17 years) in firearm-owning households. First block participants (control) completed a baseline survey about child safety behaviours (including firearms). Second block participants (intervention) completed a baseline survey, watched the safe firearm storage video and evaluated acceptability. Participants completed a 3-month follow-up survey about firearm safety behaviours and knowledge recall. Demographic and clinical variables were compared between the intervention and control groups using Fisher’s exact and χ2 tests. McNemar’s test was used to compare firearm storage behaviours at the initial and 3-month visit within each group.ResultsResearch staff approached 1264 caregivers; 371 consented to participate (29.4%) and 144 (38.8%) endorsed firearm ownership. There were 95 participants in the control group and 62 in the intervention group. Follow-up was lower in the intervention group (53.7% vs 37.1%, p=0.04). Among participants viewing the video, 80.3% liked the video and 50.0% felt they learnt something new from the video.ConclusionsVideo-based firearm education in a paediatric emergency department is acceptable among a population of caregivers of adolescents with household firearms. This is a higher-risk group that may uniquely benefit from consistent education in the paediatric emergency department. Further study with larger populations is needed to evaluate intervention effectiveness.Trial registrationThe study was registered with ClinicalTrials.gov (NCT05168878).

BackgroundObtaining informed consent for clinical research in the pediatric emergency department (ED) is challenging. Our objective was to understand the factors that influence parental consent for ED studies.MethodsThis was a cross-sectional survey assessing parents’ willingness to enroll their children into an ED research study. Parents reporting a willingness to enroll in ED studies were presented with two hypothetical scenarios, a low-risk and a high-risk study, and then asked about decision influencers affecting consent. Parents expressing a lack of willingness to enroll were asked which decision influencers impacted their consent decision.ResultsAmong 118 parents, 90 (76%) stated they would be willing to enroll their child into an ED study; of these, 86 (96%) would consent for a low-risk study and 54 (60%) would consent for a high-risk study. Caucasian parents, and those with previous research exposure, were more likely to report willingness to participate. Those who would consent to the high-risk study cited “benefits that research would provide to future children” most strongly influenced their decision to agree.ConclusionsED investigators should highlight the benefits for future children and inquire about parents’ previous exposure to research to enhance ED research enrollment. Barriers to consent in non-Caucasian families should be further investigated.ImpactObtaining consent for pediatric emergency research is challenging and this study identified factors influencing parental consent for research in EDs.Benefits for future children and parents’ previous research experience were two of the most influential factors in parents’ willingness to consent to ED research studies.These findings will help to improve enrollment in ED research studies and better our understanding of how to promote the health and well-being of pediatric patients.

Background and Objectives Despite limited evidence, cannabidiol-rich cannabis extracts have been popularly used in pediatrics. With increased use, it is critical to determine basic pharmacokinetic parameters of cannabidiol in these extracts in the pediatric population. The objective of this study was to determine the disposition of oral cannabidiol cannabis extracts and drug interactions in children with pediatric epilepsy. Methods We conducted a prospective observational study evaluating the disposition of oral cannabidiol in children (< 18 years of age) receiving cannabidiol extracts for epilepsy. Subjects underwent serial blood draws after oral cannabidiol administration. Cannabidiol and metabolites, along with anticonvulsant concentrations were determined. Results Twenty-nine patients had sufficient pharmacokinetic data and were included in the analysis. Mean age was 9.7 years (standard deviation 4.3) and 17 patients (59%) were male. Median peak plasma cannabidiol concentrations was 13.1 ng/mL (interquartile range 6.8–39.3 ng mL); median time to peak of 2.0 h (interquartile range 2.0–4.0 h). Mean acute elimination half-life of oral cannabidiol was 6.2 h (standard deviation 1.8 h). There was an observed half-life of degradation of 533 days noted for cannabidiol concentrations when stored for 0.6–3.1 years. There was some impact on cannabidiol pharmacokinetic parameters when cannabidiol was co-administered with zonisamide (elimination rate constant and V1) and levetiracetam (elimination rate constant). Conclusions In pediatric patients using oral cannabidiol-rich cannabis extract for epilepsy, the time to peak concentration of plasma cannabidiol and average acute elimination half-life were shorter than those reported for adults. Co-administration of zonisamide and levetiracetam had some impact on cannabidiol pharmacokinetic parameters. There was an observed degradation of plasma cannabidiol in long-term storage. Clinical registration ClinicalTrials.gov Identifer no. NCT02447198.

Hemorrhagic shock is a principal cause of death among trauma patients within the first 24 hours after injury. Optimal fluid resuscitation strategies have been examined for nearly a century, more recently with several randomized controlled trials. Hypotensive resuscitation, also called permissive hypotension, is a resuscitation strategy that uses limited fluids and blood products during the early stages of treatment for hemorrhagic shock. A lower-than-normal blood pressure is maintained until operative control of the bleeding can occur. The randomized controlled trials examining restricted fluid resuscitation have demonstrated that aggressive fluid resuscitation in the prehospital and hospital setting leads to more complications than hypotensive resuscitation, with disparate findings on the survival benefit. Since the populations studied in each randomized controlled trial are slightly different, as is the timing of intervention and targeted vitals, there is still a need for a large, multicenter trial that can examine the benefit of hypotensive resuscitation in both blunt and penetrating trauma patients.

Blockchain has made numerous breakthroughs in the past decade as an emerging technology. The benefits, obstacles, and adoption of this technology still lack in-depth research. A qualitative research method was chosen to conduct eight semi-structured expert interviews to explore adoption within the well-being sector, supply chain functions, and the public sector. The outcomes of the thesis suggest that there is significant potential across all sectors; however, the pace of adoption and the blockchain qualities employed differ. Common themes are that large and complex ecosystems favor blockchain adoption, but more understanding of the technology and transparent legal frameworks are required across all sectors.

We describe a female patient who sustained multiple trauma including severe blunt thoracic trauma with left pulmonary laceration. She survived the pneumonectomy necessary after cardiopulmonary resuscitation (CPR). Histology of the pneumonectomy specimen showed an incidental pT1 pN1 adenocarcinoma of the upper lobe.