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Abstract: Inferior vena cava assessment is a standard component of focused cardiac ultrasound, traditionally used to qualify intravascular volume status. In this case series, we demonstrate that pediatric focused cardiac ultrasound can also diagnose inferior vena cava thrombi and masses, while distinguishing them from a potentially benign smoke-like artifact., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Advance practice providers (APPs) have been increasingly incorporated into emergency department (ED) staffing. The objective of this study was to describe patient factors that predict when pediatric patient care is provided by APPs and/or physicians. We hypothesized that APPs care for a significant proportion of pediatric patients and are more likely to care for lower acuity patients., Methods: We performed a retrospective chart review of encounters in patients aged younger than 18 years across 9 EDs from January 2018 to December 2019. Data on age, acuity level, International Classification of Diseases, Tenth Revision code, procedures performed, disposition, provider type, and length of stay were extracted from the electronic health record., Results: Of 159,035 patient encounters, 37% were cared for by an APP (30% APP independently, 7% physician + APP) and 63% by physicians independently. Advance practice providers were more likely to care for lower acuity patients (60.8% vs 4.4%, P < 0.05) and those in EDs with less pediatric emergency medicine (PEM) coverage (33.4% vs 6.8%, P < 0.05). In an adjusted multinomic regression model, APPs were less likely than physicians to care for high-acuity patients (odds ratio [OR], 0.03; 95% confidence interval [CI], 0.01-0.09), admitted patients (OR, 0.31; CI, 0.28-0.35) and patients in EDs with more PEM coverage (OR, 0.09; CI, 0.09-0.09)., Conclusions: Advance practice providers cared for more than one third of pediatric patients and tended to care for lower acuity patients and for patients in EDs with less PEM coverage. These data highlight the importance of integrating APPs into initiatives aiming to improve pediatric emergency care., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Cultural sensitivity (CS) training is vital to pediatric emergency medicine (PEM) curricula. This study aimed to explore CS in Yale PEM fellows and emergency medicine (EM) residents at Indus Hospital and Health Network (IHHN) in Pakistan through distance simulation activities., Methods: This mixed-methods analysis of an educational intervention was conducted at Yale University in collaboration with IHHN. We approached seven U.S. PEM fellows and 22 Pakistani EM residents. We performed a baseline CS assessment using the Clinical Cultural Competency Questionnaire (CCCQ). Afterward, the U.S. PEM fellows facilitated the Pakistani EM residents through six distance simulation sessions. Qualitative data were collected through online focus groups. The CCCQ was analyzed using descriptive statistics, and content analysis was used to analyze the data from the focus groups., Results: Seven U.S. PEM fellows and 18 of 22 Pakistani EM residents responded to the CCCQ at the beginning of the module. The mean (±SD) CCCQ domain scores for the U.S. PEM fellows versus the Pakistani EM residents were 2.56 (±0.37) versus 2.87 (±0.72) for knowledge, 3.02 (±0.41) versus 3.33 (±0.71) for skill, 2.86 (±0.32) versus 3.17 (±0.73) for encounter/situation, and 3.80 (±0.30) versus 3.47 (±0.47) for attitude (each out of 5 points). Our qualitative data analysis showed that intercultural interactions were valuable. There is a common language of medicine among the U.S. PEM fellows and Pakistani EM residents. The data also highlighted a power distance between the facilitators and learners, as the United States was seen as the standard of "how to practice PEM." The challenges identified were time differences, cultural practices such as prayer times, the internet, and technology. The use of local language during debriefing was perceived to enhance engagement., Conclusion: The distance simulation involving U.S. PEM fellows and Pakistani EM residents was an effective approach in assessing various aspects of intercultural education, such as language barriers, technical challenges, and religious considerations., Competing Interests: The authors have no conflicts of interest to disclose., (© 2023 Society for Academic Emergency Medicine.)

Background: Health disparities and the unequal distribution of social resources impact health outcomes. By considering social determinants of health (SDH), clinicians can provide holistic and equitable care. However, barriers such as lack of time or understanding of the relevance of SDH to patient care prevent providers from addressing SDH. Simulation curricula may improve learners' ability to address SDH in practice., Objectives: The primary objective was to increase the percentage of pediatric emergency simulations that included SDH objectives from 5% to 50% in 12 months at one institution. As a balancing metric, we examined whether trainees approved the incorporation of SDH objectives., Methods: Using the Model for Improvement approach, we conducted interviews of residents and simulation facilitators to identify challenges to integrating SDH objectives into the simulation curriculum. Review of interviews and visual representation of the system helped identify key drivers in the process. A team of simulation leaders, residents, and fellows met regularly to develop simulation cases with embedded SDH objectives. Using a plan, do, study, act approach, we tested, refined, and implemented interventions including engaging residency program and SDH leadership, piloting cases, providing facilitators concise resources, inviting SDH-specific experts to co-debrief, and eliciting and incorporating learner and facilitator feedback to improve cases. SDH topics include homelessness, undocumented status, and racism., Results: Prior to the start of the quality improvement work, SDH were rarely incorporated into emergency simulations for pediatric residents. A p-chart was used to track the percentage of monthly cases that incorporated SDH topics. During the study period, the percentage of simulations including SDH topics increased to 57% per month. Most trainees (94%) welcomed incorporating SDH objectives., Conclusions: Using the Model for Improvement, we incorporated SDH objectives into pediatric resident emergency simulations. Next steps include examining effectiveness of the curriculum, dissemination to additional learners, and examining sustainability in practice., Competing Interests: The authors declare no conflicts of interest., (© 2023 Society for Academic Emergency Medicine.)

Abstract: The combination of ketamine and propofol, commonly referred to as ketofol, is sometimes used for procedural sedation and analgesia in the pediatric emergency department. This article reviews the pharmacology, dosing, and indications, as well as adverse effects and contraindications of ketamine, propofol, and ketofol., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Context: Rap1 GTPase-activating protein (GAP) regulates the activity of Rap1, a putative oncogene. We previously reported Rap1GAP was highly expressed in normal human thyroid cells and decreased in five papillary thyroid carcinomas (PTCs)., Objectives: To confirm the significance of these findings, we analyzed Rap1GAP expression in a larger set of benign tumors (adenomas and hyperplastic nodules) and PTCs. We determined whether the presence of the BRAF(V600E) mutation or allelic loss of Rap1GAP related to changes in Rap1GAP protein expression. To determine the consequences of Rap1GAP loss, we targeted Rap1GAP in culture using small interfering RNA., Design, Patients, and Methods: A highly specific Rap1GAP antibody was applied to sections of 55 human thyroid tissues. Genomic DNA was analyzed for the presence of the BRAF(V600E) mutation, and loss of Rap1GAP. Rap1GAP expression in rat thyroid cells was abolished using small interfering RNA., Results: We observed that down-regulation of Rap1GAP in benign lesions and PTCs was common. Rap1GAP expression was more severely decreased in PTCs. Loss of Rap1GAP expression was observed in multiple histological variants of PTCs. Approximately 20% of PTCs and adenomas exhibited allelic loss of Rap1GAP. Loss of Rap1GAP was not associated with the presence of the BRAF(V600E) mutation. In vitro, loss of Rap1GAP was sufficient to increase Rap1 activity in thyroid cells., Conclusions: These data indicate that loss of Rap1GAP is a frequent event in PTC. The more frequent and greater down-regulation of Rap1GAP in PTCs compared with adenomas suggests a role for Rap1GAP depletion in the progression of human thyroid tumors, possibly through unrestrained Rap activity.