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Down syndrome regression disorder (DSRD) is a clinical symptom cluster consisting of neuropsychiatric regression without an identifiable cause. This study evaluated the clinical effectiveness of IVIg and evaluated clinical characteristics associated with relapse after therapy discontinuation. A prospective, multi-center, non-randomized, observational study was performed. Patients met criteria for DSRD and were treated with IVIg. All patients underwent a standardized wean off therapy after 9–12 months of treatment. Baseline, on therapy, and relapse scores of the Neuropsychiatric Inventory Total Score (NPITS), Clinical Global Impression-Severity (CGI-S), and the Bush-Francis Catatonia Rating Scale (BFCRS) were used to track clinical symptoms. Eighty-two individuals were enrolled in this study. Patients had lower BFCRS (MD: -6.68; 95% CI: -8.23, -5.14), CGI-S (MD: -1.27; 95% CI: -1.73, -0.81), and NPITS scores (MD: -6.50; 95% CI: -7.53, -5.47) while they were on therapy compared to baseline. Approximately 46% of the patients (n = 38) experienced neurologic relapse with wean of IVIg. Patients with neurologic relapse were more likely to have any abnormal neurodiagnostic study (χ2 = 11.82, p = 0.001), abnormal MRI (χ2 = 7.78, p = 0.005), and abnormal LP (χ2 = 5.45, p = 0.02), and a personal history of autoimmunity (OR: 6.11, p

This study aimed to learn about the experiences of families of individuals with a dual diagnosis of Down syndrome (DS) and autism spectrum disorder (ASD) (DS-ASD), and to document the journey from early concerns to diagnosis and intervention. Caregivers completed an online survey describing their journey raising a child with DS-ASD. Survey responses were analyzed qualitatively and coded into categories to highlight common themes. Stereotypy, severe communication impairments, and behavioral difficulties prompted caregivers to pursue further evaluation. There was a mean 4.65-year gap between first noticing symptoms and receiving an ASD diagnosis. Several therapeutic interventions were identified as beneficial, including behavioral and communication support. Caregivers expressed frustration and described high levels of stress and social isolation. The diagnosis of ASD in children with DS is often delayed, and caregivers’ initial concerns are frequently dismissed. Raising a child with DS-ASD can lead to social isolation and elevated caregiver stress. More research is needed to tailor diagnostic algorithms and therapeutic interventions to the unique needs of this patient population. Caregivers yearn for improved understanding of DS-ASD, more targeted therapies and educational programs, and more overall support.

The current study evaluates the concurrent relationship between parent ratings of executive functioning and maladaptive behavior among children and adolescents with Down syndrome and then repeats this evaluation using teacher reports. Parents and teachers of 63 school-age children with Down syndrome rated the child's executive functioning (Behavior Rating Inventory of Executive Function) and behaviors (Achenbach Child Behavior Checklist). For parent and teacher ratings, elevated behavior dysregulation predicted higher levels of rule-breaking, aggressive, and externalizing behavior. For teacher ratings, elevated behavior dysregulation also predicted higher levels of inattention problems. Among both parent and teacher ratings, greater metacognitive difficulties predicted challenges with attention. Understanding the relationship between these constructs has important implications for targets of intervention and developing preventative strategies.

Children and young adults with Down syndrome can demonstrate increased behavior problems compared to their typically developing peers through childhood and adolescence. This study aims to: (1) iden...

BACKGROUNDTraditionally, autism spectrum disorder in people with Down syndrome was believed to be uncommon. This misconception is rooted in the challenges that a dual diagnosis poses. In fact, evidence indicates that children with Down syndrome are at risk for autism spectrum disorder with a potentially higher prevalence than the typically developing population. The purpose of this review is to determine the reported prevalence rate of autism spectrum disorder in all individuals with Down syndrome in comparison to the prevalence rate of autism spectrum disorder in the typical population when specific diagnostic tools are used. METHODSWe will conduct a systematic review of the prevalence and incidence data and perform a meta-analysis on these results. This study will consider all studies that reported on children and adults with an existing diagnosis of Down syndrome and diagnosed by the standardized assessments for autism spectrum disorder. We will also consider the diagnoses made by team assessment (psychologist, psychiatrist & developmental pediatrician), according to DSM-III, DSM-IV or DSM-V criteria for diagnosing autism spectrum disorder or if they use autism spectrum disorder screeners. Studies will be considered from all countries that have data reporting prevalence on this topic. We will not apply language restrictions, attempting to translate studies that are not in English. We will search five databases (MEDLINE, Embase, PsychINFO, Scopus, and CINAHL). Two reviewers will conduct all screening and data extraction independently. The articles will be categorized according to key findings and a critical appraisal performed.DISCUSSIONThe results of this review will bring increased awareness of the presence of autism spectrum disorder in individuals with Down syndrome. In doing so, this may facilitate a recommendation for screening and diagnosis for autism spectrum disorder in all individuals with Down syndrome. Based on the research demonstrating the benefits of early identification and intervention on the outcomes of children with autism, we anticipate similar benefits in this population. This will guide the allocation of resources and direct future research.SYSTEMATIC REVIEW REGISTRATIONWe registerd the review title prospectively on PROSPERO on November 8, 2021. Registration number: CRD42020213282

The current study evaluates the psychometric properties of the Behavior Rating Inventory of Executive Function (BRIEF) with children with Down syndrome. Caregivers of 84 children with Down syndrome rated their child's behavior with the BRIEF. Teacher ratings were obtained for 57 children. About 40% of children with Down syndrome were reported by parents, and 70% by teachers, to exhibit clinically significant challenges with executive functioning. Distribution of scores was normal, internal consistency for subscales was questionable to primarily excellent, and inter-rater reliability was poor to good. Normative data conversions controlled for age, IQ, and gender differences, with some exceptions. The study findings suggest that the BRIEF and its subscales generally performed in a psychometrically sound manner among children with Down syndrome.

Background: Down syndrome regression disorder (DSRD) is a symptom cluster consisting of neuropsychiatric regression without cause. No studies evaluating a neurologic component to the disease have been performed. This study sought to evaluate the incidence of neurodiagnostic study abnormalities in individuals with DSRD and to determine if study abnormalities are indicative of responses to therapeutic intervention, specifically, immunotherapy. Methods: A retrospective, multi-center, case-control, study was performed. Patients were required to have subacute onset and the presence of four of five symptom groups present (cognitive decline, expressive language, sleep derangement, loss of ability to perform activities of daily living and/or a new movement disorder). The primary study outcomes were the presence of abnormalities on EEG, MRI, and cerebrospinal fluid (CSF). Secondary endpoints included therapeutic response to interventions with antidepressants, antipsychotics, benzodiazepines, electroconvulsive therapy, and immunotherapy. Findings: Individuals with DSRD were comparable to a cohort of individuals with only DS although had higher rates of autoimmune disease ( p = 0·02, 95%CI: 1·13-3·59). Neurodiagnostic abnormalities were found on EEG (n=13, 27%), neuroimaging (n=11, 23%) and CSF (n=8, 19%). Pleocytosis was appreciated in three cases, elevated total protein in eight cases, elevated IgG index in five cases, and oligoclonal bands in one case. Individuals tested within three years of onset of symptoms were more likely to have neurodiagnostic abnormalities ( p = 0·003, 95%CI: 2·29-61·40). In patients with neurodiagnostic abnormalities immunotherapy was nearly four times more likely to have a therapeutic effect than in those without neurodiagnostic abnormalities (OR: 3·8, 95%CI: 1·34-10·90). In those with normal neurodiagnostic studies (n=27), IVIg was effective in seven of eight (88%) patients as well although other immunotherapies were uniformly ineffective. Interpretation: This study reports the novel presence of neurodiagnostic testing abnormalities in individuals with DSRD, providing credence to this symptom cluster potentially being of neurologic and/or neuroimmunologic etiology. Funding Information: None to declare. Declaration of Interests: None to declare. Ethics Approval Statement: Patients were retrospectively identified following IRB approval through an institution-based audit of in-person evaluations and telemedicine-based consultations for persons with Down syndrome and neurocognitive regression from July 1 2019 to July 1 2021.

Background Infants with Down syndrome (DS) are at risk for a range of phenotypic outcomes, including delays in the onset of reaching behaviour, a critical skill that facilitates early learning. This parallel-group feasibility and pilot study presents findings from a parent-mediated micro-intervention that aimed to support the development of reaching behaviour in a sample of infants with DS. Methods Participants were 73 infants with DS and their caregivers. Infants who qualified for the home-based intervention (based on manual skill performance on Bayley Scales of Infant and Toddler Development, Third Edition items) were randomly assigned individually or by geographical region to a treatment or an alternative treatment condition that involved toy-based interactions with caregivers. Infants in the treatment condition experienced facilitated reaching during the toy-based interactions through the use of Velcro-affixed mittens and toys. Results Forty-two infants met criteria to participate in the intervention, and 37 participated in both baseline and post-treatment visits. At post-treatment, infants in the treatment condition demonstrated shorter latencies to make contact with objects and showed higher frequencies of reach attempts and swats at objects than infants in the alternative treatment group. These findings were more pronounced when examining a chronological age-restricted subgroup of infants 5 to 10 months. Conclusions Findings suggest that a syndrome-informed approach to targeted intervention may be a promising application of phenotyping science in DS and other neurogenetic conditions associated with intellectual disability.

Behavioral challenges in Down syndrome are often complex, multifactorial, and range in severity. A model that incorporates factors from the molecular to the phenotypic level can support improved understanding of the nature of behaviors within the Down syndrome population. In this chapter, we will first describe what we know about behavioral challenges in Down syndrome. We will then explore what key genetic, systemic, biological, learning, and environmental factors must be included in any approach to evaluating behavioral challenges in Down syndrome. Finally, we will discuss the relevance of creating a multidimensional dynamic approach to advance the science and understanding of behaviors in individuals with Down syndrome.

Background While delays in cognitive development are detectable during early development in Down syndrome, the neuropsychological and biomedical underpinnings of cognitive skill acquisition in this population remain poorly understood. Method To explore this issue, 38 infants with Down syndrome [mean chronological age = 9.65 months; SD = 3.64] completed the Bayley Scales of Infant Development-III and a set of laboratory tasks that measured sustained attention (duration of visual attention during a 1-min object exploration task), attention shifting (mean latency to shift attention on an alternating object presentation task) and visual short-term memory (dishabituation to a novel object on a change preference task). Results Latency to shift attention was negatively associated with Bayley Cognitive Scale raw scores, even when controlling for the effects of chronological age, r (33) = -.41, P = .02. In addition, prematurity status was associated with latency to shift attention. Conclusions Early attention shifting may be an important factor that facilitates overall cognitive skill acquisition in infants with Down syndrome, and premature birth may be a risk factor for difficulties on this dimension.

BACKGROUND Behavioural problems are common among children with Down syndrome (DS). Tools to detect and evaluate maladaptive behaviours have been developed for typically developing children and have been evaluated for use among children with intellectual and developmental disabilities. However, these measures have not been evaluated for use specifically in children with DS. This psychometric evaluation is important given that some clinically observed behaviours are not addressed in currently available rating scales. The current study evaluates the psychometric properties of the Child Behavior Checklist (CBCL), a commonly used screening tool developed for typically developing children and commonly used with children with intellectual and developmental disabilities. METHODS The study investigated the psychometric properties of the CBCL among school-aged children with DS, including an assessment of the rate of detecting behaviour problems, concerns with distribution, internal consistency, inter-rater reliability and convergent and discriminant validity with the Aberrant Behavior Checklist and Nisonger Child Behavior Rating Form. Caregivers of 88 children with DS aged 6-18 years rated their child's behaviour with the CBCL, Aberrant Behavior Checklist and Nisonger Child Behavior Rating Form. Teachers completed the Teacher Report Form. RESULTS About one-third of children with DS were reported to exhibit behaviours of clinical concern on the total score of the CBCL. Internal consistency for CBCL sub-scales was poor to excellent, and inter-rater reliability was generally acceptable. The sub-scales of the CBCL performed best when evaluating convergent validity, with variable discriminant validity. Normative data conversions controlled for age and gender differences in this sample. CONCLUSIONS The study findings suggest that, among children with DS, some CBCL sub-scales generally performed in a psychometrically sound and theoretically appropriate manner in relation to other measures of behaviour. Caution is warranted when interpreting specific sub-scales (Anxious/Depressed, Somatic Complaints and Thought Problems). The CBCL can continue to be used as a screening measure when evaluating behavioural concerns among children with DS, acknowledging poor discriminant validity and the possibility that key behaviour concerns in DS may not be captured by the CBCL screen.

Introduction: Children and young adults with Down syndrome can demonstrate increased behavior problems compared to their typically developing peers through childhood and adolescence. Though current...

Individuals with Down syndrome (DS) can develop Alzheimer’s disease as early as 30 to 40 years old, but parkinsonism is rarely described. We report on a 20-year-old woman with Down syndrome and parkinsonism who responded dramatically to carbidopa-levodopa. We propose that the occurrence of parkinsonism in individuals with DS may be underreported. Recognizing and treating this condition may improve quality of life.

Introduction Compassion fatigue, a product of burnout (BO), secondary traumatic stress (STS), and compassion satisfaction (CS), is reduced capacity and interest in being empathetic for suffering individuals. Our objective was to determine prevalence of compassion fatigue in the pediatric emergency department. Methods We administered the Professional Quality of Life instrument, including BO, STS, and CS scales, to a convenience sample of pediatric emergency department staff (physicians, nurses, technicians, social workers, child life specialists). We categorized participants as having BO (high BO, low CS, moderate-low STS scores), STS (high STS, moderate-low BO, low CS), compassion fatigue (high STS and BO, low CS), and high-risk fatigue (high STS, moderate-low BO, low CS) and low risk (moderate-high CS, moderate-low BO, low STS) of compassion fatigue. Results One hundred seventy-seven staff (50% response rate) participated. The majority were white (90%) and female (88%), with participation highest among physicians (97%). Twenty-six percent had low CS scores, 26% had high BO scores, and 20% had high STS scores. Five percent met criteria for categorization as compassion fatigue, 24% for BO, and 24% for low risk of compassion fatigue. Current personal stress was associated with higher BO scores (P = 0.008) and secondary categorization as BO (P = 0.05). Recent work stress was associated with high STS scores (P = 0.03). Discussion Five percent of participants met criteria for compassion fatigue; a significant proportion had BO, STS, or CS scores, placing them at risk of compassion fatigue. Future studies should explore factors contributing to and interventions to minimize compassion fatigue.

OBJECTIVES: Intravenous (IV) and intramuscular (IM) antibiotics have comparable efficacy in treating neonates undergoing sepsis evaluations. There are no clinical data favoring the use of either route regarding newborn pain and parental preferences. We hypothesized that pain associated with IM injections would worsen breastfeeding effectiveness and decrease parental satisfaction, making IV catheters the preferred route. METHODS: This prospective cohort study took place in an academic institution with nurseries in 2 separate hospitals, 1 providing IV antibiotics, and the other, IM antibiotics. Newborns receiving 48 hours of antibiotics were compared by using objective pain and breastfeeding scores and parental surveys. RESULTS: In 185 newborns studied, pain scores on a 7-point scale were up to 3.4 points higher in the IM compared with the IV group (P < .001). Slopes of repeated pain scores were 0.42 ± 0.08 and −0.01 ± 0.11 in the IM and IV groups, respectively (P = .002). Breastfeeding scores were similar between groups. Parents in the IV group were less likely to perceive discomfort with antibiotic administration (odds ratio [OR] 0.22; 95% confidence interval [CI] 0.06–0.74) but more likely to perceive interference with breastfeeding (OR 26; 95% CI 6.4–108) and bonding (OR 101; 95% CI 17–590) and more likely to prefer changing to the alternate route (OR 6.9; 95% CI 2.3–20). CONCLUSIONS: IM antibiotics in newborns are associated with pain sensitization and greater pain than IV dosing. Despite accurately recognizing newborn pain with the IM route, parents preferred this to the IV route, which was perceived to interfere with breastfeeding and bonding.

Delayed diagnosis of intussusception can lead to air enema failure and increased morbidity. There are limited studies reporting the accuracy of pediatric emergency medicine (PEM) physician point-of-care ultrasound (POCUS) in diagnosing intussusception.The primary objective was to evaluate the accuracy of PEM POCUS in identifying ileocolic intussusception. The secondary objective was to identify factors associated with air enema failure.This was a retrospective study of children who underwent POCUS for suspected intussusception in a pediatric emergency department between January 2001 and December 2015. Patients were included if a pediatric radiologist confirmed the POCUS examination interpretation by image review, radiology department ultrasound, or air enema. Age, symptom duration, recurrent intussusception, and location of intussusception were examined as factors for air enema failure.One hundred and two POCUS examinations were completed on 101 patients who met the inclusion criteria. The mean age of patients was 22 months. Of 75 patients with intussusception, 72 were detected with POCUS. PEM POCUS had a sensitivity of 96.0% (95% confidence interval [CI] 91.6-100.0%), specificity of 92.6% (95% CI 82.7-100.0%), positive predictive value of 97.3% (95% CI 93.6-100.0%), and negative predictive value of 89.3% (95% CI 77.8-100.0%). Air enema failure was associated with intussusception distal to the splenic flexure (odds ratio = 10.00 [95% CI 2.81-35.61]; p 0.01) and age6 months (OR = 6.83 [95% CI 1.94-24.09]; p 0.01).PEM POCUS identifies intussusception with high sensitivity and specificity. Patients6 months old or with intussusception distal to the splenic flexure had a higher risk of air enema failure.

Background Feedback is critical in training PEM fellows but often difficult in the emergency department (ED). We identified a need to develop a milestone-based feedback form to assess fellows’ performance after an ED shift. Objectives: Describe the development and implementation of an ED shift assessment tool including the frequency of assessments completed. Methods Using qualitative and quantitative data, a formative assessment tool was developed through a consensus survey completed by PEM faculty. We developed an on-demand feedback form on REDCapTM using the high-scored milestones results from the survey. After a 4-week pilot, the tool was implemented on smartphones from July 1-December 31, 2019. We used convenience sampling with the following steps: 1) fellow chose a milestone to be evaluated and submitted a request to a faculty member for feedback, 2) the faculty received an email in real-time to complete the form. Then, the fellow received an email with relative real-time feedback. Quantitative data was analyzed using descriptive statistics. Qualitative data was analyzed using thematic content analysis and partially applying open axial & selective coding procedures using grounded theory principles. Results Twenty-two (68.8%) faculty completed the consensus survey. Ten milestones scored as “Very Important” for the assessment tool with those related to Patient Care (PC) domain scoring the highest. Barriers to feedback included time management, faculty training, and difficulty in direct fellow observation. Fellows completed 57 assessments, and 17 faculty members provided feedback 46 times. The majority (52.6%) of assessments were completed by 1st year fellows. PC 4 was the most common milestone selected by fellows. Fellows most often self-assessed at an expected level of training, whereas faculty rated more favorably (expected level: 76.1%, above level: 23.9%). Conclusions The shift assessment tool was well-received by PEM faculty and fellows. We plan to investigate the impact of this tool in its practical value in providing formative feedback to our fellows as well as ways to improve this tool.

Background Musculoskeletal (MSK) infections can be difficult to diagnose in acute care settings. The utility of clinical decision tools for pediatric MSK infections in an emergency department has not been well studied. Objective Our aim was to evaluate the performance of a septic hip clinical decision rule (CDR) in the evaluation of pediatric musculoskeletal infections. Methods We performed a retrospective study of children evaluated for an MSK infection in our emergency department from 2014 to 2016. Data collection included demographics, discharge diagnoses, and clinical/laboratory predictors from the CDR. A χ2 analysis and Wilcoxon rank-sum tests compared patients with and without MSK infections. Logistic regression analysis examined the predictors for MSK infections. A receiver operating characteristic (ROC) curve was calculated to evaluate the performance of the predictors. Results Of 996 evaluations included in the final analysis, 109 (10.9%) had MSK infections. In a multivariable model, an adjusted odds ratio (OR) was significant for fever (OR 3.9, 95% confidence interval [CI] 2.4–6.4), refusal to bear weight/pseudoparalysis (OR 4.4, 95% CI 2.7–7.1), and C-reactive protein (CRP) > 2.0 mg/dL (OR 5.4, 95% CI 3.2–9.1). The probability of infection was 75.1% with five predictors present, 1.9% for zero predictors, and 5.1% if one predictor was present. An ROC curve showed an area under the curve of 0.82, indicating moderate accuracy. Conclusions A septic hip CDR demonstrates a low predicted probability of an MSK infection with zero or one clinical predictor present and moderate predictability with all five predictors. Fever, refusal to bear weight/pseudoparalysis, and CRP > 2.0 mg/dL performed best and should alert providers to consider other MSK infections in addition to septic arthritis.

Objective The aim of this study was to evaluate whether early knowledge of respiratory syncytial virus (RSV) positivity by rapid triage-based testing protocol improved emergency department (ED) throughput time and decreased ED ancillary testing and antibiotic administration. Methods A retrospective cohort study was performed of ED patients aged 2 to 12 months, presenting November 1 to March 31 for the years 2008-2013. Included patients presented with fever and upper respiratory tract symptoms. Patients were excluded if they tested positive for influenza, had chronic underlying medical problems, or were admitted or transferred from an outside facility or if no RSV result was documented. The study group was compared with infants who tested negative for RSV by the triage-based protocol and were diagnosed as having (1) bronchiolitis and (2) a viral illness. Results Of 899 patients tested for RSV within triage, the study included 713 (79%); 231 (35.3%) tested positive for RSV. When comparing children diagnosed as having bronchiolitis, there was no statistically significant difference between RSV positive and negative in ED throughput time, ED administered antibiotics, or chest radiographs, urine analyses, blood cultures, or lumbar punctures obtained. When comparing children diagnosed as having a viral illness, RSV-positive patients had less chest radiographs, urine analysis, and blood cultures performed. Conclusions Identifying the virus responsible for bronchiolitis through a triage-based protocol does not decrease ED throughput time, antibiotic administration, or chest radiographs, urine analysis, or blood cultures obtained. In infants presenting with upper respiratory tract symptoms and fever, knowing RSV infectivity through a triage-based protocol does significantly decrease chest radiographs, urine analysis, and blood cultures obtained.

1. Lina Patel, MD* 2. Deepa Kulkarni, MD* 1. *UCLA Mattel Children’s Hospital, Los Angeles, CA A 2-month-old previously healthy, full-term boy is admitted for intermittently bloody stools. This exclusively breastfed infant has had 2 to 3 blood-streaked diapers per day for the past 4 weeks. He is also noted to be fussier by the parents. There is no history of any recent illnesses, fevers, vomiting, or other signs of bleeding. His oral intake and urine output are normal. His medical history is notable for poorly controlled eczema. He does not use any medications or have any known allergies. There is no family history of any medical problems, including bleeding disorders, gastrointestinal disease, or atopy. On physical examination, he is noted to be small for age (9th percentile, previously 89th percentile) and has moderate eczema on his face and extremities. The remainder of his examination findings are normal. Initial laboratory values are significant for normocytic anemia, thrombocytopenia, and eosinophilia: white blood cell count, 16 × 103/μL (neutrophils, 27%; lymphocytes, 49%; monocytes, 3%; eosinophils, 15%); hemoglobin level, 7.8 g/dL (78.0 g/L); and platelet count, 43 × 103/μL (43 × 109/L). Further evaluation and testing revealed the final diagnosis. An …

OBJECTIVES Care process models (CPMs) for certain conditions have improved clinical outcomes in children. This study describes the implementation and impact of a CPM for the evaluation of musculoskeletal infections in a pediatric emergency department (ED). METHODS A retrospective pre-post intervention study was performed to analyze the impact of a musculoskeletal infection CPM. Patients were identified retrospectively through electronic order history for imaging of an extremity or joint and recommended laboratory tests. Clinical outcomes evaluated included hospital length of stay (LOS), time to magnetic resonance imaging (MRI), time to administration of antibiotics, hospital admission rate, and 30-day readmission rate. RESULTS Musculoskeletal infection evaluations completed in the ED were reviewed from 1 year before implementation (n = 383) and 2 years after implementation (n = 1219) of the CPM. A significant improvement in the time to antibiotic administration for all patients (4.3 vs 3.7 hours, P < 0.05) and for patients with confirmed musculoskeletal infections (9.5 vs 4.9 hours, P < 0.05) was observed after the implementation of the CPM. The overall time to MRI (13.2 vs 10.3 hours, P = 0.29) and hospital LOS (4.7 vs 3.7 days, P = 0.11) were improved for all patients but were not statistically significant. The admission rate and 30-day readmission were similar before and after the implementation of the CPM. CONCLUSIONS The implementation of a musculoskeletal infection CPM has standardized the approach to the evaluation and diagnosis of musculoskeletal infections resulting in a significant decrease in the time to administer antibiotics and a downward trend in time to MRI and hospital LOS.

Fingertip crush injuries are common hand injuries in children and often are evaluated initially in an emergency department. Nail bed injuries can be classified into subungual hematomas, simple or stellate lacerations, crush injuries, and avulsions. Emergency department physicians with good knowledge of fingertip anatomy can appropriately manage these injuries so as to prevent long-term fingertip deformities and functional deficits. The management of simple nail bed lacerations and subungual hematomas has remained somewhat controversial with much debate surrounding the necessity of removing the nail plate for repair of a nail bed laceration versus trephination alone of a large subungual hematoma. This article will discuss the management and evaluation of simple nail bed injuries by emergency department physicians to prevent chronic nail and fingertip deformities.

Childhood obesity is a major public health problem in the United States and is associated with numerous comorbidities. The relationship of obesity to risk of traumatic injury and recovery has been described, although not in depth. In adults with burns, obesity has been linked to negative impact on functional outcomes as well as increased mortality. Less is known about the impact of obesity on children with burns. The primary objective of this study was to determine the effect of obesity on length of hospital stay (LOS) among admitted pediatric burn patients. A secondary objective was to compare the difference in burn characteristics between obese and nonobese burn patients. To explore these questions, a retrospective cohort study of patients aged 0 to 18 years admitted to a children's hospital burn unit between February 1, 2000, and September 30, 2006 was performed. For the purposes of this study, obesity was defined as weight-for-length (2 years of age) or body mass index (or =2 years of age)or =95th percentile for age and gender. Patients who had concomitant, nonburn injuries were not included in the study. LOS was measured in days, and an initial univariate analysis examined the association of clinical and demographic factors with LOS. To adjust for confounding, those factors that were found to be significantly associated with LOS were entered into a stepwise linear regression. A total of 528 patients were included in the study group, 17.4% of whom were obese. Obese patients were more likely to suffer a burn of a high-risk anatomic area (72.8% vs 60.8%). Median LOS for obese patients was significantly higher than nonobese (9.3 vs 7.1 days, P.05). In the adjusted model, factors significantly associated with LOS included total body surface area burned, percent full thickness burn, Medicaid insurance status, and obesity. After controlling for these factors, obese children had a 6.5% longer LOS than nonobese children. This interesting finding raises the question of which factors are responsible for the increased length of stay for obese children hospitalized with burns. Investigating factors such as rate of complications, slower healing, or greater functional impairment may shed light on this finding.

BACKGROUND. Regional-based studies have indicated that ethnicity is associated with presentation and outcome in patients with gastric adenocarcinoma. To validate this observation in a large cohort, the authors of this report used the National Cancer Data Base (NCDB) to determine whether self-reported ethnicity influences presentation and survival in this patient population. METHODS. Patient demographics, tumor-related features, and treatment-related features were analyzed by ethnicity. Univariate analyses were performed using the chi-square test. Overall median and relative survival rates were examined by using the Kaplan-Meier method. Cox proportional-hazards models were used to identify the predictors of survival outcomes. RESULTS. Between 1995 and 2002, 81,095 cases of gastric adenocarcinoma were entered into the NCDB. There were 57,943 white patients (71.5%), 11,094 African-American patients (13.7%), 5665 Hispanic patients (7%), 4736 Asian/Pacific Islander (API) patients (5.8%), and 1657 patients of other ethnicities (2%). Significant differences were observed according to ethnicity among the variables that were compared (all P < .01). In patients with stage I and II disease, the 5-year relative survival rates for APIs (stage I, 77.2%; stage II, 48%) were more favorable than for whites (stage I, 58.7%; stage II, 32.8%), African Americans (stage I, 55.9%; stage II, 37.9%), and Hispanics (stage I, 60.8%; stage II, 39.3%). The overall median survival of APIs was more favorable than that of others (P < .01). Predictors of a better outcome were Asian race, female sex, younger age, earlier stage, lower grade, distal tumors, multimodality treatment, and care at a teaching hospital. CONCLUSIONS. Ethnicity was associated with differences in presentation and outcome of patients with gastric adenocarcinoma. APIs had a more favorable outcome than patients of other ethnicities. Further studies should target underlying biologic and socioeconomic factors to explain these differences. Cancer 2008. © 2008 American Cancer Society.

While the overall incidence of gastric cancer has declined in the United States of America, the incidence of proximal gastric cancers has increased. The purpose of this analysis was to highlight key differences between proximal and distal gastric cancer as they relate to presentation and treatment.Data on 6,099 patients diagnosed with gastric adenocarcinoma were collected as a patient care evaluation under the auspices of the American College of Surgeons Commission on Cancer. The chi-square (chi (2)) test was used for comparisons of proportions across levels of categorical variables by site.The proximal cancer group included 1,924 patients (87% cardia, 13% fundus) and the distal cancer group included 1,311 patients (85% antrum, 15% pylorus). Proportionately, proximal cancer cases were male (P0.01), younger (P0.01), and White (P0.01); whereas, distal gastric cancer cases were Black (P0.01), Hispanic (P0.01), and Asian (P = 0.01). Surgery alone (without adjuvant chemotherapy or radiation) was utilized more frequently in distal disease (39.5%) compared to proximal disease (25.7%) (P0.01). Preoperative adjuvant therapy was utilized more frequently in proximal disease (41.7%) compared to distal disease (2.1%) (P0.01).The populations that developed proximal verses distal gastric cancer differed with respect to sex, age, and racial background. Cancer-directed treatments also differed based upon tumor location. Understanding these differences may someday enable us to identify important high-risk populations, prevention strategies, and ultimately best treatment strategies. Long-term survival differences will be explored when follow-up data become available.

IntroductionWaterpipe smoking has become increasingly popular among young adults across the globe. Evidence suggests waterpipes have overtaken cigarettes in popularity among university students in the UK. This survey aims to measure the prevalence of use, awareness of the tobacco content and associated health risks of waterpipes among young adults in a non-university semi-rural deprived community in England.MethodsA self-completed questionnaire was distributed by six schools and colleges to young adults aged 16-25 in Tameside, North West England.Results210 young adults completed the survey. 12% of respondents smoke cigarettes and 16% smoke waterpipes. Of those that smoke waterpipes, 45% smoke at home and 88% smoke in shisha bars. 62% of respondents did not know that shisha waterpipes contained tobacco. 18% of respondents believe that waterpipes are less harmful than smoking cigarettes. There was no difference in knowledge of tobacco content, or of the associated health risks, between those that smoke waterpipes and those that do not. The majority of respondents (81%) stated that if they wanted to know more about how shisha tobacco could affect their health they would access information via the internet. Social networking websites was by far the most popular route for communication for messages about the health risks associated with smoking shisha waterpipes. ConclusionThese results suggest that waterpipes may have overtaken cigarettes as the method of choice for smoking tobacco among the general young adult population in the UK.

BACKGROUND Disparities in cancer outcome among different subsets of the American population related to ethnic background have been well documented. Clinical trials represent the most powerful strategy for improving cancer treatments, but racial and ethnic minority patients are frequently underrepresented among patients accrued to these protocols. Proof of comparable efficacy for a promising cancer therapy in different groups of patients requires diversity in the clinical trial populations so that study results will be generalizable. Appropriate targets for accrual of minority ethnicity patients have not previously been defined. METHODS The National Cancer Database (NCDB) is maintained jointly by the American Cancer Society and the American College of Surgeons. Information submitted by tumor registries throughout the United States represents an estimated 70% of newly diagnosed cancer cases. The authors analyzed NCDB reports on ethnic distribution of patients with breast, prostate, nonsmall cell lung, and colorectal cancer, stratified by stage of disease at diagnosis. RESULTS African Americans with cancer of the breast and prostate had the most notable patterns of disproportionate representation among populations with advanced-stage disease. The authors compiled a table of suggested accrual targets for selected solid-organ cancers based on NCDB stage-specific reports. CONCLUSIONS Clinical trial results will be more meaningful if participating patients reflect the site- and stage-specific populations that are under study. The authors recommended that clinical trial investigators incorporate accrual targets for minority ethnicity populations into the study design. Cancer 2006. © 2005 American Cancer Society.

Breast conservation therapy (BCT) and adjuvant hormonal therapy for estrogen-receptor positive breast cancers have become standard of care. Our objectives were to evaluate trends in the surgical management and adjuvant therapy for early-stage breast cancer and to identify factors predicting survival. Using the National Cancer Data Base (NCDB), patients with node-negative breast cancers less than 1 cm (T1aN0M0 and T1bN0M0) from 1993–2004 were identified. The time periods of 1993–1994, 1998–1999, and 2003–2004 were compared to analyze trends in surgical management and adjuvant therapy. Cox Proportional Hazards modeling was used to examine factors predicting survival. Overall, 123,212 cases of T1aN0M0 or T1bN0M0 breast cancer were identified. The use of breast conservation surgery increased from 61.3% in 1993/1994 to 78.3% in 2003/2004 with a concomitant decrease in the use of mastectomy. The use of radiation therapy also increased from 51.9% in 1993/1994 to 62.0% in 2003/2004. Adjuvant hormonal therapy administration rose sharply from 26.7% in 1993/1994 to 44.7% in 2003/2004. After adjusting for potential confounders, the difference in 5-year survival rates for T1a (94.3%) and T1b (93.1%) tumors was marginal (P = .04). Age, grade, size, and failure of BCS patients to receive radiation therapy and hormonal therapy were independent predictors of a higher likelihood of death. BCS utilization increased over time, but mastectomy rates may still be considered high given the small size of tumors in this cohort and the percent of patients eligible for BCT. The use of hormonal therapy increased significantly over the past decade. Further investigation into patient and physician factors affecting treatment choices is needed if BCT and hormonal therapy utilization is to increase.

To examine treatment trends in invasive lobular carcinoma (ILC) over the last 15 years and, in particular, to compare rates of recurrence and disease-free survival associated with breast conservation therapy compared with mastectomy.The biologic characteristics of ILC make it difficult to estimate the extent of the disease by either clinical examination or mammography, and can also make it difficult to detect axillary lymph node metastases. Because of this, there has been a bias toward treating ILC with aggressive therapy.Patients with ILC were selected from the National Cancer Data Base (1989-2001) using an extensive set of inclusion and exclusion criteria. A total of 21,596 patients were selected, including 8108 who received breast conservation therapy and 13,488 who received mastectomy. Analysis included demographic characteristics, trends in usage of sentinel lymph node biopsy, rates of local and distant recurrence, and 5-year disease-free survival rates.The use of breast conversation therapy increased almost threefold during the study period. From 1998 to 2001, the use of sentinel node biopsy increased more than twofold in the breast conservation group (an average of 23% in 1998 versus 57% in 2001), compared with limited usage in the mastectomy group (an average of 10% in 1998 versus 23% in 2001). Local recurrence rates were very low and disease-free survival rates were correspondingly high in both treatment groups for all diagnosis years and across all pathologic tumor size/lymph node status designations.Less invasive treatment options are becoming widely used for invasive lobular carcinoma, yielding outcomes equivalent to those seen with more aggressive treatment.

Three strains of encapsulated Enterococcus faecalis, which produced highly mucoid coalescing colonies on routine bacteriologic media, were isolated from urine specimens of patients with urinary tract infection. Encapsulation could be demonstrated through India ink preparations. The occurrence of this unusual enterococcal colony morphotype, which resembles that of a Gram-negative bacterium, may delay true identification.

INTRODUCTION: Neoadjuvant chemotherapy (NeoCTX) is standard management for locally advanced breast cancer. Phase III clinical trials reveal equivalent survival and improved breast conservation surgery (BCS) eligibility in Stage II breast cancer patients receiving neoCTX compared to postoperative CTX. Controversy persists regarding optimal integration of sentinel lymph node biopsy (SLNBx) into neoCTX protocols. We evaluated evolving surgical practice patterns regarding neoCTX, BCS, and SLNBx for Stage II breast cancer.