Pediatric Exposure Research Articles

Factors associated with pediatric silicone rod frontalis sling exposure or infection: single-institution experience of 193 eyelids.

To determine the pre-operative, peri-operative, or post-operative risk factors that contribute to pediatric frontalis sling infection or exposure. Retrospective study of 193 eyelids that underwent silicone-rod frontalis sling surgery at a single institution between 2014 and 2019. A total of 222 eyelids were originally identified. Of the 222 eyelids that underwent frontalis sling surgery, 193 (86.9%) received silicone-rod slings (SRS), 24 (10.8%) received autologous fascia lata sling (AFS), and 5 (2.3%) received Gore-Tex slings (GS). The 193 eyelids that received SRS met inclusion criteria and underwent further statistical analysis. Patients with SRS who did not receive intra-operative antibiotics had a higher risk of infection or exposure compared to patients with SRS that did receive intraoperative antibiotics (P = 0.03). There was no association between SRS exposure and the other studied risk factors (all P-values > 0.41). Intraoperative antibiotics should be considered in silicone-rod frontalis suspension surgery, as it associated with a decreased risk of exposure or infection.

The Food and Drug Administration’s Safety Surveillance of Adverse Event Cases Involving Cannabinoid Hemp Products, 2019–2023

Objective. To characterize adverse event (AE) cases received by the US Food and Drug Administration (FDA) reportedly involving cannabinoid hemp products (CHPs). Methods. We searched the FDA Adverse Event Reporting System and Center for Food Safety and Applied Nutrition Adverse Event Reporting System for cases reported directly to the FDA from 2019–2023 involving CHPs, which are defined as products containing 1 or more of the following: cannabidiol, delta-8 tetrahydrocannabinol, and emerging cannabinoids (i.e., other intoxicating cannabinoids often synthesized from hemp-derived cannabidiol). We abstracted and summarized information on reporting trends, consumer demographics, reporter information, product information, and AEs. Results. We identified 610 AE cases reportedly involving CHPs containing 1 or more of the following: delta-8 tetrahydrocannabinol (n=355), cannabidiol (n=253), and emerging cannabinoids (n=36). Multiple trends and safety issues were identified, including an annual increase in the number of cases involving intoxicating cannabinoids since 2021, potential quality issues, and the occurrence of fatalities and pediatric exposures. Conclusions. Our findings emphasize the importance of monitoring AE cases received by the FDA involving CHPs as part of a comprehensive surveillance strategy to identify trends and safety issues with these products. ( Am J Public Health. 2024;114(S8):S664–S672. https://doi.org/10.2105/AJPH.2024.307712 )

Exposure Matching-Based Pediatric Dose Selection for Drugs with Renal Excretion - Lessons Learned from Pediatric Development of Direct Oral Anticoagulants.

The pediatric clinical development programs of the direct oral anticoagulants (DOACs) edoxaban, rivaroxaban, and dabigatran have recently been completed, with apixaban close to the finish line. One common pharmacokinetic (PK) characteristic of these four DOACs is that renal excretion contributes 27% or more in their elimination, resulting in age-dependent drug clearance in both pediatric and adult subjects. Several lessons have been learned from adult exposure matching and pediatric dose selection for DOACs. The main goal of this tutorial is to provide an informed perspective on pediatric dose selection for renally excreted drugs, using these four DOACs as case examples. This tutorial is organized into seven steps: (1) consideration of age-related differences in disease and response to treatment; (2) consideration of age-related differences in drug absorption, distribution, metabolism, and excretion; (3) selection of the reference adult population and exposure for pediatric exposure matching; (4) prediction of pediatric clearance and pediatric dose selection based on data from young adults; (5) conduct and design of efficient pediatric PK and pharmacodynamic (PD) studies that inform dose selection; (6) assessment of exposure matching and dose adjustment using population PK simulation; (7) evaluation of the need for dose adjustment in pediatric sub-populations.

Exploring the link between the pediatric exposome, respiratory health, and executive function in children: a narrative review.

Asthma is a highly prevalent inflammatory condition, significantly affecting nearly six million U.S. children and impacting various facets of their developmental trajectories including neurodevelopment. Evidence supports a link between pediatric environmental exposures in two key areas: asthma and executive function (E.F.). E.F.s are a collective of higher-order cognitive processes facilitating goal-oriented behaviors. Studies also identify asthma-associated E.F. impairments in children. However, limited research has evaluated the inter-relationships among environmental exposures, asthma, and E.F. in children. This review explored relevant research to identify and connect the potential mechanisms and pathways underlying these dynamic associations. The review suggests that the role of the pediatric exposome may function through (1) several underlying biological pathways (i.e., the lung-brain axis, neuroendocrine system, and hypoxia), which could drive asthma and maladaptive E.F. in children and (2) the relationships between the exposome, asthma, and E.F. is a bidirectional linkage. The review reveals essential synergistic links between asthma and E.F. deficits, highlighting the potential role of the pediatric exposome.

General emergency physician perceptions of caring for children: A qualitative interview study.

Emergency physicians care for most children presenting to U.S. emergency departments (EDs). Pediatric exposure during emergency medicine (EM) residency can be variable and critically ill children are rarely encountered. A recent needs assessment revealed that emergency physicians feel less prepared to manage various conditions in children and that infants, regardless of presenting complaint, pose particular challenges. Emergency physician perceptions of the experience of caring for pediatric patients have not been widely examined through a qualitative lens. We designed an interview-based qualitative study to explore emergency physician perspectives on pediatric patient care. We recruited emergency physicians who graduated from residency in 2015-2019 and all rotated through the same large tertiary children's hospital. Four trained interviewers conducted in-depth, one-on-one virtual interviews. An interdisciplinary team transcribed and then coded the interviews. The team performed a conventional content analysis for themes. Recruitment continued until thematic saturation was achieved. Twelve participants completed interviews. These participants trained in five diverse residency programs. Likewise, the participants now practice in a variety of settings. Three major themes emerged from the data: (1) experience and exposure are key to establishing comfort caring for children; (2) simulation, pathways, and the pediatric anesthesia rotation are educationally useful; and (3) caring for children poses unique emotional challenges. Participants shared many recommendations for future pediatric education for EM trainees, including increasing autonomy and exposure to neonates and considering how care might differ in a community setting. This interview-based qualitative study elucidates key themes in recently graduated emergency physicians' perceived experience of caring for children. Our findings have important educational implications for this group of emergency physicians and those who share similar experiences in training and practice.

Pediatric cannabis exposures in New Jersey.

Pediatric cannabis exposures in New Jersey.

Trends in opioid exposures among young children reported to United States poison centers from 2016 to 2023

Introduction The objective of this study was to update and expand on previous studies of opioid exposures among young children reported to America’s Poison Centers, and to describe how fentanyl and medications for opioid use disorder have contributed. Methods This retrospective study investigated 34,632 reports of single-substance opioid exposure from 2016 to 2023 involving pediatric patients aged one month to six years old. Descriptive statistics, tests for data normality, and significance testing were performed where applicable. Results Of 34,632 reported exposures, 96.7% were unintentional. The median age of exposure was 2.0 years (IQR 1.33-3.0 years). Reported exposures decreased by 57.5% over the study period (r = −0.96; P < 0.001). However, there was a 300% absolute increase in deaths and major effects (r = 0.96; P < 0.001). Exposures resulting in minor, no effect, not followed, or unable to follow decreased 66.2% (r = −0.99; P < 0.001). Buprenorphine was most frequently involved, comprising 23.4% of reported exposures. Buprenorphine (OR 1.93; P < 0.001) and methadone (OR 14.98; P < 0.001) were associated with an increased risk of severe effects when compared to other prescription drugs (OR: 1). There was an absolute increase of 512% over time in reports of heroin, fentanyl, synthetic non-pharmaceutical opioids (r = 0.92; P < 0.001), which were also associated with severe effects (OR 20.1; P < 0.001). Discussion Pediatric opioid exposures have previously been reported to be relatively stable. It is likely the 57.5% reduction is exaggerated due to underreporting from health care providers. However, decreases in exposures are presumed to be balanced throughout the dataset and, therefore, without differential impact on other points of analysis. Our study highlights the continued need for enhanced poisoning prevention strategies. Conclusions The relative severity of poisonings reported to poison centers worsened over the study period. The opioids implicated have shifted away from hydrocodone, oxycodone, and tramadol, and towards fentanyl and buprenorphine.

Caregiver Adverse Childhood Experiences and Pediatric Infection-Related Outcomes.

Higher caregiver-adverse childhood experiences (ACEs) have been associated with multiple adverse pediatric outcomes. However, no studies have examined links between caregiver ACEs and infectious outcomes like antibiotic prescriptions or infection-related clinical encounters. We conducted a retrospective cohort study including patients from 2 pediatric primary care sites, serving predominantly non-Hispanic Black, publicly insured populations. Our outcomes were antibiotic prescriptions and infection-related ambulatory clinical encounters for children 0-3 years old. We captured these outcomes and additional covariates (demographics, health-related social risk screen results, and Socioeconomic Deprivation Index scores linked to geocoded street addresses) from the electronic health record. High (≥4) or low (≤3) caregiver ACEs, and individual ACE question answers, were our exposures. Multivariable logistic regression was used to determine associations with any antibiotic use. Cox proportional hazards regression was used to assess the time to first antibiotic exposure and first infection-related visit. A total of 1465 children 0-3 years were included (50.0% female, 75.0% Black, and 2.6% Hispanic). High caregiver ACEs were not associated with pediatric antibiotic exposure. The presence of caregiver-witnessed parental abuse was associated with a higher likelihood of any antibiotic exposure (odds ratio [OR 1.90]; 95% confidence interval [CI] 1.2, 3.2) and time to first antibiotic exposure (hazard ratio [HR] 1.77; 95% CI 1.23, 2.56). Sexual abuse of the caregiver was associated with time to first infection-related clinical visit (HR 1.27; 95% CI 1.05, 1.53). Certain caregiver ACEs were associated with pediatric antibiotic use and infection-related visits. Future studies need to evaluate underlying mechanisms and test effective clinical responses.

Population pharmacokinetics of eptinezumab in paediatric patients with migraine and dose selection for phase 3 paediatric migraine studies.

This population pharmacokinetics (PopPK) analysis of eptinezumab used data from a paediatric study and a prior adult PopPK model to compare eptinezumab pharmacokinetics between adult and paediatric populations to determine dose recommendations for the phase 3 paediatric studies in migraine. The data consisted of 16 adolescents and 12 children with migraine, with corresponding demographics and 278 plasma concentrations in total. PopPK analysis was performed through nonlinear mixed effect modelling and with prior knowledge taken from a previous PopPK model in adults. A two-compartment model-adjusted for body weight impact on clearances and volumes of distributions and scaled to the power of 0.75 and 1.0, respectively-was found to adequately describe the paediatric pharmacokinetic data. The simulated population showed overlap in area under the plasma concentration-time curve and maximum plasma concentration between the paediatric and adult populations, with paediatric exposures within 10%-15% above adult levels on average. To provide comparable exposure to the approved adult doses, weight-based dosing adjustments are recommended for paediatric patients weighing ≤40 kg, while no adjustments are needed for patients weighing >40 kg. These results support the dosing strategy being used in the ongoing efficacy and safety studies with eptinezumab in children and adolescents with migraine.

Tiny pills, big impacts: A systematic review on the endocrine disrupting effects of paediatric pharmaceuticals

Endocrine disrupting chemicals (EDCs) may impact children's health, with medicines as a possible exposure source. Objective: to assess the potential impact of substances in paediatric medications and essential oils on children as EDC. It is a systematic review of five databases including Medline following the PECOT approach. The review focused on publications about children exposed to medication (active ingredients or excipients of interest) and having developed clinical signs of endocrine dysfunction. Out of 946 studies identified, 28 studies were included. They revealed that parabens, lavender essential oils and anti-epileptics are the most identified pharmaceutical products. The reported outcomes relate to puberty, thyroid disorders, obesity and growth. The evidence indicates potential risks, but the overall quality of available data is limited. This systematic review exposes a lack of robust evidence linking paediatric medication exposure to EDC, predominantly relying on case reports. It cautions about potential conflicts of interest.

Preventing Pediatric Opioid Poisoning: Unusual Sources and Scenarios

This retrospective study analyzed 230 pediatric opioid exposures from a statewide poison control center over a 5-year period. Most exposures involved pharmaceutical opioids and children under two-years-old. Narrative details were reviewed to identify uncommon sources of opioids involved in poisoning and highlight the need for tailored prevention strategies and guidance.

The Impact of Legalizing Recreational Cannabis on the Children of a Neighboring State.

In the United States, cannabis is legal for adult recreational use in 24 states and Washington, DC. Unintentional pediatric cannabis exposures have increased in many states following legalization.We evaluated the relationship between recreational cannabis legalization and the rates of unintentional pediatric exposures in a neighboring state that had not undergone legalization. We obtained cannabis exposure cases for children 0-12 years from the New Mexico Poison and Drug Information Center electronic database. Only deidentified patient data from closed-case exposure encounters were abstracted. Data were grouped as precommercial and postcommercial availability in neighboring Colorado, demarcated by January 2014. We coded cannabis products as edible, not edible, or unknown. For bivariable comparisons, we used odds ratios, risk ratio, χ2 test, and Wilcoxon rank sum test. We chose a type 1 error rate of 0.05 to determine significance. There were 269 exposures over 24 years of calls. Following neighboring legalization, the median number of exposures per year increased from 4 (interquartile range 2, 5) to 24.5 (16.5, 34), the median age increased from 1.9 to 3.0 (P = 0.007), and the relative risk of the exposure involving edible products was double (relative risk = 2.0, 95% confidence interval = 1.6, 2.6). The severity of the exposures' medical effects also increased (P = 0.008). The number, severity, and type of pediatric cannabis exposures in New Mexico changed after neighboring recreational cannabis legalization. States neighboring those undergoing cannabis legalization should be prepared to respond to increased acute exposures in children.

Use of biobehavioral interventions in children undergoing surgery and associated patient-reported outcomes

Background: Biobehavioral interventions including relaxation, distraction, and mindfulness meditation exercises have been shown to decrease perioperative stress, anxiety, and pain. Our aims were to 1) quantify pediatric surgical patient-reported pre-operative exposure to and post-operative use of biobehavioral interventions; 2) understand barriers and facilitators to incorporation of biobehavioral interventions into clinical practice; and 3) evaluate associated patient-reported outcomes. Methods: We conducted an embedded mixed-methods study with a quantitative focus. Data were collected as part of the 18-hospital ENhanced Recovery In CHildren Undergoing Surgery (ENRICH-US) clinical trial for children, ages 10–18 years, undergoing elective gastrointestinal surgery. Patients/caregivers were surveyed about preoperative exposure to and postoperative use of biobehavioral interventions. Four semi-structured group interviews with 20 pediatric surgery providers were conducted. Outcomes included pain-related functional disability, health-related quality of life (HRQoL), and perioperative nervousness. Results: 41 % (n = 67) of 164 enrolled patients/caregivers reported preoperative exposure to and 71 % (n = 117) reported postoperative use of a biobehavioral intervention(s). Barriers to incorporation of biobehavioral interventions included lack of standardized workflows, clinician knowledge, and resources. Potential facilitators included media and peer-counseling. After adjusting for individual and hospital characteristics, those who reported using a biobehavioral intervention(s) were 70 % less likely to report worsened postoperative nervousness (95 % CI 0.10–0.91; p = 0.03). Reported use of a biobehavioral intervention(s) was not found to be associated with pain-related functional disability or HRQoL. Conclusions: Use of a biobehavioral intervention(s) may stabilize postoperative nervousness of children undergoing surgery. There is a need for redesign of clinical workflows and clinician training to facilitate integration of biobehavioral interventions.

Physiologically based pharmacokinetic modelling of cefoperazone in paediatrics.

Cefoperazone is commonly used off-label in the treatment of bacterial meningitis and sepsis in children, and the pharmacokinetic (PK) data are limited in this vulnerable population. The goal of this study was to develop a physiologically based pharmacokinetic (PBPK) model to predict pediatric cefoperazone exposure for rational dosing recommendations. A cefoperazone PBPK model for adults was first constructed using Simcyp V22 simulator. Subsequently, the model was extended to children based on the built in age-dependent physiological parameters, while the drug characteristics remained unchanged. The verified pediatric PBPK model was then utilized to assess the rationality of the common dosing regimens for children at different age groups. Cefoperazone PBPK model included elimination via biliary excretion, glomerular filtration, and organic anion transporter 3 (OAT3)-mediated tubular secretion. 95.2% of the observed mean concentrations and 100% of the area under the plasma drug concentration-time curve (AUC) and peak concentration (Cmax) in adults were within a twofold range of model mean predictions. Good predictive accuracy was also observed in children, including neonates. 50 mg/kg q12h cefoperazone demonstrated effective target attainment in virtual term neonates (<1 month) when the MIC was ≤1 mg/L, adhering to the stringent PK/PD target of 75% fT > MIC. 37.5 mg/kg q12h cefoperazone achieved the common 50% fT > MIC target for an MIC ≤ 0. 25 mg/L in virtual pediatric patients ranging from 1 month to 18 years of age. A pediatric PBPK model was developed for cefoperazone, and it could serve as the basis for deriving rational dosing regimens in children.

Establishing Diagnostic Reference Levels and Radiation Dose for Pediatric Head Age-Based Using Computed Tomography in Khartoum State

Computed tomography (CT) is a powerful clinical tool for the diagnosis and management of patients, enabling faster and more accurate diagnosis and the avoidance of interventional surgical techniques. A diagnostic reference level (DRL) is a tool used to aid in optimization of protection in the medical exposure of patients for diagnostic and interventional procedures. It is used in medical imaging with ionizing radiation to indicate whether, in routine conditions, the patient dose or administered activity (amount of radioactive material) from a specified procedure is unusually high or low for that procedure. Radiation dosage variance is one of the topics that arise when dealing with CT devices within medical imaging centers. Diagnostic reference levels have not been established in Sudan. The aim of this study is to propose DRLs for CT of the head for 4 pediatric age groups. The 2 levels that this study covers are volume CT dose index based on a 16-cm phantom (CTDIvol [mGy]) and the dose-length products (DLPs [mGy • cm]). These levels were investigated by conducting a survey to 6 healthcare facilities. The survey consists of questions focused on pediatric exposure parameters, CT protocols, and radiation doses for pediatric age groups &lt;1, 1-5, 5-10, and 10-16 years. For the 4 age groups in the 6 facilities that responded, the mean, 25th, 50th, and 75th percentile values of CTDIvol (mGy) for head CT were for infants (&lt;1 year), 21.2, 14.4, 17.6, and 27.0, respectively; for 1-5 years, 36.5, 15.7, 34.5, and 38.1, respectively; for 5- to 10-year group, the CTDIvol was found to be 40, 15.7, 33.5, and 47.6, respectively, and for the last group of 10-16 years, 41.6, 15.7, 37.4, and 58.3, respectively. The corresponding DLP (mGy • cm) for head CT, the mean, 25th, 50th, and 75th percentile values were as follows: for infants (&lt;1 year), 472.9, 326.9, 385.3, and 545.5, respectively; for 1-5 years, 742.9, 509.1, 689.3, and 902.9, respectively; for 5-10 years, 1,130.4, 501.7, 924.2, and 1,667.4, respectively; for 10-16 years, 1,226.4, 595.4, 870.1, and 1,255.3, respectively. The total mean CTDIvol (mGy) was 38.0, and the total mean DLP (mGy · cm) was 1,001.6. These values have been compared with other values from other similar studies; the summary for these comparisons concluded that the majority of CTDIvol 16-cm phantom and DLP 16-cm phantom values for the head were higher than DRLs reported from other studies in other countries. Therefore, for risk reduction, it is necessary to establish DRLs for pediatric CT in Sudan.

Pediatric urinary tract infections caused by poultry-associated Escherichia coli.

Escherichia coli is the leading cause of urinary tract infections (UTIs) in children and adults. The gastrointestinal tract is the primary reservoir of uropathogenic E. coli, which can be acquired from a variety of environmental exposures, including retail meat. In the current study, we used a novel statistical-genomic approach to estimate the proportion of pediatric UTIs caused by foodborne zoonotic E. coli strains. E. coli urine isolates were collected from DC residents aged 2 months to 17 years from the Children's National Medical Center Laboratory, 2013-2014. During the same period, E. coli isolates were collected from retail poultry products purchased from 15 sites throughout DC. A total of 52 urine and 56 poultry isolates underwent whole-genome sequencing, core genome phylogenetic analysis, and host-origin prediction by a Bayesian latent class model that incorporated data on the presence of mobile genetic elements (MGEs) among E. coli isolates from multiple vertebrate hosts. A total of 56 multilocus sequence types were identified among the isolates. Five sequence types-ST10, ST38, ST69, ST117, and ST131-were observed among both urine and poultry isolates. Using the Bayesian latent class model, we estimated that 19% (10/52) of the clinical E. coli isolates in our population were foodborne zoonotic strains. These data suggest that a substantial portion of pediatric UTIs in the Washington DC region may be caused by E. coli strains originating in food animals and likely transmitted via contaminated poultry meat.IMPORTANCEEscherichia coli UTIs are a heavy public health burden and can have long-term negative health consequences for pediatric patients. E. coli has an extremely broad host range, including humans, chickens, turkeys, pigs, and cattle. E. coli derived from food animals is a frequent contaminant of retail meat products, but little is known about the risk these strains pose to pediatric populations. Quantifying the proportion of pediatric UTIs caused by food-animal-derived E. coli, characterizing the highest-risk strains, and identifying their primary reservoir species could inform novel intervention strategies to reduce UTI burden in this vulnerable population. Our results suggest that retail poultry meat may be an important vehicle for pediatric exposure to zoonotic E. coli strains capable of causing UTIs. Vaccinating poultry against the highest-risk strains could potentially reduce poultry colonization, poultry meat contamination, and downstream pediatric infections.

Abstract A015: Exploiting endogenous replication stress with a novel targeted therapy in Ewing sarcoma

Abstract Ewing sarcoma (EwS) is a rare and aggressive disease that typically affects the bone of children and young adults. Although there are moderate 5-year survival rates for primary disease, there is a high rate of recurrence and a lack of targeted therapies in this setting. Furthermore, pediatric exposure to chemotherapies leads to an increased risk of long-term complications, including secondary cancers, cardiomyopathy, and infertility. Therefore, there is a desperate need for targeted therapies which improve therapeutic outcomes and reduce exposure to chemotherapy in these patients. Like many pediatric cancers, EwS has a low mutational burden. Instead, it is driven by chromosomal translocation between a FET family member, EWSR1, and an ETS family member, usually FLI1. The EWSR1-FLI1 fusion protein acts as an aberrant and oncogenic transcription factor, disrupting cell cycle control, cell migration, and proliferation. ETS family members in these fusions retain their ability to bind to the SWI/SNF chromatin remodeling complex, further dysregulating DNA methylation and gene expression. Although targeting of the EWSR1 fusion has not yet been successful, these elevated levels of replication stress (RS) present a unique element of vulnerability within the cell. To this end, our lab has previously identified replication stress response (RSR) inhibitors, DDKi and WEE1i, which can be utilized to exploit the characteristic ability of EwS to maintain high levels of replication stress (RS) and push EwS cells into mitotic catastrophe in vitro. Here, we evaluate the efficacy of the replication stress response inhibitors (RSRi) TAK931 (DDKi) and MK1775 (WEE1i) with chemotherapy regimens commonly utilized in the relapsed/refractory setting in vivo. Using cell line derived xenografts in NSG mice, we show that DDKi and WEE1i with irinotecan limits tumor growth significantly more than existing therapy (temozolomide + irinotecan). Dosing schedules are optimized through dosing de-escalation and alternative-day dosing strategies. We further demonstrate the ability of our RSRi combination to effectively limit tumor growth over time in vivo even when irinotecan dosage is decreased. We go on to investigate the RSRi combination in the presence of ultra-low dose irinotecan. Finally, we utilize reduced representation bisulfite sequencing to examine the epigenetic effects of these treatment regimens. Overall, the exploitation of high endogenous replication stress in EwS by targeted RSRi presents a promising potential therapeutic option for this pediatric patient population. Citation Format: Emily Isenhart, Ajay Gupta, Bryan Gillard, Kristopher Attwood, Joyce Ohm. Exploiting endogenous replication stress with a novel targeted therapy in Ewing sarcoma [abstract]. In: Proceedings of the AACR Special Conference in Cancer Research: Expanding and Translating Cancer Synthetic Vulnerabilities; 2024 Jun 10-13; Montreal, Quebec, Canada. Philadelphia (PA): AACR; Mol Cancer Ther 2024;23(6 Suppl):Abstract nr A015.

Educational concepts: A longitudinal interleaved curriculum for emergency medicine residency training.

Traditionally, emergency medicine (EM) residency programs teach non-adult emergency department activities (such as pediatric EM, point-of-care ultrasound [PoCUS], emergency medical services, and others) in a block format. In this way, a resident may have a 1-month pediatric EM rotation and then not have any further pediatric EM exposure until their next pediatric rotation 6‒9 months later. Furthermore, some rotations are only allotted for 1-month during the entire residency. A first-year EM resident may have their only formal PoCUS rotation early in the first year of training when their overall skills are developing, and their level of understanding and retention of information may not be optimal at that juncture of their residency training. This is far from ideal from an educational perspective. Learning scientists have now suggested that a longitudinal interleaved curriculum has substantial advantages over the traditional block format. This curriculum allows for a "spaced retrieval" practice that enhances retention of material and develops thinking processes that are important in clinical practice. The increased continuity of clinical experience has been shown to improve educational outcome and learner satisfaction. We developed a novel longitudinal interleaved curriculum for our EM resident trainees. This curriculum encompasses the entire 3 years of residency training and has the goals of increasing EM knowledge and clinical skills and being excellent preparation for board certification examinations. This concept has clear educational benefits. While adapting an existing medical training program would be challenging, a longitudinal curriculum could be phased in to replace a traditional EM curriculum.

Pediatric chronic pain and exposure to bullying as perpetrator or victim.

Pediatric chronic pain and exposure to bullying as perpetrator or victim.

Epidemiologic Trends In Children With Toxicologic Exposures Requiring Intensive Care Before and During the COVID-19 Pandemic.

Pediatric poison exposures are a common reason for pediatric intensive care unit (PICU) -admission. The purpose of this study was to examine the exposure trends and patient outcomes in 2018-2019 compared with 2020-2021 amidst the COVID-19 pandemic. This was a retrospective cohort study of patients 18 years of age or younger with a suspected toxicologic exposure from January 2018 to March 2021. The primary endpoint was rate of PICU admissions between the 2 cohorts. Secondary endpoints included medical outcome stratified by severity, PICU length of stay, and need for mechanical ventilation. Our study included a total of 340 patients with median age 14.5 (IQR, 11.9-16.1) years. There was no significant difference in age, sex, or race between the 2 cohorts. The percentage of patients admitted to the PICU for poison exposures was significantly higher in the COVID-19 cohort compared with the pre-COVID-19 cohort (8.4% vs 3.7%, p < 0.01). Severity of medical outcomes differed between the groups; the COVID-19 cohort had more extreme clinical presentations of no effect or death (p < 0.01). No significant difference was found among the remaining secondary outcomes. Classes of substances ingested were comparable with baseline poison center data. Poisoning-related PICU admissions occurred at more than twice the pre-pandemic rate. This may emphasize the effect of the COVID-19 pandemic on pediatric access and exposure to poisons.