Care Of Pediatric Patients Research Articles

Establishing a Graft-Versus-Host Disease (GVHD)-Focused Multidisciplinary Telehealth Clinic

Graft-versus-host disease (GVHD) is a complication following allogeneic hematopoietic cell transplant that frequently causes multiorgan affection and decrease in quality of life. Global assessment and care of these patients require a multidisciplinary approach, but access to focused clinics is limited given their scarcity and location in major cities, as well as mobility and transportation challenges that frequently affect these patients. Thus, we established a multispecialty GVHD telehealth (TH) clinic and hypothesized that a virtual platform will expand access to clinical care in children and adults. The clinic team members included BMT specialist, nursing, dermatologist, dentist, nutritionist, physiatrist, research personnel, and others as needed. We evaluated all GVHD-related visits (in-person and TH) conducted in a single center from 01/2022 to 12/2022. Ninety-three patients received a total of 308 visits, and one-third were via TH. Approximately half of the in-person group had at least 1 TH visit, and 10 patients were seen exclusively via TH. Most patients had advanced chronic GVHD. More male patients were seen in GVHD clinic, but female patients had increased in clinic visits via TH (41% TH versus 32% in-person). One-third of clinic visits were from patients of racial and ethnic minorities. While only 6% (n = 12/217) of in-person visits were for patients living >100 miles from the center, 34% (n = 31/91) of TH visits were from far distances including out-of-state. At baseline, the most common patient-reported symptoms in a subset of patients included fatigue, disturbed sleep, and distress. Fifteen patients completed a follow-up symptom survey and reported significantly reduced distress regarding their GVHD (P = .02), although other symptoms remained stable. A multidisciplinary TH clinic provided care for adult and pediatric patients with GVHD. We demonstrated preliminary feasibility of building a robust TH platform with a collaborative multispecialty approach that allowed access and continuity of medical care. Gender inequalities were reduced, and distance to our center represented a lesser barrier to attending specialized care via TH. Additionally, patients reported a significant reduction in distress. Our findings support the ongoing development of a virtual platform to improve access to specialized GVHD care.

Post-Surgical Dental Precautions/Prophylaxis in Pediatric Patients: Results of a 2023 Survey of the Membership of the Pediatric Orthopaedic Society of North America (POSNA)

IntroductionGuidelines regarding post-surgical dental care have been common in adult total joint arthroplasty patients, despite limited supporting evidence in the literature. There is anecdotal evidence that similar precautions are implemented frequently in post-operative pediatric orthopaedic patients without any published evidence to guide clinicians. Material and MethodsA survey of the Active Members of the Pediatric Orthopaedic Society of North America (POSNA) was performed to assess the use of post-surgical guidelines regarding dental care (procedures and prohylaxis) in pediatric patients. A 20-question survey regarding this subject was developed with the input of, and approved by, the Evidence-Based Practice Committee of POSNA, and a link to participate was distributed to the Active Membership. ResultsOne hundred and seventy-three POSNA members opened the link to the survey. 163 respondents self-identified as Active, for a response rate of 19.8%. One hundred and fifty-seven (96.3%) reported direct involvement in surgical and post-surgical care of pediatric orthopaedic patients. Sixty-two (39.4%) indicated use of a post-operative protocol regarding dental interventions. Forty percent of those indicating use of guidelines were uncertain of the specifics of the protocol(s) used at their institution. Eighty-five percent of those utilizing protocols felt that the use of guidelines was a valuable topic for investigation. ConclusionsThese results demonstrate that many of the active members of POSNA utilize post-surgical guidelines for dental care, particularly for those patients who have undergone spinal surgery with permanent implants. This is despite the fact that there is limited evidence to support their use in adult total joint patients, and no literature regarding use of such guidelines in pediatric orthopaedic patients. Level of EvidenceLevel V

Enhanced Care for Pediatric Patients With Generalized Lichen Planus: Diagnosis and Treatment Tips.

The rarity of generalized lichen planus (LP) in children often leads to misdiagnosis or delayed treatment, impacting the patient's quality of life. We describe the utility of a punch biopsy to confirm the diagnosis of LP in a 7-year-old girl. The inclusion of an intramuscular corticosteroid injection in the treatment plan offered prompt symptom relief.

Implementation of Virtual Reality Pain Alleviation Therapeutic into Routine Pediatric Clinical Care: Experiences and Perspectives of Stakeholders.

Virtual reality (VR) needs to be implemented in clinical settings to improve pediatric patient care during painful medical procedures. Engaging doctors and nurses to lead the adoption of new clinical techniques can facilitate the transition from research to routine practice. Integrating VR into routine clinical practice could reduce patient pain and anxiety, making medical procedures smoother and more efficient. This feasibility pilot quality improvement (QI) project provides evidence for broader expansion and implementation of VR into different clinical areas. Medical providers (doctors and nurses) implemented VR during brief pediatric medical procedures and completed a demographics and feasibility survey. Qualitative feedback from semi-structured interviews indicated VR's ease of use and effectiveness in reducing anxiety and easing medical procedures. Patients (n = 30) played the VR game during either their medically necessary pin-pulling or needlestick procedures within three clinical environments. Children ranged from 5-16 years and were 50% male. The majority of patients reported enjoyment (mean 8.2 out of 10) with VR during the procedure, and only one minor technical issue was reported. Qualitative semi-structured interview data showed the benefits of using VR, including its ease of use, decreased observed anxiety, and patients having an easier time getting through the medical procedures. Feedback from medical providers regarding the dissemination of VR into pediatric clinical environments showed promising results. Standardized guidelines are needed to further implement VR pain alleviation into standard care in real-world clinical settings. This pilot study suggests that VR could be a valuable tool in pediatric pain management, warranting further research and broader clinical implementation.

Palliative Care for Dialysis-Dependent Pediatric Patients: A Survey of Providers, Nurses, and Caregivers.

Dialysis-dependent pediatric patients and their families face significant biopsychosocial burdens and low health-related quality of life. Palliative care consultations can alleviate some degree of suffering for patients and families but remain underutilized within pediatric nephrology. Little is known about how providers, nurses, and caregivers perceive palliative care integration into the multidisciplinary care of dialysis-dependent pediatric patients. This study surveyed pediatric nephrology providers (physicians and advanced practice providers), inpatient pediatric nephrology bedside nurses, and caregivers of dialysis-dependent pediatric patients at a freestanding tertiary care children's hospital in Dallas, Texas. Participants completed a survey regarding knowledge about, experiences with, and perceptions of palliative care in pediatric nephrology. 10 providers, 20 nurses, and 18 caregivers completed the survey. Although 80% of providers and all nurses agreed that palliative care would benefit dialysis-dependent pediatric patients, most believed that palliative care is not as important in pediatric nephrology as it should be. 70% of providers and 45% of nurses believed that they understand the scope of palliative care. 90% of providers and all nurses desired more palliative care education. Of the 22% of caregivers whose child had already received palliative care services, all found the consultation to be helpful. Many providers and nurses worried that a palliative care consultation would signal to families that the nephrology team would be giving up on their child and that their child is approaching the end of life. However, no caregivers thought that a consultation would mean that the nephrology team would be giving up on their child and only 6% worried that it would indicate that their child is approaching the end of life. These data support further palliative care education for pediatric nephrology providers and nurses and more robust and systematic involvement of subspecialty palliative care for dialysis-dependent pediatric patients.

Multifaceted approach to successful management of pediatric acute liver failure: High-volume plasma exchange as a pivotal intervention

Abstract: Pediatric acute liver failure (pALF) poses a formidable clinical challenge characterized by rapid hepatocyte necrosis and pro-inflammatory events. The urgency of pALF necessitates advanced therapeutic modalities, prompting the exploration of high-volume plasma exchange (HVPE) as a sophisticated intervention. This case report delves into the intricate management of a 16-year-old female with hyperacute liver failure secondary to hepatitis A, highlighting the critical need for nuanced and multidisciplinary approaches. The case unfolds through a detailed description of symptoms, clinical decision-making, and the therapeutic journey. The management includes a calculated deferral of liver transplantation in favor of HVPE, with a focus on the rationale for choosing HVPE over continuous renal replacement therapy. Technical aspects of the procedure, such as blood volume calculations and procedural details, are meticulously outlined. Laboratory investigations track the patient’s progress, showcasing the profound impact of HVPE on clinical and laboratory recovery. The patient’s response to HVPE is evident in the comprehensive clinical and laboratory recovery observed after the intervention. The resolution of encephalopathy, successful extubation, and eventual discharge highlight the positive outcomes achieved through the judicious application of HVPE. However, the procedure is not without challenges, as the emergence of hypertension during the second and third cycles and a lone episode of seizure require swift and careful management. The management of pALF demands a sophisticated and multidimensional approach, especially when liver transplantation is not immediately feasible. This case report underscores the nuanced decision-making involved in selecting extracorporeal therapies, with a focus on the successful application of HVPE. HVPE, as recommended by the American Society for Apheresis, emerges as a promising intervention in the context of pALF, offering a viable option when liver transplantation is deferred due to advanced encephalopathy. The favorable outcomes and considerations of cost-effectiveness and procedural simplicity further accentuate the potential of HVPE as a cornerstone in the critical care of pediatric patients with acute liver failure.

An Analysis of Ocular Biometrics: A Comprehensive Retrospective Study in a Large Cohort of Pediatric Cataract Patients.

Objectives: This study aims to provide a comprehensive analysis of ocular biometric parameters in pediatric patients with cataracts to optimize surgical outcomes. By evaluating various biometric data, we seek to enhance the decision-making process for intraocular lens (IOL) placement, particularly with advanced technologies like femtosecond lasers. Methods: This retrospective comparative study included pediatric patients with cataracts who underwent ocular biometric measurements and cataract extraction with anterior vitrectomy at the Medical University of Vienna between January 2019 and December 2021. Parameters measured included corneal diameter (CD), axial length (AL), corneal thickness (CT) and flat and steep keratometry (Kf and Ks). The study explored the correlations between these parameters and IOL placement. Results: A total of 136 eyes from 68 pediatric patients were included in the study. Significant positive correlations were found between corneal diameter, age and AL. The mean CD was 11.4 mm, mean AL was 19.5 mm, CT was 581.2 ± 51.8 µm, Kf was 7.76 ± 0.55 mm and Ks 7.41 ± 0.59 mm, respectively. Older pediatric patients with larger corneal diameters and longer ALs were more likely to receive in-the-bag IOL implantation. Conversely, younger patients often required alternative IOL placements or remained aphakic. Our data indicated that over 95% of the study population and all patients aged one year and older had a corneal diameter of 10 mm or larger. Conclusions: Detailed ocular biometric analysis is crucial for optimizing both surgical outcomes and postoperative care in pediatric cataract patients. The positive correlations between CD, age and AL underline the importance of individualized surgical planning tailored to each patient's unique anatomical features. Additionally, our findings suggest that the use of a femtosecond laser is both feasible and safe for pediatric patients aged one year and older, potentially offering enhanced surgical precision and improved outcomes.

Advanced statistical approaches for predicting pain after pediatric thoracotomy: a cross-sectional study using zero-inflated and Poisson models

BackgroundThoracotomy is one of the surgical procedures most burdened by chronic post-operative pain. There is poor evidence regarding the possibility that even in pediatric patients, thoracotomy can be followed by post-operative pain. The primary objective of this analysis is to identify associations with home pain therapy, pain intensity, and possible protective factors acting on chronic pain in this population.MethodsA retrospective cross-sectional study was conducted at Ospedale Pediatrico Bambino Gesù IRCCS. The study included pediatric patients undergoing thoracotomy. For statistical analyses, a logistic model and a zero-inflated strategy were implemented to explore associations and predict factors related to home-based analgesic therapy and pain intensity.ResultsGender and age were identified as significant factors in the assignment of home therapy, with males having over seven times the risk compared to females (OR = 7.06, 95% CI = [2.11, 29.7]). At the last measurement, pain intensity was positively associated with age and the number of pain events during the week.ConclusionsThe study highlights significant factors influencing post-thoracotomy pain management in pediatric patients. These findings underscore the importance of tailored pain management strategies that consider gender and age to improve post-operative care and outcomes in pediatric thoracotomy patients.

Revision Chiari surgery in adults: surgical evaluation algorithm and outcomes in a continuity-of-care practice.

Patients with a prior surgical history for Chiari malformation (CM) as a child or an adult who presents with a recurrence or persistence of symptoms pose a challenging clinical scenario. The authors analyzed preoperative presentations, surgical histories, and outcomes of adult CM revision cases to create an algorithm for the assessment of revision surgery in adult CM patients and contrast this with the care of pediatric CM patients within the context of an integrated continuity-of-care CM practice seeing pediatric and adult patients. The authors retrospectively reviewed the records of patients with CM0, -1, and -1.5 who were 21 years of age or older, had a prior history of CM surgery as either children or adults, and underwent revision surgery as adults at the authors' institution from December 2009 to February 2020. The cohort was divided into three groups depending on the type of revision surgery performed: posterior fossa decompression with or without duraplasty (PFD/D group), occipitocervical fusion without ventral decompression (OCF group), and ventral decompression in the form of endoscopic endonasal odontoidectomy (VD group). A total of 50 adult revision cases were divided into 30 PFD/D cases, 13 OCF cases, and 7 VD cases. Forty cases had previously undergone one CM surgery, and 10 had undergone two. Preoperatively, the PFD/D group had significantly fewer cases of diagnosed craniocervical instability (CCI), Ehlers-Danlos syndrome, and dysautonomia than the OCF and VD groups. A retroflexed odontoid was significantly more common in the VD group than in the PFD/D and OCF groups. Postoperatively, rates of improvement were 60.0% with PFD/D, 84.6% with OCF, and 85.7% with VD, but differences in these rates were not statistically significant. In this challenging group of CM patients, possible etiologies warranting additional surgery included residual dorsal compression, persistent syrinx, CCI, and ventral brainstem compression from a significant retroflexed odontoid. Outcomes after revision were often favorable, but careful evaluation, patient selection, and communication with patients are needed in deciding to reoperate. The suggested algorithm can aid decision-making.

Parenteral Beta-Lactam/Beta-Lactamase Inhibitor Ordering in Hospitals That Provide Care for Pediatric Patients.

The purpose of this study was to define current practices related to beta-lactam/beta-lactamase inhibitor (BL/BLI) dose descriptions in hospitals that provide care for pediatric patients and to identify perceived implications of standardizing BL/BLI dose communication and ordering to a total drug-based strategy. A 27-item electronic survey was distributed via 4 pediatric pharmacy and infectious diseases listservs. Survey questions pertained to hospital demographics, dosing communication practices, BL/BLI ordering and labeling practices, obstacles to safe BL/BLI use, and the effects of potential standardization to a total drug communication strategy. SPSS was used for quantitative analysis and MAXQDA was used for qualitative analysis. A total of 140 unique survey responses were analyzed after exclusion of incomplete responses and reconciliation of multiple responses from the same institution. Overall, 56.2% of institutions order BL/BLIs by BL component for pediatric patients, and 22% of institutions order by BL component for adult patients. Approximately half (51.8%) of respondents felt that standardizing to total drug would have a negative effect at their institution; perception of potential effect varied based on the institution's ordering strategy. Communication and ordering of BL/BLIs is inconsistent across institutions and between pediatric and adult patients. In the short term, the perception is that standardization would compound institutional challenges.

Pediatric metabolic and bariatric surgery: indications and preoperative multidisciplinary evaluation

The standard of care for pediatric patients with severe obesity considering metabolic and bariatric surgery is a preoperative multidisciplinary evaluation. A multidisciplinary team allows for the efficient use of variable personnel expertise to evaluate, manage, and support a pediatric patient and family through metabolic and bariatric surgery. This review discusses the purpose, recommended team members, patient selection, content, and benefits of the multidisciplinary preoperative evaluation. This evaluation should reduce barriers to care and optimize patient safety and outcomes while taking into consideration the unique developmental needs of this age group.

Competency assessment in pediatric dental practice: A study on recent dental graduates in integrated curriculum.

This study aimed to investigate the relationship between various independent variables, such as cumulative grade point average (CGPA), socio-economic backgrounds, anxiety levels, and the self-rated competency levels, across six domains outlined by the American Dental Education Association (ADEA) of recently graduating dental students during pediatric patient care. This cross-sectional study was conducted at the College of Dentistry, Jouf University, Saudi Arabia. It included 74 participants (37 final-year dental students and 37 dental interns). Multiple logistic regression was employed to analyze the association between various independent variables (including CGPA, grade point average [GPA] in didactic, practical, and clinical courses, socio-economic backgrounds, gender, and self-reported student anxiety) and self-rated ADEA competency in pediatric dental practice within general dentistry (p<0.05). Final-year dental students were 28.5 times more likely to be competent in professionalism (C2) than interns (adjusted odds ratio [AOR]=28.54, p=0.001). In professionalism (C2), males were 91% less likely to be competent than females (AOR=0.09, p=0.001). A high GPA in didactic courses increased the likelihood of competence in health promotion (C4) by 3.4 times compared with an average GPA (AOR=3.41, p=0.071). Regarding the establishment and maintenance of oral health (C6B), final-year dental students were 4.4 times more likely to be competent than interns (AOR=4.41, p=0.013). This study identified key factors affecting clinical competency during pediatric patient care among newly graduating dentists. It highlighted the influence of gender differences, academic performance (GPA), and anxiety levels among graduates as significant predictors.

The Epidemiology of Out-of-Hospital Pediatric Airway Management in the 2019 ESO Data Collaborative

Objectives Airway management is a fundamental skill that Emergency Medical Services (EMS) clinicians must be prepared to perform on patients of any age. We performed one of the first epidemiological studies of out-of-hospital pediatric airway management utilizing the ESO data set. Methods We used the 2019 ESO Data Collaborative public release research data set. We performed a descriptive analysis of all patients <18 years receiving at least one of the following airway management interventions: nasopharyngeal airway, oropharyngeal airway, noninvasive positive pressure ventilation (NIPPV), airway suctioning, bag-valve-mask ventilation (BVM), tracheal intubation (TI), supraglottic airway (SGA) or surgical airway placement. We determined the success rates for BVM, TI and SGA. Results Among 7,422,710 911 EMS activations, there were 346,912 pediatric encounters that resulted in patient care. Airway management occurred in 27,071 encounters (7,803 per 100,000 pediatric EMS patient care events). Use of BVM, intubation or supraglottic airway insertion occurred in 3,496 encounters (1,007 per 100,000 pediatric EMS patient care events). Ventilation with BVM occurred in 2,226 encounters (642 per 100,000 pediatric EMS patient care events), TI in 935 pediatric EMS patient care encounters (270 per 100,000 patient care encounters), and supraglottic airway insertion in 335 patient encounters (97 per 100,000 patient care encounters). Overall TI success was 71.4%, rapid sequence intubation success was 86.3%, and SGA success was 87.2%. Overall TI first pass success rate was 63.1%. Conclusions In the ESO cohort, advanced airway management of children occurred in only 5.9 in 10,000 911 emergency encounters. Overall and first pass success rates for TI were low. These data provide contemporary perspectives of pediatric prehospital airway management in the United States.

Current surgical practice for central venous access to deliver chemotherapy and enteral access for nutritional support in pediatric patients with an oncological diagnosis.

Central venous access through tunneled central venous catheters (CVCs) are one of the cornerstones of modern oncologic practice in pediatric patients since CVCs provide a reliable access route for the administration of chemotherapy. Establishing best practices for CVC management in children with cancer is essential to optimize care. This article reviews current best practices, including types of devices, their placement, complications, and long-term outcomes. Additionally, nutrition status and nutritional support are also very important determinants of outcomes and care in pediatric surgical oncology patients. We review current nutritional assessment, support, access for enteral and parenteral nutrition delivery, and their complications, mainly from a surgical perspective. Overall, access surgery, whether for CVCs, or for enteral access can be challenging, and best practice guidelines supported by current though limited evidence are necessary to minimize complications and optimize outcomes.

Brain Tumors in Pediatric Patients

Pediatric brain tumors are the most common solid tumors in children, comprising a diverse group of neoplasms that vary in histology, location, and behavior. Common types include astrocytomas, medulloblastomas, ependymomas, and brainstem gliomas. Symptoms often depend on the tumor's location and may include headaches, nausea, vomiting, balance issues, and cognitive or behavioral changes. Advances in imaging, surgical techniques, and therapies, including radiation and chemotherapy, have improved outcomes. However, treatment can have long-term effects on cognitive and physical development, making comprehensive care and follow-up essential for pediatric patients. Early published reviews on pediatric brain tumors may have several lacunae, such as limited data on long-term outcomes, emerging treatment modalities, and the genetic and molecular underpinnings of various tumor types. They might also inadequately address the psychosocial impacts on patients and families. Therefore, a comprehensive review is needed to synthesize the latest research on pediatric brain tumors, encompassing advancements in diagnosis, treatment, and survivorship care. This updated review will provide valuable insights for clinicians, researchers, and policymakers to improve managing and supporting children with brain tumors. The review covers various aspects of pediatric brain tumors, focusing on choroid plexus tumors and spinal cord tumors. It discusses treatment strategies, highlighting surgical, radiotherapy, and chemotherapy options. The review also details presenting signs and symptoms of brain tumors in children, such as headaches, nausea, vomiting, balance issues, and changes in behavior or cognition. These insights aim to enhance early diagnosis and effective management, improving outcomes for affected children. This review addresses gaps in earlier studies on pediatric brain tumors by providing comprehensive insights into choroid plexus and spinal cord tumors, updated treatment strategies, and detailed symptoms. It synthesizes recent research to enhance early diagnosis and management, meeting current needs for effective, tailored treatment and improving patient outcomes.

Barriers to Care for Pediatric Patients with Obesity.

This review article emphasizes the challenges pediatric patients face during obesity treatment. Prior research has been compartmentalized, acknowledging that stigma, the ability to implement lifestyle changes, social health determinants, and healthcare accessibility are considerable impediments for obese children. These issues emerge at various levels, including the individual or family, the community and school, and even national policy. This suggests the need for a more comprehensive, team-based approach to tackle pediatric obesity. Understanding these barriers is the first step toward creating effective strategies and solutions to overcome these challenges.

A Clinician's Guide To Effectively Transitioning and Transferring Care For Pediatric Patients With Inflammatory Bowel Diseases From The Pediatric To Adult Gastroenterologist.

Transition of care for pediatric patients with inflammatory bowel diseases (IBD) is a continuous, dynamic process that takes place over several years with a coordinated approach executed by a multidisciplinary team. We review the concepts, tools, and research in effective transitioning and transfer of care for adolescent/young adult patients with IBD. Given the constraints within the healthcare system, effective transitioning can be challenging to implement in everyday clinical practice. Different barriers include resources and expertise in effective transitioning by pediatric and adult gastroenterology healthcare providers and the impact of non-gastrointestinal issues facing young adult patients who are learning to manage and coordinate all aspects of their medical care and health maintenance. Factors that facilitate successful care transitioning and transfer include structured transitioning programs, utilization of validated transition checklists, and IBD medical summaries. Proactive transitioning by pediatric gastroenterologists in partnership with their emerging young adult patients with IBD leads to better clinical and psychosocial outcomes and ultimately, effective transfer of care to adult gastroenterology. By utilizing utilize comprehensive transition assessment tools and medical summaries in partnership with their patients, pediatric and adult gastroenterology teams can better prepare patients as they transfer to independent care and health maintenance.

Bringing Virtual Reality to Mainstream Pediatric Care.

Virtual reality (VR) stands as an innovative technology transforming our interactions with the digital world. Its integration into health care has proven advantageous for both patients and health care providers across multiple levels and modalities. Given that VR is becoming increasingly accessible and prevalent, health care providers should explore incorporating the technology into their practices, particularly within the pediatric population, which is becoming progressively more accustomed to the technology. This topic synopsis provides a broad discussion of the current literature, exploring current and probable future applications of VR in pediatric patient care, particularly in improving the hospital experience, facilitating education during hospitalizations, providing an alternative to pharmacological therapy for pain management, and enhancing mental health care practices.

A novel model of care for paediatric patients with developmental disabilities and associated behaviours of concern.

Children and adolescents with autism spectrum disorder and/or intellectual disability often present to emergency departments with behaviours of concern: irritability, aggression and self-injurious behaviour. The objective of this study was to design, implement and evaluate a new model of care to support these patients and their families following presentation to reduce the need for re-presentation. We designed and evaluated a new model of care for these patients, comprising consultations with a developmental paediatrician and a child psychiatrist, referral to a specialist behavioural service and 6 weeks of care coordination by a clinical nurse consultant. Using a quality improvement framework, iterative improvements were made to the model via a series of plan-do-study-act cycles. Re-presentation rates were compared with a control group of patients who presented with behaviours of concern but were not recruited into the study. Participating families and treating clinicians were surveyed at 2 and 6 weeks post-enrolment to gather qualitative feedback about their experience of the model. A total of 31 families participated in the study. Three- and 6-month re-presentation rates were 48.7% and 36.3% lower than the control group. Qualitative evaluation of the model by both families and clinicians was positive. The model was feasible and acceptable. Families reported feeling heard and understood, and that the intervention was helpful and provided a positive path forwards. The findings suggest that a simple model of care can be successfully implemented and provide meaningful benefits for families of children with behaviours of concern, including reduced crisis-oriented help-seeking.

Is Access to Optimal Concussion Care for Pediatric Athletes Limited by Geography?

To evaluate access to optimal concussion care based on a pediatric patients' geography; the hypothesis is that differential access across the Unites States exists. Employed a novel strategy using internet searches to find local care, mimicking what families might do in different parts of the country. Virtual internet searches. Not applicable. Various metropolitan and rural geographic regions within each state in the United States. Evaluate access (defined as distance to clinic and ability to see pediatric patients) and optimal care (defined as self-referral process and presence of multidisciplinary care). Search strategy yielded 490 results. Overall ∼60% were within 50 miles of searched locations with significant differences in access based on rural versus metropolitan areas ( P < 0.0001); in rural areas, only ∼22% of results were within 50 miles. Only about one-third of the results (n = 157) saw pediatric patient with no differences between regions. There was significant regional and geographic variation for optimal care regarding both self-referral processes and access to multidisciplinary care. A diverse group of specialists was represented in search results for concussion care. Nationwide, there is an overall lack of access to multidisciplinary concussion care for pediatric patients. Additionally, those in rural communities face more limitations related to access to facilities with increased distances from closest clinic sites.