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IMPORTANCEUrgent care (UC) centers are a growing option to address children's acute care needs, which may cause unanticipated changes in health care use. OBJECTIVES To identify factors associated with high UC reliance among children enrolled in Medicaid and examine the association between UC reliance and outpatient health care use. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study used deidentified data on 4 133 238 children from the Marketscan Medicaid multistate claims database to calculate UC reliance and outpatient health care use. Children were younger than 19 years, with 11 months or more of continuous Medicaid enrollment and 1 or more UC, emergency department (ED), primary care provider (PCP; physician, advanced practice nurse, or physician assistant; well-child care [WCC] or non-WCC), or specialist outpatient visit during the 2017 calendar year. Statistical analysis was conducted from November 11 to 26, 2019. EXPOSURES Urgent care, ED, PCP (WCC and non-WCC), and specialist visits based on coded location of services.MAIN OUTCOMES AND MEASURES Urgent care reliance, calculated by the number of UC visits divided by the sum of total outpatient (UC, ED, PCP, and specialist) visits. High UC reliance was defined as UC visits totaling more than 33% of all outpatient visits. RESULTSOf 4 133 238 children in the study, 2 090 278 (50.6%) were male, with a median age of 9 years (interquartile range, 4-13 years). A total of 223 239 children (5.4%) had high UC reliance.Children 6 to 12 years of age were more likely to have high UC reliance compared with children 13 to 18 years of age (adjusted odds ratio, 1.07; 95% CI, 1.06-1.09). Compared with white children, black children (adjusted odds ratio, 0.81; 95% CI, 0.81-0.82) and Hispanic children (adjusted odds ratio, 0.61; 95% CI, 0.60-0.61) were less likely to have high UC reliance. Adjusted for age, sex, race/ ethnicity, and presence of chronic or complex conditions, children with high UC reliance had significantly fewer PCP encounters (WCC: adjusted rate ratio, 0.60; 95% CI, 0.60-0.61; and non-WCC: adjusted rate ratio, 0.41; 95% CI, 0.41-0.41), specialist encounters (adjusted rate ratio, 0.31; 95% CI, 0.31-0.31), and ED encounters (adjusted rate ratio, 0.68; 95% CI, 0.67-0.68) than children with low UC reliance. CONCLUSIONS AND RELEVANCEHigh UC reliance occurred more often in healthy, nonminority, school-aged children and was associated with lower health care use across other outpatient settings.There may be an opportunity in certain populations to ensure that UC reliance does not disrupt the medical home model.

Juvenile polyarteritis nodosa (PAN) is a rare, necrotizing vasculitis, primarily affecting small to medium-sized muscular arteries. Cardiac involvement amongst patients with PAN is uncommon and reports of coronary artery aneurysms in juvenile PAN are exceedingly rare. We describe a 16 year old girl who presented with fever, arthritis and two giant coronary artery aneurysms, initially diagnosed as atypical Kawasaki disease and treated with IVIG and methylprednisolone. Her persistent fevers, arthritis, myalgias were refractory to treatment, and onset of a vasculitic rash suggested an alternative diagnosis. Based on angiographic abnormalities, polymyalgia, hypertension and skin involvement, this patient met criteria for juvenile PAN. She was treated with six months of intravenous cyclophosphamide and high dose corticosteroids for presumed PAN related coronary vasculitis. Maintenance therapy was continued with azathioprine and the patient currently remains without evidence of active vasculitis. She remains on anticoagulation for persistence of the aneurysms. This case illustrates a rare and unusual presentation of giant coronary artery aneurysms in the setting of juvenile PAN.

Background Virtual reality (VR) has shown promise in reducing children’s pain and anxiety during venipuncture, but studies on VR lack objective observations of pediatric coping. Notably, the process of capturing objective behavioral coping data can be labor- and personnel-intensive. Objective The primary aims of this pilot trial were to assess the feasibility of conducting a trial of VR in a pediatric emergency department and the feasibility of documenting observed coping behaviors during pediatric procedures. Secondarily, this study examined whether VR affects child and caregiver coping and distress during venipuncture in the pediatric emergency department. Methods This stratified, randomized, controlled pilot trial compared coping and distress between child life–supported VR engagement and child life specialist support without VR during painful procedures in children aged 7-22 years in the pediatric emergency department. An external control (reference group) received no standardized support. Primary feasibility outcomes included rates of recruitment, rates of withdrawal from VR, and rates of completed Child Adult Medical Procedure Interaction Scale-Short Form (CAMPIS-SF) observations. Secondary clinical outcomes were applied to venipuncture procedures and included CAMPIS-SF coping and distress (range 0-1.0), pain and anxiety on a visual analog scale (range 0-10), and cybersickness symptoms. Results Overall recruitment was 93% (66/71), VR withdrawal rate was 27% (4/15), and of the completed procedures, 100% (63/63) CAMPIS-SF observations were completed. A total of 55 patients undergoing venipuncture in the pediatric emergency department were included in the analyses of clinical outcomes: 15 patients (15 caregivers) randomized to VR, 20 patients (15 caregivers) randomized to child life specialist support, and 20 patients (17 caregivers) in the reference group. Patient coping differed across groups with higher coping in the VR group and child life specialist group than in the reference group (P=.046). There were no significant differences in the distress and pain ratings for patients and caregivers between the groups. Caregivers rated the lowest perceived anxiety in the child life specialist group (P=.03). There was no apparent change in cybersickness symptoms before and after VR use (P=.37). Conclusions Real-time documentation of observed behaviors in patients and caregivers was feasible during medical procedures in which VR was utilized, particularly with the availability of research staff. VR and child life specialists improved coping in children during venipuncture procedures. Given the high participation rate, future studies to evaluate the efficacy of VR are recommended to determine whether an off-the-shelf VR headset can be a low-cost and low-risk tool to improve children’s coping during venipuncture or other related procedures. Trial Registration ClinicalTrials.gov NCT03686176; https://clinicaltrials.gov/ct2/show/NCT03686176

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AI relates broadly to the science of developing computer systems to imitate human intelligence, thus allowing for the automation of tasks that would otherwise necessitate human cognition. Such technology has increasingly demonstrated capacity to outperform humans for functions relating to image recognition. Given the current lack of cost-effective confirmatory testing, accurate diagnosis and subsequent management depend on visual detection of characteristic findings during otoscope examination. The aim of this manuscript is to perform a comprehensive literature review and evaluate the potential application of artificial intelligence for the diagnosis of ear disease from otoscopic image analysis.

BACKGROUND: Pediatric emergency department (PED) overcrowding and prolonged boarding times (admission order to PED departure) decrease quality of care. Timely transfer of patients from the PED to inpatient units is a key driver that relieves overcrowding. In 2015, PED boarding time at our hospital was 10% longer than the national benchmark. We described a resident-led quality-improvement initiative to decrease PED mean boarding times by 10% (from 173 to 156 minutes) within 6 months among general pediatric admissions. METHODS: We applied Plan-Do-Study-Act (PDSA) methodology. PDSA 1 (October 2016) interventions were bundled to include streamlined mobile communications, biweekly educational presentations, and reminder signs. PDSA 2 (August 2017) provided alternative workflows for senior residents. Outcomes were mean PED boarding times for general pediatrics admissions. The proportion of PICU transfers within 12 hours of admission served as a balancing measure. Statistical process control charts were used to analyze boarding times and PICU transfer rates. RESULTS: Leading up to PDSA 1, monthly mean boarding times decreased from 173 to 145 minutes and were sustained throughout the study period and up to 1 year after study completion. The X-bar chart demonstrated a shift with 57 consecutive months of mean boarding times below the preintervention mean. There were no changes in PICU transfer rates within 12 hours of admission. CONCULSIONS: Resident-led quality improvement efforts, including education and streamlined workflow, significantly improved PED boarding time without causing harm to patients.