Background Pediatric appendicitis accounts for an estimated 7% to 10% of abdominal pain cases in the emergency department (ED). The diagnosis is time-consuming, and the investigative process depends on physician assessment, resulting in delays in diagnosis and therapeutic management. The utility of an advanced nursing directive (AND) to expedite this process is unclear and needs further exploration. Objective This study aims to describe key components of ED flow in patients with suspected appendicitis seen at a pediatric ED and pilot a directive that allows ED nurses to perform an order set that includes blood work, urine tests, analgesics, fluids, and an abdominal-pelvis ultrasound prior to physician assessment. Methods This study involves conducting a retrospective chart review alongside a quality improvement initiative to compare key ED flow metrics before and after AND implementation. Primary outcome measures include median time from ED triage assessment to ultrasound completion, analgesia administration, blood work results, and time to disposition (consult or discharge), alongside other key ED flow metrics for suspected appendicitis. Secondary outcomes will involve patient and caretaker satisfaction surveys. Descriptive statistics will be used to summarize the data. For differences in proportions, a chi-square test will be used. The Student t test will be used for continuous variables. A variable-controlled run chart will be performed to assess impact on ED flow metrics. Patient and family satisfaction surveys are administered immediately after the directive encounter and 7 days afterward. Results There are currently 3900 patients who have been screened, 344 patients who have been enrolled, and 90 patients who have received the medical directive since implementation in June 2020. Interim results on reduction of time to diagnostic and therapeutic ED flow parameters and satisfaction surveys are expected to be published in February 2022. The final study endpoint will be in June 2022. Conclusions This study proposes a novel protocol for improving the diagnosis and treatment of suspected pediatric appendicitis through implementation of an evidence-based AND. This model may provide a standardized, international pathway for management of common pediatric and adult emergencies. International Registered Report Identifier (IRRID) RR1-10.2196/33158

Electric kick scooters (e-scooters) are a form of micro-mobility devices that have been implemented in city streets worldwide as a viable travel solution. E-scooter companies have launched in over 100 U.S cities and various international cities, including Paris, Berlin, London, Rome, Madrid, Singapore, Auckland, Tel Aviv, and Brisbane. On January 1st 2020, Ontario launched its pilot program to permit e-scooters onto provincial roads. Due to the implementation and recent growth of this new technology, it is important to evaluate what is already known about e-scooter use and what remains to be discovered. We conducted a literature review to understand the general prevalence of e-scooter usage, common injury patterns, demographics of patients commonly involved in e-scooter injuries, and risk factors associated with injuries. We also sought to understand the current legislation surrounding e-scooter use in Ontario, other provinces across Canada, and other countries. Common injuries included: extremity fractures, facial fractures, lacerations and head injuries (including concussions and intracranial hemorrhages). Most commonly injured riders were men between 20- 40 years old, and our findings indicate that limited helmet use and acute alcohol intoxication may contribute to e-scooter injuries. These findings can help to direct future research questions and prepare primary care and emergency room physicians for the potential surge in e-scooter use here in Ontario, Canada.

TCF20-associated neurodevelopmental disorder (TAND) is a rare and phenotypically variable genetic condition. Common features include intellectual disability, neurobehavioural concerns, postnatal tall stature and hypotonia.Two unrelated early adolescent males were referred to genetics for assessment of developmental delay. The first male of Caucasian descent had a history of autism spectrum disorder (ASD), mitral valve prolapse and subtle craniofacial dysmorphisms. The second male of Somali descent had a history of intellectual disability, thick corpus callosum and ASD. Whole-exome sequencing revealed a pathogenic variant inTCF20in both individuals. Further testing revealed that the former individual’s mother was mosaic for theTCF20 pathogenic variant.We report two individuals withTCF20pathogenic variants presenting with unique findings, including thick corpus callosum, family history of mosaicism and cardiac anomalies. These examples expand the TAND phenotype, describe associated dysmorphism in a minority group and highlight the importance of rare disease research.

Primary Subject area Epidemiology Background Asthma, the most common chronic illness affecting Canadian youth, can profoundly and adversely impact a child’s quality of life. Previous studies have shown a diagnosis of asthma can influence a child’s physical and socio-emotional functioning. Current data on asthma prevalence rates among Canadian children is scarce, and it is still unclear how this diagnosis impacts their development at school entry. Objectives The goals of the current study were to 1) examine the prevalence of teacher-reported asthma in Canadian kindergarten children, and 2) investigate the association between asthma and children’s concurrent developmental health. Design/Methods A cross sectional, population-level study of kindergarten children diagnosed with asthma as reported on the Early Development Instrument (EDI), was carried out in Canada from 2010-2015. Children’s developmental health in kindergarten was measured with the EDI. This 103-item questionnaire is completed by teachers for their students aged 4-6 years and covers demographic information, as well as five different domains of development. Descriptive statistics were examined for children with and without asthma. The level of statistical significance was adjusted using a Bonferroni correction to account for multiple hypothesis testing. The chi-square and one-way ANOVA statistics, as well as effect sizes (Cramer’s V, and eta squared) were reported for all descriptive analyses. Results 958 children (0.002% of the final analytical sample) were identified as having a teacher-reported diagnosis of asthma. Compared to their peers, children with asthma were significantly more likely to: be male (68.2% vs 51.2%); have a special needs designation (19.0% vs 3.6%); have a functional impairment (53.5% vs 15.9%); be identified by their teachers as needing further developmental assessment (32.3% vs. 13.1%); and miss, on average, 3 more days of school than their peers (9.44 vs. 6.71). They were also more likely to fall below a vulnerability threshold on one or more of the developmental domains (55.9% vs. 28.8%, Figure 1). Conclusion It is likely that the EDI captures only severe cases of asthma, as parents are more likely to disclose their child’s illness to teachers if it may influence their ability to function in a classroom. As such, children with asthma, especially those with severe forms, may require additional support. A partnership in which physicians provide preventative care, and teachers provide academic and classroom assistance, may help to ensure the optimal development of children with asthma, and close gaps between them and their peers.

BACKGROUND Pediatric appendicitis accounts for an estimated 7-10% of abdominal pain cases in the emergency department (ED). The diagnosis is time consuming, and the investigative process is dependent on physician assessment, resulting in delays in diagnosis and therapeutic management. The utility of an advanced nursing directive to expedite this process is unclear and needs further exploration. OBJECTIVE Our study aims to describe key components of ED flow in suspected appendicitis patients seen at a pediatric ED and pilot a directive that allows ED nurses to perform an order-set that includes blood work, urine tests, analgesics, fluids, and order an abdominal-pelvis ultrasound prior to physician assessment. METHODS This study involves conducting a retrospective chart review alongside a quality improvement initiative to compare key ED flow metrics before and after advanced nursing directive implementation. Primary outcome measures include median time from ED triage assessment to ultrasound completion, analgesia administration, bloodwork results, time to disposition (consult or discharge), alongside other key ED flow metrics for suspected appendicitis. Secondary outcomes will involve patient and caretaker satisfaction surveys. Descriptive statistics will be used to summarize the data. For differences in proportions, a χ2 test will be used. Student’s t-test will be used for continuous variables. A variable-controlled run chart will be performed to assess impact on ED flow metrics. Patient and family satisfaction surveys are administered immediately after the directive encounter and seven days afterwards. RESULTS There are currently 3900 patients who have been screened, 344 patients enrolled, and 90 patients who have received the medical directive since implementation in June 2020. Interim results on reduction of time to diagnostic and therapeutic ED flow parameters and satisfaction surveys are expected to be published in February 2022. The final study endpoint will be in June 2022. CONCLUSIONS This study proposes a novel protocol for improving the diagnosis and treatment of suspected pediatric appendicitis through implementation of an evidence-based advanced nursing directive. This model may provide a standardized, international pathway for management of common pediatric and adult emergencies.