<p>Due to the life cycle of its vector, Lyme disease has known seasonal variation. However, investigations focused on children have been limited. Our objective was to evaluate the seasonality of pediatric Lyme disease in three endemic regions in the United States. We enrolled children presenting to one of eight Pedi Lyme Net participating emergency departments. Cases were classified based on presenting symptoms: early (single erythema migrans (EM) lesion), early-disseminated (multiple EM lesions, headache, cranial neuropathy, or carditis), or late (arthritis). We defined a case of Lyme disease by the presence of an EM lesion or a positive two-tier Lyme disease serology. To measure seasonal variability, we estimated Fourier regression models to capture cyclical patterns in Lyme disease incidence. While most children with early or early-disseminated Lyme disease presented during the summer months, children with Lyme arthritis presented throughout the year. Clinicians should consider Lyme disease when evaluating children with acute arthritis throughout the year.</p>

<p><b>BACKGROUND: </b>The Rule of 7's classifies children as low-risk for Lyme meningitis with the absence of the following: ≥7 days of headache, any cranial neuritis or ≥70% cerebrospinal fluid mononuclear cells. We sought to broadly validate this clinical prediction rule in children with meningitis undergoing evaluation for Lyme disease.</p><p><b>METHODS: </b>We performed a patient-level data meta-analysis of 2 prospective and 2 retrospective cohorts of children ≤21 years of age with cerebrospinal fluid pleocytosis who underwent evaluation for Lyme disease. We defined a case of Lyme meningitis with a positive 2-tier serology result (positive or equivocal first-tier enzyme immunoassay followed by a positive supplemental immunoblot). We applied the Rule of 7's and report the accuracy for the identification of Lyme meningitis.</p><p><b>RESULTS: </b>Of 721 included children with meningitis, 178 had Lyme meningitis (24.7%) and 543 had aseptic meningitis (75.3%). The pooled data from the 4 studies showed the Rule of 7's has a sensitivity of 98% [95% confidence interval (CI): 89%-100%, I2 = 71%], specificity 40% (95% CI: 30%-50%, I2 = 75%), and a negative predictive value of 100% (95% CI: 95%-100%, I2 = 55%).</p><p><b>CONCLUSIONS: </b>The Rule of 7's accurately identified children with meningitis at low-risk for Lyme meningitis for whom clinicians should consider outpatient management while awaiting Lyme disease test results.</p>

<p><strong>BACKGROUND: </strong>Disparities exist in the care children receive in the emergency department (ED) based on their insurance type. It is unknown if these differences exist among children transferred from outside EDs to pediatric tertiary care EDs.</p>

<p><strong>OBJECTIVE: </strong>To compare reasons for transfer and services received at pediatric tertiary care EDs between children with private and public insurance.</p>

<p><strong>METHODS: </strong>We performed a secondary analysis of a multicenter survey of ED providers transferring patients to pediatric tertiary care EDs in three major U.S. cities. Risk differences (RD) and 95% confidence intervals (CI) were calculated to compare reasons for transfer and care received at pediatric tertiary care EDs based on insurance type.</p>

<p><strong>RESULTS: </strong>There were 561 surveys completed by transferring providers describing reasons for transfer to pediatric tertiary care EDs with 52.2% of patients with private insurance and 47.8% with public insurance. We found no significant differences between privately and publicly insured children in reason for transfer for subspecialty consultation or need for admission. We found no significant differences in frequency of admission, radiologic studies, or ED procedures at the receiving facilities. However, a greater proportion of privately insured children had a subspecialty consultation at receiving facilities compared to publicly insured children (RD 9.7, 95% CI 2.0 to 17.4).</p>

<p><strong>CONCLUSIONS: </strong>Transferred pediatric patients with private insurance were more likely to have subspecialty consultations than children with public insurance. Further studies are needed to better characterize the interplay between patients' insurance type and both the request for, and the provision of, ED subspecialty consultations.</p>

<p><strong>OBJECTIVES: </strong>The aims of this study were to (1) assess the reasons for pediatric interfacility transfers as identified by transferring providers and review the emergency medical care delivered at the receiving facilities and (2) investigate the emergency department (ED) care among the subpopulation of patients discharged from the receiving facility.</p>

<p><strong>METHODS: </strong>We performed a multicenter, cross-sectional survey of ED medical providers transferring patients younger than 18 years to 1 of 4 US tertiary care pediatric hospitals with a subsequent medical record review at the receiving facility. Referring providers completed surveys detailing reasons for transfer.</p>

<p><strong>RESULTS: </strong>Eight hundred thirty-nine surveys were completed by 641 providers for 25 months. The median patient age was 5.7 years. Sixty-two percent of the patients required admission. The most common reasons for transfer as cited by referring providers were subspecialist consultation (62%) and admission to a pediatric inpatient (17%) or intensive care (6%) unit. For discharged patients, plain radiography (26%) and ultrasonography (12%) were the most common radiologic studies. Procedural sedation (16%) was the most common ED procedure for discharged patients, and 55% had a subspecialist consult at the receiving facility. Ten percent of interfacility transfers did not require subspecialty consult, ED procedure, radiologic study, or admission.</p>

<p><strong>CONCLUSIONS: </strong>Approximately 4 of 10 interfacility transfers are discharged by the receiving facility, suggesting an opportunity to provide more comprehensive care at referring facilities. On the basis of the care provided at the receiving facility, potential interventions might include increased subspecialty access and developing both ultrasound and sedation capabilities.</p>

<p><strong>OBJECTIVES: </strong>The aim of this study was to determine the reasons for pediatric emergency department (ED) transfers and the professional characteristics of transferring providers.</p>

<p><strong>METHODS: </strong>We performed a multicenter, cross-sectional survey of ED medical providers transferring patients younger than 18 years to 1 of 4 tertiary care children's hospitals. Referring providers completed surveys detailing the primary reasons for transfer and their medical training.</p>

<p><strong>RESULTS: </strong>The survey data were collected for 25 months, during which 641 medical providers completed 890 surveys, with an overall response rate of 25%. Most pediatric patients were seen by physicians (89.4%) with predominantly general emergency medicine training (64.2%). The median age of patients seen was 5.6 years. The 3 most common diagnoses were closed extremity fracture (12.2%), appendicitis (11.6%), and pneumonia (3.7%). The 3 most common reasons for transfer were need for medical/surgical subspecialist consultation (62.6%), admission to the inpatient unit (17.1%), and admission to the intensive care unit (6.5%). When asked about the need for supportive pediatric services, referring providers ranked pediatric subspecialty and pediatric inpatient unit availability as the highest.</p>

<p><strong>CONCLUSIONS: </strong>Most pediatric interfacility ED transfers are referred by general emergency medicine physicians who often transfer for inpatient admission or subspecialty consultation. Understanding the needs of the community-based ED providers is an important step to forming more collaborative efforts for regionalized pediatric emergency care.</p>