Effect of Routine Child Physical Abuse Screening Tool on Emergency Department Efficiency.

OBJECTIVES: Physical abuse is a significant cause of morbidity and mortality for children. Routine screening by emergency nurses has been proposed to improve recognition, but the effect on emergency department (ED) workflow has not yet been assessed. We sought to evaluate the feasibility of routine screening and its effect on length of stay in a network of general EDs. METHODS: A 2-question child physical abuse screening tool was deployed for children <6 years old who presented for care in a system of 27 general EDs. Data were compared for the 6 months before and after screening was deployed (4/1/2019-10/2/2019 vs 10/3/2019-3/31/2020). The main outcome was ED length of stay in minutes. RESULTS: There were 14,133 eligible visits in the prescreening period and 16,993 in the screening period. Screening was completed for 13,404 visits (78.9%), with 116 (0.7%) screening positive. The mean ED length of stay was not significantly different in the prescreening (95.9 minutes) and screening periods (95.2 minutes; difference, 0.7 minutes; 95% CI, -1.5, 2.8). Among those who screened positive, 29% were reported to child protective services. On multivariable analysis, implementation of the screening tool did not impact overall ED length of stay. There were no significant differences in resource utilization between the prescreening and screening periods. CONCLUSIONS: Routine screening identifies children at high risk of physical abuse without increasing ED length of stay or resource utilization. Next steps will include determining rates of subsequent serious physical abuse in children with or without routine screening.

Accuracy of parental perception of nighttime breathing in children with Down syndrome after adenotonsillectomy.

STUDY OBJECTIVES: Clinical practice guidelines recommend screening all children with Down syndrome for obstructive sleep apnea with polysomnography by age 4 years. Because persistent obstructive sleep apnea (obstructive apnea-hypopnea index > 1 event/h) following adenotonsillectomy (T&A) is common in children with Down syndrome, it is important to know whether clinicians can rely on parental assessment postoperatively. The primary objective is to identify accuracy of parental perception of nighttime breathing following T&A compared with preoperative assessment. METHODS: Patients with Down syndrome who underwent T&A along with polysomnography prior to and after the surgical procedure were included. Parents completed a 3-question pre- and postsurgery survey regarding nighttime symptoms. The responses were categorized into 3 groups: infrequent (< 3 nights/wk), sometimes (> 3 nights/wk but < 6 nights/wk), or frequent (≥ 6 nights/wk) on at least 1 question. The primary end point was identifying the accuracy of parental perception of nighttime breathing in children with Down syndrome following T&A. RESULTS: A total of 256 children met inclusion criteria, of which 117 (46%) were included. A total of 71 (68%) children had an obstructive apnea-hypopnea index > 5 events/h preoperatively compared with 55 (47%) postoperatively. There was no association between parents' perception of symptoms and obstructive sleep apnea categorization postoperatively (P > .05) or of parents' perception of symptoms improving and obstructive sleep apnea categorization improving postoperatively (P > .05). CONCLUSIONS: Despite previous experience, parents are unable to predict nighttime breathing patterns following a T&A. We recommend obtaining a polysomnogram rather than relying on parental assessment to determine whether a T&A has been successful. CITATION: Chabuz CA, Lackey TG, Pickett KL, Friedman NR. Accuracy of parental perception of nighttime breathing in children with Down syndrome after adenotonsillectomy. J Clin Sleep Med. 2024;20(2):237-243.

Retrospective chart review of patient socioeconomic status and language preference associated with live video telehealth in a pediatric dermatology practice.

Pediatric teledermatology rapidly expanded with the COVID-19 pandemic, and the impacts of this expansion on patients' access to care have not yet been entirely defined. In this retrospective study of 3027 patients in an academic pediatric dermatology practice, patients who identified as having a primary language other than English were less likely to access pediatric dermatology care during the COVID lockdown. This study did not identify a significant or meaningful difference in age, geography, socioeconomic status, ethnicity, or race between patients who were offered pediatric dermatology care that was either in-person or via synchronous telehealth. These findings are overall reassuring that there were not major disparities in telehealth utilization during the COVID shelter-in-place mandate, although highlight the need for institutions to ensure systems are in place to enhance telehealth access for patients with non-English primary language.

Child physical abuse and COVID-19: Trends from nine pediatric trauma centers.

BACKGROUND: Economic, social, and psychologic stressors are associated with an increased risk for abusive injuries in children. Prolonged physical proximity between adults and children under conditions of severe external stress, such as witnessed during the COVID-19 pandemic with "shelter-in-place orders", may be associated with additional increased risk for child physical abuse. We hypothesized that child physical abuse rates and associated severity of injury would increase during the early months of the pandemic as compared to the prior benchmark period. METHODS: We conducted a nine-center retrospective review of suspected child physical abuse admissions across the Western Pediatric Surgery Research Consortium. Cases were identified for the period of April 1-June 30, 2020 (COVID-19) and compared to the identical period in 2019. We collected patient demographics, injury characteristics, and outcome data. RESULTS: There were no significant differences in child physical abuse cases between the time periods in the consortium as a whole or at individual hospitals. There were no differences between the study periods with regard to patient characteristics, injury types or severity, resource utilization, disposition, or mortality. CONCLUSIONS: Apparent rates of new injuries related to child physical abuse did not increase early in the COVID-19 pandemic. While this may suggest that pediatric physical abuse was not impacted by pandemic restrictions and stresses, it is possible that under-reporting, under-detection, or delays in presentation of abusive injuries increased during the pandemic. Long-term follow-up of subsequent rates and severity of child abuse is needed to assess for unrecognized injuries that may have occurred.

Random survival forests for dynamic predictions of a time-to-event outcome using a longitudinal biomarker.

BACKGROUND: Risk prediction models for time-to-event outcomes play a vital role in personalized decision-making. A patient's biomarker values, such as medical lab results, are often measured over time but traditional prediction models ignore their longitudinal nature, using only baseline information. Dynamic prediction incorporates longitudinal information to produce updated survival predictions during follow-up. Existing methods for dynamic prediction include joint modeling, which often suffers from computational complexity and poor performance under misspecification, and landmarking, which has a straightforward implementation but typically relies on a proportional hazards model. Random survival forests (RSF), a machine learning algorithm for time-to-event outcomes, can capture complex relationships between the predictors and survival without requiring prior specification and has been shown to have superior predictive performance. METHODS: We propose an alternative approach for dynamic prediction using random survival forests in a landmarking framework. With a simulation study, we compared the predictive performance of our proposed method with Cox landmarking and joint modeling in situations where the proportional hazards assumption does not hold and the longitudinal marker(s) have a complex relationship with the survival outcome. We illustrated the use of the RSF landmark approach in two clinical applications to assess the performance of various RSF model building decisions and to demonstrate its use in obtaining dynamic predictions. RESULTS: In simulation studies, RSF landmarking outperformed joint modeling and Cox landmarking when a complex relationship between the survival and longitudinal marker processes was present. It was also useful in application when there were several predictors for which the clinical relevance was unknown and multiple longitudinal biomarkers were present. Individualized dynamic predictions can be obtained from this method and the variable importance metric is useful for examining the changing predictive power of variables over time. In addition, RSF landmarking is easily implementable in standard software and using suggested specifications requires less computation time than joint modeling. CONCLUSIONS: RSF landmarking is a nonparametric, machine learning alternative to current methods for obtaining dynamic predictions when there are complex or unknown relationships present. It requires little upfront decision-making and has comparable predictive performance and has preferable computational speed.

Electrolyte-Free Spectroscopy and Imaging of Graphite Intercalation.

Engineering electrode materials for optoelectronic and energy storage applications requires a fundamental understanding of intercalation using spatially-resolved techniques. However, spectroscopic methods can have limited spatial resolution and low intensity since the signal passes through electrolyte. Here, a device geometry is presented in which the electrolyte is laterally separated from the area probed spectroscopically, so that the signal does not pass through the electrolyte. This geometry enables us to visualize ion transport with optical microscopy and monitor charge transfer with Raman and visible reflectance spectroscopies. In addition, vibrational changes are probed in the mid-IR, a region previously difficult to access due to electrolyte absorption. This geometry will allow many layered electrodes to be probed in situ using time- and spatially-resolved techniques, including photon and electron spectroscopies.

Predisposing Risk Factors for Stress Fractures in Collegiate Cross-Country Runners.

ABSTRACT: Giffin, KL, Knight, KB, Bass, MA, and Valliant, MW. Predisposing risk factors and stress fractures in collegiate cross-country runners. J Strength Cond Res 35(1): 227-232, 2021-The purpose of this study was to explore factors associated with increased stress fractures in collegiate cross-country runners. Subjects in this study were 42 male and female cross-country runners at a Division I university. Each athlete completed a questionnaire regarding smoking status, vitamin/mineral intake, previous stress fracture history, birth control usage, menstrual status, and demographic information. Nutritional assessment using a 3-day food record and measurements of whole body, lumbar spine, and hip bone mineral densities (BMDs) were also conducted on each athlete. Results indicated that 40% of the female and 35% of the male runners reported a history of stress fracture, and that all of them did not meet the recommended daily energy intake or adequate intakes for calcium or vitamin D required for their amount of training. Two-tailed t-test found statistically higher incidences of lumbar spine BMD in male and female runners whose daily calcium and vitamin D intakes were below minimum requirements as well as for women whose caloric intake was below the required level. When data on the lumbar spine was evaluated, 31% of subjects (31.8% of the male and 30% of the female runners) were identified as having osteopenia and 4.8% with osteoporosis. Results warrant a need for future longitudinal studies.

Preparation of dihydroxy polycyclic aromatic hydrocarbons and activities of two dioxygenases in the phenanthrene degradative pathway.

Dihydroxy phenanthrene, fluoranthene, and pyrene derivatives are intermediates in the bacterial catabolism of the corresponding parent polycyclic aromatic hydrocarbon (PAH). Ring-opening of the dihydroxy species followed by a series of enzyme-catalyzed reactions generates metabolites that funnel into the Krebs Cycle with the eventual production of carbon dioxide and water. One complication in delineating these pathways and harnessing them for useful purposes is that the initial enzymatic processing produces multiple dihydroxy PAHs with multiple ring opening possibilities and products. As part of a systematic effort to address this issue, eight dihydroxy species were synthesized and characterized as the dimethoxy or diacetate derivatives. Several dihydroxy compounds were examined with two dioxygenases in the phenanthrene degradative pathway in Mycobacterium vanbaalenii PYR-1. One, 3,4-dihydroxyphenanthrene, was processed by PhdF with a kcat/Km of 6.0 × 106 M-1s-1, a value that is consistent with the annotated function of PhdF in the pathway. PhdI processed 1-hydroxy-2-naphthoate with a kcat/Km of 3.1 × 105 M-1s-1, which is also consistent with the proposed role in the pathway. The observations provide the first biochemical evidence for these two reactions in M. vanbaalenii PYR-1 and, to the best of our knowledge, the first biochemical evidence for the reaction of PhdF with 3,4-dihydroxyphenanthrene. Although PhdF is upregulated in the presence of pyrene, it did not process two dihydroxypyrenes. Methodology was developed for product analysis of the extradiol dioxygenases.

Intercalation of Layered Materials from Bulk to 2D.

Intercalation in few-layer (2D) materials is a rapidly growing area of research to develop next-generation energy-storage and optoelectronic devices, including batteries, sensors, transistors, and electrically tunable displays. Identifying fundamental differences between intercalation in bulk and 2D materials will play a key role in developing functional devices. Herein, advances in few-layer intercalation are addressed in the historical context of bulk intercalation. First, synthesis methods and structural properties are discussed, emphasizing electrochemical techniques, the mechanism of intercalation, and the formation of a solid-electrolyte interphase. To address fundamental differences between bulk and 2D materials, scaling relationships describe how intercalation kinetics, structure, and electronic and optical properties depend on material thickness and lateral dimension. Here, diffusion rates, pseudocapacity, limits of staging, and electronic structure are compared for bulk and 2D materials. Next, the optoelectronic properties are summarized, focusing on charge transfer, conductivity, and electronic structure. For energy devices, opportunities also emerge to design van der Waals heterostructures with high capacities and excellent cycling performance. Initial studies of heterostructured electrodes are compared to state-of-the-art battery materials. Finally, challenges and opportunities are presented for 2D materials in energy and optoelectronic applications, along with promising research directions in synthesis and characterization to engineer 2D materials for superior devices.

Maturation of Breathing-Related Inhibitory Neurotransmission in the Medulla Oblongata of the Embryonic and Perinatal Zebra Finch (Taeniopygia guttata).

The medullary portion of the embryonic zebra finch hindbrain was isolated and superfused with physiologically relevant artificial cerebral spinal fluid. This in vitro preparation produced uninterrupted rhythmic episodes of neural activity via cranial nerve IX (glossopharyngeal) from embryonic day 4 (E4) through hatching on E14. Cranial nerve IX carries motor activity to the glottis during the inspiratory phase of breathing, and we focused on the role of synaptic inhibition during the embryonic and perinatal maturation of this branchiomotor outflow. We show that spontaneous neural activity (SNA) is first observed on E4 and temporally transforms as the embryo ages. To start, SNA is dependent on the excitatory actions of GABAA and glycine. As the embryo continues to develop, GABAergic and glycinergic neurotransmission take on a modulatory role, albeit an excitatory one, through E10. After that, data show that GABAergic and glycinergic neurotransmission switches to a phenotype consistent with inhibition, coincident with the onset of functional breathing. We also report that the inhibitory action of GABAergic and glycinergic receptor gating is not necessary for the spontaneous generation of branchiomotor motor rhythms in these birds near hatching. This is the first report focusing on the development of central breathing-related inhibitory neurotransmission in birds during the entire period of embryogenesis.

Control of Surface and Edge Oxidation on Phosphorene.

Phosphorene is emerging as an important two-dimensional semiconductor, but controlling the surface chemistry of phosphorene remains a significant challenge. Here, we show that controlled oxidation of phosphorene determines the composition and spatial distribution of the resulting oxide. We used X-ray photoemission spectroscopy to measure the binding energy shifts that accompany oxidation. We interpreted these spectra by calculating the binding energy shift for 24 likely bonding configurations, including phosphorus oxides and hydroxides located on the basal surface or edges of flakes. After brief exposure to high-purity oxygen or high-purity water vapor at room temperature, we observed phosphorus in the +1 and +2 oxidation states; longer exposures led to a large population of phosphorus in the +3 oxidation state. To provide insight into the spatial distribution of the oxide, transmission electron microscopy was performed at several stages during the oxidation. We found crucial differences between oxygen and water oxidants: while pure oxygen produced an oxide layer on the van der Waals surface, water oxidized the material at pre-existing defects such as edges or steps. We propose a mechanism based on the thermodynamics of electron transfer to interpret these observations. This work opens a route to functionalize the basal surface or edges of two-dimensional (2D) black phosphorus through site-selective chemical reactions and presents the opportunity to explore the synthesis of 2D phosphorene oxide by oxidation.

Cortisol and stimulus-induced arousal level differentially impact memory for items and backgrounds.

Most studies examine the effects of stress on memory for visual information test memory for entire scenes. However, arousal levels may differentially influence memory for backgrounds as opposed to items. Participants encoded scenes that included a negative-high-arousal, negative-moderate-arousal, or neutral item on a neutral background. After a 30-minute (Experiment 1) or 48-hour delay (Experiment 2), participants underwent a stressor or control task while heart rate was recorded. A recognition memory task was then given with items and backgrounds presented separately. High-arousal images had a greater detriment in background memory than moderate-arousal images. Further, though there was evidence that change in cortisol level at retrieval was associated with impaired memory for items, it was not associated with detriments in background memory. Increased heart rate was associated with impaired memory for both items and backgrounds. This suggests that the level of sympathetic and cortisol reactivity differentially affects memory for items and backgrounds.

Experimental Demonstration of an Electride as a 2D Material.

Because of their loosely bound electrons, electrides offer physical properties useful in chemical synthesis and electronics. For these applications and others, nanosized electrides offer advantages, but to-date no electride has been synthesized as a nanomaterial. We demonstrate experimentally that Ca2N, a layered electride in which layers of atoms are separated by layers of a 2D electron gas (2DEG), can be exfoliated into two-dimensional (2D) nanosheets using liquid exfoliation. The 2D flakes are stable in a nitrogen atmosphere or in select organic solvents for at least one month. Electron microscopy and elemental analysis reveal that the 2D flakes retain the crystal structure and stoichiometry of the parent 3D Ca2N. In addition, the 2D flakes exhibit metallic character and an optical response that agrees with DFT calculations. Together these findings suggest that the 2DEG is preserved in the 2D material. With this work, we bring electrides into the nanoregime and experimentally demonstrate a 2D electride, Ca2N.

The effective dose of different scanning protocols using the Sirona GALILEOS(®) comfort CBCT scanner.

OBJECTIVES: To determine the effective dose and CT dose index (CTDI) for a range of imaging protocols using the Sirona GALILEOS(®) Comfort CBCT scanner (Sirona Dental Systems GmbH, Bensheim, Germany). METHODS: Calibrated optically stimulated luminescence dosemeters were placed at 26 sites in the head and neck of a modified RANDO(®) phantom (The Phantom Laboratory, Greenwich, NY). Effective dose was calculated for 12 different scanning protocols. CTDI measurements were also performed to determine the dose-length product (DLP) and the ratio of effective dose to DLP for each scanning protocol. RESULTS: The effective dose for a full maxillomandibular scan at 42 mAs was 102 ± 1 µSv and remained unchanged with varying contrast and resolution settings. This compares with 71 µSv for a maxillary scan and 76 µSv for a mandibular scan with identical milliampere-seconds (mAs) at high contrast and resolution settings. CONCLUSIONS: Changes to mAs and beam collimation have a significant influence on effective dose. Effective dose and DLP vary linearly with mAs. A collimated maxillary or mandibular scan decreases effective dose by approximately 29% and 24%, respectively, as compared with a full maxillomandibular scan. Changes to contrast and resolution settings have little influence on effective dose. This study provides data for setting individualized patient exposure protocols to minimize patient dose from ionizing radiation used for diagnostic or treatment planning tasks in dentistry.

Pedestrian traffic deaths among residents, visitors, and homeless persons--Clark County, Nevada, 2008-2011.

Motor vehicle collisions and crashes are a leading cause of death among Nevada residents aged 5-34 years, representing 14% of all injury deaths in that age group in 2010. During 2008-2011, a total of 173 pedestrian deaths from motor vehicle collisions occurred in Nevada, accounting for 16% of motor vehicle deaths in the state. Approximately 75% (2 million persons) of Nevada residents live in Clark County, which includes the city of Las Vegas. To analyze pedestrian traffic deaths in Clark County among residents, visitors, and homeless persons, the Southern Nevada Health District used coroner's office data and death certificate data for the period 2008-2011. The results indicated that the average annual pedestrian traffic death rates from motor vehicle collisions during this period were 1.4 per 100,000 population for residents, 1.1 for visitors, and 30.7 for homeless persons. Among the three groups, time of day, location of motor vehicle collisions, and pedestrian blood alcohol concentration (BAC) differed. Effective interventions to increase roadway safety, such as lowering speed limits in areas with greater pedestrian traffic, targeting interventions during hours when alcohol-impaired walking is more likely, and modifying roadway designs to increase protection of pedestrians, might decrease pedestrian deaths among all three groups.

Van wyk and grumbach syndrome: an unusual case and review of the literature.

BACKGROUND: The syndrome consisting of primary hypothyroidism, precocious puberty, and massive ovarian cysts was termed Van Wyk and Grumbach syndrome in 1960. Little is known about the effect of the cysts on ovarian tumor markers. CASE: A 12-year-old Caucasian female presented with headaches and fatigue. Imaging to evaluate her headaches revealed a pituitary macroadenoma. Soon after her macroadenoma was discovered, she presented to the emergency room with abdominal pain. Imaging at that time revealed massive bilateral ovarian masses with the left measuring 17 × 13 × 8.5 cm and the right measuring 18 × 11 × 10 cm. Ovarian tumor markers were drawn at this time, most of which were highly elevated. Subsequent evaluation revealed extreme hypothyroidism. Given these findings of a pituitary macroadenoma, bilateral ovarian masses, and severe hypothyroidism, the patient was diagnosed with Van Wyk and Grumbach syndrome. We followed the cyst conservatively and the ovaries and tumor markers returned to normal after adequate thyroid replacement. COMMENTS: This case supports conservative treatment as the first-line approach to massive ovarian cysts caused by hypothyroidism. In addition this case shows that tumor markers can be abnormal in the absence of a malignancy in this setting. Before proceeding with surgical evaluation, exclusion of hypothyroidism to exclude this rare but treatable syndrome should be undertaken. The most important diagnostic clue that the cyst may be caused by an endocrine source is the finding of bilateral ovarian cysts rather than one ovary affected as seen in most ovarian malignancies in this age group.

A phase I clinical trial of the hu14.18-IL2 (EMD 273063) as a treatment for children with refractory or recurrent neuroblastoma and melanoma: a study of the Children's Oncology Group.

PURPOSE: Evaluate the clinical safety, toxicity, immune activation/modulation, and maximal tolerated dose of hu14.18-IL2 (EMD 273063) in pediatric patients with recurrent/refractory neuroblastoma and other GD2-positive solid tumors. EXPERIMENTAL DESIGN: Twenty-seven pediatric patients with recurrent/refractory neuroblastoma and one with melanoma were treated with a humanized anti-GD2 monoclonal antibody linked to human interleukin 2 (IL-2). Cohorts of patients received hu14.18-IL2, administered i.v. over 4 hours for three consecutive days, at varying doses. Patients with stable disease, partial, or complete responses were eligible to receive up to three additional courses of therapy. RESULTS: Most of the clinical toxicities were anticipated and similar to those reported with IL-2 and anti-GD2 monoclonal antibody therapy and to those noted in the initial phase I study of hu14.18-IL2 in adults with metastatic melanoma. The maximal tolerated dose was determined to be 12 mg/m2/d, with agent-related dose-limiting toxicities of hypotension, allergic reaction, blurred vision, neutropenia, thrombocytopenia, and leukopenia. Three patients developed dose-limiting toxicity during course 1; seven patients in courses 2 to 4. Two patients required dopamine for hypotension. There were no treatment-related deaths, and all toxicity was reversible. Treatment with hu14.18-IL2 led to immune activation/modulation as evidenced by elevated serum levels of soluble IL-2 receptor alpha (sIL2Ralpha) and lymphocytosis. The median half-life of hu14.18-IL2 was 3.1 hours. There were no measurable complete or partial responses to hu14.18-IL2 in this study; however, three patients did show evidence of antitumor activity. CONCLUSION: Hu14.18-IL2 (EMD 273063) can be administered safely with reversible toxicities in pediatric patients at doses that induce immune activation. A phase II clinical trial of hu14.18-IL2, administered at a dose of 12 mg/m2/d x 3 days repeated every 28 days, will be done in pediatric patients with recurrent/refractory neuroblastoma.

[Hypertension and primary glomerulonephritis in adults. A study of 302 cases]. / Hypertension artérielle et glomérulonéphrites primitives de l'adulte. Etude de 302 cas.

The purpose of the present work was to show the place of hypertension in primary glomerulonephritis in adults. Hypertension was defined as diastolic blood pressure above 90 mmHg and renal insufficiency as serum creatinine above 135 mc mol/L. Secondary glomerulonephritis was excluded. The study was performed in 302 patients with primary glomerulonephritis biopsied between March 1994 and March 1996. They were 183 males and 119 females, aged from 16 to 63 years (mean: 29.8 years). The incidence of hypertension at the time of admission was 46.6%: 141/302 cases. The only consideration of prolonged hypertension (excluded transient hypertension of acute nephritic syndrome) shows an incidence of 31.4%: 95/302 cases (table). Frequency of hypertension (HT) in different types of primary glomerulonephritis (GN): [table: see text] The histological types observed in these cases of hypertension were represented essentially by the proliferative lesions: 73% (72/95 cases) who were grouped mainly in proliferative glomerulonephritis postinfectious and IgA nephropathy. No proliferative lesions: 24% (23/95 cases) were especially represented by focal segmental sclerosis. Renal insufficiency noted in 69 cases on 95 hypertensions was probably the result of the parallel evolution of hypertension renal lesions and those belonging to these histologic types. In conclusion, this study shows a narrow correlation between the hypertension and proliferative glomerulonephritis in our young adults population.