Nasopharyngeal Swabs in Pediatric Patients With Thrombocytopenia and Anticoagulant Use.

BACKGROUND: Nasopharyngeal (NP) swabbing is a technique that is commonly used to test pediatric patients for viral infections with increased use during the coronavirus disease 2019 pandemic. Complications from NP swabbing are rare and seem to occur more frequently in patients at risk of bleeding. Little is known about institutional or individual practices and experiences with NP swab testing in pediatric patients with risk factors for bleeding. METHODS: We conducted a survey study of pediatric hematology/oncology (PHO) attending physicians to assess practices and experiences with NP swab testing in pediatric patients with thrombocytopenia and/or on anticoagulation. RESULTS: There were 130 total respondents (5.6%, n = 130/2327) from 6 countries. Relatively few respondents (n = 17/130, 13.1%) reported that their institution had a policy specifying a lower-level platelet cutoff for patients undergoing NP swabbing. The median platelet cutoff below which NP swabs are not performed according to existing policies is 30,000×10(9)/L (interquartile range: 20,000 to 40,000). The median cutoff based on the opinion of the respondents was 10,000 (interquartile range: 10,000 to 20,000). There were 24 episodes of epistaxis among PHO patients that were NP swabbed; many adverse events (56.5%, n = 13/23) were described as persistent, severe, and/or required intervention. Three reported cases of epistaxis with anticoagulation or antiplatelet therapy occurred in patients with concomitant thrombocytopenia. Only 1 respondent (n = 1/130, 0.7%) reported an institutional policy for limiting NP swabs in patients on anticoagulant therapy. NP (66.9%) and nares (33.1%) were the most common sources of coronavirus disease 2019 testing that were reported. CONCLUSION: A small percentage of institutions in this survey have a policy restricting NP swabs in PHO patients. The discrepancy between lower platelet cutoffs proposed by experts and institutional policy suggests that existing policies may be too conservative. Expert guidelines are needed on this topic. Other bleeding risk factors (eg, aspirin use and von Willebrand disease) should be considered in policies and guidelines.

MIRRORS program: Helping pregnant and postpartum women and families with substance use problems.

Background: Pregnant and postpartum women with substance use disorders are a highly vulnerable population, especially when this is compounded by homelessness or unstable housing, justice involvement, and/or co-occurring mental health challenges. The MIRRORS (Maternal Initiative for Reflective Recovery-Oriented Residential Services) program provided expanded and enhanced residential substance use disorder treatment, prevention and recovery support for women and children through integrated, trauma-informed care and services strengthened by a comprehensive and coordinated family systems approach. This paper describes the program and provides evaluation of the outcomes. Methods: Pregnant and postpartum women (n = 215) were assessed at 3 time points: intake, discharge and 6-months post-intake using standardized measures of family functioning, parenting, recovery capital, and other outcomes. Multilevel modeling was employed to examine individual differences in trends over time. Results: Over 80% of participants reported that the MIRRORS program enhanced their recovery treatment experience. Women reported significant improvements in general family functioning, problem solving, behavioral control, affective responsiveness, and communication. Participants also reported increased recovery capital and improved parental monitoring over time. Conclusions: Outcomes indicate that the MIRRORS program was effective in improving family functioning and reducing substance use, thus enhancing women's functioning and recovery.

Emergency Department Use of Neuroimaging in Children and Adolescents Presenting with Headache.

OBJECTIVES: To evaluate emergency department use and outcomes of neuroimaging for headache in a free-standing children's hospital system. STUDY DESIGN: We prospectively enrolled children aged 6-18 years who presented to the emergency department with a chief complaint of headache from September 2015 to September 2016. Standardized data collection was performed in real time, including telephone follow-up as needed, and imaging outcome was determined through a chart review. Using multivariable logistic regression, we estimated the associations between clinically important patient characteristics and neuroimaging. RESULTS: Of 294 enrolled patients, 53 (18%) underwent neuroimaging (computed tomography or magnetic resonance imaging) and 2 (0.7%) had clinically important intracranial findings. Presenting with abnormal neurologic examination findings (OR, 11.55; 95% CI, 3.24-41.22), no history of similar headaches (OR, 2.13; 95% CI, 1.08-4.18), and white race (OR, 3.04; 95% CI, 1.51-6.12) were significantly associated with an increased odds of undergoing imaging in multivariable regression models. CONCLUSIONS: Our observed emergency department imaging rate was 26.5 times higher than our positive result rate, suggesting there is room to decrease unnecessary neuroimaging. Associations for abnormal examination and new headache type are consistent with the American Academy of Neurology clinical imaging recommendations. The increased odds of imaging white patients suggests bias that should be addressed. The low rate of positive findings supports the need for an evidence-based clinical decision tool for neuroimaging in the acute care setting.

Univariate and multivariate skewness and kurtosis for measuring nonnormality: Prevalence, influence and estimation.

Nonnormality of univariate data has been extensively examined previously (Blanca et al., Methodology: European Journal of Research Methods for the Behavioral and Social Sciences, 9(2), 78-84, 2013; Miceeri, Psychological Bulletin, 105(1), 156, 1989). However, less is known of the potential nonnormality of multivariate data although multivariate analysis is commonly used in psychological and educational research. Using univariate and multivariate skewness and kurtosis as measures of nonnormality, this study examined 1,567 univariate distriubtions and 254 multivariate distributions collected from authors of articles published in Psychological Science and the American Education Research Journal. We found that 74 % of univariate distributions and 68 % multivariate distributions deviated from normal distributions. In a simulation study using typical values of skewness and kurtosis that we collected, we found that the resulting type I error rates were 17 % in a t-test and 30 % in a factor analysis under some conditions. Hence, we argue that it is time to routinely report skewness and kurtosis along with other summary statistics such as means and variances. To facilitate future report of skewness and kurtosis, we provide a tutorial on how to compute univariate and multivariate skewness and kurtosis by SAS, SPSS, R and a newly developed Web application.

Adolescent Presents With Altered Mental Status and Elevated Anion Gap After Suicide Attempt by Ethylene Glycol Ingestion.

We report the case of a 16-year-old healthy adolescent male who presented to the local emergency department with altered mental status. En route to a tertiary care facility, he began to decompensate and was found to be markedly acidotic. Further investigation revealed an elevated anion gap, and physical examination showed only abdominal pain and decreased level of consciousness. A broad differential diagnosis was considered at the time of the patient's presentation at the tertiary care center including ingestion of a volatile alcohol, sepsis, and an abdominal catastrophe. Although fomepizole and emergent dialysis were being initiated, laboratory tests confirmed ethylene glycol poisoning. This case demonstrates the importance of early recognition of potential ingestions in patients with altered mental status and supportive laboratory findings.

Association between school learning models and psychological and social health visits to the emergency room.

Objectives: We aimed to assess the impact of in-person and distance school learning models on children's visits to the emergency department (ED) for psychological or social ("psychosocial") complaints. Methods: We analyzed presentations to one emergency department in a mid-sized Midwestern city. We used the public school system schedule to determine in-person and distance learning periods by the grade level. We calculated the incidence of visits to the emergency department during academic years 2018-2019, 2019-2020, and 2020-2021, with particular attention to the time after March 13, 2020, which was the pandemic period. We compared the incidence of visits during in-person versus distance learning school models. Results: A total of 7181 visits occurred during the academic years studied, 17.1% due to psychosocial complaints. The incidence of psychosocial visits to the ED was lower during distance learning than during the pandemic in-person learning period (given per 1000 student years: 20.5 vs. 24.1, p = 0.14). This difference was statistically significant among middle schoolers (23.3 vs. 46.6, p < 0.001). While not statistically significant, the difference among high schoolers was pragmatically relevant (38.2 vs. 49.3, p = 0.086). Conclusions: Distance learning was associated with a decrease in the incidence of psychosocial visits to the emergency department relative to in-person learning. Future investigation is required to verify results and better understand any causative relationships.

Effects of granulocyte-colony stimulating factor on chromosome aneuploidy and replication asynchrony in healthy peripheral blood stem cell donors.

As peripheral blood has surpassed bone marrow as a predominant source of stem cells for transplantation, use of the cytokine granulocyte colony-stimulating factor (G-CSF) to mobilize peripheral blood stem cells (PBSCs) is increasing. Issues regarding potential genotoxic effects of even short-term, low-dose G-CSF treatment for the healthy donors have been raised. To address the question of chromosomal instability, we used FISH to evaluate the peripheral blood lymphocytes of 22 PBSC donors and 22 matched controls at 5 time points over a 12-month period. The specimens obtained were a pre-G-CSF, followed by collections at the time of PBSC harvest (days 5-7) and at 2, 6, and 12 months after donation. Eight additional PBSC donors provided a single sample at 12 months. Nine loci (mapped to chromosomes 7, 8, 9, 17, 21, and 22) were evaluated for aneuploidy, including 3 mapped to chromosome 7 because of the specific relevance of monosomy 7. Replication timing was evaluated for chromosome 15 and 17 loci. No evidence was found of G-CSF-induced chromosomal instability. This work supports the epidemiologic data that have demonstrated no increased risk for hematologic malignancies in G-CSF-primed PBSC donors.

18-year-old with Abdominal Pain Due to Congenital Bowel Malrotation: A Case Report.

INTRODUCTION: Congenital bowel malrotation resulting in midgut volvulus is traditionally regarded as a diagnosis of infancy. Rarely, congenital bowel malrotation is diagnosed in adolescents or adults and requires a high index of suspicion. Presentations can be acute or chronic, and physical examination findings are nonspecific. Diagnosis is primarily achieved through abdominal computed tomography (CT) or during exploratory laparotomy. The pathophysiology in late-onset malrotation is similar to neonatal malrotation, with a division of Ladd's bands - peritoneal fibrous bands that connect the cecum to the right lower quadrant retroperitoneum - as the definitive treatment. We present a case of congenital bowel malrotation in an adolescent with persistent and worsening migratory abdominal pain. CASE REPORT: An 18-year-old female presented to the emergency department with two days of poorly localized abdominal pain and nausea. Initial evaluation was unremarkable and she was discharged home with a diagnosis of constipation. She returned two days later with worsening abdominal pain and new onset emesis. Given her persistent and worsening symptoms an abdominal CT was performed, which revealed malrotation of the bowel. Taken together, her CT findings and abdominal symptoms were concerning for symptomatic congenital bowel malrotation and she underwent a Ladd procedure. She remained asymptomatic both at discharge and at two-week postoperative follow-up. CONCLUSION: Symptomatic congenital bowel malrotation is more common in older children and adults than has traditionally been thought. Physicians must consider this diagnosis in their differential when working up a patient for acute or chronic intermittent abdominal pain to prevent potentially severe sequelae.

Parental monitoring, family conflict, and adolescent alcohol use: A longitudinal latent class analysis.

This study examined relationships among parental monitoring, family conflict, and subgroups of adolescent alcohol use identified through longitudinal latent class analyses (LLCA). Differences in these subgroups across sex and race/ethnicity were also examined. The present study used data (N = 4,067; 51% male, 49% female) collected during a longitudinal study in which adolescents completed questionnaires each semester for seven semesters, beginning in spring of their freshman year of high school until spring of their senior year. LLCA demonstrated three classes of drinking over time (low, increasing, and moderate use). The majority of adolescents were increasing-use drinkers. Moderate drinkers were more likely to be male than female; nondrinkers were most likely to be African American; and increasing-use drinkers were more likely to be Mexican American. Adolescents who received less maternal monitoring and experienced more family conflict were more likely to be identified in the class of moderate alcohol use compared to nonuse. These results highlight the importance of encouraging parental monitoring and decreasing family conflict to reduce the likelihood of adolescent alcohol use throughout the high school years (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Snoozing: an examination of a common method of waking.

STUDY OBJECTIVES: Snoozing was defined as using multiple alarms to accomplish waking, and considered as a method of sleep inertia reduction that utilizes the stress system. Surveys measured snoozing behavior including who, when, how, and why snoozing occurs. In addition, the physiological effects of snoozing on sleep were examined via wearable sleep staging and heart rate (HR) activity, both over a long time scale, and on the days that it occurs. We aimed to establish snoozing as a construct in need of additional study. METHODS: A novel survey examined snoozing prevalence, how snoozing was accomplished, and explored possible contributors and motivators of snoozing behavior in 450 participants. Trait- and day-level surveys were combined with wearable data to determine if snoozers sleep differently than nonsnoozers, and how snoozers and nonsnoozers differ in other areas, such as personality. RESULTS: 57% of participants snoozed. Being female, younger, having fewer steps, having lower conscientiousness, having more disturbed sleep, and being a more evening chronotype increased the likelihood of being a snoozer. Snoozers had elevated resting HR and showed lighter sleep before waking. Snoozers did not sleep less than nonsnoozers nor did they feel more sleepiness or nap more often. CONCLUSIONS: Snoozing is a common behavior associated with changes in sleep physiology before waking, both in a trait- and state-dependent manner, and is influenced by demographic and behavioral traits. Additional research is needed, especially in detailing the physiology of snoozing, its impact on health, and its interactions with observational studies of sleep.

Inhibition of ATR Reverses a Mitochondrial Respiratory Insufficiency.

Diseases that affect the mitochondrial electron transport chain (ETC) often manifest as threshold effect disorders, meaning patients only become symptomatic once a certain level of ETC dysfunction is reached. Cells can invoke mechanisms to circumvent reaching their critical ETC threshold, but it is an ongoing challenge to identify such processes. In the nematode Caenorhabditis elegans, severe reduction of mitochondrial ETC activity shortens life, but mild reduction actually extends it, providing an opportunity to identify threshold circumvention mechanisms. Here, we show that removal of ATL-1, but not ATM-1, worm orthologs of ATR and ATM, respectively, key nuclear DNA damage checkpoint proteins in human cells, unexpectedly lessens the severity of ETC dysfunction. Multiple genetic and biochemical tests show no evidence for increased mutation or DNA breakage in animals exposed to ETC disruption. Reduced ETC function instead alters nucleotide ratios within both the ribo- and deoxyribo-nucleotide pools, and causes stalling of RNA polymerase, which is also known to activate ATR. Unexpectedly, atl-1 mutants confronted with mitochondrial ETC disruption maintain normal levels of oxygen consumption, and have an increased abundance of translating ribosomes. This suggests checkpoint signaling by ATL-1 normally dampens cytoplasmic translation. Taken together, our data suggest a model whereby ETC insufficiency in C. elegans results in nucleotide imbalances leading to the stalling of RNA polymerase, activation of ATL-1, dampening of global translation, and magnification of ETC dysfunction. The loss of ATL-1 effectively reverses the severity of ETC disruption so that animals become phenotypically closer to wild type.

Profiles and academic trajectories of cognitively gifted children with autism spectrum disorder.

Gifted children with autism spectrum disorder (ASD) are often referred to as twice-exceptional, the term that highlights the co-occurrence of exceptional challenges and exceptional giftedness. This study performed secondary data analysis on samples of twice-exceptional children from the Pre-Elementary Education Longitudinal Study and the Special Education Elementary Longitudinal Study datasets. The results provide a descriptive profile of twice-exceptional (e.g. demographics, average academic performance, and services utilized), trajectory plots that indicate how academic performance changes over time, and multilevel analyses that model growth in academic outcomes using demographics, school services, and giftedness as predictors. Some of the key findings are that twice-exceptional students show not only higher initial levels of academic performance, but they improve over time relative to the non-gifted ASD counterparts and-with the exception of Letter Word Matching-even relative to the general population. Moreover, they benefit from mental health services disproportionately. Together, the results offer a deeper understanding of the twice-exceptional autistic population, their academic performance over time, and the services that they utilize.

Time and Other Considerations in Mediation Design.

This article serves as a practical guide to mediation design and analysis by evaluating the ability of mediation models to detect a significant mediation effect using limited data. The cross-sectional mediation model, which has been shown to be biased when the mediation is happening over time, is compared with longitudinal mediation models: sequential, dynamic, and cross-lagged panel. These longitudinal mediation models take time into account but bring many problems of their own, such as choosing measurement intervals and number of measurement occasions. Furthermore, researchers with limited resources often cannot collect enough data to fit an appropriate longitudinal mediation model. These issues were addressed using simulations comparing four mediation models each using the same amount of data but with differing numbers of people and time points. The data were generated using multilevel mediation models, with varying data characteristics that may be incorrectly specified in the analysis models. Models were evaluated using power and Type I error rates in detecting a significant indirect path. Multilevel longitudinal mediation analysis performed well in every condition, even in the misspecified conditions. Of the analyses that used limited data, sequential mediation had the best performance; therefore, it offers a viable second choice when resources are limited. Finally, each of these models were demonstrated in an empirical analysis.