Past, present, and future of sustainable intensive care: narrative review and a large hospital system experience.

Healthcare systems are large contributors to global emissions, and intensive care units (ICUs) are a complex and resource-intensive component of these systems. Recent global movements in sustainability initiatives, led mostly by Europe and Oceania, have tried to mitigate ICUs' notable environmental impact with varying success. However, there exists a significant gap in the U.S. knowledge and published literature related to sustainability in the ICU. After a narrative review of the literature and related industry standards, we share our experience with a Green ICU initiative at a large hospital system in Texas. Our process has led to a 3-step pathway to inform similar initiatives for sustainable (green) critical care. This pathway involves (1) establishing a baseline by quantifying the status quo carbon footprint of the affected ICU as well as the cumulative footprint of all the ICUs in the healthcare system; (2) forming alliances and partnerships to target each major source of these pollutants and implement specific intervention programs that reduce the ICU-related greenhouse gas emissions and solid waste; and (3) finally to implement a systemwide Green ICU which requires the creation of multiple parallel pathways that marshal the resources at the grass-roots level to engage the ICU staff and institutionalize a mindset that recognizes and respects the impact of ICU functions on our environment. It is expected that such a systems-based multi-stakeholder approach would pave the way for improved sustainability in critical care.

Identified Needs in Pediatric Education for Emergency Medicine Physicians: A Qualitative Analysis.

OBJECTIVES: General emergency medicine (EM) physicians provide most pediatric emergency care in the United States, yet EM physicians feel underprepared to manage pediatric emergencies. Pediatric emergency medicine (PEM) education during EM residency is variable, and learner preferences regarding educational experiences have not been widely explored through a qualitative lens. We aimed to better describe EM physicians' PEM educational needs and preferred teaching methods. METHODS: In 2021, as part of a survey querying senior EM residents and recent graduates from 8 diverse EM programs regarding perceived preparedness for PEM emergencies, educational needs and content delivery methods were assessed using 2 free-text questions. Qualitative analysis included deidentification and iterative coding of the data with double coding of 100% of the comments. We performed conventional content analysis of responses to identify emerging themes. RESULTS: The overall response rate for the survey was 53% (N = 129 out of 242 eligible participants) with 84 distinct free-text responses. Major themes included: 1) desire for education regarding neonates, infants, and critically ill children, especially airway management and 2) need for help translating lessons from PEM rotations to community EM practice. Respondents desired more autonomy during training. Their preferred PEM educational modality was simulation, and they appreciated online clinical pathways for just-in-time decision support. CONCLUSIONS: This qualitative study of EM physicians proximal to training adds to a prior needs assessment by describing in detail desired pediatric content and preferred delivery. The findings can be used to better inform the development of PEM curricula for this group of EM physicians.

Precise functional connections between the dorsal anterior cingulate cortex and areas recruited for physical inference.

Recent work has identified brain areas that are engaged when people predict how the physical behaviour of the world will unfold-an ability termed intuitive physics. Among the many unanswered questions about the neural mechanisms of intuitive physics is where the key inputs come from: Which brain regions connect up with intuitive physics processes to regulate when and how they are engaged in service of our goals? In the present work, we targeted the dorsal anterior cingulate cortex (dACC) for study based on characteristics that make it well-positioned to regulate intuitive physics processes. The dACC is richly interconnected with frontoparietal regions and is implicated in mapping contexts to actions, a process that would benefit from physical predictions to indicate which action(s) would produce the desired physical outcomes. We collected resting state functional magnetic resonance imaging (MRI) data in 17 participants and used independent task-related runs to find the pattern of activity during a physical inference task in each individual participant. We found that the strongest resting state functional connections of the dACC not only aligned well with physical inference-related activity at the group level, it also mirrored individual differences in the positioning of physics-related activity across participants. Our results suggest that the dACC might be a key structure for regulating the engagement of intuitive physics processes in the brain.

Persistence of Escherichia coli in the microbiomes of red Romaine lettuce (Lactuca sativa cv. 'Outredgeous') and mizuna mustard (Brassica rapa var. japonica) - does seed sanitization matter?

BACKGROUND: Seed sanitization via chemical processes removes/reduces microbes from the external surfaces of the seed and thereby could have an impact on the plants' health or productivity. To determine the impact of seed sanitization on the plants' microbiome and pathogen persistence, sanitized and unsanitized seeds from two leafy green crops, red Romaine lettuce (Lactuca sativa cv. 'Outredgeous') and mizuna mustard (Brassica rapa var. japonica) were exposed to Escherichia coli and grown in controlled environment growth chambers simulating environmental conditions aboard the International Space Station. Plants were harvested at four intervals from 7 days post-germination to maturity. The bacterial communities of leaf and root were investigated using the 16S rRNA sequencing while quantitative polymerase chain reaction (qPCR) and heterotrophic plate counts were used to reveal the persistence of E. coli. RESULT: E. coli was detectable for longer periods of time in plants from sanitized versus unsanitized seeds and was identified in root tissue more frequently than in leaf tissue. 16S rRNA sequencing showed dynamic changes in the abundance of members of the phylum Proteobacteria, Firmicutes, and Bacteroidetes in leaf and root samples of both leafy crops. We observed minimal changes in the microbial diversity of lettuce or mizuna leaf tissue with time or between sanitized and unsanitized seeds. Beta-diversity showed that time had more of an influence on all samples versus the E. coli treatment. CONCLUSION: Our results indicated that the seed surface sanitization, a current requirement for sending seeds to space, could influence the microbiome. Insight into the changes in the crop microbiomes could lead to healthier plants and safer food supplementation.

The building blocks of intuitive physics in the mind and brain.

There has been a recent wave of interest in understanding the mental processes underlying intuitive physics - our ability to apprehend the physical structure of the world and anticipate how objects will behave as a scene's dynamics unfold. While work to uncover the neural mechanisms of intuitive physics is just in its beginnings, vibrant lines of neuropsychological research are investigating the many facets of cognition intimately linked with the 'physics engine in the mind'. This special issue brings together a collection of papers that delve into the interactions between intuitive physics and related domains such as audiovisual scene analysis, action planning, and decision making, providing a view of the larger landscape of mental processes that allow us to predict how physical events will unfold in the next moments and plan our behaviors accordingly.

What tool representation, intuitive physics, and action have in common: The brain's first-person physics engine.

An overlapping set of brain regions in parietal and frontal cortex are engaged by different types of tasks and stimuli: (i) making inferences about the physical structure and dynamics of the world, (ii) passively viewing, or actively interacting with, manipulable objects, and (iii) planning and execution of reaching and grasping actions. We suggest the observed neural overlap is because a common superordinate computation is engaged by each of those different tasks: A forward model of physical reasoning about how first-person actions will affect the world and be affected by unfolding physical events. This perspective offers an account of why some physical predictions are systematically incorrect - there can be a mismatch between how physical scenarios are experimentally framed and the native format of the inferences generated by the brain's first-person physics engine. This perspective generates new empirical expectations about the conditions under which physical reasoning may exhibit systematic biases.

Clinical Features and Biomarkers Suggestive of Bloodstream Infection in Pediatric Patients With Intestinal Failure and Central Venous Lines for Parenteral Nutrition: A Retrospective Pilot Study.

OBJECTIVES: This study aimed to describe demographic, clinical, and laboratory values in febrile pediatric intestinal failure patients with indwelling central venous catheters presenting to the emergency department to determine if there are low-risk features predictive of negative blood cultures that could help identify a subset that do not need hospitalization and/or broad-spectrum antibiotics. METHODS: We conducted a retrospective cohort study of febrile patients younger than 18 years with diagnosis of intestinal failure requiring a central venous catheter for home parenteral nutrition to identify factors associated with normal blood cultures to identify a low-risk subset. RESULTS: Of 119 encounters, 46% had a bloodstream infection. Children with a bloodstream infection were older than those without. A normal lactate and heart rate were associated with negative blood cultures. CONCLUSION: Pediatric intestinal failure patients with a central venous catheter for home parenteral nutrition presenting to the emergency department with fever and found to have a normal lactate and heart rates had lower rates of bloodstream infection. Although we were unable to create a highly sensitive clinical decision-making rule to identify a low-risk cohort because of the low number of patients meeting both criteria, the promising candidate variables identified merit for future multicenter studies.

Credentialing Pediatric Emergency Medicine Faculty in Point-of-Care Ultrasound: Expert Guidelines.

ABSTRACT: As point-of-care ultrasound (POCUS) becomes standard practice in pediatric emergency medicine (PEM), it is important to have benchmarks in place for credentialing PEM faculty in POCUS. Faculty must be systematically trained and assessed for competency in order to be credentialed in POCUS and granted privileges by an individual institution. Recommendations on credentialing PEM faculty are needed to ensure appropriate, consistent, and responsible use of this diagnostic and procedural tool. It is our intention that these guidelines will serve as a framework for credentialing faculty in PEM POCUS.

Functional neuroanatomy of intuitive physical inference.

To engage with the world-to understand the scene in front of us, plan actions, and predict what will happen next-we must have an intuitive grasp of the world's physical structure and dynamics. How do the objects in front of us rest on and support each other, how much force would be required to move them, and how will they behave when they fall, roll, or collide? Despite the centrality of physical inferences in daily life, little is known about the brain mechanisms recruited to interpret the physical structure of a scene and predict how physical events will unfold. Here, in a series of fMRI experiments, we identified a set of cortical regions that are selectively engaged when people watch and predict the unfolding of physical events-a "physics engine" in the brain. These brain regions are selective to physical inferences relative to nonphysical but otherwise highly similar scenes and tasks. However, these regions are not exclusively engaged in physical inferences per se or, indeed, even in scene understanding; they overlap with the domain-general "multiple demand" system, especially the parts of that system involved in action planning and tool use, pointing to a close relationship between the cognitive and neural mechanisms involved in parsing the physical content of a scene and preparing an appropriate action.

Ocular Point-of-Care Ultrasound in the Pediatric Emergency Department.

OBJECTIVE: Point-of-care ultrasound has become an important adjunct for diagnostic assessment in pediatric emergency medicine. In this case series, we demonstrate how ocular point-of-care ultrasound is used to correctly diagnose ocular pathologies and to expedite care. METHODS/RESULTS: We present a series of cases in which the point-of-care ultrasound ocular examination proved valuable in the timely diagnosis of pathologies involving the lens, vitreous, retina, and retrobulbar segment of the eye. CONCLUSION: Point-of-care ultrasound may facilitate diagnosis in children with ocular complaints, even in young and uncooperative patients, and should be considered in children of all ages.

Point-of-Care Ultrasound to Identify Congenital Heart Disease in the Pediatric Emergency Department.

The first presentation of congenital heart disease can be a diagnostic challenge in the emergency department. We report on 2 cases where point-of-care ultrasound identified gross cardiac abnormalities in 2 children and expedited disposition and downstream care.

Accuracy of Point-of-Care Ultrasonography for Pediatric Ankle Sprain Injuries.

OBJECTIVES: In children with radiograph fracture-negative lateral ankle injuries, the main objective of this pilot study was to explore the accuracy, sensitivity, and specificity of point-of-care ultrasound (POCUS) performed by a pediatric emergency physician in diagnosing anterior talofibular ligament injuries, radiographically occult distal fibular fractures, and effusions compared with reference standard magnetic resonance imaging (MRI). METHODS: This was a prospective cohort pilot study. Children aged 5 to 17 years with an isolated, acute lateral ankle injury and fracture-negative ankle radiographs were eligible for enrolment. Within 1 week of the injury, enrolled children returned for MRI and POCUS of both ankles. RESULTS: Seven children were enrolled, with a mean age 12.1 (SD, 3.0) years. Overall, POCUS agreed with MRI with respect to anterior talofibular ligament injury in 4 (57%) of 7 cases. Of the 2 cases with MRI-confirmed ligament damage, POCUS accurately identified and graded the extent of ligament damage in 1 case. Point-of-care ultrasound falsely identified ligament injuries in 2 cases. Both imaging modalities confirmed the absence of cortical fractures in all 7 cases. For all findings, POCUS sensitivity and specificity were 57% and 86%, respectively. CONCLUSIONS: In this pilot study, we established that POCUS diagnosed the specific pathology of radiograph-negative lateral ankle injuries with poor sensitivity but good specificity. Thus, POCUS could act as a tool to exclude significant ligamentous and radiographically occult bony injury in these cases. A larger study is needed to validate the utility of POCUS for this common injury.

National Survey on Pediatric Acute Agitation and Behavioral Escalation in Academic Inpatient Pediatric Care Settings.

BACKGROUND: Pediatric acute agitation and behavioral escalation (PAABE) is common and disruptive to pediatric inpatient health care. There is a paucity of literature on PAABE in noncritical care inpatient pediatric care settings with little consensus on its evaluation and management. METHODS: In January 2016, a 34-question survey was e-mailed to pediatric hospitalists and consultation-liaison psychiatrists through their respective professional listservs. Excluded responses included incomplete surveys, and surveys from providers in community care settings. The survey consisted of multiple-choice questions, rating scales, and free-text responses relating to the identification, education, and evaluation and management of PAABE at the respondent's respective hospital. RESULTS: Responses were obtained from 38 North American academic children's hospitals. Of the respondents, 69.3% were pediatric hospitalists and 30.7% were pediatric psychiatry consultants. Most respondents practice in urban areas (84.2%), and in hospitals with ≥100 beds (89.4%). Overall, 84.2% of the respondents encountered PAABE at least once a month and as frequently as every week. Most respondents (70.0%) rated PAABE as an 8 or higher on a 10-point Likert scale. Despite being highly important and common, 53.9% of respondents do not screen for risk factors for PAABE, 63.6% reported no formal process to facilitate caregiver involvement in managing PAABE, and 59.7% indicated no physician training in PAABE evaluation and management. CONCLUSION: Many pediatric hospitals identify PAABE as a great concern, yet there is little training, screening, or standardization of care in PAABE. There is a need to consolidate existing knowledge regarding PAABE, while developing enhanced collaboration, training, and standardized practice in inpatient PAABE.

Emergency Point-of-Care Ultrasound Diagnosis of Retained Soft Tissue Foreign Bodies in the Pediatric Emergency Department.

The presence of a foreign body (FB), its depth and size, is often indeterminate by clinical examination. Conventional imaging such as a radiograph can fail to visualize soft tissue FBs. We present 2 cases where point-of-care ultrasound was used to detect previously unidentified FBs.

Point-of-Care Ultrasound Use to Differentiate Hematoma and Sarcoma of the Thigh in the Pediatric Emergency Department.

Hematomas and soft tissue sarcomas can be difficult to differentiate clinically, even with the addition of traditional imaging modalities. There are several case reports of sarcomas being misdiagnosed as hematomas, most commonly with a history of mild trauma. In this case report, we described a sarcoma initially misinterpreted as a hematoma on ultrasound. Key clinical features and sonographic findings that may assist clinicians using point-of-care ultrasound to correctly differentiate sarcomas from hematomas are reviewed. A soft tissue mass larger than 5 cm, with internal vascular Doppler flow, presenting without a clear mechanism of injury or with constitutional symptoms should be considered as suspicious for malignancy.

Precision Medicine With Point-of-Care Ultrasound: The Future of Personalized Pediatric Emergency Care.

The Precision Medicine Initiative spearheaded by the National Institute of Health has pioneered a new model of health care focused on health care delivery that is tailored to an individual. Medical advances have already provided clinicians with the tools to better predict treatment outcomes based on the individual needs of each patient's disease process. Three-dimensional printing allows medical devices and implants to be custom made-to-order. Technological advances in preoperative imaging have augmented the ability for surgeons to plan a specific surgical approach for each patient. In a similar vein, point-of-care ultrasound offers the emergency care provider an opportunity to move beyond protocols and provide precise medical care tailored to the acute needs of each ill or injured emergent patient. In this article, we explore several cutting-edge applications of point-of-care ultrasound that can help providers develop a personalized approach to resuscitation and emergent procedures in pediatrics.

Unimpaired attentional disengagement in toddlers with autism spectrum disorder.

A prominent hypothesis holds that 'sticky' attention early in life in children with autism spectrum disorder (ASD) limits their ability to explore and learn about the world. Under this hypothesis, the core clinical symptoms of ASD - restricted interests, repetitive behaviors and impaired social/communication abilities - could all result from impaired attentional disengagement during development. However, the existence of disengagement deficits in children with ASD is controversial, and a recent study found no deficit in 5- to 12-year-olds with ASD. Nonetheless, the possibility remains that disengagement is impaired earlier in development in children with ASD, altering their developmental trajectory even if the attentional deficit itself is remediated or compensated for by the time children with ASD reach school age. Here, we tested this possibility by characterizing attentional disengagement in a group of toddlers just diagnosed with ASD (age 21 to 37 months). We found strikingly similar performance between the ASD and age-matched typically developing (TD) toddlers, and no evidence of impaired attentional disengagement. These results show that even at a young age when the clinical symptoms of ASD are first emerging, disengagement abilities are intact. Sticky attention is not a fundamental characteristic of ASD, and probably does not play a causal role in its etiology.

Point-of-Care Ultrasound Findings Associated With Langerhans Cell Histiocytosis in the Pediatric Emergency Department.

Langerhans cell histiocytosis is a rare disease characterized by clonal proliferation of Langerhans-type cells, causing local or systemic effects. One of the most affected sites in children is the skull. We describe 2 cases of children presenting to the pediatric emergency department with symptoms isolated to the scalp and the point-of-care focused skull ultrasound findings, which assisted in the diagnosis of Langerhans cell histiocytosis in both cases.

Emergency Point-of-Care Ultrasound Diagnosis of Diaphragmatic Hernia in the Pediatric Emergency Department.

We present a case series of 2 patients who presented to a pediatric emergency department with history and symptoms suggestive of diaphragmatic hernia. Point-of-care ultrasound was used at the bedside to demonstrate the presence of bowel in the thorax and accurately guided the care of these children.

Traumatic Femoral Artery Thrombosis Diagnosed by Point-of-Care Ultrasonography in the Pediatric Emergency Department.

Femoral artery injuries are a rare complication of blunt trauma in children that require expeditious diagnosis and treatment to prevent permanent limb dysfunction. Point-of-care ultrasonography of femoral vessels is a well-established emergency physician technique for ruling out deep vein thrombosis and guiding femoral vessel catheterization. We present the first report of a pediatric emergency physician diagnosing a traumatic femoral artery thrombus using point-of-care ultrasonography.