Contribution of implicit memory to adaptation of movement extent during reaching against unpredictable spring-like loads: insensitivity to intentional suppression of kinematic performance.

We examined the extent to which intentionally underperforming a goal-directed reaching task impacts how memories of recent performance contribute to sensorimotor adaptation. Healthy human subjects performed computerized cognition testing and an assessment of sensorimotor adaptation, wherein they grasped the handle of a horizontal planar robot while making goal-directed out-and-back reaching movements. The robot exerted forces that resisted hand motion with a spring-like load that changed unpredictably between movements. The robotic test assessed how implicit and explicit memories of sensorimotor performance contribute to the compensation for the unpredictable changes in the hand-held load. After each movement, subjects were to recall and report how far the hand moved on the previous trial (peak extent of the out-and-back movement). Subjects performed the tests under two counter-balanced conditions: one where they performed with their best effort, and one where they intentionally sabotaged (i.e., suppressed) kinematic performance. Results from the computerized cognition tests confirmed that subjects understood and complied with task instructions. When suppressing performance during the robotic assessment, subjects demonstrated marked changes in reach precision, time to capture the target, and reaction time. We fit a set of limited memory models to the data to identify how subjects used implicit and explicit memories of recent performance to compensate for the changing loads. In both sessions, subjects used implicit, but not explicit, memories from the most recent trial to adapt reaches to unpredictable spring-like loads. Subjects did not "give up" on large errors, nor did they discount small errors deemed "good enough". Although subjects clearly suppressed kinematic performance (response timing, movement variability, and self-reporting of reach error), the relative contributions of sensorimotor memories to trial-by-trial variations in task performance did not differ significantly between the two testing conditions. We conclude that intentional performance suppression had minimal impact on how implicit sensorimotor memories contribute to adaptation of unpredictable mechanical loads applied to the hand.

Using Comic-Based Concussion Discharge Instructions to Address Caregiver Health Literacy in the Emergency Department.

INTRODUCTION: This study compared the effectiveness of comic-based with text-based concussion discharge instructions on improving caregiver knowledge. This study also examined the role of social determinants of health on comprehension instructions. METHODS: This was an observational study of the caregivers of pediatric concussion patients. Caregivers' health literacy and demographics related socioeconomic factors were obtained. After the patients' evaluation in the emergency department, caregivers were given printed comic-based concussion discharge instructions. Caregivers were contacted 3 days later and tested overall knowledge of discharge instructions' content. These survey results were compared with historical controls who received text-based instructions. RESULTS: A total of 120 participants were recruited, and 86 participants completed follow-up procedures. When comparing the caregivers' recall ability with a comic-based vs traditional text-based instructions, caregivers with comic-based content were more likely to accurately recall overall discharge instructions (77.5% vs 44%, P < .001), particularly physical rest and activity restrictions (86.5% vs 63%, P < .001). Caregivers also were less likely to misidentify a red flag symptom (7.5% vs 19%, P < .04). Comic-based instructions did not increase recall of cognitive rest instructions or postconcussive symptoms. When examining demographic factors, caregivers who could not recall 3 postconcussive symptoms were more likely to be Hispanic or Black, less likely to be college educated, and more likely to have low health literacy. DISCUSSION: Novel methods should be explored to adequately prepare caregivers for continuing postconcussive care at home. Discharge instructions must be tailored to address caregivers' baseline health literacy and how caregivers digest and retain information.

Longitudinal Assessment of Acute Concussion Outcomes Through SMS Text (ConText Study).

OBJECTIVE: Mild traumatic brain injury (mTBI), or concussion, is a common health problem that has seen a recent increase in US adolescents. This study uses SMS text messaging (a mobile health [mHealth] tool) to report patient symptoms. We aim to better characterize mTBI recovery and hypothesize that this mHealth tool will have high retention rates and correlate with a conventional means of assessing symptoms, the Post-Concussion Symptom Inventory (PCSI). METHODS: A prospective observational cohort pilot study. Thirty-one pediatric patients with acute mTBI were recruited to characterize their injury and report their symptoms via text messaging. Patients reported symptoms once every 3 days for the first 21 days, then once a week for 6 weeks. RESULTS: There was a strong and positive correlation between the PCSI and the mHealth tool (rs = 0.875, P < 0.000, n = 22). Retention was 74% until symptom resolution and 42% until study completion. Patients with balance deficits had a significantly higher somatization score than those with normal balance (6.53 ± 3.25 vs 2.56 ± 2.30, t(22) = 3.211, P < 0.01). CONCLUSIONS: This pilot study demonstrates that this tool is a valid and easy-to-use method of reporting pediatric mTBI symptoms-it replicates and identifies novel findings. Our results suggest that there may be a relationship between balance and the manifestation of somatic symptoms. Retention rates were lower than predicted, indicating that text messaging may not be the ideal format in this population. Text messaging may still have other applications for short-term communication/symptom measurement.

Concussion Referral and Practice Patterns by Pediatric Emergency Medicine Providers.

OBJECTIVES: Concussion is a commonly encountered diagnosis for pediatric emergency medicine (PEM) providers, yet little is known regarding referral patterns to specialists. Our goal was to assess PEM providers' referral patterns and current usage of standardized evaluation tools. METHODS: This study was conducted as cross-sectional survey of PEM providers recruited from the American Academy of Pediatrics Section on Emergency Medicine Listserv. Surveys were distributed at 3 time points between December 1, 2020, and February 28, 2021, and included multiple choice, Likert scale, and free text questions. Descriptive statistics and bivariate analyses were used to describe the sample and compare responses between those with variable experience and confidence in concussion management. RESULTS: In total, 162 of 491 Listserv members (33.0%) completed the survey. The factors most often reported to assist in referral decisions were history of severe (92.6%) or multiple (90.7%) prior concussions, prolonged symptom duration (89.5%), and severity of current symptoms (84.6%). Most providers reported having large experience (63.0%) and confidence (54.9%) in managing concussion. Standardized symptom scales (8.0%), vestibular (11.7%) and balance assessments (13.0%), and prognostic tools (6.8%) were infrequently used. Most (64.2%) providers felt specialty referral was important. More than 80% reported high likelihood to use an accurate risk stratification tool to facilitate referral. CONCLUSIONS: Although most PEM providers reported significant experience and confidence in managing pediatric concussion, standardized assessment tools were infrequently used. Most were likely to use a risk stratification tool to assist in specialty referral. Future studies should assess the ability of targeted referral strategies to improve recovery for concussed youth.

Incidence of Neck Pain in Patients With Concussion in a Pediatric Emergency Department.

OBJECTIVES: The aims of the study were (1) to determine the frequency of neck pain in patients diagnosed with mild traumatic brain injury (mTBI) or concussion in a pediatric level 1 trauma center emergency department (ED), (2) to identify variables associated with neck pain in this population, and (3) to report on aspects of care received in the ED including imaging and medication use. METHODS: This is a retrospective chart review of 652 patients presenting to a pediatric ED with diagnosis of concussion/mTBI. Charts were reviewed for the following information: baseline demographic information, mechanism of injury, cause of mTBI, presence or absence of neck pain, point tenderness in the neck on physical examination, and whether the patient followed up within our health system in the 6 months after injury. Charts were also reviewed for other concussion-related symptoms, medication given in the ED, imaging performed in the ED, cervical spine clearance in the ED, and referrals made. For those patients who did have follow-up appointments within our system, additional chart review was performed to determine whether they sought follow-up treatment for symptoms related to concussion/neck pain and the duration of follow-up. Statistical analyses focused on the prevalence of neck pain in the sample. We subsequently explored the degree to which neck pain was associated with other collected variables. RESULTS: Of 652 patients, 90 (13.8%) reported neck pain. Acceleration/deceleration injury and motor vehicle accident were predictive of neck pain. Neck pain was less common in those reporting nausea and vomiting. Direct impact of the head against an object was associated with reduced odds of neck pain, but after adjusting for other variables, this was no longer statistically significant. Patients with neck pain were older than those without neck pain. Patients with neck pain were more likely to receive ibuprofen or morphine and undergo imaging of the spine. They were also more likely to receive a referral and follow-up with neurosurgery. There was no significant difference between groups with respect to concussion-related follow-up visits or follow-up visits to a dedicated concussion clinic. CONCLUSIONS: Neck pain is a common symptom in pediatric patients with mTBI, although it was more likely in older patients and those presenting with acceleration/deceleration mechanisms. Although patients with neck pain were more likely to receive a referral and follow-up with neurosurgery, they were not more likely to have concussion-related follow-up visits. Indeed, most patients had no follow-up visits related to their concussion, which supports the notion that concussion is a self-limiting condition.

Contributions of implicit and explicit memories to sensorimotor adaptation of movement extent during goal-directed reaching.

We examined how implicit and explicit memories contribute to sensorimotor adaptation of movement extent during goal-directed reaching. Twenty subjects grasped the handle of a horizontal planar robot that rendered spring-like resistance to movement. Subjects made rapid "out-and-back" reaches to capture a remembered visual target at the point of maximal reach extent. The robot's resistance changed unpredictably between reaches, inducing target capture errors that subjects attempted to correct from one trial to the next. Each subject performed over 400 goal-directed reaching trials. Some trials were performed without concurrent visual cursor feedback of hand motion. Some trials required self-assessment of performance between trials, whereby subjects reported peak reach extent on the most recent trial. This was done by either moving a cursor on a horizontal display (visual self-assessment), or by moving the robot's handle back to the recalled location (proprioceptive self-assessment). Control condition trials performed either without or with concurrent visual cursor feedback of hand motion did not require self-assessments. We used step-wise linear regression analyses to quantify the extent to which prior reach errors and explicit memories of reach extent contribute to subsequent reach performance. Consistent with prior reports, providing concurrent visual feedback of hand motion increased reach accuracy and reduced the impact of past performance errors on future performance, relative to the corresponding no-vision control condition. By contrast, we found no impact of interposed self-assessment on subsequent reach performance or on how prior target capture errors influence subsequent reach performance. Self-assessments were biased toward the remembered target location and they spanned a compressed range of values relative to actual reach extents, demonstrating that declarative memories of reach performance systematically differed from actual performances. We found that multilinear regression could best account for observed data variability when the regression model included only implicit memories of prior reach performance; including explicit memories (self-assessments) in the model did not improve its predictive accuracy. We conclude therefore that explicit memories of prior reach performance do not contribute to implicit sensorimotor adaptation of movement extent during goal-directed reaching under conditions of environmental uncertainty.

Multimedia Evaluation of EMT-Paramedic Assessment and Management of Pediatric Respiratory Distress.

BACKGROUND: The prehospital care of asthma, bronchiolitis and croup is directed by evidence-based Emergency Medical Services (EMS) protocols. Determining the appropriate intervention for these conditions requires Emergency Medical Technicians-Paramedics (EMT-Ps) to correctly differentiate asthma/bronchospasm, bronchiolitis, and croup. The diagnostic accuracy of EMT-Ps for these pediatric respiratory distress conditions is unknown. OBJECTIVE: We hypothesized increasing provider age, years of provider experience, higher volume of pediatric cases, self-reported comfort with pediatric patients, and having children of one's own would be associated with increased accuracy in diagnosis on a validated multimedia questionnaire. METHODS: This is a cross-sectional study of paramedics from a single EMS agency who completed a validated, case-based questionnaire between July and September 2018. The multimedia questionnaire consisted of four cases, each of which included patient videos and lung sound recordings. Paramedics were asked to assess the severity of distress and ascribe the correct diagnosis and prehospital intervention for each case. Each paramedic completed the questionnaire independently. We defined high questionnaire performance a priori as correctly identifying the diagnosis for ≥75% of cases and used multivariate regression to assess factors associated with high questionnaire performance. Provider age and EMS experience were reported in years and analyzed as continuous variables. Volume of pediatric cases was dichotomized to <1 and ≥1 case per shift and having children was dichotomized to either having children or not having children. RESULTS: Of 514 paramedics, 420 (82%) completed the questionnaire. Overall, paramedics correctly assessed the severity of respiratory distress 92% of the time. However, they only ascribed the correct diagnosis 50% and selected the correct intervention(s) 38% of the time. Increasing age, years of experience, higher volume of pediatric cases, self-reported comfort with pediatric patients, and having children of their own were not associated with questionnaire performance. CONCLUSION: Paramedics accurately assessed severity of distress in multimedia cases of asthma/bronchospasm, bronchiolitis and croup in children, but showed significant room for improvement in correctly identifying the diagnosis and in selecting appropriate intervention(s). Age, years of EMS experience, higher volume of clinical pediatric cases, self-reported comfort with pediatric patients, and having children of their own were not associated with questionnaire performance.

Parental Knowledge and Recall of Concussion Discharge Instructions.

INTRODUCTION: Children increasingly are being seen in the emergency department for a concussion, or mild traumatic brain injury (mTBI). A key aim of the ED visit is to provide discharge advice that can help parents to identify an evolving neurosurgical crisis, facilitate recovery, and prevent reinjury. The present study examined parents' knowledge of symptoms and recall of discharge instructions after their adolescent's mTBI and the effect of supplementing written discharge instructions with verbal instruction and reinforcement. METHODS: We performed a nested observational study of parents/caregivers of patients who participated in a larger mTBI study. After their adolescent's mTBI, parents were given verbal and standardized written instructions. The ED discharge process was observed using a structured checklist, and parents were surveyed 3 days after discharge on knowledge and recall of discharge instructions. RESULTS: Ninety-three parents completed the postsurvey. Nearly 1 in 5 parents were confused about when to return to the emergency department after evaluation for head injury. Up to 1 in 4 parents could not recall specific discharge advice related to concussion. Parents who received verbal reinforcement of written discharge instructions were more likely to recall them. CONCLUSION: Emergency nurses and clinicians should strive to utilize both verbal and written discharge instructions with families to help increase understanding.

The Effectiveness of Prescribed Rest Depends on Initial Presentation After Concussion.

OBJECTIVE: To evaluate if patients with signs of injury respond differently to prescribed rest after concussion compared with patients with symptoms only. STUDY DESIGN: Secondary analysis was completed of a prospective randomized controlled trial (NCT01101724) of pediatric concussion patients aged 11-18 years. Patients completed computerized neurocognitive testing and standardized balance assessment at the emergency department within 24 hours of injury and on follow-up (3 and 10 days). Patients were randomized to rest or usual care and completed activity and symptom diaries for 10 days after injury. A series of 2?×?2 ANOVAs with grouping factors of patient group (symptoms, signs) and treatment arm (prescribed rest, standard of care) were used to examine differences on clinical measures. Univariate nonparametric test (ie, ?2 with ORs and 95% CIs) was used to examine the association between treatment arm and symptom status 1-9 days after injury. RESULTS: A 2?×?2 factorial ANOVA revealed a significant patient group × treatment arm interaction for symptom score at 3 days after injury (F?=?6.31, P?=?.01, ?2?=?0.07). Prescribed rest increased the likelihood of still being symptomatic at days 1-6 and 8 (P?

Onychomadesis as a Late Complication of Hand-Foot-Mouth Disease: A Case Series Shedding Light on Nail Shedding.

Hand-foot-mouth disease is a viral illness frequently caused by enterovirus and coxsackievirus. Traditionally, this disease initially causes malaise, fever, and rash with vesicles in the mouth, as well as on the hands and feet. Occasionally, more severe presentations and late postinfectious sequelae occur, including onychomadesis, nail matrix arrest. We describe a series of 4 cases of onychomadesis and its evaluation following recent hand-foot-mouth disease during this current enteroviral season as a way to ensure appropriate clinician diagnosis and guidance.

Cannabis Legalization and Resource Use for Ingestions by Young Children.

OBJECTIVE: In conjunction with widening legalization, there has been a rapid rise in unintentional cannabis ingestions in young children. We sought to determine if the legal status of recreational cannabis was associated with resource use in young children with cannabis poisoning. METHODS: This retrospective cross-sectional study of the Pediatric Health Information System included emergency department encounters between January 2016 and April 2023 for children <6 years of age with a diagnosis indicating cannabis ingestion. The primary exposure was recreational cannabis legalization status in the state in which the encounter occurred. We used logistic regression models to determine the association of recreational cannabis legality with resource utilization outcomes, adjusting for demographic covariates. RESULTS: We included 3649 children from 47 hospitals; 29% of encounters occurred in places in which recreational cannabis was legal. Compared with environments in which recreational cannabis was illegal, cannabis-legal locations had lower uses of advanced neuroimaging (24% vs 35%; adjusted odds ratio [aOR], 0.65; 95% confidence interval [CI]: 0.55-0.77), lumbar puncture (1.6% vs 3.8%; aOR, 0.42; 95% CI: 0.24-0.70), ICU admission (7.9% vs 11%; aOR, 0.71; 95% CI: 0.54-0.93), and mechanical ventilation (0.8% vs 2.9%; aOR, 0.30; 95% CI: 0.14-0.58). Urine testing was more common in places in which recreational cannabis was legal (71% vs 58%; aOR, 1.87; 95% CI: 1.59-2.20). CONCLUSIONS: State-level legalization of recreational cannabis was associated with a significant decrease in the utilization of advanced medical resources in cases of cannabis intoxication in children. These findings suggest the need for a focus on policies and procedures to minimize invasive testing in cases of cannabis intoxication in children.

Improving Turnaround Time of Transabdominal Pelvic Ultrasounds with Ovarian Doppler in a Pediatric Emergency Department.

Introduction: Adnexal torsion is an emergent surgical condition. Transabdominal pelvic ultrasound (US) with ovarian Doppler is used to diagnose adnexal torsion and requires a sufficient bladder volume. Reduce the turnaround time for US by 25% in girls 8-18 years of age who present to the emergency department (ED) for 24 months. Methods: Our baseline period was from January 2020 to June 2021, and the intervention period was from July 2021 to June 2023. Patients 8-18 years old who required an US in the ED were included. There are two key drivers: early identification of US readiness and expeditious bladder filling. Interventions were (1) bladder volume screening; (2) utilization of bladder volume nomogram to identify US readiness; (3) epic order panels; and (4) rapid intravenous fluid method. The primary outcome was US turnaround time. Secondary outcomes were percentage of patients requiring invasive interventions to fill the bladder and patients with an US study duration of ≤45 minutes. The percent of patients screened by bladder scan was used as a process measure. Balancing measures used episodes of fluid overload and ED length of stay. Results: Turnaround time for USs improved from 112.4 to 101.6 minutes. The percentage of patients who had successful USs without invasive bladder filling improved from 32.1% to 42.6%. Bladder volume screening using a bladder scan increased from 40.3% to 82.9%. The successful first-pass US completion rate improved from 77% to 90% consistently. Conclusions: Through quality improvement methodology, we have identified pelvic US readiness earlier, eliminated some invasive bladder-filling measures, and implemented a rapid fluid protocol. We have sustained these successful results for 2 years. This study can be generalized to any ED with similar patients.

Adverse Safety Events in Emergency Medical Services Care of Children With Out-of-Hospital Cardiac Arrest.

Importance: Survival for children with out-of-hospital cardiac arrest (OHCA) remains poor despite improvements in adult OHCA survival. Objective: To characterize the frequency of and factors associated with adverse safety events (ASEs) in pediatric OHCA. Design, Setting, and Participants: This population-based retrospective cohort study examined patient care reports from 51 emergency medical services (EMS) agencies in California, Georgia, Oregon, Pennsylvania, Texas, and Wisconsin for children younger than 18 years with an OHCA in which resuscitation was attempted by EMS personnel between 2013 and 2019. Medical record review was conducted from January 2019 to April 2022 and data analysis from October 2022 to February 2023. Main Outcomes and Measure: Severe ASEs during the patient encounter (eg, failure to give an indicated medication, 10-fold medication overdose). Results: A total of 1019 encounters of EMS-treated pediatric OHCA were evaluated; 465 patients (46%) were younger than 12 months. At least 1 severe ASE occurred in 610 patients (60%), and 310 patients (30%) had 2 or more. Neonates had the highest frequency of ASEs. The most common severe ASEs involved epinephrine administration (332 [30%]), vascular access (212 [19%]), and ventilation (160 [14%]). In multivariable logistic regression, the only factor associated with severe ASEs was young age. Neonates with birth-related and non-birth-related OHCA had greater odds of a severe ASE compared with adolescents (birth-related: odds ratio [OR], 7.0; 95% CI, 3.1-16.1; non-birth-related: OR, 3.4; 95% CI, 1.2-9.6). Conclusions and Relevance: In this large geographically diverse cohort of children with EMS-treated OHCA, 60% of all patients experienced at least 1 severe ASE. The odds of a severe ASE were higher for neonates than adolescents and even higher when the cardiac arrest was birth related. Given the national increase in out-of-hospital births and ongoing poor outcomes of OHCA in young children, these findings represent an urgent call to action to improve care delivery and training for this population.

Functional Assessment of Concussion Tool Application in a Pediatric Concussion Clinic.

BACKGROUND: Traditional concussion symptom scales do not assess function. We piloted a mobile app-based assessment that aims to measure the functional impact of symptoms. METHODS: Patients with concussion completed the Functional Assessment of Concussion Tool and traditional symptom scales postinjury. RESULTS: Linear regression assessed the predictive value of the Functional Assessment of Concussion Tool symptom number and function rating compared to scores on 2 traditional symptom scales across 4 symptom domains. The mobile app symptom number predicted scores on traditional symptom scales across domains. The rating score predicted traditional scale scores in 2 domains. The mobile health tool did not predict recovery. DISCUSSION: This mobile health concussion symptom assessment may measure the functional impact of symptoms, though further study is needed.

The Effects of Rest on Concussion Symptom Resolution and Recovery Time: A Meta-analytic Review and Subgroup Analysis of 4329 Patients.

BACKGROUND: Numerous individual studies suggest that rest may have a negative effect on outcomes following concussion. PURPOSE: To perform a systematic meta-analysis of the effects of prescribed rest compared with active interventions after concussion. STUDY DESIGN: Meta-analysis; Level of evidence, 4. METHODS: A meta-analysis (using the Hedges g) of randomized controlled trials and cohort studies was conducted to evaluate the effects of prescribed rest on symptoms and recovery time after concussion. Subgroup analyses were performed for methodological, study, and sample characteristics. Data sources were obtained from systematic search of key terms using Ovid Medline, Embase, Cochrane Database of Systematic Reviews, APA PsycINFO, Web of Science, SPORTDiscus, and ProQuest dissertations and theses through May 28, 2021. Eligible studies were those that (1) assessed concussion or mild traumatic brain injury; (2) included symptoms or days to recovery for ≥2 time points; (3) included 2 groups with 1 group assigned to rest; and (4) were written in the English language. RESULTS: In total, 19 studies involving 4239 participants met criteria. Prescribed rest had a significant negative effect on symptoms (k = 15; g = -0.27; SE = 0.11; 95% CI, -0.48 to -0.05; P = .04) but not on recovery time (k = 8; g = -0.16; SE = 0.21; 95% CI, -0.57 to 0.26; P = .03). Subgroup analyses suggested that studies with shorter duration (<28 days) (g = -0.46; k = 5), studies involving youth (g = -0.33; k = 12), and studies focused on sport-related concussion (g = -0.38; k = 8) reported higher effect sizes. CONCLUSION: The findings support a small negative effect for prescribed rest on symptoms after concussion. Younger age and sport-related mechanisms of injury were associated with a greater negative effect size. However, the lack of support for an effect for recovery time and the relatively small overall numbers of eligible studies highlight ongoing concerns regarding the quantity and rigor of clinical trials in concussion. REGISTRATION: CRD42021253060 (PROSPERO).

Stratification of risk for emergent intracranial abnormalities in children with headaches: a Pediatric Emergency Care Applied Research Network (PECARN) study protocol.

INTRODUCTION: Headache is a common chief complaint of children presenting to emergency departments (EDs). Approximately 0.5%-1% will have emergent intracranial abnormalities (EIAs) such as brain tumours or strokes. However, more than one-third undergo emergent neuroimaging in the ED, resulting in a large number of children unnecessarily exposed to radiation. The overuse of neuroimaging in children with headaches in the ED is driven by clinician concern for life-threatening EIAs and lack of clarity regarding which clinical characteristics accurately identify children with EIAs. The study objective is to derive and internally validate a stratification model that accurately identifies the risk of EIA in children with headaches based on clinically sensible and reliable variables. METHODS AND ANALYSIS: Prospective cohort study of 28 000 children with headaches presenting to any of 18 EDs in the Pediatric Emergency Care Applied Research Network (PECARN). We include children aged 2-17 years with a chief complaint of headache. We exclude children with a clear non-intracranial alternative diagnosis, fever, neuroimaging within previous year, neurological or developmental condition such that patient history or physical examination may be unreliable, Glasgow Coma Scale score<14, intoxication, known pregnancy, history of intracranial surgery, known structural abnormality of the brain, pre-existing condition predisposing to an intracranial abnormality or intracranial hypertension, head injury within 14 days or not speaking English or Spanish. Clinicians complete a standardised history and physical examination of all eligible patients. Primary outcome is the presence of an EIA as determined by neuroimaging or clinical follow-up. We will use binary recursive partitioning and multiple regression analyses to create and internally validate the risk stratification model. ETHICS AND DISSEMINATION: Ethics approval was obtained for all participating sites from the University of Utah single Institutional Review Board. A waiver of informed consent was granted for collection of ED data. Verbal consent is obtained for follow-up contact. Results will be disseminated through international conferences, peer-reviewed publications, and open-access materials.

Antimicrobial adhesive films by plasma-enabled polymerisation of m-cresol.

This work reveals a versatile new method to produce films with antimicrobial properties that can also bond materials together with robust tensile adhesive strength. Specifically, we demonstrate the formation of coatings by using a dielectric barrier discharge (DBD) plasma to convert a liquid small-molecule precursor, m-cresol, to a solid film via plasma-assisted on-surface polymerisation. The films are quite appealing from a sustainability perspective: they are produced using a low-energy process and from a molecule produced in abundance as a by-product of coal tar processing. This process consumes only 1.5 Wh of electricity to create a 1 cm2 film, which is much lower than other methods commonly used for film deposition, such as chemical vapour deposition (CVD). Plasma treatments were performed in plain air without the need for any carrier or precursor gas, with a variety of exposure durations. By varying the plasma parameters, it is possible to modify both the adhesive property of the film, which is at a maximum at a 1 min plasma exposure, and the antimicrobial property of the film against Escherichia coli, which is at a maximum at a 30 s exposure.

Shelf-Life Optimisation of Plasma Polymerised (2,2,6,6-Tetramethylpiperidin-1-yl)oxyl (TEMPOpp) Coatings; A New Possible Approach to Tackle Infections in Chronic Wounds.

Chronic wounds fail to heal and are accompanied by an ongoing infection. They cause suffering, shorten lifespans, and their prevalence is increasing. Unfortunately, the medical treatment of chronic wounds has remained unchanged for decades. A novel approach to break the biological vicious cycle is the long-lived radical (2,2,6,6-Tetramethylpiperidin-1-yl)oxyl (TEMPO). TEMPO can be plasma polymerised (TEMPOpp) into thin coatings that have antimicrobial properties. However, due to its radical nature, quenching causes it to lose effectiveness over time. Our aim in this study was to extend the shelf-life of TEMPOpp coatings using various storage conditions: Namely, room temperature (RT), room temperature & vacuum sealed (RTV), freezer temperature & vacuum sealed (FTV). We have analysed the coatings' quality via the surface analytical methods of X-Ray Photoelectron spectroscopy (XPS) and electron paramagnetic resonance (EPR); finding marked differences among the three storage conditions. Furthermore, we have compared the antimicrobial efficacy of the stored coatings against two major bacterial pathogens, Staphylococcus aureus and Staphylococcus epidermidis, commonly found in chronic wounds. We did so both qualitatively via live/dead staining, as well as quantitatively via (2-methoxy-4-nitro-5-sulfophenyl)-5-[(phenylamino) carbonyl]-2H-tetrazolium (XTT) viability assay for up to 15 weeks in 5 weeks increments. Taken all together, we demonstrate that samples stored under FTV conditions retain the highest antimicrobial activity after 15 weeks and that this finding correlates with the retained concentration of nitroxides.

Five days of fever and myocardial inflammation.

Multisystem inflammatory syndrome in children is an emerging pediatric illness associated with severe acute respiratory syndrome coronavirus 2 infection. The syndrome is rare, and evidence-based guidelines are lacking. This report reviews a patient who presented for medical care multiple times early in the course of his illness, thus offering near-daily documentation of symptoms and laboratory abnormalities. The patient did not have thrombocytopenia, anemia, or myocardial inflammation until the fifth day of fever. These laboratory abnormalities coincided with the onset of rash, conjunctival injection, vomiting, and diarrhea: clinical signs that could serve as indicators for when to obtain blood tests. The timing of this patient's onset of multisystem involvement suggests that testing for multisystem inflammatory syndrome in children after only 24 h of fever, as the Centers for Disease Control and Prevention recommends, may yield false-negative results. Testing for multisystem inflammatory syndrome in children after 4 days of fever may be more reliable.