The Pediatric Emergency Research Network: A Decade of Global Research Cooperation in Pediatric Emergency Care.

OBJECTIVES: The Pediatric Emergency Research Network (PERN) was launched in 2009 with the intent for existing national and regional research networks in pediatric emergency care to organize globally for the conduct of collaborative research across networks. METHODS: The Pediatric Emergency Research Network has grown from 5- to 8-member networks over the past decade. With an executive committee comprising representatives from all member networks, PERN plays a supportive and collaborative rather than governing role. The full impact of PERN's facilitation of international collaborative research, although somewhat difficult to quantify empirically, can be measured indirectly by the observed growth of the field, the nature of the increasingly challenging research questions now being addressed, and the collective capacity to generate and implement new knowledge in treating acutely ill and injured children. RESULTS: Beginning as a pandemic response with a high-quality retrospective case-controlled study of H1N1 influenza risk factors, PERN research has progressed to multiple observational studies and ongoing global randomized controlled trials. As a recent example, PERN has developed sufficient network infrastructure to enable the rapid initiation of a prospective observational study in response to the current coronavirus disease 2019 pandemic. In light of the ongoing need for translation of research knowledge into equitable clinical practice and to promote health equity, PERN is committed to a coordinated international effort to increase the uptake of evidence-based management of common and treatable acute conditions in all emergency department settings. CONCLUSIONS: The Pediatric Emergency Research Network's successes with global research, measured by prospective observational and interventional studies, mean that the network can now move to improve its ability to promote the implementation of scientific advances into everyday clinical practice. Achieving this goal will involve focus in 4 areas: (1) expanding the capacity for global randomized controlled trials; (2) deepening the focus on implementation science; (3) increasing attention to healthcare disparities and their origins, with growing momentum toward equity; and (4) expanding PERN's global reach through addition of sites and networks from resource-restricted regions. Through these actions, PERN will be able to build on successes to face the challenges ahead and meet the needs of acutely ill and injured children throughout the world.

Automated low-cost device to produce sub-micrometric polymer fibers based on blow spun method.

Attending the latest advances in polymeric fibers, the design of low-cost, and high-quality scientific equipment for obtaining fibers seemed essential. To overcome this challenge, a 3D printable prototype was designed, assembled, and validated to obtain fibers using the SBS method. The particular configuration of the prototype consisted of controlling the process conditions such as working distance and injection flow, as well as other parameters such as RPM and the axial movement of the cylindrical collector. Thus, these parameters were automated using a microcontroller (Arduino) that receives information from an Android device with bluetooth connectivity to control each of the elements of the equipment. Subsequently, the repeatability and reproducibility of the fibers was verified using polymers such as polystyrene (PS), polysulfone (PSF) and polyethylene oxide (PEO); furthermore, PSF fibers were manufactured to analyze the influence of working distance and the axial movement of the collector on their production.

Evaluation of interobserver agreement for postoperative pain and sedation assessment in cats.

OBJECTIVE To evaluate agreement between observers with different training and experience for assessment of postoperative pain and sedation in cats by use of a dynamic and interactive visual analog scale (DIVAS) and for assessment of postoperative pain in the same cats with a multidimensional composite pain scale (MCPS). DESIGN Randomized, controlled, blinded study. ANIMALS 45 adult cats undergoing ovariohysterectomy. PROCEDURES Cats received 1 of 3 preoperative treatments: bupivacaine, IP; meloxicam, SC with saline (0.9% NaCl) solution, IP, (positive control); or saline solution only, IP (negative control). All cats received premedication with buprenorphine prior to general anesthesia. An experienced observer (observer 1; male; native language, Spanish) used scales in English, and an inexperienced observer (observer 2; female; native language, French) used scales in French to assess signs of sedation and pain. Rescue analgesia was administered according to MCPS scoring by observer 1. Mean pain and sedation scores per treatment and time point, proportions of cats in each group with MCPS scores necessitating rescue analgesia, and mean MCPS scores assigned at the time of rescue analgesia were compared between observers. Agreement was assessed by intraclass correlation coefficient determination. Percentage disagreement between observers on the need for rescue analgesia was calculated. RESULTS Interobserver agreements for pain scores were good, and that for sedation scores was fair. On the basis of observer 1's MCPS scores, a greater proportion of cats in the negative control group received rescue analgesia than in the bupivacaine or positive control groups. Scores from observer 2 indicated a greater proportion of cats in the negative control group than in the positive control group required rescue analgesia but identified no significant difference between the negative control and bupivacaine groups for this variable. Overall, disagreement regarding need for rescue analgesia was identified for 22 of 360 (6.1%) paired observations. CONCLUSIONS AND CLINICAL RELEVANCE Interobserver differences in assessing pain can lead to different conclusions regarding treatment effectiveness.

Agreement among undergraduate and graduate veterinary students and veterinary anesthesiologists on pain assessment in cats and dogs: A preliminary study.

This study investigated agreement among undergraduate and graduate veterinary students and veterinary anesthesiologists on video pain assessment at the University of Montreal. Pain assessment in dogs and cats appeared to be affected by gender, previous experience, and degree of training despite a small population of observers.

Accord entre étudiants de premier cycle, diplômés en médicine vétérinaire et anesthésistes pour l'évaluation de la douleur chez les chats et les chiens : étude préliminaire. Cette étude a évalué l'accord entre les étudiants de premier cycle, les étudiants diplômés en médicine vétérinaire et les anesthésiologistes vétérinaires pour l'évaluation de la douleur sur vidéo, à l'Université de Montréal. L'évaluation de la douleur chez les chiens et les chats était influencée par le sexe, l'expérience antérieure et le niveau de formation, malgré une population d'observateurs limitée.(Traduit par les auteurs).

Is this child sick? Usefulness of the Pediatric Assessment Triangle in emergency settings.

OBJECTIVE: The Pediatric Assessment Triangle is a rapid assessment tool that uses only visual and auditory clues, requires no equipment, and takes 30-60s to perform. It's being used internationally in different emergency settings, but few studies have assessed its performance. The aim of this narrative biomedical review is to summarize the literature available regarding the usefulness of the Pediatric Assessment Triangle in clinical practice. SOURCES: The authors carried out a non-systematic review in the PubMed®, MEDLINE®, and EMBASE® databases, searching for articles published between 1999-2016 using the keywords "pediatric assessment triangle," "pediatric triage," "pediatric assessment tools," and "pediatric emergency department." SUMMARY OF THE FINDINGS: The Pediatric Assessment Triangle has demonstrated itself to be useful to assess sick children in the prehospital setting and make transport decisions. It has been incorporated, as an essential instrument for assessing sick children, into different life support courses, although little has been written about the effectiveness of teaching it. Little has been published about the performance of this tool in the initial evaluation in the emergency department. In the emergency department, the Pediatric Assessment Triangle is useful to identify the children at triage who require more urgent care. Recent studies have assessed and proved its efficacy to also identify those patients having more serious health conditions who are eventually admitted to the hospital. CONCLUSIONS: The Pediatric Assessment Triangle is quickly spreading internationally and its clinical applicability is very promising. Nevertheless, it is imperative to promote research for clinical validation, especially for clinical use by emergency pediatricians and physicians.

Initial Asthma Severity Assessment Tools as Predictors of Hospitalization.

BACKGROUND: Assessment tools to classify and prioritize patients, such as systems of triage, and indicators of severity, such as clinical respiratory scores, are helpful in guiding the flow of asthmatic patients in the emergency department. OBJECTIVE: Our aim was to assess the performance of the Pediatric Assessment Triangle (PAT), triage level (TL), Pulmonary Score (PS), and initial O2 saturation (O2 sat), in predicting hospitalization in pediatric acute asthma exacerbations. STUDY DESIGN: Retrospective study evaluating PAT, TL, and PS at presentation, and initial O2 sat of asthmatic children in the pediatric emergency department (PED). The primary outcome measure was the rate of hospitalization. Secondary outcomes were length of stay (LOS) in the PED and admission to the pediatric intensive care unit (PICU). RESULTS: PAT, TL, PS, and initial O2 sat were recorded in 14,953 asthmatic children. Multivariate analysis yielded the following results: Abnormal PAT and more severe TLs (I-II) were independent risk factors for hospitalization (odds ratio [OR] 1.6, 95% confidence interval [CI] 1.4-1.8; OR 3.4, 95% CI 2.6-4.3, respectively) and longer LOS (OR 1.5, 95% CI 1.3-1.7; OR 2.6, 95% CI 2-3.3, respectively). PS > 3 showed a strong association with hospitalization (OR 8.1, 95% CI 7-9.4), PICU admission (OR 9.6, 95% CI 3-30.9) and longer LOS (OR 6.2, 95% CI 5.6-6.9). O2 sat < 94% was an independent predictor of admission (OR 5.2, 95% CI 4.6-5.9), PICU admission (OR 4.6, 95% CI 4.5-4.6), and longer LOS (OR 4.6, 95% CI 4.1-5.2). CONCLUSIONS: PAT, TL, PS, and initial O2 sat are good predictors of hospitalization in pediatric acute asthma exacerbations.

Environmental management and labour productivity: The moderating role of capital intensity.

Recent years have seen firms improve their environmental practices, although the question still remains as to whether or not investing in such practices is or is not beneficial or simply a matter of image. This study focuses on labour productivity as a measure of performance, and we argue that the impact of greater environmental performance on that productivity is moderated by capital intensity. A sample of 2823 plants provides empirical evidence to support our approach. Specifically, the analyses, making use of estimates based on multiple regression models, reveal that environmental management has a positive impact on labour productivity in organisations with low capital intensity, although that impact becomes negative in cases of high capital intensity.

The Validity of the Pediatric Assessment Triangle as the First Step in the Triage Process in a Pediatric Emergency Department.

OBJECTIVE: This study aimed to assess the association between pediatric assessment triangle (PAT) findings during triage and markers of severity in a pediatric emergency department (PED). METHODS: During the study period, patients arriving to the PED were classified by trained nurses with the Pediatric Canadian Triage and Acuity Scale using a computer system, from which data were obtained and analyzed retrospectively. The primary outcome measure was the percentage of children hospitalized related with PAT findings. The secondary outcome measures were the admission to the intensive care unit (%), PED length of stay, and performance of blood tests (%). RESULTS: Among the 302,103 episodes included, there were abnormal PAT findings in 24,120 cases (7.9%). Multivariate analysis adjusted for age confirmed that PAT findings and triage level were independent risk factors for admission (odds ratio [OR], 2.21; 95% confidence interval [CI], 2.13-2.29; OR, 6.01; 95% CI, 5.79-6.24, respectively). Abnormal findings in appearance or in more than 1 PAT component were even more strongly associated with admission (3.99; 95% CI, 3.63-4.38; 14.99, 95% CI, 11.99-18.74, respectively). When adjusted for triage level and age, abnormal PAT findings were also an independent risk factor for intensive care unit admission (OR, 4.44; 95% CI, 3.77-5.24) and a longer stay in the PED (OR, 1.78; 95% CI, 1.72-1.84). CONCLUSIONS: Abnormal findings in the PAT applied by trained nurses at triage identify patients with a higher risk of hospitalization. The PAT seems to be a valid tool for identifying the most severe patients as a first step in the triage process.

Is this child sick? Usefulness of the Pediatric Assessment Triangle in emergency settings / Esta criança está doente? Utilidade do Triângulo de Avaliação Pediátrica nas configurações de emergência

Abstract Objective: The Pediatric Assessment Triangle is a rapid assessment tool that uses only visual and auditory clues, requires no equipment, and takes 30-60 s to perform. It's being used internationally in different emergency settings, but few studies have assessed its performance. The aim of this narrative biomedical review is to summarize the literature available regarding the usefulness of the Pediatric Assessment Triangle in clinical practice. Sources: The authors carried out a non-systematic review in the PubMed®, MEDLINE®, and EMBASE® databases, searching for articles published between 1999-2016 using the keywords "pediatric assessment triangle," "pediatric triage," "pediatric assessment tools," and "pediatric emergency department." Summary of the findings: The Pediatric Assessment Triangle has demonstrated itself to be useful to assess sick children in the prehospital setting and make transport decisions. It has been incorporated, as an essential instrument for assessing sick children, into different life support courses, although little has been written about the effectiveness of teaching it. Little has been published about the performance of this tool in the initial evaluation in the emergency department. In the emergency department, the Pediatric Assessment Triangle is useful to identify the children at triage who require more urgent care. Recent studies have assessed and proved its efficacy to also identify those patients having more serious health conditions who are eventually admitted to the hospital. Conclusions: The Pediatric Assessment Triangle is quickly spreading internationally and its clinical applicability is very promising. Nevertheless, it is imperative to promote research for clinical validation, especially for clinical use by emergency pediatricians and physicians.

Resumo Objetivo: O Triângulo de Avaliação Pediátrica é uma ferramenta de avaliação rápida que usa apenas pistas visuais e auditivas, não necessita de equipamentos e leva de 30-60 segundos. Tem sido usado internacionalmente em diferentes configurações de emergência, porém poucos estudos avaliaram seu desempenho. O objetivo desta análise biomédica narrativa é resumir a literatura disponível com relação à utilidade do Triângulo de Avaliação Pediátrica na prática clínica. Fontes: Fizemos uma análise não sistemática nas bases de dados do PubMed®, Medline® e Embase® em busca de artigos publicados entre 1999-2016 com as palavras-chave "triângulo de avaliação pediátrica", "triângulo pediátrico", "ferramentas de avaliação pediátrica" e "departamento de emergência pediátrica". Resumo dos achados: O Triângulo de Avaliação Pediátrica demonstrou ser útil na avaliação de crianças doentes na configuração pré-hospitalar e na tomada de decisões de transporte. Ele foi incorporado, como um instrumento essencial na avaliação de crianças doentes, em diferentes cursos de apoio de vida, apesar de pouco ter sido escrito sobre a eficácia de ensino do Triângulo de Avaliação Pediátrica. Pouco foi publicado sobre o desempenho do Triângulo de Avaliação Pediátrica na avaliação inicial no departamento de emergência (DE). No DE, o Triângulo de Avaliação Pediátrica é útil para identificar, na triagem, crianças que exigem cuidado mais urgente. Estudos recentes avaliaram e provaram a eficácia do Triângulo de Avaliação Pediátrica também na identificação dos pacientes com doenças de saúde mais graves e, eventualmente, são internados no hospital. Conclusões: O Triângulo de Avaliação Pediátrica se difunde rapidamente de forma internacional e sua aplicabilidade clínica é muito promissora. Contudo, é essencial promover pesquisa para validação clínica, principalmente para o uso clínico por pediatras e médicos de emergência.

Elaboration of a risk map in a paediatric Emergency Department of a teaching hospital.

OBJECTIVE: To develop a risk map in a paediatric ED of a tertiary teaching hospital, combining proactive and reactive strategies. METHODS: Between June and December 2013, a multidisciplinary committee in a paediatric Emergency Department (ED) in Bilbao (Basque Country of Spain) mapped the patient's journey and identified potential risks to patients (proactive strategy). The researchers also analysed incidents reported by professionals and caregivers (mainly parents) in the paediatric ED from November 2004-December 2013 (reactive strategies). Combining the results of both strategies, we applied the 'Failure mode and effects analysis' tool to identify and prioritise high or very high-risk situations and apply them to the risk map. RESULTS: Using proactive strategies, 49 opportunities for failures, 60 effects and 252 causes were identified. The most common failures were related to the discharge of the patient; the most common effects were complaints by parents, long stay in the ED, delay in diagnosis/treatment and unnecessary treatment. Main causes were not including the family in the process, shift change, incorrect identification of the patient and computer errors. Using reactive strategies, 1795 reported incidents were analysed. The most common incidents were related to medical equipment (38%), resources/organisation of staff (17%), clinical process (15%), facilities (12%) and medication errors (5%). Proactive strategies identified risks in tests, treatment and discharge. The reactive strategy added risks concerning prehospital transfer, triage, medical care, tests, treatment and discharge. CONCLUSIONS: Proactive and reactive strategies, involving professionals and caregivers, can complement each other in identifying potential patient safety risks in a paediatric ED.

Assessment of tandem mass spectrometry and high-resolution mass spectrometry for the analysis of bupivacaine in plasma.

Triple quadrupole mass spectrometers coupled with high performance liquid chromatography are workhorses in quantitative bioanalyses. They provide substantial benefits including reproducibility, sensitivity and selectivity for trace analysis. Selected reaction monitoring allows targeted assay development but datasets generated contain very limited information. Data mining and analysis of nontargeted high-resolution mass spectrometry profiles of biological samples offer the opportunity to perform more exhaustive assessments, including quantitative and qualitative analysis. The objectives of this study were to test method precision and accuracy, to statistically compare bupivacaine drug concentration in real study samples and to verify if high-resolution and accurate mass data collected in scan mode can actually permit retrospective data analysis, more specifically, extract metabolite related information. The precision and accuracy data presented using both instruments provided equivalent results. Overall, the accuracy ranged from 106.2 to 113.2% and the precision observed was from 1.0 to 3.7%. Statistical comparisons using a linear regression between both methods revealed a coefficient of determination (R(2)) of 0.9996 and a slope of 1.02, demonstrating a very strong correlation between the two methods. Individual sample comparison showed differences from -4.5 to 1.6%, well within the accepted analytical error. Moreover, post-acquisition extracted ion chromatograms at m/z 233.1648 ± 5 ppm (M - 56) and m/z 305.2224 ± 5 ppm (M + 16) revealed the presence of desbutyl-bupivacaine and three distinct hydroxylated bupivacaine metabolites. Post-acquisition analysis allowed us to produce semi-quantitative evaluations of the concentration-time profiles for bupicavaine metabolites.