Systematic expression analysis of plasticity-related genes in mouse brain development brings PRG4 into play.

BACKGROUND: Plasticity-related genes (Prgs/PRGs) or lipid phosphate phosphatase-related proteins (LPPRs) comprise five known members, which have been linked to neuronal differentiation processes, such as neurite outgrowth, axonal branching, or dendritic spine formation. PRGs are highly brain-specific and belong to the lipid phosphate phosphatases (LPPs) superfamily, which influence lipid metabolism by dephosphorylation of bioactive lipids. PRGs, however, do not possess enzymatic activity, but modify lipid metabolism in a way that is still under investigation. RESULTS: We analyzed mRNA expression levels of all Prgs during mouse brain development, in the hippocampus, neocortex, olfactory bulbs, and cerebellum. We found different spatio-temporal expression patterns for each of the Prgs, and identified a high expression of the uncharacterized Prg4 throughout brain development. Unlike its close family members PRG3 and PRG5, PRG4 did not induce filopodial outgrowth in non-neuronal cell lines, and does not localize to the plasma membrane of filopodia. CONCLUSION: We showed PRG4 to be highly expressed in the developing and the adult brain, suggesting that it is of vital importance for normal brain function. Despite its similarities to other family members, it seems not to be involved in changes of cell morphology; instead, it is more likely to be associated with intracellular signaling.

Visual attention during pediatric resuscitation with feedback devices: a randomized simulation study.

BACKGROUND: The aim of this study was to investigate the effect of feedback devices on visual attention and the quality of pediatric resuscitation. METHODS: This was a randomized cross-over simulation study at the Medical University of Vienna. Participants were students and neonatal providers performing four resuscitation scenarios with the support of feedback devices randomized. The primary outcome was the quality of resuscitation. Secondary outcomes were total dwell time (=total duration of visit time) on areas of interest and the workload of participants. RESULTS: Forty participants were analyzed. Overall, chest compression (P < 0.001) and ventilation quality were significantly better (P = 0.002) when using a feedback device. Dwell time on the feedback device was 40.1% in the ventilation feedback condition and 48.7% in the chest compression feedback condition. In both conditions, participants significantly reduced attention from the infant's chest and mask (72.9 vs. 32.6% and 21.9 vs. 12.7%). Participants' subjective workload increased by 3.5% (P = 0.018) and 8% (P < 0.001) when provided with feedback during a 3-min chest compression and ventilation scenario, respectively. CONCLUSIONS: The quality of pediatric resuscitation significantly improved when using real-time feedback. However, attention shifted from the manikin and other equipment to the feedback device and subjective workload increased, respectively. IMPACT: Cardiopulmonary resuscitation with feedback devices results in a higher quality of resuscitation and has the potential to lead to a better outcome for patients. Feedback devices consume attention from resuscitation providers. Feedback devices were associated with a shift of visual attention to the feedback devices and an increased workload of participants. Increased workload for providers and benefits for resuscitation quality need to be balanced for the best effect.

Point-of-Care Ultrasound to Evaluate the Acute Abdomen: A Case of Bowel Perforation After Unknown Single Magnet Ingestion.

ABSTRACT: We report the case of a 3-year-old boy who presented to the pediatric emergency department in undifferentiated shock with an acute abdomen. Point-of-care ultrasound revealed viscous perforation with a large amount of free fluid. Intraoperatively, a single magnet was discovered as the likely cause of bowel perforation and the resulting state of shock.

PRG3 and PRG5 C-Termini: Important Players in Early Neuronal Differentiation.

The functional importance of neuronal differentiation of the transmembrane proteins' plasticity-related genes 3 (PRG3) and 5 (PRG5) has been shown. Although their sequence is closely related, they promote different morphological changes in neurons. PRG3 was shown to promote neuritogenesis in primary neurons; PRG5 contributes to spine induction in immature neurons and the regulation of spine density and morphology in mature neurons. Both exhibit intracellularly located C-termini of less than 50 amino acids. Varying C-termini suggested that these domains shape neuronal morphology differently. We generated mutant EGFP-fusion proteins in which the C-termini were either swapped between PRG3 and PRG5, deleted, or fused to another family member, plasticity-related gene 4 (PRG4), that was recently shown to be expressed in different brain regions. We subsequently analyzed the influence of overexpression in immature neurons. Our results point to a critical role of the PRG3 and PRG5 C-termini in shaping early neuronal morphology. However, the results suggest that the C-terminus alone might not be sufficient for promoting the morphological effects induced by PRG3 and PRG5.

Readiness for and Response to Coronavirus Disease 2019 Among Pediatric Healthcare Providers: The Role of Simulation for Pandemics and Other Disasters.

OBJECTIVES: Early preparation for the training and education of healthcare providers, as well as the continuation or modification of routine medical education programs, is of great importance in times of the coronavirus disease 2019 pandemic or other public health emergencies. The goal of this study was to characterize these self-reported efforts by the pediatric simulation community. DESIGN: This was a global, multicenter survey developed via a Delphi process. SETTING: International survey study. SUBJECTS: The survey was sent to 555 individual members of the three largest international pediatric simulation societies (The International Pediatric Simulation Society, International Network for Simulation-based Pediatric Innovation, Research & Education, and Netzwerk Kindersimulation e.V.) between April 27, 2020, and May 18, 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Description of coronavirus disease 2019 pandemic simulation-based preparation activities of pediatric acute and critical care healthcare providers. The Delphi process included 20 content experts and required three rounds to reach consensus. The survey was completed by 234 participants (42.2%) from 19 countries. Preparation differed significantly between the geographic regions, with 79.3% of Anglo-American/Anglo-Saxon, 82.6% of Indian, and 47.1% of European participants initiating specifically coronavirus disease 2019-related simulation activities. Frequent modifications to existing simulation programs included the use of telesimulation and virtual reality training. Forty-nine percent of institutions discontinued noncoronavirus disease 2019-related simulation training. CONCLUSIONS: The swift incorporation of disease-specific sessions and the transition of standard education to virtual or hybrid simulation training modes occurred frequently. The approach used, however, depended heavily on local requirements, limitations, and circumstances. In particular, the use of telesimulation allowed education to continue while maintaining social distancing requirements.

Closing the Loop: Program Description and Qualitative Analysis of a Pediatric Posttransfer Follow-up and Feedback Program.

OBJECTIVES: Follow-up and feedback foster improvement. General emergency medicine providers working in community hospitals desire follow-up and feedback on pediatric patients transferred to children's hospitals. We implemented a novel program to provide these data to our colleagues. The objective of this study was to explore stakeholder perspectives of our program. METHODS: We provided secure, electronic reports on transfers from 7 general emergency departments (GEDs). Patient follow-up and feedback data were delivered to the GED's pediatric emergency care coordinator. Seven pediatric emergency care coordinators and 2 children's hospital liaisons participated in semistructured interviews. Five researchers coded and analyzed transcribed data using the constant comparative method of grounded theory. Codes were refined and clustered to develop themes. RESULTS: Perceived values of the program included GED appreciation of closing the loop on transferred patients, providing education, and informing quality improvement. Participants valued the concise and timely nature of the reports and their empathetic delivery. Facilitators of program implementation included established professional relationships between the GED and the children's hospital liaisons and a GED's culture of self-inquiry. Barriers to program implementation included potential medicolegal exposure and the time burden for report generation and processing. Suggested programmatic improvements included focusing on generalizable, evidence-based learning points and analyzing care trends. CONCLUSIONS: Stakeholders of our pediatric posttransfer follow-up and feedback program reported many benefits and provided key suggestions that may promote successful dissemination of similar programs nationwide. Examining data trends in transferred children may focus efforts to improve the care of children across all emergency care settings.

Eye-tracking during simulation-based neonatal airway management.

BACKGROUND: Eye-tracking devices help to understand provider behavior during medical tasks. The aim of this study was to assess participants' gaze behavior and usability of eye-tracking glasses during airway management in a simulated neonatal resuscitation. METHODS: This study was an observational simulation-based study. The team member assigned to airway management wore head-mounted eye-tracking glasses. Main outcome measures were airway providers' gaze, dwell time (total amount of time a participant fixates certain areas of interest), and usability of eye-tracking glasses. RESULTS: Data from 13 participants were included. There were significant differences in dwell time during the scenario (p < 0.001), with participants spending twice as much time on the newborn and instruments as on the monitor and other staff. Participants spent about 25% more time focusing on another provider while the provider was inserting the umbilical vein catheter than in all other times of interest (intervals of time with meaningful events) (p = 0.04). The use of the glasses was perceived easy and not disturbing. CONCLUSIONS: Eye-tracking glasses enhance our understanding of providers' gaze and perspective during simulated neonatal airway management. Future studies will better characterize the ideal use in real situations.

Stress as tool or toxin: physiologic markers and subjective report in neonatal simulation.

BACKGROUND: Cognitive appraisal of stress can influence performance. Increased awareness could facilitate titration to optimal stress levels. This study's primary aim was to investigate whether physiologic variables change with increasingly stressful simulations. Secondary aims include effect of stress on procedural competency and whether individuals recognize their experienced stress. METHODS: This was a single-center, mixed-method, simulation-based study. Participants completed three scenarios requiring resuscitation under increasingly stressful conditions. Wearable biometric devices recorded physiologic parameters. Subjects completed surveys assessing knowledge and perceived stress. Intubation success or failure was noted. Heart rate variability (HRV) analysis was used as a proxy for stress. RESULTS: Twelve participants completed the study. Survey analysis revealed progressive amplification of endorsement of affective states associated with stress. Median low frequency (LF)/high frequency (HF) ratio from scenario 1 (median = 2.29, IQR = 1.97, 3.91) was significantly lower than scenario 2 (median = 4.7, IQR = 2.32, 8.35, p = 0.04) and scenario 3 (median = 4.63, IQR = 2.2, 7.43, p = 0.04). Changes in HRV were noted during all scenarios irrespective of subjective self-assessment of stress. Procedural proficiency suffered during more stressful scenarios. CONCLUSIONS: This study demonstrates alterations in subjective assessment and objective physiologic data in simulations with increasing stress. HRV is useful as a proxy for stress response and does not always correlate with perception.

Pediatric Readiness in the Emergency Department and Its Association With Patient Outcomes in Critical Care: A Prospective Cohort Study.

OBJECTIVES: Pediatric mortality in Latvia remains one of the highest among Europe. The purpose of this study was to assess the quality of pediatric acute care and pediatric readiness and determine their association with patient outcomes using a patient registry. DESIGN: This was a prospective cohort study. Pediatric readiness was measured using the weighted pediatric readiness score based on a 100-point scale. The processes of care were measured using in situ simulations to generate a composite quality score. Clinical outcome data-including PICU and hospital length of stay as well as 6-month mortality-were collected from the Pediatric Intensive Care Audit Network registry. The associations between composite quality score and weighted pediatric readiness score on patient outcomes were explored with mixed-effects regressions. SETTING: This study was conducted in all Latvian Emergency Departments and in the national PICU. PATIENTS: All patients who were transferred into the national PICU were included. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: All (16/16) Latvian Emergency Departments participated with a mean composite quality score of 35.3 of 100 and a median weighted pediatric readiness score of 31 of 100. A total of 254 patients were included in the study and followed up for a mean of 436 days, of which nine died (3.5%). Higher weighted pediatric readiness score was associated significantly with lower length of stay in both the PICU and hospital (adjusted ß, -0.06; p = 0.021 and -0.36; p = 0.011, respectively) and lower 6-month mortality (adjusted odds ratio, 0.93; 95% CI, 0.88-0.98). CONCLUSIONS: These data provide a national assessment of pediatric emergency care in a European country. Pediatric readiness in the emergency department was associated with patient outcomes in this population of pediatric patients transferred to the national PICU.

LPA1 , LPA2 , LPA4 , and LPA6 receptor expression during mouse brain development.

BACKGROUND: LPA is a small bioactive phospholipid that acts as an extracellular signaling molecule and is involved in cellular processes, including cell proliferation, migration, and differentiation. LPA acts by binding and activating at least six known G protein-coupled receptors: LPA1-6 . In recent years, LPA has been suggested to play an important role both in normal neuronal development and under pathological conditions in the nervous system. RESULTS: We show the expression pattern of LPA receptors during mouse brain development by using qRT-PCR, in situ hybridization, and immunocytochemistry. Only LPA 1 , LPA 2, LPA 4, and LPA 6 mRNA transcripts were detected throughout development stages from embryonic day 16 until postnatal day 30 of hippocampus, neocortex, cerebellum, and bulbus olfactorius in our experiments, while expression of LPA 3 and LPA 5 genes was below detection level. In addition to our qRT-PCR results, we also analyzed the cellular protein expression of endogenous LPA receptors, with focus on LPA1 and LPA2 within postnatal brain slices and primary neuron differentiation with and without cytoskeleton stabilization and destabilization. CONCLUSIONS: The expression of LPA receptors changes depends on the developmental stage in mouse brain and in cultured hippocampal primary neurons. Interestingly, we found that commercially available antibodies for LPA receptors are largely unspecific.

GPS Devices in a Simulated Mass Casualty Event.

OBJECTIVE: The aim of this study was to assess the staff perception of a global positioning system (GPS) as a patient tracking tool at an emergency department (ED) receiving patients from a simulated mass casualty event. METHODS: During a regional airport disaster drill a plane crash with 46 pediatric patients was simulated. Personnel from airport fire, municipal fire, law enforcement, emergency medical services, and emergency medicine departments were present. Twenty of the 46 patient actors required transport for medical evaluation, and we affixed GPS devices to 12 of these actors. At the hospital, ED staff including attending physicians, fellows and nurses working in the ED during the time of the drill accessed a map through an application that provided real-time geolocation of these devices. The primary outcome was staff reception of the GPS device as assessed via Likert scale survey after the event. The secondary outcomes were free text feedback from staff and event debriefing observations. RESULTS: Queried registered nurses, attending physicians, and pediatric emergency medicine fellows perceived the GPS device as an advantage for patient care during a disaster. The GPS device allowed multiple-screen real-time tracking and improved situational awareness in cases with and without EMS radio communication prior to arrival at the hospital. CONCLUSION: ED staff reported that the use of GPS trackers in a disaster improved real-time tracking and could potentially improve patient management during a mass casualty event.

Extracranial Internal Carotid Aneurysm in a 10-Year-Old Boy Diagnosed via Ultrasound.

BACKGROUND: Extracranial carotid aneurysms in children are extremely rare but carry a high mortality and morbidity. For pediatric patients, they are often complications of pharyngeal infections and surgical trauma but can also arise from congenital and inflammatory diseases. They have a wide range of presentation from an asymptomatic mass to a rapidly fatal hemorrhage. CASE: A 10-year-old boy presented to the emergency department with complaints of a neck mass and residual cough from a recent upper respiratory infection. Ultrasound revealed a carotid aneurysm that was further characterized by magnetic resonance angiography as a 3-cm aneurysm of the internal carotid artery. The patient was taken for surgery where he underwent resection and placement of an interposition graft. The procedure was well tolerated and the boy recovered fully. DISCUSSION: Carotid aneurysms in children can present with 1 or more of the following: a pulsatile neck mass, hematemesis, epistaxis, neurologic symptoms, and symptoms of airway compression. Although ultrasound is the preferred initial test, the choice of additional imaging for further characterization will depend most on the patient age, hemodynamic stability, airway status, and availability of pediatric anesthesia. Hemodynamic and neurologic status should be monitored closely, and clinicians must also be prepared for a potentially complicated airway. Surgery is indicated for children owing to high risk of neurologic complications. CONCLUSIONS: Although these lesions are rare, it is crucial that physicians recognize when there is a need for further evaluation so that these children have the most favorable outcomes possible.

Vaginal Foreign Bodies: The Potential Role of Point-of-Care-Ultrasound in the Pediatric Emergency Department.

Transabdominal point-of-care ultrasound may be a helpful tool during the evaluation of children with suspected vaginal foreign bodies. We discuss the case of an 11-year-old girl presenting after having placed a pen into her vagina. The patient attempted to remove the pen, but there was concern the cap may have been retained in the vagina. Point-of-care ultrasound findings confirmed a retained pen cap that was subsequently removed by pediatric surgery. We discuss the role of transabdominal point-of-care ultrasound for the detection of vaginal foreign bodies in pediatric patients.

Atlanto-Axial Subluxation After Adenoidectomy.

Atlanto-axial subluxation is a rare but potentially serious complication after otolaryngological procedures. We are describing a case of a 4-year-old child who developed atlanto-axial subluxation of the cervical spine after adenoidectomy. Our patient underwent adenoidectomy and, 18 days later, presented to the emergency department with her neck tilted to the left in a cock-robin position and complaining of neck pain persisting since the surgery. A multiplanar 3-dimensional computed tomography was obtained and confirmed the diagnosis of an atlanto-axial subluxation (Fielding type 3). She was managed conservatively with the application of a cervical collar, anti-inflammatory medication, and manual reduction under anesthesia later in the course because of persistence of her symptoms. It is important to consider this diagnosis in any child who undergoes ENT surgical procedures complaining of neck pain subsequent to surgery or holding the head in a fixed position persistently after surgery. Early diagnosis is important to reduce the time between the onset of symptoms and reduction to reduce the risk or need for surgical intervention.

Management of infants born with severe neonatal alloimmune thrombocytopenia: the role of platelet transfusions and intravenous immunoglobulin.

BACKGROUND: Neonatal alloimmune thrombocytopenia (NAIT) is a fetomaternal incompatibility most commonly induced by maternal anti-HPA-1a alloantibodies. Transfusion of immunologically compatible platelets (PLTs) to prevent cerebral hemorrhage, the most severe complication in affected newborns, is usually recommended. Such PLT concentrates, however, are often not readily available. STUDY DESIGN AND METHODS: The efficacy of random-donor PLT transfusions and intravenous immunoglobulin (IVIG) for the management of 17 neonates across four centers with unexpected, severe NAIT was evaluated. Neonates were treated with random-donor PLTs alone (n=7), random-donor PLTs with IVIG (n=8), or matched HPA-1bb PLTs (n=2). RESULTS: All but one patient (treated with random PLTs and IVIG) achieved a posttransfusion PLT count of higher than 30 × 10(9) /L after the first PLT transfusion. The PLT count remained higher than 30 × 10(9) /L for longer than 24 hours in five of seven, seven of eight, and two of four newborns who received random-donor PLTs alone, random-donor PLTs with IVIG, or matched HPA-1bb PLTs, respectively. None of the newborns developed major bleeding or intracranial hemorrhage. IVIG did not appear to improve either posttransfusion PLT counts or total PLT transfusion requirements. CONCLUSION: Transfusion of random-donor PLTs alone was effective at correcting critically low PLT counts and should be considered as first-line treatment of newborns with unexpected severe NAIT.

Development of Distance Simulation Educator Guidelines in Healthcare: A Delphi Method Application.

INTRODUCTION: The abrupt disruption of in-person instruction in health care during the COVID-19 pandemic resulted in the rapid adoption of distance simulation as an immediate alternative to providing in-person simulation-based education. This massive instructional shift, combined with the lack of educator training in this domain, led to challenges for both learners and educators. This study aimed to disseminate the first set of competencies required of and unique to effective distance simulation educators. METHODS: This was a multiphasic and iterative modified Delphi study validating the content of carefully and rigorously synthesized literature. Experts were invited from around the globe to participate in this study with mandatory attendance at an annual health care simulation conference to openly discuss the guidelines presented as competencies in this document. We divided each competency into "Basic" and "Advanced" levels, and agreement was sought for these levels individually. The experts provided their opinion by choosing the options of "Keep, Modify, or Delete." A free-marginal kappa of 0.60 was chosen a priori. RESULTS: At the conclusion of the Delphi process, the number of competencies changed from 66 to 59, basic subcompetencies from 216 to 196, and advanced subcompetencies from 179 to 182. CONCLUSIONS: This article provides the first set of consensus guidelines to distance simulation educators in health care, and paved the way for further research in distance simulation as a modality.

Debriefing Methods for Simulation in Healthcare: A Systematic Review.

ABSTRACT: Debriefing is a critical component in most simulation experiences. With the growing number of debriefing concepts, approaches, and tools, we need to understand how to debrief most effectively because there is little empiric evidence to guide us in their use. This systematic review explores the current literature on debriefing in healthcare simulation education to understand the evidence behind practice and clarify gaps in the literature. The PICO question for this review was defined as "In healthcare providers [P], does the use of one debriefing or feedback intervention [I], compared to a different debriefing or feedback intervention [C], improve educational and clinical outcomes [O] in simulation-based education?" We included 70 studies in our final review and found that our current debriefing strategies, frameworks, and techniques are not based on robust empirical evidence. Based on this, we highlight future research needs.

Understanding the Effects of Health Care Distance Simulation: A Systematic Review.

ABSTRACT: The use of distance simulation has rapidly expanded in recent years with the physical distance requirements of the COVID-19 pandemic. With this development, there has been a concurrent increase in research activities and publications on distance simulation. The authors conducted a systematic review of the peer-reviewed distance health care simulation literature. Data extraction and a risk-of-bias assessment were performed on selected articles. Review of the databases and gray literature reference lists identified 10,588 titles for review. Of those, 570 full-text articles were assessed, with 54 articles included in the final analysis. Most of these were published during the COVID-19 pandemic (2020-2022). None of the included studies examined an outcome higher than a Kirkpatrick level of 2. Most studies only examined low-level outcomes such as satisfaction with the simulation session. There was, however, a distinction in studies that were conducted in a learning environment where all participants were in different locations ("distance only") as compared with where some of the participants shared the same location ("mixed distance"). This review exclusively considered studies that focused solely on distance. More comparative studies exploring higher level outcomes are required to move the field forward.

Health Care Simulation in Person and at a Distance: A Systematic Review.

ABSTRACT: Distance simulation is a method of health care training in which the learners and facilitators are in different physical locations. Although methods of distance simulation have existed in health care for decades, this approach to education became much more prevalent during the COVID-19 pandemic. This systematic review studies a subset of distance simulation that includes combined in-person and distance simulation elements, identified here as "mixed- distance simulation." A review of the distance simulation literature identified 10,929 articles. Screened by inclusion and exclusion criteria, 34 articles were ultimately included in this review. The findings of this review present positive and negative aspects of mixed-distance simulation formats, a description of the most frequent configurations related to delivery, terminology challenges, as well as future directions including the need for faculty development, methodological rigor, and reporting details.

Society for Simulation in Healthcare Guidelines for Simulation Training.

BACKGROUND: Simulation has become a staple in the training of healthcare professionals with accumulating evidence on its effectiveness. However, guidelines for optimal methods of simulation training do not currently exist. METHODS: Systematic reviews of the literature on 16 identified key questions were conducted and expert panel consensus recommendations determined using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. OBJECTIVE: These evidence-based guidelines from the Society for Simulation in Healthcare intend to support healthcare professionals in decisions on the most effective methods for simulation training in healthcare. RESULTS: Twenty recommendations on 16 questions were determined using GRADE. Four expert recommendations were also provided. CONCLUSIONS: The first evidence-based guidelines for simulation training are provided to guide instructors and learners on the most effective use of simulation in healthcare.