Ideal chest compression site for cardiopulmonary resuscitation in fontan circulation patients with dextrocardia.

BACKGROUND: We aimed to identify the ideal chest compression site for cardiopulmonary resuscitation (CPR) in patients with a single ventricle with dextrocardia corrected by Fontan surgery. METHODS: The most recent stored chest computed tomography images of all patients with a single ventricle who underwent Fontan surgery were retrospectively analysed. We reported that the ideal chest compression site is the largest part of the compressed single ventricle. To identify the ideal chest compression site, we measured the distance from the midline of the sternum to the point of the maximum sagittal area of the single ventricle as a deviation and calculated the area fraction of the compressed structures. RESULTS: 58 patients (67.2% male) were analysed. The mean right deviation from the midline of the sternum to the ideal compression site was similar to the mean sternum width (32.85 ± 15.61 vs. 31.05 ± 6.75 mm). When chest compression was performed at the ideal site, the area fraction of the single ventricle significantly increased by 7%, which was greater than that of conventional compression (0.15 ± 0.10 vs. 0.22 ± 0.11, P < 0.05). CONCLUSIONS: When performing CPR on a patient with Fontan circulation with dextrocardia, right-sided chest compression may be better than the conventional location.

Voice reduction in cardiac auscultation sounds with reference signals measured from vocal resonators.

This study proposes the use of vocal resonators to enhance cardiac auscultation signals and evaluates their performance for voice-noise suppression. Data were collected using two electronic stethoscopes while each study subject was talking. One collected auscultation signal from the chest while the other collected voice signals from one of the three voice resonators (cheek, back of the neck, and shoulder). The spectral subtraction method was applied to the signals. Both objective and subjective metrics were used to evaluate the quality of enhanced signals and to investigate the most effective vocal resonator for noise suppression. Our preliminary findings showed a significant improvement after enhancement and demonstrated the efficacy of vocal resonators. A listening survey was conducted with thirteen physicians to evaluate the quality of enhanced signals, and they have received significantly better scores regarding the sound quality than their original signals. The shoulder resonator group demonstrated significantly better sound quality than the cheek group when reducing voice sound in cardiac auscultation signals. The suggested method has the potential to be used for the development of an electronic stethoscope with a robust noise removal function. Significant clinical benefits are expected from the expedited preliminary diagnostic procedure.

Predictors of Caregiver Satisfaction With Pediatric Laceration Repair in the Pediatric Emergency Department.

OBJECTIVES: The objective of this study was to define the care factors that are important to caregivers' satisfaction with pediatric laceration repair and the overall emergency department (ED) experience. METHODS: This was a cross-sectional observation study performed in an urban tertiary hospital. The caregivers of patients younger than 18 years who presented to the ED for laceration repair completed a survey. Demographic data were analyzed. Univariate and multivariate logistic regressions were used to determine the factors related to satisfaction with the laceration repair and the overall ED experience. RESULTS: Fifty-five caregivers were enrolled. Most of the children had facial lacerations (n = 44, 80%). The median length of ED stay was 181 minutes (interquartile range [IQR], 157-208 minutes). The children's median age was 41.8 months (IQR, 23-91 months); the caregivers' median age was 37 years (IQR, 35-41 years). Most lacerations were repaired by plastic surgeons (81.8%). In the multivariate regression analysis, preparation before the procedure, mid-income family, caring attitude of the nurse, cosmetic outcome, and measures to control the patient's anxiety were significantly related to the caregiver's satisfaction with laceration repair (P < 0.05), whereas preparation before the procedure and ED environment were significantly related to the caregiver's satisfaction with the overall ED experience (P < 0.05). CONCLUSIONS: Preparation before the procedure was significantly related to the caregiver's satisfaction with both pediatric laceration repair and the overall PED experience. The strongest predictors were cosmetic outcome for laceration repair and preparation for the procedure for the overall PED experience. Our findings suggest that improvements in various aspects will increase parent satisfaction.

Factors contributing to uncertainty in paediatric abdominal ultrasound reports in the paediatric emergency department.

BACKGROUND: Abdominal pain, which is a common cause of children presenting to the paediatric emergency department (PED), is often evaluated by ultrasonography (US). However, uncertainty in US reports may necessitate additional imaging. OBJECTIVE: In this study, we evaluated factors contributing to uncertainty in paediatric abdominal US reports in the PED. MATERIALS AND METHODS: This retrospective cohort study included children younger than 18 years of age who underwent abdominal US in the PED of the study hospital between January 2017 and December 2019. After exclusion, the researchers manually reviewed and classified all US reports as 'certain' or 'uncertain'. Univariate and multivariate logistic regression analyses were performed to identify the factors contributing to uncertain reports. RESULTS: In total, 1006 patients were included in the final analysis., 796 patients were tagged as having certain reports, and 210 as having uncertain reports. Children with uncertain reports had a significantly higher rate of undergoing an additional computed tomography (CT) scan (31.0% vs. 2.5%, p < 0.001) and a longer PED median length of stay (321.0 (Interquartile range (IQR); 211.3-441.5) minutes vs. 284.5 (IQR; 191.8-439.5) minutes, p = 0.042). After logistic regression, US performed by a radiology resident (odds ratio, 5.01; 95% confidence interval, 3.63-7.15) was the most significant factor contributing to uncertainty in paediatric abdominal US reports followed by obesity and age. CONCLUSION: Several factors contribute to uncertainty in paediatric abdominal US reports. Uncertain radiological reports increase the likelihood of additional CT scans. Measures to improve the clarity of radiological reports must be considered to improve the quality of care for children visiting the PED.

Tablet personal computer distraction during intravenous placement for young children in the pediatric emergency department: A pilot study.

BACKGROUND: Intravenous (IV) placement is a common procedure experienced by children visiting the pediatric emergency department (PED). However, uncontrolled anxiety and pain cause children to interfere with the procedure. In this pilot study, we sought to evaluate the effectiveness of tablet personal computers as a distraction method during IV placement. METHODS: This is a single-center pilot study conducted at a tertiary teaching hospital. Children visiting the PED were eligible if they were aged 3-5 years and required IV placement during the PED visit. After written consent was obtained from the guardian, the child was randomly assigned to a control group or an intervention group. For the intervention group, an animated video was played via tablet PC during IV placement. For both groups, children's anxiety, heart rate, and pain scale scores (the Face, Legs, Activity, Cry, Consolability and Evaluation Enfant Douleur) and guardian satisfaction were recorded. RESULTS: 22 children were eligible for the final analysis. There was no significant difference in the pain scale scores between the two groups, with the exception of the degree of pain relief after the procedure measured using Evaluation Enfant Douleur (intervention group: 6.0, interquartile range (IQR): 4.2-6.8, and control group; 3.0, IQR: 2.0-3.8, P = 0.011) and Face, Legs, Activity, Cry, Consolability (intervention group: 4.0, IQR: 4.0-4.2 and control group; 3.0, IQR: 1.5-3.5, P = 0.043). CONCLUSION: In this pilot study, distraction using tablet personal computers may have reduced children's distress during the recovery phase after venipuncture. Further study with a larger sample size and different methods of distraction is essential.

A Novel Infant Chest Compression Assist Device Using a Palm Rather Than Fingers: A Randomized Crossover Trial.

Objective: We developed a novel compression assist device (palm presser) to perform chest compressions using a palm in infant cardiopulmonary resuscitation (CPR). We hypothesized that the palm presser will increase compression depth without increasing hands-off time and will reduce rescuer fatigue compared with the two-finger technique (TFT).Methods: In this randomized crossover manikin trial, participants performed two minutes of CPR with a 30:2 compression:ventilation ratio using the palm presser and the TFT in randomized sequence on an infant manikin. CPR parameters, including compression depth and hands-off time, were collected to compare CPR quality between the palm presser and the TFT. The linear mixed-effect model was used to control the carryover effect of a crossover design in the analysis of CPR parameters. To evaluate rescuer fatigue, we compared changes in compression depth over time and calculated the odds of sufficiently deep compressions over time between the two groups.Results: The palm presser resulted in greater mean compression depth (41.5 ± 1.6 mm vs. 36.8 ± 5.5 mm, p < 0.001), greater sufficiently deep compressions (80.9 ± 27.8% vs. 42.4 ± 35.4%, p < 0.001), and better correct hand position (99.9 ± 0.5% vs. 83.9 ± 25.3%, p = 0.013) than the TFT. Total compressions, compression rate, total ventilations, volume of ventilations, and hands-off time were not significantly different between the two groups. The mean change in compression depth over time was greater with the TFT than with the palm presser (regression coefficient: -0.024 [95% CI -0.030 to -0.018] vs. -0.004 [95% CI -0.006 to -0.002]). The odds of a compression depth greater than 40 mm increased 2.8 times (95% CI 2.2 to 3.4) with the TFT during the first minute compared with the last minute, whereas the corresponding odds ratio when using the palm presser was not significantly different in the first and last minutes (OR: 1.2 [95% CI 0.9 to 1.5]).Conclusions: Compression with palm pressers resulted in greater compression depth without increasing hands-off time and reduced rescuer fatigue compared with compression with the TFT in simulated infant CPR with manikins.

Interexaminer reliability of pharyngeal injection and palatine tonsillar hypertrophy in a pediatric emergency department.

OBJECTIVES: To evaluate the interrater reliability of throat examinations in children according to the major and training stage. STUDY DESIGN: We performed a prospective observational study of interrater reliability. The participants included physicians with various amounts of experience and majors who were working in an urban, tertiary hospital. We collected 20 photos of the throats of children who presented to the pediatric emergency department (ED) and performed 2 surveys (with or without medical history). The primary outcome was the interrater agreement for pharyngeal injection (PI) and palatine tonsillar hypertrophy (PTH), and the secondary outcome was the interrater agreement for PI and PTH in subgroups of examiners divided by major and duration of clinical experience. RESULTS: Thirty-three examiners participated in this study. The overall percent agreement for PI was 0.669, and Fleiss' kappa was 0.296. The interrater reliability was similar before and after providing patients' medical history. The overall percent agreement for PTH was 0.408, and Kendall's W was 0.674. When the patients' medical history was provided, Kendall's W increased (0.692). In the subgroup analysis, Fleiss' kappa for PI ranged from 0.257 to 0.33, and Kendall's W for PTH ranged from 0.593 to 0.711. CONCLUSION: Examiners' agreement for PTH was more reliable than that for PI when evaluating children who visited the ED. The interrater reliability did not improve with increased clinical experience. These findings should be considered in the examination of pharyngeal pathology.

Different effects of the nonsteroidal anti-inflammatory drugs meclofenamate sodium and naproxen sodium on proteasome activity in cardiac cells.

The use of nonsteroidal anti-inflammatory drugs (NSAIDs) like meclofenamate sodium (MS), used to reduce pain, has been associated with an increased risk of cardiovascular disease (CVD). Naproxen (NAP), another NSAID, is not associated with increased risk of CVD. The molecular mechanism(s) by which NSAIDs induce CVD is unknown. We investigated the effects of MS and NAP on protein homeostasis and cardiotoxicity in rat cardiac H9c2 cells and murine neonatal cardiomyocytes. MS, but not NAP, significantly inhibited proteasome activity and reduced cardiac cell viability at pharmacological levels found in humans. Although proteasome subunit gene and protein expression were unaffected by NSAIDs, MS treated cell lysates showed higher 20S proteasome content, while purified proteasomes from MS treated cells had lower proteasome activity and higher levels of oxidized subunits than proteasomes from control cells. Addition of exogenous proteasome to MS treated cells improved cell viability. Both MS and NAP increased ROS production, but the rate of ROS production was greater in MS than in NAP treated cells. The ROS production is likely from mitochondria, as MS inhibited mitochondrial Complexes I and III, major sources of ROS, while NAP inhibited Complex I. MS also impaired mitochondrial membrane potential while NAP did not. Antioxidants were able to prevent the reduced cell viability caused by MS treatment. These results suggest that NSAIDs induce cardiotoxicity by a ROS dependent mechanism involving mitochondrial and proteasome dysfunction and may explain why some NSAIDs should not be given to patients for long periods.

The current trend of emergency airway management: a clinical review.

Airway management is a fundamental and intricate process that involves a sequence of integrated tasks. Situations requiring emergency airway management may occur in emergency department, intensive care units, and various other spaces. Emergency airway management can face a variety of challenges during preparation, intubation, and post-intubation, and may result in significant complications for the patients. Therefore, many countries are establishing step-by-step systemization and detailed guidelines, and updating the content based on the latest research. This clinical review introduces the current trends in emergency airway management, such as emergency airway management algorithms, comparison of video and direct laryngoscopy, rapid sequence intubation, pediatric airway management, pre-hospital airway management, surgical airway management, and airway management education.

Unpowered scooter injuries in children and risk factors for traumatic brain injuries: An 8-year cross-sectional study using a national registry in South Korea.

INTRODUCTION: Head trauma accounts for a large proportion of unpowered scooter injuries in children. Traumatic brain injury (TBI) is the leading cause of considerable mortality and morbidity in children, who are the main users of unpowered scooters. The aim of this study was to explore the characteristics of unpowered scooter injuries in children and to identify predictors of the occurrence of TBI. METHODS: A multicentre observational retrospective study was conducted using the Emergency Department-based Injury In-depth Surveillance (EDIIS) database in South Korea. Children aged 2 to 18 years old with unpowered scooter injuries between 2011 and 2018 were eligible for inclusion in this study, and the primary outcome was TBI defined based on the International Classification of Diseases, 10th Revision (ICD-10) code. RESULTS: The annual rate of unpowered scooter injuries per 1,000 injured patients increased throughout the study period from 1.4 in 2011 to 16.4 in 2018 (P for trend < 0.001). Of the 3,892 children who had unpowered scooter injuries, 353 (9.2 %) had TBI. Children were at a higher risk of unpowered scooter TBI if they were aged between 2 and 5 years (adjusted odds ratio [aOR]: 1.37; 95 % confidence interval (CI): 1.09-1.73), were male (aOR: 1.45; 95 % CI: 1.14-1.86), were injured either on sidewalks (aOR: 1.80; 95 % CI: 1.20-2.70) or on driveways (aOR: 2.31; 95 % CI: 1.41-3.79), and experienced a fall (aOR: 1.98; 95 % CI: 1.15-3.43). Additionally, children injured after a blunt force were at a lower risk of TBI (aOR: 0.28; 95 % CI: 0.15-0.53). CONCLUSION: Unpowered scooter injuries in children are increasing in South Korea. It is essential for younger children riding unpowered scooters to wear helmets and for caregivers to actively supervise their children to prevent TBI.

Effect of a Virtual Reality Environment Using a Domed Ceiling Screen on Procedural Pain During Intravenous Placement in Young Children: A Randomized Clinical Trial.

Importance: Distraction using virtual reality (VR) has been found to provide a clinically significant reduction in the experience of pain during various painful procedures. Commercially available VR systems usually require the user to wear a head-mounted display helmet, which can be challenging for young children, and whether VR can reduce pain during intravenous (IV) placement in young children is currently unknown. Objective: To determine whether a VR environment using a novel domed ceiling screen reduces distress among children over the course of IV placement compared with standard care in a pediatric emergency department. Design, Setting, and Participants: This randomized clinical trial was conducted from June 3, 2020, to February 8, 2021, at an urban tertiary academic children's hospital. Included were children aged 6 months to 4 years undergoing IV placement in the pediatric emergency department. Intervention: Children in the intervention group lay on a bed to experience a VR animation using a domed ceiling screen during the IV placement procedure, which was performed as usual. Children in the control group also lay on a bed during the procedure but did not view a VR animation. Main Outcomes and Measures: The primary outcome was pain scores measured using the Face, Legs, Activity, Cry, and Consolability (FLACC) scale at 4 time points during IV placement: immediately after the child lay down on the bed (T1), the moment the tourniquet was applied (T2), the moment a sterile alcohol swab was applied (T3), and the moment the needle penetrated the skin (T4). Results: Of the 88 children included in the final analysis, 44 received VR distraction (median [IQR] age, 24.0 [14.5-44.0] months; 27 boys [61.4%]), and 44 received standard care (median [IQR] age, 23.0 [15.0-40.0] months; 26 boys [59.1%]). The median [IQR] FLACC scores at T4 were 6.0 (1.8-7.5) in the intervention group and 7.0 (5.5-7.8) in the control group. The ordinal logistic regression model showed that children in the VR intervention group vs the control group had a lower probability of higher FLACC scores (odds ratio, 0.53; 95% CI, 0.28-0.99; P = .046). Conclusions and Relevance: The findings of this trial indicate that displaying VR using a domed ceiling screen may be an effective distraction method that reduces distress in young children undergoing IV placement. Trial Registration: isrctn.org Identifier: KCT0005122.

Brain natriuretic peptide as a clinical screening tool for the diagnosis of Kawasaki disease.

N-terminal pro-brain natriuretic peptide (NT-proBNP) has been studied as a diagnostic screening tool for Kawasaki disease (KD). However, brain natriuretic peptide (BNP) has been less studied while has less variability among age groups. We aimed to find out if BNP can be used as a diagnostic screening tool for KD in Korea. This was a retrospective cohort study performed in a single pediatric emergency department. Patients younger than 19 years of age who presented with fever and underwent BNP examination for suspected KD was included. The primary outcome was the diagnostic performance of BNP for KD, and the secondary outcome was the diagnostic performance of BNP for coronary artery aneurysm (CAA). We also derived a scoring system for predicting KD and CAA. Of the 778 patients who were finally included, 400 were not diagnosed with KD and 378 were diagnosed with KD. The odds ratio of BNP at the cutoff of 30 pg/mL for KD was 7.80 (95% CI, 5.67-10.73) in the univariate analysis and 3.62 (95% CI, 2.33-5.88) in the multivariable analysis. The odds ratio of BNP at the cutoff of 270 pg/mL for CAA was 3.67 (95% CI, 2.18-6.19) in the univariate analysis and 2.37 (95% CI, 1.16-8.74) in the multivariable analysis. The AUC of KD and CAA were 0.884 and 0.726, respectively, which was the highest AUCs among all variables. Additionally, we proposed a scoring system for KD and CAA. It is important to clinically suspect KD and CAA in children with high BNP levels.

Delta Neutrophil Index Does Not Differentiate Bacterial Infection without Bacteremia from Viral Infection in Pediatric Febrile Patients.

Introduction: We sought to determine whether the delta neutrophil index (DNI), a marker that is reported to be used to predict the diagnosis, prognosis, and disease severity of bacteremia and sepsis, is useful in differentiating bacterial infection without bacteremia (BIWB) from viral infections (VI) in pediatric febrile patients in the emergency department (ED). Method: We conducted a retrospective analysis of febrile patients' medical records from the pediatric ED of the teaching hospital. The patients with BIWB and those with VI were identified with a review of medical records. The primary outcome was the diagnostic performance of DNI in differentiating BIWB from VI. The secondary outcome was a comparison of the diagnostic performances of DNI, CRP, WBC, and neutrophil count between the two groups. Results: A total of 151 (26.3%) patients were in the BIWB group, and 423 (73.7%) were in the VI group. There was no significant difference in DNI between the two groups (3.51 ± 6.90 vs. 3.07 ± 5.82, mean ± SD, BIWB vs. VI). However, CRP levels were significantly higher in the BIWB group than in the VI group (4.56 ± 5.45 vs. 1.39 ± 2.12, mean ± SD, BIWB vs. VI, p < 0.05). The AUROCs of DNI, WBC count, neutrophil levels, RDW, and CRP levels were 0.5016, 0.5531, 0.5631, 0.5131, and 0.7389, respectively, and only CRP levels were helpful in differentiating BIWB from VI. Conclusion: In the absence of bacteremia, DNI would not be helpful in differentiating BIWB from VI in pediatric febrile patients.

Machine learning-based prediction of critical illness in children visiting the emergency department.

OBJECTIVES: Triage is an essential emergency department (ED) process designed to provide timely management depending on acuity and severity; however, the process may be inconsistent with clinical and hospitalization outcomes. Therefore, studies have attempted to augment this process with machine learning models, showing advantages in predicting critical conditions and hospitalization outcomes. The aim of this study was to utilize nationwide registry data to develop a machine learning-based classification model to predict the clinical course of pediatric ED visits. METHODS: This cross-sectional observational study used data from the National Emergency Department Information System on emergency visits of children under 15 years of age from January 1, 2016, to December 31, 2017. The primary and secondary outcomes were to identify critically ill children and predict hospitalization from triage data, respectively. We developed and tested a random forest model with the under sampled dataset and validated the model using the entire dataset. We compared the model's performance with that of the conventional triage system. RESULTS: A total of 2,621,710 children were eligible for the analysis and included 12,951 (0.5%) critical outcomes and 303,808 (11.6%) hospitalizations. After validation, the area under the receiver operating characteristic curve was 0.991 (95% confidence interval [CI] 0.991-0.992) for critical outcomes and 0.943 (95% CI 0.943-0.944) for hospitalization, which were higher than those of the conventional triage system. CONCLUSIONS: The machine learning-based model using structured triage data from a nationwide database can effectively predict critical illness and hospitalizations among children visiting the ED.

Feasibility Study of a Fully Synchronous Virtual Critical Care Elective Focused on Learner Engagement.

BACKGROUND: The COVID-19 pandemic disrupted clinical education for medical students. With the rise of variants, meaningful in-person clinical experiences remain threatened. This report describes the design, implementation, and evaluation of a fully synchronous virtual critical care elective for medical students focused on learner engagement. METHODS: The two-week elective was offered during June and July 2020 in the COVID-19 extracorporeal membrane oxygenation (ECMO) unit. Medical students remotely participated in multidisciplinary rounds with the attending physician connected from the bedside via a head-mounted camera providing the first-person video view. Other team members connected outside the negative pressure area. Learners electronically completed daily intensive care unit (ICU) goals sheet (GS) for each patient. The daily completion percentage of the GS assessed the learner engagement, and the learners evaluated the experience with a five-point Likert scale survey. RESULTS: Nine medical students participated in two separate cohorts. Cohort A had 53 patient encounters, and Cohort B had 45 patient encounters totaling 301.5 total hours of supervised virtual patient interaction. The mean completion percentage of the daily ICU GS for the combined cohorts was 77.8%, (with a standard deviation of 9.6%), with sustained or increased completion from start to finish for all learners. All medical students agreed that the daily ICU GS was helpful for following rounds, organizing patient assessments and plans, and participating in patient care. The majority (88.9%) agreed that the elective increased their comfort in caring for critically ill patients. CONCLUSIONS: During the COVID-19 pandemic, a fully synchronous virtual critical care elective successfully utilized the first-person view and daily ICU GS to promote and assess learner engagement.

Validation of Pediatric Emergency Care Applied Research Network (PECARN) rule in children with minor head trauma.

The Pediatric Emergency Care Applied Research Network (PECARN) rule is commonly used for predicting the need for computed tomography (CT) scans in children with mild head trauma. The objective of this study was to validate the PECARN rule in Korean children presenting to the pediatric emergency department (PED) with head trauma. This study was a multicenter, retrospective, observational cohort study in two teaching PEDs in Korea between August 2015 and August 2016. In this observational study, 448 patients who visited PEDs were included in the final analysis. Risk stratification was performed with clinical decision support software based on the PECARN rule, and decisions to perform CT scans were subsequently made. Patients were followed-up by phone call between 7 days and 90 days after discharge from the PED. The sensitivity and specificity were analyzed. The sensitivity was 100% for all age groups, and no cases of clinically important traumatic brain injury (ciTBI) were identified in the very-low-risk group. CT scans were performed for 14.7% of patients in this study and for 33.8% in the original PECARN study. The PECARN rule successfully identified low-risk patients, and no cases of ciTBI were missed despite the reduced proportion of patients undergoing CT scans.

Role of the urinary N-acetyl-beta-D-glucosaminidase/creatinine (NAG/Cr) ratio in discriminating between true and false pyuria in sterile urine bag specimens.

INTRODUCTION: Urethral catheterization (CATH) and suprapubic aspiration (SA) are reliable methods of collecting urine for the diagnosis of urinary tract infections (UTIs), but both are invasive and difficult. Therefore, urine collection through a sterile urine bag (SUB) is commonly used for UTI screening. However, when pyuria is found in SUB specimens, it is difficult to interpret whether this result is true or false. OBJECTIVE: We aimed to determine the diagnostic performance of the urinary NAG/Cr ratio in detecting true pyuria in SUB specimens for children with suspected UTIs. STUDY DESIGN: This retrospective study included children 2-24 months of age presenting to the pediatric emergency department (PED) and in whom urinary NAG and creatinine levels were measured and a urine culture was performed between January 1, 2018, and December 31, 2019. Children with the presence of pyuria in SUB specimens were categorized into true or false pyuria groups depending on whether pyuria was present in CATH specimens. The diagnostic performance of the urinary NAG/Cr ratio in detecting true pyuria was identified using receiver operating characteristic (ROC) curve analysis. The optimal cutoff was calculated based on ROC curve analysis. Sensitivity, specificity, and positive and negative likelihood ratios were assessed for optimal cutoff values. RESULTS: Among 606 children with measured urinary NAG levels, 144 children with pyuria in SUB specimens were included in the analyses. Pyuria was consistently present in the CATH specimens of 67 (46.5%) children and absent in those of 77 (44.5%) children. The urinary NAG/Cr ratio was significantly higher in the true pyuria group than in the false pyuria group (21.5 IU/g; 95% confidence interval [CI]: 12.3-35.6; vs 9.6 IU/g; 95% CI: 6.7-16.1, P < 0.001). The area under the ROC curve (AUC) for the urinary NAG/Cr ratio was 0.776 (95% CI: 0.700-0.851). The optimal cutoff of 18.85 IU/g corresponded to the best combination of sensitivity (58.2, 95% CI: 46.4-70.0) and specificity (83.3, 95% CI: 74.7-91.6), with positive and negative likelihood ratios of 3.49 (95% CI: 2.04-5.97) and 0.50 (95% CI: 0.37-0.68), respectively. CONCLUSION: The urinary NAG/Cr ratio may be a potential indicator discriminating true pyuria from false pyuria in SUB specimens in the PED. However, large prospective studies are required to implement the NAG/Cr ratio in clinical practice.

Virtual reality environment using a dome screen for procedural pain in young children during intravenous placement: A pilot randomized controlled trial.

We assessed the feasibility and potential efficacy of a virtual reality (VR) environment using a dome screen as a distraction method in young children during intravenous (IV) placement in the pediatric emergency department. This randomized controlled pilot study enrolled children aged 2 to 6 years who underwent IV placement into either the intervention group or the control group. Children in the intervention group experienced VR using a dome screen during IV placement. The child's pain intensity was measured using the Face, Legs, Activity, Cry, and Consolability (FLACC) scale at four time points of IV placement: immediately after arrival to the blood collection room (base); immediately after the child laid down on the bed (preparation); when the tourniquet was applied (tourniquet); and the moment at which the needle penetrated the skin (venipuncture). The guardian's satisfaction and rating of the child's distress were assessed using a 5-point Likert-type questionnaire. We recruited 19 children (9 in the intervention group and 10 in the control group). Five children in the control group were excluded from the analysis because of missing video recordings (n = 3), failed first attempt at IV placement (n = 1), and the child's refusal to lie on the bed during the procedure (n = 1). No side effects of VR were reported during the study period. Although the average FLACC scale score at each time point (preparation, tourniquet, venipuncture) was lower in the intervention group than the control group, the difference was not statistically significant (2.3, interquartile range [IQR]: 2.0-3.0; vs. 3.3, IQR: 2.7-6.7, P = 0.255). There were no statistically significant differences between the groups in the guardian's satisfaction and anxiety or his/her rating of the child's pain and anxiety. The guardians and emergency medical technicians reported satisfaction with the use of VR with a dome screen and considered it a useful distraction during the procedure. VR using a dome screen is a feasible distraction method for young children during IV placement. A larger clinical trial with further development of the VR environment and study process is required to adequately evaluate the efficacy of VR using a dome screen.

Perceptions of Barriers and Facilitators to Becoming a Medical Professional Among Underrepresented Undergraduate and Postbaccalaureate Learners.

OBJECTIVE: To assess underrepresented undergraduate and postbaccalaureate learners' perceptions of (1) the medical field, (2) barriers that might prevent individuals from pursuing professional medical careers, and (3) resources that assist in overcoming these barriers. PARTICIPANTS AND METHODS: A qualitative study with focus groups was designed to achieve the objective. Participants were recruited from a community initiative to provide early exploration of the medical field to disadvantaged and minority individuals. Thirty-five individuals voluntarily participated in semistructured interviews. Audio from the interviews was analyzed using a qualitative descriptive approach and thematic analysis. This study was conducted from October 20, 2018, to April 6, 2019. RESULTS: Participants identified multiple characteristics related to the health care work environment and desirable attributes of health care personnel. The following barriers were identified: financial burden, lacking knowledge of the path to becoming a medical professional, inadequate social support, and lacking the metrics of a competitive candidate. Resources identified by participants to overcome barriers included professional networks and programmatic considerations. CONCLUSION: The study participants discussed negative and positive aspects of the health care environment, such as implicit and explicit biases and attributes that promote or sustain success. Participants expounded on financial, academic, social, and personal factors as barriers to success. In regard to resources that were believed to be helpful to mitigate barriers and promote success, participants commented on activities that simulate a professional medical environment, include networking with medical personnel, support well-being, and provide exposure to structured information on the process of obtaining professional medical training.