Anticoagulation practices associated with bleeding and thrombosis in pediatric extracorporeal membrane oxygenation; a multi-center secondary analysis.

To determine associations between anticoagulation practices and bleeding and thrombosis during pediatric extracorporeal membrane oxygenation (ECMO), we performed a secondary analysis of prospectively collected data which included 481 children (<19 years), between January 2012 and September 2014. The primary outcome was bleeding or thrombotic events. Bleeding events included a blood product transfusion >80 ml/kg on any day, pulmonary hemorrhage, or intracranial bleeding, Thrombotic events included pulmonary emboli, intracranial clot, limb ischemia, cardiac clot, and arterial cannula or entire circuit change. Bleeding occurred in 42% of patients. Five percent of subjects thrombosed, of which 89% also bled. Daily bleeding odds were independently associated with day prior activated clotting time (ACT) (OR 1.03, 95% CI= 1.00, 1.05, p=0.047) and fibrinogen levels (OR 0.90, 95% CI 0.84, 0.96, p <0.001). Thrombosis odds decreased with increased day prior heparin dose (OR 0.88, 95% CI 0.81, 0.97, p=0.006). Lower ACT values and increased fibrinogen levels may be considered to decrease the odds of bleeding. Use of this single measure, however, may not be sufficient alone to guide optimal anticoagulation practice during ECMO.

Impact of Expanding Telephonic Codes in a State Medicaid Program During COVID-19.

Background: The recent pandemic caused by the 2019 novel coronavirus (COVID-19) resulted in declaration of a national emergency (NE) in March 2020. The Centers for Medicare and Medicaid Services quickly responded with temporary expansion of telehealth coverage policies. Aim: To determine the impact of implementing a temporary telephonic code set in a state Medicaid population by comparing the utilization patterns of telehealth claims before and after a NE announcement. Methods: This was a retrospective cohort study conducted with the Arizona Medicaid program, the Arizona Health Care Cost Containment System (AHCCCS). Data include telehealth claims submitted to AHCCCS between January and May 2020 by contracted managed care organizations. Results: Approximately 2.3 million telehealth claims were analyzed in this study. Utilization of the audio-visual (A/V) modality increased 1,610% and telephonic visits increased 408% compared with pre-NE. Compared with pre-NE, three provider type groups increased their utilization of telephonic visits from 1.8% to 50.8% as a result of the temporary telephonic set post-NE. Rural counties had higher rates of telephonic modality adoption, whereas urban counties adopted the A/V modality more readily. Ten telephonic codes constituted 87% of all telehealth claims, with the majority of those codes used for behavioral health and established office visit types. Conclusion: The telephonic modality was adopted more frequently in rural areas and the A/V modality in urban areas. There were several new provider types utilizing telehealth as a result of the temporary telephonic code set implementation.

Activated clotting time in inpatient diagnostic and interventional settings.

Monitoring for the anticoagulant effect of unfractionated (UFH) at the point of care using activated clotting time in real time is vital where risk of thrombosis is high. Although monitoring UFH effect is a routine and important task, changing from one ACT instrument type or technology to another must be preceded by a clinical and statistical evaluation to determine the suitability and repeatability and establish normal and treatable ranges of this newer instrument. In this multi-center prospective evaluation we tested 1236 paired ACT+ samples, and 463 paired ACT-LR samples (1699 total) from enrolled study subjects. Clinical settings included CVOR cardiopulmonary bypass, at the beside in extracorporeal life support (ELS), the Cardiac Catheterization Lab (CCL) during diagnostic studies and percutaneous coronary interventions (PCI), interventional radiology procedures and EP interventions. This study found more consistent clinical performance from the GEM Hemochron 100 as compared to the current clinical model, the Hemochron Signature Elite. The bias of GEM Hemochron 100 for ACT+ and ACT-LR was greatest in the setting of the CVOR where ACT levels were high. ACT-LR measurements by the GEM Hemochron 100 were comparable to the SE when performed in settings of CCL, ECM, EP and ICU. Results obtained for both ACT-LR and ACT+ in all clinical settings in this study using the GEM Hemochron 100 are as accurate and more repeatable as those with the current clinically available Signature Elite.

Reuniting Long Lost Cousins: a Novel Curriculum in Imaging Informatics for Clinical Informatics Fellows.

We developed a curriculum of imaging informatics for clinical informatics fellows. While imaging informatics and clinical informatics are related fields, they have distinct bodies of knowledge. The aim of this curriculum is to prepare clinical informatics fellows for questions regarding imaging informatics on the clinical informatics board certification examination, prepare fellows to handle issues and requests involving imaging informatics in their future roles as clinical informaticists, and develop sufficient knowledge and skills in order to interface with imaging and radiology domain experts. We mapped ACGME core competencies for clinical informatics and the clinical informatics skills and attributes to topics covered in this curriculum. Topics covered included orders vs. encounter-based workflow, understanding imaging informatics operations and the differences between an IT department leading digital image management and the radiology department, clinical decision support for radiology, procuring and integrating new modalities into a PACS system, troubleshooting slow application performance in a PACS environment, imaging sharing, artificial intelligence (AI) in imaging including AI bias, validation of models within home institution and regulatory issues, and structured reporting vs. Natural Language Processing to mine radiology report data. These topics were covered in interactive didactic sessions as well as a journal club. Future work will expand to include hands-on learning and a formal evaluation of this curriculum with current fellows and recent graduates.

Repeated measurements of ERGs and VEPs using chloral hydrate sedation and propofol anesthesia in young children.

PURPOSE: Sedation with chloral hydrate or anesthesia using propofol allow ocular examination and testing in young children, but these drugs may affect electrophysiologic recordings. We compared the flash and pattern ERGs and VEPs recorded with each drug in a cohort of young children enrolled in a prospective study of optic nerve hypoplasia (ONH) syndrome. METHODS: ERGs and VEPs to light-adapted, standard, full-field flashes, to standard and steady-state pattern-reversal (PR) were recorded with cycloplegia in 9 participants. Age range at the first session, with chloral hydrate was 8-23 mo; at the second session with propofol it was 20-29 mo. Examiners masked to the drug and clinical conditions measured the waveforms for longitudinal, paired comparisons between the sessions. RESULTS: Flash ERG amplitudes did not differ between sessions; peak times were longer at the second session (propofol) by clinically insignificant amounts (< 2 ms, p = 0.002). Standard PERGs had larger amplitudes and later peaks in the second session (propofol) than with chloral hydrate (P50 2.9 vs 4.7 µV, p = 0.016 and 43 vs 52 ms, p < 0.001; N95 4.0 vs 6.1 µV, p = 0.003 and 91 vs 98.5 ms p = 0.034.). These differences were present for those with an interval of  > 10 mo between sessions (n = 5, 10 eyes) but not for those with a shorter inter-test interval (< 8 mo, p > 0.05, n = 4). Magnitudes of the steady-state PERGs did not differ between tests but the waveforms had earlier peaks at the second test with propofol. Flash VEP waveforms were present in 10/18 eyes and showed 72% agreement for recordability between sessions. Standard pattern VEPs were recordable in only a few eyes in this cohort with ONH. CONCLUSIONS: Light-adapted flash ERG waveforms were generally similar with chloral hydrate and with propofol. Larger PERGs with later peaks, found in the second session (propofol) could reflect maturation of the PERG generators, as the differences found were associated with a greater age difference between the sessions, but we do not rule out that small differences in the waveforms may be drug-related. There are insufficient VEP data from these children with ONH to identify drug-related or maturational effects on VEPs.

Altered speech with migraine attacks: A prospective, longitudinal study of episodic migraine without aura.

BACKGROUND AND OBJECTIVE: Some individuals with migraine report the presence of speech changes during their migraine attacks. The goal of this study was to compare objective features of speech during the migraine pre-attack, the migraine attack, and during the interictal period. METHODS: This was a prospective, longitudinal, observational study of adults with episodic migraine and healthy non-migraine controls. Participants provided speech samples three times per day using a speech elicitation tool included within a mobile app. Six complementary speech features that capture articulation and prosody were extracted from speech samples. Participants with migraine maintained a daily headache diary using the same app. A mixed effects model and t-tests were used to investigate differences in speech features between controls, the migraine pre-attack phase, the migraine attack, and the interictal period. RESULTS: In total, 56,767 speech samples were collected, including 43,102 from 15 individuals with migraine and 13,665 from matched healthy controls. Significant group-level differences in speech features were identified between those with migraine and healthy controls and within the migraine group during the pre-attack vs. attack vs. interictal periods (all p < .05). Most consistently, speech changes occurred in the speaking rate, articulation rate and precision, and phonatory duration. Within-subject analysis revealed that seven of 15 individuals with migraine showed significant change in at least one speech feature when comparing the migraine attack vs. interictal phase and four showed similar changes when comparing the pre-attack vs. interictal phases. CONCLUSIONS: Changes in speech occurred in almost half of the individuals during migraine attacks. Once confirmed in subsequent studies, speech changes could be considered a feature of the migraine attack.

Development of the Pediatric Extracorporeal Membrane Oxygenation Prediction Model for Risk-Adjusting Mortality.

OBJECTIVES: To develop a prognostic model for predicting mortality at time of extracorporeal membrane oxygenation initiation for children which is important for determining center-specific risk-adjusted outcomes. DESIGN: Multivariable logistic regression using a large national cohort of pediatric extracorporeal membrane oxygenation patients. SETTING: The ICUs of the eight tertiary care children's hospitals of the Collaborative Pediatric Critical Care Research Network. PATIENTS: Five-hundred fourteen children (< 19 yr old), enrolled with an initial extracorporeal membrane oxygenation run for any indication between January 2012 and September 2014. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 514 first extracorporeal membrane oxygenation runs were analyzed with an overall mortality of 45% (n = 232). Weighted logistic regression was used for model selection and internal validation was performed using cross validation. The variables included in the Pediatric Extracorporeal Membrane Oxygenation Prediction model were age (pre-term neonate, full-term neonate, infant, child, and adolescent), indication for extracorporeal membrane oxygenation (extracorporeal cardiopulmonary resuscitation, cardiac, or respiratory), meconium aspiration, congenital diaphragmatic hernia, documented blood stream infection, arterial blood pH, partial thromboplastin time, and international normalized ratio. The highest risk of mortality was associated with the presence of a documented blood stream infection (odds ratio, 5.26; CI, 1.90-14.57) followed by extracorporeal cardiopulmonary resuscitation (odds ratio, 4.36; CI, 2.23-8.51). The C-statistic was 0.75 (95% CI, 0.70-0.80). CONCLUSIONS: The Pediatric Extracorporeal Membrane Oxygenation Prediction model represents a model for predicting in-hospital mortality among children receiving extracorporeal membrane oxygenation support for any indication. Consequently, it holds promise as the first comprehensive pediatric extracorporeal membrane oxygenation risk stratification model which is important for benchmarking extracorporeal membrane oxygenation outcomes across many centers.

Factors Associated with Bleeding and Thrombosis in Children Receiving Extracorporeal Membrane Oxygenation.

RATIONALE: Extracorporeal membrane oxygenation (ECMO) is used for respiratory and cardiac failure in children but is complicated by bleeding and thrombosis. OBJECTIVES: (1) To measure the incidence of bleeding (blood loss requiring transfusion or intracranial hemorrhage) and thrombosis during ECMO support; (2) to identify factors associated with these complications; and (3) to determine the impact of these complications on patient outcome. METHODS: This was a prospective, observational cohort study in pediatric, cardiac, and neonatal intensive care units in eight hospitals, carried out from December 2012 to September 2014. MEASUREMENTS AND MAIN RESULTS: ECMO was used on 514 consecutive patients under age 19 years. Demographics, anticoagulation practices, severity of illness, circuitry components, bleeding, thrombotic events, and outcome were recorded. Survival was 54.9%. Bleeding occurred in 70.2%, including intracranial hemorrhage in 16%, and was independently associated with higher daily risk of mortality. Circuit component changes were required in 31.1%, and patient-related clots occurred in 12.8%. Laboratory sampling contributed to transfusion requirement in 56.6%, and was the sole reason for at least one transfusion in 42.2% of patients. Pump type was not associated with bleeding, thrombosis, hemolysis, or mortality. Hemolysis was predictive of subsequent thrombotic events. Neither hemolysis nor thrombotic events increased the risk of mortality. CONCLUSIONS: The incidences of bleeding and thrombosis are high during ECMO support. Laboratory sampling is a major contributor to transfusion during ECMO. Strategies to reduce the daily risk of bleeding and thrombosis, and different thresholds for transfusion, may be appropriate subjects of future trials to improve outcomes of children requiring this supportive therapy.

Predictive value of N95 waveforms of pattern electroretinograms (PERGs) in children with optic nerve hypoplasia (ONH).

PURPOSE: As part of a long-term, prospective study of prenatal and clinical risk factors for optic nerve hypoplasia (ONH) at Children's Hospital Los Angeles, pattern ERGs (PERGs) were evaluated for prognostic value using an automated objective and robust analytical method. METHODS: Participants were 33 children with ophthalmoscopically diagnosed ONH [disc diameter-to-disc macula ratio (DD/DM) less than 0.35 in one or both eyes on fundus photographs]. Using cycloplegia and chloral hydrate sedation in one session before 26 months of age, we recorded PERGs to checkerboard reversal using five check sizes. Participants were followed with clinical and psychometric testing until 5 years of age. PERGs were analysed using automated robust statistics based on magnitude-squared coherence and bootstrapping optimized to objectively quantify PERG recovery in the challenging recordings encountered in young patients. PERG measures in the fixating or better-seeing eyes were compared with visual outcome data. RESULTS: PERG recording was complete to at least three check sizes in all eyes and to all five sizes in 79%. Probability of recording a PERG that is significantly different from noise varied with check size from 73% for the largest checks to 30% for the smallest checks (p = 0.002); smaller waveforms were associated with earlier implicit times. The presence of significant PERGs in infancy is associated with better visual outcomes; the strongest association with visual outcome was for the threshold check size with a significant N95 component (ρ = 0.398, p = 0.02). CONCLUSIONS: Automated statistically robust signal-processing techniques reliably and objectively detect PERGs in young children with ONH and show that congenital deficits of retinal ganglion cells are associated with diminished or non-detectable PERGs. The later negativity, N95, was the best indicator of visual prognosis and was most useful to identify those with good visual outcomes (≤0.4 LogMAR). Although PERGs reflect function of the inner layers of the central retina, they lack the specificity required to determine prognosis reliably in individual cases.

Comparison of human expert and computer-automated systems using magnitude-squared coherence (MSC) and bootstrap distribution statistics for the interpretation of pattern electroretinograms (PERGs) in infants with optic nerve hypoplasia (ONH).

PURPOSE: Pattern electroretinograms (PERGs) have inherently low signal-to-noise ratios and can be difficult to detect when degraded by pathology or noise. We compare an objective system for automated PERG analysis with expert human interpretation in children with optic nerve hypoplasia (ONH) with PERGs ranging from clear to undetectable. METHODS: PERGs were recorded uniocularly with chloral hydrate sedation in children with ONH (aged 3.5-35 months). Stimuli were reversing checks of four sizes focused using an optical system incorporating the cycloplegic refraction. Forty PERG records were analysed; 20 selected at random and 20 from eyes with good vision (fellow eyes or eyes with mild ONH) from over 300 records. Two experts identified P50 and N95 of the PERGs after manually deleting trials with movement artefact, slow-wave EEG (4-8 Hz) or other noise from raw data for 150 check reversals. The automated system first identified present/not-present responses using a magnitude-squared coherence criterion and then, for responses confirmed as present, estimated the P50 and N95 cardinal positions as the turning points in local third-order polynomials fitted in the -3 dB bandwidth [0.25 … 45] Hz. Confidence limits were estimated from bootstrap re-sampling with replacement. The automated system uses an interactive Internet-available webpage tool (see http://clinengnhs.liv.ac.uk/esp_perg_1.htm). RESULTS: The automated system detected 28 PERG signals above the noise level (p ≤ 0.05 for H0). Good subjective quality ratings were indicative of significant PERGs; however, poor subjective quality did not necessarily predict non-significant signals. P50 and N95 implicit times showed good agreement between the two experts and between experts and the automated system. For the N95 amplitude measured to P50, the experts differed by an average of 13% consistent with differing interpretations of peaks within noise, while the automated amplitude measure was highly correlated with the expert measures but was proportionally larger. Trial-by-trial review of these data required approximately 6.5 h for each human expert, while automated data processing required <4 min, excluding overheads relating to data transfer. CONCLUSIONS: An automated computer system for PERG analysis, using a panel of signal processing and statistical techniques, provides objective present/not-present detection and cursor positioning with explicit confidence intervals. The system achieves, within an efficient and robust statistical framework, estimates of P50 and N95 amplitudes and implicit times similar to those of clinical experts.

Association of bleeding and thrombosis with outcome in extracorporeal life support.

OBJECTIVE: Changes in technology and increased reports of successful extracorporeal life support use in patient populations, such as influenza, cardiac arrest, and adults, are leading to expansion of extracorporeal life support. Major limitations to extracorporeal life support expansion remain bleeding and thrombosis. These complications are the most frequent causes of death and morbidity. As a pilot project to provide baseline data for a detailed evaluation of bleeding and thrombosis in the current era, extracorporeal life support patients were analyzed from eight centers in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network. STUDY DESIGN: Retrospective analysis of patients (< 19 yr) reported to the Extracorporeal Life Support Organization registry from eight Collaborative Pediatric Critical Care Research Network centers between 2005 and 2011. SETTING: Tertiary children's hospitals within the Collaborative Pediatric Critical Care Research Network. SUBJECTS: The study cohort consisted of 2,036 patients (13% with congenital diaphragmatic hernia). INTERVENTIONS: None. MAIN RESULTS: In the cohort of patients without congenital diaphragmatic hernia (n = 1,773), bleeding occurred in 38% of patients, whereas thrombosis was noted in 31%. Bleeding and thrombosis were associated with a decreased survival by 40% (relative risk, 0.59; 95% CI, 0.53-0.66) and 33% (odds ratio, 0.67; 95% CI, 0.60-0.74). Longer duration of extracorporeal life support and use of venoarterial cannulation were also associated with increased risk of bleeding and/or thrombotic complications and lower survival. The most common bleeding events included surgical site bleeding (17%; n = 306), cannulation site bleeding (14%; n = 256), and intracranial hemorrhage (11%; n = 192). Common thrombotic events were clots in the circuit (15%; n = 274) and the oxygenator (12%; n = 212) and hemolysis (plasma-free hemoglobin > 50 mg/dL) (10%; n = 177). Among patients with congenital diaphragmatic hernia, bleeding and thrombosis occurred in, respectively, 45% (n = 118) and 60% (n = 159), Bleeding events were associated with reduced survival (relative risk, 0.62; 95% CI, 0.46-0.86) although thrombotic events were not (relative risk, 0.92; 95% CI, 0.67-1.26). CONCLUSIONS: Bleeding and thrombosis remain common complications in patients undergoing extracorporeal life support. Further research to reduce or eliminate bleeding and thrombosis is indicated to help improve patient outcome.

Imaging Informatics Education in Clinical Informatics Programs: Perspective from Imaging and Clinical Informatics Professionals.

BACKGROUND: Imaging and Clinical Informatics are domains of biomedical informatics. Imaging Informatics topics are often not covered in depth in most Clinical Informatics fellowships. While dedicated Imaging Informatics fellowships exist, they may not have the same rigor as ACGME (Accreditation Council for Graduate Medical Education) accredited Clinical Informatics fellowships and they do not provide a direct path toward subspecialty board certification. OBJECTIVES: We compared published curricula and test content between Clinical and Imaging Informatics fellowship programs. We then highlighted differences between training programs and identified overlapping topics and opportunities for additional education for each type of trainee. METHODS: Published consensus curricula and topics were extracted for each specialty. Two informaticists compared topics as shared or not shared between specialties. Next, test content outlines were compared for each specialty exam, extracted, and classified as shared or not shared content. A Venn diagram was created to highlight areas unique to each specialty as well as areas of overlap. RESULTS: There were 139 Clinical Informatics topics compared with 97 Imaging Informatics topics. Of the 139 Clinical Informatics topics, 115 (83%) were covered in the Imaging Informatics curriculum. Of the 97 Imaging Informatics topics, 74 (76%) were covered in the Clinical Informatics curriculum. When using test content outline data, 170 out of 397 (43%) Imaging Informatics topics matched to 64 out of 139 (46%) Clinical Informatics topics. We describe examples of overlapping topics and those unique to each program to identify potential areas to expand. CONCLUSION: Imaging Informatics and Clinical Informatics fellowship programs have some overlap with areas unique to each. Our review may help guide those seeking informatics education and potential certification. As enterprise imaging evolves, these differences may become more important and create knowledge gaps, if not systematically evaluated.

BIRC5 expression is a poor prognostic marker in Ewing sarcoma.

BACKGROUND: BIRC5 (Survivin), an inhibitor of apoptosis protein (IAP), is over-expressed in several human cancers and increased expression is associated with poor prognosis. The goal of the current study was to evaluate the role of BIRC5 in Ewing sarcoma (ES), the second most common pediatric bone sarcoma. PROCEDURE: BIRC5 protein expression was determined in ES cell lines using Western Blot analysis. Functional role of survivin on growth and viability of ES cells was assessed by siRNA knockdown of BIRC5 and by using a small molecule inhibitor YM155. Immunohistochemical analysis for BIRC5 protein was performed on patient tumor samples using an anti-survivin antibody. The degree of BIRC5 protein expression was correlated with clinical parameters and patient outcome. RESULTS: BIRC5 is over-expressed in a panel of ES cell lines. Gene silencing of BIRC5 in the ES cell line TC-71 decreases cell growth by more than 50% for each BIRC5 siRNA construct compared to non-silencing siRNA control constructs. YM155 also reduces ES cell growth and viability with an EC(50) ranging from 2.8 to 6.2 nM. BIRC5 protein is expressed in majority of the ES tumor samples with minimal expression in normal tissue (P < 0.005). Tumors with more than 50% expression are associated with worse overall survival than tumors with less than 50% expression (Hazard Ratio: 6.05; CI: 1.7-21.4; P = 0.04). CONCLUSION: BIRC5 is over-expressed in ES cell lines and tumor samples. Further, it plays an important role in cell growth and viability in vitro. Higher degree of expression in patients is an independent poor prognostic factor.

Association of prepregnancy body mass index and gestational weight gain on severity of optic nerve hypoplasia.

BACKGROUND: Optic nerve hypoplasia (ONH) is a birth defect of unknown etiology and a leading cause of visual impairment in developed countries. Recent studies suggest that factors of deprivation and exposures of poor nutritional status, such as lower gestational weight gain (GWG), may be associated with increased risk of ONH. The present study describes the prenatal features of mothers of ONH cases, including prepregnancy BMI and GWG, and the associations with clinical features of disease severity. METHODS: Retrospective study of prenatal records for cases of ONH enrolled in a research registry. Prepregnancy BMI and GWG were compared to maternal characteristics and clinical findings of ONH severity including bilaterality, hypopituitarism, and neuroradiographic abnormalities. RESULTS: Compared to population-based normative data of births in the United States, mothers of ONH cases (n = 55) were younger (23.3 vs. 25.8 years; p = 0.03), with higher incidence of inadequate GWG (34.0% vs. 20.4%; p = 0.03) predominantly in the first and second trimesters. The presence of major brain malformations was associated with younger maternal age (21.6 [IQR 19.4, 24.7] vs. 24.9 years [IQR 22.1, 28.5] [p = 0.02]), primiparity (44.1% vs. 13.3%; p = 0.05) and decreased prepregnancy BMI (20.9 kg/m2 [19, 22.5] vs. 25.5 kg/m2 [21.3, 28.2]; p < 0.01). CONCLUSION: Decreased prepregnancy BMI and inadequate GWG correlated with clinical features of ONH severity, specifically bilateral disease and presence of major brain malformations.

Consequences of COVID-19 on adolescents in Arizona: A longitudinal study protocol.

Introduction: The long-term impact of COVID-19 is unknown. We developed a 5-year prospective cohort study designed to generate actionable community-informed research about the consequences of COVID-19 on adolescents ages 12-17 years in Arizona. Methods: The study has two primary outcomes: 1) acute and long-term outcomes of COVID-19 illness and 2) symptoms of depression and anxiety. Data is collected using an online survey with plans to integrate qualitative data collection methods. The survey is administered at baseline, 4, and 8 months in year one, and annually in years two through five. This study is informed by Intersectionality Theory, which considers the diverse identities adolescents have that are self and socially defined and the influence they have collectively and simultaneously. To this end, a sample of variables collected is race/ethnicity, language usage, generational status, co-occurring health conditions, and gender. Additional measures capture experiences in social contexts such as home (parent employment, food, and housing security), school (remote learning, type of school), and society (racism). Results: Findings are not presented because the manuscript is a protocol designed to describe the procedure instead of report results. Discussion: The unique contributions of the study is its focus on COVID-19 the illness and COVID-19 the socially experienced pandemic and the impact of both on adolescents.

Elucidating symptoms of COVID-19 illness in the Arizona CoVHORT: a longitudinal cohort study.

OBJECTIVE: To elucidate the symptoms of laboratory-confirmed COVID-19 cases as compared with laboratory-confirmed negative individuals and to the untested general population among all participants who reported symptoms within a large prospective cohort study. SETTING AND DESIGN: This work was conducted within the framework of the Arizona CoVHORT, a longitudinal prospective cohort study conducted among Arizona residents. PARTICIPANTS: Eligible participants were any individual living in Arizona and were recruited from across Arizona via COVID-19 case investigations, participation in testing studies and a postcard mailing effort. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measure was a comparison of the type and frequency of symptoms between COVID-19-positive cases, tested but negative individuals and the general untested population who reported experiencing symptoms consistent with COVID-19. RESULTS: Of the 1335 laboratory-confirmed COVID-19 cases, 180 (13.5%) reported having no symptoms. Of those that did report symptoms, the most commonly reported were fatigue (82.2%), headache (74.6%), aches, pains or sore muscles (66.3%), loss of taste or smell (62.8) and cough (61.9%). In adjusted logistic regression models, COVID-19-positive participants were more likely than negative participants to experience loss of taste and smell (OR 12.1; 95% CI 9.6 to 15.2), bone or nerve pain (OR 3.0; 95% CI 2.2 to 4.1), headache (OR 2.6; 95% CI 2.2 to 3.2), nausea (OR 2.4; 95% CI 1.9 to 3.1) or diarrhoea (OR 2.1; 95% CI 1.7 to 2.6). Fatigue (82.9) and headache (74.9) had the highest sensitivities among symptoms, while loss of taste or smell (87.2) and bone or nerve pain (92.9) had the high specificities among significant symptoms associated with COVID-19. CONCLUSION: When comparing confirmed COVID-19 cases with either confirmed negative or untested participants, the pattern of symptoms that discriminates SARS-CoV-2 infection from those arising from other potential circulating pathogens may differ from general reports of symptoms among cases alone.

Direct fluorescent-antibody testing followed by culture for diagnosis of 2009 H1N1 influenza A.

During the 2009 H1N1 influenza A outbreak, 773 children were tested for influenza by direct fluorescent-antibody testing with PCR confirmation. Direct fluorescent-antibody testing has a specificity of 99.6% but a sensitivity of only 65.0%. Physicians should recognize diagnostic limitations of direct fluorescent-antibody testing, which missed one-third of infected individuals.

Utility of portable spirometry in a pediatric emergency department in children with acute exacerbation of asthma.

OBJECTIVES: The primary purpose of this study was to determine if portable spirometers can be successfully used in an emergency department (ED) in children with an acute exacerbation of asthma. The secondary purpose of this study was to determine if a validated clinical asthma score (CAS) correlates with the spirometry results in children with an acute exacerbation of asthma. METHODS: Children between the ages of 6 and 17 years who presented to an urban free-standing children's hospital ED with an acute exacerbation of asthma were enrolled in our study. On arrival, the CAS was recorded and then portable spirometry was performed. Attempts were continued until acceptable and reproducible flow loop measurements were obtained or until the patient was unable to perform further attempts. Outcomes included success at spirometry and correlation of spirometry with the CAS. RESULTS: A total of 101 patients were enrolled in this study. Of those patients, only 35 (35%) were able to successfully perform portable spirometry. Successful spirometry attempts were associated with older age (10.4 vs. 8.9, p = .01), lower respiratory rates (24.8 vs. 30.2, p = .001), lower heart rates (110 vs. 124, p = .004), and lower CASs (8.4 vs. 9.7, p = .001). Increasing asthma severity correlated with a decreased likelihood of successfully obtaining a useful forced expiratory volume in 1 second (FEV(1)) measurement (p = .013). Compared with cases of mild asthma, a patient with moderate asthma is 33% less likely to be able to perform spirometry, and a patient with severe asthma 93% less likely to perform spirometry. The CAS correlated poorly with the more objective measure of FEV(1)% predicted in those with mild asthma. CONCLUSION: Many children are incapable of using portable spirometry for the evaluation of acute exacerbations of asthma in the ED. The clinical asthma scoring system demonstrated poor correlation with portable spirometry measurements in terms of severity classification.

Child abuse education: an objective evaluation of resident and attending physician knowledge.

OBJECTIVE: The objective of the study was to evaluate residents' and practicing physicians' medical knowledge of child abuse and maltreatment. METHODS: In a freestanding pediatric hospital and community hospital, a 30-question survey was administered to pediatric residents, general pediatricians (GPs), and pediatric emergency medicine (PEM) physicians. The institution's child protection team developed the questions, which were pilot tested for validity. Question content covered major concepts in child abuse and neglect. Information on previous training of child abuse was also collected. RESULTS: There were 95 respondents, 64.2% (n = 61) were residents, 19% (n = 18) were GPs, and 16.8% (n = 16) were PEM physicians. Overall, the average score was 63.3% (SD, 13.8%). There was a statistically significant difference in the knowledge of child abuse and neglect across physician categories (P < 0.001). Pediatric emergency medicine physicians scored the highest (76.9 [SD, 9.1]) compared with GPs (66.7 [SD, 12.4]; P = 0.018) and pediatric residents (60.4 [SD, 12.9]; P < 0.001). There was no difference in the level of knowledge across residency training years (P = 0.076). CONCLUSIONS: With a mean score in our study of 63.3%, there appears to be an overall lack of knowledge in child abuse. These findings highlight the need for increased education in child maltreatment.

Bedside ultrasound in the diagnosis of pediatric clavicle fractures.

OBJECTIVE: The objective of the study was to determine the diagnostic accuracy of pediatric emergency physicians in diagnosing clavicle fractures by bedside ultrasound (US). METHODS: This was a prospective study of pediatric emergency department (ED) patients with suspected clavicle fractures conducted in a tertiary-care, freestanding pediatric hospital. A convenience sample of patients younger than 17 years underwent bedside US for detection of clavicle fracture by pediatric emergency physicians with limited US training. Ultrasound findings were compared with standard radiographs, which were considered the criterion standard. Pain scores using the validated color analog scale (0-10) were determined before and during US. Total length of stay in the ED, time to US, and time to radiograph were recorded. RESULTS: Fifty-eight patients were enrolled, of which 39 (67%) had fracture determined by radiograph. Ultrasound interpretation gave a sensitivity of 89.7% (95% confidence interval [CI], 75.8%-97.1%) and specificity of 89.5% (95% CI, 66.9%-98.7%). Positive and negative predictive values were 94.6% (95% CI, 81.8%-99.3%) and 81.0% (95% CI, 58.1%-94.5%), respectively. Positive and negative likelihood ratios were 8.33 and 0.11, respectively. Pain scores averaged 4.7 before US and 5.2 during US (P = 0.204). There was a statistically significant difference between mean time to US (76 minutes) and mean time to radiograph (107 minutes) (P < 0.001). CONCLUSIONS: Pediatric emergency physicians with minimal formal training can accurately diagnose clavicle fractures by US. In addition, US itself is not associated with an increase in pain and may reduce length of stay in the ED.