Effect of Prearrival Orders on Time to Antibiotics for Immunocompromised Oncology Patients Presenting to the Emergency Department With Fever.

OBJECTIVE: Pediatric cancer patients with fever are at risk for invasive bacterial infection. The administration of antibiotics to these patients within the first hour of evaluation is viewed as a quality of care metric with potential to improve outcome. We sought to evaluate the impact of prearrival patient orders on the timeliness of antibiotic administration for this patient population presenting to the emergency department (ED) because of fever. METHODS: A single-site pediatric ED intervention study was performed. Four hundred thirty-nine consecutively referred febrile immunocompromised pediatric oncology patients were included in the study. The intervention used structured monthly messages sent to oncology and emergency medicine providers highlighting specific roles in prehospital communication and in ED-based care emphasizing the use of standardized, prearrival order (PAO) sets. Primary outcome measures were time to antibiotic administration (TTA) and the proportions of patients receiving PAO placement and antibiotics within 60 minutes of ED arrival. Results were analyzed for the preintervention (September 2016-July 2017), intervention (August 2017-February 2018), and postintervention (March-December 2018) periods. RESULTS: Improvements occurred across the study periods in the proportion of patients with PAO placement (preintervention, 68%; intervention, 82%; postintervention, 87%; P = 0.001) as well as in the percentages of patients receiving antibiotics in less than 60 minutes (preintervention, 73%; intervention, 84%; postintervention, 85%; P = 0.02). Median TTA decreased from 48 to 40 minutes ( P = 0.018). Linear regression with TTA as a dependent variable revealed that PAO placement predicted a shorter TTA, decreasing by more than 15 minutes ( B = -15.90; [95% confidence interval, -20.03--11.78]; P < 0.001). CONCLUSIONS: Standardizing elements of prehospital communication and ED-based care using PAO sets resulted in significant improvements in time to antibiotics and in the proportion of febrile immunocompromised oncology patients receiving antibiotics within 60 minutes of ED arrival.

Electrophysiological evidence that psychopathic personality traits are associated with atypical response to salient distractors.

Event-related potentials (ERPs) were used to assess the neural mechanisms underlying visual-spatial attention abnormalities associated with psychopathic personality traits. Sixty-nine undergraduates (56 women, 13 men) completed the Psychopathic Personality Inventory-Revised (PPI-R; Lilienfeld & Widows, 2005) and performed two cognitive tasks in which search displays containing a lateralized singleton encircled a fixation point that changed luminance from trial-to-trial. When searching for the singleton as a target, PPI-R scores were uncorrelated with ERP measures of its salience (Ppc), goal-directed selection (N2pc), and working memory evaluation (negative amplitude CDA). In contrast, when responding to the changes in luminance at fixation and ignoring the lateral singleton as a salient distractor, PPI-R Self-Centered Impulsivity factor scores were positively correlated with a potential indicator of distractor suppression (a sustained positive amplitude CDA). These findings provide support for a neurophysiological interpretation of the changes in visual-spatial attention associated with psychopathic personality traits: normal selection of target information accompanied by greater elimination of distractor information at a later visual working memory stage.

Parasagittal vertex clots on head CT in infants with subdural hemorrhage as a predictor for abusive head trauma.

BACKGROUND: Abusive head trauma (AHT) is the most common cause of subdural hemorrhage (SDH) in infants younger than 12 months old. Clot formation in the parasagittal vertex seen on imaging has been associated with SDH due to AHT. There have been very few studies regarding these findings; to our knowledge, no studies including controls have been performed. OBJECTIVE: To describe parasagittal vertex clots on head computed tomography (CT) in infants with SDH and AHT compared to patients with SDH and accidental trauma, and to evaluate for parasagittal vertex clots in the absence of SDH in the setting of known accidental head trauma. MATERIALS AND METHODS: All infants younger than 12 months old with SDH present on CT scan were retrospectively identified from 2004 to 2014. Blinded, independent review of all CT scans for clot formation at the parasagittal vertex was performed by a pediatric neuroradiologist. RESULTS: Ninety-nine patients were eligible for analysis. Mean age was 4 months. Fifty-seven (57.6%) were male. Fifty-five (55.6%) patients were identified as having AHT and 22 (22.2%) had accidental trauma. Forty-five (81.2%) patients with AHT had parasagittal vertex clots present on CT scan compared to 8 (36.4%) patients with accidental trauma. Compared to patients without parasagittal vertex clots, those with parasagittal vertex clots were more likely to have AHT (66.2% vs. 32.3%, P=0.001), no known mechanism of injury (69.1% vs. 32.3%, P=0.015), retinal hemorrhage (75% vs. 35.5%, P=0.002) and hypoxic-ischemic changes (25% vs. 0%, P=0.002). Patients with parasagittal vertex clots have eight times the odds of AHT compared to patients without parasagittal vertex clots. Age-matched control patients who underwent head CT scan due to a history of accidental head injury without SDH were identified (n=87); no patient in the control group had parasagittal vertex clots. CONCLUSION: The finding of parasagittal vertex clots on CT scans should raise suspicion for abuse and prompt further investigation, especially in the setting of no known, uncertain or inconsistent mechanism of injury.

Spontaneous pneumorrhachis.

Pneumomediastinum is a relatively uncommon occurrence in pediatric patients. After mediastinal air leak, air may dissect through a variety of tissue planes within the chest, neck, and abdomen. We report the case of a 16-year-old adolescent boy who presented with spontaneous pneumomediastinum accompanied by the presence of air within the spinal canal. We suggest use of the term "spontaneous pneumorrhachis" to distinguish this type of presentation from other potential causes.

Pediatric Lyme Disease Presenting as a Ruptured Popliteal Cyst: A Report of 3 Cases.

CASES: This case report describes 3 pediatric patients presenting with acute calf or knee pain, calf swelling, and a ruptured popliteal cyst diagnosed by magnetic resonance imaging. Lyme disease was serologically confirmed in each case. In all instances, treatment was delayed because of atypical presentation. All patients responded favorably after antibiotic therapy. CONCLUSION: The differential diagnosis of Lyme disease should be considered in the context of children presenting with atraumatic unilateral calf pain and a ruptured popliteal cyst. Otherwise, this unusual presentation could delay diagnosis or result in unnecessary surgical intervention, particularly in pediatric patients.

The role of selective attention in the positivity offset: Evidence from event related potentials.

Some research suggests that positive and negative valence stimuli may be processed differently. For example, negative material may capture and hold attention more readily than equally arousing positive material. This is called the negativity bias, and it has been observed as both behavioural and electroencephalographic (EEG) effects. Consequently, it has been attributed to both automatic and elaborative processes. However, at the lowest levels of arousal, faster reaction times and stronger EEG responses to positive material have been observed. This is called the positivity offset, and the underlying cognitive mechanism is less understood. To study the role of selective attention in the positivity offset, participants completed a negative affective priming (NAP) task modified to dissociate priming for positive and negative words. The task required participants to indicate the valence of a target word, while simultaneously ignoring a distractor. In experiment 1, a behavioural facilitation effect (faster response time) was observed for positive words, in stark contrast to the original NAP task. These results were congruent with a previously reported general categorization advantage for positive material. In experiment 2, participants performed the task while EEG was recorded. In additional to replicating the behavioural results from experiment 1, positive words elicited a larger Late Positive Potential (LPP) component on ignored repetition relative to control trials. Surprisingly, negative words elicited a larger LPP than positive words on control trials. These results suggest that the positivity offset may reflect a greater sensitivity to priming effects due to a more flexible attentional set.

Opportunities for Interaction : Natural Observations of Children's Social Behavior in Five Societies.

We examine the opportunities children have for interacting with others and the extent to which they are the focus of others' visual attention in five societies where extended family communities are the norm. We compiled six video-recorded datasets (two from one society) collected by a team of anthropologists and psychologists conducting long-term research in each society. The six datasets include video observations of children among the Yasawas (Fiji), Tanna (Vanuatu), Tsimane (Bolivia), Huatasani (Peru), and Aka (infants and children 4-12 years old; Central African Republic). Each dataset consists of a series of videos of children ranging in age from 2 months to 12 years in their everyday contexts. We coded 998 videos and identified with whom children had opportunities to interact (male and female adults and children) as well as the number of individuals and the proportion of observed time that children spent with these individuals. We also examined the proportion of time children received direct visual gaze (indicating attention to the child). Our results indicate that children less than 5 years old spend the majority of their observed time in the presence of one female adult. This is the case across the five societies. In the three societies from which we have older children (Aka, Yasawa, Peru), we find a clear shift around 5 years of age, with children spending the majority of their time with other children. We also coded the presence or absence of a primary caregiver and found that caregivers remained within 2 ft of target children until 7 years of age. When they were in the company of a primary caregiver, children older than seven spent the majority of their time more than 2 ft from the caregiver. We found a consistent trend across societies with decreasing focal attention on the child with increasing child age. These findings show (1) remarkable consistency across these societies in children's interaction opportunities and (2) that a developmental approach is needed to fully understand human development because the social context is dynamic across the lifespan. These data can serve as a springboard for future research examining social development in everyday contexts.

Impact of changes in infant death classification on the diagnosis of sudden infant death syndrome.

This study evaluates the hypothesis that a decline in sudden infant death syndrome in Minnesota is associated with increases in other categories of sudden unexpected infant death. Matched birth and death certificates, autopsy reports, and home visit questionnaires were reviewed for 722 sudden unexpected infant deaths that occurred from January 1, 1996 through December 31, 2002. Descriptive data and cause of death were recorded. Cause of death was compared for 2 periods: early (1996-1998) and late (2000-2002). The age of the infant at death, sex, race, and infant death rates were similar between the 2 periods ( P = .637). Sudden infant death syndrome declined by 50.1% (P < .001). Overlay deaths increased 235.5% (P < .01). Asphyxia related deaths increased 259.6% (P < .001). Injury-related deaths increased 840.0% (P < .001). A decline in sudden infant death syndrome in Minnesota was associated with increased deaths in categories that are asphyxial in nature and are potentially preventable.

Spatiotemporal dynamics of reward and punishment effects induced by associative learning.

While reward associative learning has been studied extensively across different species, punishment avoidance learning has received far less attention. Of particular interest is how the two types of learning change perceptual processing of the learned stimuli. We designed a task that required participants to learn the association of emotionally neutral images with reward, punishment, and no incentive value outcomes through trial-and-error. During learning, participants received monetary reward, neutral outcomes or avoided punishment by correctly identifying corresponding images. Results showed an early bias in favor of learning reward associations, in the form of higher accuracy and fewer trials needed to reach learning criterion. We subsequently assessed electrophysiological learning effects with a task in which participants viewed the stimuli with no feedback or reinforcement. Critically, we found modulation of two early event-related potential components for reward images: the frontocentral P2 (170-230 ms) and the anterior N2/Early Anterior Positivity (N2/EAP; 210-310 ms). We suggest that reward associations may change stimuli detection and incentive salience as indexed by P2 and N2/EAP. We also reported, on an exploratory basis, a late negativity with frontopolar distribution enhanced by punishment images.

Electrophysiological evidence of early attentional bias to drug-related pictures in chronic cannabis users.

Behavioral and electrophysiological correlates of attentional bias to cannabis-related cues were investigated in a marijuana dependent group and a non-user group employing a drug Stroop task in which cannabis-related, negative and neutral images were presented. Behaviorally, cannabis users were less accurate during drug-containing blocks than non-users. Electrophysiologically, in chronic marijuana-users, an early positive ERP enhancement over left frontal scalp (EAP, 200-350ms) was present in response to drug-containing blocks relative to negative blocks. This effect was absent in the non-user group. Furthermore, drug-containing blocks gave rise to enhanced voltage of a posterior P300 (300-400ms), and a posterior sustained slow wave (LPP, 400-700ms) relative to negative blocks. However, such effects were similar between cannabis users and non-users. Brain source imaging in cannabis users revealed a generator for the EAP effect to drug stimuli in left ventromedial prefrontal cortex/medial orbitofrontal cortex, a region active in fMRI studies of drug cue-reactivity and a target of the core dopaminergic mesolimbic pathway involved in the processing of substances of abuse. This study identifies the timing and brain localization of an ERP correlate of early attentional capture to drug-related pictures in chronic marijuana users. The EAP to drug cues may identify a new electrophysiological marker with clinical implications for predicting abstinence versus relapse or to evaluate treatment interventions.

Electrophysiology of blunted emotional bias in psychopathic personality.

Diminished emotional capacity is a core characteristic of psychopathic personality. We examined behavioral and electrophysiological differences in attentional bias to emotional material in 34 healthy individuals rated high or low in psychopathic traits using the short form of the Psychopathic Personality Inventory-Revised (18 high-trait, 16 low-trait). While performing an emotional Stroop task, high-trait participants displayed reduced emotional modulation of the late positive potential (LPP, 400-600 ms), and early anterior positivity (EAP, 200-300 ms) amplitudes. Results suggest blunted bias to affective content in psychopathic personality, characterized by diminished early capture to emotional salience (EAP) and dampened cognitive emotional processing (LPP).