Scalp Staples Placed in a Pediatric Emergency Department: Feasibility and Benefits of Home Removal.

OBJECTIVES: Scalp lacerations are a common occurrence in the pediatric population. A preferred method of closure in a busy pediatric emergency department (PED) is skin staples, because of their ease of use and rapid application. However, using skin staples also demands that the child have a follow-up visit for their removal. This study examines whether caregivers can be taught how to safely remove their child's skin staples at home, obviating the need for a return clinic visit and its associated costs. METHODS: This is a prospective, convenience study of 30 children older than 4 years presenting with a scalp laceration that the attending physician chose to close with skin staples. Caregivers of enrolled children completed an initial survey and received training in skin staple removal in the PED. Upon discharge, caregivers were given the staple removal device and specific instructions indicating the date for staple removal and how to access an online video reviewing proper staple removal technique. Caregivers were contacted after anticipated staple removal for completion of a follow-up survey. We recorded caregiver success rate at staple removal and measured potential benefits with regard to lost wages, transportation costs, and missed school time. Data were analyzed using descriptive statistics. RESULTS: Twenty-eight (93%) of 30 enrolled caregivers were successful in completely removing their child's staples; one caregiver did not attempt removal and another was lost to follow-up. Twenty-five caregivers (83%) completed follow-up surveys. All caregivers reported that if given a future choice, they would prefer to remove their child's staples at home rather than return to a clinic and all said that they would be "very comfortable" if they needed to remove staples again in the future. Sixty-four percent of caregivers estimated that it would have taken greater than 2 hours to attend a clinic for staple removal. Thirty-two percent of caregivers would have lost greater than US $100 in wages. Eighty-eight percent of children would have missed school time, with 46% having to miss an entire school day. CONCLUSIONS: Caregivers who were taught how to remove their child's scalp staples in the PED before discharge were highly successful at home. Ninety-three percent of enrolled patients had their staples completely removed and no complications were reported. Benefits included avoiding lost wages, lost time attending a follow-up clinic, and lost time from school. Staple removal is a simple technique that can easily be taught to caregivers in a matter of minutes and lead to greater patient and parent satisfaction.

Characterizing Individual Differences in a Dynamic Stabilization Task Using Machine Learning.

INTRODUCTION: Being able to identify individual differences in skilled motor learning during disorienting conditions is important for spaceflight, military aviation, and rehabilitation.METHODS: Blindfolded subjects (N = 34) were strapped into a device that behaved like an inverted pendulum in the horizontal roll plane and were instructed to use a joystick to stabilize themselves across two experimental sessions on consecutive days. Subjects could not use gravitational cues to determine their angular position and many soon became spatially disoriented.RESULTS: Most demonstrated minimal learning, poor performance, and a characteristic pattern of positional drifting during horizontal roll plane balancing. To understand the wide range of individual differences observed, we used a Bayesian Gaussian Mixture method to cluster subjects into three statistically distinct groups that represent Proficient, Somewhat Proficient, and Not Proficient performance. We found that subjects in the Not Proficient group exhibited a suboptimal strategy of using very stereotyped large magnitude joystick deflections. We also used a Gaussian Naive Bayes method to create predictive classifiers. As early as the second block of experimentation (out of ten), we could predict a subject's final group with 80% accuracy.DISCUSSION: Our findings indicate that machine learning can help predict individual performance and learning in a disorienting dynamic stabilization task and identify suboptimal strategies in Not Proficient subjects, which could lead to personalized and more effective training programs.Vimal VP, Zheng H, Hong P, Fakharzadeh LN, Lackner JR, DiZio P. Characterizing individual differences in a dynamic stabilization task using machine learning. Aerosp Med Hum Perform. 2020; 91(6):479-488.

Recipients with blood group A associated with longer survival rates in cardiac valvular bioprostheses.

BACKGROUND: Pigs/bovines share with humans some of the antigens present on cardiac valves. Two such antigens are: the major xenogenic Ag, "Gal" present in all pig/bovine very close to human B-antigen of ABO-blood-group system; the minor Ag, pig histo-blood-group AH-antigen identical to human AH-antigen and present by some animals. We hypothesize that these antigens may modify the immunogenicity of the bioprosthesis and also its longevity. ABO distribution may vary between patients with low (<6 years) and high (≥15 years) bioprostheses longevity. METHODS: Single-centre registry study (Paris, France) including all degenerative porcine bioprostheses (mostly Carpentier-Edwards 2nd/3rd generation heart valves) explanted between 1985 and 1998 and some bovine bioprostheses. For period 1998-2014, all porcine bioprostheses with longevity ≥13 years (follow-up ≥29 years). Important predictive factors for bioprosthesis longevity: number, site of implantation, age were collected. Blood group and other variables were entered into an ordinal logistic regression analysis model predicting valve longevity, categorized as low (<6 years), medium (6-14.9 years), and high (≥15 years). FINDINGS: Longevity and ABO-blood group were obtained for 483 explanted porcine bioprostheses. Mean longevity was 10.2 ±â€¯3.9 years [0-28] and significantly higher for A-patients than others (P = 0.009). Using multivariate analysis, group A was a strong predictive factor of longevity (OR 2.09; P < 0.001). For the 64 explanted bovine bioprosthesis with low/medium longevity, the association, with A-group was even more significant. INTERPRETATION: Patients of A-group but not B have a higher longevity of their bioprostheses. Future graft-host phenotyping and matching may give rise to a new generation of long-lasting bioprosthesis for implantation in humans, especially for the younger population. FUND: None.

Method for Studies of Orientation and Exploratory Behavior in Humans. Effects of Emotional Stress.

We developed a new experimental model for studies of orientation and exploratory behavior in humans. This method allows analysis of variants of orientation and exploratory behavior in humans, including risky behavior, and cognitive and individual typological parameters. The model allows distinguishing examinees with high and low orientation and exploratory activity, which helps to determine their psychoemotional status. Surprisingly, individuals in emotional strain demonstrated longer orientation and exploratory behavior. This allows them to achieve the results more rapidly during purposeful behavior under similar conditions. This model provides the tool for evaluation of the electrophysiological, autonomic, and biochemical mechanisms of orientation and exploratory behavior of humans.

Protecting the most vulnerable: litigation from pediatric otolaryngologic procedures and conditions.

OBJECTIVES/HYPOTHESIS: To identify allegations raised in litigation stemming from pediatric otolaryngologic procedures and conditions. STUDY DESIGN: Retrospective analysis of a legal database. METHODS: The authors reviewed jury verdict and settlement reports on the WestlawNext database from 1994 to 2013 for cases involving pediatric plaintiffs and alleged negligence in otolaryngologic procedures and conditions. RESULTS: Of the 78 cases included, 52.6% were resolved with a payment; aggregate payments exceeded $69 million, and median jury-awarded damages and settlements were $874,190 and $250,000, respectively. Adenotonsillectomy was the most commonly litigated procedure. Otolaryngologists were defendants in 42 (53.8%) cases, with pediatricians and anesthesiologists the next most commonly named defendants. Forty-six (59.0%) cases involved alleged negligence in operative management, whereas other factors included permanent injury (44.9%), misdiagnosis/failure to diagnose in a timely manner (41.0%), death (35.9%), and requiring additional surgery. Airway-related complications and allegedly permanent injuries significantly increased the size of payments. Awards were highest in cases with plaintiffs at 1 to 5-years of age and lowest among children older than 10 years of age. CONCLUSIONS: Unique considerations specific to pediatric patients are involved in malpractice litigation, and damages awarded were considerable. By including the specific factors listed in this analysis in a comprehensive informed consent process, and recognizing concerns specific to this patient population, practitioners in multiple specialties may potentially reduce liability. Clear communication with parents is a critical component of this process.

A fully immunized child with a cochlear implant and Streptococcus pneumoniae meningitis 3 years after implantation.

Cochlear implants have been associated with increased risks of bacterial meningitis in children, notably but not limited to implants with a sialastic accessory piece called a positioner. Because of the associated risks, these devices were ultimately recalled by the Food and Drug Administration in 2002. We present a case of a fully immunized 4-year-old child with a cochlear implant without a positioner who developed Streptococcus pneumoniae meningitis 3 years after implantation. The case highlights the increased risk for bacterial meningitis in the presence of cochlear implants regardless of device type, immunization status, or time after implantation especially in the context of middle- and inner-ear structural anomalies.

Soluble HLA-G protein secreted by allo-specific CD4+ T cells suppresses the allo-proliferative response: a CD4+ T cell regulatory mechanism.

We recently reported that the nonclassical HLA class I molecule HLA-G was expressed in the endomyocardial biopsies and sera of 16% of heart transplant patients studied. The aim of the present report is to identify cells that may be responsible for HLA-G protein expression during the allogeneic reaction. Carrying out mixed lymphocyte cultures in which the responder cell population was depleted either in CD4(+) or CD8(+) T cells, we found that soluble HLA-G5 protein but not the membrane-bound HLA-G isoform was secreted by allo-specific CD4(+) T cells from the responder population, which suppressed the allogeneic proliferative T cell response. This inhibition may be reversed by adding the anti-HLA-G 87G antibody to a mixed lymphocyte culture. That may indicate a previously uncharacterized regulatory mechanism of CD4(+) T cell proliferative response.

Implication of HLA-G molecule in heart-graft acceptance.

HLA-G found in five of 31 heart-transplant recipients was associated with a decrease of acute and chronic rejection episodes.