Decision-Making in the Pediatric Emergency Department-A Survey of Guidance Strategies among Residents.

(1) Introduction: Working in an emergency department requires fast and straightforward decisions. Therefore, decision guidance represents an essential tool for successful patient-centered care. Beyond the residents' own knowledge and experience, printed books have been the primary source of information in the past. The aim of this study was to discover which strategies current residents use the most and to identify alternative quick reference strategies in the digital age. (2) Materials and Methods: This study analyzed the responses of a short questionnaire directed at 41 residents in a single pediatric emergency department (32 pediatric and 9 pediatric surgery residents) over a period of one month. (3) Results: Thirty-three (80.5%) residents answered the entire questionnaire. Strikingly, responses indicated that printed books are still pivotal in guiding decision-making. In addition, the acquisition of information via computers or smartphones plays an increasing role. However, the opinion and council of the attending physician is still of great value to the residents and is not to be underestimated. Overall, most of the residents would prefer to have access to a specially designed smartphone application. (4) Conclusions: Certainty and validity are essential in decision-making in a pediatric emergency department. Although printed books and attending physicians are still considered as reliable sources of information, internet-based information plays an increasing role. In order to provide the best up-to-date and most recent information, a validated and consistently updated smartphone application could be a useful option.

Association of intraindividual tacrolimus variability with de novo donor-specific HLA antibody development and allograft rejection in pediatric kidney transplant recipients with low immunological risk.

BACKGROUND: Tacrolimus (Tac) intraindividual variability (TacIPV) in pediatric kidney transplant patients is only poorly understood. We investigated the impact of TacIPV on de novo donor-specific HLA antibodies (dnDSA) development and allograft rejection in Caucasian pediatric recipients of a living or deceased donor kidney with low immunological risk. METHODS: This was a single-center retrospective study including 48 pediatric kidney transplant recipients. TacIPV was calculated based on coefficient of variation (CV%) 6-12 months posttransplant. TacIPV cutoff was set at the median (25%). Outcome parameters were dnDSA development and rejection episodes. RESULTS: In total, 566 Tac levels were measured with median 11.0 (6.0-17.0) measurements per patient. The cutoff of 25% corresponded to the median CV% in our study cohort (25%, IQR 18-35%) and was comparable to cutoffs determined by receiver operating characteristic (ROC) curve analysis. High TacIPV was associated with higher risk of dnDSA development (HR 3.4, 95% CI 1.0-11.1, P = 0.047; Kaplan-Meier analysis P = 0.018) and any kind of rejection episodes (HR 4.1, 95% CI 1.1-14.8, P = 0.033; Kaplan-Meier analysis P = 0.010). There was a clear trend towards higher TacIPV below the age of 6 years. TacIPV (CV%) was stable over time. A TacIPV (CV%) cutoff of 30% or IPV quantification by mean absolute deviation (MAD) showed comparable results. CONCLUSIONS: High TacIPV is associated with an increased risk of dnDSA development and rejection episodes > year 1 posttransplant even in patients with low immunological risk profile. Therefore, in patients with high TacIPV, potential causes should be addressed, and if not resolved, changes in immunosuppressive therapy should be considered. A higher resolution version of the Graphical abstract is available as Supplementary information.

Overview of digital health teaching courses in medical education in Germany in 2020.

Objective: The digitalization of the healthcare system poses new challenges for physicians. Thus, the relevance of learning digital competencies (DiCo), such as dealing with data sets, apply telemedicine or using apps, is already growing in medical education. DiCo should be clearly separated from digitized teaching formats, which have been increasingly used since the COVID 19 pandemic. This article outlines the faculties in Germany where DiCo are already integrated into medical education. Methods: Courses with DiCo as teaching content were collected by a literature research on Pubmed and Google as well as by contacting all dean's offices and other persons responsible for teaching at German medical faculties. The courses were summarized in a table. Results: In a first survey, 16 universities were identified that offer courses on DiCo. In the elective area at the universities, 17 courses and in the compulsory area eight courses could be identified. The scope and content of the courses diverged between compulsory curricula, integrated courses of different lengths, and elective courses that are one-time or longitudinally integrated. The topics taught are heterogeneous and include fundamentals of medical informatics such as data management on the one hand and a collection of e.g. ethics, law, apps, artificial intelligence, telemedicine and robotics on the other hand. Conclusion: Currently, only some German medical faculties offer courses on DiCo. These courses vary in scope and design. They are frequently part of the elective curriculum and only reach some of the students. The possibility of embedding DiCo in the already existing cross-sectional area appears limited. In view of the ongoing digitalization of healthcare, it is necessary to make future courses on DiCo accessible to all medical students. In order to drive this expansion forward, the implementation of the new learning objectives catalogue, in which DiCo are integrated, a network formation, a teaching qualification as well as the involvement of students is recommended.

Being earthbound: Arendt, process and alienation in the Anthropocene.

Hannah Arendt developed a twofold account of 'being earthbound' directly relevant to Anthropocene debates regarding the political. For Arendt, both senses of 'being earthbound' arose as humans began to act into nature, not merely upon it. The first sense is oriented to a political ontology of process, which arose as human actions - political, technological, scientific - nullified modernist conceits separating humans from nature. The second sense is one of earth alienation, which is referenced specifically to a scientific praxis coincident with advances in science and technology that alienates common sense experiences in politics. Though not unqualified, these two senses of being earthbound anchor our argument that Arendt offered prescient resources for understanding the political in the Anthropocene at the intersection of science, capital and world. The article ends by contrasting Arendt's account of being earthbound with Bruno Latour's recent interventions on the politics of Gaia.

The role of disgust in body image disturbance: Incremental predictive power of self-disgust.

The relationship between disgust and symptoms of disorders characterized by body image disturbance (BID) is increasingly being examined. In cognitive-behavioral models of psychopathology, disgust may function as a negative emotional response to perceived body defects, leading to avoidance and compulsive behavior. Little research has examined the role of self-disgust - a form of disgust that may be particularly relevant to the body. The present study is a descriptive analysis of the association between BID and self-disgust, controlling for other related variables. Two non-clinical samples completed measures of BID, self-disgust, negative affect, anxiety sensitivity, disgust propensity, and disgust sensitivity. Although BID was associated with all three forms of disgust at the bivariate level, in multivariate analyses self-disgust emerged as a unique predictor of BID, above and beyond all included variables, although effect sizes were small. Potential implications for understanding, preventing, and treating body image-related disorders are discussed.

Social learning in the Anthropocene: Novel challenges, shadow networks, and ethical practices.

The Anthropocene presents novel challenges for environmental management. This paper considers the challenges that the Anthropocene poses for social learning techniques in adaptive management. It situates these challenges with respect to how anthropogenic forcing on the Earth system affects the conditions required for: (1) The cooperative exercises of social learning; (2) The techniques used for assessing the fit of institutions to social-ecological systems; and, (3) The strategies employed for identifying management targets that are transformed by human action. In view of these challenges, the paper then examines how the practices of shadow networks may provide paths for incorporating a broader, more robust suite of social learning practices in the Anthropocene. The paper emphasizes how novel challenges in the Anthropocene demand increased attention to ethical practices, particularly those that establish center-periphery relationships between social learning communities and shadow networks.

Hydrogen peroxide stabilization in one-dimensional flow columns.

Rapid hydrogen peroxide decomposition is the primary limitation of catalyzed H(2)O(2) propagations in situ chemical oxidation (CHP ISCO) remediation of the subsurface. Two stabilizers of hydrogen peroxide, citrate and phytate, were investigated for their effectiveness in one-dimensional columns of iron oxide-coated and manganese oxide-coated sand. Hydrogen peroxide (5%) with and without 25 mM citrate or phytate was applied to the columns and samples were collected at 8 ports spaced 13 cm apart. Citrate was not an effective stabilizer for hydrogen peroxide in iron-coated sand; however, phytate was highly effective, increasing hydrogen peroxide residuals two orders of magnitude over unstabilized hydrogen peroxide. Both citrate and phytate were effective stabilizers for manganese-coated sand, increasing hydrogen peroxide residuals by four-fold over unstabilized hydrogen peroxide. Phytate and citrate did not degrade and were not retarded in the sand columns; furthermore, the addition of the stabilizers increased column flow rates relative to unstabilized columns. These results demonstrate that citrate and phytate are effective stabilizers of hydrogen peroxide under the dynamic conditions of one-dimensional columns, and suggest that citrate and phytate can be added to hydrogen peroxide before injection to the subsurface as an effective means for increasing the radius of influence of CHP ISCO.

Enhanced stability of hydrogen peroxide in the presence of subsurface solids.

The stabilization of hydrogen peroxide was investigated as a basis for enhancing its downgradient transport and contact with contaminants during catalyzed H(2)O(2) propagations (CHP) in situ chemical oxidation (ISCO). Stabilization of hydrogen peroxide was investigated in slurries containing four characterized subsurface solids using phytate, citrate, and malonate as stabilizing agents after screening ten potential stabilizers. The extent of hydrogen peroxide stabilization and the most effective stabilizer were solid-specific; however, phytate was usually the most effective stabilizer, increasing the hydrogen peroxide half-life to as much as 50 times. The degree of stabilization was nearly as effective at 10 mM concentrations as at 250 mM or 1 M concentrations. The effect of stabilization on relative rates of hydroxyl radical activity varied between the subsurface solids, but citrate and malonate generally had a greater positive effect than phytate. The effect of phytate, citrate, and malonate on the relative rates of superoxide generation was minimal to somewhat negative, depending on the solid. The results of this research demonstrate that the stabilizers phytate, citrate, and malonate can significantly increase the half-life of hydrogen peroxide in the presence of subsurface solids during CHP reactions while maintaining a significant portion of the reactive oxygen species activity. Use of these stabilizers in the field will likely improve the delivery of hydrogen peroxide and downgradient treatment during CHP ISCO.