Risk Factors and Management Outcomes in Pediatric Epistaxis at an Emergency Department.

BACKGROUND: Most cases of pediatric epistaxis are spontaneous and self-resolve. However, a subset of children may experience significant bleeding and require procedural or medical intervention. OBJECTIVE: We aim to identify risk factors associated with moderate and severe epistaxis in the emergency department (ED) and explore management outcomes. METHODS: We retrospectively reviewed all patients under 22 years old with epistaxis who presented to our ED between 2013 and 2022. Epistaxis severity was defined as mild (required nasal compression or intranasal medications), moderate (required cautery or packing), or severe (required factor replacement, transfusion, hospital admission, or surgery). We performed univariable and multinomial regression analyses, with risk factors and outcomes analyzed according to severity. RESULTS: Of 858 visits, 41 (5%) patients had moderate and 67 (8%) had severe epistaxis. Patients with moderate epistaxis were older than those with mild and severe epistaxis (median 15.6 vs. 8.3 vs. 10.7 years, p < 0.001). In regression analysis, moderate epistaxis was associated with older age, prior ED visit within 72 h, and antiplatelet medication use (p < 0.01). Severe epistaxis was associated with bleeding disorders, nasal procedures within 30 days, and anticoagulation medication use (p ≤ 0.001). Bleeding over 30 min prior to arrival was associated with both moderate and severe epistaxis (p < 0.05). Of the 67 patients with severe epistaxis, 10 (15%) required factor replacement, 28 (42%) required transfusion, 52 (77%) required hospital admission, and 5 (7%) underwent surgery. CONCLUSION: Epistaxis severity is associated with certain risk factors. However, most cases of pediatric epistaxis are mild and do not require intervention or ED evaluation.

Social research to understand farmer and agricultural stakeholder attitudes towards bovine tuberculosis vaccination of cattle.

BACKGROUND: This social research study employed a behavioural insights framework, Easy, Attractive, Social, Timely ('EAST'), to identify cues that may influence farmer and stakeholder attitudes towards the deployment of CattleBCG vaccine. METHODS: The EAST framework was employed to develop policy scenarios consisting of several cues likely to affect vaccine uptake. These scenarios consisted of a government-led approach, an individual farmer-led approach, and a third approach, also farmer-led but organised collectively. The government approach was mandatory, while the farmer-led approaches were both voluntary. The scenarios were tested during farmer participatory workshops (n = 8) and stakeholder interviews (n = 35). RESULTS: Overall, the EAST framework provided a useful approach for gathering behavioural insights around attitudes towards cattle vaccination. We found an overall receptiveness towards the idea of vaccinating cattle against bovine tuberculosis, particularly where clear, transparent messaging around the likely efficacy is mobilised, where clarity around potential implications for trading is provided, and where vaccine doses are provided free of charge and administered by veterinarians and veterinary technicians. In general, these factors were a pre-requisite to a mandatory (government-led) national approach, which was the preferred deployment mechanism among farmers and stakeholders. However, these conditions would also likely facilitate a voluntary vaccination programme. LIMITATIONS: Trust in those involved in delivering a vaccine programme and trust in the vaccine itself represent a crucial aspect of farmer and stakeholder attitudes towards cattle vaccination; however, this aspect was not covered by the EAST framework. CONCLUSION: EAST provided a novel framework for examining attitudes towards cattle vaccination with CattleBCG, although we recommend incorporating a 'trust' component in future iterations.

Emergency Medicine Virtual Conference Participants' Engagement with Competing Activities.

INTRODUCTION: Residency didactic conferences transitioned to a virtual format during the COVID-19 pandemic. This format creates questions about effective educational practices, which depend on learner engagement. In this study we sought to characterize the competitive demands for learner attention during virtual didactics and to pilot methodology for future studies. METHODS: This was a prospective, observational, cohort study of attendees at virtual didactics from a single emergency medicine residency, which employed a self-report strategy informed by validated classroom assessments of student engagement. We deployed an online, two-question survey polling across six conference days using random signaled sampling. Participants reported all activities during the preceding five minutes. RESULTS: There were 1303 responses over 40 survey deployments across six nonadjacent days. Respondents were residents (63.4%); faculty (27.5%); fellows (2.3%); students (2%); and others (4.8%). Across all responses, about 85% indicated engagement in the virtual conference within the last five minutes of the polls. The average number of activities engaged in was 2.0 (standard deviation = 1.1). Additional activities included education-related (34.2%), work-related (21.1%), social (18.8%), personal (14.6%), self-care (13.4%), and entertainment (4.4%). CONCLUSION: Learners engage in a variety of activities during virtual didactics. Engagement appears to fluctuate temporally, which may inform teaching strategies. This information may also provide unique instructor feedback. This pilot study demonstrates methodology for future studies of conference engagement and learning outcomes.

Is TCC-EZ a Suitable Alternative to Gold Standard Total-Contact Casting?

BACKGROUND: The total-contact cast (TCC) is the gold standard for off-loading diabetic foot ulcers (DFUs) given its nonremovable nature. However, this modality remains underused in clinical settings due to the time and experience required for appropriate application. The TCC-EZ is an alternative off-loading modality marketed as being nonremovable and having faster and easier application. This study aims to investigate the potential of the TCC-EZ to reduce foot plantar pressures. METHODS: Twelve healthy participants (six males, six females) were fitted with a removable cast walker, TCC, TCC-EZ, and TCC-EZ with accompanying brace removed. These off-loading modalities were tested against a control. Pedar-X technology measured peak plantar pressures in each condition. Statistical analysis of four regions of the foot (rearfoot, midfoot, forefoot, and hallux) was conducted with Friedman and Wilcoxon signed rank tests. Significance was set at P < .05. RESULTS: All of the off-loading conditions significantly reduced pressure compared with the control, except the TCC-EZ without the brace in the hallux region. There was no statistically significant difference between TCC-EZ and TCC peak pressure in any foot region. The TCC-EZ without the brace obtained significantly higher peak pressures than with the brace. The removable cast walker produced similar peak pressure reduction in the midfoot and forefoot but significantly higher peak pressures in the rearfoot and hallux. CONCLUSIONS: The TCC-EZ is a viable alternative to the TCC. However, removal of the TCC-EZ brace results in minimal plantar pressure reduction, which might limit clinical applications of the TCC-EZ.

Access Denied: The Proliferation of American Medical Abortion Laws, 2000-2018.

INTRODUCTION: Medical abortion is a safe, effective, and often preferred method of terminating an unintended pregnancy, but access can be made difficult by the laws of a state. Despite modern efforts to prevent unintended pregnancies in the U.S., they comprise almost half of pregnancies and 95% of abortions, signifying that abortion is a necessary and desired healthcare service. This study's purpose is to describe the proliferation of American medical abortion access laws between 2000 and 2018. METHODS: Policy surveillance methods were used in 2018 to collect 7 types of U.S. medical abortion access restriction laws in place as of December 1, 2018. Statutory histories were reviewed in 2019 to record the laws' years of enactment, substantive amendment, and repeal. RESULTS: A total of 35 states restricted medical abortion access as of 2018. Medical abortion laws increased from 16 in 2000 to 96 by 2018, and only 1 was repealed. A total of 25 states had multiple laws restricting medical abortion access in 2018. Medical abortion access laws surged from 2010 to 2017, but none were passed in 2018. Medical abortion access is generally most restricted in Midwestern and Southern states and least restricted in Western and Northeastern states. CONCLUSIONS: Although evidence demonstrates medical abortion's safety and efficacy, its access is increasingly limited by law in many states. Further research examining the impacts of these laws on women's health and the consequences of unintended births on women, children, families, and society is needed.

Tongue protrusion as the presenting symptom of parapharyngeal abscess.

Deep neck space infections are commonly seen in the pediatric population. The diagnosis, however, can be challenging to make and requires a high degree of suspicion because of developmental and age-related factors in children and non-specific presenting symptoms. Diagnosis becomes further complicated in patients whose comorbid conditions mask some of the more severe systemic symptoms. We present a case of a 2-year-old female with Trisomy 21 who presented with a chief concern of "tongue swelling" per parents. After initially failing treatment for presumed angioedema caused by an angiotensin-converting enzyme inhibitor, she was ultimately diagnosed with a parapharyngeal abscess with extension and mass effect causing tongue protrusion. This case represents a novel early presentation of a common infection and highlights the challenges of diagnosing deep neck space infections in children.

Mouth Care in Assisted Living: Potential Areas for Improvement.

BACKGROUND: Poor oral care may lead to systemic disease, and there is evidence that assisted living (AL) residents lack quality oral care; in AL, poor care may be due to staff knowledge and attitudes, as well as organizational barriers to providing care. OBJECTIVES: Determine AL staff knowledge and attitudes regarding mouth care and barriers to changing care. DESIGN: Self-administered repeated-measures questionnaires completed before and after oral care training. SETTING AND PARTICIPANTS: A total of 2012 direct care staff and administrators from 180 AL communities. METHODS: Nine knowledge questions and 8 attitude and practice intention questions, and open-ended questions regarding training and obstacles to providing oral care. RESULTS: Overall, 2012 participants completed pretraining questionnaires, and 1977 completed posttraining questionnaires. Baseline knowledge was high, but staff were not uniformly aware of the systemic-oral link whereby mouth care affects pneumonia and diabetes. Almost all staff reported learning a new technique (96%), including for residents who resist care (95%). Suggested areas to improve mouth care included having more hands-on experience. The primary perceived obstacles to care centered around residents who resist care and a lack of time. CONCLUSIONS AND IMPLICATIONS: Based on reports of having benefitted from training, AL staff overwhelmingly noted that new knowledge was helpful, suggesting the benefit of skills-based training, especially in dementia care. Mouth care in AL has been sorely understudied, and merits additional attention.

Improving the Pediatric Emergency Department Learning Experience: A Simulation-Based Orientation for Pediatric PGY 1 Residents.

Introduction: Rotations in the pediatric emergency department (PED) may expose residents to very few critically ill patients. In our previous work, interns at our institution showed low self-confidence in decision-making and preparedness to stabilize acutely ill patients. In order to improve this, we designed a new, peer-led, simulation-based orientation to the PED rotation for interns focusing on workflow and decision-making. The cases presented learners with practical and generalizable challenges, such as ordering initial labs and medications and defining the ultimate disposition for the patient. Methods: This orientation curriculum was designed for first-year residents using high-fidelity simulation mannequins. In the first of two cases, learners managed a 10-year-old boy presenting with status asthmaticus who required continuous albuterol and parenteral magnesium to achieve stability for admission. In the second case, a 4-year-old girl with short gut syndrome and an indwelling central line presented with fever, was found to be septic, but responded well to fluid resuscitation and antibiotic therapy. Results: Over 2 years of implementation, 39 residents participated. Pre- and postintervention Likert-based survey evaluations showed significant increases in confidence in decision-making and preparedness to stabilize acutely ill children that were not seen in a control group during the pilot year. A subsequent class-wide implementation showed similar significant improvements, as well as increased comfort initiating treatment prior to staffing. Discussion: Using simulation mannequins in a case-based orientation can improve PGY 1 residents' self-confidence and sense of preparedness during their first rotation in the PED.

Advances in Medical Education and Implications for the Pediatric Emergency Department.

The learning environment of the pediatric emergency department is composed of many layers that provide opportunity for intervention to improve the education of residents and medical students. Creating an intentional plan of targeted interventions at the levels of learner, teacher, and department can create a culture where education is highly regarded. This article briefly defines the learning environment and explores strategies for improving clinical teaching at these various levels through improved teacher-learner relationships, entrustment, and the implementation of teaching strategies that can be easily incorporated into the busy and time-stretched work of the pediatric emergency department.

Redefining the Team in Team-Based Care: Role of Public Health.

In North Carolina, our public health infrastructure consists of a state health department and 85 local health departments representing all 100 counties. The state health department, local health departments, health systems, and clinical providers work literally and figuratively as a team to improve the health of our citizens. In this article, we provide examples of the critical role of public health practitioners as part of the broader team addressing health, specifically in the areas of chronic disease, communicable disease, oral health, environmental health, and maternal and child health.

A large-scale study of indicators of sub-clinical mastitis in dairy cattle by attribute weighting analysis of milk composition features: highlighting the predictive power of lactose and electrical conductivity.

Sub-clinical mastitis (SCM) affects milk composition. In this study, we hypothesise that large-scale mining of milk composition features by pattern recognition models can identify the best predictors of SCM within the milk composition features. To this end, using data mining algorithms, we conducted a large-scale and longitudinal study to evaluate the ability of various milk production parameters as indicators of SCM. SCM is the most prevalent disease of dairy cattle, causing substantial economic loss for the dairy industry. Developing new techniques to diagnose SCM in its early stages improves herd health and is of great importance. Test-day Somatic Cell Count (SCC) is the most common indicator of SCM and the primary mastitis surveillance approach worldwide. However, test-day SCC fluctuates widely between days, causing major concerns for its reliability. Consequently, there would be great benefit to identifying additional efficient indicators from large-scale and longitudinal studies. With this intent, data was collected at every milking (twice per day) for a period of 2 months from a single farm using in-line electronic equipment (346 248 records in total). The following data were analysed: milk volume, protein concentration, lactose concentration, electrical conductivity (EC), milking time and peak flow. Three SCC cut-offs were used to estimate the prevalence of SCM: Australian ≥ 250 000 cells/ml, European ≥200 000 cells/ml and New Zealand ≥ 150 000 cells/ml. At first, 10 different Attribute Weighting Algorithms (AWM) were applied to the data. In the absence of SCC, lactose concentration featured as the most important variable, followed by EC. For the first time, using attribute weighted modelling, we showed that the concentration of lactose in milk can be used as a strong indicator of SCM. The development of machine-learning expert systems using two or more milk variables (such as lactose concentration and EC) may produce a predictive pattern for early SCM detection.

Accuracy of Smartphone-Based Pulse Oximetry Compared with Hospital-Grade Pulse Oximetry in Healthy Children.

BACKGROUND: Pulse oximetry, a ubiquitous, noninvasive method to monitor oxygen saturation (SpO2), requires larger, nonportable equipment. Smartphone pulse oximeter applications (apps) provide a portable, cost-effective option, but are untested in children. We hypothesize that smartphone pulse oximetry will not be inferior to standard pulse oximetry measured in healthy children. MATERIALS AND METHODS: Two main types of pulse oximetry apps, a camera-based app (CBA) that uses a phone camera flash and lens and a probe-based app (PBA) that uses an external plug-in probe, were compared with standard pulse oximetry measured in children ages 2-13 years without a respiratory complaint and a triage SpO2 ≥97% seen in a pediatric Emergency Department. Two investigators obtained heart rate and SpO2 using each app. Inter-rater reliability was tested using interclass correlations (ICCs), and Bland-Altman method was used to compare app values to triage measurements. RESULTS: Eighty-one patients were enrolled. ICC for SpO2 for PBA and CBA were 0.73 and -0.24, respectively. The 95% limits of agreement between the PBA SpO2 and triage SpO2 were -2.8 to +2.5 compared with -4.1 to +3.5 for the CBA SpO2 and triage SpO2. Mean differences between triage SpO2 and the PBA SpO2 (-0.17%) and triage SpO2 and CBA SpO2 (-0.33%) were not statistically significant. DISCUSSION AND CONCLUSIONS: Smartphone-based pulse oximetry is not inferior to standard pulse oximetry in pediatric patients without hypoxia. Reliability was superior for PBA compared with CBA, with more precise agreement for the PBA compared with the CBA. Future studies should test pulse oximetry apps in a hypoxic pediatric population.

Using Twitter to increase content dissemination and control educational content with Presenter Initiated and Generated Live Educational Tweets (PIGLETs).

Live-tweeting during educational presentations is typically learner-generated and can lead to misquoted information. Presenter curated tweets have not been well described. We created Presenter Initiated and Generated Live Educational Tweets (PIGLETs) with the goal to broaden the reach of educational conferences. We hypothesized that using PIGLETs would increase the reach and exposure of our material. We developed a prospective single-arm intervention study performed during the "Not Another Boring Lecture" workshops presented at two national conferences in 2015. Presenters tweeted PIGLETs linked to unique hashtags #NotAnotherBoringLecture and #InnovateMedEd. Analytic software was used to measure the following outcomes: (1) number of tweets published by presenters versus learners, (2) reach (users exposed to content containing the hashtag), and (3) exposure (total number of times content was delivered). One hundred and twenty-six participants attended the workshops. A total of 636 tweets (including retweets) were sent by presenters containing the study hashtags, compared with 162 sent by learners. #NotAnotherBoringLecture reached 47,200 users and generated 136,400 impressions; #InnovateMedEd reached 36,400 users and generated 79,100 impressions. PIGLETs allowed presenters to reach a significant number of learners, as well as control the content delivered through Twitter. PIGLETs can be used to augment educational sessions beyond the physical confines of the classroom.

Estimating herd prevalence of bovine brucellosis in 46 USA states using slaughter surveillance.

Making valid inferences about herd prevalence from data collected at slaughter is difficult because the observed sample is dependent on the number of animals sampled from each herd, which varies with herd size and culling practices, and the probability of a positive test result, which depends on variable within-herd prevalence levels as well as test sensitivity and specificity. In this study, brucellosis herd prevalence among beef cow-calf operations is estimated from slaughter surveillance data using a method that combines process modeling with Bayesian inference. Inferences are made for two populations; the first population comprises cow-calf beef herds in a typical U.S. state. The second population represents all beef herds in a collection of 46 low-risk states. The Bayesian Monte Carlo method used in this study links process model inputs to observed surveillance results via Bayes Theorem. The surveillance evidence across multiple years is accumulated at a discounted rate based on the probability of introducing new infection into an area. The process model's inputs include herd size, culling rate per herd, within-herd prevalence, serologic test performance, and the probability of successfully investigating positive results. The surveillance results comprise the number of cows and bulls tested at slaughter and the number of affected herds detected each year. The results find at least 95% confidence that brucellosis herd prevalence among beef cow-calf herds is less than 0.014% (3 per 21,500 herds) and 0.00081% (5 per 6,15,770) after 5 years of slaughter surveillance (with no detections of affected herds) in a typical U.S. state and across 46 low-risk U.S. states, respectively. These results were based on conservative modeling assumptions, but sensitivity analysis suggests only slight changes in the results from changing the assumed process model input values. The most influential analytic input was the probability of introducing new infection into a putatively brucellosis-free state or group of states.