Design and Evaluation of a Curriculum on Intimate Partner Violence for Medical Students in an Emergency Medicine Clerkship.

Purpose: Intimate partner violence (IPV) is a widespread public health issue that is relevant to all areas of medicine. Patients who suffer from IPV often contact the health care system via the emergency department, making this a particularly important but too often overlooked issue in this setting. Education on IPV varies in medical schools and emergency medicine (EM) educational programs, and evidence suggests that a barrier to assessing for IPV is a lack of adequate training of clinicians. In this study, we sought to design, implement and evaluate the efficacy of a curriculum on IPV geared towards medical students on an EM clerkship. Methods: We assembled a multi-disciplinary team of EM education faculty, a resident content expert on IPV, and social workers to design a two-part curriculum that was administered to medical students on an EM clerkship. The curriculum involved a 20-minute narrated slide presentation viewed asynchronously, followed by a 1-hour case-based discussion session. The curriculum was evaluated using a 13-item self-assessment survey on knowledge, comfort level and skill in managing victims of IPV, administered electronically before and after the curriculum. Survey results were compared pre- and post-curriculum using Wilcoxon signed-rank test. Results: Thirty-four students completed the curriculum and 26 completed both the pre and post self-assessment surveys. A statistically significant improvement in knowledge, comfort level and skills was observed in 11 of the 13 survey elements. Conclusion: Based on the self-assessment survey results, this curriculum was well received and successfully increased participants' comfort, knowledge and skill level regarding assessment of patients for IPV. This is a focused and feasible curriculum that can be easily incorporated into an EM clerkship to provide effective education on a relevant but often overlooked topic.

Anxiety Disorders in Children.

Anxiety disorders are the most common mental health disorders in children with clearly defined and empirically based treatment. However, assessment and treatment pose several obstacles for pediatric providers. A child who may have age-appropriate communication skills will still struggle to accurately report the presence, timing, and severity of symptoms. Reports from parents, caregivers, and teachers are often subjective and can focus on 1 aspect of the child's behavior. Untreated, anxiety disorders have an adverse effect on a child's functioning, and impairments in physical health, academic performance, and social competence can lead to lifelong consequences. Well-validated and rapidly administered screening tools can be used to gather data from schools and other resources to inform the diagnosis, guide treatment recommendations, and track improvements. Limited training on behavioral health diagnosis and fear of "black box warnings" have left many pediatric clinicians reluctant to prescribe medications. There are readily available practice guidelines for these medications, and data documenting the efficacy of these medications for children should encourage their use.

Impact of underground storm drain systems on larval ecology of Culex and Aedes species in urban environments of Southern California.

An extensive network of storm water conveyance systems in urban areas, often referred to as the "underground storm drain system" (USDS), serves as significant production habitats for mosquitoes. Knowledge of whether USDS habitats are suitable for newly introduced dengue vectors Aedes aegypti and Ae. albopictus will help guide surveillance and control efforts. To determine whether the USDS functions as a suitable larval habitat for Culex, Ae. aegypti and Ae. albopictus in southern California, we examined mosquito habitat utilization and larval survivorship using laboratory microcosm studies. The data showed that USDS constituted 4.1% of sampled larval habitats for Ae. aegypti and Ae. albopictus, and 22.0% for Cx. quinquefasciatus. Furthermore, USDS water collected in the summer completely inhibited Aedes larval development, but yielded a 15.0% pupation rate for Cx. quinquefasciatus. Food supplementation in the microcosms suggests that nutrient deficiency, toxins and other factors in the USDS water led to low success or complete failure of larval development. These results suggest that USDS habitats are currently not major productive larval habitats for Aedes mosquitoes in southern California. Our findings prompt inclusion of assessments of pupal productivity in USDS habitats and adult mosquito resting sites in the mosquito surveillance program.

Multicenter Real-World Assessment of the Effectiveness of V-Go Wearable Insulin Delivery Device in Adult Patients with Type 2 Diabetes (ENABLE Study): A Retrospective Analysis.

PURPOSE: Patch-like wearable insulin delivery devices are gaining acceptance as a treatment modality for insulin delivery in patients with diabetes. These devices aim to simplify and optimize insulin delivery while reducing barriers associated with a basal-bolus insulin regimen. As clinicians aim to learn more about this method of insulin delivery, real-world evidence can provide insight for patient identification and treatment guidance. This study was performed to evaluate the change in glycemic control (A1C) and insulin total daily dose (TDD) after switching to V-Go wearable insulin delivery device in a type 2 diabetes population with suboptimal control using conventional insulin delivery regimens. PATIENTS AND METHODS: Electronic health records were queried to identify patients meeting inclusion criteria. Study objectives evaluated change in A1C and insulin TDD compared to baseline. A total of 283 patients were enrolled across 9 diabetes specialty sites. RESULTS: A1C significantly decreased from baseline at 3 months (-1.01% ± 0.09; P=0.0001) and 7 months (-1.04% ± 0.10; P<0.0001) after switching to V-Go. TDD of insulin significantly decreased at 3 months (-17 ± 3 U/day; P<0.0001) and 7 months (-14 ± 3 U/day; P<0.0001). Stratifying by prescribed baseline insulin regimen (basal-bolus, basal only or premix) or diabetes duration (<5 years to >20 years) demonstrated significant glycemic improvements from baseline with V-Go regardless of baseline regimen or duration of diabetes. After 7 months of V-Go use, the percent of patients considered high risk (A1C >9.0%) was reduced by nearly half (46% to 24%), and 52% of patients overall achieved an A1C <8%. CONCLUSION: This study represents the largest real-world study of the effectiveness of V-Go in patients with type 2 diabetes. Significant improvements in glycemic control with a reduction in insulin utilization were achieved across varying baseline insulin regimens and regardless of diabetes duration supporting the clinical benefits of this patch-like wearable insulin delivery device.

Use of the sport concussion assessment tools in the emergency department to predict persistent post-concussive symptoms in children.

AIM: The Sport Concussion Assessment Tool v3 (SCAT3) and its child version (ChildSCAT3) are composite tools including a symptom scale, a rapid cognitive assessment (standardised assessment of concussion (SAC)) and the modified Balance Error Scoring System (mBESS). It is unclear whether their use for the acute assessment of paediatric concussion in the emergency department (ED) may help predict persistent post-concussive symptoms (PPCS). We aim to assess the predictive value of the main SCAT3/ChildSCAT3 components for PPCS when applied in the ED. METHODS: A single-site, prospective longitudinal cohort study of children aged 5-18 years assessed within 48 h of their concussion at the ED of a state-wide tertiary paediatric hospital and followed up at the affiliated concussion clinic, between November 2013 and August 2017. PPCS was defined as ≥2 new or worsening symptoms at 1 month post-injury using the Post-Concussive Symptom Inventory. RESULTS: Of the 370 children enrolled, 213 (57.7% <13 years old) provided complete data. Of these, 34.7% had PPCS at 1 month post-injury (38.2% of children <13 years and 30.0% ≥13 years of age, P = 0.272). The adjusted ORs from multiple logistic regression models, for number and severity of symptoms, and for the SAC and mBESS performance in both the ChildSCAT3/SCAT3, were all not significant. The area under the curve of receiver operator characteristic curves for all analysed ChildSCAT3/SCAT3 components was below 0.6. CONCLUSIONS: Although SCAT3 and ChildSCAT3 are recommended tools to assist with concussion diagnosis and monitoring of patient recovery, their use in the ED does not seem to help predict PPCS.

Trajectories and Predictors of Clinician-Determined Recovery after Child Concussion.

By age 16, 20% of children will suffer a concussion. Many experience persisting post-concussive symptoms (PCS), the cause(s) of which remain unclear. We mapped concussion recovery to 3 months post-injury and explored non-modifiable (e.g., age, sex, pre-injury factors, injury mechanism, acute PCS) and modifiable (post-acute child symptoms) predictors of persisting symptoms in order to identify opportunities for early intervention. We conducted a prospective, longitudinal study in the emergency department of a tertiary, pediatric hospital recruiting children within 48 h of concussion (T0), with follow-up at 2 days (T1), 2 weeks (T2), 1 month (T3), and 3 months (T4). Primary outcome was T2 clinician diagnosis. Clinical history, injury mechanism, acute symptoms, and physical and cognitive function were assessed. Parents rated child behavior and fatigue, and their mental health. We enrolled 256 participants, 72% males: 62 (24.3%) were symptomatic at T2. Recovered and symptomatic groups endorsed similar pre-injury PCS, but group differences were found at T1 across all PCS subscales, except Emotional, where symptoms were not evident until T2. By T2, there was significant PCS reduction, steepest in the "Recovered" group, which also had a lower rate of pre-injury psychiatric diagnoses, acute CT scans and less severe parent-rated PCS at T1 than the symptomatic group. They all demonstrated lower parent-rated PCS and less internalizing behaviors (all, p < 0.01). No differences were detected for child age, sex, injury factors, pre-injury parent-rated PCS, or acute physical and cognitive status. Our findings also highlight the importance of considering both pre- and post-injury mental health status in managing post-concussion.

Does a computerized neuropsychological test predict prolonged recovery in concussed children presenting to the ED?

Computerized neuropsychological tests (CNTs) are widely used internationally in concussion management. Their prognostic value for predicting recovery post-concussion is poorly understood, particularly in pediatric populations. The aim of the present study was to examine whether cognitive functioning (measured by CogSport) has prognostic value for predicting rapid versus slow recovery. This is a prospective longitudinal observational cohort study conducted at a state-wide tertiary pediatric hospital. Data were collected at 1-4, 14, and 90 days post-injury. Eligible children were aged ≥5 and <18 years presenting to the Emergency Department having sustained a concussion within 48 h. Concussion was defined according to the Zurich/Berlin Consensus Statement on Concussion in Sport. Dependent variables were reaction times and error rates on the CogSport Brief Battery. In total, 220 cases were analyzed; 98 in a rapid recovery group (asymptomatic at 14 days post-injury, mean age 11.5 [3.2], 73.5% male) and 122 in a slow recovery group (symptomatic at 14 days post-injury, mean age 12.0 [3.1], 69.7% male). Longitudinal GEE analyses modeled the trajectories of both mean log10-transformed reaction time and error rates between groups over time (1-4, 14 and 90 days). Both group main and interaction (time by group) terms for all models were non-significant (p > .05). Cognitive functioning, measured by CogSport and assessed within 1-4 days of concussion, does not predict prolonged recovery in a pediatric sample. Further, there were no significant group differences at any time point. Considering the widespread use and promotion of CNTs, it is important that clinicians understand the significant limitations of the CogSport battery.

Protocol for a prospective, longitudinal, cohort study of recovery pathways, acute biomarkers and cost for children with persistent postconcussion symptoms: the Take CARe Biomarkers study.

INTRODUCTION: The majority of children who sustain a concussion will recover quickly, but a significant minority will experience ongoing postconcussive symptoms, known as postconcussion syndrome (PCS). These symptoms include emotional, behavioural, cognitive and physical symptoms and can lead to considerable disability. The neurobiological underpinnings of PCS are poorly understood, limiting potential clinical interventions. As such, patients and families frequently re-present to clinical services, who are often ill equipped to address the multifactorial nature of PCS. This contributes to the high cost of concussion management and the disability of children experiencing PCS. The aims of the present study are: (1) to plot and contrast recovery pathways for children with concussion from time of injury to 3 months postinjury, (ii) evaluate the contribution of acute biomarkers (ie, blood, MRI) to delayed recovery postconcussion and (3) estimate financial costs of child concussion to patients attending the emergency department (ED) of a tertiary children's hospital and factors predicting high cost. METHODS AND ANALYSIS: Take C.A.Re is a prospective, longitudinal study at a tertiary children's hospital, recruiting and assessing 525 patients aged 5-<18 years (400 concussion, 125 orthopaedic injury) who present to the ED with a concussion and following them at 1-4 days, 2 weeks, 1 month and 3 months postinjury. Multiple domains are assessed: preinjury and postinjury, clinical, MRI, blood samples, neuropsychological, psychological and economic. PCS is defined as the presence of ≥2 symptoms on the Post Concussive Symptoms Inventory rated as worse compared with baseline 1 month postinjury. Main analyses comprise longitudinal Generalised Estimating Equation models and regression analyses of predictors of recovery and factors predicting high economic costs. ETHICS AND DISSEMINATION: Ethical approval has been obtained through the Royal Children's Hospital Melbourne Human Research Ethics Committee (33122). We aim to disseminate the findings through international conferences, international peer-reviewed journals and social media. TRIAL REGISTRATION NUMBER: ACTRN12615000316505; Results.

Validation of a Score to Determine Time to Postconcussive Recovery.

BACKGROUND: A reliable, developmentally appropriate and standardized method for assessing postconcussive symptoms (PCS) is essential to accurately determine recovery postconcussion and to effectively manage return to normal activities. The aim of this study was to develop an evidence-based, psychometrically validated approach to determining clinically useful cutoff scores by using a commonly administered PCS measure. METHODS: The current study was a prospective, longitudinal observational study conducted between July 2013 and November of 2015 at a statewide tertiary pediatric hospital. Participants were 120 children (5-18 years of age) presenting to the emergency department with a concussion within 48 hours of injury. PCS were assessed by using the Postconcussion Symptom Inventory (PCSI), acutely, 1 to 4 days postinjury and 2 weeks postinjury. Using comprehensive clinical assessment as gold standard, we assessed the clinical cutoff discrimination ability of PCSI at 2 weeks postinjury by using published approaches, and then varying each approach to optimize their discrimination ability. RESULTS: Existing and potential clinical cutoff scores were explored in predicting delayed recovery. Receiver operating characteristic curve results returned acceptable discrimination and sensitivity when PCSI items increased in severity from preinjury by 1 or more. Compared with a published cutoff score being 3+ items with increased severity, the current study suggests a more stringent cutoff requirement of 2+ is better able to accurately classify symptomatic children. CONCLUSIONS: This study provides the first validated index (2+ items, 1+ severity) of concussion recovery for children and youth. Further studies in more varied samples are needed to establish the effectiveness of this method.

Protocol for a prospective, longitudinal, cohort study of postconcussive symptoms in children: the Take C.A.Re (Concussion Assessment and Recovery Research) study.

INTRODUCTION: A substantial minority of children who sustain a concussion suffer prolonged postconcussive symptoms. These symptoms can persist for more than 1 month postinjury and include physical, cognitive, behavioural and emotional changes. Those affected can develop significant disability, diminishing their quality of life. The precise prevalence of postconcussive symptoms following child concussion is unclear, with heterogeneous and at times conflicting results published regarding factors that predict children at risk for developing long-lasting postconcussive symptoms. The aim of the Take C.A.Re (Concussion Assessment and Recovery Research) study is to provide an in-depth multidimensional description of the postconcussive recovery trajectories from a physical, neurocognitive and psychosocial perspective in the 3 months following concussion, with a focus on the early postconcussive period, and identification of factors associated with prolonged recovery. METHODS AND ANALYSIS: Take C.A.Re is a prospective, longitudinal study at a tertiary children's hospital, recruiting and assessing patients aged 5-<18 years who present to the emergency department with a concussion and following them at 1-4 days, 2 weeks, 1 month and 3 months postinjury. Multiple domains are assessed: postconcussive symptoms, balance and coordination, neurocognition, behaviour, quality of life, fatigue, post-traumatic stress symptoms, parental distress and family burden. 'Delayed recovery' is operationalised as the presence of ≥ 3 symptoms on the Post Concussive Symptoms Inventory rated as worse compared with baseline. Main analyses comprise analysis of variance (recovery trajectories, delayed vs normal recovery groups) and regression analyses of predictors of recovery (preinjury, acute and family factors). ETHICS AND DISSEMINATION: Ethical approval has been obtained through the Royal Children's Hospital Melbourne Human Research Ethics Committee (33122). We aim to disseminate the findings through international conferences, international peer-reviewed journals and social media. TRIAL REGISTRATION NUMBER: ACTRN12615000316505.

Disease dynamics and persistence of Musca domestica salivary gland hypertrophy virus infections in laboratory house fly (Musca domestica) populations.

Past surveys of feral house fly populations have shown that Musca domestica salivary gland hypertrophy virus (MdSGHV) has a worldwide distribution, with an average prevalence varying between 0.5% and 10%. How this adult-specific virus persists in nature is unknown. In the present study, experiments were conducted to examine short-term transmission efficiency and long-term persistence of symptomatic MdSGHV infections in confined house fly populations. Average rates of disease transmission from virus-infected to healthy flies in small populations of 50 or 100 flies ranged from 3% to 24% and did not vary between three tested geographical strains that originated from different continents. Introduction of an initial proportion of 40% infected flies into fly populations did not result in epizootics. Instead, long-term observations demonstrated that MdSGHV infection levels declined over time, resulting in a 10% infection rate after passing through 10 filial generations. In all experiments, induced disease rates were significantly higher in male flies than in female flies and might be explained by male-specific behaviors that increased contact with viremic flies and/or virus-contaminated surfaces.

Preliminary results of a phase I trial of prophylactic ethanol-lock administration to prevent mediport catheter-related bloodstream infections.

BACKGROUND: Catheter-related bloodstream infections remain costly with no simple prevention. We report preliminary results of a phase I trial of ethanol-lock administration to prevent mediport catheter-related bloodstream infections in children. METHODS: Twelve patients receiving intravenous antibody treatments for neuroblastoma were enrolled. On 4 days of each 5-day antibody cycle, 70% ethanol was administered instead of heparin to dwell in each patient's mediport overnight. We used clinical monitoring/questionnaires to assess symptoms and measured blood ethanol levels and liver functions. Patients were tracked for positive blood cultures. Time to infection for ethanol-lock-treated patients was compared with historical controls. RESULTS: We administered 123 ethanol-locks. No adverse symptoms attributable to ethanol occurred; one patient's urticaria worsened. Blood ethanol levels averaged 11 mg/dL. The study was voluntarily suspended after 3 patients' catheters became occluded, 1 of which fractured. A positive blood culture occurred in 1 (8%) of 12 patients, but suspension of the study precluded statistical power to detect impact on time to infection. CONCLUSIONS: Although children with mediport catheters exhibited nontoxic blood ethanol levels and a low rate of bloodstream infections following prophylactic ethanol-lock use, there was a high incidence of catheter occlusion. Adjustments are necessary before adopting ethanol-locks for routine prophylaxis against catheter infections in children.

Efficacy of residual bifenthrin applied to landscape vegetation against Aedes albopictus.

The daytime biting mosquito Aedes albopictus is a nuisance pest commonly found in suburban yards. The recommended course of treatment for Ae. albopictus is to keep yards free of water-holding containers; however, infestations may require additional control methods such as residual pesticide applications to vegetation. Five plants commonly found in yards or in uncultivated areas in Gainesville, FL were chosen as substrates for evaluation of the effectiveness of residual bifenthrin against 5-7-day-old female Ae. albopictus. Knockdown of mosquitoes after 1 h of exposure was highest the day of and 7 days after treatment. Plant species clearly impacted the effectiveness of residual bifenthrin. One-hour knockdown 7 days after treatment remained high (>62%) only on azalea and holly bush vegetation. Knockdown counts 24 h after exposure demonstrated that residual efficacy of bifenthrin was highest on azalea, with >77% mortality for up to 35 days. Additional bioassays revealed significant differences in the knockdown rates of male, female, gravid, and blood-fed Ae. albopictus exposed to residual bifenthrin treatments, with the highest knockdown observed on the day of and 7 days after treatment.

Field evaluation of CDC and Mosquito Magnet X traps baited with dry ice, CO2 sachet, and octenol against mosquitoes.

The Centers for Disease Control and Prevention (CDC) light traps and Mosquito Magnet X (MMX) traps baited with dry ice, octenol, and a new formulation (granular) of carbon dioxide (CO2) were evaluated against adult mosquitoes in the field. The results showed that the MMX traps (68.6%) baited with dry ice collected more mosquitoes compared to the CDC light traps (32.4%) only. The CDC traps baited with dry ice (64%) collected significantly more mosquitoes than traps baited with CO2 sachets (11%) or octenol (23%). The MMX traps baited with dry ice (85.5%) collected significantly more mosquitoes than traps baited with CO2 sachets (6.5%) or octenol (9%). The CDC traps baited with the formulations of normal and slow release CO2 sachets collected more mosquitoes than the formulation of fast release sachets. The CDC traps baited with fresh sachets and 24-h-exposed sachets collected significantly more mosquitoes than the traps baited with 48-h- and 72-h-exposed sachets.

Characterization of vaginal microflora of healthy, nonpregnant women by chaperonin-60 sequence-based methods.

OBJECTIVE: The purpose of this study was to use a novel method that was based on the application of chaperonin-60 sequencing to describe the vaginal microflora of 16 healthy women. STUDY DESIGN: Asymptomatic women consented for vaginal swabs to be collected at the time of a clinical pelvic examination. Total genomic DNA was isolated from the vaginal swabs. Degenerate, universal polymerase chain reaction primers were used to amplify an approximately 555 base pair region of the universal chaperonin-60 gene, which is found in all eubacteria and eukaryotes, from the total genomic DNA and libraries of cloned polymerase chain reaction products were constructed. Library clones were sequenced, and the resulting sequences were assigned to taxonomic groups on the basis of similarity to reference sequence data. Presence of Chlamydophila psittaci sequences in the samples was confirmed by species-specific polymerase chain reaction. RESULTS: Sixteen of the 23 women who were enrolled had normal flora by Nugent's score of <4 and had adequate polymerase chain reaction product for assessment. Vaginal flora libraries were dominated by a variety of sequences with similarity to Lactobacillus spp L. crispatus, L. iners, L. gasseri, L. jensenii, and L. buchneri. Other sequences that were identified included representatives of Gardnerella spp, sequences with similarity to Porphyromonas spp and Megasphaera spp and sequences identical to C psittaci. CONCLUSION: Culture-independent, chaperonin-60 sequence-based molecular methods can lead to the identification of greater diversity within defined taxa compared with those that are identified by standard culture-based methods and to the identification of novel organisms that were not previously associated with vaginal flora.

Evaluation of upstream point treatment in flowing water ditches by Aquabac (Bacillus thuringiensis var. israelensis) against Culex quinquefasciatus.

The effectiveness of the upstream point treatment by AQUABAC Biolarvicide (Bacillus thuringiensis var. israelensis, Biological Larvicide Aqueous Suspension) against Culex quinquefasciatus Say in slow-flowing water ditches has been evaluated in St. Augustine Beach, St. Johns County, FL. The upstream point treatment by AQUABAC (liquid) at 0.5 liter/acre provided significant levels of larval control of Cx. quinquefasciatus for all sections of the downstream for 9 days. The upstream point treatment method by larvicides may have potential for use, minimize environmental impacts, and reduce cost and labor in mosquito-control operation for slow-flowing water ditches.

Heat shock protein 90 modulates the unfolded protein response by stabilizing IRE1alpha.

The molecular chaperone HSP90 regulates stability and function of multiple protein kinases. The HSP90-binding drug geldanamycin interferes with this activity and promotes proteasome-dependent degradation of most HSP90 client proteins. Geldanamycin also binds to GRP94, the HSP90 paralog located in the endoplasmic reticulum (ER). Because two of three ER stress sensors are transmembrane kinases, namely IRE1alpha and PERK, we investigated whether HSP90 is necessary for the stability and function of these proteins. We found that HSP90 associates with the cytoplasmic domains of both kinases. Both geldanamycin and the HSP90-specific inhibitor, 514, led to the dissociation of HSP90 from the kinases and a concomitant turnover of newly synthesized and existing pools of these proteins, demonstrating that the continued association of HSP90 with the kinases was required to maintain their stability. Further, the previously reported ability of geldanamycin to stimulate ER stress-dependent transcription apparently depends on its interaction with GRP94, not HSP90, since geldanamycin but not 514 led to up-regulation of BiP. However, this effect is eventually superseded by HSP90-dependent destabilization of unfolded protein response signaling. These data establish a role for HSP90 in the cellular transcriptional response to ER stress and demonstrate that chaperone systems on both sides of the ER membrane serve to integrate this signal transduction cascade.