Resolution of Acute Priapism in Two Children With Sickle Cell Disease Who Received Nitrous Oxide.

BACKGROUND: Nitrous oxide (N O) is an inhalational medication that has anxiolytic, amnestic, potent venodilatory and mild-to-moderate analgesic properties commonly used in the emergency department (ED) setting. N2 O has a rapid onset of action (<5 minutes) and recovery (<5 minutes) and can be quickly titrated to effect without the need for IV access. It has few side effects, does not require renal or hepatic metabolism for excretion and has no reports of allergic reaction. Priapism is a serious complication of sickle cell disease (SCD) affecting approximately 35% of males, with an adverse impact on quality of life. Treatment options are limited and not evidence based, including hydration, alkalization, analgesia, oxygenation to prevent further sickling, and exchange transfusion. Patients who do not respond within 4 hours often require a painful invasive procedure that includes aspiration of blood from the corpus cavernosum and phenylephrine injections. Case reports have described a therapeutic benefit from oral pseudoephedrine, sildenafil, and intravenous (IV) arginine, however controlled clinical trials are lacking. Although a 50:50 nitrous oxide/oxygen mix is commonly used in France to enhance analgesia in patients with SCD and vasoocclusive pain events (VOE) not sufficiently responding to IV morphine, there are no reports of its use to treat priapism. We describe the effects of N2 O for the treatment of acute priapism associated with SCD in a pediatric ED. METHODS: This is a case series of two adolescent boys with Hb-SS who on 3 separate occasions presented to the ED with acute priapism that failed oral therapy (pseudoephedrine and opioids). N2 O gas was utilized to help facilitate IV catheter placement. RESULTS: In each presentation (at ages 8 and 10 years for patient 1; age 15 years for patient 2), the patient experienced complete resolution of the priapism within 4-15 min of receiving N2 O (max 60%). The patients were discharged from the ED following each presentation and had no recurrence during the subsequent week. CONCLUSIONS: Priapism is a challenging complication of SCD associated with long-term morbidity and a paucity of treatment options. Opioids are commonly used. Given the risks and inconsistent results of current recommended therapy, N2 O may represent a potential opioid-sparing treatment option for priapism presenting to the ED that warrants further investigation. Although anecdotal, N2 O inhalation is an intervention to consider during a time when a treating ED physician may have few alternatives.

Mobile Software as a Medical Device (SaMD) for the Treatment of Epilepsy: Development of Digital Therapeutics Comprising Behavioral and Music-Based Interventions for Neurological Disorders.

Digital health technologies for people with epilepsy (PWE) include internet-based resources and mobile apps for seizure management. Since non-pharmacological interventions, such as listening to specific Mozart's compositions, cognitive therapy, psychosocial and educational interventions were shown to reduce epileptic seizures, these modalities can be integrated into mobile software and delivered by mobile medical apps as digital therapeutics. Herein, we describe: (1) a survey study among PWE about preferences to use mobile software for seizure control, (2) a rationale for developing digital therapies for epilepsy, (3) creation of proof-of-concept mobile software intended for use as an adjunct digital therapeutic to reduce seizures, and (4) broader applications of digital therapeutics for the treatment of epilepsy and other chronic disorders. A questionnaire was used to survey PWE with respect to preferred features in a mobile app for seizure control. Results from the survey suggested that over 90% of responders would be interested in using a mobile app to manage their seizures, while 75% were interested in listening to specific music that can reduce seizures. To define digital therapeutic for the treatment of epilepsy, we designed and created a proof-of-concept mobile software providing digital content intended to reduce seizures. The rationale for all components of such digital therapeutic is described. The resulting web-based app delivered a combination of epilepsy self-care, behavioral interventions, medication reminders and the antiseizure music, such as the Mozart's sonata K.448. To improve long-term patient engagement, integration of mobile medical app with music and multimedia streaming via smartphones, tablets and computers is also discussed. This work aims toward development and regulatory clearance of software as medical device (SaMD) for seizure control, yielding the adjunct digital therapeutic for epilepsy, and subsequently a drug-device combination product together with specific antiseizure medications. Mobile medical apps, music, therapeutic video games and their combinations with prescription medications present new opportunities to integrate pharmacological and non-pharmacological interventions for PWE, as well as those living with other chronic disorders, including depression and pain.

A rapid kinetic dye test to predict the adsorption of 2-methylisoborneol onto granular activated carbons and to identify the influence of pore volume distributions.

The authors have developed a kinetic dye test protocol that aims to predict the competitive adsorption of 2-methylisoborneol (MIB) to granular activated carbons (GACs). The kinetic dye test takes about two hours to perform, and produces a quantitative result, fitted to a model to yield an Intraparticle Diffusion Constant (IDC) during the earlier times of dye sorption. The dye xylenol orange was probed into six coconut-based GACs and five bituminous-based GACs that hosted varied pore distributions. Correlations between xylenol orange IDCs and breakthrough of MIB at 4 ppt in rapid small-scale column tests (RSSCTs) were found with R²s of 0.85 and 0.95 for coconut carbons that processed waters with total organic carbon (TOCs) of 1.9 and 2.2 ppm, respectively, and with an R² of 0.94 for bituminous carbons that processed waters with a TOC of 2.5 ppm. The author sought to study the influence of the pore sizes, which provide the adsorption sites and the diffusion conduits that are necessary for the removal of those compounds. For coconut carbons, a linear correlation was established between the xylenol orange IDCs and the volume of pores in the range of 23.4-31.8 Å widths (R² = 0.98). For bituminous carbons, best correlation was to pores ranging from 74 to 93 Å widths (R² = 0.94). The differences in adsorption between coconut carbons and bituminous carbons have been attributed to the inherently dissimilar graphene layering resulting from the parent materials and the activation processes. When fluorescein dye was employed in the kinetic dye tests, the correlations to RSSCT-MIB performance were not as high as when xylenol orange was used. Intriguingly, it was the same pore size ranges that exhibited the strongest correlation for MIB RSSCT's, xylenol orange kinetics, and fluoroscein kinetics. When methylene blue dye was used, sorption occurred so rapidly as to be out of the scope of the IDC model.

Instinctive Clinical Teaching: Erasing the Mental Boundary Between Clinical Education and Patient Care to Promote Natural Learning.

Effective clinical teaching is essential in physician education, yet faculty members rarely receive formal training in clinical teaching. Formal models for training clinical educators are often tedious and require significant time and effort. Instinctive clinical teaching allows clinicians to seamlessly integrate and promote effective teaching into their clinical practice. The approach is guided by similarities between the components of Kolb's experiential learning cycle-concrete experience, reflective observation, abstract conceptualization, and active experimentation-and the elements of the patient care process-history and physical, initial assessment, differential, hypothesis, final diagnosis, management, and follow-up. Externalization of these clinical thought processes allows for inclusion of learners and promotes effective clinical teaching.

Measured and perceived environmental characteristics are related to accelerometer defined physical activity in older adults.

BACKGROUND: Few studies have investigated both the self-perceived and measured environment with objectively determined physical activity in older adults. Accordingly, the aim of this study was to examine measured and perceived environmental associations with physical activity of older adults residing across different neighborhood types. METHODS: One-hundred and forty-eight older individuals, mean age 64.3 ± 8.4, were randomly recruited from one of four neighborhoods that were pre-determined as either having high- or low walkable characteristics. Individual residences were geocoded and 200 m network buffers established. Both objective environment audit, and self-perceived environmental measures were collected, in conjunction with accelerometer derived physical activity behavior. Using both perceived and objective environment data, analysis consisted of a macro-level comparison of physical activity levels across neighborhood, and a micro-level analysis of individual environmental predictors of physical activity levels. RESULTS: Individuals residing in high-walkable neighborhoods on average engaged in 11 min of moderate to vigorous physical activity per day more than individuals residing in low-walkable neighborhoods. Both measured access to non-residential destinations (b = .11, p < .001) and self-perceived access to non-residential uses (b = 2.89, p = .031) were significant predictors of time spent in moderate to vigorous physical activity. Other environmental variables significantly predicting components of physical activity behavior included presence of measured neighborhood crime signage (b = .4785, p = .031), measured street safety (b = 26.8, p = .006), and perceived neighborhood satisfaction (b = .5.8, p = .003). CONCLUSIONS: Older adult residents who live in high-walkable neighborhoods, who have easy and close access to nonresidential destinations, have lower social dysfunction pertinent to crime, and generally perceive the neighborhood to a higher overall satisfaction are likely to engage in higher levels of physical activity behavior. Efforts aimed at promoting more walkable neighborhoods could influence activity levels in older adults.

Searching for first-degree familial relationships in California's offender DNA database: validation of a likelihood ratio-based approach.

A validation study was performed to measure the effectiveness of using a likelihood ratio-based approach to search for possible first-degree familial relationships (full-sibling and parent-child) by comparing an evidence autosomal short tandem repeat (STR) profile to California's ∼1,000,000-profile State DNA Index System (SDIS) database. Test searches used autosomal STR and Y-STR profiles generated for 100 artificial test families. When the test sample and the first-degree relative in the database were characterized at the 15 Identifiler(®) (Applied Biosystems(®), Foster City, CA) STR loci, the search procedure included 96% of the fathers and 72% of the full-siblings. When the relative profile was limited to the 13 Combined DNA Index System (CODIS) core loci, the search procedure included 93% of the fathers and 61% of the full-siblings. These results, combined with those of functional tests using three real families, support the effectiveness of this tool. Based upon these results, the validated approach was implemented as a key, pragmatic and demonstrably practical component of the California Department of Justice's Familial Search Program. An investigative lead created through this process recently led to an arrest in the Los Angeles Grim Sleeper serial murders.

Carbonless footprints: promoting health and climate stabilization through active transportation.

OBJECTIVE: Our objective was to describe how active transportation can help meet health and greenhouse gas emissions goals, and the ability of urban form strategies to impact both issues. In addition, we wanted to assess if there is an inverse relationship between active and motorized forms of travel. METHODS: A cross-sectional analysis of travel diary data was used to measure relationships among energy (kcal) burned from walking, energy (kcal) burned from motorized transportation, and the ratio of the two (the transport energy index) with regional accessibility and local walkability when adjusting for demographic factors. Multiple linear regression and descriptive statistics were employed to estimate these relationships. RESULTS: Transit accessibility, residential density, and intersection density were positive predictors of walk energy and the energy index and inverse predictors of motorized energy. The land use mix variable was negatively and significantly associated with energy burned from walking and from motorized transportation, with no significant impact on the transport energy index. Because a mixed land use pattern places destinations closer together, it reduces distances and thus energy demands for both walking and driving. CONCLUSIONS: The results support the concept, previously untested empirically, that similar urban form strategies can have cobenefits for both physical activity and climate change.

A randomized clinical trial of lidocaine gel for reducing infant distress during urethral catheterization.

OBJECTIVES: The purpose of this study was to determine whether a lidocaine-enhanced lubricant that was used topically and instilled into the urethra decreased infants' distress that was associated with catheterization. METHODS: Eligible study participants were febrile 2- to 24-month-old pediatric emergency department patients in need of a catheter-obtained urinalysis. Patients were randomly assigned to 1 of 3 groups. Patients had catheterization performed after a 4-minute protocol that included a topical lubricant control, topical and intraurethral lubricants, or topical and intraurethral lidocaines. All patients were filmed during the procedure and evaluated at 3 phases: the start of the study, time of instillation, and at the time of maximal catheter insertion. The 3 phases were analyzed by blinded coders using the Modified Behavioral Pain Scale. RESULTS: A total of 45 patients were enrolled in 1 of the 3 study groups. Patients who received lidocaine had a lower overall distress at a level approaching significance at the time of catheterization (phase 3; P = 0.065) and a significantly lower distress as measured by crying during the catheterization (phase 3; P = 0.036) than infants who did not have a lubricant instilled into the urethra. CONCLUSIONS: The use of topical and intraurethral lidocaine resulted in a lower distress when compared with a topical lubricant, at a level approaching significance for global distress. When a subsection of the total distress score that measured infant cry was evaluated, the difference between the intraurethral lidocaine group and the group without intraurethral instillation was statistically significant. Although the results are promising, intraurethral lidocaine did not fully alleviate discomfort associated with urethral catherization. The use of lidocaine is suggested for pediatric patients undergoing urethral catherization; however, evaluation of additional agents and techniques for further decreasing pain is also warranted.

Operationalizing environmental indicators for physical activity in older adults.

This qualitative study describes environmental supports and barriers to physical activity in an older adult sample drawn from low- and high-walkable neighborhoods. Thirty-seven individuals age 55 and over were recruited and answered open-ended survey questions, with a subsample invited back to partake in a semistructured interview. Content analysis identified categories and themes linking perceptions of neighborhood-environment characteristics to activity. Emerging categories and themes did not differ across neighborhood walkability, so results are presented for both groups combined. Infrastructure was the most common category identified to encourage activity, specifically, well-maintained sidewalks, bike paths or lanes, and traffic control. Other categories of land use, landscape, and aesthetics were reported. Poorly maintained or missing sidewalks, crosswalks, bike paths or lanes, and traffic safety were categories that discouraged activity. In conclusion, the information obtained is helpful in solidifying which environmental characteristics are important to measure as they relate to activity behavior in an older adult population.

A randomized, controlled trial of sucrose analgesia in infants younger than 90 days of age who require bladder catheterization in the pediatric emergency department.

OBJECTIVES: To determine whether an oral sucrose solution improves pain response for infants undergoing bladder catheterization in an emergency department (ED) population. METHODS: A randomized, double-blinded study comparing the analgesic effects of a sucrose solution to placebo for infants < or = 90 days of age and requiring bladder catheterization. Infants with prior bladder catheterization, previous painful procedures that day, or neurological or genital abnormalities were excluded. Infants were assigned baseline pain scores and then given 2 mL of sucrose or water 2 minutes before catheterization. Trained pediatric ED nurses rated the infants for pain, presence of cry, and time to return to baseline. RESULTS: Eighty-three patients were enrolled; 40 were randomized to sucrose, and 40, to placebo. Baseline pain scores were similar within each age group. Overall, sucrose did not produce a significant analgesic effect. In subgroup analysis, infants 1-30 days of age receiving sucrose showed a smaller change in pain scores (2.9 vs. 5.3, p = 0.035), were less likely to cry with catheterization (29% vs. 72%, p = 0.008), and returned to baseline more rapidly after catheter removal (10 seconds vs. 37 seconds, p = 0.04) compared with infants who received placebo. Infants older than 30 days of age who received sucrose did not show statistically significant differences in pain scores, crying, or time to return to baseline behavior. CONCLUSIONS: There was no overall treatment effect when using an oral sucrose solution before bladder catheterization in infants younger than 90 days of age. However, infants younger than or equal to 30 days of age who received sucrose had smaller increases in pain scores, less crying, and returned to baseline more rapidly than infants receiving placebo. Older infants did not show an improved pain response with oral sucrose.

Posttraumatic stress responses in children: awareness and practice among a sample of pediatric emergency care providers.

BACKGROUND: Research suggests that up to 4 of 5 children experience symptoms of an acute stress response (ASR) after a motor vehicle-related injury, and approximately 25% will develop posttraumatic stress disorder (PTSD). The degree to which physicians recognize this problem has not been reported. Our objective was to evaluate current awareness and practices of a cohort of pediatric emergency care providers regarding posttraumatic stress in children. METHODS: Participants were identified from a list of the American Academy of Pediatrics Section on Emergency Medicine and surveyed on their awareness of ASR after motor vehicle-related injury, risk factors for developing PTSD, and practices regarding emergency department (ED) interventions. Surveys from physicians not practicing clinical emergency medicine were excluded. RESULTS: Of 322 surveys returned, 287 responses met inclusion criteria. Among these respondents, 198 (69%) were pediatric emergency medicine board certified or eligible and 260 (91%) practiced in a designated pediatric ED. Only 20 of 287 respondents (7%) believed that children were likely to develop symptoms of posttraumatic stress at levels previously described. Also in contrast to recent literature, 248 respondents (86%) felt that severity of injury was associated with future development of PTSD. Associated parental injury was identified accurately as a risk factor by 250 respondents (87%). Of interest, only 31 respondents (11%) were aware of any available tools to assess risk for PTSD. In addition, 56 of 287 respondents (20%) indicated that they would not use such tools in the ED, most commonly citing time and cost constraints. Finally, only 52 respondents (18%) reported giving any verbal guidance and only 9 (3%) provided any written instructions about posttraumatic stress to their patients and families. CONCLUSIONS: Findings suggest that physicians underestimate the likely development of an ASR and PTSD in the pediatric population. At present, few physicians offer written or even verbal instruction related to the development of posttraumatic symptoms. Physician education along with a systematic approach of assessment and intervention is necessary to address the gap between underrecognition of this concern and desired clinical practice.

Herbal therapy use in a pediatric emergency department population: expect the unexpected.

BACKGROUND: In recent years investigators have reported widespread use of alternative medicine. Some herbal therapies have potentially harmful side effects as well as adverse interactions with medications. Data are lacking on the use in children and caregiver understanding of these products. OBJECTIVES: To determine the reported use of herbal products among a pediatric emergency department population and to evaluate the caregivers' understanding and source of information concerning these products. DESIGN/METHODS: A convenience sampling of pediatric emergency department patients and their caregivers occurred during a 3-month period in 2001. The interview consisted of 18 questions regarding the types of non-Food and Drug Administration-regulated herbal products and home remedies used, general product knowledge and sources of information used by the child's caregiver (including discussions with their child's primary physician). RESULTS: One hundred forty-two (93%) of 153 families approached participated in the study. The mean patient age was 5.3 years (range: 3 weeks-18 years). Forty-five percent of caregivers reported giving their child an herbal product, and 88% of these caregivers had at least 1 year of college education. Of the children receiving these therapies, 53% had been given 1 type and 27% were given 3 or more in the past year. The most common therapies reportedly used were aloe plant/juice (44%), echinacea (33%), and sweet oil (25%). The most dangerous potential herbal and prescription medication combination reported was ephedra and albuterol in an adolescent with asthma. The most unusual products reportedly used included turpentine, pine needles, and cowchips. Of all people interviewed, 77% did not believe or were uncertain if herbal products had any side effects and only 27% could name a potential side effect. Sixty-six percent were unsure or thought that herbal products did not interact with other medications and only 2 people correctly named a drug interaction. Of the people who used these therapies, 80% reported either friends or relatives as their primary source of information. Only 45% of those giving their children herbal products report discussing the use with their child's primary health care provider. CONCLUSION: Herbal and home therapies are commonly used in this pediatric population. An unexpectedly wide variety of products were reportedly given to this patient population. Caregivers reported limited knowledge regarding potential adverse medication interactions and side effects. Limited discussions with the child's primary health care provider were reported. It is therefore important for health care providers to have knowledge about herbal medications, to inquire about their use and to educate families about the risk/benefit as well as potential interactions these products may have with over-the-counter and prescription medications.