The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies.

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure, challenges with timely access to a mental health professional, the nature of a busy ED environment, and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affects patient care and ED operations. Strategies to improve care for MBH emergencies, including systems level coordination of care, is therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

Simulation-based interdisciplinary education improves intern attitudes and outlook toward colleagues in other disciplines.

BACKGROUND: Cooperative interdisciplinary patient care is a modern healthcare necessity. While various medical and surgical disciplines have independent educational requirements, a system-wide simulation-based curriculum composed of different disciplines provides a unique forum to observe the effect of interdisciplinary simulation-based education (IDSE). Our hypothesis: IDSE positively affects intern outlook and attitudes towards other medical disciplines. METHODS: Using an established interdisciplinary simulation curriculum designed for first year interns, we explored the relative effect of IDSE on between-discipline intern attitudes in a convergent, parallel, mixed-methods study. Data sources included novel pre-post anonymous survey measurements (10-point Likert scale), focus groups, direct observations, and reflective field notes. This quasi-experimental pilot study was conducted at an academic, tertiary care medical center with two cohorts of interns: one exposed to IDSE and one exposed to an independent within-discipline simulation curriculum. RESULTS: IDSE exposed interns demonstrated statistically significant improvements when comparing mean pre-test and post-test score differences in five of seven areas: perceived interdisciplinary collegiality ([Formula: see text] = 0.855; p = 0.0002), respect (x̅ = 0.436; p = 0.0312), work interactions ([Formula: see text] = 0.691; p = 0.0069), perceived interdisciplinary attitudes (x̅ = 0.764; p = 0.0031), and comfort in interdisciplinary learning (x̅ = 1.164; p < 0.0001). There were no changes in interdisciplinary viewpoints observed among non-IDSE interns. IDSE interns were comfortable when learning with interns of different disciplines and believed others viewed their discipline positively compared to non-IDSE interns. Qualitative data uncovered the following themes related to the impact of IDSE including: 1) Relationship building, 2) Communication openness, 3) Attitude shifting, and 4) Enhanced learner experience. CONCLUSIONS: IDSE positively influenced intern outlook on and attitudes towards other medical disciplines. This unique learning environment provided interns an opportunity to learn clinical case management while learning about, from, and with each other; subsequently breaking traditional discipline-specific stereotypes and improving interdisciplinary relations. Future explicit focus on IDSE offers opportunity to improve interdisciplinary interactions and patient care.

Integrating social vulnerability into high-resolution global flood risk mapping.

High-resolution global flood risk maps are increasingly used to inform disaster risk planning and response, particularly in lower income countries with limited data or capacity. However, current approaches do not adequately account for spatial variation in social vulnerability, which is a key determinant of variation in outcomes for exposed populations. Here we integrate annual average exceedance probability estimates from a high-resolution fluvial flood model with gridded population and poverty data to create a global vulnerability-adjusted risk index for flooding (VARI Flood) at 90-meter resolution. The index provides estimates of relative risk within or between countries and changes how we understand the geography of risk by identifying 'hotspots' characterised by high population density and high levels of social vulnerability. This approach, which emphasises risks to human well-being, could be used as a complement to traditional population or asset-centred approaches.

The Krüppel-like factor 2 and Krüppel-like factor 4 genes interact to maintain endothelial integrity in mouse embryonic vasculogenesis.

BACKGROUND: Krüppel-like Factor 2 (KLF2) plays an important role in vessel maturation during embryonic development. In adult mice, KLF2 regulates expression of the tight junction protein occludin, which may allow KLF2 to maintain vascular integrity. Adult tamoxifen-inducible Krüppel-like Factor 4 (KLF4) knockout mice have thickened arterial intima following vascular injury. The role of KLF4, and the possible overlapping functions of KLF2 and KLF4, in the developing vasculature are not well-studied. RESULTS: Endothelial breaks are observed in a major vessel, the primary head vein (PHV), in KLF2-/-KLF4-/- embryos at E9.5. KLF2-/-KLF4-/- embryos die by E10.5, which is earlier than either single knockout. Gross hemorrhaging of multiple vessels may be the cause of death. E9.5 KLF2-/-KLF4+/- embryos do not exhibit gross hemorrhaging, but cross-sections display disruptions of the endothelial cell layer of the PHV, and these embryos generally also die by E10.5. Electron micrographs confirm that there are gaps in the PHV endothelial layer in E9.5 KLF2-/-KLF4-/- embryos, and show that the endothelial cells are abnormally bulbous compared to KLF2-/- and wild-type (WT). The amount of endothelial Nitric Oxide Synthase (eNOS) mRNA, which encodes an endothelial regulator, is reduced by 10-fold in E9.5 KLF2-/-KLF4-/- compared to KLF2-/- and WT embryos. VEGFR2, an eNOS inducer, and occludin, a tight junction protein, gene expression are also reduced in E9.5 KLF2-/-KLF4-/- compared to KLF2-/- and WT embryos. CONCLUSIONS: This study begins to define the roles of KLF2 and KLF4 in the embryonic development of blood vessels. It indicates that the two genes interact to maintain an intact endothelial layer. KLF2 and KLF4 positively regulate the eNOS, VEGFR2 and occludin genes. Down-regulation of these genes in KLF2-/-KLF4-/- embryos may result in the observed loss of vascular integrity.

Mapping urban living standards and economic activity in developing countries with energy data.

Urban data deficits in developing countries impede evidence-based planning and policy. Could energy data be used to overcome this challenge by serving as a local proxy for living standards or economic activity in large urban areas? To answer this question, we examine the potential of georeferenced residential electricity meter data and night-time lights (NTL) data in the megacity of Karachi, Pakistan. First, we use nationally representative survey data to establish a strong association between electricity consumption and household living standards. Second, we compare gridded radiance values from NTL data with a unique dataset containing georeferenced median monthly electricity consumption values for over 2 million individual households in the city. Finally, we develop a model to explain intra-urban variation in radiance values using proxy measures of economic activity from Open Street Map. Overall, we find that NTL data are a poor proxy for living standards but do capture spatial variation in population density and economic activity. By contrast, electricity data are an excellent proxy for living standards and could be used more widely to inform policy and support poverty research in cities in low- and middle-income countries.

High-resolution rural poverty mapping in Pakistan with ensemble deep learning.

High resolution poverty mapping supports evidence-based policy and research, yet about half of all countries lack the survey data needed to generate useful poverty maps. To overcome this challenge, new non-traditional data sources and deep learning techniques are increasingly used to create small-area estimates of poverty in low- and middle-income countries (LMICs). Convolutional Neural Networks (CNN) trained on satellite imagery are emerging as one of the most popular and effective approaches. However, the spatial resolution of poverty estimates has remained relatively coarse, particularly in rural areas. To address this problem, we use a transfer learning approach to train three CNN models and use them in an ensemble to predict chronic poverty at 1 km2 scale in rural Sindh, Pakistan. The models are trained with spatially noisy georeferenced household survey containing poverty scores for 1.67 million anonymized households in Sindh Province and publicly available inputs, including daytime and nighttime satellite imagery and accessibility data. Results from both hold-out and k-fold validation exercises show that the ensemble provides the most reliable spatial predictions in both arid and non-arid regions, outperforming previous studies in key accuracy metrics. A third validation exercise, which involved ground-truthing of predictions from the ensemble model with original survey data of 7000 households further confirms the relative accuracy of the ensemble model predictions. This inexpensive and scalable approach could be used to improve poverty targeting in Pakistan and other low- and middle-income countries.

ARAG, an Antioxidant-Rich Gel, Shows Superiority to Mepilex Ag in the Treatment of Deep Partial Thickness Burns without Sacrificing Antimicrobial Efficiency.

Current treatments for deep tissue burns are limited, and most serve only to enhance hydration or prevent bacterial growth. This leaves burn healing dependent on slow natural processes to debride the wound and reestablish the epidermal and dermal layers of the skin. Infections are well known to destabilize this process through a variety of mechanisms, most notably through increased inflammation and the resulting oxidative stress. In this study, we show that ARAG (an antioxidant-rich antimicrobial gel) can suppress the growth of multiple bacteria commonly found to infect burns (Klebsiella pneumoniae, Proteus vulgaris, Pseudomonas aeruginosa, and Staphylococcus aureus). This inhibition is comparable to that conferred by silver ion release from burn dressings such as Mepilex-Ag. We further show, using a porcine model for deep partial-thickness burns, that ARAG allows for enhanced wound healing over Mepilex-Ag, the current standard of care. Histological findings indicate this is likely due to increased wound debridement and dampening of late inflammatory processes, leading to more balanced physiologic healing. Taken together, these findings show promise for ARAG as a superior alternative to the current standard of care.

Detecting natural occlusion boundaries using local cues.

Occlusion boundaries and junctions provide important cues for inferring three-dimensional scene organization from two-dimensional images. Although several investigators in machine vision have developed algorithms for detecting occlusions and other edges in natural images, relatively few psychophysics or neurophysiology studies have investigated what features are used by the visual system to detect natural occlusions. In this study, we addressed this question using a psychophysical experiment where subjects discriminated image patches containing occlusions from patches containing surfaces. Image patches were drawn from a novel occlusion database containing labeled occlusion boundaries and textured surfaces in a variety of natural scenes. Consistent with related previous work, we found that relatively large image patches were needed to attain reliable performance, suggesting that human subjects integrate complex information over a large spatial region to detect natural occlusions. By defining machine observers using a set of previously studied features measured from natural occlusions and surfaces, we demonstrate that simple features defined at the spatial scale of the image patch are insufficient to account for human performance in the task. To define machine observers using a more biologically plausible multiscale feature set, we trained standard linear and neural network classifiers on the rectified outputs of a Gabor filter bank applied to the image patches. We found that simple linear classifiers could not match human performance, while a neural network classifier combining filter information across location and spatial scale compared well. These results demonstrate the importance of combining a variety of cues defined at multiple spatial scales for detecting natural occlusions.

Emergency medicine residents spend over 7.5 months of their 3-year residency on the electronic health record.

BACKGROUND: Use of the electronic health record (EHR) is a standard component of modern patient care. Although EHRs have improved since inception, cumbersome workflows decrease the time for residents to spend on clinical and educational activities. This study aims to quantify the time spent interacting with the EHR during a 3-year emergency medicine (EM) residency. METHODS: System records of time spent actively engaged in EHR use were analyzed for 98 unique EM residents over a period of 5 years from July 2015 to June 2020. Time spent on the EHR was totaled to give a career time, with a "work month" defined as a 4-week period of 70.5 h per week, based on Accreditation Council for Graduate Medical Education work hour restrictions for EM residents. Engagement in specific activities such as chart review, documentation preparation, and order entry were separately analyzed. RESULTS: Over their 3-year training, a resident interacted with the EHR for 2,171 continuous hours. This amounts to 30.8 work weeks or 7.7 work months. Chart review was the most time-intensive activity at 11.42 weeks. Documentation accounted for 9.91 weeks, with an average career total of 7,280 notes created. Additionally, each resident spent 4.57 weeks on order entry, with 46,347 orders entered during training. While the number of charts opened increased after first year of residency, average time spent on each activity per patient decreased. CONCLUSIONS: This unique study quantifies the total time an EM resident spends on the EHR during a 3-year residency. Use of the EHR accounted for over 7.5 work months or nearly 21% of their training. Residents spend a substantial portion of their training interacting with the EHR and workflow improvements to reduce EHR time are critical for maximizing training time.

Incentives and barriers to pursuing pediatric emergency medicine fellowship: A cross-sectional survey of emergency residents.

BACKGROUND: Pediatric emergency physicians complete either a pediatric or emergency residency before fellowship training. Fewer emergency graduates are pursuing a pediatric emergency fellowship during the past decade, and the reasons for this decrease are unclear. OBJECTIVES: The purpose of this study was to explore emergency residents' incentives and barriers to pursuing a fellowship in pediatric emergency medicine (PEM). METHODS: This was a cross-sectional survey-based study. In 2016, we emailed the study survey to all Emergency Medicine Residents' Association (EMRA) members. Survey questions included respondents' interest in a PEM fellowship and perceived incentives and barriers to PEM. RESULTS: Of 6620 EMRA members in 2016, 322 (5.0%) responded to the survey. Respondents were 59.6% male, with a mean age of 30.6 years. A total of 105 respondents (32.6%) were in their first year of emergency medicine residency, 92 (28.6%) were in their second year, 77 (23.9%) were in their third year, and 48 (14.9%) were in their fourth or fifth year. A total of 102 (31.8%) respondents planned to pursue fellowship training, whereas 120 (37.4%) were undecided. A total of 140 (43.8%) respondents reported considering a PEM fellowship at some point. Among these respondents, the most common incentives for PEM fellowship were (1) a desire to improve pediatric care in community emergency departments (86, 26.7%), (2) to develop an academic focus (54, 16.8%), and (3) because a mentor encouraged a PEM fellowship (40, 12.4%). A perceived lack of financial benefit (142, 44.1%) and length of PEM fellowship training (89, 27.6%) were the most commonly reported barriers. CONCLUSION: In a cross-sectional survey of EMRA members, almost half of the respondents considered a PEM fellowship. PEM leaders who want to promote emergency medicine to pediatric emergency residents will need to leverage the incentives and mitigate the perceived barriers to a PEM fellowship to increase the number of emergency residency applicants.

Unifying Resident Education: 12 Interdisciplinary Critical Care Simulation Scenarios.

Introduction: Unified critical care training within residency education is a necessity. We created a simulation-based curriculum designed to educate residents on core topics and procedural skills, which crossed all adult disciplines caring for critically ill patients. Methods: Residents from seven adult disciplines participated in this annual program during intern year. Learners were grouped into mixed discipline cohorts. Each cohort attended three distinct 4-hour simulation-based sessions, each consisting of four scenarios followed by postevent debriefing. The curriculum included 12 total clinical scenarios. Scenarios covered a broad array of complex critical care topics facing all adult specialties and reinforced important system-specific initiatives. Assessments evaluated clinical performance metrics, self-reported confidence in curricular topics, procedural and communication skills, resident satisfaction, and interdisciplinary attitudes. Results: Quantitative and qualitative data analyzed in three published works over the past 9 years of curricular programming has demonstrated highly satisfied learners along with improved: clinical performance; self-reported confidence in clinical topics, procedural, and communication skills; and interdisciplinary collegiality. Discussion: Purposeful focus on curricular development that integrates basic, clinical, and procedural content, while promoting the development of interdisciplinary relationships and the practice of critical thinking skills, is vital for successful education and patient care. This curriculum was well received by interns, covered difficult to obtain GME milestones, and provided an opportunity for interdisciplinary education. In an era of limited time for devoted bedside teaching and variable training exposures to certain disease processes, the development and implementation of this curriculum has filled a void within our system for unified resident education.

Beware of the Zebra: Nine-year-old with Fever.

An otherwise healthy nine-year-old female who spoke only French presented with abdominal pain, vomiting, intermittent fevers, fatigue, and headache. She then quickly became febrile and altered requiring intubation. When treating a healthy child, the physician may initially develop a differential that includes common illnesses. Yet, as emergency medicine providers, we must be thinking about the "zebras" in order to not miss potentially deadly, curable diseases.

A Mixed-methods Comparison of Participant and Observer Learner Roles in Simulation Education.

BACKGROUND: Traditional simulation-based education prioritizes participation in simulated scenarios. The educational impact of observation in simulation-based education compared with participation remains uncertain. Our objective was to compare the performances of observers and participants in a standardized simulation scenario. METHODS: We assessed learning differences between simulation-based scenario participation and observation using a convergent, parallel, quasi-experimental, mixed-methods study of 15 participants and 15 observers (N = 30). Fifteen first-year residents from six medical specialties were evaluated during a simulated scenario (cardiac arrest due to critical hyperkalemia). Evaluation included predefined critical actions and performance assessments. In the first exposure to the simulation scenario, participants and observers underwent a shared postevent debriefing with predetermined learning objectives. Three months later, a follow-up assessment using the same case scenario evaluated all 30 learners as participants. Wilcoxon signed rank and Wilcoxon rank sum tests were used to compare participants and observers at 3-month follow-up. In addition, we used case study methodology to explore the nature of learning for participants and observers. Data were triangulated using direct observations, reflective field notes, and a focus group. RESULTS: Quantitative data analysis comparing the learners' first and second exposure to the investigation scenario demonstrated participants' time to calcium administration as the only statistically significant difference between participant and observer roles (316 seconds vs. 200 seconds, p = 0.0004). Qualitative analysis revealed that both participation and observation improved learning, debriefing was an important component to learning, and debriefing closed the learning gap between observers and participants. CONCLUSIONS: Participants and observers had similar performances in simulation-based learning in an isolated scenario of cardiac arrest due to hyperkalemia. Findings support current limited literature that observation should not be underestimated as an important opportunity to enhance simulation-based education. When paired with postevent debriefing, scenario observers and participants may reap similar educational benefits.

Academic Life in Emergency Medicine Blog and Podcast Watch: Respiratory Emergencies.

The Academic Life in Emergency Medicine (ALiEM) Approved Instructional Resources (AIR) Series and Approved Instruction Resources Professional (AIR-Pro) Series were created in 2014 and 2015, respectively, to address the need for curation of online educational content as well as a nationally available curriculum that meets individualized interactive instruction criteria. These two programs identify high-quality educational blog and podcast content using an expert-based approach. We summarize the accredited posts on respiratory emergencies that met our a priori determined quality criteria per evaluation by eight experienced faculty educators in emergency medicine.

CHEMGENIE: integration of chemogenomics data for applications in chemical biology.

Increasing amounts of biological data are accumulating in the pharmaceutical industry and academic institutions. However, data does not equal actionable information, and guidelines for appropriate data capture, harmonization, integration, mining, and visualization need to be established to fully harness its potential. Here, we describe ongoing efforts at Merck & Co. to structure data in the area of chemogenomics. We are integrating complementary data from both internal and external data sources into one chemogenomics database (Chemical Genetic Interaction Enterprise; CHEMGENIE). Here, we demonstrate how this well-curated database facilitates compound set design, tool compound selection, target deconvolution in phenotypic screening, and predictive model building.

2018 Academic Emergency Medicine Consensus Conference: Advancing Pediatric Emergency Medicine Education Through Research and Scholarship.

To achieve high-quality emergency care for pediatric patients nationwide, it is necessary to define the key elements for pediatric emergency medicine (PEM) education and scholarship that would: 1) close the gaps in fundamental PEM education and 2) promote systems and standards that assure an ongoing communication of best practices between tertiary pediatric institutions, general (nonchildren's) hospital emergency departments, and urgent care centers. A working group of medical educators was formed to review the literature, develop a framework for consensus discussion at the breakout session, and then translate their findings into recommendations for future research and scholarship. The breakout session consensus discussion yielded many recommendations. The group concluded that future progress depends on multicenter collaborations as a PEM education research network and a unified vision for PEM education that bridges organizations, providers, and institutions to assure the best possible outcomes for acutely ill or injured children.

Pediatric Abdominal Pain: An Emergency Medicine Perspective.

Abdominal pain is a common complaint that leads to pediatric patients seeking emergency care. The emergency care provider has the arduous task of determining which child likely has a benign cause and not missing the devastating condition that needs emergent attention. This article reviews common benign causes of abdominal pain as well as some of the cannot-miss emergent causes.

Consensus development of a pediatric emergency medicine clerkship curriculum.

INTRODUCTION: As emergency medicine (EM) has become a more prominent feature in the clinical years of medical school training, national EM clerkship curricula have been published to address the need to standardize students' experiences in the field. However, current national student curricula in EM do not include core pediatric emergency medicine (PEM) concepts. METHODS: A workgroup was formed by the Clerkship Directors in Emergency Medicine and the Pediatric Interest Group of the Society of Academic Emergency Medicine to develop a consensus on the content to be covered in EM and PEM student courses. RESULTS: The consensus is presented with the goal of outlining principles of pediatric emergency care and prioritizing students' exposure to the most common and life-threatening illnesses and injuries. CONCLUSION: This consensus curriculum can serve as a guide to directors of PEM and EM courses to optimize PEM knowledge and skills education.

Pediatric seizures.

Seizures are a commonly encountered condition within the emergency department and, because of this, can engender complacency on the part of the physicians and staff. Unfortunately, there is significant associated morbidity and mortality with seizures, and they should never be regarded as routine. This point is particularly important with respect to seizures in pediatric patients. The aim of this review is to provide a current view of the various issues that make pediatric seizures unique and to help elucidate emergent evaluation and management strategies.