Improving Head CT Scan Decisions for Pediatric Minor Head Trauma in General Emergency Departments: A Pragmatic Implementation Study.

STUDY OBJECTIVE: To measure the effectiveness of a multimodal strategy, including simultaneous implementation of a clinical decision support system, to sustain adherence to a clinical pathway for care of children with minor head trauma treated in general emergency departments (EDs). METHODS: Prospective, type III hybrid effectiveness-implementation cohort study with a nonrandomized stepped-wedge design and monthly repeated site measures. The study population included pediatric minor head trauma encounters from July 2018 to December 2020 at 21 urban and rural general ED sites in an integrated health care system. Sites received the intervention in 1 of 2 steps, with each site providing control and intervention observations. Measures included guideline adherence, the computed tomography (CT) scan rate, and 72-hour readmissions with clinically important traumatic brain injury. Analysis was performed using multilevel hierarchical modeling with random intercepts for the site and physician. RESULTS: During the study, 12,670 pediatric minor head trauma encounters were cared for by 339 clinicians. The implementation of the clinical pathway resulted in higher odds of guideline adherence (adjusted odds ratio 1.12 [95% confidence interval 1.03 to 1.22]) and lower odds of a CT scan (adjusted odds ratio 0.96 [95% confidence interval 0.93 to 0.98]) in intervention versus control months. Absolute risk difference was observed in both guideline adherence (site median: +2.3% improvement) and the CT scan rate (site median: -6.6% reduction). No 72-hour readmissions with confirmed clinically important traumatic brain injury were identified. CONCLUSION: Implementation of a minor head trauma clinical pathway using a multimodal approach, including a clinical decision support system, led to sustained improvements in adherence and a modest, yet safe, reduction in CT scans among generally low-risk patients in diverse general EDs.

Native Bacterial Community Convergence in Augmented and Stimulated Ureolytic MICP Biocementation.

Microbially induced calcite precipitation is a biomineralization process with numerous civil engineering and ground improvement applications. In replicate soil columns, the efficacy and microbial composition of soil bioaugmented with the ureolytic bacterium Sporosarcina pasteurii were compared to a biostimulation method that enriches native ureolytic soil bacteria in situ under conditions analogous to field implementation. The selective enrichment resulting from sequential stimulation treatments strongly selected for Firmicutes (>97%), with Sporosarcina and Lysinibacillus comprising 60 to 94% of high-throughput 16S rDNA sequences in each suspended community sample. Seven species of the former and two of the latter were present in greater than 10% abundance at different times, demonstrating unexpected within-genus diversity and robustness in the suspended phase of this highly selective environment. Based on longer 16S sequences, it was inferred that augmented S. pasteurii competed poorly with natural bacteria, decreasing to below detection after nine treatments, while the native microbial community was enriched to approximately that present in the stimulated columns. These analyses were corroborated by the observed convergence in bulk ureolytic rates and calcite contents between techniques. However, a 10-fold discrepancy between the observed cell density and an activity-based estimate indicates the attached community, uncharacterized despite efforts, substantially contributes to bulk behavior.

Intravenous Magnesium in Asthma Pharmacotherapy: Variability in Use in the PECARN Registry.

OBJECTIVE: To examine the use, efficacy, and safety of intravenous magnesium sulfate (IVMg) in children with asthma whose emergency department (ED) management is recorded in the Pediatric Emergency Care Applied Research Network (PECARN) Registry. STUDY DESIGN: This multicenter retrospective cohort study analyzed clinical data from 7 EDs from 2012 to 2017. We described use of IVMg in children aged 2-17 years treated for acute asthma and its effect on blood pressure. We also used multivariable analysis to examine factors associated with use of IVMg and its association with return visits within 72 hours. RESULTS: Across 61 854 asthma visits for children, clinicians administered IVMg in 6497 (10.5%). Median time from triage to IVMg administration was 154 minutes (IQR 84, 244). During 22 495 ED visits resulting in hospitalization after ED treatment, IVMg was administered in 5774 (25.7%) (range by site 15.9%, 50.6%). Patients were discharged home from the ED after 11.1% of IVMg administrations, and hypotension occurred after 6.8%. Variation in IVMg use was not explained by patient characteristics. Revisits did not differ between patients discharged after IVMg and those not receiving IVMg. CONCLUSIONS: In PECARN Registry EDs, administration of IVMg occurs late in ED treatment, for a minority of the children likely to benefit, with variation between sites, which suggests the current clinical role for IVMg in preventing hospitalization is limited. Discharge after IVMg administration is likely safe. Further research should prospectively assess the efficacy and safety of early IVMg administration.

Prospective study of serum and ionized magnesium pharmacokinetics in the treatment of children with severe acute asthma.

PURPOSE: Intravenous (IV) magnesium sulfate (MgSO4) is clinically useful as adjunct therapy in treating acute asthma exacerbations. Despite its clinical utility, the disposition of magnesium in children is poorly described. The purpose of this study is to describe the pharmacokinetics (PK) of ionized and total serum magnesium following IV MgSO4 administration in children with severe acute asthma. METHODS: Thirty-two children receiving 50 mg/kg IV MgSO4 for acute asthma exacerbations at Primary Children's Hospital in Salt Lake City, UT, were prospectively enrolled in the study. Blood samples were collected before, as well as 30 min and 2 h after each child's IV MgSO4 dose, and used to determine total serum and ionized magnesium concentrations. The collected data were analyzed using population PK techniques using NONMEM® software. RESULTS: Total serum magnesium concentrations were used to externally validate our previously published model constructed with retrospective data (median prediction error 10.3%, median absolute prediction error 18.1%). The mean (%CV) observed endogenous ionized magnesium concentration was calculated to be 6.0 mg/L (12%), approximately one third of the same value for endogenous total serum magnesium (17.6 mg/L (22%)) in this dataset. Weight was a significant predictor of both clearance and volume in a population PK model describing ionized magnesium concentrations. No adverse events were observed in this pediatric cohort. CONCLUSIONS: This prospective study supports and extends our previous PK analysis of total serum magnesium concentrations. Ionized and total serum magnesium followed similar PK profiles following IV MgSO4 administration in children. A single bolus infusion of IV MgSO4 was safe in this small sample of children receiving it for acute asthma.

Diversity of Sporosarcina-like Bacterial Strains Obtained from Meter-Scale Augmented and Stimulated Biocementation Experiments.

Microbially Induced Calcite Precipitation (MICP) is a biomediated soil cementation process that offers an environmentally conscious alternative to conventional geotechnical soil improvement technologies. This study provides the first comparison of ureolytic bacteria isolated from sand cemented in parallel, meter-scale, MICP experiments using either biostimulation or bioaugmentation approaches, wherein colonies resembling the augmented strain ( Sporosarcina pasteurii ATCC 11859) were interrogated. Over the 13 day experiment, 47 of the 57 isolates collected were strains of Sporosarcina and the diversity of these strains was high, with 20 distinct strains belonging to 5 species identified. Although the S. pasteurii inoculant used for augmentation was recovered immediately after introduction in the augmented specimen, the strain was not recovered after 8 days in either augmented or stimulated soils, suggesting that it competes poorly with indigenous bacteria. Past studies on the physiological properties of S. pasteurii ATCC 11859 suggest that close relatives may have selective advantages under the biogeochemical conditions employed during MICP; however, the extent to which these properties apply to isolates of the current study is unknown. Whole cell urease kinetic properties were investigated for representative isolates and suggest up to 100-fold higher rates of carbonate production when compared to other biomediated processes proposed for MICP.

Noise-robust speech triage.

A method is presented in which conventional speech algorithms are applied, with no modifications, to improve their performance in extremely noisy environments. It has been demonstrated that, for eigen-channel algorithms, pre-training multiple speaker identification (SID) models at a lattice of signal-to-noise-ratio (SNR) levels and then performing SID using the appropriate SNR dependent model was successful in mitigating noise at all SNR levels. In those tests, it was found that SID performance was optimized when the SNR of the testing and training data were close or identical. In this current effort multiple i-vector algorithms were used, greatly improving both processing throughput and equal error rate classification accuracy. Using identical approaches in the same noisy environment, performance of SID, language identification, gender identification, and diarization were significantly improved. A critical factor in this improvement is speech activity detection (SAD) that performs reliably in extremely noisy environments, where the speech itself is barely audible. To optimize SAD operation at all SNR levels, two algorithms were employed. The first maximized detection probability at low levels (-10 dB ≤ SNR < +10 dB) using just the voiced speech envelope, and the second exploited features extracted from the original speech to improve overall accuracy at higher quality levels (SNR ≥ +10 dB).

A strategic cleaning assessment program: menu cleanliness at restaurants.

The importance of clean food contact surfaces has been recognized; however, the importance of cleanliness on nonfood contact surfaces such as menus may be underestimated. The aim of the study described in this article was to determine the cleanliness of restaurant menus, evaluate typical cleaning methods used in a restaurant, and provide recommendations for improving menu cleanliness. The authors' study used an adenosine triphosphate meter to assess the cleanliness of the menus. A pretest identified the most commonly touched areas of the menu by consumers. Based on the results of the pretest, menus were collected from casual-family dining restaurants and analyzed for cleanliness. Results suggested that menus should be cleaned after each shift and that menus distributed by the staff when guests are seated are cleaner than those kept on the table.

Home Delivery Meal Kits Online Food Safety-Related Information: A Perspective.

The recent popularity of home delivery meal kits (HMK) has prompted concerns about its integrity and safety. On the basis of a food safety-related information evaluation of the common US-based HMK vendors' websites, this perspective highlights opportunities for improvement with the adequacy and accessibility of relevant information on HMK websites, an important resource for communicating food safety best practices to consumers. Identified gaps in information and inadequate delivery protocols potentially increase the risk of offering unsafe food to consumers. Suggestions for future research and recommendations for vendors, policymakers, and regulators to help protect consumers from potential foodborne illness risks are also discussed.

Synergistic Evolution of Alloy Nanoparticles and Carbon in Solid-State Lithium Metal Anode Composites at Low Stack Pressure.

Solid-state batteries with Li metal anodes can offer increased energy density compared to Li-ion batteries. However, the performance of pure Li anodes has been limited by morphological instabilities at the interface between Li and the solid-state electrolyte (SSE). Composites of Li metal with other materials such as carbon and Li alloys have exhibited improved cycling stability, but the mechanisms associated with this enhanced performance are not clear, especially at the low stack pressures needed for practical viability. Here, we investigate the structural evolution and correlated electrochemical behavior of Li metal composites containing reduced graphene oxide (rGO) and Li-Ag alloy particles. The nanoscale carbon scaffold maintains homogeneous contact with the SSE during stripping and facilitates Li transport to the interface; these effects largely prevent interfacial disconnection even at low stack pressure. The Li-Ag is needed to ensure cyclic refilling of the rGO scaffold with Li during plating, and the solid-solution character of Li-Ag improves cycling stability compared to other materials that form intermetallic compounds. Full cells with sulfur cathodes were tested at relatively low stack pressure, achieving 100 stable cycles with 79% capacity retention.

How activation, entanglement, and searching a semantic network contribute to event memory.

Free-association norms indicate that words are organized into semantic/associative neighborhoods within a larger network of words and links that bind the net together. We present evidence indicating that memory for a recent word event can depend on implicitly and simultaneously activating related words in its neighborhood. Processing a word during encoding primes its network representation as a function of the density of the links in its neighborhood. Such priming increases recall and recognition and can have long-lasting effects when the word is processed in working memory. Evidence for this phenomenon is reviewed in extralist-cuing, primed free-association, intralist-cuing, and single-item recognition tasks. The findings also show that when a related word is presented in order to cue the recall of a studied word, the cue activates the target in an array of related words that distract and reduce the probability of the target's selection. The activation of the semantic network produces priming benefits during encoding, and search costs during retrieval. In extralist cuing, recall is a negative function of cue-to-distractor strength, and a positive function of neighborhood density, cue-to-target strength, and target-to-cue strength. We show how these four measures derived from the network can be combined and used to predict memory performance. These measures play different roles in different tasks, indicating that the contribution of the semantic network varies with the context provided by the task. Finally, we evaluate spreading-activation and quantum-like entanglement explanations for the priming effects produced by neighborhood density.

A case of infraorbital lichen sclerosus.

We present a 57-year-old man with erosive lichen sclerosus isolated to the infraorbital area.

Enhancing medical device training with hybrid physical-virtual simulators: smart peripherals for virtual devices.

We introduce a novel platform for medical device training: hybrid physical-virtual simulators of medical devices, combining touchscreen-enabled virtual emulations of real devices with sensorized physical peripherals to enable tactile, hands-on interaction between the trainee, simulated device and standardized patients or mannequins. The system enables objective measurement and recording of trainee performance, including interactions with both the virtual device elements and the physical components, and can include metrics and feedback not available in the real device. The system also includes an integrated wireless signaling device for use with standardized patients. We present the implementation of an example system, a virtual defibrillator with sensorized paddles and wireless signaling of successful defibrillator operation.

Fast-Food Optimal Defaults Reduce Calories Ordered, as Well as Dietary Autonomy: A Scenario-Based Experiment.

BACKGROUND: Low-calorie menu items as optimal defaults may encourage healthier choices when people eat out. Limited research has studied default effects from the restauranteurs' perspective, as well as the public health perspective. OBJECTIVE: To examine the effects of optimal defaults on calories ordered, dietary autonomy, and visit intention in the context of a fast-food drive-through. DESIGN: Between-subjects randomized scenario-based experiment. PARTICIPANTS/SETTING: In all, 377 adults who lived in the United States were recruited through a crowdsourcing platform in July 2020. INTERVENTION: Participants were asked to visualize ordering a combo meal in a fast-food drive-through. They were randomly assigned to order from 1 of 3 menu boards: (1) menu items available for combos by customer choice, (2) combos that included traditional high-calorie default items, or (3) combos that included low-calorie optimal defaults. MAIN OUTCOME MEASURES: Differences in calories ordered among groups, dietary autonomy, and restaurant visit intention. ANALYSIS: Statistical tests included multiple regression, Kruskal-Wallis, χ2, and 1-way analysis of variance. Covariates such as education and sex were tested in regression models as potential confounders. RESULTS: Compared with the choice combo meals, optimal combo meals reduced calories ordered by consumers (-337 kcal, standard error = 19, P < .001), while traditional combos increased them (+132 kcal, standard error = 20, P < .001). No significant difference was found in visit intention. Dietary autonomy was affected by the optimal defaults (P = .025), even in participants with high health concern. Conversely, the traditional combo's effect on dietary autonomy was moderated by health concern (B = -0.26, P = .023), with only individuals with very high levels of health concern perceiving less autonomy. CONCLUSIONS: Optimal defaults provided a robust reduction in calories ordered but had implications for dietary autonomy.

Visual Cues and Optimal Defaults in Fast-Food Combo Meals Benefit Health-Concerned Consumers-A Randomized Scenario-Based Experiment.

BACKGROUND: The use of low-calorie menu items as optimal defaults and visual cues may nudge consumers to healthier choices at restaurants. However, little is known regarding their effects on emotions and behavioral intentions, particularly among people with different levels of health concern. OBJECTIVE: Evaluate optimal defaults and visual cues' effect on anticipated pleasure and order intention depending upon consumers' health concern level. DESIGN: Between-subjects randomized scenario-based experiment. PARTICIPANTS/SETTING: In all, 636 US adults recruited through an online crowdsourcing platform in July 2020. INTERVENTION: Participants saw 1 of 6 menu boards in a fast-food drive-through simulation. Half the menu boards included meal photos with (1) menu items to be arranged as a combo by choice (ie, create-your-own combo); (2) traditional combos that included high-calorie default items; or (3) optimal combos that included low-calorie default items. The remaining 3 boards were identical without photos. MAIN OUTCOME MEASURES: Anticipated pleasure, order intention, and health concern were evaluated with 7-point Likert scales. ANALYSIS: Statistical tests included multiple regression, Kruskal-Wallis, χ2, and analysis of variance. Education and sex were tested as potential confounders. RESULTS: Optimal combos negatively affected anticipated pleasure (P = .003) and order intention (P < .001) compared with choice combos. Order intention reduction was the same for traditional and optimal combos (P = .128). The presence of photos changed order intention for optimal combos but varied by consumer's health concern level. When health concern was lower, photos decreased the likelihood of ordering the optimal combos (B = -3.06, P = .001), but when health concern was higher, photos enhanced ordering intention compared with the choice group (B = 0.60, P = .001). The photos did not affect anticipated pleasure for any level of health concern. CONCLUSIONS: The adverse effect of optimal defaults and how visual cues may reduce their negative effect should be considered in menu design.

Delayed song maturation and territorial aggression in a songbird.

Asymmetries in competitive ability can determine the outcome of social interactions in animals and are often expressed through differences in sexual traits. Competitive ability (resource holding potential, RHP), trait expression and ultimately reproductive success may vary with an individual's age or experience. In some species, reproductively mature males delay acquisition of some adult traits and thereby signal their young age. Theory on animal contests predicts that individuals assess the RHP of an opponent relative to their own, such that escalation is more common between evenly matched opponents. Here, we test predictions from this hypothesis that males respond to a territorial intruder based on their RHP relative to the intruder's RHP. We simulated white-crowned sparrows (Zonotrichia leucophrys) intruding into the territory of a recruit or return. Playback of a song repertoire simulating a young male (recruit) elicited a weaker response from established territory holders (return), but a stronger response from recruits. Playback of a single song type simulating an older male elicited the opposite responses. This indicates that males distinguished between simulated young and old intruders based on song, and responded differently depending on their own experience. Our study highlights the possibility that receiver as well as sender traits should be considered when interpreting animal interactions.

Should we fear "flu fear" itself? Effects of H1N1 influenza fear on ED use.

BACKGROUND: Surges in patient volumes compromise emergency departments' (EDs') ability to deliver care, as shown by the recent H1N1 influenza (flu) epidemic. Media reports are important in informing the public about health threats, but the effects of media-induced anxiety on ED volumes are unclear. OBJECTIVE: The aim of this study is to examine the effect of widespread public concern about flu on ED use. METHODS: We reviewed ED data from an integrated health system operating 18 hospital EDs. We compared ED visits during three 1-week periods: (a) a period of heightened public concern regarding flu before the disease was present ("Fear Week"), (b) a subsequent period of active disease ("Flu Week"), and (c) a week before widespread concern ("Control Week"). Fear Week was identified from an analysis of statewide Google electronic searches for "swine flu" and from media announcements about flu. Flu Week was identified from statewide epidemiological data. RESULTS: Data were reviewed from 22 608 visits during the study periods. Fear Week (n = 7712) and Flu Week (n = 7687) were compared to Control Week (n = 7209). Fear Week showed a 7.0% increase in visits (95% confidence interval, 6-8). Pediatric visits increased by 19.7%, whereas adult visits increased by 1%. Flu Week showed an increase over Control Week of 6.6% (95% confidence interval, 6-7). Pediatric visits increased by 10.6%, whereas adult visits increased by 4.8%. CONCLUSION: At a time of heightened public concern regarding flu but little disease prevalence, EDs experienced substantial increases in patient volumes. These increases were significant and comparable to the increases experienced during the subsequent epidemic of actual disease.

A novel automated drug simulant recognition system for naturalistic real-time medical simulation.

The ability for a medical simulator to automatically recognize and respond to a "drug" injected during a training exercise offers powerful capabilities for objective assessment and real-time interaction. To address some of the limitations of available mannequin drug recognition systems, we developed a novel sensing system that recognizes an IV-injected agent based on an inherent property of the fluid. Our system uses varying concentrations of saline to represent different drugs and identification is made via conductivity measurement. The system also determines the volume administered and the time over which the dose is injected. Simulant solutions in IV bags (e.g., simulated Hextend or crystalloids) can be identified even if the bag is placed at a distance from the body. The system may offer advantages for field training exercises, as no external components need to be attached to the syringe or IV bag.

BodyWindows: enhancing a mannequin with projective augmented reality for exploring anatomy, physiology and medical procedures.

Augmented reality offers the potential to radically extend and enhance the capabilities of physical medical simulators such as full-body mannequin trainers. We have developed a system that transforms the surface of a mannequin simulator into both a display screen and an input device. The BodyWindows system enables a user to open, size, and reposition multiple viewports onto the simulator body. We demonstrate a dynamic viewport that displays a beating heart. Similar viewports could be used to display real-time physiological responses to interventions the user applies to the mannequin, such as injection of a simulated drug. Viewport windows can be overlapping and show anatomy at different depths, creating the illusion of "cutting" multiple windows into the body to reveal structures at different depths from the surface. The developed low-cost interface employees an IR light pen and the Nintendo Wiimote. We also report experiments using the Microsoft Kinect computer vision sensor to provide a completely hand-gesture based interface.

PleurAlert: an augmented chest drainage system with electronic sensing, automated alerts and internet connectivity.

We have enhanced a common medical device, the chest tube drainage container, with electronic sensing of fluid volume, automated detection of critical alarm conditions and the ability to automatically send alert text messages to a nurse's cell phone. The PleurAlert system provides a simple touch-screen interface and can graphically display chest tube output over time. Our design augments a device whose basic function dates back 50 years by adding technology to automate and optimize a monitoring process that can be time consuming and inconvenient for nurses. The system may also enhance detection of emergency conditions and speed response time.