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COVID-19 vaccinations are now recommended in the United States (U.S.) for children ≥ 6 months old. However, pediatric vaccination rates remain low, particularly in the Hispanic/Latinx population.Using the 4C vaccine hesitancy framework (calculation, complacency, confidence, convenience), we examined parental attitudes in the emergency department (ED) towards COVID-19 vaccination, identified dimensions of parental vaccine hesitancy, and assessed parental willingness to have their child receive the COVID-19 vaccine.As part of a larger multi-methods study examining influenza vaccine hesitancy, we conducted interviews that included questions about COVID-19 vaccine authorization for children. We used directed content analysis to extract qualitative themes from 3 groups of parents in the ED: Hispanic/Latinx Spanish speaking (HS), Hispanic/Latinx English speaking (HE), non-Hispanic/non-Latinx White English speaking (WE). Themes were triangulated with the Parent Attitudes about Childhood Vaccines (PACV) survey, where higher scores indicate increased vaccine hesitancy.Factors influencing vaccine hesitancy were mapped to the 4C framework from 58 sets of interviews and PACVs. HE and HS parents, compared to WE parents, had less knowledge about COVID-19 and its vaccine, and more beliefs in COVID-19 vaccine myths. However, both HS and HE parent groups were more inclined to endorse COVID-19 vaccine effectiveness as a reason to have their children vaccinated. HS parents felt that COVID-19 increased their fear of illnesses in general and were worried about confusing COVID-19 with other infections. Median PACV scores of HS (Mdn = 20) and HE (Mdn = 20) parent groups were higher than of WE parents (Mdn = 10), but parental willingness to have their child receive COVID-19 vaccination was similar across groups.Higher COVID-19 vaccine hesitancy among HS and HE parents compared to WE parents may be attributed to insufficient knowledge about COVID-19, its vaccine, along with COVID-19 vaccine myths. Efforts to provide targeted vaccine education to different populations is warranted.

Two previously unreported dimethylpyranoflavanones, pyronomelodorones A and B (1 and 2), along with five known compounds, 7-O-methyldihydrowogonin (3), 5,6,7-trimethoxyflavanone (4), 5,6-dihydroxy-7-methoxy-dihydroflavone (5), 5,7,8-trimethoxydihydroflavone (6), and pinostrobin (7), were isolated from the roots of Melodorum fruticosum. The structures of all isolates were fully characterized using spectroscopic data and comparison with the previous literature. All isolates were evaluated for their in vitro α-glucosidase inhibition and their cytotoxicity against KB, HepG2, and MCF7 cell lines. Among the isolates, compound 1 exhibited the most inhibitory activity against α-glucosidase and was superior to the positive control with an IC50 value of 1.32 μM. Compounds 1 and 2 showed weak cytotoxicity against the three human cancer cell lines, with IC50 values in the range of 53.3–79.0 μM.

Introduction:The majority of pediatric medications are dosed according to weight and therefore accurate weight assessment is essential. However, this can be difficult in the unpredictable and peripatetic prehospital care setting, and medication errors are common. The Handtevy method and the Broselow tape are two systems designed to guide Emergency Medical Services (EMS) providers in both pediatric patient weight estimation and medication dosing. The accuracy of the Handtevy method of weight estimation as practiced in the field by EMS has not been previously examined.Study Objective:The primary objective of this study was to examine the field performance of the Handtevy method and the Broselow tape with respect to prehospital patient weight estimation.Methods:This was a retrospective chart review of trauma and non-trauma patients transported by EMS to the emergency department (ED) of a quaternary care children’s hospital from January 1, 2021 through June 30, 2021. Demographic data, ED visit information, prehospital weight estimation, and medication dosing were collected and analyzed. Scale-based weight from the ED was used as the standard for comparison.Results:A total of 509 patients Conclusion:This study demonstrated no statistically significant difference between the use of the Handtevy or Broselow methods with respect to prehospital weight estimation. While further research is necessary, these results suggest similar field performance of the Broselow and Handtevy methods.

Depolymerization of lignin is an important step to obtain a lignin monomer for the synthesis of functional chemicals. In the context of more lignin produced from biomass and pulp industry, converting real lignin with low purity is still required more studies. In this study, the influence of solvent composition and reaction parameters such as binary solvents ratio, time, and temperature, the solvent-to-lignin ratio on the depolymerization of rice straw lignin was investigated carefully. Essential lignin-degraded products including liquid product (LP), char (solid), and gas were obtained, and their yields were directly influenced by reaction conditions. Results show that the maximum lignin conversion rate of 92% and LP yield of 66% was under the condition of 275°C, 30 min, 75 : 1 (mL solvent/1 g lignin), and ethanol 50%. Gas chromatography-mass spectroscopy (GC-MS) analysis was used for the analysis of the depolymerization products and identified 11 compounds which are mainly phenolic compounds such as 2-ethylphenol, 3-ethylphenol, phenol, methyl 2,4,6-trimethylbenzoate. The structure changes of LP and char in various conditions were analyzed using Fourier-transform infrared (FTIR).

In a world where demands for freshwater are ever-growing, wastewater remediation becomes a global concern. Especially, water, which is contaminated by oil, dyes, poses challenges to the management of water resources. The development of innovative processes for wastewater treatment is still a major obstacle. With regard to its fast removal rate and environmental compatibility, cellulose aerogel composites are recently considered as a potential contributor for water remediation. In this study, cellulose aerogel composites are fabricated using the sol-gel method from two-agroindustrial wastes: pineapple leaf fibers and cotton waste fibers in alkali-urea solution followed by freeze-drying. The prepared cellulose aerogel composites are extremely lightweight with a low density (0.053−0.069 g.cm−3) and high porosity of nearly 95%. It is worth noting that the mechanical strength of the cellulose aerogel composites is remarkably improved with their Young’s modulus increasing by 5-9 times compared to that of the previous aerogel composites using polyvinyl alcohol as a binder. The as-synthesized aerogel composites are directly applied to adsorb cationic methylene blue and exhibit a maximum adsorption uptake of 34.01 g.g-1. The methyltrimethoxysilane-coated cellulose aerogel composites also show their ability to deal with oil pollution with a maximum oil adsorption capacity of 15.8 g.g−1 within only 20 sec. Besides the oil removal, our developed cellulose aerogel composites have demonstrated their capability in treating dye-contaminated wastewater for the first time based on their evidenced ability to eliminate methylene blue.

Background: Increased data availability has prompted the creation of clinical decision support systems. These systems utilise clinical information to enhance health care provision, both to predict the likelihood of specific clinical outcomes or evaluate the risk of further complications. However, their adoption remains low due to concerns regarding the quality of recommendations, and a lack of clarity on how results are best obtained and presented. Methods: We used autoencoders capable of reducing the dimensionality of complex datasets in order to produce a 2D representation denoted as latent space to support understanding of complex clinical data. In this output, meaningful representations of individual patient profiles are spatially mapped in an unsupervised manner according to their input clinical parameters. This technique was then applied to a large real-world clinical dataset of over 12,000 patients with an illness compatible with dengue infection in Ho Chi Minh City, Vietnam between 1999 and 2021. Dengue is a systemic viral disease which exerts significant health and economic burden worldwide, and up to 5% of hospitalised patients develop life-threatening complications. Results: The latent space produced by the selected autoencoder aligns with established clinical characteristics exhibited by patients with dengue infection, as well as features of disease progression. Similar clinical phenotypes are represented close to each other in the latent space and clustered according to outcomes broadly described by the World Health Organisation dengue guidelines. Balancing distance metrics and density metrics produced results covering most of the latent space, and improved visualisation whilst preserving utility, with similar patients grouped closer together. In this case, this balance is achieved by using the sigmoid activation function and one hidden layer with three neurons, in addition to the latent dimension layer, which produces the output (Pearson, 0.840; Spearman, 0.830; Procrustes, 0.301; GMM 0.321). Conclusion: This study demonstrates that when adequately configured, autoencoders can produce two-dimensional representations of a complex dataset that conserve the distance relationship between points. The output visualisation groups patients with clinically relevant features closely together and inherently supports user interpretability. Work is underway to incorporate these findings into an electronic clinical decision support system to guide individual patient management.

This paper attempts to develop an application that converts Tamil and Vietnamese speech to text, with a view to encourage usage and indirectly ensure linguistic preservation of a classical language. The application converts spoken Tamil and Vietnamese to text without auto-correction, code-mixing or code-switching. This paper proposed a complete web application, which, when perfected, could be used to act as a teaching tool to encourage correct pronunciation of syllables and words for native and non-native Tamil and Vietnamese speakers. The paper further explores similarities and differences in the two contexts.

ImportancePediatric emergency department (ED) visits for mental health crises are increasing. Patients who frequently use the ED are of particular concern, as pediatric mental health ED visits are commonly repeat visits. Better understanding of trends and factors associated with mental health ED revisits is needed for optimal resource allocation and targeting of prevention efforts.ObjectiveTo describe trends in pediatric mental health ED visits and revisits and to determine factors associated with revisits.Design, Setting, and ParticipantsIn this cohort study, data were obtained from 38 US children’s hospital EDs in the Pediatric Health Information System between October 1, 2015, and February 29, 2020. The cohort included patients aged 3 to 17 years with a mental health ED visit.ExposuresCharacteristics of patients, encounters, hospitals, and communities.Main Outcomes and MeasuresThe primary outcome was a mental health ED revisit within 6 months of the index visit. Trends were assessed using cosinor analysis and factors associated with time to revisit using mixed-effects Cox proportional hazards regression.ResultsThere were 308 264 mental health ED visits from 217 865 unique patients, and 13.2% of patients had a mental health revisit within 6 months. Mental health visits increased by 8.0% annually (95% CI, 4.5%-11.4%), whereas all other ED visits increased by 1.5% annually (95% CI, 0.1%-2.9%). Factors associated with mental health ED revisits included psychiatric comorbidities, chemical restraint use, public insurance, higher area measures of child opportunity, and presence of an inpatient psychiatric unit at the presenting hospital. Patients with psychotic disorders (hazard ratio [HR], 1.42; 95% CI, 1.29-1.57), disruptive or impulse control disorders (HR, 1.36; 95% CI, 1.30-1.42), and neurodevelopmental disorders (HR, 1.22; 95% CI, 1.14-1.30) were more likely to revisit. Patients with substance use disorders (HR, 0.60; 95% CI, 0.55-0.66) were less likely to revisit.Conclusions and RelevanceMarkers of disease severity and health care access were associated with mental health revisits. Directing hospital and community interventions toward identified high-risk patients is needed to help mitigate recurrent mental health ED use and improve mental health care delivery.

Background Communication failures secondary to damaged infrastructure have caused difficulties in coordinating disaster responses. Two-way radios commonly serve as backup communication for hospitals. However, text messaging has become widely adopted in daily life and new technologies such as wireless mesh network (WMN) devices allow for text messaging independent of cellular towers, Wi-Fi networks, and electrical grids. Objective To examine the accuracy of communication using text-based messaging transmitted over WMN devices (TEXT-WMN) compared to voice transmitted over two-way radios (VOICE-TWR) in disaster simulations. Secondary outcomes were patient triage accuracy, perceived workload, and device preference. Methods 2 × 2 Latin square crossover design: 2 simulations (each involving 15 min of simulated hospital-wide disaster communication) by 2 modalities (TEXT-WMN and VOICE-TWR). Physicians were randomized to one of two sequences: VOICE-TWR first and TEXT-WMN second; or TEXT-WMN first and VOICE-TWR second. Analyses were conducted using linear mixed effects modeling. Results On average, communication accuracy significantly improved with TEXT-WMN compared to VOICE-TWR. Communication accuracy also significantly improved, on average, during the second simulation compared to the first. There was no significant change in triage accuracy with either TEXT-WMN or VOICE-TWR; however, triage accuracy significantly improved, on average, during the second simulation compared to the first. On average, perceived workload was significantly lower with TEXT-WMN compared to VOICE-TWR, and was also significantly lower during the second simulation compared to the first. Most participants preferred TEXT-WMN to VOICE-TWR. Conclusion TEXT-WMN technology may be more effective and less burdensome than VOICE-TWR in facilitating accurate communication during disasters.

A small number of children in the United States use a disproportionate share of emergency healthcare services. Our study objective was to examine characteristics associated with frequent pediatric emergency department (PED) utilization.A retrospective cohort-sequential study of patients seen in the PED of an urban children's hospital was conducted. Patients were categorized into 2 groups: infrequent users (4 visits during index year 2017) and frequent users (≥4 visits in 2017). Frequent PED users were further divided into persistent frequent (≥4 visits in the year before and after 2017) and incidental frequent (≥4 visits in 2017). Patient- and visit-level characteristics were analyzed for associations with PED utilization.In 2017, there were 82,361 visits by 56,767 patients to our PED. Frequent users comprised 4% of the total patient volume but accounted for 13% of visits. Compared with infrequent users, frequent users were younger, more likely publicly insured, and English speaking. Frequent user visits were more likely to occur outside clinic hours, be triaged as emergent, and involve subspecialists. Compared with visits by incidental frequent users, visits by persistent frequent users were more likely to be emergent or urgent, and involve subspecialists, diagnostic imaging, laboratory testing, and medication administration.Although the percentage of frequent users to a PED in 2017 was low, they made up a disproportionate share of total visits. Differences between persistent and incidental frequent PED users suggest that these subgroups may benefit from tailored interventions to reduce frequent PED utilization.

Two previously unreported dimethylpyranoflavanones, pyronomelodorones A and B (

OBJECTIVES Infant cardiopulmonary resuscitation (CPR) has been taught to caregivers of infants in inpatient settings. There are no studies to date that look at teaching infant CPR in the emergency department (ED). Using a framework of cognitive load theory, we compared teaching infant CPR to caregivers in a pediatric ED versus an inpatient setting. METHODS Knowledge tests, 1-minute infant CPR performances on a Resusci Baby QCPR (Laerdal) manikin, and self-reported questionnaires were completed before and after caregivers were self-taught infant CPR using Infant CPR Anytime kits. The proportions of chest compression depth and rate that met quality standards from the American Heart Association's Basic Life Support program were measured. RESULTS Seventy-four caregivers participated. Mean knowledge scores (out of a total score of 15) increased in both settings (ED preintervention: Mean (M) = 4.53 [SD = 1.97]; ED postintervention: M = 10.47 [SD = 2.90], P < 0.001; inpatient preintervention: M = 4.83 (SD = 2.08); inpatient postintervention: M = 10.61 [SD = 2.79], P < 0.001). Improvement in the proportion of chest compression that met high quality standards for depth increased in the inpatient group only. Neither groups had improvements in compression rates. There were no statistically significant differences in the difficulty of learning CPR, frequency of interruptions/distractions, or difficulty staying concentrated in learning CPR between the 2 settings. CONCLUSIONS Caregivers in the ED and inpatient settings after a self-instructional infant CPR kit did not demonstrate adequate infant CPR performance. However, both groups gained infant CPR knowledge. Differences in cognitive loads between the 2 settings were not significant.

Each year, the global annual production of coconut fibre (CF) is around 350×103 t, while they are utilized for fine art, fertilization, and animal feed. However, there have not seen many engineering applications to utilize these materials. The coir with high cellulose content of over 40 % has potential for high-value engineering applications like fabricating cellulose-based aerogels. Recently, the cellulose aerogel from CF was formed using a sol-gel method in an NaOH/Urea solution, with an anticipated completion time of 7 d due to the time required for gelation and solvent exchange, which might take up to 4 d. This demonstrates that the present approach is subject to several time limitations. To improve this, for the first time, a novel fabrication of aerogels from the CF with chemical pre-treatment in advance has been successfully developed by using polyvinyl alcohol (PVA) and xanthan gum (XTG) as biodegradable binders. The treated CFs are dispersed homogeneously into a PVA/XTG solution, followed by freeze-drying to remove water, leaving behind a highly porous called CF aerogel. The influences of CF content on CF aerogels' physical and mechanical characteristics, as well as oil adsorption and thermal conductivity, have all been thoroughly investigated. For oil removal, the fabricated CF aerogels are surface-modified with methyltrimethoxysilane (MTMS) to enhance their hydrophobicity. This method required 2 times less time and used fewer chemicals while retaining the same oil adsorption capabilities of up to 20 g/g as previous CF aerogel and demonstrating additional good insulation of 0.040 W/(m·K). Thus, this study provides a new novel approach to synthesize an oil-absorbing and insulating CF aerogel.

To describe the social needs of families screened by the Community Health Advocates Team (CHAT) Desk, situated within a pediatric emergency department (PED); and to evaluate the effectiveness of this help desk in connecting families to community resources.Trained undergraduates, onsite in the PED 30 hours/week during daytime and evening hours, weekdays and weekends, screened a convenience sample of families of patients in the PED for social needs, and provided information on available community resources. Families were offered a follow-up phone call several weeks after their PED visit to assess program satisfaction and success, and identify remaining social needs.Between January 2019 and March 2020, CHAT Desk screened and assisted 682 families. CHAT routinely provided resources about free outdoor recreational activities for families, but after that, the most commonly provided informational resources pertained to: health care (n = 200), housing (n = 143), and food (n = 137). Of families who completed the follow-up phone call (n = 294), almost half (n = 134, 46%) reported being able to contact at least one of the resources; 100 reported that the resource was able to assist them, and 99 families planned to continue using the resource. When asked about satisfaction, 93% (n = 274) reported being very satisfied or somewhat satisfied with CHAT; 94% (n = 276) said they would recommend it to others.The PED of a busy tertiary care children's hospital is an opportune location to screen families for social needs, and provide them with information on requested community resources.

Chitosan hydrogel is a smart and highly applicable drug delivery carrier because of its nature, biocompatibility, biodegradability, and ability to encapsulate, carry and release the drug to the desired target flexibly depending on the conditions of the patient. Not only developing delivery systems but natural compounds are also increasingly being studied in supporting the treatment of diseases. However, the physicochemical and pharmacokinetic issues of the phytochemicals are remaining. This review summarizes the remarkable properties of chitosan hydrogel; approaches to loading natural extracts on the hydrogels to overcome the susceptibility of the phytochemicals to degradation; and their applications in biomedical fields. The drug loading efficiency, release profile, in vitro and in vivo results of the chitosan hydrogels carrying natural compounds are discussed to point out the remaining challenges of combining the extracts with chitosan hydrogels and controlling the release of the carried substances.

This method note presents Q methodology as a useful tool for evaluators to add to their practice toolbox. Q methodology, which involves both quantitative and qualitative techniques, can help researchers and evaluators systematically understand subjectivity and the communicability of opinions and perspectives. We first provide an overview of Q methodology, followed by a brief summary of how evaluators are using Q, and an explanation of the steps for implementing Q methodology. Either by itself or with other methods, the potential uses of Q methodology in evaluation are diverse. For practical demonstration, we describe how Q methodology was used in a recent evaluation in the UK to understand stakeholder subjectivity within the program. We then reflect upon the pros and cons of using Q in program evaluation, concluding that it constitutes a worthwhile tool for evaluating complex programs. Keywords: Q methodology, methods, quantitative, qualitative, subjectivity

OBJECTIVE: The objective was to investigate the impact of affective, social, behavioral, and cognitive factors on pediatric emergency department (PED) provider mood changes during clinical shifts, with the introduction of a novel on‐shift measure. METHODS: The nominal group technique was used to generate the ED experience survey (EDES), encompassing factors that may influence PED provider mood. Providers were alerted via experience sampling method to complete the EDES and positive and negative affect schedule at randomly generated times. Analyses were conducted using multilevel modeling of moods within shifts within persons. RESULTS: Measures were completed 221 times during 137 shifts by 52 PED providers. Positive mood tended to increase with higher self‐rated capacity to deal with challenging patient situations (p

Objectives: Anxiety and anticipatory stressors are commonly experienced by children visiting the Pediatric Emergency Department (PED), but little research exists that addresses the efficacy of interventions to decrease this stress. This one-sample pretest-postest pilot study gathered preliminary data on the feasibility and effectiveness of utilizing audiobooks to reduce fear and state anxiety in children in the PED.Methods: Participants were 131 children in kindergarten through 8th grade (M = 9.4 years, 54% female), triaged urgent or emergent, presenting to the PED. Participants self-reported fear (Children's Fear Scale) and state anxiety (modified State-Trait Anxiety Inventory for Children; mSTAIC) before and after listening to an age-appropriate audiobook (two options). Data regarding patient experience were also collected. Paired samples t-test was used to examine pre–post intervention changes in fear and state anxiety.Results: Significant, albeit small, improvements in fear and the mSTAIC states of nervous, calm, happy, and relaxed were found after use of the audiobook (Cohen's dz = 0.22–0.35). Small, yet significant correlations were found between child age/grade level and improvements in fear and in the mSTAIC states of scared and relaxed, suggesting that the audiobook was more beneficial for older participants. Over 60% of participants liked the audiobook content “a lot” as well as enjoyed listening to the audiobook “a lot.” Without prompting, 15% of participants requested to listen to an additional audiobook.Conclusions: Listening to an audiobook is feasible and could be effective in decreasing fear and state anxiety for children during a waiting period in the PED. The technology is low-cost, simple, and portable. The results of this study should be interpreted with prudence due to the lack of a control group and results that, although significant, were modest based on effect size conventions; future studies should explore the impact of audiobooks on patient stress with an expanded sample size and control group.

In March 2020, the American College of Emergency Physicians (ACEP) published a national strategic plan for COVID-19, which provides general guidelines yet leaves logistical details for institutions to determine. Key capabilities from this plan provided a crucial foundation for a 16-day Emergency Department (ED) surge planning process at one pediatric institution. This paper describes critical milestones and lessons learned during this brief period, including derivation of criteria for ED surge activation, a full-scale surge drill, and the resultant ED surge protocol. The framework of real-time evaluation was used throughout the planning process and involved constant and iterative synthesis of real-time feedback from multidisciplinary stakeholders for responsive decision-making. Ultimately, the objective of this paper is to provide timely and readily actionable information to other institutions seeking guidance to apply the ACEP strategic plan for COVID-19.

Improvement of biomass utilization productivity following cascading strategy is a priority for the biorefinery-based circular bioeconomy. In recent years, the field of energy research has seen an increasing interest in bio-products from paddy-based biorefinery, but the utilization of the entire value of paddy biomass to guide the commercial viability of its products has not been got feasible outcomes. Here we propose a potential pathway for a conceptual paddy biorefinery framework by addressing wastes for producing more products. The feasibility of the integrated biorefinery was demonstrated by the conversion of wastes into value-added products such as nano-silica and lignin. In particular, this is the first time that silica recovered from bioethanol system was continued to be reused to produce ZSM-5 and Ni/ZSM-5 as catalysts of rice straw lignin depolymerization achieving high conversion of lignin up to 95% and fair yield of phenolic products up to 41%. Material flow of an integrated biorefinery model was reported to give a future outlook for making most of the processing routes of rice residues. We also established a life cycle that follows the circular bioeconomy concept and discussed the relationship between each of potential bioproducts and their market opportunities.

Coir, known as coconut fibers, are an abundant cellulosic source in Vietnam, which are mostly discarded when copra and coconut water are taken, causing environmental pollution and waste of potential biomass. In this research, carbon aerogels from chemically pretreated coir were successfully synthesized via simple sol-gel process with NaOH-urea solution, economical freeze-drying, and carbonization. The samples, including pretreated coir, coir aerogels, and carbon aerogels, are characterized using FTIR spectroscopy, SEM, XRD spectroscopy, and TGA. The carbon aerogels exhibit low density (0.034–0.047 g/cm3), high porosity (97.63–98.32 %), and comparable motor oil sorption capacity (22.71 g/g). The properties of carbon aerogels are compared with those of coir aerogels, indicating such better values than those of coir aerogels. Coir-derived carbon aerogels is a potential replacement for the hydrophobically-coated cellulose aerogels in term of treating oil spills.

Background The utility of testing for urinary tract infection (UTI) in febrile infants with bronchiolitis is indeterminate. Objective The objective of this study was to investigate if the incidence of UTIs in febrile infants 2 to 12 months of age with bronchiolitis is higher than the presumed incidence of asymptomatic bacteriuria and determine risk factors associated with UTIs in this population. Methods This prospective multicenter cross-sectional study was conducted in the emergency departments of 6 children's hospitals between November 2011 and June 2015. We obtained a convenience sample of febrile infants with bronchiolitis 2 to 12 months of age who were tested for UTI. Patient characteristics analyzed included age, maximum temperature, duration of fever, ethnicity, sex, and circumcision status. Results A total of 442 patients (including 86 from a previously published pilot study) were enrolled. Mean age was 5.5 months, 65.2% were Latino, 50.9% were male, and 27.6% of male infants were circumcised. Urinary tract infections were found in 33 patients (7.69%, binomial; 95% confidence interval [CI], 5.19%-10.33%). Urinary tract infections were not related to age, height of temperature, duration of fever, or ethnicity. Uncircumcised males were significantly more likely to have UTIs than circumcised males (7.64% vs 0%, P = 0.03). Odds ratios (ORs) were lower for circumcised males but not uncircumcised males when compared with females (OR, 0.12; CI, 0.0-0.71; P = 0.01 vs OR, 0.77; CI, 0.33-1.74; P = 0.64). Conclusions Febrile infants 2 to 12 months of age with bronchiolitis have a clinically significant incidence of UTI, suggesting that UTI evaluation should be considered in these patients.

Ultrasound (US) is the preferred method of initial evaluation for appendicitis in pediatrics. However, limited accuracy of US for appendicitis is an obstacle to implementation of US-first protocols at facilities less experienced with US.The primary objective was to demonstrate changes in diagnostic accuracy of US for appendicitis over time, after implementation of an US-first protocol. Secondary objectives included evaluating trends in utilization and factors associated with accuracy of US.We reviewed 5 years of pediatric emergency department encounters that included US evaluations for appendicitis. The primary outcome was conclusive US (fully visualized normal appendix or unequivocal appendicitis) vs. equivocal US (partially visualized or nonvisualized appendix). We also analyzed rates of conclusive US over time; accuracy, sensitivity, and specificity of US for appendicitis; and associations of US accuracy with patient gender, body mass index, and ultrasonographer's experience.A conclusive US report was found in 267 of 1058 encounters (25.2%); overall accuracy rate was 24.5%. Over 5 years, the diagnostic accuracy of US for appendicitis improved significantly from 13.9% to 31.5% (p = 0.001). Overall sensitivity was 80.7% and specificity was 77.6%. Male gender and dedicated US of the appendix were significantly associated with conclusive US (ps 0.001). Higher body mass index was significantly associated with equivocal US (p 0.001). Ultrasonographer experience was not significantly associated with conclusive US (p = 0.22).An US-first imaging protocol for appendicitis in children shows chronologic improvement in diagnostic accuracy. This may provide encouragement to facilities using computed tomography-based diagnostic protocols to implement US-first protocols to reduce childhood radiation exposure.

Although evaluative thinking lies at the heart of what we do as evaluators and what we hope to promote in others through our efforts to build evaluation capacity, researchers have given limited attention to measuring this concept. We undertook a research study to better understand how instances of evaluative thinking may present in practice-based settings-specifically within four state asthma control programs funded by the Centers for Disease Control and Prevention's National Asthma Control Program. Through content analyses of documents as well as interviews and a subsequent focus group with four state asthma control programs' evaluators and program managers we identified and defined twenty-two indicators of evaluative thinking. Findings provide insights about what practitioners may wish to look for when they intend to build evaluative thinking and the types of data sources that may be more or less helpful in such efforts.

Lotus (Nelumbo nucifera Gaertn.) commonly distributed in low-lying and flooded areas like Southern Vietnam provides flowers, leaves, seeds, embryos, and edible rhizomes. All parts of the plant show good pharmacokinetic properties, especially lotus embryos and leaves. Studies have shown that lotus plums and leaves have many bioactive compounds such as alkaloids, flavonoids, triterpenoids, and polyphenols, in which alkaloids are one of mainly bioactive compound kinds. So that, there are many studies investigating extraction methods that increase the amount of alkaloid from lotus leaves, embryos. There are some conventional extract methods such as soak, heat reflux, Soxhlet, etc… and some modern extract methods as microwave, ultrasounds, enzyme assisted, supercritical fluids (S-CO2). At present, lotus leaves, embryos and their bioactivities can have application potential in the supplementary food such as protect-liver, anti-neurotic, etc.. The aim of this paper is to review a variety of develop methods used in the alkaloid extraction from lotus embryos, leaves. Besides, this study also introduces some pharmacokinetic properties of alkaloid which can use in functional foods.

IntroductionA simple, portable capillary refill time (CRT) simulator is not commercially available. This device would be useful in mass-casualty simulations with multiple volunteers or mannequins depicting a variety of clinical findings and CRTs. The objective of this study was to develop and evaluate a prototype CRT simulator in a disaster simulation context.MethodsA CRT prototype simulator was developed by embedding a pressure-sensitive piezo crystal, and a single red light-emitting diode (LED) light was embedded, within a flesh-toned resin. The LED light was programmed to turn white proportionate to the pressure applied, and gradually to return to red on release. The time to color return was adjustable with an external dial. The prototype was tested for feasibility among two cohorts: emergency medicine physicians in a tabletop exercise and second year medical students within an actual disaster triage drill. The realism of the simulator was compared to video-based CRT, and participants used a Visual Analog Scale (VAS) ranging from “completely artificial” to “as if on a real patient.” The VAS evaluated both the visual realism and the functional (eg, tactile) realism. Accuracy of CRT was evaluated only by the physician cohort. Data were analyzed using parametric and non-parametric statistics, and mean Cohen’s Kappas were used to describe inter-rater reliability.ResultsThe CRT simulator was generally well received by the participants. The simulator was perceived to have slightly higher functional realism (P=.06, P=.01) but lower visual realism (P=.002, P=.11) than the video-based CRT. Emergency medicine physicians had higher accuracy on portrayed CRT on the simulator than the videos (92.6% versus 71.1%; PConclusionsA simple, LED-based CRT simulator was well received in both settings. Prior to widespread use for disaster triage training, validation on participants’ ability to accurately triage disaster victims using CRT simulators and video-based CRT simulations should be performed.ChangTP,SantillanesG,ClaudiusI,PhamPK,KovedJ,CheyneJ,Gausche-HillM,KajiAH,SrinivasanS,DonofrioJJ,BirC.Use of a novel, portable, LED-based capillary refill time simulator within a disaster triage context.Prehosp Disaster Med.2017;32(4):451–456.

OBJECTIVE: To determine if a new, non-validated mental health screener can detect the prevalence of alcohol/drug abuse, traumatic exposure, and behavioral symptoms in adolescents and young adults seeking care in a pediatric emergency department (ED) for medical complaints. METHODS: An 11-item mental health screener (Emergency Department Distress Response Screener [ED-DRS] investigator developed) was created. Patients 12 years or older seen for medical complaints were assessed by physicians using the ED-DRS. Data were analyzed using the Kuder-Richardson Formula 20, χ test, Mann-Whitney U test, and Spearman correlation. RESULTS: Among 992 ED patients, mean age was 15.11 ± 2.10 years (46.2% boys; 53.8% girls). Approximately 77.9% were Hispanic/Latino. Symptomatic patients (S) answered "yes" to at least 1 ED-DRS item; asymptomatic patients answered "no" to all items. The S patients comprised 47.5% of the sample; asymptomatic patients comprised 52.5%. Among S patients, alcohol/drug abuse frequency was 14%. The traumatic exposure frequencies included: 33.5% physically or emotionally traumatized, 29.3% bullied, 21.2% physically abused, 8.1% touched inappropriately and 7.0% exposed to domestic violence. Behavioral symptom frequencies included: 33.8% depressed mood, 30.4% anxiety, 23.8% high energy behavior, 6.6% hallucinations, and 6.2% suicidal/homicidal ideation. CONCLUSIONS: Although patients present to the ED with medical complaints, they may be at risk for concomitant mental health problems potentially discoverable using the ED-DRS. Language: en

Objective National rates of left (or leaving) without being seen (LWBS) in pediatric emergency departments (PED) are higher than general emergency departments. We investigated coexisting perspectives on LWBS. Methods Q-methodology was implemented through a mixed-methods design. Semistructured interviews elicited a concourse of caregivers' thoughts on waiting in the PED and their consideration of LWBS. Themes from the concourse were identified and framed as statements. Caregivers sorted these statements, which ranged from choosing to stay versus leave the PED before their child is seen by a physician. Sorted data were analyzed through centroid factor analysis. Results Seventy-seven caregivers contributed interview data, from which 31 themes were identified and framed as statements. Thirty-one different caregivers contributed Q-sort data, from which 2 factors were revealed, each representing a unique perspective on LWBS. Most caregivers (26 of 31) shared the following perspective: "I would leave the PED before my child is seen by a doctor if there are no reassessments for my child while we are in the queue, no updates on our queue position, or no explanations for wait time." The remaining caregivers (5 of 31) perceived feelings of uncertainty and helplessness, lack of updates, and competing obligations as primary influences on LWBS. Conclusions Elements that factor into caregivers' decision to LWBS from a PED include lack of reassessments, lack of updates on queue position, and lack of information about the triage process. Quality improvement interventions for decreasing LWBS rates should account for diverse coexisting perspectives such as these.

background Academic emergency medicine is a constant balance between efficiency and education. We developed a new model called swarming, where the bedside nurse, resident, and attending/fellow simultaneously evaluate the patient, including initial vital signs, bedside triage, focused history and physical examination, and discussion of the treatment plan, thus creating a shared mental model. Objectives To combine perceptions from trainee physicians, supervising physicians, nurses, and families with in vivo measurements of emergency department swarms to better conceptualize the swarming model. Methods This mixed methods study was conducted using a convergent design. Qualitative data from focus groups with nurses, residents, and attendings/fellows were analyzed using directed content analysis. Swarming encounters were observed in real time; durations of key aspects and family satisfaction scores were analyzed using descriptive statistics. The qualitative and quantitative findings were integrated a posteriori. Results From the focus group data, 54 unique codes were identified, which were grouped together into five larger themes. From 39 swarms, mean (±SD) time (minutes) spent in patient rooms: nurses = 6.8 (±3.0), residents = 10.4 (±4.1), and attendings/fellows = 9.4 (±4.3). Electronic documentation was included in 67% of swarms, and 39% included orders initiated at the bedside. Mean (±SD) family satisfaction was 4.8 (±0.7; Likert scale 1-5). Conclusions Swarming is currently implemented with significant variability but results in high provider and family satisfaction. There is also consensus among physicians that swarming improves trainee education in the emergency setting. The benefits and barriers to swarming are underscored by the unpredictable nature of the ED and the observed variability in implementation. Our findings provide a critical foundation for our efforts to refine, standardize, and appraise our swarming model.

To determine the frequency of abdominal radiographs obtained in healthy children aged 6 months to 18 years to diagnose constipation in a pediatric emergency department, and evaluate the impact of quality improvement (QI) interventions on their use.QI study over 2.5 years at a large urban quaternary care children's hospital emergency department. Interventions consisted of educational presentations and individualized abdominal radiograph data reporting. The primary outcome measure was the percentage of abdominal radiographs performed on healthy patients discharged home with a diagnosis of constipation before and after QI interventions.The baseline total percentage of abdominal radiographs performed in otherwise healthy children discharged home with a diagnosis of constipation was 36% (October 2016 to January 2018). According to questionnaire results, ruling out obstruction was the most common reason for ordering an abdominal radiograph. After the QI interventions, the total percentage of abdominal radiograph decreased to 18% (April 2018 to March 2019). This 18% decrease was significant (P .001) and sustained over a 12-month follow-up period. Throughout the study period, the average length of stay was 1.07 hours longer for children who had an abdominal radiograph. Clinically important return visits to the emergency department were uncommon during the postintervention phase (125/1830 [6.8%]), and not associated with whether or not an abdominal radiograph was performed at the initial visit.After these QI interventions, we noted a significant and sustained decrease in the percentage of abdominal radiographs obtained for otherwise healthy patients discharged home with a diagnosis of constipation.

Background There is a paucity of data regarding risk factors associated with suboptimal breastfeeding practices in urbanized areas of low-middle income countries (LMICs). Methods Through a large prospective birth cohort, which enrolled 6706 infants in Vietnam between 2009 and 2013, we investigated the practice of exclusive breastfeeding during hospital stay in urban and semi-rural populations and aimed to identify factors associated with suboptimal breastfeeding practices. Univariate and multivariable logistic regression were performed to determine factors associated with not exclusive breastfeeding during hospital stay. Results Of 6076 mothers, 33% (2187) breastfed their infant exclusively before hospital discharge; 9% (364/4248) in urban and 74% (1823/2458) in semi-rural areas. Exclusive breastfeeding up to 4 months was recorded in 15% (959/6210) of participants; this declined to Conclusions To our knowledge, this is the first large-scale investigation aimed at identifying factors associated with exclusive breastfeeding during hospital stay in Vietnam. Breastfeeding promotion strategies should prioritize common risk factors in hospital, such as Caesarean section and neonatal complications, and other location specific factors associated with socioeconomics.

Objectives Adolescent female patients who are not sexually active and who present to a pediatric emergency department with abdominal pain require a full bladder prior to transabdominal ultrasound. Procedures to fill the bladder are largely institution or provider dependent. We examined adolescent females' attitudes and opinions toward 2 common methods of bladder filling, intravenous fluid administration and transurethral Foley catheter placement, by means of a Q-sort study. Methods Two convenience samples of adolescent female patients in the pediatric emergency department at an academic children's hospital participated in the study. In part 1, subjects underwent a semistructured interview to elicit their opinions regarding 2 methods of bladder filling: intravenous fluid or transurethral catheter. The summation of subject statements was then narrowed down to a final Q set of 25 statements. In part 2, a second sample of subjects independently arranged this Q set according to their own agreement or disagreement with each statement. Principal components analysis was conducted to examine factors or collections of statements representing a shared viewpoint and to describe commonalities. Results Part 1 was completed with 9 subjects, and part 2 with 26 subjects. Factors revealed from the Q-sort data included acceptance of tests deemed medically necessary, desire for parental involvement, and a wish to minimize discomfort. Most adolescents aligned with 1 of these 3 factors. Conclusions Adolescent female patients varied in their attitudes and opinions regarding intravenous catheter hydration and Foley catheter placement for transabdominal ultrasound. Knowledge of adolescent viewpoints may help better inform practitioner-patient communication for this procedure.

IntroductionTerrorism and natural catastrophes have made disaster preparedness a critical issue. Despite the documented vulnerabilities of children during and following disasters, gaps remain in health care systems regarding pediatric disaster preparedness. This research study examined changes in knowledge acquisition of pediatric disaster preparedness among medical and non-medical personnel at a children’s hospital who completed an online training course of five modules: planning, triage, age-specific care, disaster management, and hospital emergency code response.MethodsA multi-disciplinary team within the Pediatric Disaster Resource and Training Center at Children’s Hospital Los Angeles (Los Angeles, California USA) developed an online training course. Available archival course data from July 2009 to August 2012 were analyzed through linear growth curve multi-level modeling, with module total score as the outcome (0 to 100 points), attempt as the Level 1 variable (any module could be repeated), role in the hospital (medical or non-medical) as the Level 2 variable, and attempt by role as the cross-level effect.ResultsA total of 44,115 module attempts by 5,773 course participants (3,686 medical personnel and 2,087 non-medical personnel) were analyzed. The average module total score upon first attempt across all participants ranged from 60.28 to 80.11 points, and participants significantly varied in how they initially scored. On average in the planning, triage, and age-specific care modules: total scores significantly increased per attempt across all participants (average rate of change ranged from 0.59 to 1.84 points) and medical personnel had higher total scores initially and through additional attempts (average difference ranged from 13.25 to 16.24 points). Cross-level effects were significant in the disaster management and hospital emergency code response modules: on average, total scores were initially lower among non-medical personnel compared to medical personnel, but non-medical personnel increased their total scores per attempt by 3.77 points in the disaster management module and 6.40 points in the hospital emergency code response module, while medical personnel did not improve their total scores through additional attempts.Conclusion:Medical and non-medical hospital personnel alike can acquire knowledge of pediatric disaster preparedness. Key content can be reinforced or improved through successive training in an online course.PhamPK, BeharSM, BergBM, UppermanJS, NagerAL. Pediatric online disaster preparedness training for medical and non-medical personnel: a multi-level modeling analysisPrehosp Disaster Med.2018;33(4):349–354.