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Contactless vital signs (VS) measurement with video photoplethysmography (vPPG), motion analysis (MA), and passive infrared thermometry (pIR) has shown promise.To compare conventional (contact-based) and experimental contactless VS measurement approaches for emergency department (ED) walk-in triage in pandemic conditions.Patients' heart rates (HR), respiratory rates (RR), and temperatures were measured with cardiorespiratory monitor and vPPG, manual count and MA, and contact thermometers and pIR, respectively.There were 475 walk-in ED patients studied (95% of eligible). Subjects were 35.2 ± 20.8 years old (range 4 days‒95 years); 52% female, 0.2% transgender; had Fitzpatrick skin type of 2.3 ± 1.4 (range 1‒6), Emergency Severity Index of 3.0 ± 0.6 (range 2‒5), and contact temperature of 36.83°C (range 35.89-39.4°C) (98.3°F [96.6‒103°F]). Pediatric HR and RR data were excluded from analysis due to research challenges associated with pandemic workflow. For a 30-s, unprimed "Triage" window in 377 adult patients, vPPG-MA acquired 377 (100%) HR measurements featuring a mean difference with cardiorespiratory monitor HR of 5.9 ± 12.8 beats/min (R = 0.6833) and 252 (66.8%) RR measurements featuring a mean difference with manual RR of -0.4 ± 2.6 beats/min (R = 0.8128). Subjects' Emergency Severity Index components based on conventional VS and contactless VS matched for 83.8% (HR) and 89.3% (RR). Filtering out vPPG-MA measurements with low algorithmic confidence reduced VS acquired while improving correlation with conventional measurements. The mean difference between contact and pIR temperatures was 0.83 ± 0.67°C (range -1.16-3.5°C) (1.5 ± 1.2°F [range -2.1-6.3°F]); pIR fever detection improved with post hoc adjustment for mean bias.Contactless VS acquisition demonstrated good agreement with contact methods during adult walk-in ED patient triage in pandemic conditions; clinical applications will need further study.

Objective: Investigators conducted pilot sessions in live Emergency Department (ED) settings to prepare for formal comparative study of contact and experimental non-contact vital signs (VS) measurement devices. Methods: Contact-based cardiorespiratory monitors (CM) and video photoplethysmography (vPPG) measured heart rates (HR); contact thermometers and passive infrared thermography (pIR) obtained core and surface temperatures. Subject VS data comprised two 25-min CM and vPPG recordings (initial unprimed “Triage Check” window; four 1-min “Full Check” windows; 20min of “Resting” intervals) and temperature measurements. Results: Forty-eight of 102 approached patients participated: at least 5 subjects each in 0-12mo, 1-5y, 6-12y, 13-17y age-groups, and at least 2 subjects each in 18-29y, 30-39y, 40-49y, 50-59y, 60-69y, 70-79y, 80+y age-groups. Subjects were 40.4% female with median Fitzpatrick skin type of 3.0 (interquartile range 1-3: 2.0-5.0), ESI score of 3.0 (2.0-3.0), and core temperature of 98.6°F (97.9-99.1°F). Twelve subjects were excluded from vPPG analysis due to inadequate lighting, excessive motion, and/or datastream loss. From the remaining 36 subjects with median HR CM of 78.2bpm (69.8-94.8bpm), vPPG measured median HR vPPG of 75.0bpm (68.3-93.0bpm) from 170 (70.5%) of 241 possible Full Check windows; the median difference between HR CM and HR vPPG was 0.6bpm (-0.2-2.3bpm). All Emergency Severity Index (ESI) HR components for 34 subjects with Triage Check HR vPPG measurements matched CM-based ESI HR components. Median differences between contact and pIR temperatures ranged from −5.4°F to −4.4°F. Conclusion: vPPG and pIR devices experimentally measured select live VS with promising results. Significance: Pilot data and protocol testing set the groundwork for full-scale ED vPPG-pIR investigation.

Accurate non-contact acquisition of patient vital signs will advance emergency care. In order to assess promising candidate technologies., an observational study was conducted with healthy volunteers to test two hypotheses: 1. Video photoplethysmography and motion analysis (vPPG-MA) and infrared thermography (IR) will accurately and concurrently measure heart rate (HR) and respiratory rate (RR)., and body temperature., respectively. 2. Non-contact approaches will exhibit comparable and reliable performance against standard contact cardiorespiratory monitors (CM). HR and RR were measured with CM and vPPG-MA; core and surface temperatures were obtained using oral thermometry and two IR cameras., respectively. Subjects were videorecorded at rest; during sustained exercise at 50%., 60%., and 70% of age-predicted maximum HR; and 1., 3., and 5 min post-exertion. vPPG-MA HR and RR measurements were calculated for video segments corresponding to ED use-cases: Triage (unprimed) 30s check., Routine 30s check, Abbreviated “Spot” 10s check., and Full 60s check. Descriptive statistics and Bland-Altman analyses were performed on vPPG-MA and IR measurements against synchronous CM measurements. Thirty volunteers exhibited a HR range of 43-146bpm., a RR range of 8-29bpm., and an oral temperature range of 96.2-99.5°F on CM. vPPG-MA obtained 972 (98.2% of scheduled) HR and 591 (98.5%) RR measurements; mean differences between Full 60s vPPG-MA and CM were −0.9±5.5bpm (-0.9±5.3%; 95% CI: −11.6–9.8bpm) for HR, and 0.9±3.1bpm (4.8±17.6%; −5.1–6.9bpm) for RR; other video segments performed similarly. IR acquired temperatures ~4°F lower than oral thermometers. vPPG-MA and IR thermography successfully measured select vital signs concurrently. vPPG-MA‘s observed level of agreement with CM, along with temperature offsets identified for IR-based thermometry., have set the foundation for live ED clinical studies.

Recent investigations have demonstrated that the classic hypochloremic, hypokalemic, metabolic alkalosis of hypertrophic pyloric stenosis (HPS) is not a common finding.Some have suggested a trend over time, but none has investigated factors contributing to laboratory derangement, such as duration of vomiting or patient age at presentation. We sought to determine the proportion of patients with HPS with normal and abnormal laboratory findings as a function of year of presentation, duration of vomiting, and patient age.This is a retrospective chart review of 205 patients younger than 6 months with operative diagnosis of HPS at a tertiary, regional pediatric center from 2000 to 2009. We examined the acid-base status and electrolyte levels (serum bicarbonate [CO2], serum potassium [K], and serum chloride [Cl]) at the time of the index visit to determine the proportion of normal, high, and low values for each as a function of year of presentation, duration of vomiting, and patient age.The proportion of HPS cases with normal CO2 was 62%; low serum CO2, 20%; and high CO2, 18%. The proportion with normal serum K was 57%; low K, 8%; and high K, 35%. The proportion with normal Cl was 69%; low Cl, 25%; and high Cl, 6%. Logistic regression analysis demonstrated that the prevalence of metabolic alkalosis increased across the decade, whereas the prevalence of metabolic acidosis decreased and that advancing age was associated with the presence of alkalosis.We observed that normal laboratory values are the most common finding in HPS and that metabolic alkalosis was found more commonly in the latter part of the decade and in older infants.

Background: Little has been written about the geographic basis of emergency department (ED) visits. Objective: The objective of this study is to describe the impact of geography on ED visits. Methods: A retrospective analysis was conducted of ED visits during a 1-year period at a single institution using spatial interaction analysis that models the pattern of flow between a series of origins (census block groups) and a destination (ED). Patients were assigned to census block groups based upon their verified home address. The study hospital is the only Level I trauma, pediatric, and tertiary referral center in the area. There are 11 other hospitals with EDs within a 40-mile radius. Each patient visit within this radius, including repeat visits, was included. Patients with an invalid home address, a post office box address, or those who lived outside a 40-mile radius were excluded. ED visits per 100 population were calculated for each census block group. Results: There were 98,584 (95%) visits by 63,524 patients that met study inclusion criteria. Visit rates decreased with increasing distance from the ED (p < 0.0001). Nineteen percent of patients lived within 2 miles, 48% within 4 miles, and 92% within 12 miles of the ED. The Connecticut border, 7 miles south of the ED (p < 0.0001), the Connecticut River, 1 mile west of the ED (p < 0.0001), and the presence of a competing ED within 1 mile (p < 0.0001) negatively impacted block group ED visit rates. Travel distance was related to the percentage of visits that were high acuity (p < 0.0001), daytime (p < 0.01), or resulted in admission (p < 0.0001). Conclusions: Geography and travel distance significantly impact ED visits.

Objectives The objective was to assess whether testicular torsion is associated with low testicular tissue saturation of oxygen (StO2) as measured by transscrotal near-infrared spectroscopy (NIRS) and to compare the differences in NIRS values between testicles of the same patient, both in patients with testicular torsion and in healthy controls. Methods This was an observational study of healthy controls and patients with surgically confirmed testicular torsion who were recruited from males under 30 years of age presenting to the emergency department (ED). The hypothesis was that the difference in NIRS values for the control's two testicles would be zero, and that the difference between the torsed and healthy testicles on an individual patient would not be zero. Based on animal data, the study was powered to detect an absolute difference of StO2 of 47%. Results The mean StO2 for the left control patients' testicles was 73.6% (95% confidence interval [CI] = 68.0% to 79.1%) and the mean StO2 for the right controls' testicles for controls was 73.6% (95% CI = 66.9% to 80.4%; n = 17). The absolute difference in NIRS StO2 for left minus right for each individual was 3.5% (95% CI = 1.8% to 5.4%), which was significantly different (p = 0.0007), and refuted the hypothesis that there was no significant difference in StO2 between left and right testes in healthy patients. In the testicular torsion group, the torsed side had a mean StO2 of 82.8% (95% CI = 68.7% to 96.9%), and the contralateral nontorsed testes had a mean of 85.8% (95% CI = 72.3% to 99.3%). The mean StO2 difference, nontorsed minus torsed was 3.0% (range = –1% to 9%, 95% CI = –2% to 8%; p = 0.174), refuting the hypothesis that torsed testes would demonstrate significantly lower values for StO2. Conclusions While pilot animal investigations support a potential role for transscrotal NIRS for the detection of testicular torsion, this first clinical translation of animal findings reveals that the investigated, transcutaneous, reflectance geometry NIRS device failed to demonstrate symmetric oxygenation of left and right testes in healthy controls and also failed to demonstrate depressed tissue saturation of oxygen values in patients with confirmed testicular torsion. While limited by a small sample size, other problems such as inability to calibrate depth of measurement of StO2 may have led to falsely elevated readings in patients with torsion. Resumen Valoracion Espectroscopica Infrarroja de la Saturacion de Oxigeno Tisular en los Testiculos Sanos y Torsionados Objetivos Valorar si la torsion testicular (TT) se asocia con la saturacion de oxigeno (SatO2) tisular testicular baja medida con espectroscopia infrarroja (EIR) transescrotal, y comparar las diferencias en los valores de EIR entre los testiculos del mismo paciente, tanto en pacientes con TT como en controles sanos. Metodologia Estudio observacional de controles sanos y pacientes con TT confirmada quirurgicamente en varones menores de 30 anos que acudieron al servicio de urgencias (SU). La hipotesis fue que la diferencia en los valores de EIR para los dos testiculos del control seria cero, y que la diferencia entre los testiculos sanos y torsionados en un mismo paciente no seria cero. Basandose en datos de animales, el estudio tuvo potencia para detectar una diferencia absoluta de SatO2 de un 47%. Resultados La media de SatO2 para los testiculos izquierdos de los pacientes controles fue de un 73,6% (IC 95% = 68,0% a 79,1%) y para los testiculos derechos fue de un 73,6% (IC 95% = 66,9% a 80,4%) (n = 17). La diferencia absoluta en la SatO2 mediante EIR para el izquierdo menos derecho para cada individuo fue de un 3,5% (IC 95% = 1,8% a 5,4%), y esta diferencia fue significativa (p = 0,0007), lo cual rechaza la hipotesis que no habia diferencias significativas en SatO2 entre los testiculos derechos e izquierdos en los pacientes sanos. En el grupo de TT, el lado torsionado demostro una media de SatO2 de un 82,8% (IC 95% = 68,7% a 96,9%), y la de los testiculos contralaterales no torsionados fue de un 85,8% (IC 95% = 72,3% a 99,3%). La diferencia media de SatO2, entre los no torsionados y los torsionados fue de un 3,0% (rango -1% a 9%, IC 95% = -2% a 8%; p= 0,174). De nuevo, se rechazo la hipotesis que los testiculos torsionados demostrarian valores menores de SatO2. Conclusiones Mientras que las investigaciones piloto en animales respaldan un papel potencial de la EIR transescrotal para la deteccion de TT, este primer estudio translacional de los hallazgos en animales releva que el dispositivo de EIR investigado, de reflexion geometrica y transcutaneo, fallo en demostrar la oxigenacion simetrica de los testiculos derechos e izquierdos en los controles sanos y tambien en demostrar la disminucion de los valores de la saturacion tisular de oxigeno en pacientes con TT confirmada. A pesar de la limitacion del pequeno tamano de la muestra, otros problemas, como una incapacidad para calibrar la profundidad de la medicion de la SatO2, pueden haber permitido lecturas falsamente elevadas en los pacientes con torsion.

A staged pattern of cathepsin B cleavage of MHC class II alpha, beta-bound invariant (Ii) chain and release of fragments was defined. Charge-loss mutations in the Ii chain were created in three clusters of cathepsin B putative cleavage sites R78K80K83K86, K137K143, and R151K154. Products of HLA-DR1 alpha, beta and wild type (WT) or mutant Ii genes, co-transfected into COS1 cells, were cleaved by cathepsin B and immunoprecipitated by antibodies either to MHC class II chains or to different Ii epitopes. In WT Ii, cathepsin B digestion generated two forms of p21 Ii fragments: a p21 recognized by anti-C-terminus antibodies and a p21 recognized by an antibody to a determinant near the N-terminus. C-terminal p21 was released from MHC class II alpha, beta chains upon its formation while N-terminal p21 remained associated with MHC class II alpha, beta chains. Mutations at K137K143 inhibited the generation of N-terminal p21 by cathepsin B. Mutation at R78K80K83K86 led to an accumulation of MHC class II-bound N-terminal p21 without the appearance of MHC class II-bound p14, p10, and p6 fragments after cathepsin B digestion. These results indicate that cathepsin B cleaves wild type Ii first about K137K143 to produce a MHC class II-associated N-terminal p21, which is then cleaved about R78K80K83K86 to generate p14, p10 and finally p6 which still associates with MHC class II alpha, beta chains. This pattern of staged cleavage and release of Ii might be related to a concerted mechanism regulating the binding of antigenic peptides to MHC class II molecules.

We determined whether experimental testicular torsion results in gonadal cooling and whether testicular temperature changes can be detected by infrared thermography.A nonblinded, randomized, controlled trial was done in 6 anesthetized sheep. Thermocouple probes recorded testicular temperature every 15 minutes for 6 hours after experimental side 720-degree medial testicular torsion with orchiopexy or control side sham procedure with orchiopexy and for 75 minutes after procedure reduction. Color Duplex ultrasound was done to control the experimental assignment. Mean hemiscrotal infrared thermography temperatures were calculated and nonparametric repeated measures analysis was performed to determine whether there were significant changes in temperature as a function of the experimental condition and time.Testicular torsion resulted in significant testicular cooling by probe and infrared thermography (p0.05 and0.0001, respectively), which was promptly reversed upon the reduction of experimental torsion. Two hours after experimental torsion the median temperature difference (control side minus torsion side) was 2.5C for the probe and 1.7C for infrared thermography.Experimental testicular torsion resulted in significant gonadal cooling that was detectable by infrared thermography of the hemiscrotum. The applicability of these findings to the clinical setting remains to be determined.

Study objective To assess whether near-infrared spectroscopy can detect testicular hypoxia in a sheep model of testicular torsion within 6 hours of experimental torsion. Methods This was a randomized, controlled, nonblinded study. Trans-scrotal, near-infrared, spectroscopy-derived testicular tissue saturation of oxygen values were obtained from the posterior hemiscrota of 6 anesthetized sheep at baseline and every 15 minutes for 6 hours after either experimental-side, 720-degree, unilateral, medial testicular torsion and orchidopexy or control-side sham procedure with orchidopexy and then for 75 minutes after reduction of torsion and pexy. Color Doppler ultrasonography was performed every 30 minutes to confirm loss of vascular flow on the experimental side, return of flow after torsion reduction, and preserved flow on the control side. Results Near infrared spectroscopy detected a prompt, sustained reduction in testicular tissue saturation of oxygen after experimental torsion. Further, it documented a rapid return of these values to pretorsion levels after reduction of torsion. Experimental-side testicular tissue saturation of oxygen fell from a median value of 59% (interquartile range [IQR] 57% to 69%) at baseline to 14% (IQR 11% to 29%) at 2.5 hours of torsion, and postreduction values were approximately 70%. Control-side testicular tissue saturation of oxygen values increased from a median value of 67% (IQR 59% to 68%) at baseline to 77% (IQR 77% to 94%) at 2.5 hours and remained at approximately 80% for the entire protocol. The difference in median testicular tissue saturation of oxygen between experimental and control sides, using the Friedman test, was found to be significant ( P =.017). Conclusion This study demonstrates the feasibility, in a sheep model, of using near-infrared spectroscopy for the noninvasive diagnosis of testicular torsion and for quantification of reperfusion after torsion reduction. The applicability of these findings, from an animal model using complete torsion, to the clinical setting remains to be established.

Background and Objectives. Children in the emergency department (ED) with acute asthma were enrolled to assess the impact of asthma on their activities of daily living and evaluate their access to care and preventive strategies, determine the proportion who adhered to the National Heart, Lung, and Blood Institute (NHLBI) guidelines for proper steps to take at home during an acute asthma exacerbation, and compare adherence rates for those with persistent and mild intermittent asthma.Design and Methods. Children 2 to 18 years old who presented to the Children’s Hospital of Philadelphia’s ED with acute asthma exacerbations were enrolled prospectively. Parents and patients completed the 108-item Asthma Exacerbation Response Questionnaire with a focus on determining the home management steps they took both at the onset of the asthma exacerbation and just before coming to the ED.Results. Among the 433 children studied, 76% had at least 1 doctor visit, 75% had at least 1 ED visit, and 43% had at least 1 hospitalization for asthma in the preceding 12 months. Overall, 64% had persistent asthma by NHLBI criteria, yet just 4% were cared for by an allergist or pulmonologist, 38% took daily anti-inflammatory therapy, and 18% received a daily inhaled corticosteroid. Also, 48% did not use a holding chamber with their metered-dose inhalers, and 66% did not use their peak flow meters. Regarding exacerbation response, 71% did not have a written action plan, and 89% did not maintain a symptom diary. Both at the onset of wheezing and just before coming to the ED, administration of a β2-agonist was the only step that the majority of children performed. One-third or fewer followed the other steps recommended by the NHLBI, including using a peak flow meter, beginning oral corticosteroids, calling or going to see the doctor, or going to the ED. Children with persistent asthma were not more adherent to the guidelines than those with mild intermittent disease.Conclusions. Asthma has a significant adverse effect on the lives of these children. The NHLBI guidelines, first published a decade ago, were designed to reduce asthma’s increasing morbidity and mortality, but this study uncovered a high rate of nonadherence with many aspects of the guidelines, including preventive strategies and home management of an exacerbation.

To determine the ability of children and adolescents with acute asthma exacerbations to adhere to national guidelines for proper metered-dose inhaler (MDI) and peak flow meter (PFM) technique and to define characteristics associated with improper use.A prospective study in which the patients were instructed to use a placebo MDI or a PFM in the emergency department exactly as at home. Technique was graded on the basis of performance of specific steps recommended by national guidelines.Children and adolescents (aged 2-18 years) with acute asthma exacerbations in the emergency department of an urban children's hospital with acute asthma.Thirty-three (45.2%) of 73 patients using an MDI (MDI group) demonstrated multiple steps improperly compared with 60 (44.4%) of 135 using an MDI with a holding chamber (MDI-HC group; P =.92). In the MDI group, young ages of the patients (P.008) and the parents (P.003) were associated with improper use. In the MDI-HC group, factors independently and significantly associated with improper use were no hospitalizations within the past year, parent assistance of the patient with MDI-HC use, and nondaily use of the MDI-HC. Also, 165 (82.9%) of 199 children who, per national guidelines, should be using a PFM at home, did not. Eighty-two (73.9%) of 111 patients demonstrated perfect performance of all PFM steps.Among children with acute asthma, we found high rates of improper MDI use and PFM underuse. A greater emphasis must be placed on teaching methods to optimize drug delivery and to instruct patients about the importance of self-monitoring of disease severity.