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Objectives The renal nephrometry score uses imaging characteristics such as lesion diameter, location, and proximity to hilar vessels to categorize renal masses by complexity for preoperative planning. These characteristics may also be used to determine the best approach to targeted renal biopsy. This study was conducted to investigate the impact of renal lesion characteristics as measured by the renal nephrometry score on the choice of modality used for performing a targeted renal lesion biopsy and increasing the chance of yielding a diagnostic biopsy. Materials and Methods All targeted computed tomography (CT)/ultrasound-guided renal biopsies performed by our radiology department from January 2017 to February 2020 were reviewed. Radiological characteristics and pathological outcomes were recorded with data on lesion size/ side, location in craniocaudal/anterior–posterior planes, endophytic/exophytic/mixed nature, and skin-lesion distance. Statistical Analysis Chi-squared tests, multivariate analysis, and t-tests were used in this study. Results Of the 145 consecutive patients included in the study, 86.2% (125/145) biopsies were diagnostic. About 54.5% (79/145) biopsies were ultrasound-guided, while 45.5% (66/145) were CT-guided. About 62.1% (90/145) biopsies revealed renal cell carcinoma. The highest rate of diagnostic biopsy was in the exophytic, laterally positioned mass either entirely below lower polar or above upper polar line. Ultrasound was preferred for lesions under 4cm and 4 to 7cm (p = 0.06). CT was used for anterior lesions and ultrasound for posterior and lateral lesions (p Conclusions Our study highlights some factors radiologists should consider when predicting whether CT or ultrasound guidance is more appropriate and the probability of achieving a diagnostic biopsy based on lesion characteristics. At our institution, both modalities achieved high accuracy, although we favored ultrasound in lateral, posterior, and small lesions. These factors should be weighed against local experience and preference.

Intuition, expressed as verbal arguments or axiom formulations, has often been used as a guiding principle for fuzzy number ranking (FNR). This chapter adopts the multi-attribute decision making (MADM) framework to analyze such intuition with three results. First, intuition in FNR should have involved multiple attributes, which are often implicated in the existing ranking methods. Then, we suggest three attributes (i.e., representative x-value, x-value range, overall membership ratio), which can be used to characterize the FNR intuition. Second, we decouple two issues in FNR: selection of attributes and aggregation of values, where aggregation is concerned with the trade-off among attributes to determine a single index for FNR. Then, the discount factors are proposed for the attributes of range and membership ratio to model the trade-off and formulate a ranking index. Third, the decoupling of attributes and aggregation reveals a fundamental tension between information content and the satisfaction of the FNR axioms. That is, if we can consider more information (in terms of attributes) as relevant to FNR, the ranking method will likely violate some FNR axioms. However, if we consider less information, the ranking method will be less sensitive to distinguish some fuzzy numbers for ranking. In the end, the proposed multi-attribute approach can provide a practical aspect to analyze and address the FNR problems.

BACKGROUND The use of electronic clinical decision support (CDS) systems for pediatric critical care trials is rare. We sought to describe in detail the use of a CDS tool (Children's Hospital Euglycemia for Kids Spreadsheet [CHECKS]), for the management of hyperglycemia during the 32 multicenter Heart And Lung Failure-Pediatric Insulin Titration trial. RESEARCH QUESTION In critically ill pediatric patients who were treated with CHECKS, how was user compliance associated with outcomes; and what patient and clinician factors might account for the observed differences in CHECKS compliance? STUDY DESIGN AND METHODS During an observational retrospective study of compliance with a CDS tool used during a prospective randomized controlled trial, we compared patients with high and low CHECKS compliance. We investigated the association between compliance and blood glucose metrics. We describe CHECKS and use a computer interface analysis framework (the user, function, representation, and task analysis framework) to categorize user interactions. We discuss implications for future randomized controlled trials. RESULTS Over a 4.5-year period, 658 of 698 children were treated with the CHECKS protocol for ≥24 hours with a median of 119 recommendations per patient. Compliance per patient was high (median, 99.5%), with only 30 patients having low compliance (

Mental model is a term that has been discussed in three contexts: (1) how mental models are understood in cognitive psychology, (2) how learners learn in science subjects, and (3) how people solve practical problems. Since mental models have been discussed in different contexts, this paper aims to conduct an integrative literature review that analyzes the materials published on mental models and their relevance for engineering education. The outcome of the review is a conceptual framework of mental models for engineering education with two highlights. First, mental models can help characterize learners’ (mis-)understanding of scientific concepts and technical systems. Second, mental models are of practical use when learners are engaged in some problem-solving tasks. In turn, mental models have a potential to support deep learning and project-based learning.

Direct expansion solar assisted heat pump (DX-SAHP) systems have the potential to provide the heat load required for domestic hot water (DHW) sustainably and with minimum emissions. DX-SAHPs utilize a solar thermal collector to evaporate a working fluid. By using less energy in the process, these systems can achieve higher coefficients of performance (COP) than those afforded by conventional air source heat pumps. With Calgary possessing the highest solar potential in Canada of about 2396 hours of sunlight available 333 days a year [1], the implementation of such systems would make technical and economic sense. In this paper, the design, fabrication, and testing of a DX-SAHP system for cold climates is presented. A mathematical model representing the system was developed by combining the Hottel-Whillier-Bliss equation for the solar collector and a control volume analysis using the first law of thermodynamics for the heat pump cycle. Theoretical results demonstrate that a COP in the range of 3.4–4.5 is achievable. With the promising theoretical results, an experimental test setup was designed, constructed, and instrumented to determine the long-term performance of a DX-SAHP under local climatic conditions.

Background Dipeptidyl peptidase-4 inhibitors (DPP-4I) have demonstrated survival benefit in patients with cancer, but their impact on patients with prostate cancer (PCa), especially with androgen deprivation therapy (ADT), is unclear. This study examined the impact of DPP-4I use on mortality risks in patients with type 2 diabetes (T2D) and PCa receiving ADT. Methods Adults with T2D and PCa who received metformin and ADT attending public hospitals in Hong Kong between 1 January 2006 and 31 March 2021 were retrospectively identified. Patients with

Iteration is a major cause contributing to an increase in project duration and cost. By adopting the traditional models of design structure matrix and reward Markov chain, this paper proposes a hyb...

This article describes a 4 $\times $ 112 Gb/s digital receiver targeting long-reach (LR) channels. An SNR optimized approach is presented, which relaxes the ADC resolution requirement and the number of FFE taps without sacrificing BER. The discrete-time front end overcomes gain–BW limitations to provide 10+ dB gain at 28 GHz. A 56-GS/s ADC then converts the signal to 6-b digital consuming only 195 mW. The following DFE-FFE-based digital equalizer is capable of compensating 36-dB loss achieving a BER of 2e−5. Furthermore, TDC and ISI filter-based low-latency timing recovery meet jitter tolerance specs over a wide range of data rates from 10 to 112 Gb/s, including 28-Gb/s NRZ. The overall receiver consumes 338 mW with 3.18-pJ/bit energy efficiency.

As one of the GEN-IV nuclear reactor systems proposed by GEN-IV International Forum, the sodium-cooled fast reactor features the energy generation with fast spectrum and a closed fuel cycle for fuel breeding and actinide management. In order to validate system codes for reactor system analyses and to improve code performance, benchmark activities of experimental transients of fast reactors were performed by worldwide institutions. The Shut-down Heat Removal Tests in Experimental Breeder Reactor II were proposed in the context of the International Atomic Energy Agency. In this work, loss-of-flow tests performed in Experimental Breeder Reactor II are analyzed using system thermal-hydraulic code CATHARE. Evolutions of important reactor parameters such as core power, coolant flow rate, temperatures in core and in the intermediate heat exchanger are predicted and compared against experimental data. The sodium pool is further modeled by using a 3D model in CATHARE-3 and its verification is also conducted in the benchmark. Qualitative agreement is obtained for the reactor parameters predicted by CATHARE. The inherent passive safety characteristics of Experimental Breeder Reactor II in unprotected loss-of-flow transient is demonstrated, and the stratification effects in sodium pool are able to be identified with the 3D model. The results obtained in this work are expectable to provide some valuable insights for future sodium-cooled fast reactor transient accident analyses by coupling system thermal-hydraulic codes and CFD tools.

Objectives We explored the age-dependent heterogeneity in the efficacy of prophylaxis with enoxaparin against central venous catheter-associated deep venous thrombosis in critically ill children. Design Post hoc analysis of a Bayesian phase 2b randomized clinical trial. Setting Seven PICUs. Patients Children less than 18 years old with newly inserted central venous catheter. Interventions Enoxaparin started less than 24 hours after insertion of central venous catheter and adjusted to anti-Xa level of 0.2-0.5 international units/mL versus usual care. Measurements and main results Of 51 children randomized, 24 were infants less than 1 year old. Risk ratios of central venous catheter-associated deep venous thrombosis with prophylaxis with enoxaparin were 0.98 (95% credible interval, 0.37-2.44) in infants and 0.24 (95% credible interval, 0.04-0.82) in older children greater than or equal to 1 year old. Infants and older children achieved anti-Xa level greater than or equal to 0.2 international units/mL at comparable times. While central venous catheter was in situ, endogenous thrombin potential, a measure of thrombin generation, was 223.21 nM.min (95% CI, 8.78-437.64 nM.min) lower in infants. Factor VIII activity, a driver of thrombin generation, was also lower in infants by 45.1% (95% CI, 15.7-74.4%). Median minimum platelet count while central venous catheter was in situ was higher in infants by 39 × 103/mm3 (interquartile range, 17-61 × 103/mm3). Central venous catheter:vein ratio was not statistically different. Prophylaxis with enoxaparin was less efficacious against central venous catheter-associated deep venous thrombosis at lower factor VIII activity and at higher platelet count. Conclusions The relatively lesser contribution of thrombin generation on central venous catheter-associated thrombus formation in critically ill infants potentially explains the age-dependent heterogeneity in the efficacy of prophylaxis with enoxaparin.

This article presents a multiprotocol DSP-DAC-based SerDes architecture. The lookup table (LUT)-based DSP provides flexible number of taps for equalization, and soft switching driver allows 1.2-Vpp transmit swing to achieve higher SNR. The architecture employs cascaded phase-locked loop (PLL)-based flexible clocking to support a wide range of data rates from 10 to 112 Gb/s. The $LC$ PLL generates 10.25–14.5 GHz but distributes a divided version of the clock between 2.25 and 3.625 GHz with less than 140-fs integrated jitter. The local ring PLL multiplies the clock to 28 GHz but keeps the jitter less than 180 fs thanks to wide loop bandwidth. The transmitter is implemented in 7-nm FinFET consuming 175 mW with 1.56-pJ/bit efficiency.

Objectives We obtained preliminary evidence on the efficacy of early prophylaxis on the risk of central venous catheter-associated deep venous thrombosis and its effect on thrombin generation in critically ill children. Design Bayesian phase 2b randomized clinical trial. Setting Seven PICUs. Patients Children less than 18 years old with a newly inserted central venous catheter and at low risk of bleeding. Intervention Enoxaparin adjusted to anti-Xa level of 0.2-0.5 international units/mL started at less than 24 hours after insertion of central venous catheter (enoxaparin arm) versus usual care without placebo (usual care arm). Measurements and main results At the interim analysis, the proportion of central venous catheter-associated deep venous thrombosis on ultrasonography in the usual care arm, which was 54.2% of 24 children, was significantly higher than that previously reported. This resulted in misspecification of the preapproved Bayesian analysis, reversal of direction of treatment effect, and early termination of the randomized clinical trial. Nevertheless, with 30.4% of 23 children with central venous catheter-associated deep venous thrombosis on ultrasonography in the enoxaparin arm, risk ratio of central venous catheter-associated deep venous thrombosis was 0.55 (95% credible interval, 0.24-1.11). Including children without ultrasonography, clinically relevant central venous catheter-associated deep venous thrombosis developed in one of 27 children (3.7%) in the enoxaparin arm and seven of 24 (29.2%) in the usual care arm (p = 0.02). Clinically relevant bleeding developed in one child randomized to the enoxaparin arm. Response profile of endogenous thrombin potential, a measure of thrombin generation, was not statistically different between trial arms. Conclusions These findings suggest the efficacy and safety of early prophylaxis that should be validated in a pivotal randomized clinical trial.

OBJECTIVES Noninvasive ventilation is widely used to avoid tracheal intubation in critically ill children. The objective of this study was to assess whether noninvasive ventilation failure was associated with severe tracheal intubation-associated events and severe oxygen desaturation during tracheal intubation. DESIGN Prospective multicenter cohort study of consecutive intubated patients using the National Emergency Airway Registry for Children registry. SETTING Thirteen PICUs (in 12 institutions) in the United States and Canada. PATIENTS All patients undergoing tracheal intubation in participating sites were included. Noninvasive ventilation failure group included children with any use of high-flow nasal cannula, continuous positive airway pressure, or bilevel noninvasive ventilation in the 6 hours prior to tracheal intubation. Primary tracheal intubation group included children without exposure to noninvasive ventilation within 6 hours before tracheal intubation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Severe tracheal intubation-associated events (cardiac arrest, esophageal intubation with delayed recognition, emesis with aspiration, hypotension requiring intervention, laryngospasm, pneumothorax, pneumomediastinum) and severe oxygen desaturation (< 70%) were recorded prospectively. The study included 956 tracheal intubation encounters; 424 tracheal intubations (44%) occurred after noninvasive ventilation failure, with a median of 13 hours (interquartile range, 4-38 hr) of noninvasive ventilation. Noninvasive ventilation failure group included more infants (47% vs 33%; p < 0.001) and patients with a respiratory diagnosis (56% vs 30%; p < 0.001). Noninvasive ventilation failure was not associated with severe tracheal intubation-associated events (5% vs 5% without noninvasive ventilation; p = 0.96) but was associated with severe desaturation (15% vs 9% without noninvasive ventilation; p = 0.005). After controlling for baseline differences, noninvasive ventilation failure was not independently associated with severe tracheal intubation-associated events (p = 0.35) or severe desaturation (p = 0.08). In the noninvasive ventilation failure group, higher FIO2 before tracheal intubation (≥ 70%) was associated with severe tracheal intubation-associated events. CONCLUSIONS Critically ill children are frequently exposed to noninvasive ventilation before intubation. Noninvasive ventilation failure was not independently associated with severe tracheal intubation-associated events or severe oxygen desaturation compared to primary tracheal intubation.

Background Understanding the epidemiology and clinical course of multisystem inflammatory syndrome in children (MIS-C) and its temporal association with coronavirus disease 2019 (Covid-19) is important, given the clinical and public health implications of the syndrome. Methods We conducted targeted surveillance for MIS-C from March 15 to May 20, 2020, in pediatric health centers across the United States. The case definition included six criteria: serious illness leading to hospitalization, an age of less than 21 years, fever that lasted for at least 24 hours, laboratory evidence of inflammation, multisystem organ involvement, and evidence of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) based on reverse-transcriptase polymerase chain reaction (RT-PCR), antibody testing, or exposure to persons with Covid-19 in the past month. Clinicians abstracted the data onto standardized forms. Results We report on 186 patients with MIS-C in 26 states. The median age was 8.3 years, 115 patients (62%) were male, 135 (73%) had previously been healthy, 131 (70%) were positive for SARS-CoV-2 by RT-PCR or antibody testing, and 164 (88%) were hospitalized after April 16, 2020. Organ-system involvement included the gastrointestinal system in 171 patients (92%), cardiovascular in 149 (80%), hematologic in 142 (76%), mucocutaneous in 137 (74%), and respiratory in 131 (70%). The median duration of hospitalization was 7 days (interquartile range, 4 to 10); 148 patients (80%) received intensive care, 37 (20%) received mechanical ventilation, 90 (48%) received vasoactive support, and 4 (2%) died. Coronary-artery aneurysms (z scores ≥2.5) were documented in 15 patients (8%), and Kawasaki’s disease–like features were documented in 74 (40%). Most patients (171 [92%]) had elevations in at least four biomarkers indicating inflammation. The use of immunomodulating therapies was common: intravenous immune globulin was used in 144 (77%), glucocorticoids in 91 (49%), and interleukin-6 or 1RA inhibitors in 38 (20%). Conclusions Multisystem inflammatory syndrome in children associated with SARS-CoV-2 led to serious and life-threatening illness in previously healthy children and adolescents. (Funded by the Centers for Disease Control and Prevention.)

Objective Social health is an important component of recovery following critical illness as modeled in the pediatric Post-Intensive Care Syndrome framework. We conducted a scoping review of studies measuring social outcomes (measurable components of social health) following pediatric critical illness and propose a conceptual framework of the social outcomes measured in these studies. Data sources PubMed, EMBASE, PsycINFO, CINAHL, and the Cochrane Registry Study selection We identified studies evaluating social outcomes in pediatric intensive care unit (PICU) survivors or their families from 1970–2017 as part of a broader scoping review of outcomes after pediatric critical illness. Data extraction We identified articles by dual review and dual-extracted study characteristics, instruments, and instrument validation and administration information. For instruments used in studies evaluating a social outcome, we collected instrument content and described it using qualitative methods adapted to a scoping review. Data synthesis Of 407 articles identified in the scoping review, 223 (55%) evaluated a social outcome. The majority were conducted in North America and the United Kingdom, with wide variation in methodology and population. Among these studies, 38 unique instruments were used to evaluate a social outcome. Specific social outcomes measured included individual (independence, attachment, empathy, social behaviors, social cognition, and social interest), environmental (community perceptions and environment), and network (activities and relationships) characteristics, together with school and family outcomes. While many instruments assessed more than one social outcome, no instrument evaluated all areas of social outcome. Conclusions The full range of social outcomes reported following pediatric critical illness were not captured by any single instrument. The lack of a comprehensive instrument focused on social outcomes may contribute to under-appreciation of the importance of social outcomes and their under-representation in PICU outcomes research. A more comprehensive evaluation of social outcomes will improve understanding of overall recovery following pediatric critical illness.

Objective To examine medical and psychosocial risk factors associated with the development of acute stress in parents of patients unexpectedly admitted to the PICU. Design Cross-sectional observational study. Setting Two tertiary care children's hospitals with mixed medical/surgical/cardiac PICU. Patients Parents of patients unexpectedly admitted to the PICU. Intervention None. Measurements and Main Results 265 parents of 188 children were enrolled of whom 49 parents (18%) met ASD qualification and 108 (41%) parents developed ASD symptoms as determined by the ASDS-5 scale. Risk factors making parents likely to meet ASD qualification include parents from area served by Penn State (p Conclusions A combination of psychosocial parental risk factors and patient factors were associated with acute stress in parents. Further studies evaluating targeted hospital interventions towards parents most at-risk are needed.

Tracheal intubation (TI) practice across pediatric emergency departments (EDs) has not been comprehensively reported. We aim to describe TI practice and outcomes in pediatric EDs in contrast to those in intensive are units (ICUs) and use the data to identify quality improvement targets.Consecutive TI encounters from pediatric EDs and ICUs in the National Emergency Airway Registry for Children (NEAR4KIDS) database from 2015 to 2018 were analyzed for patient, provider, and practice characteristics and outcomes: adverse TI-associated events (TIAEs), oxygen desaturation (SpOA total of 756 TIs in 13 pediatric EDs and 12,512 TIs in 51 pediatric/cardiac ICUs were reported. Median (interquartile range [IQR]) patient age for ED TIs was higher (32 [7-108] months) than that for ICU TIs (15 [3-91] months; p 0.001). Proportion of TIs for respiratory decompensation (52% of ED vs. 64% ICU), shock (26% vs. 14%), and neurologic deterioration (30% vs. 11%) also differed by location. Limited neck mobility was reported more often in the ED (16% vs. 6%). TIs in the ED were performed more often via video laryngoscopy (64% vs. 29%). Adverse TIAE rates (15.6% ED, 14% ICU; absolute difference = 1.6%, 95% confidence interval [CI] = -1.1 to 4.2; p = 0.23) and severe TIAE rates (5.4% ED, 5.8% ICU; absolute difference = -0.3%, 95% CI = -2.0 to 1.3; p = 0.68) were not different. Oxygen desaturation was less commonly reported in ED TIs (13.6%) than ICU TIs (17%, absolute difference = -3.4%, 95% CI = -5.9 to -0.8; p = 0.016). Among ED TIs, shock as an indication (adjusted odds ratio [aOR] = 2.15, 95% CI = 1.26 to 3.65) and limited mouth opening (aOR = 1.74, 95% CI = 1.04 to 2.93) were independently associated with TIAEs.While TI characteristics vary between pediatric EDs and ICUs, outcomes are similar. Shock and limited mouth opening were independently associated with adverse TI events in the ED.

Team-based learning is recognized as an important opportunity for teamwork skill development, experiential learning, and learning from peers. However, team-based learning presents many challenges. ...

OBJECTIVES We assessed the growth, distribution, and characteristics of pediatric intensive care in 2016. DESIGN Hospitals with PICUs were identified from prior surveys, databases, online searching, and clinician networking. A structured web-based survey was distributed in 2016 and compared with responses in a 2001 survey. SETTING PICUs were defined as a separate unit, specifically for the treatment of children with life-threatening conditions. PICU hospitals contained greater than or equal to 1 PICU. SUBJECTS Physician medical directors and nurse managers. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS PICU beds per pediatric population (< 18 yr), PICU bed distribution by state and region, and PICU characteristics and their relationship with PICU beds were measured. Between 2001 and 2016, the U.S. pediatric population grew 1.9% to greater than 73.6 million children, and PICU hospitals decreased 0.9% from 347 to 344 (58 closed, 55 opened). In contrast, PICU bed numbers increased 43% (4,135 to 5,908 beds); the median PICU beds per PICU hospital rose from 9 to 12 (interquartile range 8, 20 beds). PICU hospitals with greater than or equal to 15 beds in 2001 had significant bed growth by 2016, whereas PICU hospitals with less than 15 beds experienced little average growth. In 2016, there were eight PICU beds per 100,000 U.S. children (5.7 in 2001), with U.S. census region differences in bed availability (6.8 to 8.8 beds/100,000 children). Sixty-three PICU hospitals (18%) accounted for 47% of PICU beds. Specialized PICUs were available in 59 hospitals (17.2%), 48 were cardiac (129% growth). Academic affiliation, extracorporeal membrane oxygenation availability, and 24-hour in-hospital intensivist staffing increased with PICU beds per hospital. CONCLUSIONS U.S. PICU bed growth exceeded pediatric population growth over 15 years with a relatively small percentage of PICU hospitals containing almost half of all PICU beds. PICU bed availability is variable across U.S. states and regions, potentially influencing access to care and emergency preparedness.

Previous studies report worse short-term outcomes with hypoglycemia in critically ill children. These studies relied on intermittent blood glucose measurements, which may have introduced detection bias. We analyzed data from the Heart And Lung Failure-Pediatric INsulin Titration trial to determine the association of hypoglycemia with adverse short-term outcomes in critically ill children.Nested case-control study.Thirty-five PICUs. A computerized algorithm that guided the timing of blood glucose measurements and titration of insulin infusion, continuous glucose monitors, and standardized glucose infusion rates were used to minimize hypoglycemia.Nondiabetic children with cardiovascular and/or respiratory failure and hyperglycemia. Cases were children with any hypoglycemia (blood glucose60 mg/dL), whereas controls were children without hypoglycemia. Each case was matched with up to four unique controls according to age group, study day, and severity of illness.None.A total of 112 (16.0%) of 698 children who received the Heart And Lung Failure-Pediatric INsulin Titration protocol developed hypoglycemia, including 25 (3.6%) who developed severe hypoglycemia (blood glucose40 mg/dL). Of these, 110 cases were matched to 427 controls. Hypoglycemia was associated with fewer ICU-free days (median, 15.3 vs 20.2 d; p = 0.04) and fewer hospital-free days (0 vs 7 d; p = 0.01) through day 28. Ventilator-free days through day 28 and mortality at 28 and 90 days did not differ between groups. More children with insulin-induced versus noninsulin-induced hypoglycemia had zero ICU-free days (35.8% vs 20.9%; p = 0.008). Outcomes did not differ between children with severe versus nonsevere hypoglycemia or those with recurrent versus isolated hypoglycemia.When a computerized algorithm, continuous glucose monitors and standardized glucose infusion rates were used to manage hyperglycemia in critically ill children with cardiovascular and/or respiratory failure, severe hypoglycemia (blood glucose40 mg/dL) was uncommon, but any hypoglycemia (blood glucose60 mg/dL) remained common and was associated with worse short-term outcomes.

This session will cover global landscape funds and how experiences can inform modalities for climate investment going forward, as well as exploring how to manage and plan the scope for aid to the Global South.

IMPORTANCE: Refinement of criteria for multisystem inflammatory syndrome in children (MIS-C) may inform efforts to improve health outcomes. OBJECTIVE: To compare clinical characteristics and outcomes of children and adolescents with MIS-C vs those with severe coronavirus disease 2019 (COVID-19). SETTING, DESIGN, AND PARTICIPANTS: Case series of 1116 patients aged younger than 21 years hospitalized between March 15 and October 31, 2020, at 66 US hospitals in 31 states. Final date of follow-up was January 5, 2021. Patients with MIS-C had fever, inflammation, multisystem involvement, and positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reverse transcriptase–polymerase chain reaction (RT-PCR) or antibody test results or recent exposure with no alternate diagnosis. Patients with COVID-19 had positive RT-PCR test results and severe organ system involvement. EXPOSURE: SARS-CoV-2. MAIN OUTCOMES AND MEASURES: Presenting symptoms, organ system complications, laboratory biomarkers, interventions, and clinical outcomes. Multivariable regression was used to compute adjusted risk ratios (aRRs) of factors associated with MIS-C vs COVID-19. RESULTS: Of 1116 patients (median age, 9.7 years; 45% female), 539 (48%) were diagnosed with MIS-C and 577 (52%) with COVID-19. Compared with patients with COVID-19, patients with MIS-C were more likely to be 6 to 12 years old (40.8% vs 19.4%; absolute risk difference [RD], 21.4% [95% CI, 16.1%-26.7%]; aRR, 1.51 [95% CI, 1.33-1.72] vs 0-5 years) and non-Hispanic Black (32.3% vs 21.5%; RD, 10.8% [95% CI, 5.6%-16.0%]; aRR, 1.43 [95% CI, 1.17-1.76] vs White). Compared with patients with COVID-19, patients with MIS-C were more likely to have cardiorespiratory involvement (56.0% vs 8.8%; RD, 47.2% [95% CI, 42.4%-52.0%]; aRR, 2.99 [95% CI, 2.55-3.50] vs respiratory involvement), cardiovascular without respiratory involvement (10.6% vs 2.9%; RD, 7.7% [95% CI, 4.7%-10.6%]; aRR, 2.49 [95% CI, 2.05-3.02] vs respiratory involvement), and mucocutaneous without cardiorespiratory involvement (7.1% vs 2.3%; RD, 4.8% [95% CI, 2.3%-7.3%]; aRR, 2.29 [95% CI, 1.84-2.85] vs respiratory involvement). Patients with MIS-C had higher neutrophil to lymphocyte ratio (median, 6.4 vs 2.7, P

While buffer tanks are common to address the short-cycling concern of hydronic heating systems, they involve water mixing, where the boiler’s hot water is mixed with the system’s return water. This water mixing condition brings concerns of the performance of the boilers and the in-space heating equipment (e.g., radiant floors and terminal units) due to the reduced temperature differences (ΔT) through these devices. Then, a non-mixing concept is introduced by putting a movable separation plate in a buffer tank, which can store supply hot water and return cold water separately. To examine this non-mixing concept, a simulation study is conducted by developing two hydronic system models with mixing and non-mixing concepts. After simulating these models under continuous heating loads, it is observed that the non-mixing model can achieve better system efficiency (e.g., 86.7% versus 82.0% for low heating loads) due to better boiler’s efficiency and less system cycles. In addition, it is noted that the non-mixing concept allows better control of supply water temperature, which can better support the outdoor reset control of boilers.

Objectives To evaluate the effect of a tracheal intubation safety bundle on adverse tracheal intubation-associated events across 15 PICUs. Design Multicenter time-series study. Setting PICUs in the United States. Patients All patients received tracheal intubations in ICUs. Interventions We implemented a tracheal intubation safety bundle as a quality-improvement intervention that includes: 1) quarterly site benchmark performance report and 2) airway safety checklists (preprocedure risk factor, approach, and role planning, preprocedure bedside "time-out," and immediate postprocedure debriefing). We define each quality-improvement phase as baseline (-24 to -12 mo before checklist implementation), benchmark performance reporting only (-12 to 0 mo before checklist implementation), implementation (checklist implementation start to time achieving > 80% bundle adherence), early bundle adherence (0-12 mo), and sustained (late) bundle adherence (12-24 mo). Bundle adherence was defined a priori as greater than 80% of checklist use for tracheal intubations for 3 consecutive months. Measurements and main results The primary outcome was the adverse tracheal intubation-associated event, and secondary outcomes included severe tracheal intubation-associated events, multiple tracheal intubation attempts, and hypoxemia less than 80%.From January 2013 to December 2015, out of 19 participating PICUs, 15 ICUs (79%) achieved bundle adherence. Among the 15 ICUs, the adverse tracheal intubation-associated event rates were baseline phase: 217/1,241 (17.5%), benchmark reporting only phase: 257/1,750 (14.7%), early 0-12 month complete bundle compliance phase: 247/1,591 (15.5%), and late 12-24 month complete bundle compliance phase: 137/1,002 (13.7%). After adjusting for patient characteristics and clustering by site, the adverse tracheal intubation-associated event rate significantly decreased compared with baseline: benchmark: odds ratio, 0.83 (0.72-0.97; p = 0.016); early bundle: odds ratio, 0.80 (0.63-1.02; p = 0.074); and late bundle odds ratio, 0.63 (0.47-0.83; p = 0.001). Conclusions Effective implementation of a quality-improvement bundle was associated with a decrease in the adverse tracheal intubation-associated event that was sustained for 24 months.

This paper describes a 4 × 112 Gb/s digital receiver targeting Long Reach (LR) channels. The discrete time front-end overcomes gain-BW limitations to provide 10+dB gain at 28GHz. A 56GS/s ADC then converts the signal to 6-b digital consuming only 195mW. The following DFE-FFE based digital equalizer is capable of compensating 36 dB loss achieving BER of 2e-5. Furthermore, TDC and ISI filter based low latency timing recovery meets jitter tolerance specs over a wide range of data rates (25Gb/s NRZ to 106.25Gb/s PAM-4). The overall receiver consumes 338mW with 3.18pJ/bit energy efficiency

The reverse-bias current-voltage characteristics of commercial 1200 V 4H-silicon-carbide junction barrier Schottky (SiC-JBS) rectifiers are studied both experimentally and through numerical simulation. The reverse leakage current measured from physical devices is observed to display both a strong temperature and field dependence. A model is presented to explain the observed behavior based on a combination of trap-assisted tunneling and a thermionic-emission mechanism through a potential barrier located at the metal-SiC interface. The study shows that a two-level trapping model can be necessary to properly explain the measured data. Excellent agreement between the models and the measurements is obtained over a wide range of bias and temperature.

OBJECTIVES Evaluate differences in tracheal intubation-associated events and process variances (i.e., multiple intubation attempts and oxygen desaturation) between pediatric cardiac ICUs and noncardiac PICUs in children with underlying cardiac disease. DESIGN Retrospective cohort study using a multicenter tracheal intubation quality improvement database (National Emergency Airway Registry for Children). SETTING Thirty-six PICUs (five cardiac ICUs, 31 noncardiac ICUs) from July 2012 to March 2016. PATIENTS Children with medical or surgical cardiac disease who underwent intubation in an ICU. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Our primary outcome was the rate of any adverse tracheal intubation-associated event. Secondary outcomes were severe tracheal intubation-associated events, multiple tracheal intubation attempt rates, and oxygen desaturation. There were 1,502 tracheal intubations in children with underlying cardiac disease (751 in cardiac ICUs, 751 in noncardiac ICUs) reported. Cardiac ICUs and noncardiac ICUs had similar proportions of patients with surgical cardiac disease. Patients undergoing intubation in cardiac ICUs were younger (median age, 1 mo [interquartile range, 0-6 mo]) compared with noncardiac ICUs (median 3 mo [interquartile range, 1-11 mo]; p < 0.001). Tracheal intubation-associated event rates were not different between cardiac ICUs and noncardiac ICUs (16% vs 19%; adjusted odds ratio, 0.74; 95% CI, 0.54-1.02; p = 0.069). However, in a sensitivity analysis comparing cardiac ICUs with mixed ICUs (i.e., ICUs caring for children with either general pediatric or cardiac diseases), cardiac ICUs had decreased odds of adverse events (adjusted odds ratio, 0.71; 95% CI, 0.52-0.97; p = 0.033). Rates of severe tracheal intubation-associated events and multiple attempts were similar. Desaturations occurred more often during intubation in cardiac ICUs (adjusted odds ratio, 1.61; 95% CI, 1.04-1.15; p = 0.002). CONCLUSIONS In children with underlying cardiac disease, rates of adverse tracheal intubation-associated events were not lower in cardiac ICUs as compared to noncardiac ICUs, even after adjusting for differences in patient characteristics and care models.

The biosand filter is a household-level water treatment technology used globally in low-resource settings. As of December 2016, over 900,000 biosand filters had been implemented in 60 countries around the world. Local, decentralized production is one of the main advantages of this technology, but it also creates challenges, especially in regards to quality control. Using the current recommended proportions for the biosand filter concrete mix, slump was measured at water-to-cement ratios of 0.51, 0.64 and 0.76, with two replicates for each level. Twenty-eight-day strength was tested on four replicate cylinders, each at water-to-cement ratios of 0.51, 0.59, 0.67 and 0.76. Wet curing and dry curing were compared for 28-day strength and for their effect on shrinkage. Maximum strength occurred at water-to-cement ratios of 0.51–0.59, equivalent to 8–9.3 L water for a full-scale filter assuming saturated media, corresponding to a slump class of S1 (10–40 mm). Wet curing significantly improved strength of the concrete mix and reduced shrinkage. Quality control measures such as the slump test can significantly improve the quality within decentralized production of biosand filters, despite localized differences in production conditions.

Oxygen desaturation during tracheal intubation is known to be associated with adverse ICU outcomes in critically ill children. We aimed to determine the occurrence and severity of desaturation during tracheal intubations and the association with adverse hemodynamic tracheal intubation-associated events.Retrospective cohort study as a part of the National Emergency Airway Registry for Children Network's quality improvement project from January 2012 to December 2014.International PICUs.Critically ill children younger than 18 years undergoing primary tracheal intubations in the ICUs.tracheal intubation processes of care and outcomes were prospectively collected using standardized operational definitions. We defined moderate desaturation as oxygen saturation less than 80% and severe desaturation as oxygen saturation less than 70% during tracheal intubation procedures in children with initial oxygen saturation greater than 90% after preoxygenation. Adverse hemodynamic tracheal intubation-associated event was defined as cardiac arrests, hypo or hypertension requiring intervention, and dysrhythmia.A total of 5,498 primary tracheal intubations from 31 ICUs were reported. Moderate desaturation was observed in 19.3% associated with adverse hemodynamic tracheal intubation-associated events (9.8% among children with moderate desaturation vs 4.4% without desaturation; p0.001). Severe desaturation was observed in 12.9% of tracheal intubations, also significantly associated with hemodynamic tracheal intubation-associated events. After adjusting for patient, provider, and practice factors, the occurrence of moderate desaturation was independently associated with hemodynamic tracheal intubation-associated events: adjusted odds ratio 1.83 (95% CI, 1.34-2.51; p0.001). The occurrence of severe desaturation was also independently associated with hemodynamic tracheal intubation-associated events: adjusted odds ratio 2.16 (95% CI, 1.54-3.04; p0.001). Number of tracheal intubation attempts was also significantly associated with the frequency of moderate and severe desaturations (p0.001).In this large tracheal intubation quality improvement database, we found moderate and severe desaturation are reported among 19% and 13% of all tracheal intubation encounters. Moderate and severe desaturations were independently associated with the occurrence of adverse hemodynamic events. Future quality improvement interventions may focus to reduce desaturation events.

In the 40 years since Professor Roy Meadow first described ‘Munchausen Syndrome by Proxy’, there have been a number of significant developments, including terminology, definition, prevalence and management. The Royal College of Paediatrics and Child Health (RCPCH) guidance on Perplexing Presentations (PP)/Fabricated or Induced Illness (FII) in Children outlines procedures in order to safeguard children who present with perplexing presentations and fabricated or induced illness. It offers practical advice on how to recognise it, how to manage risk and how to manage these presentations. This guideline was commissioned and developed by the RCPCH. There was input from a wide range of paediatric generalists and subspecialists, as well as social work practitioners and several organisations and commissioning groups. Although written primarily for paediatricians, it is of direct relevance to general practitioners (GPs), other specialists, social care and education. See box 1 for a link to the full guideline and other related resources. Box 1 ### Resources While this guidance supersedes the 2009 RCPCH guideline entitled Fabricated or induced illness by carers: a practical guide for paediatricians, it does not fully replace it or render it obsolete. For the ‘high risk’ or physically injurious FII cases, the detailed management guidance in the 2009 document is still applicable. The RCPCH Child Protection Companion 2013 extended the definition of FII by introducing the term Perplexing Presentations with new suggestions for their management. This guideline supports a cultural …

In incremental eco-design improvements, design engineers attempt to modify an existing product via some eco-design measures to reduce the product’s environmental impacts (e.g. reduction of material...

Access to primary research data is vital for the advancement of science. To extend the data types supported by community repositories, we built a prototype Image Data Resource (IDR) that collects and integrates imaging data acquired across many different imaging modalities. IDR links data from several imaging modalities, including high-content screening, super-resolution and time-lapse microscopy, digital pathology, public genetic or chemical databases, and cell and tissue phenotypes expressed using controlled ontologies. Using this integration, IDR facilitates the analysis of gene networks and reveals functional interactions that are inaccessible to individual studies. To enable re-analysis, we also established a computational resource based on Jupyter notebooks that allows remote access to the entire IDR. IDR is also an open source platform that others can use to publish their own image data. Thus IDR provides both a novel on-line resource and a software infrastructure that promotes and extends publication and re-analysis of scientific image data.

Internet of things (IoT) devices such as self-driven cars and home appliances are creating massive amounts of data traffic. Obviously, such demand trickles down to every electrical interface in a network. Therefore, next-generation data centers need to evolve accordingly to accommodate the bandwidth demand of a rapidly changing world of technology. Since the channel loss is not improving at the same rate, most of the standards are adopting multilevel signaling to make more efficient use of the frequency spectrum. A 4×112Gb/s PAM-4 transmitter presented in this work is leading this trend to keep electrical signaling viable and relevant for future data centers. It introduces three techniques to enable flexibility over different protocols and achieves 1.56pJ/b (175mW at 112Gb/s data rate including clocking) energy efficiency. First, improving signal-to-noise ratio is key to achieve lower BER in multilevel signaling. This work introduces a ‘soft-switching’ H-bridge output driver to enable a 1.2V peak-to-peak differential output swing without exposing devices beyond breakdown voltage. Second, ‘flex clocking’ is achieved by combining a central LC-PLL with a per-lane sub-sampling ring PLL. This combination enables flexible clock generation to seamlessly support data rates between 10Gb/s NRZ and 112Gb/s PAM-4. This clocking architecture enables low-frequency clock distribution for power saving and is easily scalable to more lanes. Third, a DSP-DAC-based transmitter is used to support an arbitrary number of equalization taps and different modulation schemes [1]. A segmented lookup-table-based (LUP-based) implementation further reduces the DSP power.

Background There are no tests to identify critically ill children at high risk of deep venous thrombosis (DVT). In this exploratory study, we aimed to identify proteins that are associated with incident DVT in critically ill adolescents. Procedure Plasma samples were obtained from critically ill adolescents within 24 hours after initiation of cardiopulmonary support. The adolescents were followed with ultrasound to detect the development of DVT of the lower extremity and clinically for bleeding. Thrombin-antithrombin complex and prothrombin fragment 1+2 were measured using immunosorbent assays, whereas procoagulation and anticoagulation factors were measured using multiplex assays. Plasma samples were also analyzed using SOMAscan, an aptamer-based capture assay. The associations between DVT and the log-transformed level of the proteins were assessed using logistic regression adjusting for the presence of femoral venous catheter and severity of illness. Associations were expressed as odds ratio (OR) for every log-fold increase in level of the protein with 95% confidence interval (CI). Results Plasma from 59 critically ill adolescents, of whom 9 developed incident DVT, was analyzed. The median age of the adolescents was 15.1 years (interquartile range, 14.0-16.7 years). Higher levels of thrombin-antithrombin complex (OR: 31.54; 95% CI: 2.09-475.92) and lower levels of factor XIII (OR: 0.03; 95% CI: 0.002-0.44) were associated with DVT. CD36, MIC-1, and EpoR were marginally associated with DVT. Only factor XIII was associated with clinically relevant bleeding (OR: 0.27; 95% CI: 0.08-0.97). Conclusions We identified candidate protein biomarkers for incident DVT. We plan to validate our findings in adequately powered studies.

Faced with the need to support a growing number of whole slide imaging (WSI) file formats, our team has extended a long-standing community file format (OME-TIFF) for use in digital pathology. The format makes use of the core TIFF specification to store multi-resolution (or "pyramidal") representations of a single slide in a flexible, performant manner. Here we describe the structure of this format, its performance characteristics, as well as an open-source library support for reading and writing pyramidal OME-TIFFs.

Two-dimensional (2D) modeling is reported for InGaP/GaAs/InGaAs four-junction solar cell with tunnel junctions. The cell basic physical properties were demonstrated. The simulated results indicate one-sun efficiency about 40.1% with short-circuit current density as 126.63 A/m2 and open-circuit voltage as 3.69V. High efficiency up to 45.9% under 100 sun illumination could be achieved.

In this paper, the FDFD is used to analyze Vertical Cavity Surface Emitting Laser (VCSEL). Based on the structure of the VCSEL, two main models can be used; the 2.5D and the 3D Finite Difference Frequency Domain (FDFD). The full vectorial solver is well suited for the fundamental as well as the higher-order modes and includes different field polarization. The method was used to solve both the reference VCSEL and the Surface-Relief VCSEL.

Objectives To investigate adaptive skills, behavior, and quality health-related quality of life in children from 32 centers enrolling in the Heart And Lung Failure-Pediatric INsulin Titration randomized controlled trial. Study design This prospective longitudinal cohort study compared the effect of 2 tight glycemic control ranges (lower target, 80-100 mg/dL vs higher target, 150-180 mg/dL) 1-year neurobehavioral and health-related quality of life outcomes. Subjects had confirmed hyperglycemia and cardiac and/or respiratory failure. Patients aged 2-16 years old enrolled between April 2012 and September 2016 were studied at 1 year after intensive care discharge. The primary outcome, adaptive skills, was assessed using the Vineland Adaptive Behavior Scale. Behavior and health-related quality of life outcomes were assessed as secondary outcomes using the Pediatric Quality of Life and Child Behavior Checklist at baseline and 1-year follow-up. Group differences were evaluated using regression models adjusting for age category, baseline overall performance, and risk of mortality. Results Of 369 eligible children, 358 survived after hospital discharge and 214 (60%) completed follow-up. One-year Vineland Adaptive Behavior Scale-II composite scores were not different (mean ± SD, 79.9 ± 25.5 vs 79.4 ± 26.9, lower vs higher target; P = .20). Improvement in Pediatric Quality of Life total health from baseline was greater in the higher target group (adjusted mean difference, 8.2; 95% CI, 1.1-15.3; P = .02). Conclusions One-year adaptive behavior in critically ill children with lower vs higher target glycemic control did not differ. The higher target group demonstrated improvement from baseline in overall health. This study affirms the lack of benefit of lower glucose targeting. Trial registration ClinicalTrials.gov : NCT01565941 .