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Background It is unknown if probiotics exert pathogen-specific effects in children with diarrhea secondary to acute gastroenteritis. Methods Analysis of patient-level data from 2 multicenter randomized, placebo controlled trials conducted in pediatric emergency departments in Canada and the United States. Participants were 3–48 months with >3 diarrheal episodes in the preceding 24 hours and were symptomatic for Results Pathogens were identified in specimens from 59.3% of children (928/1565). No pathogen groups were less likely to experience an MVS score ≥9 based on treatment allocation (test for interaction = 0.35). No differences between groups were identified for adenovirus (adjusted relative risk [aRR]: 1.42; 95% confidence interval [CI]: .62, 3.23), norovirus (aRR: 0.98; 95% CI: .56, 1.74), rotavirus (aRR: 0.86; 95% CI: .43, 1.71) or bacteria (aRR: 1.19; 95% CI: .41, 3.43). At pathogen-group and among individual pathogens there were no differences in diarrhea duration or the total number of diarrheal stools between treatment groups, regardless of intervention allocation or among probiotic sub-groups. Among adenovirus-infected children, those administered the L. rhamnosus R0011/L. helveticus R0052 product experienced fewer diarrheal episodes (aRR: 0.65; 95% CI: .47, .90). Conclusions Neither probiotic product resulted in less severe disease compared to placebo across a range of the most common etiologic pathogens. The preponderance of evidence does not support the notion that there are pathogen specific benefits associated with probiotic use in children with acute gastroenteritis. Clinical Trials Registration NCT01773967 and NCT01853124.

The COVID-19 pandemic has forced Indian engineering institutions (EIs) to bring their previous half-shut shades completely down. Attracting new admissions to EI campuses during the pandemic have become a ‘now or never’ situation for EIs. During crisis situations, EIs have struggled to return to their normal track. The pandemic has drastically changed students' behavior and family preferences due to mental stress and the emotional life associated with it. Consequently, it has become the need of hour to examine the choice characteristics influencing the selection of EIs during the COVID-19 pandemic. The purpose of this study is to critically examine institutional influence and pandemic influence that affects students’ choice about engineering institutions (EIs) during COVID-19 pandemic situation and consequently to study relationships between them. A quantitative research, conducted through a self-report survey composed by a closed-ended structured questionnaire was performed on the students who were recently enrolled in the EIs (academic year 2020–2021) belonging to North Maharashtra region of India during the pandemic. The findings of this study have revealed that institutional and pandemic influence have directed EI choice under the COVID-19 pandemic. It is also found that pandemic influence is positively affected by institutional influence. The study demonstrated that EIs can attract new enrollments by repositioning their institutional characteristics that regulate pandemic influence. The study can be a measuring tool for policy makers to attract new enrollments under pandemic situation., Engineering education, Choice characteristics, Institutional influence, Pandemic influence, Suitability under the COVID-19.

OBJECTIVES To identify independent predictors of and derive a risk score for invasive herpes simplex virus (HSV) infection. METHODS In this 23-center nested case-control study, we matched 149 infants with HSV to 1340 controls; all were ≤60 days old and had cerebrospinal fluid obtained within 24 hours of presentation or had HSV detected. The primary and secondary outcomes were invasive (disseminated or central nervous system) or any HSV infection, respectively. RESULTS Of all infants included, 90 (60.4%) had invasive and 59 (39.6%) had skin, eyes, and mouth disease. Predictors independently associated with invasive HSV included younger age (adjusted odds ratio [aOR]: 9.1 [95% confidence interval (CI): 3.4–24.5] 28 days), prematurity (aOR: 2.3, 95% CI: 1.1 to 5.1), seizure at home (aOR: 6.1, 95% CI: 2.3 to 16.4), ill appearance (aOR: 4.2, 95% CI: 2.0 to 8.4), abnormal triage temperature (aOR: 2.9, 95% CI: 1.6 to 5.3), vesicular rash (aOR: 54.8, (95% CI: 16.6 to 180.9), thrombocytopenia (aOR: 4.4, 95% CI: 1.6 to 12.4), and cerebrospinal fluid pleocytosis (aOR: 3.5, 95% CI: 1.2 to 10.0). These variables were transformed to derive the HSV risk score (point range 0–17). Infants with invasive HSV had a higher median score (6, interquartile range: 4–8) than those without invasive HSV (3, interquartile range: 1.5–4), with an area under the curve for invasive HSV disease of 0.85 (95% CI: 0.80–0.91). When using a cut-point of ≥3, the HSV risk score had a sensitivity of 95.6% (95% CI: 84.9% to 99.5%), specificity of 40.1% (95% CI: 36.8% to 43.6%), and positive likelihood ratio 1.60 (95% CI: 1.5 to 1.7) and negative likelihood ratio 0.11 (95% CI: 0.03 to 0.43). CONCLUSIONS A novel HSV risk score identified infants at extremely low risk for invasive HSV who may not require routine testing or empirical treatment.

Background Febrile infants commonly present to emergency departments for evaluation. Objective We describe the variation in diagnostic testing and hospitalization of febrile infants ≤60 days of age presenting to the emergency departments in the Pediatric Emergency Care Applied Research Network. Methods We enrolled a convenience sample of non-critically ill–appearing febrile infants (temperatures ≥38.0°C/100.4°F) ≤60 days of age who were being evaluated with blood cultures in 26 Pediatric Emergency Care Applied Research Network emergency departments between 2008 and 2013. Patients were divided into younger (0–28 days of age) and older (29–60 days of age) cohorts for analysis. We evaluated diagnostic testing and hospitalization rates by infant age group using chi-square tests and by site using analysis of variance. Results Four thousand seven hundred seventy-eight patients were eligible for analysis, of whom 1517 (32%) were 0–28 days of age. Rates of lumbar puncture and hospitalization were high (>90%) among infants ≤28 days of age, with chest radiography (35.5%) and viral testing (66.2%) less commonly obtained. Among infants 29–60 days of age, lumbar puncture (69.5%) and hospitalization (64.4%) rates were lower and declined with increasing age, with chest radiography (36.5%) use unchanged and viral testing (52.7%) slightly decreased. There was substantial variation between sites in the older cohort of infants, with lumbar puncture and hospitalization rates ranging from 40% to 90%. Conclusions The evaluation and disposition of febrile infants ≤60 days of age is highly variable, particularly among infants who are 29–60 days of age. This variation demonstrates an opportunity to modify diagnostic and management strategies based on current epidemiology to safely decrease invasive testing and hospitalization.

Disruption of anterior cruciate ligament (ACL) is a common ligamentous injury of the knee. The best choice of graft for reconstruction remains undecided. This prospective, randomized clinical trial aimed to compare clinical results of bone-patellar tendon-bone (BPTB) grafts and four-strand semitendinosus-gracilis (QHT) grafts for ACL reconstruction over a 1-year follow-up interval in Indian population. Methods 42 consecutive patients with ACL injury were recruited, by pick and draw method and allotted into two groups with 21 patients in each group. Group A patients underwent arthroscopic ACL reconstruction using BPTB graft while QHT autograft was used for patients in Group B. All the patients underwent standard ipsilateral arthroscopic ACL reconstruction procedure using a single incision, antero-medial (AM) portal technique for BPTB or the QHT autograft by a same surgeon. Patients were followed up regularly for a minimum period of 1 year. Results After one year, the Cincinnati score was 91 ± 4.117 in BPTB group and 89.29 ± 5.371 in QHT group (P = 0.282). There was no significant difference between the two groups in the mean scores with respect to pain, overall activity level and running in the Cincinnati score. None of the patients complained of the knee giving way. Similarly, at 1 year, the Lysholm score was 92.84 ± 2.630 and 90.55 ± 2.395 in the two groups respectively (P = 0.842). There were no episodes of locking or instability and there was no significant difference in the mean Lysholm scores regarding pain and squatting. Conclusion There was no significant functional difference between the two grafts in terms of Lysholm and the Cincinnati score, anterior knee laxity and altered sensation over proximal leg. The patients with QHT groups performed better than BPTB functionally at 6 month so early return to sport is possible even with QHT autograft.

Objective To compare the risk of serious bacterial infection between infants aged ≤60 days who are febrile in the emergency department (ED) and those who have only a history of fever and are afebrile on arrival to the ED. Study design In this secondary analysis of a multicenter prospective study using data collected between December 2008 and May 2013, we compared the rate of serious bacterial infection (urinary tract infection [UTI], bacteremia, and/or bacterial meningitis) between infants who have a history of fever but are afebrile on arrival to the ED and those with fever documented in the ED (rectal temperature ≥38.0 °C) using relative risk (RR) with 95% CI. Stratified analyses were performed for age (≤28 and 29-60 days) and serious bacterial infection type. Infants born prematurely and those with a clinical focal infection or serious illness were excluded. Results A total of 3825 infants (mean age, 35.2 days; 56.9% male) were included. Of the 1233 (32.2%) who were afebrile in the ED, 108 (8.8%) had a serious bacterial infection (UTI, n = 94 [7.6%]; bacteremia, n = 19 [1.5%]; bacterial meningitis, n = 8 [0.6%]). Of the 2592 infants (67.8%) who were febrile in the ED, 331 (12.8%) had a serious bacterial infection (UTI, n = 285 [11.0%]; bacteremia, n = 61 [2.4%]; bacterial meningitis, n = 17 [0.7%]). The RR for serious bacterial infection for afebrile vs febrile infants was 0.68 (95% CI, 0.56-0.84). A lower risk of serious bacterial infection was also seen among afebrile vs febrile infants aged ≤28 days (RR, 0.69; 95% CI, 0.52-0.93) and age 29-60 days (RR, 0.67; 95% CI, 0.50-0.89). Conclusions The prevalence of serious bacterial infection is lower in infants aged ≤60 days with a history of fever compared with those who are febrile on arrival to the ED. The small risk reduction in this group is unlikely to alter decision making.

This is a revision of the previous joint Policy Statement titled “Guidelines for Care of Children in the Emergency Department.” Children have unique physical and psychosocial needs that are heightened in the setting of serious or life-threatening emergencies. The majority of children who are ill and injured are brought to community hospital emergency departments (EDs) by virtue of proximity. It is therefore imperative that all EDs have the appropriate resources (medications, equipment, policies, and education) and capable staff to provide effective emergency care for children. In this Policy Statement, we outline the resources necessary for EDs to stand ready to care for children of all ages. These recommendations are consistent with the recommendations of the Institute of Medicine (now called the National Academy of Medicine) in its report “The Future of Emergency Care in the US Health System.” Although resources within emergency and trauma care systems vary locally, regionally, and nationally, it is essential that ED staff, administrators, and medical directors seek to meet or exceed these recommendations to ensure that high-quality emergency care is available for all children. These updated recommendations are intended to serve as a resource for clinical and administrative leadership in EDs as they strive to improve their readiness for children of all ages.

* Abbreviation: SSE — : serious safety event Two decades ago, the seminal Institute of Medicine (now the National Academies of Sciences, Engineering, and Medicine) report To Err Is Human: Building a Safer Health System first highlighted the influence of poorly designed health care delivery systems and suboptimal processes as contributors to patient safety.1 Substantial progress has occurred since then, including creation of a federally mandated Child Health Patient Safety Organization,2 which uses a standardized taxonomy for patient safety events, contributory factors, and severity of harm,3 with shared learning by dissemination of reports to individual institutions and to the public.4 In this issue of Pediatrics , Burrus et al analyze and report on 4 years of serious safety events (SSEs) from 44 Child Health Patient Safety Organization–participating hospitals regarding the types of safety events, severity of … Address correspondence to Prof Prashant Mahajan, CS Mott Children’s Hospital of Michigan, 1540 East Hospital Dr Room 2-737, SPC 4260, Ann Arbor MI 48109-4260. E-mail: pmahajan{at}med.umich.edu.

Building facial analysis systems that generalize to extreme variations in lighting and facial expressions is a challenging problem that can potentially be alleviated using natural-looking synthetic data. Towards that, we propose LEGAN, a novel synthesis framework that leverages perceptual quality judgments for jointly manipulating lighting and expressions in face images, without requiring paired training data. LEGAN disentangles the lighting and expression subspaces and performs transformations in the feature space before upscaling to the desired output image. The fidelity of the synthetic image is further refined by integrating a perceptual quality estimation model, trained with face images rendered using multiple synthesis methods and their crowd-sourced naturalness ratings, into the LEGAN framework as an auxiliary discriminator. Using objective metrics like FID and LPIPS, LEGAN is shown to generate higher quality face images when compared with popular GAN models like StarGAN and StarGAN-v2 for lighting and expression synthesis. We also conduct a perceptual study using images synthesized by LEGAN and other GAN models and show the correlation between our quality estimation and visual fidelity. Finally, we demonstrate the effectiveness of LEGAN as training data augmenter for expression recognition and face verification tasks.

BACKGROUND: Between-country variation in health care resource use and its impact on outcomes in acute care settings have been challenging to disentangle from illness severity by using administrative data. METHODS: We conducted a preplanned analysis employing patient-level emergency department (ED) data from children enrolled in 2 previously conducted clinical trials. Participants aged 3 to RESULTS: In adjusted analysis, unscheduled revisits within 7 days did not differ (adjusted odds ratio [aOR]: 0.72; 95% confidence interval (CI): 0.50 to 1.02). At the index ED visit, although participants in Canada were assessed as being more dehydrated, intravenous fluids were administered more frequently in the United States (aOR: 4.6; 95% CI: 2.9 to 7.1). Intravenous fluid administration rates did not differ after enrollment (aOR: 1.4; 95% CI: 0.7 to 2.8; US cohort with Canadian as referent). Overall, intravenous rehydration was higher in the United States (aOR: 3.8; 95% CI: 2.5 to 5.7). Although hospitalization rates during the 7 days after enrollment (aOR: 1.1; 95% CI: 0.4 to 2.6) did not differ, hospitalization at the index visit was more common in the United States (3.9% vs 2.3%; aOR: 3.2; 95% CI: 1.6 to 6.8). CONCLUSIONS: Among children with gastroenteritis and similar disease severity, revisit rates were similar in our 2 study cohorts, despite lower rates of intravenous rehydration and hospitalization in Canadian-based EDs.

The COVID-19 pandemic has forced Indian engineering institutions (EIs) to bring their previous half-shut shades completely down. Fetching new admissions to EI campuses during the pandemic has become a ‘now or never’ situation for EIs. During crisis situations, institutions have struggled to return to the normal track. The pandemic has drastically changed students’ behavior and family preferences due to mental stress and the emotional life attached to it. Consequently, it becomes a prerequisite, and emergencies need to examine the choice characteristics influencing the selection of EI during the COVID-19 pandemic.The purpose of this study is to critically examine institutional influence and pandemic influence due to COVID-19 that affects students’ choice about an engineering institution (EI) and consequently to explore relationships between institutional and pandemic influence. The findings of this quantitative research, conducted through a self-reported survey, have revealed that institutional and pandemic influence have governed EI choice under the COVID-19 pandemic. Second, pandemic influence is positively affected by institutional influence. The study demonstrated that EIs will have to reposition themselves to normalize pandemic influence by tuning institutional characteristics that regulate situational influence and new enrollments. It can be yardstick for policy makers to attract new enrollments under pandemic situations.

Background: Urinary tract infections (UTIs) are the most common serious bacterial infection in young febrile infants, and the urinalysis (UA) is an accurate screening test for emergency department (ED) evaluation. Precise estimates of risk of concomitant bacteremia and/or bacterial meningitis (invasive bacterial infections; IBI) in febrile infants ≤ 60 days have been based on presence of UTIs rather than positive UAs, and lack large prospective study. Objective: We sought to determine the prevalence of IBIs in febrile infants 0-28 …

Fever is one of the most common presenting complaints among infants brought to pediatric emergency. Although most of the infants have benign, self-limiting viral infections, approximately 10% of all may have serious bacterial infection. Clinical examination alone is insufficient to detect serious bacterial infection in well appearing infants, and a standardized approach is always sought for. However, guidelines used in the United States or European countries may not be applicable in a tropical country like India. Deviation from these guidelines leads to challenges of unwarranted hospitalization and antibiotic usage, extra cost of care and risk of antimicrobial resistance. Various prediction rules can detect a low risk infant with negative predictive values ranging from 93.7-100%. While use of biomarkers such as C reactive protein and procalcitonin can be reliable, it is costly and may not be applicable to the local population. Validation studies over varied population are needed in future.

Importance Despite guidelines endorsing oral rehydration therapy, intravenous fluids are commonly administered to children with acute gastroenteritis in high-income countries. Objective To identify factors associated with intravenous fluid administration and hospitalization in children with acute gastroenteritis. Design, setting, and participants This study is a planned secondary analysis of the Pediatric Emergency Research Canada (PERC) and Pediatric Emergency Care Applied Research Network (PECARN) probiotic trials. Participants include children aged 3 to 48 months with 3 or more watery stools in 24 hours between November 5, 2013, and April 7, 2017, for the PERC study and July 8, 2014, and June 23, 2017, for the PECARN Study. Children were from 16 pediatric emergency departments throughout Canada (6) and the US (10). Data were analyzed from November 2, 2018, to March 16, 2021. Exposures Sex, age, preceding health care visit, distance between home and hospital, country (US vs Canada), frequency and duration of vomiting and diarrhea, presence of fever, Clinical Dehydration Scale score, oral ondansetron followed by oral rehydration therapy, and infectious agent. Main outcomes and measures Intravenous fluid administration and hospitalization. Results This secondary analysis of 2 randomized clinical trials included 1846 children (mean [SD] age, 19.1 [11.4] months; 1007 boys [54.6%]), of whom 534 of 1846 (28.9%) received oral ondansetron, 240 of 1846 (13.0%) received intravenous rehydration, and 67 of 1846 (3.6%) were hospitalized. The following were independently associated with intravenous rehydration: higher Clinical Dehydration Scale score (mild to moderate vs none, odds ratio [OR], 8.73; 95% CI, 5.81-13.13; and severe vs none, OR, 34.15; 95% CI, 13.45-86.73); country (US vs Canada, OR, 6.76; 95% CI, 3.15-14.49); prior health care visit with intravenous fluids (OR, 4.55; 95% CI, 1.32-15.72); and frequency of vomiting (per 5 episodes, OR, 1.66; 95% CI, 1.39-1.99). The following were independently associated with hospitalization: higher Clinical Dehydration Scale score (mild to moderate vs none, OR, 11.10; 95% CI, 5.05-24.38; and severe vs none, OR, 23.55; 95% CI, 7.09-78.25) and country (US vs Canada, OR, 3.37; 95% CI, 1.36-8.40). Oral ondansetron was associated with reduced odds of intravenous rehydration (OR, 0.21; 95% CI, 0.13-0.32) and hospitalization (OR, 0.44; 95% CI, 0.21-0.89). Conclusions and relevance Intravenous rehydration and hospitalization were associated with clinical evidence of dehydration and lack of an oral ondansetron-supported oral rehydration period. Strategies focusing on oral ondansetron administration followed by oral rehydration therapy in children with dehydration may reduce the reliance on intravenous rehydration and hospitalization. Trial registration ClinicalTrials.gov Identifiers: NCT01853124 (PERC) and NCT01773967 (PECARN).

BACKGROUND Diagnostic decision making, especially in emergency departments, is a highly complex cognitive process that involves uncertainty and susceptibility to errors. A combination of factors, including patient factors (eg, history, behaviors, complexity, and comorbidity), provider-care team factors (eg, cognitive load and information gathering and synthesis), and system factors (eg, health information technology, crowding, shift-based work, and interruptions) may contribute to diagnostic errors. Using electronic triggers to identify records of patients with certain patterns of care, such as escalation of care, has been useful to screen for diagnostic errors. Once errors are identified, sophisticated data analytics and machine learning techniques can be applied to existing electronic health record (EHR) data sets to shed light on potential risk factors influencing diagnostic decision making. OBJECTIVE This study aims to identify variables associated with diagnostic errors in emergency departments using large-scale EHR data and machine learning techniques. METHODS This study plans to use trigger algorithms within EHR data repositories to generate a large data set of records that are labeled trigger-positive or trigger-negative, depending on whether they meet certain criteria. Samples from both data sets will be validated using medical record reviews, upon which we expect to find a higher number of diagnostic safety events in the trigger-positive subset. Machine learning will be used to evaluate relationships between certain patient factors, provider-care team factors, and system-level risk factors and diagnostic safety signals in the statistically matched groups of trigger-positive and trigger-negative charts. RESULTS This federally funded study was approved by the institutional review board of 2 academic medical centers with affiliated community hospitals. Trigger queries are being developed at both organizations, and sample cohorts will be labeled using the triggers. Machine learning techniques such as association rule mining, chi-square automated interaction detection, and classification and regression trees will be used to discover important variables that could be incorporated within future clinical decision support systems to help identify and reduce risks that contribute to diagnostic errors. CONCLUSIONS The use of large EHR data sets and machine learning to investigate risk factors (related to the patient, provider-care team, and system-level) in the diagnostic process may help create future mechanisms for monitoring diagnostic safety. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/24642

OBJECTIVES: To determine the time to positivity for bacterial pathogens and contaminants in blood and cerebrospinal fluid (CSF) cultures in a cohort of febrile infants ≤60 days of age. METHODS: This was a secondary analysis of prospective observational multicenter study of noncritically ill infants ≤60 days of age with temperatures ≥38°C and blood cultures (December 2008 to May 2013). The main outcome was time to positivity for bacterial pathogens and contaminants. RESULTS: A total of 256 of 303 (84.49%) patients with positive blood cultures, and 73 of 88 (82.95%) with positive CSF cultures met inclusion criteria. Median time (interquartile range [IQR]) to positivity for blood cultures was 16.6 hours (IQR 12.6–21.9) for bacterial pathogens (n = 74) and 25.1 hours (IQR 19.8–33.0) for contaminants (n = 182); P < .001. Time to bacterial pathogen positivity was similar in infants 0 to 28 days of age (15.8 hours [IQR 12.6–21.0]) and 29 to 60 days of age (17.2 [IQR 12.9–24.3]; P = .328). Median time to positivity for CSF was 14.0 hours (IQR 1.5–21.0) for bacterial pathogens (n = 22) and 40.5 hours (IQR 21.2–62.6) for contaminants (n = 51); P < .001. A total of 82.4% (95% confidence interval, 71.8–90.3) and 81.8% (95% confidence interval, 59.7%–94.8%) of blood and CSF cultures showed bacterial pathogen positivity within 24 hours. CONCLUSIONS: Among febrile infants ≤60 days of age, time to blood and CSF positivity was significantly shorter for bacterial pathogens than contaminants. Most blood and CSF cultures for bacterial pathogens were positive within 24 hours. With our findings, there is potential to reduce duration of hospitalization and avoid unnecessary antibiotics.

Objective Few prospective studies have assessed the occurrence of radiographic pneumonia in young febrile infants. We analyzed factors associated with radiographic pneumonias in febrile infants 60 days or younger evaluated in pediatric emergency departments. Study design We conducted a planned secondary analysis of a prospective cohort study within 26 emergency departments in a pediatric research network from 2008 to 2013. Febrile (≥38°C) infants 60 days or younger who received chest radiographs were included. Chest radiograph reports were categorized as "no," "possible," or "definite" pneumonia. We compared demographics, Yale Observation Scale scores (>10 implying ill appearance), laboratory markers, blood cultures, and viral testing among groups. Results Of 4778 infants, 1724 (36.1%) had chest radiographs performed; 2.7% (n = 46) had definite pneumonias, and 3.9% (n = 67) had possible pneumonias. Patients with definite (13/46 [28.3%]) or possible (15/67 [22.7%]) pneumonias more frequently had Yale Observation Scale score >10 compared with those without pneumonias (210/1611 [13.2%], P = 0.002) in univariable and multivariable analyses. Median white blood cell count (WBC), absolute neutrophil count (ANC), and procalcitonin (PCT) were higher in the definite (WBC, 11.5 [interquartile range, 9.8-15.5]; ANC, 5.0 [3.2-7.6]; PCT, 0.4 [0.2-2.1]) versus no pneumonia (WBC, 10.0 [7.6-13.3]; ANC, 3.4 [2.1-5.4]; PCT, 0.2 [0.2-0.3]; WBC, P = 0.006; ANC, P = 0.002; PCT, P = 0.046) groups, but of unclear clinical significance. There were no cases of bacteremia in the definite pneumonia group. Viral infections were more frequent in groups with definite (25/38 [65.8%]) and possible (28/55 [50.9%]) pneumonias than no pneumonias (534/1185 [45.1%], P = 0.02). Conclusions Radiographic pneumonias were uncommon, often had viruses detected, and were associated with ill appearance, but few other predictors, in febrile infants 60 days or younger.

OBJECTIVES: Vascular access device decision-making for pediatric patients remains a complex, highly variable process. To date, evidence-based criteria to inform these choices do not exist. The objective of the Michigan Appropriateness Guide for Intravenous Catheters in pediatrics (miniMAGIC) was to provide guidance on device selection, device characteristics, and insertion technique for clinicians, balancing and contextualizing evidence with current practice through a multidisciplinary panel of experts. METHODS: The RAND Corporation and University of California, Los Angeles Appropriateness Method was used to develop miniMAGIC, which included the following sequential phases: definition of scope and key terms, information synthesis and literature review, expert multidisciplinary panel selection and engagement, case scenario development, and appropriateness ratings by an expert panel via 2 rounds. RESULTS: The appropriateness of the selection, characteristics, and insertion technique of intravenous catheters commonly used in pediatric health care across age populations (neonates, infants, children, and adolescents), settings, diagnoses, clinical indications, insertion locations, and vessel visualization devices and techniques was defined. Core concepts including vessel preservation, insertion and postinsertion harm minimization (eg, infection, thrombosis), undisrupted treatment provision, and inclusion of patient preferences were emphasized. CONCLUSIONS: In this study, we provide evidence-based criteria for intravenous catheter selection (from umbilical catheters to totally implanted venous devices) in pediatric patients across a range of clinical indications. miniMAGIC also highlights core vascular access practices in need of collaborative research and innovation.

Objectives Using case review to determine whether a patient experienced a delayed diagnosis is challenging. Measurement would be more accurate if case reviewers had access to multi-expert consensus on grading the likelihood of delayed diagnosis. Our objective was to use expert consensus to create a guide for objectively grading the likelihood of delayed diagnosis of appendicitis, new-onset diabetic ketoacidosis (DKA), and sepsis. Methods Case vignettes were constructed for each condition. In each vignette, a patient has the condition and had a previous emergency department (ED) visit within 7 days. Condition-specific multi-specialty expert Delphi panels reviewed the case vignettes and graded the likelihood of a delayed diagnosis on a five-point scale. Delayed diagnosis was defined as the condition being present during the previous ED visit. Consensus was defined as ≥75% agreement. In each Delphi round, panelists were given the scores from the previous round and asked to rescore. A case scoring guide was created from the consensus scores. Results Eighteen expert panelists participated. Consensus was achieved within three Delphi rounds for all appendicitis and sepsis vignettes. We reached consensus on 23/30 (77%) DKA vignettes. A case review guide was created from the consensus scores. Conclusions Multi-specialty expert reviewers can agree on the likelihood of a delayed diagnosis for cases of appendicitis and sepsis, and for most cases of DKA. We created a guide that can be used by researchers and quality improvement specialists to allow for objective case review to determine when delayed diagnoses have occurred for appendicitis, DKA, and sepsis.

Key Points Question What factors are associated with a potentially missed diagnosis of appendicitis in the emergency department among adults and children? Findings In this cohort study of 123 711 patients diagnosed with appendicitis, insurance claims data indicated that appendicitis was potentially missed in 6.0% of adults and 4.4% of children during the initial emergency department visit. Factors associated with potentially missed appendicitis included female sex, the coexistence of abdominal pain and constipation, and the presence of comorbidities. Meaning Population-based estimates of the rates of potentially missed appendicitis reveal opportunities for improvement and identify factors that may alert clinicians and mitigate the risk of missed diagnosis., Importance Appendicitis may be missed during initial emergency department (ED) presentation. Objective To compare patients with a potentially missed diagnosis of appendicitis (ie, patients with symptoms associated with appendicitis, including abdominal pain, constipation, nausea and/or vomiting, fever, and diarrhea diagnosed within 1-30 days after initial ED presentation) with patients diagnosed with appendicitis on the same day of ED presentation to identify factors associated with potentially missed appendicitis. Design, Setting, and Participants In this cohort study, a retrospective analysis of commercially insured claims data was conducted from January 1 to December 15, 2019. Patients who presented to the ED with undifferentiated symptoms associated with appendicitis between January 1, 2010, and December 31, 2017, were identified using the Clinformatics Data Mart administrative database (Optum Insights). The study sample comprised eligible adults (aged ≥18 years) and children (aged, This cohort study uses insurance claims data to compare patients with a potentially missed diagnosis of appendicitis with those diagnosed with appendicitis during the initial emergency department visit to identify factors associated with potentially missed appendicitis among adults and children.

* Abbreviations: ED — : emergency department miniMAGIC — : Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics NTCVAD — : nontunneled central vascular access device PED — : pediatric emergency department PICC — : peripherally inserted central catheter PIVC — : peripheral intravenous catheter VAD — : vascular access device Vascular access devices (VADs) are commonly inserted, often in a time sensitive manner, in critically ill children to provide life-sustaining therapy, including but not limited to fluid resuscitation, antibiotics, vasopressors, or parenteral nutrition, and for hemodynamic monitoring. Among children admitted to the pediatric emergency department (PED), VAD selection is limited to peripheral intravenous catheter (PIVC), intraosseous device, and nontunneled central vascular access device (NTCVAD). VAD selection is more varied in the PICU and includes peripherally inserted central catheter (PICC), midline catheter, tunneled cuffed central VAD, and totally implanted venous device in addition to those that are available in the PED. Regardless of setting of care, currently there is no evidence-based guidance for VAD selection. In general, PIVCs are the mainstay for critically ill children in the PED, and PIVC and NTCVAD are the mainstays for those in the PICU. However, given the concerns of central line–associated bloodstream … Address correspondence to Sarah B. Kandil, MD, Department of Pediatrics, Yale School of Medicine, Yale University, 333 Cedar St, New Haven, CT 06520. E-mail: sarah.kandil{at}yale.edu

Purpose The purpose of this paper is to examine the relationships of service marketing mix (SMM) as service input and service output in terms of students’ performance, satisfaction and referral act in context to higher and technical education (HTE) through the application of structural equation modeling. Design/methodology/approach A quantitative research, conducted through a self-administered survey composed by a closed-ended structured questionnaire, was incorporated for the students who were enrolled in the technical educational institutions situated in the Khandesh region of India. Findings The findings of this study revealed that traditional SMM is statistically linked with the performance of students in terms of skill and knowledge enhancement, satisfaction and referral act of students, which are perceptible new emerging SMM; performance, pleasure and pointing out in terms of service output. Practical implications Integrating SMM as service input and service output are productive for HTE in enhancing growth (quantitatively) by the inclusivity of diversified students and development (qualitatively) by enhancing their performance for global standing, making them satisfied and motivating them for recommending their institution to others. This integration can be utilized as a yardstick by the institutions for staying ahead in students’ market with a distinctive competitive advantage. Social implications Growth and development of HTE will raise a society’s quality of life and thereby increase a country’s socio-economic status. Originality/value The study has exhibited SMM as input and output of a service system that is useful for the growth and development of HTE. The measurement tool presented is effective in (re)framing policies on SMM as service input based on desired service output.

Background: Despite the popular belief that probiotics are most efficacious when treating acute childhood diarrhea if started early and when symptoms are more severe, the data supporting these assumptions are unclear. We sought to evaluate whether the efficacy of probiotics depends on the duration and severity of diarrhea prior to treatment. Methods: This was a pre-planned secondary analysis of two randomized placebo-controlled trials in children 3-48 months of age with acute gastroenteritis, conducted in sixteen emergency departments in North America evaluating the efficacy of two probiotic products. Participants were categorized in severity groups according to the duration (< 24h, 24 – < 72h, and ≥ 72h) and the frequency of diarrhea episodes in the 24 hours (≤ 3, 4 – 5 and ≥ 6) prior to presentation. We used regression models to assess the interaction between pre-treatment diarrhea severity groups and treatment arm (probiotic or placebo) on the presence of moderate-to-severe gastroenteritis defined by a Modified Vesikari Scale score ≥9. Secondary outcomes included diarrhea frequency and duration, unscheduled healthcare provider visits and hospitalization. Findings: 1,770 children were included, 882 (50%) received a probiotic. The development of moderate-to-severe gastroenteritis symptoms following the initiation of treatment did not differ between groups [probiotic - 18.4% (162/882) vs. placebo - 18.3% (162/888); RR 1.00; 95%CI: 0.87, 1.16; P=0.95]. There was no evidence of interaction between baseline severity and treatment (P=0.61) for the primary or any of the secondary outcomes: diarrhea duration (P=0.88), maximum diarrheal episodes in a 24 hour period (P=0.87), unscheduled health care visits (P=0.21) and hospitalization (P=0.87). Interpretation: In children 3 to 48 months with acute gastroenteritis the lack of effect of probiotics is not explained by the duration of symptoms or frequency of diarrheal episodes prior to presentation. Trial Registration: Clinicaltrials.gov # NCT01773967 and # NCT01853124. Funding Statement: This work is supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (R01HD071915) and by the Canadian Institutes of Health Research (grants 286384 and 325412). Declaration of Interests: Dr. David Schnadower received in-kind study drug and placebo from iHeath Inc., however the company did not contribute financially to the study or to the investigators, and their employees do not have access study data. I-Health personnel had no role in study design, collection management, analysis and interpretation of data; nor did they have any role or authority in writing the report nor the decision to submit the trial for publication. Dr. Stephen Freedman has received in-kind (study drug and placebo) from Lallemand Health Solutions. He provides consulting services to Takeda Pharmaceutical Company, RedHill Biopharma Ltd and Eligo Bioscience S.A.S. on childhood intestinal disorders and is supported by the Alberta Children’s Hospital Foundation Professorship in Child Health and Wellness. All other authors report no relevant conflicts. Ethics Approval Statement: The studies were approved by all local Institutional Review Boards. Written informed consent was obtained from the legal guardians of all participants.

Medical errors threaten patient safety, especially in the pediatric emergency department (ED) where overcrowding, multiple handoffs, and workflow interruptions are common. Errors related to process variance involve situations that are not consistent with standard ED operations or routine patient care.We performed a planned subanalysis of the Pediatric Emergency Care Applied Research Network incident reporting data classified as process variance events. Confidential deidentified incident reports (IRs) were collected and classified by 2 independent investigators. Events categorized as process variance were then subtyped for severity and contributing factors. Data were analyzed using descriptive statistics.The study intention was to describe and measure reported medical errors related to process variance in 17 EDs in the Pediatric Emergency Care Applied Research Network from 2007 to 2008.Between July 2007 and June 2008, 2906 eligible reports were reviewed. Process variance events were identified in 15.4% (447/2906). The majority were related to patient flow (35.4%), handoff communication (17.2%), and patient identification errors (15.9%). Most staff involved included nurses (47.9%) and physicians (28%); trainees were infrequently reported. The majority of events did not result in harm (65.7%); 17.9% (80/447) of cases were classified as unsafe conditions but did not reach the patient. Temporary harm requiring further treatment or hospitalization was reported in 5.6% (25/447). No events resulted in permanent harm, near death, or death. Contributing factors included human factors (92.1%), in particular handoff communication, interpersonal skills, and compliance with established procedures, and system-level errors (18.1%), including unclear or unavailable policies and inadequate staffing levels.Although process variance events accounted for approximately 1 in 6 reported safety events, very few led to patient harm. Because human and system-level factors contributed to most of these events, our data provide an insight into potential areas for further investigation and improvements to mitigate errors in the ED setting.

OBJECTIVE: Insufficient sleep is common among caregivers and is associated with worse health outcomes; however, the contributors to poor sleep among caregivers are unknown. We investigated the cross-sectional association between socioeconomic status (SES), psychosocial stressors and sleep among caregivers. METHODS: Caregivers (n=98) of teenagers with asthma self-reported sleep duration (hours), sleep quality (very good to very bad), education (< high school to college graduate), income ($15,000 to $50,000), and psychosocial stressors (stress, worry, social support, depressive symptoms, nightly awakenings due to caregiving). Logistic and linear regression models were performed to study the association of between SES, psychosocial stressors and sleep, adjusting for possible confounders. RESULTS: Caregivers on average were 45.5 years, female (89%) and African American (90%). Average sleep duration was 5.9 hours (standard deviation: 1.5), 72% reported short sleep (

Introduction The impact of telemedicine on the access and quality of paediatric emergency care remains largely unexplored because most studies to date are focused on adult emergency care. We performed a systematic review of the literature to determine if telemedicine is effective in improving quality of paediatric emergency care with regards to access, process measures of care, appropriate disposition, patient-centred outcomes and cost-related outcomes. Methods We developed a systematic review protocol in accordance with PRISMA (Preferred Reporting Items for Systematic Review) guidelines. We included studies that evaluated the impact of synchronous and asynchronous forms of telemedicine on patient outcomes and process measures in the paediatric emergency care setting. Inclusion criteria were study setting, study design, intervention type, age, outcome measures, publication year and language. Results Overall, 1.9% (28/1434) studies met study inclusion and exclusion criteria. These studies revealed that telemedicine increased accuracy of patient assessment in the pre-clinical setting, improved time-to disposition, guided referring emergency department (ED) physicians in performing appropriate life-saving procedures and led to cost savings when compared to regular care. Studies focused on telepsychiatry demonstrated decreased length of stay (LOS), transfer rates and improved patient satisfaction scores. Discussion Our comprehensive review revealed that telemedicine enhances paediatric emergency care, enhances therapeutic decision-making and improves diagnostic accuracy, and reduces costs. Specifically, telemedicine has its most significant impact on LOS, access to specialized care, cost savings and patient satisfaction. However, there was a relative lack of randomized control trials, and more studies are needed to substantiate its impact on morbidity and mortality.

In this diagnostic accuracy study of clinical and biomarker variables in the diagnosis of serious bacterial infections (SBIs), including pneumonia, in febrile children (age

There is a rapid growth of technical education in last decade in terms of the number of institutes and intake capacity in India but non-directional. There is noticeable gap in between the actual no. of enrollments and intake capacity of these institutes. In the year 2015-2016, as per AICTE, New Delhi, 46% of seats were vacant in Technical Education in India. Segmentation and the ‘People' factor of service mixing is very important aspects in education services. The purpose of this article is to highlight the influence of the people mix on geographical and demographical factors of students in selecting technical educational institutes. Different communication strategies of people mix can be used based on geographical and demographical factors, which will confirm growth as well as the development of technical education in the proper direction.

The Accreditation Council for Graduate Medical Education requires training in quality improvement (QI) but does not provide specifics of content or methods. We aimed to describe the current state of pediatric emergency medicine (PEM) fellowship training in QI and the integration of such QI training with related institutional efforts. We surveyed PEM fellowship program directors (PDs) between January 2017 and March 2017. A group of PEM-boarded physicians with expertise in QI created survey questions to assure face validity. Questions were focused on the current QI curricula, the integration of QI training within institutional efforts, and future fellowship needs in QI training. Of the 81 eligible PDs surveyed, 70 (86.4%) completed surveys. A formal QI curriculum was present in 68.9% of programs. A median of 12 hours was dedicated to the curriculum over the entire course of fellowship. Thirty (42.8%) PDs felt that their fellows were integrated into the broader departmental QI efforts. Only 3 (4.3%) PDs reported that they had evaluated the efficacy of the QI curriculum in their fellowship. QI training is common among PEM fellowship programs. However, integration, as well as formal evaluation of efficacy, is uncommon.

Study objective We determine the optimal correction factor for cerebrospinal fluid WBC counts in infants with traumatic lumbar punctures. Methods We performed a secondary analysis of a retrospective cohort of infants aged 60 days or younger and with a traumatic lumbar puncture (cerebrospinal fluid RBC count ≥10,000 cells/mm3) at 20 participating centers. Cerebrospinal fluid pleocytosis was defined as a cerebrospinal fluid WBC count greater than or equal to 20 cells/mm3 for infants aged 28 days or younger and greater than or equal to 10 cells/mm3 for infants aged 29 to 60 days; bacterial meningitis was defined as growth of pathogenic bacteria from cerebrospinal fluid culture. Using linear regression, we derived a cerebrospinal fluid WBC correction factor and compared the uncorrected with the corrected cerebrospinal fluid WBC count for the detection of bacterial meningitis. Results Of the eligible 20,319 lumbar punctures, 2,880 (14%) were traumatic, and 33 of these patients (1.1%) had bacterial meningitis. The derived cerebrospinal fluid RBCs:WBCs ratio was 877:1 (95% confidence interval [CI] 805 to 961:1). Compared with the uncorrected cerebrospinal fluid WBC count, the corrected one had lower sensitivity for bacterial meningitis (88% uncorrected versus 67% corrected; difference 21%; 95% CI 10% to 37%) but resulted in fewer infants with cerebrospinal fluid pleocytosis (78% uncorrected versus 33% corrected; difference 45%; 95% CI 43% to 47%). Cerebrospinal fluid WBC count correction resulted in the misclassification of 7 additional infants with bacterial meningitis, who were misclassified as not having cerebrospinal fluid pleocytosis; only 1 of these infants was older than 28 days. Conclusion Correction of the cerebrospinal fluid WBC count substantially reduced the number of infants with cerebrospinal fluid pleocytosis while misclassifying only 1 infant with bacterial meningitis of those aged 29 to 60 days.

Objectives The aim of this study was to describe the epidemiology of radiologic safety events using an analysis of deidentified incident reports (IRs) collected within a large multicenter pediatric emergency medicine network. Methods This study is a report of a planned subanalysis of IRs that were classified as radiologic events. The parent study was performed in the PECARN (Pediatric Emergency Care Applied Research Network). Incident reports involving radiology were classified into subtypes: delay in test, delay in results, misread or changed reading, wrong patient, wrong site, or other. The severity of radiology-related incidents was characterized. Contributing factors were identified and classified as environmental, equipment, human (employee), information technology systems, parent or guardian, or systems based. Results Two hundred three (7.0%) of the 2906 IRs submitted during the study period involved radiology. Eighteen of the hospitals submitted at least 1 IR and 15 of these hospitals reported at least 1 radiologic event. The most common type of radiologic event was misread/changed reading, which accounted for over half of all IRs (50.3%). Human factors were the most frequent contributing factor identified and accounted for 67.6% of all factors. The severity of events ranged from unsafe conditions to events with temporary harm that required hospitalization. Conclusions We described the epidemiology of radiology-related IRs from a large multicenter pediatric emergency research network. The study identified specific themes regarding types of radiologic errors, including the systems issues and the contributing factors associated with those errors. Results from this analysis may help identify effective intervention strategies to ameliorate the frequency of radiology-related safety events in the emergency department setting.

— There is a rapid growth of technical education in last decade in terms of the no. of institutes and intake capacity in India but with improper and non-directional development. As per AICTE reports, there is noticeable gap in between the actual no. of enrolments and intake capacity of these institutes. In the year 2015-16, 46% of seats were vacant in Technical Education in India. Segmentation and 'People' factor of service mix is very important aspects in education services. The purpose of this paper is to highlight the influence of people mix on geographical and demographical factors of students in selecting technical educational institute. The study found that geographical and demographical factors of students are highly related with the people mix in selection of technical educational institute. Several studies have revealed that the marketing segmentation of technical education will be better developed if we consider geographical and demographical factors and then implementing people mix. It is found that there are some People mix-influencers-related to the institute and previous schools along with peoples associated with the students that are associated with geographical and demographical factors. So, it is useful to consider this association rather than considering only traditional factors. This article provides empirical support for the importance of such factors and their effect on educational choices. Different communication strategies of people mix can be used based on geographical and demographical factors which will proceed to not only growth but development of technical education in proper direction also. The paper represents new form of geographical and demographical factors with various people mix of educational service, that together affects students' decision in selecting their technical educational institute.

OBJECTIVES: In preparation for a clinical trial of therapeutic agents for children with moderate-to-severe blunt traumatic brain injuries (TBIs) in emergency departments (EDs), we conducted this feasibility study to 1) determine the number and clinical characteristics of eligible children, 2) determine the timing of patient and guardian arrival to the ED, and 3) describe the heterogeneity of TBIs on computed tomography (CT) scans. METHODS: We conducted a prospective observational study at 16 EDs of children ≤ 18 years of age presenting with blunt head trauma and Glasgow Coma Scale (GCS) scores of 3-12. We documented the number of potentially eligible patients, timing of patient and guardian arrival, patient demographics and clinical characteristics, severity of injuries, and cranial CT findings. RESULTS: We enrolled 295 eligible children at the 16 sites over 6 consecutive months. Cardiac arrest and non-survivable injuries were the most common characteristics that would exclude patients from a future trial. Most children arrived within 2 hours of injury, but most guardians did not arrive until 2-3 hours after the injury. There was a substantial range in types of TBIs, with subdural hemorrhages being the most common. CONCLUSION: Enrolling children with moderate-to-severe TBI into time sensitive clinical trials will require large numbers of sites, meticulous preparation and coordination, and will prove challenging to obtain informed consent given the timing of patient and guardian arrival. The Federal Exception from Informed Consent for Emergency Research will be an important consideration for enrolling these children. This article is protected by copyright. All rights reserved.This article is protected by copyright. All rights reserved. Language: en

Objective To create an operational definition and framework to study diagnostic error in the emergency department setting. Methods We convened a 17-member multidisciplinary panel with expertise in general and pediatric emergency medicine, nursing, patient safety, informatics, cognitive psychology, social sciences, human factors, and risk management and a patient/caregiver advocate. We used a modified nominal group technique to develop a shared understanding to operationally define diagnostic errors in emergency care and modify the National Academies of Sciences, Engineering, and Medicine's conceptual process framework to this setting. Results The expert panel defined diagnostic errors as "a divergence from evidence-based processes that increases the risk of poor outcomes despite the availability of sufficient information to provide a timely and accurate explanation of the patient's health problem(s)." Diagnostic processes include tasks related to (a) acuity recognition, information and synthesis, evaluation coordination, and (b) communication with patients/caregivers and other diagnostic team members. The expert panel also modified the National Academies of Sciences, Engineering, and Medicine's diagnostic process framework to incorporate influence of mode of arrival, triage level, and interventions during emergency care and underscored the importance of outcome feedback to emergency department providers to promote learning and improvement related to diagnosis. Conclusions The proposed operational definition and modified diagnostic process framework can potentially inform the development of measurement tools and strategies to study the epidemiology and interventions to improve emergency care diagnosis.

Objective To examine the association between the medical imaging utilization and information related to patients’ socioeconomic, demographic and clinical factors during the patients’ ED visits; and to develop predictive models using these associated factors including natural language elements to predict the medical imaging utilization at pediatric ED. Methods Pediatric patients’ data from the 2012–2016 United States National Hospital Ambulatory Medical Care Survey was included to build the models to predict the use of imaging in children presenting to the ED. Multivariable logistic regression models were built with structured variables such as temperature, heart rate, age, and unstructured variables such as reason for visit, free text nursing notes and combined data available at triage. NLP techniques were used to extract information from the unstructured data. Results Of the 27,665 pediatric ED visits included in the study, 8394 (30.3%) received medical imaging in the ED, including 6922 (25.0%) who had an X-ray and 1367 (4.9%) who had a computed tomography (CT) scan. In the predictive model including only structured variables, the c-statistic was 0.71 (95% CI: 0.70–0.71) for any imaging use, 0.69 (95% CI: 0.68–0.70) for X-ray, and 0.77 (95% CI: 0.76–0.78) for CT. Models including only unstructured information had c-statistics of 0.81 (95% CI: 0.81–0.82) for any imaging use, 0.82 (95% CI: 0.82–0.83) for X-ray, and 0.85 (95% CI: 0.83–0.86) for CT scans. When both structured variables and free text variables were included, the c-statistics reached 0.82 (95% CI: 0.82–0.83) for any imaging use, 0.83 (95% CI: 0.83–0.84) for X-ray, and 0.87 (95% CI: 0.86–0.88) for CT. Conclusions Both CT and X-rays are commonly used in the pediatric ED with one third of the visits receiving at least one. Patients’ socioeconomic, demographic and clinical factors presented at ED triage period were associated with the medical imaging utilization. Predictive models combining structured and unstructured variables available at triage performed better than models using structured or unstructured variables alone, suggesting the potential for use of NLP in determining resource utilization.

Importance: While the literature documenting health disparities has advanced in recent decades, less is known about the pattern of racial/ethnic disparities in emergency care in the United States. Objective: To describe the trends and differences of health outcomes and resource utilization among racial/ethnic groups in US emergency care for adult patients over a 12-year period. Design, Setting, and Participants: This cross-sectional study of emergency department (ED) data from the nationally representative National Hospital Ambulatory Medical Survey (NHAMCS) examined multiple dimensions of ED care and treatment from 2005 to 2016 among adults in the US. Main Outcomes and Measures: The main outcomes include ED care outcomes (hospital admission, ICU admission, and death in the ED/hospital), resource utilization outcomes (medical imaging use, blood test, and procedure use), and patients' waiting time in the ED. The main exposure variable is race/ethnicity including white patients (non-Hispanic), black patients (non-Hispanic), Hispanic patients, Asian patients, and Other. Results: During the 12-year study period, NHAMCS collected data on 247,989 adult (> 18 years old) ED encounters, providing a weighted sample of 1,065,936,835 ED visits for analysis. Asian patients were 1.21 times more likely than white patients to be admitted to the hospital following an ED visit (aOR 1.21, 95% CI 1.12-1.31). Hispanic patients presented no significant difference in hospital admission following an ED visit (aOR 1.01, 95% CI 0.97-1.06) with white patients. Black patients were 7% less likely to receive an urgent ESI score than white patients less likely to receive immediate or emergent scores, as opposed to semi- or non-urgent scores. Black patients were also 10% less likely than white patients to be admitted to the hospital and were 1.26 times more likely than white patients to die in the ED or hospital. Conclusions and Relevance: Race is associated with significant differences in ED treatment and admission rates, which may represent disparities in emergency care. Hispanic and Asian Americans were equal or more likely to be admitted to the hospital compared to white patients. Black patients received lower triage scores and higher mortality rates. Further research is needed to understand the underlying causes and long-term health consequences of these disparities.

The recruitment setting plays a key role in the evaluation of behavioral interventions. We evaluated a behavioral intervention for urban adolescents with asthma in three randomized trials conducted separately in three different settings over the course of 8 years. We hypothesized that characteristics of trial participants recruited from the ED and clinic settings would be significantly different from that of youth participating in the school-based trials. The intervention evaluated was Puff City, a web-based program that uses tailoring to improve asthma management behaviors.The present analysis includes youth aged 13-19 years who reported a physician diagnosis of asthma and symptoms at trial baseline. In the three trials, all participants were randomized post-baseline to a web-based, tailored intervention (treatment) or generic web-based asthma education (control).Compared to school-based trial participants, ED participants had significantly more acute-care visits for asthma (Compared to participants in the school-based trials, participants recruited from ED and clinic settings differed significantly in terms of healthcare use, as well as psychosocial and sociodemographic factors. These factors can inform intervention content, and may impact external validity of behavioral interventions for asthma.

Background. Acute severe childhood asthma is an infrequent, but potentially life-threatening emergency presentation. There is a wide range of different approaches to this condition, with very little supporting evidence, leading to significant variation in practice. To improve knowledge in this area, there must first be consensus on how to conduct clinical trials, so that valid comparisons can be made between future studies. We have formed an international working group comprising paediatricians and emergency physicians from North America, Europe, Asia, the Middle East, Africa, South America, Central America, Australasia and the United Kingdom. Methods / design. A five-stage approach will be used: (1) A comprehensive list of outcomes relevant to stakeholders will be compiled through systematic reviews and qualitative interviews with patients, families, and clinicians; (2) A Delphi methodology will be applied to reduce the comprehensive list to a core outcome set; (3) We will review current clinical practice guidelines, existing clinical trials, and literature regarding bedside assessment of asthma severity. We will then identify practice differences in clinical assessment of asthma severity, and determine whether further prospective work is needed to achieve agreement on inclusion criteria for clinical trials on acute paediatric asthma in the emergency department setting; (4) A retrospective chart review in Australia and New Zealand will identify the incidence of serious clinical complications in children hospitalized with acute severe asthma, such as intubation, ICU admission, and death. Understanding the incidence of such outcomes will allow us to understand how common (and therefore how feasible) particular outcomes are in an asthma ED population; (5) Finally, a meeting of the PERN asthma working group will be held, with invitation of other clinicians interested in acute asthma research, and patients / families. The group will be asked to achieve consensus on a core set of outcomes and to make recommendations for the conduct of clinical trials on acute severe asthma. If this is not possible, the group will agree on a series of prioritized steps to achieve this aim. Discussion The development of an international consensus on core outcomes is an important first step towards the development of consensus guidelines and standardised protocols for RCTs in this population. This will enable us to better interpret and compare future studies, reduce risks of study heterogeneity and outcome reporting bias, and improve the evidence base for the management of this important condition.

Author(s): Moore, Brian; Shah, Manish I; Owusu-Ansah, Sylvia; Gross, Toni; Brown, Kathleen; Gausche-Hill, Marianne; Remick, Katherine; Adelgais, Kathleen; Lyng, John; Rappaport, Lara; Snow, Sally; Wright-Johnson, Cynthia; Leonard, Julie C; AMERICAN ACADEMY OF PEDIATRICS, Committee on Pediatric Emergency Medicine and Section on Emergency Medicine EMS Subcommittee; AMERICAN COLLEGE OF EMERGENCY PHYSICIANS, Emergency Medical Services Committee; EMERGENCY NURSES ASSOCIATION, Pediatric Committee; NATIONAL ASSOCIATION OF EMERGENCY MEDICAL SERVICES PHYSICIANS, Standards and Clinical Practice Committee; NATIONAL ASSOCIATION OF EMERGENCY MEDICAL TECHNICIANS, Emergency Pediatric Care Committee; Pediatric Readiness in Emergency Medical Services Systems; POLICY STATEMENT; Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of All Children

There is a global variation in policies that define clear indications for pediatric intensive care unit (PICU) admissions. In resource-limited countries where PICU service availability is limited, the admission criteria to PICU are urgently needed to optimize the utilization of available intensive care services and to maximize patient benefit. The objective of these consensus recommendations on PICU admission criteria is to provide a framework and reference for future policy development by professional societies and governments. Design: The consensus recommendations were developed by a multidisciplinary consensus task force comprised of international experts in pediatric critical care, emergency medicine, trauma, critical care, and health policy stakeholders during the 2016 annual INDUSEM WORLD CONGRESS in Bengaluru, India. Measurements and Main Results: A task force steering committee completed a global literature search about PICU admission criteria development, reviewed PICU admission guidelines published by a variety of professional organizations worldwide, and performed a literature review of relevant publications. The objectives of this task force is to provide a framework for validated approach to determine appropriateness of intensive care unit (ICU) admission in India (resource-limited setting) based on (a) prioritization modeling; (b) general clinical criteria; (c) clinical and objective parameters; and (d) other criteria. The expert consensus panel then discussed and ranked proposed criteria according to scientific evidence, the current standard of care, and expert opinion in the context of the Indian health system. The general subject was addressed in sections: admission criteria and benefits of different levels of care. Following the appraisal of the literature, discussion, and consensus, recommendations were written. Conclusion: Although these are consensus recommendations, the subjects addressed encompass complex ethical and medicolegal aspects of patient care that affect daily clinical practice. The scarcity of high-quality evidence made it difficult to answer all the questions asked related to ICU admission. Despite these limitations, the members of the task force believe that these recommendations provide a comprehensive framework to guide practitioners in making informed decisions during the admission process. This publication is designed to assist in future development of health policies to ensure effective resource allocation, maximize healthcare benefits, and improve access to quality care for children.

Background Although oral rehydration therapy is recommended for children with acute gastroenteritis (AGE) with none to some dehydration, intravenous (IV) rehydration is still commonly administered to these children in high-income countries. IV rehydration is associated with pain, anxiety, and emergency department (ED) revisits in children with AGE. Objectives We sought to better understand the factors associated with IV rehydration in children with AGE in order to inform knowledge translation strategies. Design/Methods This was a planned secondary analysis of the Pediatric Emergency Research Canada (PERC) and Pediatric Emergency Care Applied Research Network (PECARN) randomized, controlled trials of oral probiotics in children with AGE-associated diarrhea. Eligible children were aged 3–48 months and reported >3 watery stools in a 24-hour period. The primary outcome was administration of IV rehydration at the index ED visit. We used mixed-effects logistic regression model to explore univariable and multivariable relationships between IV rehydration and a prioririsk factors. Results From the parent study sample of 1848 participants, 1846 had data available for analysis: mean (SD) age of 19.1 ± 11.4 months, 45.4% females. 70.2% (1292/1840) vomited within 24 hours of the index ED visit and 34.1% (629/1846) received ondansetron in the ED. 13.0% (240/1846) were administered IV rehydration at the index ED visit, and 3.6% (67/1842) were hospitalized. Multivariable predictors of IV rehydration were Clinical Dehydration Scale (CDS) score [compared to none: mild to moderate (OR: 8.1, CI: 5.5–11.8); severe (OR: 45.9, 95% CI: 20.1–104.7), P Conclusion Higher CDS scores, antiemetic use, previous healthcare visits and country were independent predictors of IV rehydration which was also associated with increased ED revisits. Knowledge translation focused on optimizing the use of antiemetics (i.e. for those with dehydration) and reducing the geographic variation in IV rehydration use may improve the ED experience and reduce ED-revisits.

* Abbreviations: ANC — : absolute neutrophil count CBC — : compete blood count CRP — : C-reactive protein CSF — : cerebrospinal fluid ED — : emergency department IBI — : invasive bacterial infection PCT — : procalcitonin Clinicians caring for young febrile infants have struggled with risk stratification algorithms for invasive bacterial infections (IBIs) (bacteremia and/or bacterial meningitis) for decades1–5 because of the tension between not wanting to miss infants with IBIs yet not wanting to over-test and over-treat these vulnerable infants.6,7 Risk stratification algorithms using compete blood counts (CBCs) with or without cerebrospinal fluid (CSF) data, developed in the 1980s and 1990s, have several limitations: (1) laboratory thresholds were not derived by statistical methods, resulting in suboptimal test accuracies; (2) algorithm precision was limited by the relatively few infants with IBIs; (3) the epidemiology of IBIs has changed in the past decades8–10 with an increase in Escherichia coli and a decrease in group B Streptococcus infections due to perinatal screening; (4) algorithm specificity has been insufficient to limit the use of lumbar punctures, empirical antibiotics, and hospitalizations; and (5) newer biomarkers, including C-reactive protein (CRP) and particularly procalcitonin (PCT), are substantially more sensitive than the CBC for detecting infants with these infections.7,11,12 In a well-conducted retrospective case-control analysis from 11 emergency departments (EDs) between 2011 … Address correspondence to Nathan Kuppermann, MD, MPH, Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, 2315 Stockton Blvd, PSSB Suite 2100, Sacramento, CA 95817. E-mail: nkuppermann{at}ucdavis.edu

To define and measure complications across a broad set of acute pediatric conditions in emergency departments using administrative data, and to assess the validity of these definitions by comparing resource utilization between children with and without complications.Using local consensus, we predefined complications for 16 acute conditions including appendicitis, diabetic ketoacidosis, ovarian torsion, stroke, testicular torsion, and 11 others. We studied patients under age 18 years using 3 data years from the Healthcare Cost and Utilization Project Statewide Databases of Maryland and New York. We measured complications by condition. Resource utilization was compared between patients with and without complications, including hospital length of stay, and charges.We analyzed 27 087 emergency department visits for a serious condition. The most common was appendicitis (n = 16 794), with 24.3% of cases complicated by 1 or more of perforation (24.1%), abscess drainage (2.8%), bowel resection (0.3%), or sepsis (0.9%). Sepsis had the highest mortality (5.0%). Children with complications had higher resource utilization: condition-specific length of stay was longer when complications were present, except ovarian and testicular torsion. Hospital charges were higher among children with complications (P .05) for 15 of 16 conditions, with a difference in medians from $3108 (testicular torsion) to $13 7694 (stroke).Clinically meaningful complications were measurable and were associated with increased resource utilization. Complication rates determined using administrative data may be used to compare outcomes and improve healthcare delivery for children.

Sooner or later the conventional interconnects used nowadays in high speed performance computing systems are going to put serious performance constraints. As the proportion of CMOS technology scaling and interconnect length scaling differs largely, the interconnect length poses drastic speed limitations on the systems. Hence as technology node scales from 14nm to 7nm shows high improvement on speed on paper but is barely achieved in reality compared to node scaling from 130nm to 90nm. As the speed of operation for HPC systems is in Gb/sec, the power consumption due to conventional interconnect will be higher. The solution to this problem is to use wireless interconnects. The wireless interconnect may be fabricated with on chip wireless transceiver. The on chip antenna and router based architecture may help in reducing those routing delays and also saving chip area. The first block in wireless receiver of wireless interconnect is Low Noise Amplifier (LNA), and this work focuses to design and analyse a CMOS LNA operating at 60 GHz, As most of the HPC systems operate at about 60 GHz. The designed LNA’s are compared on the basis of figure of merits.

Importance In young febrile infants, serious bacterial infections (SBIs), including urinary tract infections, bacteremia, and meningitis, may lead to dangerous complications. However, lumbar punctures and hospitalizations involve risks and costs. Clinical prediction rules using biomarkers beyond the white blood cell count (WBC) may accurately identify febrile infants at low risk for SBIs. Objective To derive and validate a prediction rule to identify febrile infants 60 days and younger at low risk for SBIs. Design, Setting, and Participants Prospective, observational study between March 2011 and May 2013 at 26 emergency departments. Convenience sample of previously healthy febrile infants 60 days and younger who were evaluated for SBIs. Data were analyzed between April 2014 and April 2018. Exposures Clinical and laboratory data (blood and urine) including patient demographics, fever height and duration, clinical appearance, WBC, absolute neutrophil count (ANC), serum procalcitonin, and urinalysis. We derived and validated a prediction rule based on these variables using binary recursive partitioning analysis. Main Outcomes and Measures Serious bacterial infection, defined as urinary tract infection, bacteremia, or bacterial meningitis. Results We derived the prediction rule on a random sample of 908 infants and validated it on 913 infants (mean age was 36 days, 765 were girls [42%], 781 were white and non-Hispanic [43%], 366 were black [20%], and 535 were Hispanic [29%]). Serious bacterial infections were present in 170 of 1821 infants (9.3%), including 26 (1.4%) with bacteremia, 151 (8.3%) with urinary tract infections, and 10 (0.5%) with bacterial meningitis; 16 (0.9%) had concurrent SBIs. The prediction rule identified infants at low risk of SBI using a negative urinalysis result, an ANC of 4090/µL or less (to convert to ×109per liter, multiply by 0.001), and serum procalcitonin of 1.71 ng/mL or less. In the validation cohort, the rule sensitivity was 97.7% (95% CI, 91.3-99.6), specificity was 60.0% (95% CI, 56.6-63.3), negative predictive value was 99.6% (95% CI, 98.4-99.9), and negative likelihood ratio was 0.04 (95% CI, 0.01-0.15). One infant with bacteremia and 2 infants with urinary tract infections were misclassified. No patients with bacterial meningitis were missed by the rule. The rule performance was nearly identical when the outcome was restricted to bacteremia and/or bacterial meningitis, missing the same infant with bacteremia. Conclusions and Relevance We derived and validated an accurate prediction rule to identify febrile infants 60 days and younger at low risk for SBIs using the urinalysis, ANC, and procalcitonin levels. Once further validated on an independent cohort, clinical application of the rule has the potential to decrease unnecessary lumbar punctures, antibiotic administration, and hospitalizations.