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Childhood and adolescent misuse and abuse exposures remain a serious public health challenge in the United States. This study aimed to describe recent trends and patterns of intentional substance misuse and abuse exposures among school-aged children and adolescents in the United States.This study was a retrospective cohort study of intentional misuse and abuse exposures in children 6 through 18 years reported to the National Poison Data System (NPDS) from January 1, 2000, through December 31, 2020. Demographic trends, reported clinical effects, treatments, management sites, and health outcomes were assessed overall and within four age categories: 6-9, 10-12, 13-15, and 16-18.Between 2000 and 2020, there were 338,727 cases regarding intentional misuse and abuse exposures for children ages 6 through 18 years old. Overall, misuse/abuse ingestions fluctuated over time, with a peak in 2011. The majority of intentional misuse/abuse ingestions occurred in males (58.3%), and more than 80% of all reported exposure cases occurred in youth aged 13 to 18. 32.6% of ingestions resulted in worse than minor clinical outcomes. Older age groups had a greater number of severe medical outcomes compared to younger age groups. Major or life-threatening exposures (including those resulting in death) were more common in males. Overall, deaths were rare (With over 330,000 poison center cases reported during the 20-year study period, intentional substance misuse and abuse exposures substantially impact the pediatric population. The substances most commonly misused/abused are more widely available substances such as over-the-counter medications, household products and pharmaceuticals commonly prescribed to youth. Differences in age and sex were evident, with males and adolescents more likely to abuse and misuse substances. Our study describes an upward trend in marijuana misuse/abuse exposures among youth, especially those involving edible products. These findings highlight an ongoing concern about the impact of rapidly evolving cannabis legalization on this vulnerable population.

Background: Monitoring of capillary refill time (CRT) is a common bedside assessment used to ascertain peripheral perfusion in a patient for a vast array of conditions. The literature has shown that a change in CRT can be used to recognize life-threatening conditions that cause decreased perfusion, such as sepsis, and aid in resuscitation. The current practice for calculating CRT invites subjectivity and produces a highly variable result. Innovative technology may be able to standardize this process and provide a reliable and accurate value for use in diagnostics and treatment. This study aimed to assess a new technology (DCR by ProMedix Inc.) for rapid, bedside, and noninvasive detection of CRT. Methods: This was a secondary analysis of a prospective observational study evaluating the accuracy of new technology towards CRT-guided diagnosis of sepsis. It was carried out in the adult emergency departments (ED) of an academic tertiary care medical center. Patients seeking care in the ED were determined eligible if they were > 18 years in age and exhibited chief complaints suggestive of possible sepsis. The CRT produced by the technology was compared to the gold standard manual waveform assessment. Results: 218 consecutive subject enrollments were included and multiple measurements were made on each patient. Data with irregular waveforms were excluded. A total of 692 waveforms were evaluated for CRT values by a pair of trained PhD biomedical engineers. The average age of the cohort was 50.62 and 51.4% female. Results showed a Pearson correlation coefficient of 0.91 for the device CRT compared to the CRT gold standard. The Pearson correlation coefficient for the two independent engineering review of the waveform data was 0.98. This device produces accurate, consistent results and eliminates the subjectivity of CRT measurements that is in practice currently.

Early detection of sepsis is challenging to achieve with current diagnostic methods, leading to expenditures of $27 billion annually in the United States with significant associated mortality. Various scoring systems have been proposed such as the sequential organ failure assessment (SOFA) and systemic inflammatory response syndrome (SIRS) criteria for identification of sepsis, but their sensitivities range from 60% to 70% when used in the emergency department triage. Other methods for the recognition of sepsis may rely on laboratory work, in addition to vitals monitoring, and are often outpaced by the development of sepsis. Automated alerts have not shown any reduction in mortality thus far. New technology may fill a critical gap in the early detection of sepsis. The ideal bedside screening device for would demonstrate rapid time to result, high portability, and high sensitivity to not miss cases, but also reasonable specificity to prevent provider fatigue from excessive false alerts. Non-invasive end-organ perfusion devices analyzing lactate and capillary refill time (CRT) tend to perform well in speed and portability, but may be less sensitive. Biomarker devices demonstrate a wider array of performance metrics. Those analyzing a single biomarker tend to be more sensitive but are less specific to the diagnosis of sepsis than technologies that assess multiple biomarkers, which in turn have lower sensitivity. Additionally, biomarker devices are generally invasive requiring blood samples, which may or may not be feasible in all patients especially when serial draws are needed. Sepsis is a complex disease process and most likely will require a combination of improved technology in addition to vital signs and high-risk patient history for better recognition. This review examines recent advances in the device-based early detection of sepsis between 2017 and 2020 with emphasis on bedside diagnostics, divided into markers of perfusion and biomarkers commonly implicated in sepsis.

Introduction Suicide is a leading cause of death among adolescents. Oregon ranks 17th nationally for youth suicide rates, and ingestion of medications as a means of suicide is common. Despite the high prevalence of intentional poisoning among youth in Oregon, information about medications used by children and adolescents for attempted suicide, in particular the sources of medications, is not readily available. Methods The objective of this study is to describe types and sources of medications used for intentional ingestion among patients seen by the Doernbecher Children's Hospital Child and Adolescent Psychiatry Consultation-Liaison Service. This was a retrospective analysis of patients seen by the Child and Adolescent Psychiatry Consultation-Liaison Service for intentional ingestion from 2015 to 2017. Data on 434 total intentional ingestions were collected, including demographic information, types of medications ingested, and sources of both over-the-counter (OTC) and prescription (Rx) medications. Ingestions without intent of suicide were excluded. Descriptive analysis of ingestion data was performed. Results Intentional ingestions included Rx and OTC medications in similar frequencies. For Rx medications, 68% of ingestions included patients' own Rxs. Eighty-eight percent of ingestions that were not the patients' own Rx belonged to someone else living in their home. For OTC medications, 66% of medications were available at home. Conclusions Intentional ingestions among adolescents most frequently involve medications that are readily available in their homes, and these include both OTC and Rx medications. This study highlights the importance of securing medications at home as a preventative measure and the importance of anticipatory guidance for primary care providers.

Objective Suicide is the 2nd leading cause of death in adolescence, and acute pediatric mental health emergency department (ED) visits have doubled in the past decade. The objective of this study was to evaluate physiologic parameters relationship to suicide severity.Methods This was a prospective, observational study from April 2018 thru November 2019 in a tertiary care pediatric emergency department (ED) and inpatient pediatric psychiatric unit enrolling acutely suicidal adolescent patients. Patients wore a wrist device that used photoplethysmography for 7 days during their acute hospitalization to measure heart rate variability (HRV). During that time, Columbia Suicide Severity Scores (CSSRS) were assessed at 3 time points.Results There was complete device data and follow-up for 51 patients. There was an increase in the high frequency (HF) component of HRV in patients that had a 25% or greater decrease in their CSSRS (mean difference 11.89 ms/ Hz ; p-value 0.005). Patients with a CSSRS≥15 on day of enrollment had a lower, although not statistically significant, HF component (mean difference -8.34 ms/ Hz; p-value 0.071).Conclusion We found an inverse correlation between parasympathetic activity measured through the HF component and suicidality in an acutely suicidal population of adolescents. Wearable technology may have the ability to improve outpatient monitoring for earlier detection and intervention.

Dehydration is a commonly encountered problem worldwide. Current clinical assessment is limited by subjectivity and limited provider training with children. The objective of this study is to investigate a new noninvasive, point-of-care technology that measures capillary refill combined with patient factors to accurately diagnose dehydration.This is a prospective observational study at a tertiary care children's hospital in Buenos Aires, Argentina. Patients were eligible if younger than 10 years who presented to the emergency department with vomiting and/or diarrhea whom the triage nurse deems to be potentially dehydrated. Patients had the digital capillary refill device done on presentation in addition to standard of care vital signs and weight. Patients had serial weights measured on hospital scales throughout their stay. The primary outcome was dehydration, which was calculated as a percent change in weight from admission to discharge.Seventy-six children were enrolled in the study with 56 included in the final analysis. A stepwise forward method selection chose malnutrition, temperature, and systolic blood pressure for the multivariable model. The area under the curve for the final model was fair (0.7431). To further look into the utility of such a device in the home setting where blood pressure is not available often, we reran the model without systolic blood pressure. The area under the curve for the final model was 0.7269.The digital capillary refill point-of-care device combined with readily available patient-specific factors may improve the ability to detect pediatric dehydration and facilitate earlier treatment or transfer to higher levels of care.

1. David C. Sheridan, MD, MCR* 2. Adrienne Hughes, MD*,† 3. B. Zane Horowitz, MD*,† 1. *Department of Emergency Medicine, Oregon Health & Science University, Portland, OR 2. †Oregon Poison Center, Portland, OR 1. Most poisoning events in preschool-aged children continue to be accidental ingestions in the home, ranging from medications to toys and common household products. 2. Knowledge of these common ingestions is important to properly diagnose, treat, and refer to emergent care as needed. 3. Pediatricians and emergency physicians should be familiar with new exposures and treatment options that have been recommended for some novel agents. After completing this article, readers should be able to: 1. Explain the general epidemiology and emerging trends for pediatric poisonings and exposures. 2. Become familiar with several new products that have emerged as high-risk exposures in preschool-age children. 3. Describe the potential serious clinical complications and treatment options for these new high-risk agents. There is good news and bad news when it comes to pediatric poisoning and exposures. The last full year that the American Association of Poison Control Centers reported data was 2017. (1) There were 2,115,186 human exposures called in to poison centers in the 50 states and US territories, of which children represented the largest percentages. Children younger than 6 years were the concern in 45% of calls, those 6 to 12 years of age represented 6% of calls, and adolescents 13 to 19 years of age 8% of calls. (1) Although no death of a child is considered a positive outcome, the trend in fatalities from poison exposure for toddlers has been decreasing. The good news is that of 956,871 calls to poison centers regarding preschool-age children (

Constant-voltage time-dependent dielectric breakdown (TDDB) measurements are performed on recently manufactured commercial 1.2 kV 4H-SiC power metal-oxide-semiconductor (MOS) field-effect transistors (MOSFETs) from three vendors. Abrupt changes of the electric field acceleration parameters ( $\gamma $ ) are observed at oxide electric fields ( $E_{ox}$ ) around 8.5 MV/cm to 9 MV/cm for all commercial MOSFETs. Gate leakage currents and threshold voltage shifts are also monitored under different oxide fields ( $E_{ox}= {\mathrm {8 MV/cm}}$ and 10 MV/cm). The results suggest the failure mode under high oxide electric field is modified by impact ionization or Anode Hole Injection (AHI) induced hole trapping. This observation agrees with previously published oxide reliability studies on SiC MOSFETs and suggests that constant-voltage TDDB measurements need to be carefully performed under low oxide fields to avoid lifetime overestimation caused by hole trapping. The extrapolated $t_{63\%}$ lifetimes (times to 63% failures) from TDDB measurements performed at $E_{ox} < {\mathrm {8.5 MV/cm}}$ are longer than 108 hours at 150°C for all vendors. The predicted lifetimes at $E_{ox}= {\mathrm {4 MV/cm}}$ demonstrate more than 105 times increases than the oxide lifetimes reported a decade ago, showing promising progress in SiC technology.

The coronavirus disease 2019 (COVID-19) pandemic has taken an unprecedented global toll and vaccination is needed to restore healthy living. Timely inclusion of children in vaccination trials is critical. We surveyed caregivers of children seeking care in 17 Emergency Departments (ED) across 6 countries during the peak of the pandemic to identify factors associated with intent to participate in COVID-19 vaccine trials. Questions about child and parent characteristics, COVID-19 expressed concerns and parental attitudes toward participation in a trial were asked. Of 2768 completed surveys, 18.4% parents stated they would enroll their child in a clinical trial for a COVID-19 vaccine and 14.4% would agree to a randomized placebo-controlled study. Factors associated with willingness to participate were parents agreeing to enroll in a COVID-19 vaccine trial themselves (Odds Ratio (OR) 32.9, 95% Confidence Interval (CI) (21.9–51.2)) having an older child (OR 1.0 (1.0–1.01)), having children who received all vaccinations based on their country schedule (OR 2.67 (1.35–5.71)) and parents with high school education or lower (OR 1.79 (1.18–2.74)). Mothers were less likely to enroll their child in a trial (OR 0.68 (0.47–0.97)). Only one fifth of families surveyed will consider enrolling their child in a vaccine trial. Parental interest in participation, history of vaccinating their child, and the child being older all are associated with parents allowing their child to participate in a COVID vaccine trial. This information may help decision-makers and researchers shape their strategies for trial design and participation engagement in upcoming COVID19 vaccination trials.

Objective Heart rate variability (HRV) evaluates small beat-to-beat time interval (BBI) differences produced by the heart and suggested as a marker of the autonomic nervous system. Artifact produced by movement with wrist worn devices can significantly impact the validity of HRV analysis. The objective of this study was to determine the impact of small errors in BBI selection on HRV analysis and produce a foundation for future research in mental health wearable technology.Methods This was a sub-analysis from a prospective observational clinical trial registered with clinicaltrials.gov (NCT03030924). A cohort of 10 subject’s HRV tracings from a wearable wrist monitor without any artifact were manipulated by the study team to represent the most common forms of artifact encountered.Results Root mean square of successive differences stayed below a clinically significant change when up to 5 beats were selected at the wrong time interval and up to 36% of BBIs was removed. Standard deviation of next normal intervals stayed below a clinically significant change when up to 3 beats were selected at the wrong time interval and up to 36% of BBIs were removed. High frequency HRV shows significant changes when more than 2 beats were selected at the wrong time interval and any BBIs were removed.Conclusion Time domain HRV metrics appear to be more robust to artifact compared to frequency domains. Investigators examining wearable technology for mental health should be aware of these values for future analysis of HRV studies to improve data quality.

The aim of this study was to assess national trends in recreational and suicidal ingestions of over-the-counter cough preparations that contain Coricidin.Using the American Association of Poison Control Center's National Poison Data System, we obtained data from 2004 to 2017 on patients aged 13 to 19 years with an ingestion of "Coricidin." We examined trends over time overall and ingestion intent (recreational vs suicidal) using linear regression. We compared patient characteristics, substances ingested, clinical effects and therapies, and outcomes by suicidal versus misuse or recreational intention.An initial search with the inclusion criteria found 19,213 calls that matched study inclusion criteria. On average, there was a yearly linear increase of 180.0 (95% confidence interval [CI], 136.6-223.3; P0.01) ingestions per year. Within suicide ingestions, there was an average yearly increase of 97.9 (95% CI, 66.9-128.9; P0.01) ingestions, and within misuse/recreational ingestions, there was an average yearly increase of 82.1 (95% CI, 60.3-103.9; P0.01) ingestions. The most common clinical effect was tachycardia, which occurred in 42.4% of ingestions. Altered mental status, mydriasis, and ataxia were all more common in misuse/recreational ingestions. Suicidal ingestions resulted in more hospital admissions and need for medical treatment. Recreational-use coded calls peaked in 2013, whereas calls coded for suicide attempts have continued to rise dramatically, with a 50% increase in the 14-year study period.Combination Coricidin products are a major source of morbidity in adolescents. Targeted preventive measures in primary care offices or larger-scale policy/legislative efforts may be helpful to address this.

Suicide is a leading cause of death among adolescents. Oregon ranks 17th nationally for youth suicide rates, and ingestion of medications as a means of suicide is common. Despite the high prevalence of intentional poisoning among youth in Oregon, information about medications used by children and adolescents for attempted suicide, in particular the sources of medications, is not readily available.The objective of this study is to describe types and sources of medications used for intentional ingestion among patients seen by the Doernbecher Children's Hospital Child and Adolescent Psychiatry Consultation-Liaison Service. This was a retrospective analysis of patients seen by the Child and Adolescent Psychiatry Consultation-Liaison Service for intentional ingestion from 2015 to 2017. Data on 434 total intentional ingestions were collected, including demographic information, types of medications ingested, and sources of both over-the-counter (OTC) and prescription (Rx) medications. Ingestions without intent of suicide were excluded. Descriptive analysis of ingestion data was performed.Intentional ingestions included Rx and OTC medications in similar frequencies. For Rx medications, 68% of ingestions included patients' own Rxs. Eighty-eight percent of ingestions that were not the patients' own Rx belonged to someone else living in their home. For OTC medications, 66% of medications were available at home.Intentional ingestions among adolescents most frequently involve medications that are readily available in their homes, and these include both OTC and Rx medications. This study highlights the importance of securing medications at home as a preventative measure and the importance of anticipatory guidance for primary care providers.

ObjectivesPrevious literature on the effects of marijuana exposure on neonatal outcomes has been limited by the reliance on maternal self-report. The objective of this study was to examine the relationship of prenatal marijuana exposure on neonatal outcomes in infants with marijuana exposure confirmed with meconium drug testing.DesignRetrospective cohort study.Setting and participantsMeconium drug screens obtained on infants born in a hospital system in the Pacific Northwest in the USA over a 2.5-year period. 1804 meconium drug screens were initially obtained, with 1540 drug screens included in the analysis.Primary and secondary outcome measuresNeonates with meconium drug screens positive for delta-9-tetrahydrocannabinol (THC) only were compared with neonates with negative drug screens. The following neonatal outcomes were examined: gestational age, preterm birth (Results1540 meconium drug screens were included in the analysis, with 483 positive for delta-9-THC only. Neonates exposed to delta-9-THC had significantly lower birth weight, head circumference and length (pConclusionsPrenatal marijuana exposure was significantly associated with decreases in birth weight, length and head circumference, and an increased risk of being defined as low birth weight. These findings add to the previous literature demonstrating possible negative effects of prenatal marijuana use on neonatal outcomes.

1. David C. Sheridan, MD, MCR* 2. Adrienne Hughes, MD*,† 3. B. Zane Horowitz, MD*,† 1. *Department of Emergency Medicine, Oregon Health & Science University, Portland, OR 2. †Oregon Poison Center, Portland, OR 1. There have been increases in both suicidal and recreational adolescent ingestions over time. 2. Knowledge of these common ingestions is important to properly diagnose, treat, and refer to emergent care as needed. 3. Pediatricians and emergency physicians should be familiar with these ingestions to develop preventive efforts. After completing this article, readers should be able to: 1. Explain the national trends for adolescent suicidal ingestions and recreational abuse. 2. Become familiar with ingestions of prescription drugs, over-the-counter medications, and recreational drugs of abuse. 3. Describe the potential serious clinical complications and treatment options for these ingestions. Adolescents generally do not unintentionally ingest pharmaceutical agents, as seen in the younger pediatric population. The main reasons for adolescent ingestions generally fall into 2 categories: suicidal/self-harm and recreational abuse. These 2 categories are very important and carry different levels of morbidity and mortality. The agents ingested may be unique and require different clinical management and preventive strategies. Suicidal ingestions alone now account for more than 1 million annual emergency department visits, making this a very timely and important review article. (1) Adolescent suicidality and suicide attempts are growing in number, now accounting for more than 1.12 million emergency department visits per year. (1) The reasons for this are multifactorial, with ingestions a common part of a suicide plan or attempt. One recent study evaluated national trends in suicidal ingestions over the most recent decade using the National Poison Center System, a database that consists of all calls to poison centers in the United States. (2) This study found that there were approximately 400,000 calls for “intentional-suspected suicide.” More importantly, calls about adolescent ingestions accounted for more than 80% of all intentional ingestion calls during the study period. The top 5 agents ingested included over-the-counter (OTC) medications of acetaminophen, ibuprofen, and antihistamines, as well as the prescription psychiatric …

The commercialization of silicon carbide (SiC) power metal-oxide-semiconductor field-effect-transistors (MOSFETs) has expanded during the last decade. The gate oxide reliability is the primary issue for SiC power MOSFETs since it determines the device's operational lifetime. In this work, we investigate the gate leakage currents under different gate voltages on commercial 1.2 kV SiC power MOSFETs. The impact ionization and/or anode hole injection (AHI) triggered by high oxide electric fields results in hole trapping that enhances the gate leakage current and reduces device's threshold voltage. The electron injection and trapping due to Fowler-Nordheim (F - N) tunneling tend to reduce the gate leakage current and increases threshold voltage. Constant-voltage time-dependent dielectric breakdown (TDDB) measurements are also conducted on the commercial MOSFETs. The results on gate leakage current suggest that the change of the field acceleration factor is due to enhanced gate current/hole trapping under high gate oxide fields. Therefore, it is suggested that TDDB measurements should be conducted under low gate voltages to avoid overestimation of lifetime under normal operating gate voltage.

This cross-sectional study examines the rates of intentional misuse of substances in US children aged 6 to 18 years in the past 20 years.

BACKGROUND: Increasingly, youth with mental health disorders and suicidality are presenting to emergency departments (EDs) and requiring hospitalization. For youth with suicidality, studies reveal seasonal variations in frequency of presentations but do not identify associated diagnoses or whether other primary mental health complaints also reveal seasonal variations. METHODS: Data were collected between January 2015 and December 2019 by a child and adolescent psychiatry consultation-liaison service in a pediatric ED and hospital. Descriptive analysis and multiple linear regression were performed to assess volume over time, seasonal trends, and associated diagnoses. RESULTS: A total of 2367 patients were included, with an average age of 13.9 years and female predominance (62.3%). During the study period, annual ED consultations increased 87.5% and hospital consultations increased 27.5%. Consultations revealed seasonal trends, with highest volumes during January, April, May, October, and November (P < .001; adjusted R2 = 0.59). The most frequent diagnostic categories were depressive disorders and trauma- or stressor-related disorders. Thirty-six percent of patients presented after a suicide attempt, with the highest rates in spring (P = .03; adjusted R2 = 0.19). Boarding rates revealed significant seasonality, with higher instances in February, March, April, May, and October (P = .009; adjusted R2 = 0.32). CONCLUSIONS: Mental health presentations to a pediatric ED and hospital reveal seasonal trends, with the highest volumes in fall and spring and the most common diagnoses being depressive and trauma-related disorders. Suicide attempts are highest in late spring. Knowledge of these trends should inform hospitals, mental health services, and school systems regarding staffing, safety, surveillance, and prevention.

Background: Capillary refill is an early reflection of decreased end organ perfusion resulting in shunt of blood from the extremities to vital organs. Physicians rate this as the most important factor to guide therapeutic resuscitation efforts. However, literature shows that providers have significant variability in their bedside measurement of capillary refill. Objective: The objective of this study was to develop and evaluate a novel technology to detect capillary refill in a noninvasive and rapid manner through an iterative, problem-based innovation approach. Methods: This was a prospective study at a level 1 tertiary care hospital of patients presenting to an emergency department. The research team used in a new technology that utilizes light transmission and pressure to objectively quantify extremity capillary refill time. This measurement was compared to manual refill time performed by a trained study provider. Results: Through an iterative approach the team developed a platform technology and enrolled 63 subjects in this prospective trial. 9 subjects had inadequate data and so the final cohort consisted of 54 subjects with both manual capillary refill time and the new novel technology measurement. The device measured capillary refill time showed a high degree of correlation to manual estimate of capillary refill time with a Pearson coefficient of 0.7. Conclusions: Novel technology to measure capillary refill time can significantly improve the treatment and care of multiple medical conditions that rely on timely diagnosis and initiation of resuscitation in the emergency department and other care settings. This study shows a modest correlation of technology with automated signal processing algorithms for noninvasive measurement of capillary refill. Integration of this technology into standard hospital monitors has broad applicability to make capillary refill a standard vital sign.

OBJECTIVES:To determine the prevalence of invasive bacterial infections (IBIs) and adverse events in afebrile infants with acute otitis media (AOM).METHODS:We conducted a 33-site cross-sectional study of afebrile infants ≤90 days of age with AOM seen in emergency departments from 2007 to 2017. Eligible infants were identified using emergency department diagnosis codes and confirmed by chart review. IBIs (bacteremia and meningitis) were determined by the growth of pathogenic bacteria in blood or cerebrospinal fluid (CSF) culture. Adverse events were defined as substantial complications resulting from or potentially associated with AOM. We used generalized linear mixed-effects models to identify factors associated with IBI diagnostic testing, controlling for site-level clustering effect.RESULTS:Of 5270 infants screened, 1637 met study criteria. None of the 278 (0%; 95% confidence interval [CI]: 0%–1.4%) infants with blood cultures had bacteremia; 0 of 102 (0%; 95% CI: 0%–3.6%) with CSF cultures had bacterial meningitis; 2 of 645 (0.3%; 95% CI: 0.1%–1.1%) infants with 30-day follow-up had adverse events, including lymphadenitis (1) and culture-negative sepsis (1). Diagnostic testing for IBI varied across sites and by age; overall, 278 (17.0%) had blood cultures, and 102 (6.2%) had CSF cultures obtained. Compared with infants 0 to 28 days old, older infants were less likely to have blood cultures (P < .001) or CSF cultures (P < .001) obtained.CONCLUSION:Afebrile infants with clinician-diagnosed AOM have a low prevalence of IBIs and adverse events; therefore, outpatient management without diagnostic testing may be reasonable.

The Crisis and Transition Services (CATS) program is a novel approach to safely transitioning youths from the emergency department to outpatient care. The program provides intensive community-based support during the high-risk period after discharge from the emergency department. Preliminary results indicate that the CATS program is reaching youths in a short time frame, engaging families in comprehensive safety planning, connecting youths with ongoing outpatient services, and improving family confidence in navigating mental health crises.

The novel coronavirus that results in COVID‐19 has significantly impacted the global healthcare system and economy since first reported in December 2019.1 Many countries and states have enacted stay‐at‐home orders and implemented social distancing guidelines to mitigate disease transmission. One recent Italian study described delays in seeking pediatric emergency care for fear of COVID‐19 infection, resulting in potentially avoidable intensive care unit admissions and deaths.

Objectives Pediatric mental health presentations to emergency departments (EDs) have shown dramatic increases nationally. This study aimed to identify the ability of patients discharged with mental health from the ED to establish outpatient care. Methods This was a cross-sectional study of all mental health patients aged 7 to 19 years who were seen by a child psychiatry consult team in a tertiary care pediatric ED from September 2016 to January 2017. Patients were contacted by phone at least 6 months after discharge. Data obtained included time to follow-up, reasons for delayed follow-up, type of provider seen, and frequency of outpatient visits. Results Two hundred twenty-eight charts were reviewed and 51 were successfully interviewed. The median age was 14 years and 61% were female. Most patients (61%) reported seeing a psychiatrist or therapist, whereas 19% reported a primary care provider and 19% reporting "other." The majority were able to establish care within 1 month (73%), whereas 9% reported never obtaining outpatient follow-up. Most patients (58%) were able to be seen more than once per month. The most common reason for delayed follow-up was provider availability. Conclusions This study found that a large number of patients were able to be seen within 1 month of discharge for mental health care. However, almost 10% of patients never established outpatient care, which is concerning and is an area needing further research.

Background Migraine headaches are a common reason for pediatric emergency department (ED) visits. Small studies suggest the potential efficacy of sub-anesthetic doses of propofol for migraine with a favorable side effect profile and potentially decreased length of stay (LOS). Objective The objective of this study was to compare the efficacy of low-dose propofol (LDP) to standard therapy (ST) in pediatric migraine treatment. Methods We conducted a prospective, pragmatic randomized controlled trial from April 2014 through June 2016 in the ED at two pediatric hospitals. Patients aged 7–19 years were eligible if they were diagnosed with migraine by the emergency physician and had a presenting visual analog pain score (VAS) of 6–10. Primary outcome was the percent of pain reduction. Secondary outcomes were ED LOS, 24-h rebound headache, return visits to the ED, and adverse reactions. Results Seventy-four patients were enrolled, but 8 were excluded, leaving 66 patients in the final analysis (36 ST, 30 LDP). Pain reduction was 59% for ST and 51% for LDP (p = 0.34) with 72.2% vs. 73.3% achieving a VAS ≤ 4 with initial therapy (p = 0.92). There was a nonsignificant trend toward shorter median LOS from drug administration to final disposition favoring propofol (79 min vs. 111 min; p = 0.09). Rebound headache was significantly more common in the ST vs. LDP group (66.7% vs. 25.0%; p = 0.01). Conclusions LDP did not achieve better pain reduction than ST, however, LDP was associated with significantly fewer rebound headaches and a nonsignificant trend toward shorter median LOS from drug administration to disposition.

Bupropion is often categorized as a newer generation antidepressant and assessed with serotonin reuptake inhibitors as a lower risk than older tricyclic antidepressants (TCAs). The objective of this study was to compare outcomes in adolescent suicide from ingestions between bupropion and TCA medications.An analysis of the National Poison Data System for exposures coded "suspected suicide" in adolescents (age: 13-19) was undertaken for the years 2013-2016 and included TCAs or bupropion. We compared clinical effects, therapies and medical outcomes.Over the four-year period there were 2253 bupropion and 1496 TCA adolescent suspected suicide calls. There was a significant linear increase in bupropion ingestions over the four years. Across all years, there were on average 189.2 (95% CI: 58.1-320.4; p = .01) more ingestions of bupropion than TCA. When comparing bupropion to a TCA, ingestions of bupropion were significantly more likely to be accompanied by seizure (30.7% vs 3.9%; p .01), to be admitted (74.8% vs 61.6%; p .01) and medical outcomes to be coded as a major outcome (19.3% vs 10.0%; p .01). The number of cases with death or major clinical outcome for both increased over the four-year period. Ingestions of bupropion were less likely to have hypotension (2.7% vs 8.0%; p .01) and less likely to be intubated (5.6% vs 16.4%; p .01) as compared to ingestions of TCA.Adolescents who overdose on a single medication in a suicide attempt with bupropion have a statistically significant higher incidence of major outcomes and seizures. The risks of bupropion as a potential means of suicidal gesture by overdose must be considered, and weighed against its benefits and side effect profile when choosing an appropriate agent for the treatment of depression in adolescents.

Adolescent ingestions are common reasons for calls to poison centers in United States. As opposed to younger children who mostly have unintentional exposures, adolescent ingestions often result from intentional use. This manuscript reviews recent reports on adolescent ingestions related to intentional abuse, self-harm, and use of opioid medications.

OBJECTIVES: Suicide is the second leading cause of death in the adolescent population, presenting a public health crisis. The goal of this study was to evaluate adolescent intentional ingestions in a community hospital and to identify variables associated with the risk of admission to inpatient medical and psychiatric settings. METHODS: This study was a retrospective chart review from a hospital system in the Pacific Northwest over 2 years for patients aged 9 to 18 years. Variables examined include age, sex, type of ingestion, emergency department length of stay (LOS), admission to the inpatient setting, LOS of inpatient admission, admission to psychiatry, presence of a therapist, and insurance type. RESULTS: During the study period, 233 individual intentional ingestions occurred. The most commonly ingested substances were psychiatric medications (30.9%), prescription medications (28.3%), and ibuprofen (24.0%). One-third of patients (33.9%) required admission to a medical hospital, whereas one-quarter (24.9%) required admission to a psychiatric hospital. The following variables were associated with risk of admission to a medical hospital: female sex, shorter emergency department LOS, and ingestion of psychiatric medications, prescription medication, and/or salicylates. Risk of admission to a psychiatric hospital was associated with an inpatient medical admission, an increased duration of medical admission, and an ingestion of a psychiatric medication. CONCLUSIONS: In this study, we describe important epidemiology on adolescent intentional ingestions in a community setting, providing variables associated with a risk of admission to medical and psychiatric hospitals.

Objective This study aimed to assess the association between the degree of headache relief obtained in the pediatric emergency department (PED) with abortive treatment and unscheduled return visits to the PED for a recurrent or persistent headache within 72 hours. Methods This was a retrospective observational study with 369 patients, all younger than 18 years, who presented to the PED with a primary complaint of either a headache or migraine. Patient and visit details were collected from the medical chart, along with presenting and discharge pain score. Percent pain reduction at discharge was determined through the following calculation: (Presenting Pain Score - Discharge Pain Score)/Presenting Pain Score. Associations were assessed using multivariable logistic regression. Results No significant association was found between the percent pain reduction and return to the PED (P = 0.49). Mean presenting pain score at the index visit was statistically higher for those who ended up returning to the PED versus those who did not (8.1 vs 7.4; P = 0.02). A trend toward increase in return visits was seen among patients who had a headache duration greater than 3 days (odds ratio, 1.99) and patients who experienced less than 50% pain reduction in the PED (odds ratio, 1.77). Conclusions Complete resolution in the PED may not be necessary, given the lack of association between the degree of pain relief and revisit rates. Perhaps, the goal should be to achieve at least 50% pain reduction before discharge.

OBJECTIVE The current gold-standard imaging modality for pediatric traumatic brain injury (TBI) is CT, but it confers risks associated with ionizing radiation. QuickBrain MRI (qbMRI) is a rapid brain MRI protocol that has been studied in the setting of hydrocephalus, but its ability to detect traumatic injuries is unknown. METHODS The authors performed a retrospective cohort study of pediatric patients with TBI who were undergoing evaluation at a single Level I trauma center between February 2010 and December 2013. Patients who underwent CT imaging of the head and qbMRI during their acute hospitalization were included. Images were reviewed independently by 2 neuroradiology fellows blinded to patient identifiers. Image review consisted of identifying traumatic mass lesions and their intracranial compartment and the presence or absence of midline shift. CT imaging was used as the reference against which qbMRI was measured. RESULTS A total of 54 patients met the inclusion criteria; the median patient age was 3.24 years, 65% were male, and 74% were noted to have a Glasgow Coma Scale score of 14 or greater. The sensitivity and specificity of qbMRI to detect any lesion were 85% (95% CI 73%–93%) and 100% (95% CI 61%–100%), respectively; the sensitivity increased to 100% (95% CI 89%–100%) for clinically important TBIs as previously defined. The mean interval between CT and qbMRI was 27.5 hours, and approximately half of the images were obtained within 12 hours. CONCLUSIONS In this retrospective pilot study, qbMRI demonstrated reasonable sensitivity and specificity for detecting a lesion or injury seen with neuroimaging (radiographic TBI) and clinically important acute pediatric TBI.

OBJECTIVES Mental health complaints are a frequent presentation to the pediatric emergency department (PED). It is unclear if having an on-site inpatient pediatric psychiatric unit impacts pediatric mental health care in the acute setting. The objective of this study was to compare PED mental health care between a pediatric tertiary care center with an associated inpatient child psychiatric unit (PAPED) and one that does not (NOPED) with the hypothesis that children have longer lengths of stay (LOS) at the PED without an inpatient unit. METHODS This was a retrospective, observational study of all mental health presentations aged 1 to 18 years to 2 tertiary care PEDs from March 2012 to June 2013 with a final mental health diagnosis International Classification of Diseases, Ninth Revision code. RESULTS A total of 1409 patient encounters comprised the study group. The PAPED had a significantly higher rate of admission 41.3% versus 18.8% (P < 0.0001). The LOS was significantly longer at the NOPED compared with the PAPED with a visit of 15.6 versus 6.3, respectively (P < 0.0001). When LOS was stratified for disposition, patients requiring admission from the NOPED had a significantly longer LOS of 33.4 compared with an emergency department LOS of 8.1 at the PAPED (P < 0.0001). CONCLUSIONS Mental health care in the PED seems to be affected by having an associated inpatient child psychiatric unit. Further research needs to address this growing problem and ways to utilize community resources to develop safe outpatient plans and divert admission if possible.

To describe the inpatient management of pediatric migraine and the association between specific medications and hospital length of stay (LOS).Historical cohort study review of patients age19 years of age admitted to a single tertiary care children's hospital between 2010 and 2015 for treatment of migraine headache.The cohort consisted of 58 encounters with an average patient age of 14.3 years (SD 3.2 years) with a female predominance (62%). The mean number of inpatient medications received by patients was 3 (range 1-7), with dopamine antagonists and dihydroergotamine used most commonly (67% and 59% of encounters, respectively). The average LOS was 56 hours (95% CI 48.2-63.2) and did not vary by medication received, although patients who received an opioid had a significantly longer LOS (79.2 vs 47.9 hours respectively; P .001).Children admitted to the hospital for treatment of migraine headache frequently require a large number of medications over an average hospital LOS of more than 2 days without apparent differences based on medication received other than prolonged stays for subjects who received opioids.

Background Pediatric emergency department (PED) visits among children and adolescents with acute mental health needs have increased over the past decade with long wait times in the PED awaiting disposition. Objective The objective of this study was to evaluate the effect of a new pediatric mental health liaison program with the hypothesis that this model reduces length of stay (LOS) and hospitalization rates among pediatric mental health patients. Methods This was a pre- and postintervention retrospective study of the year prior to (June 2012–June 2013) and the year after (October 2013–October 2014) implementation of a new PED psychiatric team. All patients aged 1–18 years with a mental health International Classification of Diseases-9 th Revision code were included. Patients who did not receive a Psychiatry consult in the PED were excluded. Results There were 83 encounters in the year prior to and 129 encounters in the year after the implementation of the liaison program. There was an increase in the suicidality of mental health patients during this time. There was a significant decrease in mean PED LOS of 27% (95% confidence interval [CI] 0–46%; p = 0.05) from pre- to postintervention period. The decrease in the proportion of patients admitted/transferred to an inpatient psychiatric facility in the postintervention year was statistically significant (odds ratio 0.35; 95% CI 0.17–0.71; p Conclusions The use of a dedicated child psychiatrist and mental health social worker to the PED results in significantly decreased LOS and need for admission without any change in return visit rate. Larger, multicenter studies are needed to confirm these findings.

Reliability is an important consideration during semiconductor technology development, which ensures that the performances of devices, circuits, and systems are maintained over a specified period of time, leading to successful products. Device reliability is at the core of overall product reliability, which continues to remain an important area of research and has attracted the attention of IEEE Transactions on Electron Devices (T-ED) authors and readers throughout the years. Device reliability can be classified into two broad areas: gradual drift of device performance over time or sudden failure, and both are of importance for logic, memory, RF, and power devices. Different aspects of device reliability are usually reported, such as the development of electrical or physical characterization methods, investigation and modeling of a particular phenomenon, impact of material and processes on reliability, and development of reliability tolerant technologies.

To characterize the frequency of opioid prescribing for pediatric headache in both ambulatory and emergency department (ED) settings, including prescribing rates by provider type.A retrospective cohort study of Washington State Medicaid beneficiaries, aged 7-17 years, with an ambulatory care or ED visit for headache between January 1, 2012, and September 30, 2015. The primary outcome was any opioid prescribed within 1 day of the visit.A total of 51 720 visits were included, 83% outpatient and 17% ED. There was a predominance of female (63.2%) and adolescent (59.4%) patients, and 30.5% of encounters involved a pediatrician. An opioid was prescribed in 3.9% of ED and 1.0% of ambulatory care visits (P .001). Pediatricians were less likely to prescribe opioids in both ED (-2.70 percentage point; 95% CI, -3.53 to -1.88) and ambulatory settings (-0.31 percentage point; 95% CI, -0.54 to -0.08; P .001).Opioid prescribing rates for pediatric headache were low, but significant variation was observed by setting and provider specialty. We identified opioid prescribing by nonpediatricians as a potential target for quality improvement efforts.

The molecular basis for excitation-contraction coupling in skeletal muscle is generally thought to involve conformational coupling between the L-type voltage-gated Ca(2+) channel (CaV1.1) and the type 1 ryanodine receptor (RyR1). This coupling is bidirectional; in addition to the orthograde signal from CaV1.1 to RyR1 that triggers Ca(2+) release from the sarcoplasmic reticulum, retrograde signaling from RyR1 to CaV1.1 results in increased amplitude and slowed activation kinetics of macroscopic L-type Ca(2+) current. Orthograde coupling was previously shown to be ablated by a glycine for glutamate substitution at RyR1 position 4242. In this study, we investigated whether the RyR1-E4242G mutation affects retrograde coupling. L-type current in myotubes homozygous for RyR1-E4242G was substantially reduced in amplitude (∼80%) relative to that observed in myotubes from normal control (wild-type and/or heterozygous) myotubes. Analysis of intramembrane gating charge movements and ionic tail current amplitudes indicated that the reduction in current amplitude during step depolarizations was a consequence of both decreased CaV1.1 membrane expression (∼50%) and reduced channel Po (∼55%). In contrast, activation kinetics of the L-type current in RyR1-E4242G myotubes resembled those of normal myotubes, unlike dyspedic (RyR1 null) myotubes in which the L-type currents have markedly accelerated activation kinetics. Exogenous expression of wild-type RyR1 partially restored L-type current density. From these observations, we conclude that mutating residue E4242 affects RyR1 structures critical for retrograde communication with CaV1.1. Moreover, we propose that retrograde coupling has two distinct and separable components that are dependent on different structural elements of RyR1.

Pediatric fever is one of the most common presenting complaints to emergency departments (ED). While often due to a viral illness, in young children without a source the most common bacterial infection is pyelonephritis. For this reason, when no focal source can be identified a urinary specimen is recommended. In young children who are unable to urinate on demand, a straight catheter is required to obtain a sterile specimen. This is generally a benign procedure and is performed frequently in EDs. We report a case of a young girl who underwent straight bladder catheterization and was subsequently found to have a retained catheter that had become knotted in the bladder. This case report highlights a rare complication of this common procedure and describes the technique required to remove the catheter. An understanding of these issues may avoid the need for transfer to a pediatric facility or for subspecialty consultation.

OBJECTIVE Pediatric headaches are a common presentation to emergency departments accounting for almost half a million annual visits. Providers are left with the difficult task of deciding who has a secondary headache etiology that warrants neuroimaging. METHODS We conducted a retrospective case-control study. Patients from a pediatric neuro-oncology clinic database with brain cancer and a headache at presentation were identified as cases. Controls were patients from 2 local pediatric tertiary care emergency departments with a final diagnosis of headache after negative neuroimaging. Clinical factors were decided a priori, and logistic regression was used to determine which clinical factors were related to case/control status. RESULTS A total of 334 patients (203 controls and 131 cases) were included. Patients with a history of headaches had 0.5 (95% confidence interval [CI]: 0.3-0.9; P = 0.03) times the odds of being a case. Patients with vomiting had increased odds of being a case compared with controls regardless of the time of day (early morning 1.8 [95% CI: 1.0-3.2; P = 0.04] and non-early morning 6.6 [95% CI: 2.0-21.7; P < 0.01]). Patients with neurological signs had 10.3 (95% CI: 5.4-19.4; P < 0.01) times the odds of being a case, and patients with an associated seizure had 10.9 (95% CI: 3.8-30.7; P < 0.01) times the odds of being a case. CONCLUSIONS This study identified clinical factors associated with pediatric brain neoplasms that may guide acute neuroimaging decisions. This study also provides insight into potential clinical factors to be studied prospectively to derive a clinical decision rule.