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Integrated behavioral health can improve primary care and mental health outcomes. Access to behavioral health and primary care services in Texas is in crisis because of high uninsurance rates, regulatory restrictions, and lack of workforce. To address gaps in access to care, a partnership formed among a large local mental health authority in central Texas, a federally designated rural health clinic, and the Texas A&M University School of Nursing to create an interprofessional team-based health care delivery model led by nurse practitioners in rural and medically underserved areas of central Texas. Academic–practice partners identified 5 clinics for an integrated behavioral health care delivery model. From July 1, 2020, through December 31, 2021, a total of 3183 patient visits were completed. Patients were predominantly female (n = 1719, 54%) and Hispanic (n = 1750, 55%); 1050 (33%) were living at or below the federal poverty level; and 1400 (44%) were uninsured. The purpose of this case study was to describe the first year of implementation of the integrated health care delivery model, barriers to implementation, challenges to sustainability, and successes. We analyzed data from multiple sources, including meeting minutes and agendas, grant reports, direct observations of clinic flow, and interviews with clinic staff, and identified common qualitative themes (eg, challenges to integration, sustainability of integration, outcome successes). Results revealed implementation challenges with the electronic health record, service integration, low staffing levels during a global pandemic, and effective communication. We also examined 2 patient cases to illustrate the success of integrated behavioral health and highlighted lessons learned from the implementation process, including the need for a robust electronic health record and organizational flexibility.

Background and objective: Evidence for the treatment of multisystem inflammatory syndrome in children (MIS-C) is lacking. Anakinra, which targets IL-1-mediated inflammation, is reserved for refractory cases of MIS-C; however, its use in the treatment of MIS-C is not clearly established. Patients and Methods: To examine a role for anakinra in MIS-C, we performed a single center prospective observational cohort study of all MIS-C patients diagnosed at our children’s hospital from May 15 to November 15, 2020. Demographics, clinical features, diagnostic testing, and cardiac function parameters were compared between MIS-C patients treated with intravenous immunoglobulin (IVIG) monotherapy and IVIG with anakinra (IVIG+anakinra). Results: Among 46 patients with confirmed MIS-C, 32 (70%) were in the IVIG+anakinra group, of which 9 of these patients (28%) were also given corticosteroids (CS). No patients were treated with anakinra alone. MIS-C patients in the IVIG+anakinra group were enriched in a CV shock phenotype (p=0.02), and those with CV shock were treated with higher doses of anakinra for a longer duration. Furthermore, MIS-C patients in the IVIG+anakinra group exhibited improvements in fever and cardiac function with and without CS. No significant adverse events were observed, and no differences in IL-1β levels were found among MIS-C patients in the IVIG+anakinra group. Conclusions: Anakinra treatment, which was co-administered with IVIG and primarily in patients with severe MIS-C, was associated with improvements in fever and cardiac function, and demonstrated a favorable side-effect profile. These findings suggest a role for adjunctive anakinra in the treatment of MIS-C.

Background Virtual simulation-based education is in healthcare education. This study explored nurse educators’ use of the INACSL Standards of Best Practice: Simulation© during facilitation and debriefing of virtual simulation during the pandemic. Design A quantitative exploratory research design with a researcher developed survey was used to the answer the research questions. Results A total of 129 participants responded to the survey. A plethora of strategies were reported regarding pre-briefing and debriefing. Conclusion Overall, nurse educators followed the INACSL Standards of Best Practice: Simulation© either synchronously or asynchronously. However, research is needed on the best method for pre-briefing and debriefing virtual simulation.

San Juan Basin (SJB) is a geologic structural basin located in northwest New Mexico. Comprehensive field-scale reservoir simulation work was performed in finely constructed basin-wide geologic models, targeting sequestering over 120 million metric tons of CO2 for a period of 20 years. Petrophysical properties were populated through well logs and measurements on core samples obtained from nearby wells within the study area. Various critical storage trapping mechanisms were considered. The threshold pressure in delineating AoR is formulated based on guidance provided by the Environmental Protection Agency (EPA) to ensure the safety of underground drinking water sources (USDW). Besides, a complex faulting system identified on the west side of the basin was modeled to preclude risks of CO2 migration. The faulting system at the northwestern SJB was identified through well log stratigraphy. A near-vertical faulting system was mapped that may pose uncertainties to the sealing capacities of the caprock layer. The preliminary structural map shows a relatively flat topography that deepens to the east; and a high area in the west-northwest that is produced by faulting within a Hogback Monocline. The relief on the fault/monocline averages around 4,000 to 4,500 feet. Our simulation results indicate that SJB has the potential to safely contain the proposed amount of CO2 and avoid the impact of faulting systems. Further, pressure build-up in the injection zone is the most influential factor that may endanger the drinking water aquifer through the active injection and post-injection site care phases compared to CO2 plume migration. Controlling the size of AoR will increase the overall storage capacity within the area of interest while cutting down the overhead for corrective action planning and site monitoring. This work employed realistic reservoir characterization data from San Juan Basin CarbonSAFE Phase III project to construct the reservoir simulation model, including 3D seismic, well logs, core analysis, and fluid sampling. As the worldwide commercial CO2 geologic storage projects aiming for soaring storage capacity goals, the processes in this work demonstrated the workflow to manage a large-scale CO2sequestration project in complex geological structured reservoirs.

There have been considerations since the beginning of the Coronavirus pandemic that COVID-19 infection, like any other viral illness, can trigger neurological and metabolic decompensation in patients with mitochondrial diseases. At the time of writing, there were no published reports reviewing experiences and guidelines about management of COVID-19 infection in this patient population. We present a challenging case of an adult patient with a known diagnosis of Mitochondrial Encephalomyopathy, Lactic Acidosis and Stroke-like Episodes (MELAS) complicated by COVID-19 infection. She initially presented with altered mental status and vomiting and went on to develop a stroke-like episode, pancreatitis, and pneumatosis intestinalis. We review salient features of her hospitalization, including initiation of thromboprophylaxis in relation to intravenous arginine therapy, caution regarding medications such as remdesivir, and the incidence of gastrointestinal complications.

Acute flaccid myelitis (AFM) is a disabling, polio-like illness mainly affecting children. Outbreaks of AFM have occurred across multiple global regions since 2012, and the disease appears to be caused by non-polio enterovirus infection, posing a major public health challenge. The clinical presentation of flaccid and often profound muscle weakness (which can invoke respiratory failure and other critical complications) can mimic several other acute neurological illnesses. There is no single sensitive and specific test for AFM, and the diagnosis relies on identification of several important clinical, neuroimaging, and cerebrospinal fluid characteristics. Following the acute phase of AFM, patients typically have substantial residual disability and unique long-term rehabilitation needs. In this Review we describe the epidemiology, clinical features, course, and outcomes of AFM to help to guide diagnosis, management, and rehabilitation. Future research directions include further studies evaluating host and pathogen factors, including investigations into genetic, viral, and immunological features of affected patients, host-virus interactions, and investigations of targeted therapeutic approaches to improve the long-term outcomes in this population.

Febrile infection‐related epilepsy syndrome (FIRES) is a rare catastrophic epileptic encephalopathy that presents suddenly in otherwise normal children and young adults causing significant neurological disability, chronic epilepsy, and high rates of mortality. To suggest a therapy protocol to improve outcome of FIRES, workshops were held in conjunction with American Epilepsy Society annual meeting between 2017 and 2019. An international group of pediatric epileptologists, pediatric neurointensivists, rheumatologists and basic scientists with interest and expertise in FIRES convened to propose an algorithm for a standardized approach to the diagnosis and treatment of FIRES. The broad differential for refractory status epilepticus (RSE) should include FIRES, to allow empiric therapies to be started early in the clinical course. FIRES should be considered in all previously healthy patients older than two years of age who present with explosive onset of seizures rapidly progressing to RSE, following a febrile illness in the preceding two weeks. Once FIRES is suspected, early administrations of ketogenic diet and anakinra (the IL‐1 receptor antagonist that blocks biologic activity of IL‐1β) are recommended.

Clinical learning in the first semester of nursing school is often challenging and difficult for students to assimilate multiple subjects while applying clinical skills. One college of nursing created a first semester simulation experience that helped students to enhance clinical reasoning by aligning content in multiple courses, allowing for application of information, and linked clinical skills learned each week to the concept of total patient care. The resulting change to course structure combined basic physical assessment and fundamental nursing care to one course allowing students to understand the application of assessment to nursing practice and skill.

Febrile‐infection related epilepsy syndrome (FIRES) is a devastating neurological condition characterized by a febrile illness preceding new onset refractory status epilepticus (NORSE). Increasing evidence suggests innate immune dysfunction as a potential pathological mechanism. We report an international retrospective cohort of 25 children treated with anakinra, a recombinant interleukin‐1 receptor antagonist, as an immunomodulator for FIRES. Anakinra was potentially safe with only one child discontinuing therapy due to infection. Earlier anakinra initiation was associated with shorter duration of mechanical ventilation, ICU and hospital length of stay. Our retrospective data lay the groundwork for prospective consensus‐driven cohort studies of anakinra in FIRES.

Trissolcus mitsukurii and Trissolcus japonicus are two Asian egg parasitoids associated with different pentatomids such as Halyomorpha halys. Adventive populations of T. mitsukurii were found in Northern Italy, suggesting its employment as a biological control agent (BCA) against H. halys. Nevertheless, to reduce the latter’s population, T. japonicus was released in Italy. Releasing an exotic parasitoid requires investigating the interaction between the BCA and the environment to avoid negative impacts on the entomofauna of the new habitat. Trissolcus mitsukurii is mainly associated with Nezara viridula in its native area. Therefore, we investigated and compared the ability of female T. mitsukurii and T. japonicus to distinguish between naturally released cues of H. halys and N. viridula. A single parasitoid was exposed to contact kairomones of both pests to evaluate its modifications in orthokinetic and locomotory behaviour. The behaviour of female T. mitsukurii was also tested on synthetic compounds simulating the cues of the two pentatomids. When naturally released cues were used, T. japonicus preferred the traces of H. halys, while T. mitsukurii preferred N. viridula’s cues. Moreover, the attraction of T. mitsukurii to N. viridula’s cues was confirmed with synthetic cues. Additional studies are needed to judge if this parasitoid can be used as a BCA.

Objective To describe changes in hospital-based care for children with neurologic diagnoses during the initial 6 weeks following regional Coronavirus 2019 Shelter-in-Place orders. Methods This retrospective cross-sectional study of 7 US and Canadian pediatric tertiary care institutions included emergency and inpatient encounters with a neurologic primary discharge diagnosis code in the initial 6 weeks of Shelter-in-Place (COVID-SiP), compared to the same period during the prior 3 years (Pre-COVID). Patient demographics, encounter length, and neuroimaging and electroencephalography use were extracted from the medical record. Results 27,900 encounters over 4 years were included. Compared to Pre-COVID, there was a 54% reduction in encounters during Shelter-in-Place. COVID-SiP patients were younger (median 5 years vs 7 years). The incidence of encounters for migraine fell by 72%, and encounters for acute diagnoses of status epilepticus, infantile spasms, and traumatic brain injury dropped by 53%, 55%, and 56%, respectively. There was an increase in hospital length of stay, relative utilization of intensive care, and diagnostic testing (long-term electroencephalography, brain MRI, and head CT (all PConclusion During the initial 6 weeks of SiP, there was a significant decrease in neurologic hospital-based encounters. Those admitted required a high level of care. Hospital-based neurologic services are needed to care for acutely ill patients. Precise factors causing these shifts are unknown and raise concern for changes in care seeking of patients with serious neurologic conditions. Impacts of potentially delayed diagnosis or treatment require further investigation.

Background Nurse educators are being called to transform the classroom through engaging teaching methodologies, such as the flipped classroom. However, a gap in the scientific knowledge exists explaining the experience of faculty using the flipped classroom model and its efficacy. Method A qualitative study was conducted with associate degree faculty to answer what is the experience of nurse faculty who have incorporated the flipped classroom into their courses? Results Analysis of the data identified five generalized categories. Conclusion The study provided new insight into faculty transformation.

Inpatient child neurology programs provide essential services for children. We sought to understand the current structure and challenges of inpatient pediatric neurologic care delivery in academic programs in North America.We identified a single child neurologist from 39 of the first 40 programs on the 2019-2020 US News and World Report ranking and 3 large Canadian programs to be invited to participate in an inpatient focused survey. In October 2020, these 42 child neurologists were invited to complete an anonymous on-line survey including 37 questions about the structure, workload, and challenges of their inpatient program. Data was analyzed descriptively.We received responses from 30/42 (71%) invited child neurologists from unique programs. The majority (25/30, 83%) were Child Neurology Program Directors, Inpatient Directors, and/or Division Chiefs. Two-thirds (20/30, 67%) reported a total of 2-4 inpatient services. Two-thirds (20/30, 67%) reported a primary neurology admitting service. Nearly two-thirds (19/30, 63%) reported a separate ICU service, and about one-third (11/30, 37%) reported a separate stroke/vascular service. Half of respondents (15/30, 50%) reported some attendings whose primary clinical effort is in the inpatient setting. Over half (17/30, 57%) reported having trainees interested in inpatient-focused careers. About half (16/30, 53%) reported a full-time equivalent metric for inpatient time, and under half (13/30, 43%) reported use of critical-care billing. Most respondents (26/30, 87%) endorsed that inpatient attendings frequently complete documentation/sign notes outside of normal daytime hours. During night call, attendings commonly spend 30 minutes-2 hours on patient care-related phone calls between 5pm-10pm (24/30, 80%) and receive 1-3 patient care-related phone calls after 10pm (21/30, 70%). Faculty burnout was the biggest inpatient-specific challenge before the COVID-19 pandemic (25/30, 83%), and concern about faculty well-being during the COVID-19 pandemic was reported in nearly all respondents (28/30, 93%).Academic child neurology programs in North America implement varied models for inpatient care delivery and face common challenges. The information presented in this study serves to stimulate discussion, help optimize operations, and encourage novel approaches to accomplish work and advance careers in academic inpatient child neurology.

Refereed/Peer-reviewed

ObjectiveTo create an international consensus treatment recommendation for pediatric NMDA receptor antibody encephalitis (NMDARE).MethodsAfter selection of a panel of 27 experts with representation from all continents, a 2-step Delphi method was adopted to develop consensus on relevant treatment regimens and statements, along with key definitions in pediatric NMDARE (disease severity, failure to improve, and relapse). Finally, an online face-to-face meeting was held to reach consensus (defined as ≥75% agreement).ResultsCorticosteroids are recommended in all children with NMDARE (pulsed IV preferred), with additional IV immunoglobulin or plasma exchange in severe patients. Prolonged first-line immunotherapy can be offered for up to 3–12 months (oral corticosteroids or monthly IV corticosteroids/immunoglobulin), dependent on disease severity. Second-line treatments are recommended for cases refractory to first-line therapies (rituximab preferred over cyclophosphamide) and should be considered about 2 weeks after first-line initiation. Further immunotherapies for refractory disease 1-3 months after second-line initiation include another second-line treatment (such as cyclophosphamide) and escalation to tocilizumab. Maintenance immune suppression beyond 6 months (such as rituximab redosing or mycophenolate mofetil) is generally not required, except for patients with a more severe course or prolonged impairments and hospitalization. For patients with relapsing disease, second-line and prolonged maintenance therapy should be considered. The treatment of NMDARE following herpes simplex encephalitis should be similar to idiopathic NMDARE. Broad guidance is provided for the total treatment duration (first line, second line, and maintenance), which is dictated by the severity and clinical course (i.e., median 3, 9 and 18 months in the best, average, and worst responders, respectively). Recommendations on the timing of oncologic searches are provided.ConclusionThese international consensus recommendations for the management of pediatric NMDARE aim to standardize the treatment and provide practical guidance for clinicians, rather than absolute rules. A similar recommendation could be applicable to adult patients.

Background US medical schools are increasingly integrating lifestyle medicine competencies into their academic programs. Yet, physician assistant (PA) academic programs have been slower to respond. Methods We developed, implemented, and evaluated a nutrition-centered lifestyle medicine curriculum for 2nd-year PA students (n = 24). The 4-week hybrid, 2-credit hour course activities aligned with the American College of Lifestyle Medicine competencies for primary care providers and reinforced four of the Accreditation Standards for PA Education. We combined didactic lectures with weekly hands-on cooking modules from the “Health meets Food” courseware for medical students. We employed a pre-post evaluation design including a comparison group of 2nd-year PA students in a separate program. We assessed changes in personal nutrition behaviors and knowledge and confidence for counseling in nutrition, exercise/physical activity, weight, smoking, and alcohol, using the modified 5A’s framework (assess, advise, agree, assist, and arrange) for lifestyle counseling. Results Students receiving the intervention demonstrated significantly higher gains in both knowledge and confidence for the 5A’s of nutrition counseling compared to the control group. Self-reported knowledge and confidence for the 5A’s of counseling for the other lifestyle behaviors similarly improved among the intervention group compared to the control group, but to a lesser extent. Conclusion A nutrition-centered lifestyle medicine course can demonstrate PA academic program adherence to accreditation standards, while also introducing students to nutrition and lifestyle medicine competencies. Hands-on experiences that reinforce didactic instruction may maximize student knowledge and self-efficacy for implementing lifestyle medicine into their practice.

BACKGROUND The ability of coronavirus disease 2019 (COVID-19) to cause neurological insults in afflicted adults is becoming increasingly understood by way of an ever-growing amount of international data. By contrast, the pandemic illness’s neurological effects in the pediatric population are both poorly understood and sparsely reported. OBSERVATIONS In this case, the authors reported their experience with a preschool-age child with hydrocephalus who suffered multiterritory strokes presumed secondary to immune-mediated cerebral vasculopathy as a result of asymptomatic COVID-19 infection. LESSONS Growing evidence indicates that COVID-19 can cause neurological sequelae such as encephalitis and strokes. In this case report, the authors discussed a case of cerebral vasculopathy and strokes in a pediatric patient who was positive for COVID-19.

Assessment of biometrics during exercise is evolving to create devices that are "all-inclusive", in an effort to decrease the number of devices required during exercise while providing comprehensive and accurate biometric measures. The purpose of this study was to determine the accuracy of two optical heart rate monitors, the Jabra earbud and the Mio Alpha wristwatch, during aerobic and anaerobic exercise. Twenty-two recreationally active participants (25.4 ± 6.9 years, 171 ± 11 cm, 73.9 ± 3.1 kg, and 25.2 ± 9.2% body fat) completed this study. Participants completed 30 minutes of treadmill activity, 25 minutes of high-intensity interval exercise (HIT), and 40 minutes of continuous outdoor activity of their choice, walking or running. Three heart rate (HR) monitors, (Polar chest strap, Mio Alpha, Jabra earbud) were worn during all exercises, with the Polar chest strap serving as the benchmark. HR was assessed in one-second intervals. Analyses included mean bias, mean absolute percent error (MAPE), and Lin's concordance coefficient. Overall, the Mio Alpha had a MAPE of 5.73 ± 10.19% and a moderate correlation with the benchmark, r(c) = 0.771, performing better in the treadmill and outdoor conditions. The Jabra earbud had a MAPE of 3.14 ± 6.13%, and a high correlation with the benchmark, r(c) = 0.939, performing well in all three conditions. Placing a HR monitor in an earbud is a viable option for obtaining an accurate HR assessment during different types of exercise. The accuracy of the Mio Alpha was likely affected by wrist movements during the HIT training.

Vincristine is one of the core chemotherapy agents used in the treatment of pediatric acute lymphoblastic leukemia (ALL). However, one of the major toxicities resulting from vincristine exposure is vincristine-induced peripheral neuropathy (VIPN). When VIPN results in significant morbidity, the vincristine dose may need to be reduced, thus potentially decreasing the effectiveness of treatment. To date, there are no robust biomarkers used clinically to determine which patients will be at risk for worse neuropathy. The current study included genomewide association study (GWAS) in two independent cohorts: Pediatric Oncology Group (POG) ALL trials and a multicenter study based at Indiana University in children with ALL. A meta-analysis of the cohorts identified two single-nucleotide polymorphisms (SNPs), rs1045644 and rs7963521, as being significantly (P value threshold 0.05/4749 = 1.05E-05) associated with neuropathy. Subsequently these SNPs may be effective biomarkers of VIPN in children with ALL.

OBJECTIVE: We hypothesize that patients with neurocutaneous melanocytosis-associated melanoma and ventriculoperitoneal shunts are at risk of developing intraperitoneal spread of melanoma. BACKGROUND: Neurocutaneous melanocytosis, a rare condition characterized by excessive proliferation and deposition of melanocytes in the leptomeninges and brain parenchyma, typically occurs in children with large congenital melanocytic nevi and multiple smaller congenital nevi. These patients are at heightened risk for developing NRAS+ melanomas in the central nervous system, which in turn may lead to symptomatic hydrocephalus requiring cerebrospinal fluid diversion for symptom relief. METHODS: Retrospective single-institution study of patients with histologically or radiographically confirmed NCM evaluated at Memorial Sloan Kettering Cancer Center (MSKCC) from 2001-2022. RESULTS: Of the 47 patients with a diagnosis of NCM, 44 patients had symptomatic neurological complications. Eleven patients developed hydrocephalus, 10 had CNS melanoma, and required ventriculoperitoneal shunt placement. Nine of the 10 patients ultimately died of their disease. Three patients were diagnosed with intraperitoneal melanoma, though data are unavailable for the remaining eight. CONCLUSIONS: All (n=11) patients with NCM-associated CNS melanoma required VP shunts for symptomatic relief. Ten of these patients died within 4.3 years of VP shunt placement, with a range of 1 month to 13.5 years prior to succumbing to their disease. While the intraperitoneal pathology remains unknown for 7 of the cases, 3 had confirmed intraperitoneal melanoma, suggesting that VP shunts provided the conduit to CNS melanoma seeding of the peritoneum. Obtaining baseline abdominal imaging studies prior to VP shunt placement may be helpful in the follow-up of these patients.

Immersive technologies for education have been investigated for some time; it is only recently that Virtual Reality has been widely adopted within nursing and healthcare professions. In this work in progress, we present the current status of our immersive 360 video Antepartum 360, which is targeted towards undergraduate nursing students. We discuss the creation process of Antepartum 360 including the design of the lesson structure, design of the user experience and interactions, and the filming and editing the 360 video itself. We then present the initial findings from a user study testing the effectiveness of Antepartum 360. Participant results show high levels of engagement with the 360 video, satisfaction with the effectiveness of the video, and confidence in using the application.

Importance: Overall, immunotherapy has been shown to improve outcomes and reduce relapses in individuals with N-methyl-d-aspartate receptor (NMDAR) antibody encephalitis (NMDARE); however, the superiority of specific treatments and combinations remains unclear. Objective: To map the use and safety of immunotherapies in individuals with NMDARE, identify early predictors of poor functional outcome and relapse, evaluate changes in immunotherapy use and disease outcome over the 14 years since first reports of NMDARE, and assess the Anti-NMDAR Encephalitis One-Year Functional Status (NEOS) score. Data Sources: Systematic search in PubMed from inception to January 1, 2019. Study Selection: Published articles including patients with NMDARE with positive NMDAR antibodies and available individual immunotherapy data. Data Extraction and Synthesis: Individual patient data on immunotherapies, clinical characteristics at presentation, disease course, and final functional outcome (modified Rankin Scale [mRS] score) were entered into multivariable logistic regression models. Main Outcomes and Measures: The planned study outcomes were functional outcome at 12 months from disease onset (good, mRS score of 0 to 2; poor, mRS score greater than 2) and monophasic course (absence of relapse at 24 months or later from onset). Results: Data from 1550 patients from 652 articles were evaluated. Of these, 1105 of 1508 (73.3%) were female and 707 of 1526 (46.3%) were 18 years or younger at disease onset. Factors at first event that were significantly associated with good functional outcome included adolescent age and first-line treatment with therapeutic apheresis, corticosteroids plus intravenous immunoglobulin (IVIG), or corticosteroids plus IVIG plus therapeutic apheresis. Factors significantly associated with poor functional outcome were age younger than 2 years or age of 65 years or older at onset, intensive care unit admission, extreme delta brush pattern on electroencephalography, lack of immunotherapy within the first 30 days of onset, and maintenance IVIG use for 6 months or more. Factors significantly associated with nonrelapsing disease were rituximab use or maintenance IVIG use for 6 months or more. Adolescent age at onset was significantly associated with relapsing disease. Rituximab use increased from 13.5% (52 of 384; 2007 to 2013) to 28.3% (311 of 1100; 2013 to 2019) (P