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Accurate cardiac left ventricle (LV) delineation is essential to CT-derived left ventricular ejection fraction (LVEF). To evaluate dose-reduction potential, an anatomically accurate heart phantom, with realistic X-ray attenuation is required. We demonstrated and tested a custom-made phantom using 3D-printing, and examined the influence of image noise on automatically measured LV volumes METHODS: A single coronary CT angiography (CCTA) dataset was segmented and converted to Standard Tessellation Language (STL) mesh, using open-source software. A 3D-printed model, with hollow left heart chambers, was printed and cavities filled with gelatinized contrast media. This was CT-scanned in an anthropomorphic chest phantom, at different exposure conditions. LV and "myocardium" noise and attenuation was measured. LV volume was automatically measured using two different methods. We calculated Spearmans' correlation of LV volume with noise and contrast-noise ratio respectively om 486 scans of the phantom. Source images were compared to one phantom series with similar parameters. This was done using Dice coefficient on LV short-axis segmentations.Phantom "Myocardium" and LV attenuation was comparable to measurements on source images. Automatic volume measurement succeeded, with mean volume deviation to patient images less than 2 ml. There was a moderate correlation of volume with CNR, and strong correlation of volume with image noise. With papillary muscles included in LV volume, the correlation was positive, but negative when excluded. Variation of volumes was lowest at 90-100 kVp for both methods in the 486 repeat scans. The Dice coefficient was 0.87, indicating high overlap between the single phantom series and source scan. Cost of 3D-printer and materials was 400 and 30 Euro respectively.Both anatomically and radiologically the phantom mimicked the source scans closely. LV volumetry was reliably performed with automatic algorithms.Patient-specific cardiac phantoms may be produced at minimal cost and can potentially be used for other anatomies and pathologies. This enables radiographic phantom studies without need for dedicated 3D-labs or expensive commercial phantoms.

Firearm sales in the United States (U.S.) markedly increased during the COVID-19 pandemic. Our objective was to determine if firearm injuries in children were associated with stay-at-home orders (SHO) during the COVID-19 pandemic. We hypothesized there would be an increase in pediatric firearm injuries during SHO.This was a multi institutional, retrospective study of institutional trauma registries. Patients18 years with traumatic injuries meeting National Trauma Data Bank (NTDB) criteria were included. A "COVID" cohort, defined as time from initiation of state SHO through September 30, 2020 was compared to "Historical" controls from an averaged period of corresponding dates in 2016-2019. An interrupted time series analysis (ITSA) was utilized to evaluate the association of the U.S. declaration of a national state of emergency with pediatric firearm injuries.Nine Level I pediatric trauma centers were included, contributing 48,111 pediatric trauma patients, of which 1,090 patients (2.3%) suffered firearm injuries. There was a significant increase in the proportion of firearm injuries in the COVID cohort (COVID 3.04% vs. Historical 1.83%; p 0.001). There was an increased cumulative burden of firearm injuries in 2020 compared to a historical average. ITSA showed an 87% increase in the observed rate of firearm injuries above expected after the declaration of a nationwide emergency (p 0.001).The proportion of firearm injuries affecting children increased during the COVID-19 pandemic. The pandemic was associated with an increase in pediatric firearm injuries above expected rates based on historical patterns.

Summary Background and aims Many critically ill patients experience increased blood glucose variability (BGV). The objective of the current pilot study was to assess the relationship between muscle composition (defined as average Hounsfield units (HU)) among ICU patients with an abdominal CT scan within seven days of intubation, and BGV (defined as coefficient of variation (CV)) calculated from blood glucose levels measured each morning while intubated. Methods The first serum blood glucose measurement obtained each day during intubation was recorded, blood glucose CV ((mean/SD)∗100) was calculated. Cross-sectional muscle area (CSA; cm2) at the third lumbar region was identified using the −29 to +150 HU range; muscle composition was calculated as the average HU. BGV predictors were determined using linear regression. Results Eighty-two patients were included (53% female), with a median age of 64 (25th, 75 percentile (IQR): 51, 70) years. The median CV was 29% (IQR: 20, 37); 40% of subjects required insulin. The median CSA was 100.4 cm2 (IQR: 84.0, 120.8) and muscle composition was 20.4 HU (IQR: 12.2, 29.4). Patients received only 36% of estimated calorie requirements. Insulin administration, history of diabetes, and muscle composition were significant BGV predictors. Conclusion Among these adult intubated ICU patients, higher muscle composition was associated with lower BGV. Future research is needed to corroborate these findings, determine other factors associated with poor muscle quality, and identify methods to describe muscle composition for all ICU patients.

The impact of the COVID-19 pandemic on pediatric injury, particularly relative to a community's vulnerability, is unknown. The objective of this study was to describe the change in pediatric injury during the first 6 months of the COVID-19 pandemic compared with prior years, focusing on intentional injury relative to the social vulnerability index (SVI).All patients younger than 18 years meeting inclusion criteria for the National Trauma Data Bank between January 1, 2016, and September 30, 2020, at nine Level I pediatric trauma centers were included. The COVID cohort (children injured in the first 6 months of the pandemic) was compared with an averaged historical cohort (corresponding dates, 2016-2019). Demographic and injury characteristics and hospital-based outcomes were compared. Multivariable logistic regression was used to estimate the adjusted odds of intentional injury associated with SVI, moderated by exposure to the pandemic. Interrupted time series analysis with autoregressive integrated moving average modeling was used to predict expected injury patterns. Volume trends and observed versus expected rates of injury were analyzed.There were 47,385 patients that met inclusion criteria, with 8,991 treated in 2020 and 38,394 treated in 2016 to 2019. The COVID cohort included 7,068 patients and the averaged historical cohort included 5,891 patients (SD, 472), indicating a 20% increase in pediatric injury ( p = 0.031). Penetrating injuries increased (722 [10.2%] COVID vs. 421 [8.0%] historical; p0.001), specifically firearm injuries (163 [2.3%] COVID vs. 105 [1.8%] historical; p = 0.043). Bicycle collisions (505 [26.3%] COVID vs. 261 [18.2%] historical; p0.001) and collisions on other land transportation (e.g., all-terrain vehicles) (525 [27.3%] COVID vs. 280 [19.5%] historical; p0.001) also increased. Overall, SVI was associated with intentional injury (odds ratio, 7.9; 95% confidence interval, 6.5-9.8), a relationship which increased during the pandemic.Pediatric injury increased during the pandemic across multiple sites and states. The relationship between increased vulnerability and intentional injury increased during the pandemic.Prognostic and Epidemiological; Level III.

Effect size, α level, power, and sample size are misunderstood concepts that play a major role in the design and interpretation of studies. Effect size represents the magnitude of a change in an outcome or the strength of a relationship. Often, the effect size may be more important than just relying on the α level when interpreting results from a study because it informs a researcher of the actual magnitude of the difference or relationship. Confidence intervals can also assist in making this assessment. Power represents the probability of rejecting the null hypothesis when it is false. Effect size, power, and α level are all important in the calculation of sample size needed to conduct a study. Calculating the sample size a priori and including the required number of participants is essential. Studies with small sample sizes, relative to the needed number provided from a power analysis, may lead to false negative results. Studies with grossly large sample sizes may yield statistically significant findings with small effect sizes that may not be clinically relevant. It is beneficial when all four components are clearly presented in analytic studies. Failure to include these elements may limit the ability of other researchers to replicate the study's findings and lead to difficulty when interpreting the study's results.

With the expected surge of adult patients with COVID-19, the Children's Hospital Association recommended a tiered approach to divert children to pediatric centers. Our objective was understanding changes in interfacility transfer to Pediatric Trauma Centers (PTCs) during the first 6 mo of the pandemic.Children aged18 y injured between January 1, 2016 and September 30, 2020, who met National Trauma Databank inclusion criteria from 9 PTCs were included. An interrupted time-series analysis was used to estimate an expected number of transferred patients compared to observed volume. The "COVID" cohort was compared to a historical cohort (historical average [HA]), using an average across 2016-2019. Site-based differences in transfer volume, demographics, injury characteristics, and hospital-based outcomes were compared between cohorts.Twenty seven thousand thirty one/47,382 injured patients (57.05%) were transferred to a participating PTC during the study period. Of the COVID cohort, 65.4% (4620/7067) were transferred, compared to 55.7% (3281/5888) of the HA (P 0.001). There was a decrease in 15-y-old to 17-y-old patients (10.43% COVID versus 12.64% HA, P = 0.003). More patients in the COVID cohort had injury severity scores ≤ 15 (93.25% COVID versus 87.63% HA, P 0.001). More patients were discharged home after transfer (31.80% COVID versus 21.83% HA, P 0.001).Transferred trauma patients to Level I PTC increased during the COVID-19 pandemic. The proportion of transferred patients discharged from emergency departments increased. Pediatric trauma transfers may be a surrogate for referring emergency department capacity and resources and a measure of pediatric trauma triage capability.

During the COVID-19 pandemic, children were out of school due to Stay-at-Home Orders. The objective of this study was to investigate how the COVID-19 pandemic may have impacted the incidence of burn injuries in children. Eight Level I Pediatric Trauma Centers participated in a retrospective study evaluating children

It is unclear how Stay-at-Home Orders (SHO) of the COVID-19 pandemic impacted the welfare of children and rates of non-accidental trauma (NAT). We hypothesized that NAT would initially decrease during the SHO as children did not have access to mandatory reporters, and then increase as physicians' offices and schools reopened.A multicenter study evaluating patients18 years with ICD-10 Diagnosis and/or External Cause of Injury codes meeting criteria for NAT. "Historical" controls from an averaged period of March-September 2016-2019 were compared to patients injured March-September 2020, after the implementation of SHO ("COVID" cohort). An interrupted time series analysis was utilized to evaluate the effects of SHO implementation.Nine Level I pediatric trauma centers contributed 2064 patients meeting NAT criteria. During initial SHO, NAT rates dropped below what was expected based on historical trends; however, thereafter the rate increased above the expected. The COVID cohort experienced a significant increase in the proportion of NAT patients age ≥5 years, minority children, and least resourced as determined by social vulnerability index (SVI).The COVID-19 pandemic affected the presentation of children with NAT to the hospital. In times of public health crisis, maintaining systems of protection for children remain essential.III.

Purpose Chest tube (CT) management for pediatric primary spontaneous pneumothorax (PSP) is associated with long hospital stays and high recurrence rates. To streamline management, we explored simple aspiration as a test to predict need for surgery. Methods A multi-institution, prospective pilot study of patients with first presentation for PSP at 9 children’s hospitals was performed. Aspiration was performed through a pigtail catheter, followed by 6 h observation with CT clamped. If pneumothorax recurred during observation, the aspiration test failed and subsequent management was per surgeon discretion. Results Thirty-three patients were managed with simple aspiration. Aspiration was successful in 16 of 33 (48%), while 17 (52%) failed the aspiration test and required hospitalization. Twelve who failed aspiration underwent CT management, of which 10 (83%) failed CT management owing to either persistent air leak requiring VATS or subsequent PSP recurrence. Recurrence rate was significantly greater in the group that failed aspiration compared to the group that passed aspiration [10/12 (83%) vs 7/16 (44%), respectively, P = 0.028]. Conclusion Simple aspiration test upon presentation with PSP predicts chest tube failure with 83% positive predictive value. We recommend changing the PSP management algorithm to include an initial simple aspiration test, and if that fails, proceed directly to VATS. Type of study Prospective pilot study Level of evidence Level III.

Background The Health and Social Care Professionals budget was augmented to develop rehabilitation services that facilitated hospital discharges. Early Supported discharge (ESD) for stroke is a proven model of best care for stroke patients with mild to moderate disability (Langhorne et al., 2005). A pilot was implemented with the team consisting of an Occupational Therapist, Speech and Language Therapist, Physiotherapist and Medical Social Worker. Methods The service facilitated an early discharge from the hospital with the delivery of specialist stroke rehabilitation in the home. Therapy is provided with the same intensity and expertise that would be received in hospital and is available for up to 8 weeks, it was provided using a blended model of domiciliary care and the introduction of telehealth in response to COVID 19. Data was recorded for 100 service users using an excel spreadsheet. Data was recorded to measure number of new referrals, length of stay, bed days released back into the hospital system, mode of service delivery and functional outcomes. A cost analysis was completed. Service user experience was captured using questionnaires. Results From September 2020 to July 2021, 100 patients accessed ESD with a reduction of 7.2 days in hospital stay per patient. Improvements in pre- and post- rehabilitation scores on the FIM/FAM were evident. Very positive feedback regarding the rehabilitation experience was captured within the patient satisfaction questionnaire. Therapy delivery was 60% face to face, 37% via telehealth and 3% outpatient appointments. Telehealth received good compliance but with varying reports of experience in comparison to face to face. Conclusion ESD provided in the home environment facilitated earlier discharge from hospital with positive outcomes for the hospital and service users. Telehealth ensured that rehabilitation was maintained throughout the pandemic. Telehealth increased access for patients residing outside of the catchment area. However service user preference remains face to face.

This study investigated the effects of cone-beam computed tomography (CBCT) guidance in trans-arterial chemoembolisation (TACE) procedures on the number of digital subtraction angiography (DSA) runs acquired and total patient radiation exposure in patients with hepatocellular carcinoma (HCC). A retrospective, analytical cross-sectional, single institution, study was conducted. Dose data were compared across the control (DSA guidance alone) and study (DSA and CBCT guidance) groups. A total of 122 procedures were included within the study. There was a significant reduction in the number of DSA runs (3 vs 5, p

Cholesterol stones and biliary dyskinesia have replaced hemolytic disease as the primary indication for pediatric cholecystectomy. This study looks at the cohort of pediatric patients with complicated biliary disease, defined as choledocholithiasis and/or gallstone pancreatitis, to determine the incidence and best treatment options.A retrospective review of all cholecystectomies performed over 15 years admitted to the surgical service at a single free-standing children's hospital was performed. Patient factors, indications for cholecystectomy, and final treatment were recorded. Complicated gallbladder disease was defined as having image-confirmed choledocholithiasis or gallstone pancreatitis. High-risk patients were those with imaging that demonstrated definitive choledocholithiasis or cholelithiasis with common bile duct enlargement. Low risk patients were those with cholelithiasis or gallbladder sludge on imaging combined with an elevated bilirubin and/or lipase.A total of 695 cholecystectomies were performed over the 15-year time period. Average patient age was 13.4 years. Of the 695 cholecystectomies, 457 were performed for stone disease (66%) (64 hemolytic) and 236 (34.0%) were performed for biliary dyskinesia. Hundred and three (14.8% of all cholecystectomies, 22.5% of those with stone disease) presented with choledocholithiasis and/or gallstone pancreatitis (complicated disease). In high-risk patients, 28/47 (59.6%) underwent endoscopic retrograde cholangiopancreatography/sphincterotomy. In low-risk patients (no choledocholithiasis or common duct enlargement), 13/56 (23.2%) required endoscopic retrograde cholangiopancreatography/sphincterotomy (P.05). The indication for endoscopic retrograde cholangiopancreatography after cholecystectomy was choledocholithiasis and none of these patients had bile leak complications.The incidence of pediatric complicated biliary disease due to cholesterol stones is equal to that of adults. These data suggest that a patient with imaging evidence of choledocholithiasis or common bile duct enlargement may require endoscopic retrograde cholangiopancreatography, dependent on clinical course, and this should be strongly considered before cholecystectomy. Those without such radiographic findings can undergo laparoscopic cholecystectomy and have postoperative endoscopic retrograde cholangiopancreatography if needed.

Funding Acknowledgements Type of funding sources: None. Introduction The link between obstructive sleep apnoea (OSA) and cardiovascular disease is well known. Prevalence can be very high in this population, sharing many pathophysiological drivers in addition to being a risk factor. More concerning however is the increasing number of patients with undiagnosed OSA, who are at higher risk of long-term complications such as coronary artery disease, hypertension, atrial fibrillation, heart failure or stroke. There are several OSA screening tools available to clinicians, with variable sensitivities and specificities depending on patient demographics. Predictive efficacy of the STOP-Bang screening tool in a general cardiology population with mixed cardiovascular disease has not been established. Proposal To identify the correlation between the STOP-Bang assessment score (1-8) and real-world Apnoea-Hypopnoea Index (AHI) in a general cardiology clinic population. Methods 250 successive patients in a general cardiology clinic were asked to complete a STOP-Bang assessment. Of those, 50 patients with a variety of STOP-Bang scores were randomly selected to undergo sleep studies. A STOP-Bang value of ≥ 5 was taken as high-risk for moderate-severe OSA. Statistical linear regression analysis was performed in IBM SPSS version 26. Results Of n = 50 patients, mean STOP-Bang score =3.7 (SD +/-2.17) with mean AHI =15.8, (SD +/- 14.3). See Table 1 for categories 1-8. N = 44 (88%) had AHI ≥ 5 (At least mild OSA). N = 18 (36%) had an AHI ≥ 15 (Moderate-severe OSA). N = 29 (58%) had symptoms such as sleepiness, loud snoring or witnessed apnoea. Correlation between STOP-Bang score and AHI was high, with an R value of 0.704, R2 = 0.496 (p Conclusion We discovered a very high number of patients with undiagnosed OSA of at least mild severity. We found a strong correlation between STOP-Bang score and real-world AHI in a general cardiology population with mixed cardiovascular disease with 5 as an acceptable screening score for moderate-severe OSA. Table 1 STOP-Bang Value 1 2 3 4 5 6 7 8 Patients (N=) 12 5 7 9 5 5 5 2 AHI (Mean) 6.67 6.62 9.97 11.95 24.44 22.20 39.54 35.25 Standard Deviation (±) 3.29 2.74 3.45 4.63 12.87 5.69 27.2 6.72 Summary of mean apnoea-hypopnoea index and standard deviation for each STOP-Bang patient category. Abstract Figure 1

If “Big Gods” evolved in part because of their ability to morally regulate groups of people who cannot count on kin or reciprocal altruism to get along (Norenzayan, 2013), then powerful gods would tend to be good gods. If the mechanism for this cooperation is some kind of fear of supernatural punishment (Johnson & Bering, 2006), then we may expect that mighty gods tend to be punishing gods. The present study is a statistical analysis of superhuman being concepts from 20 countries on five continents to explore whether the goodness of a god is related to its mightiness. Gods that looked more like the God of classical theism and gods that were low in anthropomorphism were more likely to be regarded as morally good and to be the target of religious practices. Mighty gods were not, however, especially likely to punish or to be a “high god.”

Concurrency and synchronization are new concepts for most undergraduate students. Writing multi-threaded programs presents new challenges in the form of brand new problems like race conditions, starvation, and deadlock. Classic synchronization problems are often used to teach these concepts with concrete sets of actors and goals. In this demo, we present a web application that allows students to execute multiple solutions with varying parameters to four common synchronization problems: Dining Philosophers, Bounded Buffer (Producer-Consumer), Readers Writers, and Unisex Bathroom as presented in the Little Book of Semaphores by Allen B. Downey (greenteapress.com/wp/semaphores/). The demo will show how students can manipulate options for: the number of threads; time to do work; time between work periods; as well as how the state of the system can be observed through visual animations. These animations can be used to observe deadlock, and overall statistics highlight starvation. The interactive nature of the tool allows students to explore the tradeoffs between different solutions, and how the parameters of a problem impact performance, resource utilization, and likelihood of deadlock.

Introduction/Objectives Public Health England 2019 report showed that extra-pulmonary tuberculosis represents over half (59.3%) of all diagnosed cases of TB in the UK. Foreign-born population had almost twice as many cases of extra-pulmonary disease (48.5%) compared with those born in the UK (27.8%). Aiming to improve early diagnosis in east London’s large migrant population, we compare baseline demographics and clinical features between UK-born and foreign-born EPTB cases. Methods We conducted a retrospective analysis of all TB cases at a large institution in East London between 2016 and 2019. Cases of EPTB were identified and comparison made between UK-born and foreign-born populations. Statistical analyses were performed using R version 4.0.2. Results 1263 patients were identified from the London TB registry as having been treated for TB between 2016 and 2019. In total we identified 850 patients (67.3%) with extra-pulmonary TB involvement. 78.2% (665/850) had extra-pulmonary disease only while 21.8% (185/850) had both pulmonary TB and extra-pulmonary disease. 69% of people (702/1018) with TB born outside the UK had extra-pulmonary involvement. UK born TB cases also recorded a significant proportion of extra-pulmonary disease at 60.9% (143/235). Foreign-born EPTB cases were significantly older than UK-born with a mean age of 41.8 and 33.2 respectively (p Central nervous system (CNS) TB was more common in UK-born populations at 15.4% compared to 8.7% in foreign-born (p=0.02). Pleural TB was also more common in UK-born at 20.3% compared to 14.7% in foreign-born (p=0.100). Foreign-born populations recorded a higher extra-thoracic lymph nodes involvement at 34% compared to UK-born at 27.3% (p=0.120). Conclusion Our data reports way more EPTB cases among the UK-born and foreign-born populations in East London (60.9% and 69% respectively) than the national average. In both population groups, EPTB predominantly affected people of South Asian ethnicity. Foreign-born EPTB cases tend to be older and have been resident in the UK for longer.