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Alternate electrocardiogram acquisition with fewer leads lacks systematic evaluation in children. This study aims to determine if electrocardiograms with fewer leads maintain diagnostic accuracy in paediatrics.
Methods:
This is a single-centre review of 200 randomly selected standard 12-lead electrocardiograms from our hospital database (2017–2020) for patients aged 2 weeks to 21 years. An overlay technique generated 8-lead (limb + V1/V6) and 6-lead (limb only) variations of the 12-lead tracings, resulting in a total of 600 electrocardiograms, which were then interpreted by two independent paediatric electrophysiologists.
Results:
In total, 18% (35/200) of the baseline electrocardiograms were abnormal. Intervals were measured in lead II for all electrocardiograms. Comparing 12-lead to 6- and 8-lead electrocardiograms, there was almost perfect agreement for specific rhythm identification (97.5–100%, κ 0.85-1). The 8-lead showed substantial agreement with 12-lead electrocardiograms when identifying specific electrocardiogram patterns (97.5–100%, κ 0.66–1). A similar degree of agreement was not demonstrated with the 6-lead variant. Utilising the 12-lead electrocardiogram as the gold standard, sensitivity and specificity of the 8- and 6-lead electrocardiogram were > 89% for specific rhythm identification. Specificity for specific pattern recognition was > 99% while sensitivity was < 90% for certain variables for both 6- and 8-lead electrocardiogram, likely due to smaller sample size and fewer abnormal electrocardiograms. There was high percent reader agreement (92.5–100%).
Conclusions:
8-lead electrocardiograms provide comparable diagnostic accuracy to 12-lead electrocardiograms for children. This information holds potential for future technological advancements in electrocardiogram acquisition tailored specifically for paediatrics. Additional studies are required to further refine conventional electrocardiogram acquisition.
Pediatric-onset multiple sclerosis (POMS) accounts for approximately 2 to 5% of all individuals with MS and is associated with an increased risk for cognitive impairment. In recent years, neuropsychological screening questionnaires have been increasingly utilized for pediatric populations in multidisciplinary settings. This study examines the clinical utility of the Colorado Learning Difficulties Questionnaire (CLDQ) and Pediatric Perceived Cognitive Functioning (Peds PCF) screening measures for identifying cognitive impairment in persons with POMS during a target neuropsychological evaluation.
Method:
Retrospective data was gathered from electronic medical records at a single pediatric hospital.
Results:
Forty-nine participants were included (69% female; 43% Hispanic/Latinx; mean age = 16.1 years old, range = 9.9 to 20.6 years old). Correlation analyses demonstrated strong interrelatedness between caregiver ratings on screening measures and performance on traditional neuropsychological measures. Effect sizes were medium across comparisons (CLDQ: Spearman’s rho = −.321 to −.563; PedsPCF: Spearman’s rho = .308 to .444). Exploratory cut-points using receiver operating characteristic analysis and Youden indices are also discussed.
Conclusions:
Comparison of scores across caregiver rating questionnaires and on a targeted neuropsychological battery suggests that the screening surveys alone may not be sensitive enough to identify children with cognitive impairments, but ratings may provide qualitatively meaningful information along with neuropsychological testing. This study illustrates how pediatric neuropsychologists can leverage screening tools to focus consultative interviews and effectively triage referrals for evaluation within an academic medical setting.
Contemporary armed conflicts have increasingly been accompanied by belligerents’ calls for civilians to support their military efforts. This article investigates the legal consequences of civilians taking up arms provided by or with the tacit support of the State. It first looks at the implications of civilian involvement from the perspective of a State's international humanitarian law (IHL) and international human rights law obligations, focusing on removing civilians from the vicinity of hostilities, informing and training civilians on the implications of directly participating in hostilities, and respecting and ensuring respect for the law. It then demonstrates that the broader fabric of public international law is tested when civilians are encouraged to engage in hostilities, through a close analysis of the challenge of attributing civilian acts to the State. The article closes with practical recommendations for States to ensure that they uphold their humanitarian and human rights obligations, and to render the law of international responsibility effective when civilians commit systemic violations of IHL.
This work aimed to demonstrate that a website, www.epidemic-em.org, encompassing “static” resources, and videos, as well as other tools, can be used to strengthen public health emergency management capacity during epidemic response.
Methods:
Existing resources were updated and developed for self-directed Emergency Operations Centers’ capacity strengthening, in order to encompass current best practices, and to emphasize how public health emergency management concepts can support epidemic response activities. These materials formed the core of the website, launched in June 2020, to which country case studies were added. In 2021, a pilot virtual training program was designed using recorded video lectures and interviews with global experts in addition to the website material, which was delivered to South African responders.
Results:
The website has been accessed in more than 135 countries, demonstrating widespread reach and interest in online and freely accessible materials to support public health emergency operations. Over 30 people participated in the pilot virtual training, and the evaluation showed improvement in knowledge, confidence in using emergency management concepts for epidemic response, and positive feedback on the virtual modality.
Conclusions:
Online tools can expand access to materials and resources for public health emergency management capacity strengthening. Virtual modalities can further serve as a powerful complement, and perhaps replacement, for traditional in-person technical assistance, despite some limitations.
Parental history (PH) of problematic substance use has been identified as a risk factor for adolescent substance use, which can lead to increased use in adulthood. Researchers hypothesize that individuals with PH exhibit premorbid differences in their reward processing, increasing their likelihood of engaging in reward-driven behavior. Studies have shown that preadolescents with PH have greater activation in their putamen and nucleus accumbens (NA); however, most research has only investigated PH of alcohol use (PHA), not PH of drug use (PHD). Additionally, limited research has assessed whether reward processing develops differently among youth with (PH+) to youth without (PH-). The present study utilizes the national, prospective Adolescent Brain Cognitive Development SM (ABCD) Study to examine whether reward anticipation in the nucleus accumbens (NA) differs in preadolescents with and without parental substance use history and whether patterns of reward anticipation change over time during a two-year follow-up period. Further, it will also examine whether PHA and PHD predict similar activation patterns.
Participants and Methods:
The current sample (N=6,600, Mage = 10.9; range = 9-13.8 years old; 46.7% female) was drawn from the national ABCD Study. To assess reward processing, the Monetary Incentive Delay Task (MID), a fMRI task-based paradigm, was administered at baseline and 2 year follow-up. The primary regions of interest (ROI) were the left and right NA and neutral vs anticipation of large rewards was the selected contrast. The Family History Assessment was used to assess problematic parental alcohol and drug use for both parents, with scores ranging from 0-2, with two indicating that both parents demonstrate problematic use. Three PH contrasts (PH- vs.PH+1, PH-vs.PH+2, & PH+1 vs. PH+2) were created for each group (PHA and PHD) (Martz et al., 2022). Separate linear mixed-effect models with predictors variables (parental contrasts, timepoint, and parental contrasts-by-time-point) and covariates (age, sex, race/ethnicity, income, parental education, parental warmth, parental monitoring, and the random effects of MRI model, family status, and subject) were run to predict reward anticipation.
Results:
Results indicated that PHA and,not PHD, was predictive of reward anticipation. PHA+1 youth showed greater activation in the l-NA (b= .02827, p= .03) and r-NA (b= .03476, p=.005), compared to PH- youth. Additionally, PHA+1 youth showed greater activation in the r-NA (b=-.07029, p=.008) compared to PHA+2 youth, but not in the l-NA. Those with PHA+2 demonstrated blunted activity in both the l-NA (b= -.07244, p=.02) and right nucleus accumbens (b= -.1091, p=001) when compared to those with PH-. No interactions with time were found.
Conclusions:
Preadolescents with a PHA+ for both parents had blunted activity in reward anticipation, conferring a unique risk not seen in youth with only one parent with problematic alcohol use, or in youth with a PH of drug use. Future research should attempt to disentangle both genetic and environmental factors that may explain these discrepancies in reward processing, as well as the protective factors that may mitigate it. The current study found no interaction between PHA+ and time, suggesting that during preadolescents, the pattern of reward functioning remains consistent, but future work should assess if this pattern holds up across adolescence
Background: Previously, our hospital manually built a static antibiogram from a surveillance system (VigiLanz) culture report. In 2019, a collaboration between the antimicrobial stewardship team (AST) and the infection control (IC) team set out to leverage data automation to create a dynamic antibiogram. The goal for the antibiogram was the ability to easily distribute and update for hospital staff, with the added ability to perform advanced tracking and surveillance of organism and drug susceptibilities for AST and IC. By having a readily available, accurate, and Clinical and Laboratory Standards Institute (CLSI)–compliant antibiogram, clinicians have the best available data on which to base their empiric antibiotic decisions. Methods: First, assessment of required access to hospital databases and selection of a visualization software (MS Power BI) was performed. Connecting SQL database feeds to Power BI enabled creation of a data model using DAX and M code to comply with the CLSI, generating the first isolate per patient per year. Once a visual antibiogram was created, it was validated against compiled antibiograms using data from the microbiology laboratory middleware (bioMerieux, Observa Integrated Data Management Software). This validation process uncovered some discrepancies between the 2 reference reports due to cascade reporting of susceptibilities. The Observa-derived data were used as the source of truth. The antibiogram prototype was presented to AST/IC members, microbiology laboratory leadership, and other stakeholders to assess functionality. Results: Following feedback and revisions by stakeholders, the new antibiogram was published on a hospital-wide digital platform (Fig. 1). Clinicians may view the antibiogram at any time on desktops from a firewall (or password)–protected intranet. The antibiogram view defaults to the current calendar year and users may interact with the antibiogram rows and columns without disrupting the integrity of the background databases or codes. Each year, simple refreshing of the Power BI antibiogram and changing of the calendar year allows us to easily and accurately update the antibiogram on the hospital-wide digital platform. Conclusions: This interdisciplinary collaboration resulted in a new dynamic, CLSI-compliant antibiogram with improved usability, increased visibility, and straightforward updating. In the future, a mobile version of the antibiogram may further enhance accessibility, bring more useful information to providers, and optimize AST/IC guidelines and education.
Medical Emergencies in A Mental Health Setting (MEAMS) was a proposed high-fidelity simulation training course specifically designed for the mental health multidisciplinary team (MDT). A team of resus officers, mental health nurses and psychiatric doctors worked to create scenarios reflecting the emergencies encountered in mental health. It aimed to gives staff simulated experience in approaching and managing a verity of complex emergencies, including physical health, as well as communication scenarios. Specifically the aims were: (1) Determine if course was perceived to benefit staff, (2) Determine if course subjectively increased staff knowledge and confidence in mental health emergencies, (3) Review for continued areas of improvement
Methods
The full day sessions were carried out in the Electroconvulsive therapy (ECT) suite, with it being modified into an immersive environment similar to wards or clinics. The faculty of medical resus officers, mental health nurses and psychiatric consultants ran the courses, with participants joining from across the MDT including nursing staff, junior doctors, consultants, students and nursing assistants.
The morning program, run by resus officers, provided education in life support, initial assessment of the unwell patient and intraosseous access. The afternoon contained various scenarios, including for example managing neuroleptic malignant syndrome. Scenarios were observed via video link by faculty, with constructive feedback and debriefs provided.
Quantitative data of knowledge and confidence was obtained pre and post sessions using Likert scales. Qualitative information regarding future proposed scenarios, areas of improvement and areas of notable value was gathered.
Results
36 staff attended the program, run over 4 days. Average knowledge and confidence (scored out of 10) improved from 4.9 pre-session to 8.1 post-session. All 36 staff felt the session was beneficial. Particular positive feedback on scenario realism, MDT working, safe/ supportive teaching and the resus faculty teaching was highlighted.
Areas for improvement highlighted included running sessions more often, widening accessibility to more staff and teaching on resus medications and fluids. A variety of further scenarios were suggested, for example management of withdrawal seizure.
Conclusion
MEAMS was felt to achieve its aims, and demonstrated clear subjective increase in staff knowledge and confidence regarding common emergencies seen in mental health settings. Further sessions and wider accessibility to the mental health MDT is anticipated to continually benefit staff. Taking on qualitative feedback, the faculty aims to continually adapt the program to provide the best possible training and education, adapting and creating new relevant scenarios.
Studies that measure environmental exposures in biological samples frequently provide participants their results. In contrast, studies using personal air monitors do not typically provide participants their monitoring results. The objective of this study was to engage adolescents who completed personal air sampling and their caregivers to develop understandable and actionable report-back documents containing the results of their personal air sampling.
Methods:
Adolescents and their caregivers who previously completed personal air sampling participated in focus groups to guide the development of report-back materials. We conducted thematic analyses of focus group data to guide the design of the report-back document and convened experts in community engagement, reporting study results, and human subjects research to provide feedback. Final revisions to the report-back document were made based on follow-up focus group feedback.
Results:
Focus groups identified critical components of an air-monitoring report-back document to include an overview of the pollutant being measured, a comparison of individual personal sampling data to the overall study population, a guide to interpreting results, visualization of individual data, and additional information on pollution sources, health risks, and exposure reduction strategies. Participants also indicated their desire to receive study results in an electronic and interactive format. The final report-back document was electronic and included background information, participants’ results presented using interactive maps and figures, and additional material regarding pollution sources.
Conclusion:
Studies using personal air monitoring technology should provide research participants their results in an understandable and meaningful way to empower participants with increased knowledge to guide exposure reduction strategies.
Although exposure therapy (ET) is an effective treatment for anxiety disorders and obsessive-compulsive disorder, many clinicians report not utilizing it. The present study targeted common utilization barriers by evaluating an intensive ET training experience in a relatively inexperienced sample of pre-professionals. Thirty-two individuals at the undergraduate or college graduate level without formal clinical experience participated as camp counsellors in a 5day exposure-based therapeutic summer camp for youth with anxiety disorders and/or obsessive-compulsive disorder. Participants were trained in ET through a progressive cascading model and answered questionnaires before and after camp. Repeated measure MANOVA revealed significantly increased feelings of self-efficacy conducting exposures, and significantly decreased feelings of disgust sensitivity and contamination-related disgust from pre-camp to post-camp. A subset of individuals providing data 1 month after the camp maintained a significant gain in ET self-efficacy. Regression analyses revealed that contamination-related disgust, but not disgust sensitivity, significantly predicted post-camp ET self-efficacy. These findings suggest that individuals early into their post-secondary education can learn ET, and the progressive cascading model holds promise in its utility across experience levels and warrants further investigation. Disgust may also play a role in feelings of competency conducting ET. Implications on dissemination and implementation efforts are also discussed.
Key learning aims
(1) How can training of CBT techniques such as exposure occur prior to graduate education?
(2) Can self-efficacy in conducting exposures meaningfully increase in an experiential training of pre-professionals?
(3) How does an individual’s tolerance of disgust impact feelings of competence conducting exposures?
Early administration of antibiotics in sepsis is associated with improved patient outcomes, but safe and generalizable approaches to de-escalate or discontinue antibiotics after suspected sepsis events are unknown.
Methods:
We used a modified Delphi approach to identify safety criteria for an opt-out protocol to guide de-escalation or discontinuation of antibiotic therapy after 72 hours in non-ICU patients with suspected sepsis. An expert panel with expertise in antimicrobial stewardship and hospital epidemiology rated 48 unique criteria across 3 electronic survey rating tools. Criteria were rated primarily based on their impact on patient safety and feasibility for extraction from electronic health record review. The 48 unique criteria were rated by anonymous electronic survey tools, and the results were fed back to the expert panel participants. Consensus was achieved to either retain or remove each criterion.
Results:
After 3 rounds, 22 unique criteria remained as part of the opt-out safety checklist. These criteria included high-risk comorbidities, signs of severe illness, lack of cultures during sepsis work-up or antibiotic use prior to blood cultures, or ongoing signs and symptoms of infection.
Conclusions:
The modified Delphi approach is a useful method to achieve expert-level consensus in the absence of evidence suifficient to provide validated guidance. The Delphi approach allowed for flexibility in development of an opt-out trial protocol for sepsis antibiotic de-escalation. The utility of this protocol should be evaluated in a randomized controlled trial.
“Bring your whole self to work” remains a common mantra of supporters of workplace diversity, equity, and inclusion (“DEI”).1 For example, disability rights advocates have long contended that hiding or downplaying one’s disability from one’s colleagues at work “create[s] an invisible layer of additional work for the individual” in being accepted at the job and negatively affects productivity.2 LGBTQ+ rights advocates have raised similar points, noting that hiding or downplaying one’s sexual orientation or gender identity from one’s colleagues hinders internal advancement of LGBTQ+ workers.3 As recently as 2019, however, a Deloitte study found that sixty-one percent of workers hid or downplayed one or more of their identities from their colleagues at work.4
The need for hollow microneedle arrays is important for both drug delivery and wearable sensor applications; however, their fabrication poses many challenges. Hollow metal microneedle arrays residing on a flexible metal foil substrate were created by combining additive manufacturing, micromolding, and electroplating approaches in a process we refer to as electromolding. A solid microneedle with inward facing ledge was fabricated with a two photon polymerization (2PP) system utilizing laser direct write (LDW) and then molded with polydimethylsiloxane. These molds were then coated with a seed layer of Ti/Au and subsequently electroplated with pulsed deposition to create hollow microneedles. An inward facing ledge provided a physical blocking platform to restrict deposition of the metal seed layer for creation of the microneedle bore. Various ledge sizes were tested and showed that the resulting seed layer void could be controlled via the ledge length. Mechanical properties of the PDMS mold was adjusted via the precursor ratio to create a more ductile mold that eliminated tip damage to the microneedles upon removal from the molds. Master structures were capable of being molded numerous times and molds were able to be reused. SEM/EDX analysis showed that trace amounts of the PDMS mold were transferred to the metal microneedle upon removal. The microneedle substrate showed a degree of flexibility that withstood over 100 cycles of bending from side to side without damaging. Microneedles were tested for their fracture strength and were capable of puncturing porcine skin and injecting a dye.
The evolution of material wealth-based inequality is an important topic in archaeological research. While a number of explanatory models have been proposed, rarely have they been adequately tested. A significant challenge to testing such models concerns our ability to define distinct, temporally short-term, residential occupations in the archaeological record. Sites often lack evidence for temporally persistent inequality, or, when present, the palimpsest nature of the deposits often make it difficult to define the processes of change on scales that are fine enough to evaluate nuanced model predictions. In this article, we use the detailed record of Housepit 54 from the Bridge River site, interior British Columbia, to evaluate several alternative hypotheses regarding the evolution of persistent material wealth-based inequality. Results of our analyses indicate that inequality appeared abruptly coincident with a decline in intra-house cooperation associated with population packing and the initiation of periodic subsistence stress. We conclude that persistent inequality in this context was a byproduct of altered social networks linked to a Malthusian transition and ceiling.
Weed management is a major constraint in organic cropping systems. In 2004, the Cornell Organic Vegetable Cropping Systems Experiment was established in central New York state using a split-plot randomized complete block design with two crop rotation entry points (split-plot factor). Four organic vegetable cropping systems that varied in cropping intensity and tillage (main plot factor) were compared: (1) intensive, (2) intermediate, (3) bio-extensive, and (4) ridge tillage. The basic crop rotation was cabbage, lettuce, potato, and winter squash, with additional short-season crops in the intensive system and with cover crops and fallow substituted for cabbage and potato in the bio-extensive system. In 2014, two uniformity trials were conducted in which oat and then a mixture of sorghum-sudangrass plus Japanese millet were grown uniformly over the entire experiment. Prior to sowing oat, soil samples were collected from each plot and an emergence bioassay was conducted to assess the soil weed seedbank. Crop biomass, weed density, and weed biomass were sampled in the uniformity crops. Soil weed seedbank density was three to four times greater in the intensive, intermediate, and ridge-tillage systems than in the bio-extensive system. The bio-extensive system also had lower weed density and weed biomass in the oat uniformity trial compared with the other three systems. Oat biomass did not differ between the cropping systems. Weed density and biomass in oat were also affected by the crop rotation entry point. Cropping system legacy effects on weed abundance and community composition were greater in the oat than in the sorghum-sudangrass plus Japanese millet uniformity trial. Our results illustrate the effects of different organic vegetable production practices on weed community structure and highlight the value of tilled fallow periods, cover crops, and prevention of weed seed rain for reducing weed populations.
This paper reports the first large-sample investigation of the maltreatment-related correlates of low-income adolescents’ narratives about their childhood experiences with primary caregivers, as assessed with a modified version of the Adult Attachment Interview (AAI) and based on official reports of abuse and neglect (maltreated n = 214, nonmaltreated n = 140; M age = 16.7 years). Drawing on factor-analytic and taxometric evidence indicating that AAI narratives vary along two state of mind (i.e., dismissing and preoccupied) and two inferred childhood experience (i.e., maternal and paternal) dimensions, here we demonstrate that the experience of maltreatment, particularly when chronic, is associated with increased risk for dismissing and preoccupied states of mind and more negative inferred childhood experiences. Although such maltreatment-related associations were generally not specific to any of the four AAI dimensions, the experience of physical and/or sexual abuse was uniquely associated with preoccupied states of mind and negative inferred paternal experiences even after controlling for the other AAI dimensions. More extensive paternal perpetration of maltreatment also was uniquely related to more negative inferred paternal experiences.