Emergency Severity Index Version 4 and Triage of Pediatric Emergency Department Patients.

Importance: Most emergency departments (EDs) across the US use the Emergency Severity Index (ESI) to predict acuity and resource needs. A comprehensive assessment of ESI accuracy among pediatric patients is lacking. Objective: To assess the frequency of mistriage using ESI (version 4) among pediatric ED visits using automated measures of mistriage and identify characteristics associated with mistriage. Design, Setting, and Participants: This cohort study used operational measures for each ESI level to classify encounters as undertriaged, overtriaged, or correctly triaged to assess the accuracy of the ESI and identify characteristics of mistriage. Participants were pediatric patients at 21 EDs within Kaiser Permanente Northern California from January 1, 2016, to December 31, 2020. During that time, version 4 of the ESI was in use by these EDs. Visits with missing ESI, incomplete ED time variables, patients transferred from another ED, and those who left against medical advice or without being seen were excluded. Data were analyzed between January 2022 and June 2023. Exposures: Assigned ESI level. Main Outcomes and Measures: Rates of undertriage and overtriage by assigned ESI level based on mistriage algorithm, patient and visit characteristics associated with undertriage and overtriage. Results: This study included 1 016 816 pediatric ED visits; the mean (SD) age of patients was 7.3 (5.6) years, 479 610 (47.2%) were female, and 537 206 (52.8%) were male. Correct triage occurred in 346 918 visits (34.1%; 95% CI, 34.0%-34.2%), while overtriage and undertriage occurred in 594 485 visits (58.5%; 95% CI, 58.4%-58.6%) and 75 413 visits (7.4%; 95% CI, 7.4%-7.5%), respectively. In adjusted analyses, undertriage was more common among children at least 6 years old compared with those younger 6 years; male patients compared with female patients; patients with Asian, Black, or Hispanic or other races or ethnicities compared with White patients; patients with comorbid illnesses compared with those without; and patients who arrived by ambulance compared with nonambulance patients. Conclusions and Relevance: This multicenter retrospective study found that mistriage with ESI version 4 was common in pediatric ED visits. There is an opportunity to improve pediatric ED triage, both in early identification of critically ill patients (limit undertriage) and in more accurate identification of low-acuity patients with low resource needs (limit overtriage). Future research should include assessments based on version 5 of the ESI, which was released after this study was completed.

Hydrogen sulfide and metal-enriched atmosphere for a Jupiter-mass exoplanet.

As the closest transiting hot Jupiter to Earth, HD 189733b has been the benchmark planet for atmospheric characterization1-3. It has also been the anchor point for much of our theoretical understanding of exoplanet atmospheres from composition4, chemistry5,6, aerosols7 to atmospheric dynamics8, escape9 and modelling techniques10,11. Previous studies of HD 189733b have detected carbon and oxygen-bearing molecules H2O and CO (refs. 12,13) in the atmosphere. The presence of CO2 and CH4 has been claimed14,15 but later disputed12,16,17. The inferred metallicity based on these measurements, a key parameter in tracing planet formation locations18, varies from depletion19,20 to enhancement21,22, hindered by limited wavelength coverage and precision of the observations. Here we report detections of H2O (13.4σ), CO2 (11.2σ), CO (5σ) and H2S (4.5σ) in the transmission spectrum (2.4-5.0 µm) of HD 189733b. With an equilibrium temperature of about 1,200 K, H2O, CO and H2S are the main reservoirs for oxygen, carbon and sulfur. Based on the measured abundances of these three main volatile elements, we infer an atmospheric metallicity of three to five times stellar. The upper limit on the methane abundance at 5σ is 0.1 ppm, which indicates a low carbon-to-oxygen ratio (<0.2), suggesting formation through the accretion of water-rich icy planetesimals. The low oxygen-to-sulfur and carbon-to-sulfur ratios also support the planetesimal accretion formation pathway23.

Strong effect of demographic changes on Tuberculosis susceptibility in South Africa.

South Africa is among the world's top eight tuberculosis (TB) burden countries, and despite a focus on HIV-TB co-infection, most of the population living with TB are not HIV co-infected. The disease is endemic across the country, with 80-90% exposure by adulthood. We investigated epidemiological risk factors for (TB) in the Northern Cape Province, South Africa: an understudied TB endemic region with extreme TB incidence (926/100,000). We leveraged the population's high TB incidence and community transmission to design a case-control study with similar mechanisms of exposure between the groups. We recruited 1,126 participants with suspected TB from 12 community health clinics and generated a cohort of 774 individuals (cases = 374, controls = 400) after implementing our enrollment criteria. All participants were GeneXpert Ultra tested for active TB by a local clinic. We assessed important risk factors for active TB using logistic regression and random forest modeling. We find that factors commonly identified in other global populations tend to replicate in our study, e.g. male gender and residence in a town had significant effects on TB risk (OR: 3.02 [95% CI: 2.30-4.71]; OR: 3.20 [95% CI: 2.26-4.55]). We also tested for demographic factors that may uniquely reflect historical changes in health conditions in South Africa. We find that socioeconomic status (SES) significantly interacts with an individual's age (p = 0.0005) indicating that protective effect of higher SES changed across age cohorts. We further find that being born in a rural area and moving to a town strongly increases TB risk, while town birthplace and current rural residence is protective. These interaction effects reflect rapid demographic changes, specifically SES over recent generations and mobility, in South Africa. Our models show that such risk factors combined explain 19-21% of the variance (r2) in TB case/control status.

Pilot trial of an electronic decision support to improve care for emergency department patients with acute heart failure.

AIMS: Emergency department (ED) providers play an important role in the management of patients with acute heart failure (AHF). We present findings from a pilot study of an electronic decision support that includes personalized risk estimates using the STRIDE-HF risk tool and tailored recommendations for initiating guideline directed medical therapy (GDMT) among appropriate patients. METHODS: Among ED patients treated for AHF who were discharged from the ED or the ED-based observation unit in two EDs from 1 January 2023 to 31 July 2023, we assess prescriptions to the four classes of GDMT at two intervals: (1) ED arrival and (2) ED discharge. Specifically, we report active prescriptions for beta-blockers (BBs), renin-angiotensin receptor system inhibitors (RASis), sodium-glucose transport protein 2 inhibitors (SGLT2is) and mineralocorticoid receptor antagonists (MRA) among patients with reduced ejection fraction (HFrEF) and mildly reduced (HFmrEF). Second, we describe rates of 30-day serious adverse events (SAE) (death, cardiopulmonary resuscitation, balloon-pump insertion, intubation, new dialysis, myocardial infarction or coronary revascularization) among patients predicted to be very low risk by STRIDE-HF and discharged home. RESULTS: Among 234 discharged patients, 55% were female and 76% were non-White. We found 51 (21.8%), 21 (9.0%) and 126 (53.8%) had HFrEF, HFmEF and HFpEF, respectively, while 36 (15.4%) were missing EF, and 51 (22%) were very low risk, 82 (35%) were low risk, 60 (26%) were medium risk and 41 (18%) were high risk. Among HFrEF patients, 68.6%, 66.7%, 25.5% and 19.6% were on a RASi, BB, SGLT2i and MRA, respectively, at ED arrival, while 42.9%, 66.7%, 14.3% and 4.8% of HFmrEF patients were on a RASi, BB, SGLT2i and MRA, respectively. Among patients with HFpEF, only 6 (4.8%) were on an SGLT2i at ED arrival. The most prescribed new medication at ED discharge was an SGLT2i, with a nearly 10% increase in the proportion of patients with an active prescription for SGLT2i at ED discharge among HFrEF and HFmEF patients. We observed no 30-day SAE among the 51 patients predicted to be very low risk and discharged home. CONCLUSIONS: Ongoing treatment with GDMT at ED arrival was sub-optimal. Initiation among appropriate patients at discharge may be feasible and safe.

Same old story with a different ending: Homophily and preferential selection of information within the US climate policy network.

The passage of the Inflation Reduction Act has been perceived as a substantial shift away from the history of more contentious climate politics in the US. We apply social network methods to interrogate an updated dataset that assesses the degree to which recent policy outcomes are a shift away from earlier policies and positions. We empirically test for homophily, a building block of polarisation, analysing four waves of survey data collected over 12 years from the community of political elites engaged in the issue of climate politics. Using Exponential Random Graph (ERG) modeling, we provide clear evidence that the stances of the top policy actors working on climate change have not shifted substantially. Instead, we document how the policy was successful due to its ability to combine the Administration's desire to support clean energy along with fossil fuel interests' aims of expanding extraction and profiting from a transition away from fossil fuels.

Downstream Emergency Department and Hospital Utilization Comparably Low Following In-Person Versus Telemedicine Primary Care for High-Risk Conditions.

BACKGROUND: Telemedicine use expanded greatly during the COVID-19 pandemic. More data is needed to understand how this shift may impact other venues of acute care delivery. OBJECTIVE: We evaluate the association of visit modality (telephone, video, or office) and downstream emergency department (ED) and hospital visits among primary care visits for acute, time-sensitive conditions. DESIGN: Observational study of patient-scheduled primary care telemedicine and office visits for acute conditions (cardiac, gastrointestinal, neurologic, musculoskeletal, and head and neck) in a large, integrated healthcare delivery system. PARTICIPANTS: Adults with a new self-booked primary care appointment for an eligible acute condition from January 1, 2022, to December 31, 2022 (with no primary care, ED, or hospital visits in prior 30 days). INTERVENTIONS: Visit modality, including office, video, or telephone. MAIN MEASURES: Seven-day ED and hospital utilization, adjusted for patient and visit characteristics. KEY RESULTS: Among 258,958 primary care visits by 239,240 adult patients, 57.7% were telemedicine visits; of these, 72.4% were telephone and 27.6% were video. Telephone visits were the timeliest, with over 70% of visits scheduled within 1 day of booking. Rates of 7-day ED utilization were low, and varied by condition group, with cardiac visits having the highest rates (4.8%) and musculoskeletal visits having the lowest (0.8%). There was less than a 1% absolute difference in ED use by visit modality for all condition types; however, telephone visits were associated with slightly higher rates than video visits. The 7-day hospitalization rate was less than 1% and observed between visit type differences varied by clinical condition. CONCLUSIONS: Among office, telephone, and video visits in primary care for potentially high-risk, time-sensitive conditions, downstream ED and hospital use were uncommon. ED utilization was lower for video visits than telephone visits, although telephone visits were timelier and may offer a safe and accessible option for acute care.

Measuring Pharmacy Student Engagement in a Pharmacotherapy Course With Required Attendance.

OBJECTIVE: This study aimed to evaluate student engagement in a pharmacotherapy course with required attendance, identify intervals where students were most and least likely to be engaged, and assess student perceptions of the importance of engagement. METHODS: In 2022, the pharmacotherapy course faculty implemented a graded attendance policy. A survey instrument was developed to gauge student engagement throughout in-class sessions and included 3 questions regarding engagement to determine whether students were on-task, off-task-related, or off-task-unrelated. Each week throughout the semester, students were randomly surveyed for a beginning, middle, and end time point. A second survey was utilized to collect perception data from students regarding attendance and engagement. The perception survey was released during the midpoint of the semester and at the end of the semester. RESULTS: The overall attendance rate was 91.1% (SD 4.64%) for the semester. Generally, students reported being on-task when surveyed. The average weekly tasks rates were 77.7% on-task, 15.8% off-task-related, and 6.5% off-task-unrelated. For the perception survey, both time points had a high response rate (82.8% midpoint survey, 77.1% end of semester). Most students had positive perceptions regarding mandatory attendance, engagement, and pre-class preparation. CONCLUSION: This study endorses high levels of student engagement in a pharmacotherapy course with required attendance. In addition, student perceptions were generally positive regarding required attendance. Future investigations need to be completed on the non-performance benefits of attending classes.

A comprehensive preanalytical protocol for fresh solid tumor biospecimens.

Nearly seventy percent of diagnostic lab test errors occur due to variability in preanalytical factors. These are the parameters involved with all aspects of tissue processing, starting from the time tissue is collected from the patient in the operating room, until it is received and tested in the laboratory. While there are several protocols for transporting fixed tissue, organs, and liquid biopsies, such protocols are lacking for transport and handling of live solid tumor tissue specimens. There is a critical need to establish preanalytical protocols to reduce variability in biospecimen integrity and improve diagnostics for personalized medicine. Here, we provide a comprehensive protocol for the standard collection, handling, packaging, cold-chain logistics, and receipt of solid tumor tissue biospecimens to preserve tissue viability.

A Method to Determine Capabilities and Resources for Spacecraft Medical Systems.

INTRODUCTION: This paper describes the method for assigning medical diagnostic and treatment capabilities and resources to the database which assists with an updated probabilistic risk analysis (PRA) tool for exploration class medical system planning. The National Aeronautics and Space Administration has used PRA since 2011 to inform mission medical system design, but existing tools are designed only for low Earth orbit. An updated PRA tool was needed to assist with exploration class missions.METHODS: A team of medical experts with a wide range of expertise and experience, including Space Medicine, was assembled to build capability and resource tables for the new PRA tool. This team met over 8 mo and used practice guidelines, literature, and experience to build capability and resource tables (CRTs) for each condition in the new PRA tool database.RESULTS: This process led to CRTs for each condition and a total of 617 distinct capabilities and 839 discrete resources.CONCLUSION: The CRT method is an effective way to translate medical practice guidelines into capabilities and resources usable by PRA tools for exploration class medical system planning. This same method may be used in commercial space ventures and in other applications in which medical predictive analytics are informative.Levin DR, Nelson AM, Zahner C, Stratton ER, Anderson A, Steller J. A method to determine capabilities and resources for spacecraft medical systems. Aerosp Med Hum Perform. 2024; 95(7):403-408.

Comparison of Short-Term Health Care Utilization Between Telemedicine-Delivered vs In-Person Care Visits for Heart Failure.

Background: Patients with heart failure (HF) are a medically complex population with frequent hospitalizations. Downstream health care utilization following primary care delivered by telemedicine compared to in-person is unknown. Objectives: The purpose of this study was to understand differences in return in-person visits, emergency department (ED) encounters, and hospitalizations following a telemedicine vs an in-person primary care visit for patients with HF seen for a HF-related complaint. Methods: This was an observational study of all primary care visits for HF from January 1, 2022, to December 31, 2022, in an integrated health care delivery system. We compared 7-day in-person follow-up visits, ED visits, and hospitalizations (all-cause and HF-specific) by index visit type. Results: We included 3,902 primary care visits with a primary diagnosis of HF. Most visits utilized telephone or video visits (58.4% total; 44.9% telephone, 13.5% video). After adjustment, telephone visits were associated with more in-person follow-up visits (6.14% vs 4.20%; adjusted OR: 1.08-2.21; P < 0.05) but fewer ED visits (6.12% vs 8.07%; adjusted OR: 0.55-0.97; P < 0.05) compared to in-person visits. Most hospitalized patients (74%) had an admitting diagnosis of HF. There was no difference between 7-day all-cause hospitalization following telephone or video visits compared to in-person visits. Conclusions: Most patients used telemedicine to address HF-specific primary care concerns. Telephone visits were associated with slightly higher short-term in-person primary care follow-up but lower ED utilization. Overall, downstream ED visits and hospitalizations were low. Telephone and video visits appear to offer safe alternatives to in-person care for HF-related primary care and are a promising health care delivery strategy.

Sex-Based Differences in the Epidemiology, Clinical Characteristics, and Outcomes Associated with Worsening Heart Failure Events in a Learning Health System.

BACKGROUND: Differences in demographics, risk factors, and clinical characteristics may contribute to variations in men and women in terms of the prevalence, clinical setting, and outcomes associated with worsening heart failure (WHF) events. We sought to describe sex-based differences in the epidemiology, clinical characteristics, and outcomes associated with WHF events across clinical settings. METHODS AND RESULTS: We examined adults diagnosed with HF from 2010 to 2019 within a large, integrated health care delivery system. Electronic health record data were accessed for hospitalizations, emergency department (ED) visits and observation stays, and outpatient encounters. WHF was identified using validated natural language processing algorithms and defined as ≥1 symptom, ≥2 objective findings (including ≥1 sign), and ≥1 change in HF-related therapy. Incidence rates and associated outcomes for WHF were compared across care setting by sex. We identified 1,122,368 unique clinical encounters with a diagnosis code for HF, with 124,479 meeting WHF criteria. These WHF encounters existed among 102,116 patients, of whom 48,543 (47.5%) were women and 53,573 (52.5%) were men. Women experiencing WHF were older and more likely to have HF with preserved ejection fraction compared with men. The clinical settings of WHF were similar among women and men: hospitalizations (36.8% vs 37.7%), ED visits or observation stays (11.8% vs 13.4%), and outpatient encounters (4.4% vs 4.9%). Women had lower odds of 30-day mortality after an index hospitalization (adjusted odds ratio 0.88, 95% confidence interval 0.83-0.93) or ED visit or observation stay (adjusted odds ratio 0.86, 95% confidence interval 0.75-0.98) for WHF. CONCLUSIONS: Women and men contribute similarly to WHF events across diverse clinical settings despite marked differences in age and left ventricular ejection fraction.

Current status of community resources and priorities for weed genomics research.

Weeds are attractive models for basic and applied research due to their impacts on agricultural systems and capacity to swiftly adapt in response to anthropogenic selection pressures. Currently, a lack of genomic information precludes research to elucidate the genetic basis of rapid adaptation for important traits like herbicide resistance and stress tolerance and the effect of evolutionary mechanisms on wild populations. The International Weed Genomics Consortium is a collaborative group of scientists focused on developing genomic resources to impact research into sustainable, effective weed control methods and to provide insights about stress tolerance and adaptation to assist crop breeding.

Emergency Department Referral of Patients With Chest Pain for Noninvasive Cardiac Testing and 2-Year Clinical Outcomes.

BACKGROUND: Noninvasive cardiac testing (NICT) has been associated with decreased long-term risks of major adverse cardiac events (MACEs) among emergency department patients at high coronary risk. It is unclear whether this association extends to patients without evidence of myocardial injury on initial ECG and cardiac troponin testing. METHODS: A retrospective cohort study was conducted of patients presenting with chest pain between 2013 and 2019 to 21 emergency departments within an integrated health care system in Northern California, excluding patients with ST-segment-elevation myocardial infarction or myocardial injury by serum troponin testing. To account for confounding by indication, we grouped patient encounters by the NICT referral rate of the initially assigned emergency physician relative to local peers within discrete time periods. The primary outcome was MACE within 2 years. Secondary outcomes were coronary revascularization and MACE, inclusive of all-cause mortality. Associations between the NICT referral group (low, intermediate, or high) and outcomes were assessed using risk-adjusted proportional hazards methods with censoring for competing events. RESULTS: Among 144 577 eligible patient encounters, the median age was 58 years (interquartile range, 48-68) and 57% were female. Thirty-day NICT referral was 13.0%, 19.9%, and 27.8% in low, intermediate, and high NICT referral groups, respectively, with a good balance of baseline covariates between groups. Compared with the low NICT referral group, there was no significant decrease in the adjusted hazard ratio of MACE within the intermediate (adjusted hazard ratio, 1.08 [95% CI, 1.02-1.14]) or high (adjusted hazard ratio, 1.05 [95% CI, 0.99-1.11]) NICT referral groups. Results were similar for MACE, inclusive of all-cause mortality, and coronary revascularization, as well as subgroup analyses stratified by estimated risk (history, electrocardiogram, age, risk factors, troponin [HEART] score: percent classified as low risk, 48.2%; moderate risk, 49.2%; and high risk, 2.7%). CONCLUSIONS: Increases in NICT referrals were not associated with changes in the hazard of MACE within 2 years following emergency department visits for chest pain without evidence of acute myocardial injury. These findings further highlight the need for evidence-based guidance regarding the appropriate use of NICT in this population.

Unveiling the paradoxes of implementing post graduate competency based medical education programs.

PURPOSE: Competency-based medical education (CBME) has gained prominence as an innovative model for post-graduate medical education, yet its implementation poses significant challenges, especially with regard to its sustainability. Drawing on paradox theory, we suggest that revealing the paradoxes underlying these challenges may contribute to our understanding of post graduate competency-based medical education (PGCBME) implementation processes and serve as a first-step in enhancing better implementation. Thus, the purpose of the current study is to identify the paradoxes associated with PGCBME implementation. METHOD: A qualitative study was conducted, as part of a larger action research, using in-depth semi-structured interviews with fellows and educators in eight Neonatal wards. RESULTS: Analysis revealed that the PGCBME program examined in this study involves three different levels of standardization, each serving as one side of paradoxical tensions; (1) a paradox between the need for standardized assessment tools and for free-flow flexible assessment tools, (2) a paradox between the need for a standardized implementation process across all wards and the need for unique implementation protocols in each ward; and 3) a paradox between the need for a standardized meaning of competency proficiency and the need for flexible and personal competency achievement indicators. CONCLUSIONS: Implementing PGCBME programs involves many challenges, some of which are paradoxical, i.e. two contradictory challenges in which solving one challenge exacerbates another. Revealing these paradoxes is important in navigating them successfully.

Low-Efficacy Mu Opioid Agonists as Candidate Analgesics: Effects of Novel C-9 Substituted Phenylmorphans on Pain-Depressed Behavior in Mice.

Low efficacy mu opioid receptor (MOR) agonists may serve as novel candidate analgesics with improved safety relative to high-efficacy opioids. This study used a recently validated assay of pain-depressed behavior in mice to evaluate a novel series of MOR-selective C9-substituted phenylmorphan opioids with graded MOR efficacies. Intraperitoneal injection of dilute lactic acid (IP acid) served as a noxious stimulus to depress locomotor activity by mice in an activity chamber composed of two compartments connected by an obstructed door. Behavioral measures included (1) crosses between compartments (vertical activity over the obstruction) and (2) movement counts quantified as photobeam breaks summed across compartments (horizontal activity). Each drug was tested alone and as a pretreatment to IP acid. A charcoal-meal test and whole-body-plethysmography assessment of breathing in 5% CO2 were also used to assess gastrointestinal (GI) inhibition and respiratory depression, respectively. IP acid produced a concentration-dependent depression in crosses and movement that was optimally alleviated by intermediate- to low-efficacy phenylmorphans with sufficient efficacy to produce analgesia with minimal locomotor disruption. Follow-up studies with two low-efficacy phenylmorphans (JL-2-39 and DC-1-76.1) indicated that both drugs produced naltrexone-reversible antinociception with a rapid onset and a duration of ~1hr. Potency of both drugs increased when behavior was depressed by a lower IP-acid concentration, and neither drug alleviated behavioral depression by a non-pain stimulus (IP lithium chloride). Both drugs produced weaker GI inhibition and respiratory depression than fentanyl and attenuated fentanyl-induced GI inhibition and respiratory depression. Results support further consideration of selective, low-efficacy MOR agonists as candidate analgesics. Significance Statement This study used a novel set of mu opioid receptor (MOR)-selective opioids with graded MOR efficacies to examine the lower boundary of MOR efficacy sufficient to relieve pain-related behavioral depression in mice. Two novel low-efficacy opioids (JL-2-39, DC-1-76.1) produced effective antinociception with improved safety relative to higher- or lower-efficacy opioids, and results support further consideration of these and other low-efficacy opioids as candidate analgesics.

A comprehensive investigation of the association between menopause symptoms and problematic eating behavior in peri- and post-menopause cisgender women.

Midlife individuals assigned female at birth are at risk for problematic eating behavior, associated with negative health outcomes. Little is known about how menopausal symptoms may increase risk in this population. The current study aimed to understand how a comprehensive range of menopause symptoms were globally associated with problematic eating behaviors. A total of 281 cisgender women (176 post-menopause, 105 peri-menopause) from the United States aged 40 to 64 were recruited utilizing Prolific, an online survey platform. Participants answered questionnaires about menopause symptoms and problematic eating. Participants were selected using demographic and health information provided in a screener survey. Participants also completed the Eating Disorder Questionnaire (EDE-Q), Women's Health Questionnaire (WHQ), Patient Health Questionnaire-8 (PHQ-8), Generalized Anxiety Disorder-7 (GAD-7), and Pittsburgh Sleep Quality Index (PSQI). Using Structural Equation Modeling, menopause symptoms explained 16.7 percent of the variance in problematic eating. Higher frequency and severity of anxiety, depression, sleep concerns, cognitive complaints, pain, and vasomotor symptoms was associated with greater frequency and severity of problematic eating behaviors, ß = .40, p < .001. Invariance testing showed no significant differences between peri- and postmenopausal women. These findings support the association between menopause symptoms and problematic eating in Midlife cisgender women and highlight the need for continued investigation.

Evaluation of techniques to break seed dormancy in Redroot pigweed (Amaranthus retroflexus).

By identifying the factors that initiate seed dormancy release, we can reliably predict whether a seed will remain dormant within or exit the seed bank and become a seedling. With regard to annual weed species, assessing which factors efficiently break seed dormancy is critical for estimating the number of weed seeds that will develop into problematic weeds. To better understand dormancy breaking in Redroot pigweed (Amaranthus retroflexus), dormant seeds were treated with cold stratification (4°C for 30 days), application of gibberellic acid (at 500, 1000, 1500, and 2000 parts per million), ultrasound (for 10, 20, 30, and 40 min), soaking in hot water (90°C for 3, 5, 7, and 10 min), and 98% sulfuric acid (for 1, 2, and 3 min). The results showed that Redroot pigweed seed dormancy was effectively broken by cold stratification, gibberellic acid, and ultrasound. Short treatments with hot water had minimal effect while longer times or treatment with sulfuric acid stopped seed germination. In addition to germination percentage, germination rate, plumule length, radicle length, seedling length, seedling dry weight, and seed vigor index were also measured; similarly, application of gibberellic acid had the most significant effect on these parameters. The results of this study add to our knowledge of what processes effectively or ineffectively break Redroot pigweed seed dormancy and promote growth.

Mental health practices in rehabilitation for youth with physical disabilities: a chart review study.

PURPOSE: Evidence on co-occurring mental health problems in youth with physical disabilities is growing, however how services are provided remains unclear. This study examined current interprofessional rehabilitation practices for physical and mental health services. METHODS: Youth (aged 15-24) followed for a physical disability that had mental health problems were identified. Chart reviews were used to identify practices. Mental health-related diagnoses/symptoms, assessments, goals, interventions, and referrals were extracted for inductive content analysis. RESULTS: Sixty charts were reviewed. Mental health problems included anxiety (n = 53), depression (n = 25), neurodevelopmental (n = 19) and personality disorders (n = 8), often (n = 36) citing more than one. No mental health assessments were found, and in 43%, no goals or interventions were evident. Relevant goals (n = 98) targeted emotional management, autonomy/communication of needs, acceptance of physical condition, socialization, routines/energy levels, school/work supports, and leisure/calming environments. Interventions (n = 104) included emotional management, formal individual/group therapy, links with external supports, routines/activities, reflection/acceptance, and school/work support. Mental health services were received in-house (n = 24) and/or externally (n = 30), plus 18 referrals pending and 14 not referred. CONCLUSION: Many had more than one mental health problem, suggesting the complexity of their condition. While some mental health goals/interventions are documented, problems may often not be reported or addressed in this context.

Further attention can be directed to the needs of youth with physical disabilities and co-occurring mental health problems as they are not fully addressed by current interdisciplinary rehabilitation practices.Follow-up (services and referrals) should be adapted to the holistic needs of youth and their goals within the rehabilitation context.Rehabilitation professionals can be provided with training to build workforce capacity in mental health screening and have access to guidance when addressing situations related to mental health or referring to external services.

Effects of 4 Testing Arena Sizes and 11 Types of Embryo Media on Sensorimotor Behaviors in Wild-Type and chd7 Mutant Zebrafish Larvae.

The larval zebrafish is a highly versatile model across research disciplines, and the expanding use of behavioral analysis has contributed to many advances in neuropsychiatric, developmental, and toxicological studies, often through large-scale chemical and genetic screens. In the absence of standardized approaches to larval zebrafish behavior analysis, however, it is critical to understand the impact on behavior of experimental variables such as the size of testing arenas and the choice of embryo medium. Using a custom-built, modular high-throughput testing system, we examined the effects of 4 testing arena sizes and 11 types of embryo media on conserved sensorimotor behaviors in zebrafish larvae. Our data show that testing arena size impacts acoustic startle sensitivity and kinematics, as well as spontaneous locomotion and thigmotaxis, with fish tested in larger arenas displaying reduced startle sensitivity and increased locomotion. We also find that embryo media can dramatically affect startle sensitivity, kinematics, habituation, and prepulse inhibition, as well as spontaneous swimming, turning, and overall activity. Common medium components such as methylene blue and high calcium concentration consistently reduced startle sensitivity and locomotion. To further address how the choice of embryo medium can impact phenotype expression in zebrafish models of disease, we reared chd7 mutant larvae, a model of CHARGE syndrome with previously characterized morphological and behavioral phenotypes, in five different types of media and observed impacts on all phenotypes. By defining the effects of these key extrinsic factors on larval zebrafish behavior, these data can help researchers select the most appropriate conditions for their specific research questions, particularly for genetic and chemical screens.

Clinical Outcomes Associated with Amoxicillin Treatment for Acute Otitis Media in Children.

BACKGROUND: Acute otitis media (AOM) is the most common reason children are prescribed antibiotics. Bacteria that produce beta-lactamase are an increasingly frequent cause of AOM and may be resistant to amoxicillin, the currently recommended treatment for AOM. We aimed to evaluate the clinical outcomes of children treated with amoxicillin for AOM and assessed whether outcomes vary by infecting pathogen or beta-lactamase production. METHODS: 205 children 6-35 months old diagnosed with AOM and prescribed amoxicillin were included. Bacterial culture and qualitative multiplex real-time polymerase chain reaction were performed on nasopharyngeal swabs collected at enrollment. Parents completed surveys assessing symptoms, antibiotic adherence, and potential adverse events. The primary outcome was treatment failure with amoxicillin. Secondary outcomes included recurrence, symptom improvement, resolution, and adverse drug events (ADE). RESULTS: 8 children (5.4%) experienced treatment failure and 14 (6.8%) had recurrence. By day 5, 152 (74.1%) children had symptom improvement and 97 (47.3%) had resolution. Parents reported ADE for 56 (27.3%) children. Among 149 children who did not take any amoxicillin before enrollment, 98 (65.8%) had one or more beta-lactamase-producing bacteria. Common bacterial otopathogens were Moraxella catarrhalis (79, 53.0%), Streptococcus pneumoniae (51, 34.2%), Haemophilus influenzae (30, 20.1%), and Staphylococcus aureus (21, 14.1%). Treatment failure did not differ between children that did (5, 5.1%) and did not (3, 5.9%) have beta-lactamase-producing otopathogens (p = .05). CONCLUSIONS: Among children diagnosed with AOM treated with amoxicillin, treatment failure was uncommon and did not differ by pathogen or beta-lactamase production. These data support guidance recommending amoxicillin despite an increasing prevalence of beta-lactamase-producing bacteria.