Assessing the New Norm: A Simulation Study to Assess Pediatric Emergency Physician Success in Critical Procedures With an Air Purifying Respirator.

INTRODUCTION: Physicians caring for patients with COVID-19 are at high risk for contracting the disease, thus, significant emphasis has been placed on personal protective equipment (PPE). The study aims to assess the impact of advanced PPE across 4 common procedures: endotracheal intubation, bag-valve mask ventilation, intraosseous (IO) insertion, and lumbar puncture (LP) performed by pediatric emergency physicians. METHOD: Physicians performed the procedures in a simulated environment. Lumbar puncture and IO were performed with standard precautions versus an air purifying respirator (APR). A direct comparison was drawn for endotracheal intubation and bag-valve mask ventilation between 2 commonly used APRs. Success rate and number of attempts toward successful completion was recorded for all 4 procedures. Physicians filled out a postprocedure survey to assess their ease of use of the APR. RESULTS: Twenty participants performed IO and LP using an APR and standard precautions. There was no statistical difference in the success rate, number of attempts, average time, or maintenance of sterility (LP only) for both procedures. Twenty total participants divided across 2 types of APR groups performed intubation and BMV. Success rate and number of attempts had no statistical difference for both procedures. Physician feedback surveys to assess the ease of use of APR compared with standard precautions had no statistically significant difference for all 4 procedures. CONCLUSIONS: Wearing increased levels of PPE did not impact procedural success, length of time, sterility, number of attempts, or the physicians' ease in our study. Physicians should be encouraged to wear all appropriate PPE.

Impact of Race and Ethnicity on Emergency Medical Services Administration of Opioid Pain Medications for Injured Children.

BACKGROUND: Treatment with analgesics for injured children is often not provided or delayed during prehospital transport. OBJECTIVE: Our aim was to evaluate racial and ethnic disparities with the use of opioids during transport of injured children. METHODS: We conducted a prospective study of injured children transported to 1 of 10 emergency departments from July 2019 to April 2020. Emergency medical services (EMS) providers were surveyed about prehospital pain interventions during transport. Our primary outcome was the use of opioids. We performed multivariate regression analyses to evaluate the association of patient demographic characteristics (race, ethnicity, age, and gender), presence of a fracture, EMS provider type (Advanced Life Support [ALS] or non-ALS) and experience (years), and study site with the use of opioids. RESULTS: We enrolled 465 patients; 19% received opioids during transport. The adjusted odds ratios (AORs) for Black race and Hispanic ethnicity were 0.5 (95% CI 0.2-1.2) and 0.4 (95% CI 0.2-1.3), respectively. The presence of a fracture (AOR 17.0), ALS provider (AOR 5.6), older patient age (AOR 1.1 for each year), EMS provider experience (AOR 1.1 for each year), and site were associated with receiving opioids. CONCLUSIONS: There were no statistically significant associations between race or ethnicity and use of opioids for injured children. The presence of a fracture, ALS provider, older patient age, EMS provider experience, and site were associated with receiving opioids.

Teaching the Arts in testing times: A Western Australian perspective on COVID impacts.

Expert secondary Arts teachers are highly trained specialists well versed in face-to-face individual and group teaching pedagogies. Given the highly personalised nature of Arts teaching practice, the shift to online teaching resulting from COVID-19 lockdowns presented many with challenges for which they had little or no formal training. Many teachers felt stressed, isolated and unsure about where to turn for help. As there are demonstrated links between stress and attrition, it is important to reflect upon the experiences of these teachers with the aim of developing future mitigation strategies. The research reported here synthesises the online teaching experiences of 15 expert Arts specialists in Western Australia and revealed that being a digital native was not in itself sufficient to ameliorate online teaching challenges. Rather, the study found that teachers with deep pedagogical practice knowledge and a reflexive/flexible approach fared better than those with high levels of technology familiarity. The importance of collegiality and mentoring in an online setting, along with a reappraisal of teaching priorities emerged as key findings and serve as a timely reminder of the importance of collaboration, especially in testing times.

A novel medical apparatus for the containment and evaluation of a pediatric patient under suspicion for highly communicable infectious disease.

BACKGROUND: Highly communicable infectious diseases (HCIDs) such as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and Ebola are a containment challenge for the emergency department (ED). Donning and doffing personal protective equipment is necessary to protect healthcare workers but is time consuming and rife with errors. Furthermore, children present an additional containment challenge since they are often unable to follow directions or be separated from family members. To address these challenges, a novel child-friendly medical apparatus was developed for the rapid containment and evaluation of a HCID patient in the ED. OBJECTIVES: The primary objective was to determine if routine emergency triage procedures (vital signs and basic physical examination) can be performed using this medical apparatus. The secondary objective was to determine if invasive procedures (bag-valve-mask ventilation and endotracheal intubation) can be performed. DESIGN: This was a prospective pilot study. A clear acrylic apparatus was built containing arm ports with gloves, simulating a specialized HCID barrier. Emergency physicians attempted routine triage procedures on a healthy volunteer and invasive procedures using a simulation mannequin through this apparatus. RESULTS: Twenty-four physicians were enrolled. All physicians (100 percent) successfully obtained vital signs, auscultated heart/lung sounds, completed bag-valve-mask ventilation, and performed intubation through the apparatus. CONCLUSIONS: This novel apparatus is a feasible tool in the rapid evaluation of a HCID patient in the ED. A future study is needed to assess protection and training using this apparatus.

Delayed Diagnosis of Injury in Pediatric Trauma Patients at a Level I Trauma Center.

BACKGROUND: Trauma care per Advanced Trauma Life Support addresses immediate threats to life. Occasionally, delays in injury diagnosis occur. Delayed diagnosis of injury (DDI) is a common quality indicator in trauma care, and pediatric DDI data are sparse. OBJECTIVE: Our aim was to describe the DDI rate in a severely injured pediatric trauma population and identify any factors associated with DDI in the pediatric population. METHODS: A prospective cohort of trauma activations in 0- to 16-year-old patients admitted to a pediatric level I trauma center over 12 months with injuries prospectively recorded were followed during admission to identify DDI. RESULTS: A total of 170 trauma activations were enrolled. Twelve patients had type I DDI (7.1%), 15 patients had type II DDI (8.8%), and 5 patients had both type I and type II DDI (2.9%). DDI patients had twice as many injuries and higher Injury Severity Scores (ISS) as non-DDI patients. DDI patients were more likely to require intensive care unit (ICU) admission, longer hospital stay, and ventilator support. Controlling for age and ISS in multivariate analysis, the number of injuries found and requiring a ventilator were significantly associated with DDI. CONCLUSIONS: This prospective study found a type I DDI rate of 7.1% and a type II DDI rate of 8.8% in the pediatric population. DDI patients had a greater number of injuries, higher ISS, higher rate of ICU admission, and were more likely to require mechanical ventilation. This study adds prospective data to the pediatric DDI literature, increases provider awareness of pediatric DDI, and lays the foundation for future study and quality improvement.

Parallel studies confirm Francisella halioticida causes mortality in Yesso scallops Patinopecten yessoensis.

Francisella halioticida is a marine bacterium originally described as the causative agent of mass mortality among giant abalone Haliotis gigantea. Recent field studies in Canada and Japan have suggested that this bacterium is also the cause of adductor muscle lesions and high mortality of Yesso scallops Patinopecten yessoensis, although a causal relationship has not been established. In the present study, the pathogenicity of F. halioticida in Yesso scallops was assessed in both Canada and Japan using bacteria isolated from diseased Yesso scallops in each respective country. Independent laboratory experiments revealed that scallops challenged with F. halioticida via bath exposure resulted in high mortality and histological lesions characterized by massive haemocyte infiltration. The presence of F. halioticida was confirmed using PCR, and F. halioticida was re-isolated from a portion of dead and surviving specimens. These results fulfill Koch's classic criteria for establishing disease causation and provide conclusive evidence that F. halioticida causes adductor muscle lesions and high mortality in Yesso scallops.

Seawater detection and biological assessments regarding transmission of the oyster parasite Mikrocytos mackini using qPCR.

Mikrocytos mackini is an intracellular parasite of oysters and causative agent of Denman Island disease in Pacific oysters Crassostrea gigas. Although M. mackini has been investigated for decades, its natural mode of transmission, mechanism for host entry, and environmental stability are largely unknown. We explored these biological characteristics of M. mackini using a recently described quantitative PCR (qPCR) assay. We detected M. mackini in the flow-through tank water of experimentally infected oysters and during disease remission in host tissues following 6 wk of elevated water temperature. Waterborne exposure of oysters to M. mackini further confirmed the potential for extracellular seawater transmission of this parasite and also identified host gill to have the highest early and continued prevalence for M. mackini DNA compared to stomach, mantle, labial palps, or adductor muscle samples. However, infections following waterborne challenge were slow to develop despite a substantial exposure (>106 M. mackini l-1 for 24 h), and further investigation demonstrated that M. mackini occurrence and infectivity severely declined following extracellular seawater incubation of more than 24 h. This study demonstrates a potential for using qPCR to monitor M. mackini in wild or farmed oyster populations during periods of disease remission or from environmental seawater samples. This work also suggests that gill tissues may provide a primary site for waterborne entry and possibly shedding of M. mackini in oysters. Further, although extracellular seawater transmission of M. mackini was possible, poor environmental stability and infection efficiency likely restricts the geographic transmission of M. mackini between oysters in natural environs and may help to explain localized areas of infection.

Rare occurrence of heart lesions in Pacific oysters Crassostrea gigas caused by an unknown bacterial infection.

On rare occasions, small cream-coloured cysts have been observed in the heart and pericardial cavity of Pacific oysters Crassostrea gigas from British Columbia, Canada. Histopathology revealed the presence of large colonies of bacteria (up to 800 µm in diameter) causing significant host response and hypertrophy of the heart epithelium. The causative bacteria were characterized as follows: Gram-negative, coccoid to small rod-shaped, typically <1.5 µm in size, cell walls highly endowed with surface fimbriae and division via binary fission. Although these bacteria shared some morphological characteristics with the order Rickettsiales, they did not require an intracellular existence for multiplication. Unfortunately, a cultured isolate was not available, and a retrospective attempt to further characterize the bacteria using DNA sequence analysis of a fragment from the 16S rDNA region proved to be uninformative.

Disease and mortality among Yesso scallops Patinopecten yessoensis putatively caused by infection with Francisella halioticida.

During the fall of 2015, up to 40% mortality occurred in juvenile Yesso scallops Patinopecten yessoensis at an aquaculture site in Baynes Sound, British Columbia, Canada. Macroscopic lesions were present in 11% of the scallops, and histopathology consisting of multifocal and diffuse haemocyte infiltration was observed in 44% of the specimens examined. Histologically, small Gram-negative intracellular bacteria-like particles were observed within necrotic haemocytes of the lesions, suggesting a bacterial aetiology. DNA was extracted from adductor muscle lesions of diseased scallops, and the 16s rDNA gene as well as the DNA-directed RNA polymerase beta subunit (rpoB) were amplified by PCR. Sequence analyses of the resulting 413 and 925 bp fragments were a 100% match to the reference sequence for Francisella halioticida, originally described as the cause of mortality in abalone from Japan. Isolation and culture of the bacteria was not possible at the time, as no further diseased specimens were available. Results from in situ hybridization assays as well as examination by transmission electron microscopy provide further evidence supporting the hypothesis that F. halioticida was the most probable causative agent of the lesions and mortality.

Proliferative renal myxosporidiosis in spawning coho salmon (Oncorhynchus kisutch) in British Columbia and Washington.

An unidentified myxosporean parasite (CKX) is described from the kidney of approximately 80% of spawning coho salmon Oncorhynchus kisutch (Walbaum) in British Columbia, Canada and Washington, United States of America. Morphological features were described using light and electron microscopy. Sequencing of polymerase chain reaction (PCR) amplified 18S ribosomal RNA gene and in situ hybridisation were used to further characterise CKX. The parasite occurred with a focal distribution within tubule epithelial cells, the tubule lumen and the interstitium as primary cells containing from one to at least 16 secondary cells. Luminal stages were degenerate and sporogony was not observed. In situ hybridisation using a digoxygenin-labelled DNA probe confirmed CKX to be the source of DNA used in PCR analyses. CKX 18S rDNA sequences were most similar (97%) to those of Sphaerospora oncorhynchi. Phylogenetic analysis revealed similarities among the 18S rDNA sequences of CKX, S. oncorhynchi and Myxidium lieberkuehni. CKX is hypothesised to be the abortive extrasporogonic development of a Sphaerospora sp. or Myxidium sp. occurring in immune-incompetent spawning and senescent salmon.

Preferential PCR amplification of parasitic protistan small subunit rDNA from metazoan tissues.

A "universal non-metazoan" polymerase chain reaction (UNonMet-PCR) that selectively amplifies a segment of nonmetazoan Small Subunit (SSU) rDNA gene was validated. The primers used were: 18S-EUK581-F (5'-GTGCCAGCAGCCGCG-3') and 18S-EUK1134-R (5'-TTTAAGTTTCAGCCTTGCG-3') with specificity provided by the 19-base reverse primer. Its target site is highly conserved across the Archaea, Bacteria, and eukaryotes (including fungi), but not most Metazoa (except Porifera, Ctenophora, and Myxozoa) which have mismatches at bases 14 and 19 resulting in poor or failed amplification. During validation, UNonMet-PCR amplified SSU rDNA gene fragments from all assayed protists (n = 16 from 7 higher taxa, including two species of marine phytoplankton) and Fungi (n = 3) but amplified very poorly or not at all most assayed Metazoa (n = 13 from 8 higher taxa). When a nonmetazoan parasite was present in a metazoan host, the parasite DNA was preferentially amplified. For example, DNA from the parasite Trypanosoma danilewskyi was preferentially amplified in mixtures containing up to 1,000 x more goldfish Carassius auratus (host) DNA. Also, the weak amplification of uninfected host (Chionoecetes tanneri) SSU rDNA did not occur in the presence of a natural infection with a parasite (Hematodinium sp.). Only Hematodinium sp. SSU rDNA was amplified in samples from infected C. tanneri. This UNonMet-PCR is a powerful tool for amplifying SSU rDNA from non-metazoan pathogens or symbionts that have not been isolated from metazoan hosts.