Gaps in pediatric emergency medicine education of emergency medicine residents: A needs assessment of recent graduates.

Background: More than 90% of pediatric patients presenting to emergency departments (EDs) in the United States are evaluated and treated in community-based EDs. Recent evidence suggests that mortality outcomes may be worse for critically ill pediatric patients treated at community EDs. The disparate mortality outcomes may be due to inconsistency in pediatric-specific education provided to emergency medicine (EM) trainees during residency training. There are few studies surveying recently graduated EM physicians assessing perceived gaps in the pediatric emergency medicine (PEM) education they received during residency. Methods: This was a prospective, survey-based, descriptive cohort study of EM residency graduates from 10 institutions across the United States who were <5 years out from residency training. Deidentified surveys were distributed via email. Results: A total of 222 responses were obtained from 570 eligible participants (39.1%). Non-ED pediatric rotations during residency training included pediatric intensive care (60%), pediatric anesthesia (32.4%), neonatal intensive care unit (26.1%), and pediatric wards (17.1%). A large percentage (42.8%) of respondents felt uncomfortable managing neonates and performing tube thoracostomy on pediatric patients (56.3%). The EM graduate's satisfaction with pediatric simulation-based training during residency was positively associated with comfort caring for neonates and infants (p < 0.0070 and p < 0.0002) and performing endotracheal intubation (p < 0.0027), lumbar puncture (p < 0.0004), and Pediatric Advanced Life Support resuscitation (p < 0.0001). Conclusions/discussion: This survey-based cohort study found considerable variation in pediatric-specific experiences during EM residency training and in perceived comfort managing pediatric patients. In general, participants were more comfortable managing older children. This study suggests that the greatest perceived knowledge gaps in PEM were neonatal medicine/resuscitation and pediatric cardiac arrest. Future research will continue to address larger cohorts, representative of the PEM education provided to EM physicians in the United States to promote future educational initiatives.

SARS-CoV-2 breakthrough infections among vaccinated individuals with rheumatic disease: results from the COVID-19 Global Rheumatology Alliance provider registry.

OBJECTIVE: While COVID-19 vaccination prevents severe infections, poor immunogenicity in immunocompromised people threatens vaccine effectiveness. We analysed the clinical characteristics of patients with rheumatic disease who developed breakthrough COVID-19 after vaccination against SARS-CoV-2. METHODS: We included people partially or fully vaccinated against SARS-CoV-2 who developed COVID-19 between 5 January and 30 September 2021 and were reported to the Global Rheumatology Alliance registry. Breakthrough infections were defined as occurring ≥14 days after completion of the vaccination series, specifically 14 days after the second dose in a two-dose series or 14 days after a single-dose vaccine. We analysed patients' demographic and clinical characteristics and COVID-19 symptoms and outcomes. RESULTS: SARS-CoV-2 infection was reported in 197 partially or fully vaccinated people with rheumatic disease (mean age 54 years, 77% female, 56% white). The majority (n=140/197, 71%) received messenger RNA vaccines. Among the fully vaccinated (n=87), infection occurred a mean of 112 (±60) days after the second vaccine dose. Among those fully vaccinated and hospitalised (n=22, age range 36-83 years), nine had used B cell-depleting therapy (BCDT), with six as monotherapy, at the time of vaccination. Three were on mycophenolate. The majority (n=14/22, 64%) were not taking systemic glucocorticoids. Eight patients had pre-existing lung disease and five patients died. CONCLUSION: More than half of fully vaccinated individuals with breakthrough infections requiring hospitalisation were on BCDT or mycophenolate. Further risk mitigation strategies are likely needed to protect this selected high-risk population.

Avoiding Misdiagnosis of Abdominal Vascular Catastrophes.

Abdominal vascular emergencies are an uncommon entity in emergency medicine, but when they present, they are often catastrophic. These time-sensitive and life-threatening diagnoses are often hidden in nonspecific complaints such as nausea, vomiting, or flank pain, so the emergency physician must remain diligent and consider these in the differential diagnoses. The following is an overview of the more common of these abdominal vascular emergencies, in the hope that they help the Emergency Physician avoid the misdiagnosis and subsequent vascular catastrophe that would follow.

Assessment of bacterial diversity in Hyalomma aegyptium, H. marginatum and H. excavatum ticks through tag-encoded pyrosequencing.

Ticks are among the most significant human-biting ectoparasites and they play a major role in transmission of many pathogenic agents to humans. In the present study, three species of Hyalomma ticks, Hyalomma aegyptium, H. marginatum and H. excavatum, were examined for the presence of zoonotic bacteria, both male and female ticks alike. Examination of microbial diversity with tag-encoded pyrosequencing indicates that H. marginatum and H. excavatum were more diversity rich than H. aegyptium. Although numerous pathogenic and non-pathogenic bacterial genera were detected, including Acidovorax, Bacillus, Bacteroides, Bdellovibrio, Clostridium, Curvibacter, Escherichia, Flavobacterium, Limnohabitans, Paenibacillus, Ralstonia, Sarcina, Sediminibacterium, Segetibacter Stenotrophomonas and Variovorax, the predominant zoonotic bacteria represented in these ticks were genera Borrelia, Francisella, and Rickettsia. To the authors' knowledge, this work represents the first detection of Yersinia enterocolitica in the tick H. excavatum, raising questions regarding the vector competency of this tick, as well as associations of different disease representations perhaps through previously unforeseen routes of pathogen introduction. Likewise, similar questions are related to the presence of Legionella pneumophila in one H. excavatum sample.

Gesture and intonation are "sister systems" of infant communication: Evidence from regression patterns of language development.

This study investigates infants' transition from nonverbal to verbal communication using evidence from regression patterns. As an example of regressions, prelinguistic infants learning American Sign Language (ASL) use pointing gestures to communicate. At the onset of single signs, however, these gestures disappear. Petitto (1987) attributed the regression to the children's discovery that pointing has two functions, namely, deixis and linguistic pronouns. The 1:2 relation (1 form, 2 functions) violates the simple 1:1 pattern that infants are believed to expect. This kind of conflict, Petitto argued, explains the regression. Based on the additional observation that the regression coincided with the boundary between prelinguistic and linguistic communication, Petitto concluded that the prelinguistic and linguistic periods are autonomous. The purpose of the present study was to evaluate the 1:1 model and to determine whether it explains a previously reported regression of intonation in English. Background research showed that gestures and intonation have different forms but the same pragmatic meanings, a 2:1 form-function pattern that plausibly precipitates the regression. The hypothesis of the study was that gestures and intonation are closely related. Moreover, because gestures and intonation change in the opposite direction, the negative correlation between them indicates a robust inverse relationship. To test this prediction, speech samples of 29 infants (8 to 16 months) were analyzed acoustically and compared to parent-report data on several verbal and gestural scales. In support of the hypothesis, gestures alone were inversely correlated with intonation. In addition, the regression model explains nonlinearities stemming from different form-function configurations. However, the results failed to support the claim that regressions linked to early words or signs reflect autonomy. The discussion ends with a focus on the special role of intonation in children's transition from "prelinguistic" communication to language.

Phase diagram and thermal expansion measurements on the system URu2-xFexSi2.

Thermal expansion, electrical resistivity, magnetization, and specific heat measurements were performed on URu2-xFexSi2 single crystals for various values of Fe concentration x in both the hidden-order (HO) and large-moment antiferromagnetic (LMAFM) regions of the phase diagram. Our results show that the paramagnetic (PM) to HO and LMAFM phase transitions are manifested differently in the thermal expansion coefficient. The uniaxial pressure derivatives of the HO/LMAFM transition temperature T0 change dramatically when crossing from the HO to the LMAFM phase. The energy gap also changes consistently when crossing the phase boundary. In addition, for Fe concentrations at xc ≈ 0.1, we observe two features in the thermal expansion upon cooling, one that appears to be associated with the transition from the PM to the HO phase and another one at lower temperature that may be due to the transition from the HO to the LMAFM phase.

Traumatic rupture of gastric pull-up after apparent mild thoracic trauma: a case report and literature review.

While elderly patients account for only 10-12% of all trauma victims, they consume 25% of trauma-related health care resources, with higher rates of mortality and complication. Presently described is the case of an elderly patient who presented to the emergency department (ED) following mild thoracic trauma, with previous history of gastric pull-up surgery. The patient had consulted another facility 48 hours earlier and was prescribed analgesia and x-ray follow-up for a mechanical fall and pain in the lower rib cage. At arrival, the patient complained of increasing dyspnea and pain at the right hemithorax. X-ray showed right hemithorax effusion, and contrast computed tomography (CT) demonstrated a large amount of contrast filling the pleural space and a relatively small point of gastric pull-up rupture in the stomach. The patient was referred to the cardiothoracic unit, but was unresponsive upon arrival and died. The aim of the present report was to raise the index of clinical suspicion of traumatic rupture of the gastric pull-up following traumatic chest injury, and to affirm that contrast CT should be the gold standard for diagnosis.

List intonation in pre-schoolers with normal and disordered language development.

The principal aim of this study was to evaluate pre-schoolers' expressive intonation in light of current debates about the underlying nature of language impairment (LI). Children with LI typically have deficits in grammar, a component of language that is phonologically represented on the segmental level. The hypothesis is that children with LI do not have deficits of this type when grammar is conveyed by intonation, a pitch-based component of language that is phonologically represented on the suprasegmental level. This study focused on the richly diversified suprasegmental patterns of sentences in which the speaker produces a series of items in a list. To address the hypothesis, list intonation in the speech of 4-year-olds with and without LI was acoustically analysed. Lists produced by children with LI were comparable to those produced by children with normal language development (NL). The results do not support the claim that LI stems from a poor understanding of grammatical principles. Rather, LI reflects an underlying impairment of segmental information processing. The discussion focuses on two characteristics of pitch contours which may account for the resilience of intonation in children with LI. Namely, steady state versus transient signals and universal symbol meanings versus arbitrary relationships between form and function.

The development of falling intonation in young children with cochlear implants: a 2-year longitudinal study.

This article describes the development of intonation in 12 cochlear implant (CI) recipients. In a previously reported study of the first year of CI use, children who were implanted late (after 24 months) acquired intonation more rapidly than the younger participants. The older children's advantage is plausibly owing to their greater maturity. However, children who were implanted early (before 25 months) did not have an advantage over the still younger control group of infants with normal hearing (NH), suggesting that the advantage requires a critical age of about 30 months. The younger CI-users reached this age in the second year of CI use. The results confirmed our expectation that even the younger CI recipients would acquire intonation more rapidly than infants with NH who had the same amount of robust hearing experience. Clinical implications are discussed in relation to the question of early versus late implantation.

Urinary tract infections in cats with chronic kidney disease.

Routine urine cultures were performed in cats with chronic kidney disease (CKD) to assess the overall prevalence and clinical signs associated with a positive urine culture (PUC). An occult urinary tract infection (UTI) was defined as a PUC not associated with clinical signs of lower urinary tract disease or pyelonephritis. Multivariate logistic and Cox proportional hazard regression models were used to evaluate the risk factors for an occult UTI and its relationship with survival. There were 31 PUCs from 25 cats. Eighty-seven percent of PUCs had active urine sediments. The most common infectious agent was Escherichia coli and most bacteria were sensitive to amoxicillin-clavulanate. Eighteen of 25 cats had occult UTIs. Among cats with occult UTI, increasing age in female cats was significantly associated with PUC; no significant association between occult UTI and survival was found and serum creatinine was predictive of survival in the short term (200 days) only. In conclusion, among cats with CKD, those with occult UTI were more likely to be older and female, but there was no association with severity of azotaemia. The presence of an occult UTI, when treated, did not influence survival.

Cranialization in a cohort of 154 consecutive patients with frontal sinus fractures (1987-2007): review and update of a compelling procedure in the selected patient.

Retrospective review of charts of 180 consecutive patients with frontal sinus fractures managed by plastic surgeons at the University of Kentucky between 1987 and 2007 was performed with institutional review board approval. Twenty-six charts did not meet the criteria. The remaining 154 records provided 1-to-20-year follow-up. The study included 34 patients who underwent cranialization and 120 patients who did not. A low-complication rate of 6% after cranialization is ascribed by the authors to meticulous sinus mucosal debridement; thorough obliteration of the frontal sinus outflow tract (with sterile gelatin sponge pledgets and bone chips from the outer cortex of the temporoparietal skull); and avoidance of avascular barriers, such as abdominal fat. As high-resolution computerized tomography with parasaggital views was introduced, an increasing ability to preoperatively define the extent of injury of the medial and lateral sinus floor was observed. The authors conclude selective use of cranialization is indicated.

Factor structures for aggression and victimization among women who used aggression against male partners.

Theories and measures of women's aggression in intimate relationships are only beginning to be developed. This study provides a first step in conceptualizing the measurement of women's aggression by examining how well three widely used measures (i.e., the Revised Conflict Tactics Scales (CTS), the Sexual Experiences Survey [SES], and the Psychological Maltreatment of Women Inventory [PMWI]) perform in assessing women's perpetration of and victimization by aggression in their intimate relationships with men. These constructs were examined in a diverse sample of 412 African American, Latina, and White women who had all recently used physical aggression against a male intimate partner. The factor structures and psychometric properties of perpetration and victimization models using these measures were compared. Results indicate that the factor structure of women's perpetration differs from that of women's victimization in theoretically meaningful ways. In the victimization model, all factors performed well in contributing to the measurement of the latent victimization construct. In contrast, the perpetration model performed well in assessing women's physical and psychological aggression but performed poorly in assessing women's sexual aggression, coercive control, and jealous monitoring. Findings suggest that the power and control model of intimate partner violence (IPV) may apply well to women's victimization but not as well to their perpetration of violence.

Children's development of intonation during the first year of cochlear implant experience.

This article describes the longitudinal development of intonation in 18 deaf children who received cochlear implants (CIs) before the age of 3 years and 12 infants with typical development (TD) who served as controls. At the time their implants were activated, the children with CIs ranged in age from 9 to 36 months. Cross-group comparisons were made when the children had equivalent amounts of robust hearing experience but different chronological ages. This article reports the results for the 6-month period ending 9 months after activation of the child's device for children with CIs, and the 6-month period ending at 12 months of age for TD infants. The findings were compared with a model of early intonation development in children with normal hearing. The results indicated that all groups progressed through one or more of the stages predicted by the normative model. At the end of the study period, however, children who had received a CI later than 24 months reached a more mature stage of intonation development than younger CI recipients. Moreover, the older CI group reached the same stage of development as the TD infants who had 3 additional months of language listening experience. The findings suggest that the developmental advantage which older children had previously demonstrated shortly after activation of their CIs is maintained throughout most or all of the first year of CI use.

The intonation-syntax interface in the speech of individuals with Parkinson's disease.

PURPOSE: This study examined the effect of Parkinson's disease (PD) on the intonational marking of final and nonfinal syntactic boundaries and investigated whether the effect of PD on intonation was sex specific. METHOD: Eight women and 8 men with PD and 16 age- and sex-matched control participants read a passage at comfortable pitch, rate, and loudness. Nuclear tones from final and nonfinal syntactic boundaries in clauses and lists were extracted. Measures of fundamental frequency (F0) were made on each tone contour. RESULTS: Individuals with PD demonstrated impaired differentiation of syntactic boundary finality/nonfinality with contour direction. They produced a lower proportion of falling contours in final boundaries and a higher proportion of falling contours in nonfinal boundaries than did control participants. Although not mediated by syntax, the effect of PD on F0 standard deviation (F0 SD) and pitch range in semitones (PRST) was sex specific. Women with PD produced greater F0 SD and PRST than did men with PD and women without PD. Men with PD produced lower PRST than did men without PD. CONCLUSIONS: Impaired intonational marking of syntactic boundaries likely contributes to dysprosody and reduced communicative effectiveness in PD. The effect of PD on intonation was sex specific. The results are not fully explained by PD-related motor execution impairments.

Evaluation of the bacterial diversity of pressure ulcers using bTEFAP pyrosequencing.

BACKGROUND: Decubitus ulcers, also known as bedsores or pressure ulcers, affect millions of hospitalized patients each year. The microflora of chronic wounds such as ulcers most commonly exist in the biofilm phenotype and have been known to significantly impair normal healing trajectories. METHODS: Bacterial tag-encoded FLX amplicon pyrosequencing (bTEFAP), a universal bacterial identification method, was used to identify bacterial populations in 49 decubitus ulcers. Diversity estimators were utilized and wound community compositions analyzed in relation to metadata such as Age, race, gender, and comorbidities. RESULTS: Decubitus ulcers are shown to be polymicrobial in nature with no single bacterium exclusively colonizing the wounds. The microbial community among such ulcers is highly variable. While there are between 3 and 10 primary populations in each wound there can be hundreds of different species present many of which are in trace amounts. There is no clearly significant differences in the microbial ecology of decubitus ulcer in relation to metadata except when considering diabetes. The microbial populations and composition in the decubitus ulcers of diabetics may be significantly different from the communities in non-diabetics. CONCLUSIONS: Based upon the continued elucidation of chronic wound bioburdens as polymicrobial infections, it is recommended that, in addition to traditional biofilm-based wound care strategies, an antimicrobial/antibiofilm treatment program can be tailored to each patient's respective wound microflora.

Testing the Efficacy of INSIGHTS on Student Disruptive Behavior, Classroom Management, and Student Competence in Inner City Primary Grades.

A prevention trial tested the efficacy of INSIGHTS into Children's Temperament as compared to a Read Aloud attention control condition in reducing student disruptive behavior and enhancing student competence and teacher classroom management. Participants included 116 first and second grade students, their parents, and their 42 teachers in six inner city schools. Teachers completed the Sutter-Eyberg Student Behavior Inventory (SESBI) and the Teacher's Rating Scale of Child's Actual Competence and Social Acceptance (TRS) at baseline and again upon completion of the intervention. Boys participating in INSIGHTS, compared with those in the Read Aloud program, showed a significant decline in attentional difficulties and overt aggression toward others. Teachers in INSIGHTS, compared to those in the attention control condition, reported significantly fewer problems managing the emotional-oppositional behavior, attentional difficulties, and covert disruptive behavior of their male students. They also perceived the boys as significantly more cognitively and physically competent.

Assessment of the Accutrend GCT and PTS CardioChek meters to measure blood triglyceride concentrations in cats.

Point-of-care (POC) meters that determine whole blood triglyceride (TG) concentrations are used in human medicine to monitor both fasting and post-prandial TG concentrations. The aim of this study was to evaluate their performance for determining feline TG concentrations. A total of 116 venous blood samples were collected from 55 cats. TG concentrations were measured in whole blood using two meters: the Accutrend glucose cholesterol triglyceride (GCT) (GCT: Roche Diagnostics) and PTS CardioChek (PTS - Polymer Technology Systems), and results compared to those determined by a National Association of Testing Authorities (NATA) accredited veterinary laboratory. The GCT was not suitable for use in cats with normal TG concentrations (<0.9 mmol/l), as it overestimated almost 80% of the values; however, this device performed better with TG concentrations between 0.9 and 2.0 mmol/l. The PTS meter performed well in cats with normal TG concentrations, correctly classifying 90% of values as 'normal', and fairly well with TG concentrations <2.0 mmol/l. The PTS meter could be used to determine whether cats have normal fasting TG concentrations or predict mild elevations in serum TG, whereas the GCT meter can only be used to predict cats with elevated TG concentrations. Although both meters have limitations in determining some TG concentrations, the PTS in particular, could be used as a screening tool to distinguish normal cats to those with hypertriglyceridaemia.

Evaluation of two portable meters for determination of blood triglyceride concentration in dogs.

OBJECTIVE: To evaluate agreement between 2 portable triglyceride meters and a veterinary laboratory for measurement of blood triglyceride concentrations in dogs and evaluate effects of Hct and blood volume analyzed. SAMPLE POPULATION: 97 blood samples collected from 60 dogs. PROCEDURES: Triglyceride concentrations were measured in blood by use of 2 meters and compared with serum triglyceride concentrations determined by a veterinary laboratory. Within- and between-day precision, accuracy, and effects of blood volume and Hct were analyzed. RESULTS: Accuracy of both meters varied with triglyceride concentration, although both accurately delineated dogs with triglyceride concentrations < 180 mg/dL versus > or = 180 mg/dL. One meter had results with excellent overall correlation with results of the standard laboratory method, with a concordance correlation coefficient of 0.94 and mean difference of 20.3 mg/dL. The other meter had a good overall concordance correlation coefficient of 0.86 with a higher absolute mean difference of -27.7 mg/dL. Results were only affected by blood volume; triglyceride concentrations determined via both meters were significantly lower when 7 microL of EDTA-anticoagulated blood was used, compared with larger volumes. CONCLUSIONS AND CLINICAL RELEVANCE: 1 meter had greater accuracy in the range of 140 to 400 mg/dL and was therefore well suited to detect hypertriglyceridemia. The other meter was accurate with triglyceride values < 140 mg/dL and yielded results similar to those of the veterinary laboratory in the range of 140 to 400 mg/dL, therefore being suitable for determination of triglyceride concentrations in nonfed dogs and dogs with mildly high concentrations.

Does the inclusion criterion of women's aggression as opposed to their victimization result in samples that differ on key dimensions of intimate partner violence?

This study is among the first attempts to address a frequently articulated, yet unsubstantiated claim that sample inclusion criteria based on women's physical aggression or victimization will yield different distributions of severity and type of partner violence and injury. Independent samples of African American women participated in separate studies based on either inclusion criterion of women's physical aggression or victimization. Between-groups comparisons showed that samples did not differ in physical, sexual, or psychological aggression; physical, sexual, or psychological victimization; inflicted or sustained injury. Therefore, inclusion criterion based on physical aggression or victimization did not yield unique samples of "aggressors" and "victims."

Relationships among Women's Use of Aggression, Their Victimization, and Substance Use Problems: A Test of the Moderating Effects of Race/Ethnicity.

This study examined whether relationships among women's aggression, their victimization, and substance use problems were moderated by race/ethnicity. Four hundred and twelve community women (150 African Americans, 150 Latinas, and 112 Whites) who recently were aggressive against a male partner completed a 2-hour computer-assisted interview. ANOVA and path analysis revealed that (a) for all women, victimization and aggression were strongly related; (b) race/ethnicity moderated the relationships between victimization and alcohol and drug use problems; and (c) no groups evidenced a relationship between alcohol or drug use problems and aggression. Findings suggest that it is essential to develop culturally relevant, gender-specific interventions to reduce both women's aggression and victimization, as well as related negative behaviors such as alcohol and drug use.