Recurrent and High‐frequency Use of the Emergency Department by Pediatric Patients

Objectives The authors sought to describe the epidemiology of and risk factors for recurrent and high‐frequency use of the emergency department (ED) by children. Methods This was a retrospective cohort study using a database of children aged 0 to 17 years, inclusive, presenting to 22 EDs of the Pediatric Emergency Care Applied Research Network (PECARN) during 2007, with 12‐month follow‐up after each index visit. ED diagnoses for each visit were categorized as trauma, acute medical, or chronic medical conditions. Recurrent visits were defined as any repeat visit; high‐frequency use was defined as four or more recurrent visits. Generalized estimating equations (GEEs) were used to measure the strength of associations between patient and visit characteristics and recurrent ED use. Results A total of 695,188 unique children had at least one ED visit each in 2007, with 455,588 recurrent ED visits in the 12 months following the index visits. Sixty‐four percent of patients had no recurrent visits, 20% had one, 8% had two, 4% had three, and 4% had four or more recurrent visits. Acute medical diagnoses accounted for most visits regardless of the number of recurrent visits. As the number of recurrent visits per patient rose, chronic diseases were increasingly represented, with asthma being the most common ED diagnosis. Trauma‐related diagnoses were more common among patients without recurrent visits than among those with high‐frequency recurrent visits (28% vs. 9%; p < 0.001). High‐frequency recurrent visits were more often within the highest severity score classifications. In multivariable analysis, recurrent visits were associated with younger age, black or Hispanic race or ethnicity, and public health insurance. Conclusions Risk factors for recurrent ED use by children include age, race and ethnicity, and insurance status. Although asthma plays an important role in recurrent ED use, acute illnesses account for the majority of recurrent ED visits. Resumen Objetivos Describir la epidemiología y los factores de riesgo de revista e hiperfrecuentación del servicio de urgencias (SU) por parte de los pacientes pediátricos. Metodología Estudio de cohorte retrospectivo mediante una base de datos de niños entre 0 y 17 años inclusive, que acudieron a 22 SU de la Pediatric Emergency Care Applied Research Network durante 2007, con un seguimiento de 12 meses tras cada visita índice. Los diagnósticos del SU de cada visita se clasificaron como traumatológico, médico agudo o enfermedades médicas crónicas. Las revisitas se definieron como cualquier visita repetida; la hiperfrecuentación se definió como cuatro o más revisitas. Se utilizaron ecuaciones de estimación generalizada para medir la fuerza de las asociaciones entre las características al paciente y la visita y la revisita del SU. Resultados Un total de 695.188 niños tuvieron al menos una visita al SU en 2007, con 455.588 revisitas al SU en los 12 meses tras las visitas índice. Un 64% de los pacientes no tuvieron revisitas, un 20% tuvo una, un 8% tuvo dos, un 4% tuvo tres y un 4% tuvo cuatro o más revisitas. Los diagnósticos médicos agudos representan la mayoría de las visitas, con independencia del número de revisitas. A medida que el número de revisitas por paciente aumentaba, las enfermedades crónicas estaban más representadas, y el asma fue el diagnóstico más común en el SU. Los diagnósticos relacionados con lo traumatológico fueron más frecuentes entre los pacientes sin revisitas que entre aquéllos con hiperfrecuentación (28% vs. 9%; p < 0,001). La alta frecuencia de revisitas fue más frecuente en las clasificaciones de gravedad más altas. En el análisis multivariable, las revisitas se asociaron con una edad más joven, raza o etnia negra o hispana, y la tenencia de un seguro de salud público. Conclusiones Los factores de riesgo para la revisita al SU por los niños incluyen la edad, la raza o etnia, y el tipo de seguro médico. Aunque el asma juega un papel importante en la revisita al SU, las enfermedades agudas representan la mayoría de la revistas al SU.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/106853/1/acem12347.pd

Occult Pneumothoraces in Children With Blunt Torso Trauma

Objectives Plain chest x‐ray (CXR) is often the initial screening test to identify pneumothoraces in trauma patients. Computed tomography (CT) scans can identify pneumothoraces not seen on CXR (“occult pneumothoraces”), but the clinical importance of these radiographically occult pneumothoraces in children is not well understood. The objectives of this study were to determine the proportion of occult pneumothoraces in injured children and the rate of treatment with tube thoracostomy among these children. Methods This was a planned substudy from a large prospective multicenter observational cohort study of children younger than 18 years old evaluated in emergency departments (EDs) in the Pediatric Emergency Care Applied Research Network (PECARN) for blunt torso trauma from May 2007 to January 2010. Children with CXRs as part of their trauma evaluations were included for analysis. The faculty radiologist interpretations of the CXRs and any subsequent imaging studies, including CT scans, were reviewed for the absence or presence of pneumothoraces. An “occult pneumothorax” was defined as a pneumothorax that was not identified on CXR, but was subsequently demonstrated on cervical, chest, or abdominal CT scan. Rates of pneumothoraces and placement of tube thoracostomies and rate differences with 95% confidence intervals (CIs) were calculated. Results Of 12,044 enrolled in the parent study, 8,020 (67%) children (median age = 11.3 years, interquartile range [IQR] = 5.3 to 15.2 years) underwent CXRs in the ED, and these children make up the study population. Among these children, 4,276 had abdominal CT scans performed within 24 hours. A total of 372 of 8,020 children (4.6%; 95% CI = 4.2% to 5.1%) had pneumothoraces identified by CXR and/or CT. The CXRs visualized pneumothoraces in 148 patients (1.8%; 95% CI = 1.6% to 2.2%), including one false‐positive pneumothorax, which was identified on CXR, but was not demonstrated on CT. Occult pneumothoraces were present in 224 of 372 (60.2%; 95% CI = 55.0% to 65.2%) children with pneumothoraces. Tube thoracostomies were performed in 85 of 148 (57.4%; 95% CI = 49.0% to 65.5%) children with pneumothoraces on CXR and in 35 of 224 (15.6%; 95% CI = 11.1% to 21.1%) children with occult pneumothoraces (rate difference = –41.8%; 95% CI = –50.8 to –32.3%). Conclusions In pediatric patients with blunt torso trauma, pneumothoraces are uncommon, and most are not identified on the ED CXR. Nearly half of pneumothoraces, and most occult pneumothoraces, are managed without tube thoracostomy. Observation, including in children requiring endotracheal intubation, should be strongly considered during the initial management of children with occult pneumothoraces. Resumen Objetivos La radiografía de tórax simple (RXT) es a menudo la prueba de despistaje inicial para identificar los neumotórax en los pacientes con traumatismo. La tomografía computarizada (TC) puede identificar neumotórax no vistos en la RXT (“neumotórax ocultos”), aunque la importancia clínica de estos neumotórax radiográficamente ocultos en los niños no está muy estudiada. Los objetivos de este estudio fueron determinar la proporción de neumotórax ocultos en los niños accidentados y el porcentaje de tratamiento con tubo de toracostomía en estos niños. Metodología Subestudio diseñado a partir de un gran estudio observacional de cohorte prospectivo multicéntrico de niños menores de 18 años atendidos en los servicios de urgencias (SU) de la Pediatric Emergency Care Applied Research Network (PECARN) que habían sido evaluados por traumatismo torácico cerrado de mayo de 2007 a enero de 2010. Se incluyeron en el análisis los niños en los que la RXT fue parte de la evaluación inicial del traumatismo. Las interpretaciones del radiólogo de las RXT y de cualquier estudio de imagen posterior, incluyendo a TC, se revisaron para la ausencia o presencia de neumotórax. Se definió “neumotórax oculto” como un neumotórax que no fue identificado en la RXT pero que fue posteriormente visualizado en la TC abdominal, torócica o cervical. Se calcularon los porcentajes de neumotórax e inserción de tubo de toracostomía y las diferencias de sus porcentajes con los intervalos de confianza (IC) al 95%. Resultados De los 12.044 incluidos en el estudio principal, se llevo a cabo una RXT en el SU en 8.020 (67%) niños (mediana de edad 11,3 años, rango intercuartílico 5,3 a 15,2), que constituyeron la población de estudio. De estos niños, 4.276 tuvieron una TC realizada en las primeras 24 horas. En 372 de los 8.020 niños (4,6%; IC 95% = 4,2% a 5,1%) se identificó un neumotórax en la RXT y/o la TC. La RXT mostró neumotórax en 148 pacientes (1,8%; IC 95% = 1,6% a 2,2%), incluyendo un falso positivo de neumotórax, que fue identificado en la RXT pero que no fue demostrado en la TC. Los neumotórax ocultos estuvieron presentes en 224 de los 372 niños con neumotórax (60,2%; IC 95% = 55,0% a 65,2%). Se insertaron tubos de toracostomía en 85 de los 148 niños con neumotórax en la RXT (57,4%; IC 95% = 49,0% a 65,5%), y en 35 de los 224 niños con neumotórax oculto (15,6%; IC 95% = 11,1% a 21,1%; diferencia de porcentajes ‐41,8%; IC 95% = ‐50,8 a ‐32,3%). Conclusiones En los pacientes pediátricos con traumatismo torácico cerrado, los neumotórax son poco frecuentes, y la mayoría no son identificados en la RXT en el SU. Casi la mitad de los neumotórax, y la mayoría de los neumotórax ocultos son manejados sin tubo de toracostomía. La observación, incluyendo en los niños que requieren intubación endotraqueal, debería ser especialmente considerada durante el manejo inicial de los niños con neumotórax ocultos.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/106913/1/acem12344.pd

Assessment and correction of skinfold thickness equations in estimating body fat in children with cerebral palsy

To assess the accuracy of skinfold equations in estimating percentage body fat in children with cerebral palsy (CP), compared with assessment of body fat from dual energy X-ray absorptiometry (DXA)

Primary and secondary defences of squid to cruising and ambush fish predators : variable tactics and their survival value

Author Posting. © The Author(s), 2010. This is the author's version of the work. It is posted here by permission of Elsevier B.V. for personal use, not for redistribution. The definitive version was published in Animal Behaviour 81 (2011): 585-594, doi:10.1016/j.anbehav.2010.12.002.Longfin squid (Loligo pealeii) were exposed to two predators, bluefish (Pomatomus saltatrix) and summer flounder (Paralichthys dentatus), representing cruising and ambush foraging tactics, respectively. During 35 trials, 86 predator–prey interactions were evaluated between bluefish and squid, and in 29 trials, 92 interactions were assessed between flounder and squid. With bluefish, squid predominantly used stay tactics (68.6%, 59/86) as initial responses. The most common stay response was to drop to the bottom, while showing a disruptive body pattern, and remain motionless. In 37.0% (34/92) of interactions with flounder, squid did not detect predators camouflaging on the bottom and showed no reaction prior to being attacked. Squid that did react, used flee tactics more often as initial responses (43.5%, 40/92), including flight with or without inking. When all defence behaviours were considered concurrently, flight was identified as the strongest predictor of squid survival during interactions with each predator. Squid that used flight at any time during an attack sequence had high probabilities of survival with bluefish (65%, 20/31) and flounder (51%, 18/35). The most important deimatic/protean behaviour used by squid was inking. Inking caused bluefish to startle (deimatic) and abandon attacks (probability of survival = 61%, 11/18) and caused flounder to misdirect (protean) attacks towards ink plumes rather than towards squid (probability of survival = 56%, 14/25). These are the first published laboratory experiments to evaluate the survival value of antipredator behaviours in a cephalopod. Results demonstrate that squid vary their defence tactics in response to different predators and that the effectiveness of antipredator behaviours is contingent upon the behavioural characteristics of the predator encountered.This study was funded by the Woods Hole Oceanographic Institution Sea Grant Program, the Massachusetts Marine Fisheries Institute, the University of Massachusetts and the Five College Coastal and Marine Sciences Program. R. T. Hanlon acknowledges partial support from ONR grant N000140610202 and the Sholley Foundation

Evaluation of a minimally invasive glucose biosensor for continuous tissue monitoring

We describe here a minimally invasive glucose biosensor based on a microneedle array electrode fabricated from an epoxy-based negative photoresist (SU8 50) and designed for continuous measurement in the dermal compartment with minimal pain. These minimally invasive, continuous monitoring sensor devices (MICoMS) were produced by casting the structures in SU8 50, crosslinking and then metallising them with platinum or silver to obtain the working and reference electrodes, respectively. The metallised microneedle array electrodes were subsequently functionalised by entrapping glucose oxidase in electropolymerised polyphenol (PP) film. Sensor performance in vitro showed that glucose concentrations down to 0.5 mM could be measured with a response times (T90) of 15 s. The effect of sterilisation by Co60 irradiation was evaluated. In preparation for further clinical studies, these sensors were tested in vivo in a healthy volunteer for a period of 3–6 h. The sensor currents were compared against point measurements obtained with a commercial capillary blood glucometer. The epoxy MICoMS devices showed currents values that could be correlated with these

Effects of antiplatelet therapy on stroke risk by brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases: subgroup analyses of the RESTART randomised, open-label trial

Background Findings from the RESTART trial suggest that starting antiplatelet therapy might reduce the risk of recurrent symptomatic intracerebral haemorrhage compared with avoiding antiplatelet therapy. Brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases (such as cerebral microbleeds) are associated with greater risks of recurrent intracerebral haemorrhage. We did subgroup analyses of the RESTART trial to explore whether these brain imaging features modify the effects of antiplatelet therapy

A mouse model with a frameshift mutation in the nuclear factor I/X (NFIX) gene has phenotypic features of Marshall-Smith syndrome

The nuclear factor I/X (NFIX) gene encodes a ubiquitously expressed transcription factor whose mutations lead to two allelic disorders characterized by developmental, skeletal, and neural abnormalities, namely, Malan syndrome (MAL) and Marshall-Smith syndrome (MSS). NFIX mutations associated with MAL mainly cluster in exon 2 and are cleared by nonsense-mediated decay (NMD) leading to NFIX haploinsufficiency, whereas NFIX mutations associated with MSS are clustered in exons 6-10 and escape NMD and result in the production of dominant-negativemutant NFIX proteins. Thus, different NFIX mutations have distinct consequences on NFIX expression. To elucidate the in vivo effects of MSS-associated NFIX exon 7 mutations, we used CRISPR-Cas9 to generate mouse models with exon 7 deletions that comprised: a frameshift deletion of two nucleotides (Nfix Del2); in-frame deletion of 24 nucleotides (Nfix Del24); and deletion of 140 nucleotides (Nfix Del140). Nfix(+/Del)2, Nfix(+/Del24), Nfix(+/Del140), Nfix(Del24/Del24), and NfixDel140/Del140 mice were viable, normal, and fertile, with no skeletal abnormalities, but Nfix(Del2/Del2) mice had significantly reduced viability (p < 0.002) and died at 2-3 weeks of age. Nfix Del2 was not cleared by NMD, and Nfix(Del2/Del2) mice, when compared to Nfix(+/+) and Nfix(+/Del2) mice, had: growth retardation; short stature with kyphosis; reduced skull length; marked porosity of the vertebrae with decreased vertebral and femoral bone mineral content; and reduced caudal vertebrae height and femur length. Plasma biochemistry analysis revealed Nfix(Del2/Del2) mice to have increased total alkaline phosphatase activity but decreased C-terminal telopeptide and procollagen-type-1-N-terminal propeptide concentrations compared to Nfix(+/+) and Nfix(+/Del2) mice. Nfix(Del2/Del2) mice were also found to have enlarged cerebral cortices and ventricular areas but smaller dentate gyrus compared to Nfix(+/+) mice. Thus, Nfix(Del2/Del2) mice provide a model for studying the in vivo effects of NFIX mutants that escape NMD and result in developmental abnormalities of the skeletal and neural tissues that are associated with MSS. (c) 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research

A Systematic Analysis of Cell Cycle Regulators in Yeast Reveals That Most Factors Act Independently of Cell Size to Control Initiation of Division

Upstream events that trigger initiation of cell division, at a point called START in yeast, determine the overall rates of cell proliferation. The identity and complete sequence of those events remain unknown. Previous studies relied mainly on cell size changes to identify systematically genes required for the timely completion of START. Here, we evaluated panels of non-essential single gene deletion strains for altered DNA content by flow cytometry. This analysis revealed that most gene deletions that altered cell cycle progression did not change cell size. Our results highlight a strong requirement for ribosomal biogenesis and protein synthesis for initiation of cell division. We also identified numerous factors that have not been previously implicated in cell cycle control mechanisms. We found that CBS, which catalyzes the synthesis of cystathionine from serine and homocysteine, advances START in two ways: by promoting cell growth, which requires CBS's catalytic activity, and by a separate function, which does not require CBS's catalytic activity. CBS defects cause disease in humans, and in animals CBS has vital, non-catalytic, unknown roles. Hence, our results may be relevant for human biology. Taken together, these findings significantly expand the range of factors required for the timely initiation of cell division. The systematic identification of non-essential regulators of cell division we describe will be a valuable resource for analysis of cell cycle progression in yeast and other organisms