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Objective: To determine test characteristics of provider judgment for empiric antibiotic provision to patients undergoing testing for a sexually transmitted infection.Study Design: We conducted a retrospective cross-sectional electronic health record review of all patients aged 13-19 years who had Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) testing sent from an urban, academic pediatric emergency department in 2012. We abstracted data, including patient demographics, chief complaint, sexually transmitted infection test results, and treatment. We calculated test characteristics comparing clinician judgment for presumptive treatment for a sexually transmitted infection with the reference standard of the actual results of testing for a sexually transmitted infection.Results: Of 1223 patient visits meeting inclusion criteria, 284 (23.2%) had a positive GC and/or CT test result. Empiric treatment was provided in 615 encounters (50.3%). Provider judgment for presumptive treatment had an overall sensitivity of 67.6% (95% CI, 61.8-73.0) and a specificity of 55% (95% CI, 51.7-58.2) for accurate GC and/or CT detection.Conclusions: Many adolescents tested for GC and CT receive empiric treatment at the initial emergency department visit. Provider judgment may lack sufficient sensitivity and specificity for identifying infected patients, resulting in the potential for undertreatment of true disease, overtreatment of uninfected patients, or both. [ABSTRACT FROM AUTHOR]

Objectives To evaluate clinician adherence to guidelines for documentation of sexual history and screening for sexually transmitted infection (STI)/HIV infection during routine adolescent well visits. Secondary objectives were to determine patient and clinician factors associated with sexual history documentation and STI/HIV testing. Study design Retrospective, cross-sectional study of 1000 randomly selected 13- to 19-year-old routine well visits at all 29 pediatric primary care practices affiliated with a children's hospital. We evaluated frequency of documentation of sexual history and testing for gonorrhea (GC)/chlamydia (CT) and HIV testing. Multivariable logistic regression was performed to identify factors associated with documentation and testing. Results Of the 1000 patient visits reviewed, 212 (21.2%; 95% CI, 18.7-23.7) had a documented sexual history, of which 45 adolescents' (21.2%; 95% CI, 15.7-26.8) encounters were documented as being sexually active. Overall, 26 (2.6%; 95% CI, 1.6-3.6) patients were tested for GC/CT and 16 (1.6%; 95% CI, 0.8-2.4) were tested for HIV infection. In multivariable analyses, factors associated with sexual history documentation included older patient age, non-Hispanic black race/ethnicity, nonprivate insurance status, and care by female clinician. Factors associated with GC/CT testing included male gender, non-Hispanic black race/ethnicity, and nonprivate insurance. HIV testing was more likely to be performed on older adolescents, those of non-Hispanic black race/ethnicity, and those with nonprivate insurance. Conclusions Pediatric primary care clinicians infrequently document sexual histories and perform STI and HIV testing on adolescent patients. Future studies should investigate provider beliefs, clinical decision-making principles, and perceived barriers to improve the sexual health care of adolescents and evaluate interventions to increase rates of adolescent sexual health screening. [ABSTRACT FROM AUTHOR]

The widespread use of aluminum oxide nanoparticles (Al 2 O 3 NPs) unavoidably causes the release of NPs into the environment, potentially having unforeseen consequences for biological processes. Due to the well-known issue of Al phytoxicity, plant interactions with Al 2 O 3 NPs are cause for concern, but these interactions remain poorly understood. This study investigated the effects of Al 2 O 3 NPs on lettuce (Lactuca sativa L.) to elucidate the similarities and differences in plant growth responses when compared to those of Al ions. Seed germination, root length, biomass production, and uptake of Al and nutrients were measured from hydroponically-grown lettuce with varying concentrations of Al 2 O 3 NPs (0, 0.4, 1, and 2 mg/mL) or AlCl 3 (0, 0.04, 0.4, and 1 mg/mL). The Al 2 O 3 NPs treatments had a positive influence on root elongation, whereas AlCl 3 significantly reduced emerging root lengths. While 0.4 mg/mL Al 2 O 3 NPs promoted biomass, 1 and 2 mg/mL showed a 10.4% and 17.9% decrease in biomass, respectively, when compared to the control. Similarly, 0.4 and 1 mg/mL AlCl 3 reduced biomass to 22.3% and 9.96%, respectively. Both treatments increased Al uptake by roots linearly; however, translocation of Al 2 O 3 NPs into shoots was limited, whereas translocation of AlCl 3 increased with increasing treatment concentration. Further, Al 2 O 3 NPs adsorbed on the roots serve as adsorbents for macronutrients, promoting their absorption and uptake in plants, but not micronutrients. Calcium uptake was the most inhibited by AlCl 3. A new in vivo imaging technique, with elemental analysis, confirmed that Al 2 O 3 NPs were assimilated as particles, not ions, suggesting that the observed phytotoxicity is not due to Al ions being released from the NPs. Thus, it is concluded that Al 2 O 3 NPs pose less phytoxicity than AlCl 3 , primarily due to NPs role on stimulated root growth, significant adsorption/aggregation on roots, limited lateral translocation to shoots, and increased uptake of macronutrients. Unlabelled Image • The Al 2 O 3 NPs aggregated onto root serve as adsorbents for plant macronutrients. • Al 2 O 3 NPs help enhance uptake of plant macronutrients, but reduce micronutrients. • In vivo images of Al 2 O 3 NPs in tissue indicate NPs are assimilated as particles. • Al 2 O 3 NPs possess a lower potential than Al ions to translocate in shoots. • Al 2 O 3 NPs do not undergo biotransformation after being taken up by roots. [ABSTRACT FROM AUTHOR]

Study Objective: Recognition of pediatric sepsis is a key clinical challenge. We evaluate the performance of a sepsis recognition process including an electronic sepsis alert and bedside assessment in a pediatric emergency department (ED).Methods: This was a cohort study with quality improvement intervention in a pediatric ED. Exposure was a positive electronic sepsis alert, defined as elevated pulse rate or hypotension, concern for infection, and at least one of the following: abnormal capillary refill, abnormal mental status, or high-risk condition. A positive electronic sepsis alert prompted team assessment or huddle to determine need for sepsis protocol. Clinicians could initiate team assessment or huddle according to clinical concern without positive electronic sepsis alert. Severe sepsis outcome defined as activation of the sepsis protocol in the ED or development of severe sepsis requiring ICU admission within 24 hours.Results: There were 182,509 ED visits during the study period, with 86,037 before electronic sepsis alert implementation and 96,472 afterward, and 1,112 (1.2%) positive electronic sepsis alerts. Overall, 326 patients (0.3%) were treated for severe sepsis within 24 hours. Test characteristics of the electronic sepsis alert alone to detect severe sepsis were sensitivity 86.2% (95% confidence interval [CI] 82.0% to 89.5%), specificity 99.1% (95% CI 99.0% to 99.2%), positive predictive value 25.4% (95% CI 22.8% to 28.0%), and negative predictive value 100% (95% CI 99.9% to 100%). Inclusion of the clinician screen identified 43 additional electronic sepsis alert-negative children, with severe sepsis sensitivity 99.4% (95% CI 97.8% to 99.8%) and specificity 99.1% (95% CI 99.1% to 99.2%). Electronic sepsis alert implementation increased ED sepsis detection from 83% to 96%.Conclusion: Electronic sepsis alert for severe sepsis demonstrated good sensitivity and high specificity. Addition of clinician identification of electronic sepsis alert-negative patients further improved sensitivity. Implementation of the electronic sepsis alert was associated with improved recognition of severe sepsis. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate accuracy of 2 established administrative methods of identifying children with sepsis using a medical record review reference standard.Study Design: Multicenter retrospective study at 6 US children's hospitals. Subjects were children >60 days to <19 years of age and identified in 4 groups based on International Classification of Diseases, Ninth Revision, Clinical Modification codes: (1) severe sepsis/septic shock (sepsis codes); (2) infection plus organ dysfunction (combination codes); (3) subjects without codes for infection, organ dysfunction, or severe sepsis; and (4) infection but not severe sepsis or organ dysfunction. Combination codes were allowed, but not required within the sepsis codes group. We determined the presence of reference standard severe sepsis according to consensus criteria. Logistic regression was performed to determine whether addition of codes for sepsis therapies improved case identification.Results: A total of 130 out of 432 subjects met reference SD of severe sepsis. Sepsis codes had sensitivity 73% (95% CI 70-86), specificity 92% (95% CI 87-95), and positive predictive value 79% (95% CI 70-86). Combination codes had sensitivity 15% (95% CI 9-22), specificity 71% (95% CI 65-76), and positive predictive value 18% (95% CI 11-27). Slight improvements in model characteristics were observed when codes for vasoactive medications and endotracheal intubation were added to sepsis codes (c-statistic 0.83 vs 0.87, P = .008).Conclusions: Sepsis specific International Classification of Diseases, Ninth Revision, Clinical Modification codes identify pediatric patients with severe sepsis in administrative data more accurately than a combination of codes for infection plus organ dysfunction. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate pediatric primary care provider (PCP) HIV screening practices, knowledge, and attitudes. Study design: Anonymous cross-sectional, internet-based survey of pediatric PCPs from 29 primary care practices. Survey items assessed current HIV screening practices and knowledge, attitudes, and perceived barriers towards screening. Provider demographics and practice characteristics were analyzed for associations with screening through logistic regression. Results: Of 190 PCPs, there were 101 evaluable responses (response rate: 53.2%). PCPs reported a screening rate for HIV of 39.6% (“most” or “all of the time”) during routine adolescent visits compared with violence (60.4%), substance abuse (92.1%), and depression (94.1%) (P < .001). Less than 10% of PCPs correctly answered questions related to Centers for Disease Control and Prevention and state HIV screening recommendations. Of 20 potential HIV screening barriers assessed, mean number of reported barriers was 4.8 (SD ± 2.9); with most concerns related to confidentiality, time for counseling, and follow-up. In a multivariable model, the only factor significantly associated with HIV screening “most” or “all of the time” during routine adolescent visits was urban practice site (aOR 9.8, 95% CI 2.9, 32.9). Provider type, sex, years since training, HIV screening guideline knowledge, and endorsing ≤5 barriers were not associated with HIV screening. Conclusions: Although providers practicing in urban areas were more likely to report screening adolescents for HIV than those in suburban areas, overall self-reported screening rates were low, and several barriers were identified commonly. Future interventions should target increasing providers' knowledge and addressing concerns about confidentiality, requirements and counseling time, and follow-up of results. [Copyright &y& Elsevier]

Study objective: We identify factors in emergency department (ED) patients presenting with apparent life-threatening events that distinguish those safe for discharge from those warranting hospitalization. Methods: Data were prospectively collected on all subjects presenting to 4 EDs with apparent life-threatening events. Patients were observed for subsequent events or interventions, defined a priori, which would have mandated hospital admission (eg, hypoxia, apnea, bradycardia that is not self-resolving, or serious bacterial infection). For patients discharged from the ED, telephone follow-up was arranged. Classification and regression tree analysis was performed to delineate admission predictors. Results: A total of 832 subjects were enrolled. The overall median age was 31.5 days (interquartile range 10 to 90 days); 427 (51.3%) were male patients, and 513 (61.7%) arrived by emergency medical services. One hundred ninety-one (23.0%) infants had a significant intervention warranting hospitalization. One hundred thirty-seven patients (16.5%) met predetermined criteria that would obviously mandate hospital admission (eg, persistent hypoxia requiring oxygen) by the end of their ED stay. In addition to these patients for whom it was obvious that admission would be necessary in the ED, classification and regression tree analysis (receiver operating curve=0.90) yielded 2 factors predictive of hospitalization: having a significant medical history and having greater than 1 apparent life-threatening event in 24 hours. The sensitivity was 89.0% (95% confidence interval 83.5% to 92.9%); specificity was 61.9% (95% confidence interval 58.0% to 65.7%). Conclusion: We found 3 variables (obvious need for admission, significant medical history, >1 apparent life-threatening event in 24 hours) that identified most but not all infants with apparent life-threatening events necessitating admission. These variables require external validation and reliability assessment before clinical implementation. [Copyright &y& Elsevier]