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Chronic graft-versus-host disease (cGVHD) is the most common cause for non-relapse mortality postallogeneic hematopoietic stem cell transplant (HSCT). However, there are no well-defined biomarkers for cGVHD or late acute GVHD (aGVHD). This study is a longitudinal evaluation of metabolomic patterns of cGVHD and late aGVHD in pediatric HSCT recipients. A quantitative analysis of plasma metabolites was performed on 222 evaluable pediatric subjects from the ABLE/PBMTC1202 study. We performed a risk-assignment analysis at day + 100 (D100) on subjects who later developed either cGVHD or late aGVHD after day 114 to non-cGVHD controls. A second analysis at diagnosis used fixed and mixed multiple regression to compare cGVHD at onset to time-matched non-cGVHD controls. A metabolomic biomarker was considered biologically relevant only if it met all 3 selection criteria: (1) P ≤ .05; (2) effect ratio of ≥1.3 or ≤0.75; and (3) receiver operator characteristic AUC ≥0.60. We found a consistent elevation in plasma α-ketoglutaric acid before (D100) and at the onset of cGVHD, not impacted by cGVHD severity, pubertal status, or previous aGVHD. In addition, late aGVHD had a unique metabolomic pattern at D100 compared with cGVHD. Additional metabolomic correlation patterns were seen with the clinical presentation of pulmonary, de novo, and progressive cGVHD. α-ketoglutaric acid emerged as the single most significant metabolite associated with cGVHD, both in the D100 risk-assignment and later diagnostic onset analysis. These distinctive metabolic patterns may lead to improved subclassification of cGVHD. Future validation of these exploratory results is needed. This trial was registered at www.clinicaltrials.gov as #NCT02067832.

Objectives Thoracostomy is often a required treatment in patients with thoracic trauma; however, performing a thoracostomy using traditional techniques can have complications. Ultrasound can be a beneficial tool for identifying the correct thoracostomy insertion site. We designed a randomized prospective study to assess if ultrasound guidance can improve thoracostomy site identification over traditional techniques. Methods Emergency medicine residents were randomly assigned to use palpation or ultrasound to identify a safe insertion site for thoracostomy placement. The target population comprised of hemodynamically stable trauma patients who received an extended focused assessment with sonography for trauma (EFAST) and a chest computed tomography (CT) exam. The resident placed a radiopaque marker on the skin of the patient where a safe intercostal space was believed to be located, either by palpation or ultrasound. Clinical ultrasound faculty reviewed the CT to confirm marker placement relative to the diaphragm. A Fischer's exact test was used to analyze the groups. Results One hundred and forty-seven patients were enrolled in the study, 75 in the ultrasound group and 72 in the landmark group. This resulted in the placement of 271 total thoracostomy site markers, 142 by ultrasound and 129 by palpation and landmarks. The ultrasound group correctly identified thoracostomy insertion sites above the diaphragm in 97.2% (138/142) of patients, while the palpation group identified a safe insertion site in 88.4% (114/129) of patients (P = .0073). Conclusion This study found that emergency medicine residents are more likely to identify a safe tube thoracostomy insertion site in trauma patients by using ultrasound, as compared to using landmarks and palpation.

Objectives Ultrasound (US)-only confirmation of central venous catheter (CVC) placement has proven to be accurate and fast when compared with the current standard chest radiograph. This procedure depends on the detection of appropriately timed atrial bubbles during central line flushing, called the rapid atrial swirl sign (RASS). The most obvious barrier to increasing the use of this technique is appropriate education and training; therefore, we proposed a novel educational approach to training emergency department (ED) physicians in the confirmation of CVC location using US and then tested its effectiveness. Methods Using an online educational model, participants were taught the background and procedural steps to confirm CVC placement using US. Subsequently, they were asked to use this knowledge to place central lines in simulation and confirm them using US. They were tested with various scenarios, including correctly and incorrectly placed lines. Their accuracy was measured, and a survey was used to assess their satisfaction with the training and applicability to practice. Results A total of 47 ED physicians completed the online training module and 24 completed the simulation testing that followed. Results showed 100% accuracy in detecting appropriately timed RASS ( 2 seconds), and no RASS in simulation. All of the participants "agreed" or "strongly agreed" that the didactic and simulation sessions improved their understanding of US confirmation of central line placement. Conclusions The use of US to confirm central line placement can be effectively taught to ED physicians using short didactic and simulation-based training. This is a reasonable approach to integrate this protocol into practice, and allow for more widespread use of this emerging technique.

The aim of this study is to systematically compare rates of erosion and chronic pain after mesh insertion for pelvic organ prolapse (POP) and stress urinary incontinence (SUI) surgery. A systematic electronic search was performed on studies that evaluated the incidence of erosion and chronic pain after mesh insertion for POP or SUI. The primary outcome measurement was to compare mesh erosion rates for POP and SUI surgery. Secondary outcome measurements were incidence of de novo pain and a comparison of patient demographics for both surgeries. Twenty-six studies on 292,606 patients (n = 9077 for POP surgery and n = 283,529 for SUI surgery) met the inclusion criteria. Median follow-up was 26.38 ± 22.17 months for POP surgery and 39.33 ± 27.68 months for SUI surgery. Overall, the POP group were older (p

Symptomatic stress urinary incontinence (SUI) and pelvic organ prolapse (POP) refractory to conservative management with pelvic floor muscle training or vaginal pessaries may warrant surgical intervention with different forms of biologic or synthetic material. However, in recent years, several global regulatory agencies have issued health warnings and recalled several mesh products due to an increase in complications such as mesh erosion, infection, chronic pain, and perioperative bleeding. At present, current surgical treatment strategies for SUI and POP are aimed at developing biological graft materials with similar mechanical properties to established synthetic meshes, but with improved tissue integration and minimal host response. This narrative review aims to highlight recent studies related to the development of biomimetic and biologic graft materials as alternatives to traditional synthetic materials for SUI/POP repair in female patients. We also investigate complications and technical limitations associated with synthetic mesh and biological biomaterials in conventional SUI and POP surgery. Our findings demonstrate that newly developed biologic grafts have a lower incidence of adverse events compared to synthetic biomaterials. However there remains a significant disparity between success in preclinical trials and long-term clinical translation. Further characterization on the optimal structural, integrative, and mechanical properties of biological grafts is required before they can be reliably introduced into clinical practice for SUI and POP surgery. Impact statement Our review article aims to outline the clinical history of developments and controversies associated with the use of synthetic mesh materials in the surgical treatment of stress urinary incontinence and pelvic organ prolapse, as well as highlighting recent advancements in the area of biological graft materials and their potential importance in an area that remains an enduring issue for patients and clinicians alike. This article aims to provide a concise summary of previous controversies in the field of urinary incontinence, while evaluating the future of potential biomaterials in this field.

OBJECTIVES We evaluated the utility of focused cardiac ultrasound to predict the length of stay in patients presenting to the emergency department with dyspnea of unclear etiology. METHODS Patients with focused cardiac ultrasound examinations performed in the emergency department for dyspnea over a 34-month period were retrospectively identified. Patients were excluded if they had a prior diagnosis of heart failure, dialysis requirement, or an etiology of dyspnea unrelated to the volume status. Left ventricular function was categorized as normal or reduced, and the inferior vena cava was categorized as normal or increased volume. A fast limited ultrasound to investigate dyspnea (FLUID) score was calculated by adding 1 point for reduced left ventricular function and 1 point for increased volume, producing a score of 0, 1, or 2. RESULTS There were 123 patients included. There was a significant correlation between the FLUID score and length of stay, with longer stays for higher scores (FLUID score 0, 7.4 hours median; FLUID score 1, 2.34 days; FLUID score 2, 5.56 days; analysis of variance P

Background Local relapse is a predominant form of recurrence among pediatric patients with Hodgkin lymphoma (PHL). Although PHL radiotherapy doses have been approximately 20 Gy, adults with Hodgkin lymphoma receiving 30 to 36 Gy experience fewer in-field relapses. We investigated the dosimetric effect of such a dose escalation to the organs at risk (OARs). Materials and Methods Ten patients with PHL treated with proton therapy to 21 Gy involved-site radiation therapy (ISRT21Gy) were replanned to deliver 30 Gy by treating the ISRT to 30 Gy (ISRT30Gy), delivering 21 Gy to the ISRT plus a 9-Gy boost to postchemotherapy residual volume (rISRTboost), and delivering 30 Gy to the residual ISRT target only (rISRT30Gy). Radiation doses to the OARs were compared. Results The ISRT30Gy escalated the dose to the target by 42% but also to the OARs. The rISRTboost escalated the residual target dose by 42%, and the OAR dose by only 17% to 26%. The rISRT30Gy escalated the residual target dose by 42% but reduced the OAR dose by 25% to 46%. Conclusion Boosting the postchemotherapy residual target dose to 30Gy can allow for dose escalation with a slight OAR dose increase. Treating the residual disease for the full 30Gy, however, would reduce the OAR dose significantly compared with ISRT21Gy. Studies should evaluate these strategies to improve outcomes and minimize the late effects.

Background In 2008 the Council of Emergency Medicine Residency Directors delineated consensus recommendations for training in biliary ultrasound for the “detection of biliary pathology”. Objectives While studies have looked at the accuracy of emergency provider performed clinical ultrasound (ECUS), we sought to evaluated if ECUS could be diagnostic for acute cholecystitis and thus obviate the need for follow-up imaging. Method We reviewed all ECUS performed between 2012 and 2017 that had a matching radiology performed ultrasound (RADUS) and a discharge diagnosis. 332 studies were identified. The sensitivity and specificity of both ECUS and RADUS were compared to the patient’s discharge diagnosis. The agreement between the ECUS and RADUS was assessed using an unweighted Cohen’s Kappa. The time from patient arrival to diagnosis by ECUS and RADUS was also compared. Results Using discharge diagnosis as the gold standard ECUS was 67% (56–78%) sensitive, 88% (84–92%) specific, NPV 90% (87–95%), PPV 60% (50–71%), +LR 5.6 (3.9–8.2), −LR 0.37 (0.27–0.52) for acute cholecystitis. RADUS was 76% (66–87%) sensitive, 97% (95–99%) specific, NPV 95% (092–97%), PPV 86% (76–95%), +LR 25.6 (12.8–51.4), and −LR 0.24 (0.15–0.38). ECUS was able to detect gallstones with 93% (89–96%) sensitivity and 94% (90–98%) specificity leading to a NPV 90% (85–95%), PPV of 95% (92–98%), +LR 14.5 (7.7–27.4), −LR 0.08 (0.05–0.13). The unweighted kappa between ECUS and RADUS was 0.57. The median time between obtaining ECUS vs. RADUS diagnosis was 124 min. Conclusions ECUS can be beneficial in ruling out acute cholecystitis, but lacks the test characteristics to be diagnostic for acute cholecystitis.

Chronic graft-versus-host disease (cGVHD) and late acute graft-versus-host disease (L-aGVHD) are understudied complications of allogeneic hematopoietic stem cell transplantation in children. The National Institutes of Health Consensus Criteria (NIH-CC) were designed to improve the diagnostic accuracy of cGVHD and to better classify graft-versus-host disease (GVHD) syndromes but have not been validated in patients

BACKGROUND Previous studies have explored posthematopoietic cell transplant (HCT) outcomes by race in adults; however, pediatric data addressing this topic are scarce. PROCEDURE This retrospective registry study included 238 White (W) and 57 Black (B) children with hematologic malignancies (HM) receiving first allogeneic HCT between 2010 and 2019 at one of the five Florida pediatric HCT centers. RESULTS We found no differences between W and B children in transplant characteristics, other than donor type. There was a significant difference in use of human leukocyte antigen (HLA)-mismatched donors (HLA-MMD) (53% W, 71% B, p = .01). When comparing HLA-MMD use to fully HLA-matched donors, B had relative risk (RR) of 1.47 (95% CI 0.7-3) of receiving a mismatched unrelated donor (MMUD), RR of 2.34 (95% CI 1.2-4.4) of receiving a mismatched related donor (MMRD), and RR of 1.9 (95% CI 0.99-3.6) of receiving a mismatched cord blood donor (MMCBD) HCT, respectively. There was no significant difference in the incidence of aGVHD (48% W, 35% B), p = .1, or cGVHD (19% W, 28% B, p = .1), or primary cause of death. Overall 24-month survival was 61% (95% CI 55%-68%) for W, and 60% (95% CI 48-75) for B children, log-rank p = .7. While HLA matching improved survival in W children, the number of B children receiving HLA-matched HCT was too small to identify the impact of HLA matching on survival. CONCLUSIONS In this contemporary cohort of children with HM, we found that B children were more likely to receive HLA-MMD transplants, but this did not adversely affect survival or GVHD rates.

During the coronavirus 2019 pandemic we converted our liver transplant waitlist candidate education and support program to a virtual format and expanded it to include ongoing engagement sessions aimed to educate and empower patients to maximize opportunity for live donor liver transplantation. Over a period of 6 months from April 2020 to Sept 2020 we included 21 patients in this pilot quality improvement program. We collected data regarding patient response and potential donor referral activity. Overall, patient response was positive, and some patients saw progress toward live donor liver transplantation by fostering inquiry of potential live liver donors. Optimization of logistical aspects of the program including program flow, technology access, and utilization is required to enhance patient experience. Long-term follow-up is needed to assess impact on the outcome of transplantation rates. Future data collection and analysis should focus on assessment of any potential disparity that may result from utilization of virtual programming. Herein we provide a framework for this type of virtual program and describe our experience.

Understanding the physics of ultrasonography may seem like an unnecessary endeavor but having a solid understanding of what is behind the image can help you acquire the optimal image as well as correctly interpret the image. Ultrasound waves are mechanical waves which are at a frequency above the range of human hearing. They are sent into tissue and are returned through the transducer, allowing the machine to interpret what is returned. Doppler factors in frequency shifts to determine movement and direction. Adjusting the frequency affects the resolution and the penetration into the tissue, whereas adjusting the gain affects the amplitude of the signal returning to the transducer. There are numerous artifacts that are crucial to identifying pathology, recognizing normal anatomy and guiding image acquisition. Lastly, when performing a procedure, consider keeping probe marker and indicator on the same side to avoid confusion.

FPBCC was formed in 2018 by five pediatric transplant programs in Florida. One of the key objectives of the consortium is to provide outcome analyses by combining HCT data from all the participating centers in order to identify areas for improvement. In this first FPBCC landscape report we describe the patient and transplant characteristics of pediatric patients undergoing first allo and auto HCT between 2014 and 2016 in Florida. The source of data was eDBtC of the CIBMTR. Over the span of 3 years, a total of 230 pediatric patients underwent allo-HCT and 104 underwent auto-HCT at the participating centers. The most significant predictor of survival in allo-HCT recipients with malignant disorders was the degree of HLA- match, while in the recipients of allo-HCT with non-malignant disorders the predictors of survival included age, donor relationship and degree of HLA match. Our analyses identified the need to improve reporting of primary cause of death and improve on donor selection process given that the degree of HLA match remains the most important predictor of survival. This first FPBCC-wide review describes the trends in pediatric HCT activity between 2014 and 2016 among the participating centers in Florida and confirms feasibility of using eDBtC data platform and collaborative approach in order to identify areas for improvement in outcomes.

Inborn errors of immunity (IEI) are a genetically heterogeneous group of disorders with a broad clinical spectrum. Identification of molecular and functional bases of these disorders is important for diagnosis, treatment, and an understanding of the human immune response. We identified 6 unrelated males with neutropenia, infections, lymphoproliferation, humoral immune defects, and in some cases bone marrow failure associated with 3 different variants in the X-linked gene TLR8, encoding the endosomal Toll-like receptor 8 (TLR8). Interestingly, 5 patients had somatic variants in TLR8 with

Introduction:The Advanced Cardiac Life Support (ACLS) guidelines were recently updated to include ultrasound confirmation of endotracheal tube (ETT) location as an adjunctive tool to verify placement. While this method is employed in the emergency department under the guidance of the most recent American College of Emergency Physicians (ACEP; Irving, Texas USA) guidelines, it has yet to gain wide acceptance in the prehospital setting where it has the potential for greater impact. The objective of this study to is determine if training critical care medics using simulation was a feasible and reliable method to learn this skill.Methods:Twenty critical care paramedics with no previous experience with point-of-care ultrasound volunteered for advanced training in prehospital ultrasound. Four ultrasound fellowship trained emergency physicians proctored two three-hour training sessions. Each session included a brief introduction to ultrasound “knobology,” normal sonographic neck and lung anatomy, and how to identify ETT placement within the trachea or esophagus. Immediately following this, the paramedics were tested with five simulated case scenarios using pre-obtained images that demonstrated a correctly placed ETT, an esophageal intubation, a bronchial intubation, and an improperly functioning ETT. Their accuracy, length of time to respond, and comfort with using ultrasound were all assessed.Results:All 20 critical care medics completed the training and testing session. During the five scenarios, 37/40 (92.5%) identified the correct endotracheal placements, 18/20 (90.0%) identified the esophageal intubations, 18/20 (90.0%) identified the bronchial intubation, and 20/20 (100.0%) identified the ETT malfunctions correctly. The average time to diagnosis was 10.6 seconds for proper placement, 15.5 seconds for esophageal, 15.6 seconds for bronchial intubation, and 11.8 seconds for ETT malfunction.Conclusions:The use of ultrasound to confirm ETT placement can be effectively taught to critical care medics using a short, simulation-based training session. Further studies on implementation into patient care scenarios are needed.

Human graft-versus-host disease (GVHD) biology beyond 3 months after hematopoietic stem cell transplantation (HSCT) is complex. The Applied Biomarker in Late Effects of Childhood Cancer study (ABLE/PBMTC1202, NCT02067832) evaluated the immune profiles in chronic GVHD (cGVHD) and late acute GVHD (L-aGVHD). Peripheral blood immune cell and plasma markers were analyzed at day 100 post-HSCT and correlated with GVHD diagnosed according to the National Institutes of Health consensus criteria (NIH-CC) for cGVHD. Of 302 children enrolled, 241 were evaluable as L-aGVHD, cGVHD, active L-aGVHD or cGVHD, and no cGVHD/L-aGVHD. Significant marker differences, adjusted for major clinical factors, were defined as meeting all 3 criteria: receiver-operating characteristic area under the curve ≥0.60, P ≤ .05, and effect ratio ≥1.3 or ≤0.75. Patients with only distinctive features but determined as cGVHD by the adjudication committee (non-NIH-CC) had immune profiles similar to NIH-CC. Both cGVHD and L-aGVHD had decreased transitional B cells and increased cytolytic natural killer (NK) cells. cGVHD had additional abnormalities, with increased activated T cells, naive helper T (Th) and cytotoxic T cells, loss of CD56bright regulatory NK cells, and increased ST2 and soluble CD13. Active L-aGVHD before day 114 had additional abnormalities in naive Th, naive regulatory T (Treg) cell populations, and cytokines, and active cGVHD had an increase in PD-1− and a decrease in PD-1+ memory Treg cells. Unsupervised analysis appeared to show a progression of immune abnormalities from no cGVHD/L-aGVHD to L-aGVHD, with the most complex pattern in cGVHD. Comprehensive immune profiling will allow us to better understand how to minimize L-aGVHD and cGVHD. Further confirmation in adult and pediatric cohorts is needed.

INTRODUCTION AND OBJECTIVE:Surgical polypropylene mesh is a material that can be used to treat pelvic organ prolapse and stress urinary incontinence. Mesh is made from non-absorbable polypropylene ...

This work describes the utilization of a new photonic heat treatment technology in combination with polyhydroxyalkanoates (PHA) materials for the development of biofriendly packaging and coated substrate materials. This technology advances the use of aqueous PHA coatings as a replacement for less environmentally friendly extruded plastic and fluorotreated packaging papers and boards. The new technology utilizes short burst photonic energy to heat PHA latex coatings. Utilizing a rapid pulse of photonic energy enables PHA particles to melt and form a film within milliseconds, as compared to conventional equilibrium drying that takes several minutes. Coatings were applied to commercially produced papers in order to validate the combined use of photonic treatment technology with PHA materials for commercial applications. Photonic treatment for both bench-top and roll-toroll pilot-scale studies resulted in kit values of 12, and 2 min Cobb values of

Flexible-hybrid printed electronics (FHPE) is a rapidly growing discipline that may be described as the precise imprinting of electrically functional traces and components onto a substrate such as paper to create functional electronic devices. The mass production of low-cost devices and components such as environmental sensors, bio-sensors, actuators, lab on chip (LOCs), radio frequency identification (RFID) smart tags, light emitting diodes (LEDs), smart fabrics and labels, wallpaper, solar cells, fuel cells, and batteries are major driving factors for the industry. Using renewable and bio-friendly materials would be advantageous for both manufacturers and consumers with the increased use of (FHPE) electronics in our daily lives. This review article describes recent developments in cellulose and nanocellulose-based materials for FHPE, and the necessary developments required to propagate their use in commercial applications. The aim of these developments is to enable the creation of FHPE devices and components made almost entirely of cellulose materials.

Mistreatment of trainees is common in the clinical learning environment. Resident mistreatment is less frequently tracked than medical student mistreatment, but data suggest mistreatment remains prevalent at the resident level. To address resident mistreatment, the authors developed an Educational Advance to engage emergency medicine residents and faculty in understanding and improving their learning environment. The authors designed a small-group session with the following goals: 1) Develop a shared understanding of mistreatment and its magnitude; 2) Recognize the prevalence of resident mistreatment data and identify the most common types of mistreatment; 3) Relate study findings to personal or institutional experiences; and 4) Generate strategies for combating mistreatment and strengthening the clinical learning environment at their home institutions. Design was a combination of presentation, small group discussion, and facilitated discussion. Results were presented to participants from a previously administered survey of resident mistreatment. Public humiliation and sexist remarks were the most commonly reported forms. Faculty were the most frequent perpetrators, followed by residents and nurses. A majority of respondents who experienced mistreatment did not report the incident. Session participants were then asked to brainstorm strategies to combat mistreatment. Participants rated the session as effective in raising awareness about resident mistreatment and helping departments develop methods to improve the learning environment. Action items proposed by the group included coaching residents about how to respond to mistreatment, displaying signage in support of a positive learning environment, zero tolerance for mistreatment, clear instructions for reporting, and intentionality training to improve behavior.

Objectives We sought to determine whether US-guided lumbar puncture reduced the rate of lumbar puncture failures for providers at an academic teaching hospital with variable lumbar puncture and US experience compared to the traditional landmark-based technique. Methods We conducted a prospective randomized controlled trial to compare US-guided lumbar puncture to the traditional landmark technique in an academic emergency department. Thirty-five patients were randomized to either have their lumbar puncture performed either via the landmark or US-guided technique. All procedures were completed by an emergency medicine resident with variable lumbar puncture and US experience. Procedural failures, the number of attempts, the time to completion, and patient pain scores were all recorded. Results The adjusted odds ratio of successfully obtaining cerebrospinal fluid (CSF) in the US-guided lumbar puncture group was 2.31 compared to the landmark-based lumbar puncture group (P = .377). It took 1.54 times more attempts to obtain CSF in the landmark group as it did in the US group (P = .046). It seemed to have no effect on postprocedural pain or the time to obtain CSF. Conclusions The use of US guidance to assist in lumbar punctures did not improve the procedural success rate over traditional landmark techniques in an academic setting with novice providers. Although using US for procedural guidance significantly decreased the number of attempts, it seemed to have no effect on postprocedural pain or the time to obtain CSF.

Introduction: Transesophageal echocardiography (TEE) is a well-established method of evaluatingcardiac pathology. It has many advantages over transthoracic echocardiography (TTE), including theability to image the heart during active cardiopulmonary resuscitation. This prospective simulation studyaims to evaluate the ability of emergency medicine (EM) residents to learn TEE image acquisitiontechniques and demonstrate those techniques to identify common pathologic causes of cardiac arrest. Methods: This was a prospective educational cohort study with 40 EM residents from two participatingacademic medical centers who underwent an educational model and testing protocol. All participantswere tested across six cases, including two normals, pericardial tamponade, acute myocardial infarction(MI), ventricular fibrillation (VF), and asystole presented in random order. Primary endpoints were correctidentification of the cardiac pathology, if any, and time to sonographic diagnosis. Calculated endpointsincluded sensitivity, specificity, and positive and negative predictive values for emergency physician (EP)-performed TEE. We calculated a kappa statistic to determine the degree of inter-rater reliability. Results: Forty EM residents completed both the educational module and testing protocol. This resultedin a total of 80 normal TEE studies and 160 pathologic TEE studies. Our calculations for the abilityto diagnose life-threatening cardiac pathology by EPs in a high-fidelity TEE simulation resulted in asensitivity of 98%, specificity of 99%, positive likelihood ratio of 78.0, and negative likelihood ratio of0.025. The average time to diagnose each objective structured clinical examination case was as follows:normal A in 35 seconds, normal B in 31 seconds, asystole in 13 seconds, tamponade in 14 seconds,acute MI in 22 seconds, and VF in 12 seconds. Inter-rater reliability between participants was extremelyhigh, resulting in a kappa coefficient across all cases of 0.95. Conclusion: EM residents can rapidly perform TEE studies in a simulated cardiac arrest environmentwith a high degree of precision and accuracy. Performance of TEE studies on human patients in cardiacarrest is the next logical step to determine if our simulation data hold true in clinical practice. [West JEmerg Med. 2017;18(5)830-834.]

Understanding why individuals opt out of living donation is crucial to enhancing protections for all living donors and to identify modifiable barriers to donation. We developed an ethical approach to conducting research on individuals who opted out of living kidney donation and applied it in a small-scale qualitative study at one US transplant centre. The seven study participants (64% response rate) had varied reasons for opting out, the most prominent of which was concern about the financial burden from lost wages during the postoperative period. Several reported feeling alone during their decision-making process. Although no participants used an alibi, a centre-provided statement of non-eligibility to donate, all believed that centres should offer alibis to help preserve donor autonomy. Given the complexity of participants' decisions and the emotions they experienced before and after deciding not to donate, we suggest approaches for independent living donor advocates to support this population. This study demonstrates that research on individuals who opt out of donation is feasible and yields valuable insight into methods to improve the evaluation experience for potential living donors.

In Ireland, influenza places a considerable burden on the health system, with the highest disease occurrence among young children and the elderly. Trivalent influenza vaccines are recommended for use in risk groups in Ireland each season. In this study, we aim to support decisions regarding alternative vaccination strategies, such as the use of quadrivalent vaccines and/or universal vaccination of children. We describe the burden of influenza among cases aged 0 to 14 years in Ireland from 2009/2010 to 2017/2018 influenza seasons, using data on clinical influenza-like illness (ILI) GP consultations reported through the sentinel GP network and reported laboratory confirmed severe influenza cases from Ireland’s Computerised Infectious Disease Reporting System. The highest GP ILI consultation rates in children were observed during seasons when influenza A(H1N1)pdm09 predominated (460/100,000 during the 2009 pandemic and 206/100,000 in 2010/2011) and during influenza B/lineage vaccine mismatched seasons (118/100,000 in 2017/2018). The 2015/2016 season was also an influenza B/lineage mismatched season, with both influenza A(H1N1)pdm09 and B predominating, with a peak ILI rate of 112/100,000. Since 2009, 3520 hospitalisations, 166 critical care admissions and 39 influenza-associated deaths were reported in children with laboratory-confirmed influenza. The total number of children hospitalised with confirmed influenza has ranged from 66 (7/100,000) in 2011/2012 when influenza A(H3N2) predominated, to 1104 (110/100,000) in the 2017/2018 season, an influenza B/lineage vaccine mismatched season. The age-specific rates for hospitalised paediatric influenza cases were highest in those aged 0–4 years, ranging from 16/100,000 in 2011/2012 to 197/100000 in 2017/2018. The 2017/2018 influenza season was a severe prolonged season, with paediatric influenza hospitalisations two times greater than the 2009 influenza pandemic. Of children in risk groups, hospitalised with influenza, during the 2016/2017 and 2017/2018 seasons, 86–88% of cases were unvaccinated. Elevated sentinel GP ILI consultation rates, influenza hospitalisation rates, and critical care admissions were observed during seasons when influenza A(H1N1)pdm09 predominated and also during influenza B/lineage vaccine mismatched seasons. Additional strategies are needed to reduce the morbidity and mortality associated with influenza in risk groups, improve vaccine uptake in at-risk children and to protect healthy children currently not eligible for influenza vaccination. The impact of influenza on the Irish population suggests that quadrivalent vaccines and/or universal childhood influenza vaccination could be considered, as in other European Member States.

Background Compared to X-ray radiation therapy, proton therapy (PT) reduces the radiation dose to organs at risk, which is expected to translate into fewer second cancers and less cardiac morbidity decades after treatment. The Children's Oncology Group high-risk pediatric Hodgkin lymphoma (PHL) protocol, AHOD1331, allows the use of PT, yet limited data exist on the use of PT in PHL. Procedure Between 2010 and 2014, 22 pediatric patients were treated with PT for PHL at our institution: 7 intermediate-risk patients, 11 high-risk patients, and 4 relapsed patients. The patients’ age ranged from 6 to 18 years old. Median follow-up was 36 months. All patients received chemotherapy before PT. Results The 2-year and 3-year overall survival rates were both 94%, and the progression-free survival rate was 86%. Recurrences occurred in three high-risk patients: one isolated in-field cervical lymph node and two in-field and out-of-field. All recurrences occurred within 5 months of completing PT. No PT-related grade 3 or higher acute or late complications were observed. Conclusion PT for PHL showed no short-term severe toxicity and yields similar short-term control to recently published large multi-institutional clinical trials.

Objectives The goal of this study was to determine the diagnostic yield of focused cardiac ultrasound (FOCUS) in hemodynamically stable patients in the emergency department and secondarily to confirm the accuracy of these studies when compared to formal echocardiography. Methods All hemodynamically stable adult patients who had an emergency physician-performed FOCUS examination completed over a 1-year period were identified using our electronic ultrasound database. Hemodynamic stability was defined as presenting systolic blood pressure higher than 90 mm Hg and not requiring any form of positive pressure ventilation. Results There were 1198 FOCUS examinations performed: 976 in hemodynamically stable patients who were included in our analysis. Twenty-seven percent of patients had new findings, including 154 (16%) new diagnoses of reduced left ventricular function, 105 (11%) new pericardial effusions, and 44 (5%) new diagnoses of RV dilatation. Dyspnea as an indication for the FOCUS examination was the strongest predictor of a positive study. Of patients included, 28% underwent formal echocardiography within 2 days and were analyzed for concordance with regard to left ventricular function and the presence of pericardial effusion. Of 270 studies, 208 were accurate, and 62 were inaccurate, for raw agreement of 77% (κ = 0.53). When stratified by sonographer experience, there was no impact on accuracy. Conclusions Focused cardiac ultrasound in the emergency department for hemodynamically stable patients revealed new findings in 27% of studies, with a modest correlation with formal echocardiography. In stable patients, FOCUS has the potential for rapid diagnosis of cardiac disease, particularly in patients with dyspnea.

Background Traditional landmark thoracostomy technique has a known complication rate up to 30%. The goal of this study is to determine whether novice providers could more accurately identify the appropriate intercostal site for thoracostomy by ultrasound guidance. Methods 33 emergency medicine residents and medical students volunteered to participate in this study during routine thoracostomy tube education. A healthy volunteer was used as the standardized patient for this study. An experienced physician sonographer used ultrasound to locate a site at mid-axillary line between ribs 4 and 5 and marked the site with invisible ink that can only be revealed with a commercially available UV LED light. Participants were asked to identify the thoracostomy site by placing an opaque marker where they would make their incision. The distance from the correct insertion site was measured in rib spaces. The participants were then given a brief hands-on training session using ultrasound to identify the diaphragm and count rib spaces. The participants were then asked to use ultrasound to identify the proper thoracostomy site and mark it with an opaque marker. The distance from the proper insertion site was measured and recorded in rib spaces. Results The participants correctly identified the pre-determined intercostal space using palpation 48% (16/33) of the time, versus the ultrasound group who identified the proper intercostal space 91% (30/33) of the time. On average, the traditional technique was placed 0.88 rib spaces away (95 CI 0.43–1.03), while the ultrasound-guided technique was placed 0.09 rib spaces away (95 CI 0.0–0.19) [P = 0.003]. Conclusions The ability to accurately locate the correct intercostal space for thoracostomy incision was improved under ultrasound guidance. Further studies are warranted to determine if this ultrasound-guided technique will decrease complications with chest tube insertion and improve patient outcomes.