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We hypothesized that an electronic sepsis alert would decrease mortality, ICU admission, vasoactive use, and organ dysfunction at day 3 and day 7. Sepsis episodes were identified by a validated computational algorithm which reflects presence of infection with organ dysfunction (cardiac, respiratory, hematologic or renal) using data in the electronic health record. B Introduction: b Pediatric sepsis is a significant cause of morbidity and mortality in children; guidelines now recommend a systematic screening tool to enhance early recognition of children with sepsis. [Extracted from the article]

B Introduction: b Racial, ethnic, and socioeconomic (SES) disparities are reported in sepsis, with increased mortality for minority and low SES groups. Patients with higher social disorganization had lower odds of mortality (Quintile 3 0.68 [0.49-0.92]; Quintile 4 0.74, [0.55-1.01]; Quintile 5 0.7 [0.51-0.95]). [Extracted from the article]

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]

Background: This article provides an overview of the current and projected climate change risks and impacts to mental health and provides recommendations for priority actions to address the mental health consequences of climate change. Discussion and conclusion: The authors argue the following three points: firstly, while attribution of mental health outcomes to specific climate change risks remains challenging, there are a number of opportunities available to advance the field of mental health and climate change with more empirical research in this domain; secondly, the risks and impacts of climate change on mental health are already rapidly accelerating, resulting in a number of direct, indirect, and overarching effects that disproportionally affect those who are most marginalized; and, thirdly, interventions to address climate change and mental health need to be coordinated and rooted in active hope in order to tackle the problem in a holistic manner. This discussion paper concludes with recommendations for priority actions to address the mental health consequences of climate change. [ABSTRACT FROM AUTHOR]

OBJECTIVES: We assessed racial differences in sepsis recognition in a pediatric emergency department (ED) with an established electronic sepsis alert system. METHODS: Quality-improvement data from June 1, 2016 to May 31, 2017 was used in this retrospective cohort study. All ED visits were included for non-Hispanic black (NHB) and non-Hispanic white (NHW) patients. The sepsis pathway was activated through the alert, 2 stages and a huddle, or outside of the alert using clinician judgment alone. We evaluated racial differences in the frequency of alerts and sepsis pathway activation within and outside of the alert. Multivariable regression adjusted for high-risk condition, sex, age, and insurance. RESULTS: There were 97 338 ED visits: 56 863 (58.4%) and 23 008 (23.6%) from NHBs and NHWs, respectively. NHWs were more likely than NHBs to have a positive second alert (adjusted odds ratio [aOR] 2.4; 95% confidence interval [CI] 2.1-2.8). NHWs were more likely than NHBs to have the sepsis pathway activated (aOR 1.4; 95% CI 1.02-2.1). Of those treated within the alert, there was no difference in pathway activation (aOR 0.93; 95% CI 0.62-1.4). Of those recognized by clinicians when the alert did not fire, NHWs were more likely than NHBs to be treated (aOR 3.4; 95% CI 1.8-6.4). CONCLUSIONS: NHWs were more likely than NHBs to be treated for sepsis, although this difference was specifically identified in the subset of patients treated for sepsis outside of the alert. This suggests that an electronic alert reduces racial differences compared with clinician judgment alone. [ABSTRACT FROM AUTHOR]

Purpose: Gabapentin is an analog of gamma-aminobutyric acid (GABA), but its complete mechanism is not well understood. Common adverse effects from gabapentin include somnolence, sedation, and dizziness. Hyperglycemia is listed as a possible adverse drug reaction in the labeling. Case reports describe hypoglycemia in patients with diabetes, peritoneal dialysis, and/or incomplete medication records. The following case report details a hypoglycemia episode as a potential result of a gabapentin use in a patient without diabetes. Summary: A 47-year old, 68 kg, white female presented to the emergency department with altered mental status. Her blood glucose level was 33 mg/dL. Gabapentin was started 1 week prior to the hypoglycemia episode. Her past medical history, concomitant medications, and other laboratory findings were not likely causes of her severe hypoglycemia. Conclusion: Gabapentin appears to have effects on several voltage-gated calcium channels. Hypoglycemia may be due to gabapentin binding to the alpha2delta subunit of the calcium channels in the pancreas. Future research should investigate gabapentin and the potential for hypoglycemia. [ABSTRACT FROM AUTHOR]

Given the distinct epidemiology of pediatric sepsis, we aimed to classify septic children into I de novo i sub-phenotypes derived from temperature trajectories and compare cytokine, immune function, and immunometabolic markers across subgroups. We performed group-based trajectory modeling (GBTM) using available temperatures over the first 72 hours of sepsis to identify latent I de novo i profiles. As an alternative approach, four sub-phenotypes defined by distinct temperature trajectories have been reported in adult sepsis. [Extracted from the article]

Background/aims: Despite evidence that preferential use of balanced/buffered fluids may improve outcomes compared with chloride-rich 0.9% saline, saline remains the most commonly used fluid for children with septic shock. We aim to determine if resuscitation with balanced/buffered fluids as part of usual care will improve outcomes, in part through reduced kidney injury and without an increase in adverse effects, compared to 0.9% saline for children with septic shock.Methods: The Pragmatic Pediatric Trial of Balanced versus Normal Saline Fluid in Sepsis (PRoMPT BOLUS) study is an international, open-label pragmatic interventional trial being conducted at > 40 sites in the USA, Canada, and Australia/New Zealand starting on August 25, 2020, and continuing for 5 years. Children > 6 months to < 18 years treated for suspected septic shock with abnormal perfusion in an emergency department will be randomized to receive either balanced/buffered crystalloids (intervention) or 0.9% saline (control) for initial resuscitation and maintenance fluids for up to 48 h. Eligible patients are enrolled and randomized using serially numbered, opaque envelopes concurrent with clinical care. Given the life-threatening nature of septic shock and narrow therapeutic window to start fluid resuscitation, patients may be enrolled under "exception from informed consent" in the USA or "deferred consent" in Canada and Australia/New Zealand. Other than fluid type, all decisions about timing, volume, and rate of fluid administration remain at the discretion of the treating clinicians. For pragmatic reasons, clinicians will not be blinded to study fluid type. Anticipated enrollment is 8800 patients. The primary outcome will be major adverse kidney events within 30 days (MAKE30), a composite of death, renal replacement therapy, and persistent kidney dysfunction. Additional effectiveness, safety, and biologic outcomes will also be analyzed.Discussion: PRoMPT BOLUS will provide high-quality evidence for the comparative effectiveness of buffered/balanced crystalloids versus 0.9% saline for the initial fluid management of children with suspected septic shock in emergency settings.Trial Registration: PRoMPT BOLUS was first registered at ClinicalTrials.gov ( NCT04102371 ) on September 25, 2019. Enrollment started on August 25, 2020. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine the frequency of physician-documented sexual histories in female adolescents who presented to an emergency department (ED) with symptoms suggestive of a sexually transmitted infection (STI). Our secondary objectives were to determine if physician-documented sexual history is associated with increased STI testing and to compare the concordance of physician-elicited sexual histories with patient-documented sexual histories by using confidential questionnaires. METHODS: We conducted a secondary analysis of a prospective study of female adolescents who presented to a pediatric ED with chief complaints of lower abdominal pain and/or genitourinary complaints. Patient charts were abstracted for the presence or absence of documented sexual histories and demographics. A subset of patients completed a questionnaire pertaining to sexual health. RESULTS: The study population comprised 327 patients; 269 (82%) patients had a physician-documented sexual history, of which 204 (76%) reported being sexually active to the physician. Patient age (odds ratio [OR]: 2.6 [95% confidence interval (CD: 1.3-5.3]) and black race (OR: 2.0 [95% CI: 1.1-3.7]) were associated with physician-documented sexual history. The documentation of a sexual history was associated with increased STI testing (OR: 3.9 [95% CI: 2.0-7.6]). In the patients (n = 109) who completed the questionnaire, physician-elicited sexual histories were highly concordant with patient-documented sexual histories on questionnaire (Spearman r = 0.90; P< .001). CONCLUSION: These results indicate that ED physicians should obtain sexual histories from symptomatic patients, because it may increase STI testing and subsequent detection. In future studies factors should be evaluated that affect physicians' willingness to assess sexual history in the ED patient. [ABSTRACT FROM AUTHOR]

Extreme weather and climate events, such as heat waves, cyclones, and floods, are an expression of climate variability. These events and events influenced by climate change, such as wildfires, continue to cause significant human morbidity and mortality and adversely affect mental health and well-being. Although adverse health impacts from extreme events declined over the past few decades, climate change and more people moving into harm's way could alter this trend. Long-term changes to Earth's energy balance are increasing the frequency and intensity of many extreme events and the probability of compound events, with trends projected to accelerate under certain greenhouse gas emissions scenarios. While most of these events cannot be completely avoided, many of the health risks could be prevented through building climate-resilient health systems with improved risk reduction, preparation, response, and recovery. Conducting vulnerability and adaptation assessments and developing health system adaptation plans can identify priority actions to effectively reduce risks, such as disaster risk management and more resilient infrastructure. The risks are urgent, so action is needed now. [ABSTRACT FROM AUTHOR]

Objective: Evidence suggests using metered dose inhaler (MDI) to treat acute asthma in the Emergency Department reduces length of stay, though methods of implementation are lacking. We modified a treatment pathway to recommend use of MDI for mild-moderate asthma in a pediatric ED. Methods: A baseline review assessed discharged patients >2 years with an asthma diagnosis and non-emergent Emergency Severity Index triage assessment (3/4). Our multi-disciplinary team developed an intervention to increase MDI use instead of continuous albuterol (CA) using the following: (1) Redesign the asthma pathway and order set recommending MDI for ESI 3/4 patients. (2) Adding a conditional order for Respiratory Therapists to reassess and repeat MDI until patient reached mild assessment. The primary outcome was the percentage discharged within 3 hours, with a goal of a 10% increase compared to pre-intervention. Balancing measures included admission and revisit rates. Results: 7635 patients met eligibility before pathway change; 12,673 were seen in the subsequent 18 months. For target patients, the percentage discharged in <3 hours increased from 39% to 49%; reduction in median length of stay was 33 minutes. We identified special cause variation for reduction in CA use from 43% to 25%; Revisit rate and length of stay for higher-acuity patients did not change; overall asthma admissions decreased by 8%. Changes were sustained for 18 months. Conclusion: A change to an ED asthma pathway recommending MDI for mild-moderate asthma led to a rapid and sustained decrease in continuous albuterol use, length of stay, and admission rate. [ABSTRACT FROM AUTHOR]

Originating in the UK in 2006, the Transition movement is oriented to local grassroots citizen-led efforts that prepare for and support a societal energy transition to a low-carbon future in response to climate change, peak oil, ecological degradation, and economic instability. Overlapping significantly with relocalization, degrowth/slow growth, local food, and related movements, and based on permaculture principles and a distributed network model, it embraces the opportunity to turn crisis into an opportunity to build more resilient, convivial, and vibrant local communities, declaring that "if it's not fun, it's not sustainable". The Transition approach has spread rapidly around the world, including initiatives in over 100 communities and cities in Canada. This paper reports on the methods and results of a Canadian community-based research study aimed at understanding how and where the movement has taken root across the country, what Transition practice looks like, challenges and opportunities encountered, and lessons learned that could be applied within the movement and by others interested in the role of citizen-led initiatives for sustainability transition. Utilising a practice theory lens, drawing on an extensive web-scan of the movement's online presence, a survey and interviews with initiative (co)founders, an e-survey of Transition members/participants, regional "structured story-dialogue" workshops, and key informant interviews, and informed by input from a Movement Advisory Group, we describe the research process and explore what success and impact mean to those most active in the movement. [ABSTRACT FROM AUTHOR]