BACKGROUND:In rural settings, children with traumatic injuries are often first evaluated by providers at non-pediatric-specialized facilities who determine if the patient's condition warrants transfer. We sought to evaluate potentially preventable transfers (PTs) in the pediatric trauma population of our rural state. METHODS:We performed a single-site retrospective cohort study at a level 1 pediatric trauma center, evaluating patients <18 years who presented as activated trauma transfers from referring facility between 1/2018-12/2023. PTs were defined as patients who were discharged from the Emergency Department or admitted for <24 h without requiring operative or procedural intervention, cross-sectional imaging or ICU admission following transfer. Bivariate analysis compared PTs to patients characterized as unpreventable transfers (UPTs) and multivariable logistic regression determined predictors of PT. RESULTS:We included 762 patients with mean age 12 years (IQR 5,15) and 65% (n = 496) male. Twenty-five percent (n = 191) were characterized as PTs, with 112 patients discharging from the Emergency Department after transfer. PTs had a lower median injury severity score than UPTs (6 versus 17, p < 0.001). Mechanism of injury was not associated with PT (p = 0.172). Injury to the head (p < 0.001), chest (p = 0.009), abdomen (p = 0.012), appendicular skeleton (p < 0.001), and nonaccidental trauma (p = 0.002) were associated with UPT. CONCLUSIONS:One-quarter of activated trauma transfers were classified as potentially preventable, with over half of those patients being discharged from the Emergency Department. Several factors were associated with PTs, most notably injury severity. Telemedicine consultation with a pediatric trauma team may provide a potential method to improve pre-transfer triage for mild and moderately injured children. LEVEL OF EVIDENCE:Level III, Prognostic/Epidemiological.

Introduction Avoidable referral of children for outpatient pediatric general surgical evaluation creates inefficient healthcare utilization and unnecessary social and financial burdens for patients and families. We sought to characterize patient and referring provider characteristics associated with avoidable patient referrals for outpatient pediatric general surgical evaluation in a rural state. Methods This is a multisite retrospective cohort study including patients <18 y referred for outpatient pediatric general surgical evaluation between November 2017 and July 2024. Avoidable referrals were defined as patients who attended pediatric general surgery clinic but did not require an in-clinic procedure, imaging, operation, or clinic follow-up within 1 y. Bivariate analysis and multivariable logistic regression were performed to evaluate for associations between patient and provider factors and avoidable referral. Results We included 5966 patients. One-quarter of referrals were identified as avoidable (n = 1402, 24%), with children 0-3 y more commonly identified as avoidable (P < 0.001). Umbilical hernia was the most common referral (n = 917); 39% of these were avoidable. Pectus excavatum was most likely to be avoidable (n = 188; 46% avoidable). Referrals for self-pay patients and those placed by emergency medicine providers were more likely to be avoidable [odds ratio 2.5, 95% Confidence Interval (CI) (1.5-4.1) P < 0.001; odds ratio 1.8, 95% CI (1.3-2.7) P < 0.001]. Avoidable referrals had a shorter average time from referral to outpatient pediatric general surgery clinic visit (34 versus 41 d, P < 0.001). Conclusions Nearly one-quarter of referrals were identified as avoidable. Development of targeted screening prior to outpatient pediatric general surgical evaluation may improve access to pediatric specialty care for indicated referrals and appropriate healthcare utilization.

Background: The correlation between peripheral saturation of peripheral oxygen (SpO2) and arterial oxygen partial pressure (PaO2) in critically ill children is essential for minimizing the risk of hyperoxia. Hyperoxia has been associated with adverse clinical outcomes, yet its definition varies across studies due to differing PaO2 thresholds. Understanding the relationship between SpO2 and PaO2 may guide optimal oxygen targets and reduce the likelihood of excessive oxygen exposure. The objective of this study was to evaluate the relationship between SpO2 and PaO2 and determine SpO2 thresholds that predict hyperoxia in mechanically ventilated pediatric patients. Subjects and Methods: This retrospective study analyzed 316 mechanically ventilated pediatric patients admitted to an intensive care unit. A total of 783 simultaneously measured SpO2–PaO2 data pairs were collected. The probability of PaO2 exceeding various hyperoxia thresholds (100 mmHg, 125 mmHg, and 250 mmHg) was calculated across different SpO2 levels using logistic regression modeling. Results: At higher SpO2 values (97%–100%), the probability of PaO2 exceeding 250 mmHg was relatively low (2%–5% at SpO2 of 99%–100%). However, the likelihood of PaO2 exceeding 100 mmHg and 125 mmHg was substantially higher, ranging from 26% to 77% and 12%–55%, respectively. For a lower SpO2 target of 88%–94%, the probability of PaO2 >100 mmHg ranges from 0% to 7%, whereas the probability of PaO2 >125 mmHg ranges from 0% to 3% of the time. Conclusions: There was a curvilinear correlation between SpO2 and Po2 with diminishing predictive accuracy at higher SpO2 levels. Targeting lower SpO2 (88%–94%) range may minimize the risk of hyperoxia.

Introduction:Excessive oxygen supplementation in critically ill children can lead to hyperoxia, resulting in systemic toxicity and worse outcomes. Despite evidence linking hyperoxia to adverse outcomes, the overuse of oxygen therapy remains a widespread practice. This quality improvement initiative aimed to reduce hyperoxia exposure among mechanically ventilated children in the pediatric intensive care unit at Arkansas Children's Hospital, aligning with the Second Pediatric Acute Lung Injury Consensus Conference guidelines. Methods:A multidisciplinary team implemented interventions in 2 Plan-Do-Study-Act cycles. The first cycle focused on staff education and standardizing oxygen saturation (SpO2) goals (90%-97%) in electronic health records. The second cycle introduced a best practice advisory to alert bedside staff when SpO2 exceeded 97% with the fraction of inspired oxygen (FiO2) greater than 0.21, prompting FiO2 weaning. Hyperoxia was defined as SpO2 98%-100% with FiO2 greater than 0.21. We collected hourly SpO2-FiO2 data pairs from mechanically ventilated patients and calculated hyperoxia rates monthly. Results:Baseline data (January 2021 through June 2022) showed an average hyperoxia rate of 54.8%. Following the first Plan-Do-Study-Act cycle, the rate decreased to 41.0%, and after best practice advisory implementation, it further dropped to 28%, sustaining this reduction for more than 12 months. Mortality and mechanical ventilation duration did not change significantly (11.7%-9.4%, P = 0.12; and 8.16-4.8 d, P = 0.11, respectively). Conclusions:Using quality improvement methodology and electronic health record-based clinical decision support tools, we successfully reduced hyperoxia rates among mechanically ventilated children in the pediatric intensive care unit. This initiative highlights the importance of standardized oxygen management and real-time staff reminders in improving care practices.

BACKGROUND:Nearly 7,000 snakebite injuries are reported yearly in the United States, with almost one quarter of those in the pediatric population. Due to increased exposure to snakes, rural children may experience different clinical outcomes for snakebite injuries. The goal of this study was to examine differences in resource utilization of rural and urban pediatric patients with snakebite injuries. METHODS:This is a retrospective cross-sectional study of patients aged 21 years and under presenting with venomous snakebites in the United States from January 1, 2016, through March 31, 2023, using the Pediatric Hospital Information System database and ICD-10 codes indicating snakebites. Comparisons were conducted to evaluate demographic and clinical characteristics in association with resource utilization and complications between patients living in rural areas and patients living in urban areas. RESULTS:The study included 2,633 patients from 23 states. The median age was 9 years; 61% of patients were male. Most patients were in the South and over 70% resided in urban areas. 82% of the population was admitted to a hospital, with median length of stay 1.59 days. Compared to urban patients, rural patients were more likely to be admitted and receive antivenom but were less likely to have an intensive care unit admission and have abnormal coagulation studies. CONCLUSIONS:Rural pediatric patients with snakebites had different resource utilization and clinical complications than urban patients.

Background: We sought to understand factors impacting timely access to outpatient pediatric general surgical care in a largely rural state. Methods: We conducted a multi-site retrospective cohort study, evaluating patients <18 years referred for outpatient pediatric general surgical evaluation from 11/1/2017-7/31/2022. Outcomes included obtaining an appointment, completing an appointment, and undergoing an operation. Time to appointment and operation were calculated. Bivariate analysis and multivariable logistic regression were performed to evaluate for associations between patient factors and the primary outcomes, as well as delay to appointment. Results: Of 5270 patients, mean age was 7.1 years (SD = 6) with 59% male. All patients obtained an appointment; 85% (n = 4498) completed an appointment within one year. Forty percent (n = 2092) underwent an operation. Mean times from referral to appointment and operation were 22.5 (SD = 33.4) and 81.5 days (SD = 137.5), respectively. Patients who identified as African American/Black (OR = 1.94, p < 0.001), had self-pay (OR = 6.33, p < 0.001), or lived >100 miles away (OR = 1.55, p < 0.001) were more likely to not complete appointments. Patients with high household income (OR = 0.70, p = 0.009) and private insurance (OR = 0.60, p < 0.001) were less likely to not complete appointments. Delay to appointment was associated with race (p = 0.020). Patients with private insurance (p < 0.001) and higher income (p = 0.020) were more likely to undergo operation. Conclusion: Fifteen percent of patients referred for outpatient pediatric general surgical evaluation did not complete an appointment within one year. Race, household resources, insurance, and travel distance were associated with completing appointments. Information about groups that have disparate access to care will inform interventions to improve this access. Type of Study: Retrospective Cohort Study. Level of Evidence: III. (c) 2024 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

Introduction:Adherence to the American Academy of Pediatrics clinical practice guidelines for screening and managing high blood pressure (BP) is low. This team sought to improve recognition and documentation of relevant diagnoses in patients aged 13-20 years who presented to general pediatric clinics.Methods:The primary outcome measure was the proportion of office visits for patients ages 13-20 with a BP >= 120/80 with a visit or problem list diagnosis of hypertension or elevated BP. Secondary measures included (1) the proportion of patients who had their BP measured in the right arm, (2) the proportion of patients who had a mid-arm circumference measurement recorded, and (3) the proportion of patients who had a second BP reading measured at the visit. Interventions addressed key drivers for evidence-based high BP screening: standard BP measurement, electronic health record clinical decision support, and clinical pathway adoption. Data were collected over a twenty-seven-month period and plotted using the Laney p' chart.Results:Provider documentation of elevated BP or hypertension improved from a baseline mean of 24% in April 2020 through January 2022 to 41% in February 2021 through June 2022. All secondary outcome measures also demonstrated significant improvement.Conclusions:This project demonstrates the feasibility of improving adherence to best practices of BP measurement in primary care clinics through education, acquisition of resources, and implementation of electronic health record flags for abnormal values.

Herein, the angiotensin I-converting enzyme (ACE) inhibitory activity, antioxidant capacity, total polyphenol contents (TPC), and phytochemical profiles of polar and non-polar extracts of dried Ziziphus jujuba fruits were investigated, along with the statistical determination of the main components responsible for ACE inhibitory activity. The non-polar extract expressed the strongest ACE inhibitory activity (99.81%) among the extracts. The non-polar extract also exhibited the highest DPPH scavenging activity (IC50 of 30.63), linoleic acid/β-carotene bleaching capacity (89.31%), and TPC (59.47 mg GAE/g). The phenolic profiles of the extracts were identified by LC-MS/MS, and the presence of seven triterpenoid species in the extracts was examined using GC-MS techniques. The principal constituents included 19 phenolics, 2 organic acids, and 4 triterpenoids. A Pearson correlation and principal component analysis were conducted to find the correlation between individual phenolic compounds and ACE inhibitory activity.

Herein, a food-to-food fortification with blueberries and black tea was performed for people suffering from iron deficiency, creating a new functional product with high consumer acceptance. Black tea was mixed with varying concentrations of sun-dried or freeze-dried blueberries and infused at different temperatures. Spectrophotometric analysis revealed that the addition of blueberries to black tea inhibited the formation of the iron-polyphenol complex by up to 97 % (p <.001). Using beta-carotene bleaching and 2,2-diphenyl-1-picrylhydrazyl assays, 50 % freeze-dried blueberry and 50 % black tea (FDFBT50) was determined to be the sample with the highest antioxidant activity (p <.001).The polyphenol profiles were investigated by high-performance liquid chromatography. Principal component analysis (PCA) was performed to categorize the tea samples. The findings demonstrated that the FDFBT50 sample was the best candidate among the samples, considering both the consumer acceptance and the bioactive parameters that showed statistically significant differences.

Parents of critically ill children in the Pediatric Intensive Care Unit (PICU) commonly experience new or worsening anxiety, which can lead to long-term sequelae in the form of post-traumatic stress disorder (PTSD). To investigate how well the PICU providers recognize and assess parental anxiety, we assessed the acute and baseline anxiety level of 30 parents in the PICU with the State-Trait Anxiety Inventory (STAI) and compared the results with the PICU physician's and nurses' assessments. All but four parents experienced higher acute anxiety scores compared to baseline, with a 34% increase in the number of parents with moderate and high anxiety scores. All PICU providers performed poorly in recognizing and assessing parental anxiety, with a tendency to underestimate the level of anxiety. Proper screening tools and strategies are essential to recognize and help parents in distress and potentially prevent long-term psychological sequelae.

Introduction: Clostridioides difficile (C. difficile) is a significant concern for children, especially for those who are hospitalized or who have underlying medical conditions. Diagnosis of C. difficile infection (CDI) in these patients can be challenging due to asymptomatic colonization. Inappropriate testing and non-adherence to laboratory testing guidelines can result in increased false-positive rates precipitating unnecessary isolation precautions and antibiotic treatment for these patients. Methods: This retrospective cohort study aimed to evaluate the effectiveness of a new diagnostic pathway for C. difficile testing that was implemented in two pediatric hospitals. The study design collected data for two years, one year before and one year after pathway implementation. The study highlighted the importance of appropriate testing and the need for interventions to improve testing practices in pediatric patients. A 2-tier testing algorithm was implemented, consisting of polymerase chain reaction (PCR) for the presence or absence of the toxin B gene and an enzyme immunoassay for toxin A/B production. The best practice advisory was used to determine when C. difficile testing should not be performed. The chi-square test and Fisher's Exact Test analyzed the data using SPSS version 29. Results: The study found a significant association between the implementation of the C. difficile testing pathway and the test positivity rates for both inpatient and emergency department (ED) patients at both hospitals. Out of 159,434 Hospital A inpatients, 71 had positive C. difficile test results, and out of 11,109 Hospital B inpatients, nine had positive test results. Similarly, out of 121,951 Hospital A ED patients, eight had positive test results, and out of 67,999 Hospital B ED patients, 16 had positive test results. The study found a statistically significant association between the pre and post pathway implementation years for both hospitals (p<0.001 for Hospital B inpatient and ED, p=0.033 for Hospital A inpatient, and p=0.004 for Hospital A ED). Conclusion: Adherence to laboratory testing guidelines, appropriate testing based on factors such as the patient's age, underlying health conditions, recent antibiotic use, and the presence of other infections or illnesses can reduce unnecessary testing and false-positive rates. False-positive results can occur in pediatric patients due to the high rate of asymptomatic colonization, making it essential to use a combination of clinical symptoms, history, and appropriate diagnostic testing to minimize the risk of misdiagnosis.

We explore production planning in all-you-care-to-eat food service operations, where lack of marginal revenue associated with lost sales constrains the applicability of cost-minimizing strategies. We integrate forecast uncertainty considerations into an operational model of food service production, and derive strategies that minimize food waste subject to target shortfall probabilities. We model this situation using a nonlinear penalty function formulation, utilizing kernel density estimation to characterize deviations from demand forecasts, allowing enumeration of the efficient frontier between conflicting objectives of demand shortfall and food waste, where food waste is measured by either its mass or its embodied CO2-equivalent emissions. When food waste is measured using the weight of wasted food, reducing the substitution threshold (minimum-allowable production level for leftover substitution) for meat-based items at certain meals is preferable. Alternatively, when using CO2-equivalents embodied in wasted food, a variety of strategies, including reducing the substitution threshold at certain meals, increasing the percentage of demands that are satisfied from leftovers at certain meals, and increasing the allowable shortfall probability for beef-based meals, are all attractive. The results provide insight into targeted production level modifications, rather than broad increases or decreases, that can help food service operators manage the tradeoff between these conflicting objectives.

The use of existing water resources and sustainability problems as a result of global warming and climate change became an even bigger problem with the importance of hygiene during the COVID-19 pandemic. In this research, the water consumption behavior will be researched and the correlation between water consumption and COVID-19 case numbers will be investigated in Bursa, Turkey. The monthly mean water consumption for 758,500 domicile subscribers using the central tariff from 2018–2020 was calculated. Results obtained using the SPSS 23 IBM program observed a 20.18% increase in water consumption in Bursa in general during COVID-19. As Bursa province has both rural and industrial urban structures, when this increase is examined on a county basis, increase rates were 10% in regions with dense industry and mean 34% in rural areas. When the correlation between case numbers during the COVID-19 period (March 2020-January 2021) and water consumption is examined, a negative correlation is notable (Pearson-Correlation=-0.616). As the case numbers increased in the continuing COVID-19 pandemic, the reduction in water consumption may be explained by warnings to citizens to reduce water use through written and oral media due to reservoir fill rates falling below 5%. These results provide beneficial information revealing the effects of COVID-19 on water consumption behavior and use of water resources in urban and rural areas.

Gerçek dünyadaki her sistemin bir çalışma programı bulunmaktadır. Sistemin işleyişini iyileştirmek yâda değiştirmek veya yeni bir sistem oluşturmak için alınması gereken kararların maliyet ve zaman açısından değerlendirilmesi gerekmektedir. Bu değerlendirmenin kolay ve etkili bir biçimde karmaşık sistemler üzerinde yapılabilmesi, benzetim modelleri ile mümkün olmaktadır. Simio, bu benzetim programlarından biri olup kullanımı kolay ve 3 boyutlu görsele sahiptir. Bu çalışmanın amacı, yeni kullanılmaya başlanan Simio benzetim programını günlük hayattan bir örnek üzerinde uygulayarak, tanıtılmasını sağlamaktır. Örnekte, bir banka işletmesinin müşteri memnuniyetini sağlayabilmesi adına yeterli elemana sahip olup olmadığının yanı sıra gerekli görülmesi halinde yeni bir çalışanın işe alınması ya da işten çıkarılmasının ekonomik olarak etkisine bakılmıştır. Gerçekleştirilen benzetim modeli sonucunda, banka işletmesinin mevcut kaynaklarla iyi bir şekilde yönetilebileceği ve tasarruf yapmak için bir veznedarın işten çıkarılmasıyla yine de mutlu bir banka işletmesine sahip olunabileceği gösterilmiştir. Sonuç olarak Simio benzetim programı, gerçek yaşam modellerinin benzetiminde kolaylıkla kullanılabileceği gösterilmiştir.

Kültürel mirasımız olan müzeler, sosyo-kültürel bir olgu olmakla birlikte, ekonomi bakımından etkin rol oynamaktadır. Giriş ücretlerinin fiyatlandırılma konusu müze yönetimlerindeki başlıca sorunudur. Fiyatlandırma sorunun çözümü için farklı farklı bilet türleri kullanılmaktadır. Bu çalışmada sadece tam bilet satışları için geçerli olan farklı ücretten müzeye erişim değerlerini belirleyerek, müzenin gelir yönetim politikasını geliştirmek amaçlanmıştır. Bu erişim değerleri hava şartlarına bağlı olarak üç grupta sınıflandırılabilir; Sıradan müşteri giriş, Seçkin müşteri girişi ve Önemli müşteri girişi. Havanın kötü olduğu günlerde daha çok müşteri çekebilmek için ziyaretçilere hediyelik eşya verilmesi karı nasıl etkileyeceğinin araştırılması değerlendirilmiştir. Daha önce belirlenen en uygun müze işletim fiyatı kullanılarak, ortalama fazladan yıllık gelir hesaplanmış ve diğer giriş politikaları ile karşılaştırma yapılmıştır. Yapılan çalışmada, Topkapı Palas Müzesinden Ocak 2010’dan Aralık 2012’ye kadar toplanan veriler kullanılmıştır. Sonuç olarak, müze işletiminden kâr elde etmek için Sıradan müşteri yüzdeliği en fazla toplam ziyaretçi sayısının %60 kadar olası gerekmekte ve en düşük VİP, Seçkin giriş ücretleri sırasıyla 400TL ve 200TL olarak belirlenmiştir.

Food service operations in an all-you-care-to-eat environment need to consider two conflicting objectives: a desire to reduce overproduction food waste (and its corresponding environmental impacts), and an aversion to shortfalls (in which some customer demands go unsatisfied). A particular challenge in such buffet-style operations is the absence of any lost marginal revenue associated with lost sales that can be used to measure the shortfall cost, complicating any attempt to determine a minimum-cost solution. This research presents a multi-criteria optimization approach to identify the efficient frontier of points lying between the minimum-waste and minimum-shortfall solutions. In particular, we identify optimal production adjustments relative to demand forecasts, demand thresholds for utilization of leftovers, and percentages of demand to be satisfied by leftovers, considering two alternative metrics for overproduction waste: mass; and greenhouse gas emissions (to account for the embodied chemical usage during farming, transportation, and landfill decomposing of overproduced food waste). A statistical analysis of the changes in decision variable values across each of the efficient frontiers can then be performed to identify the key variables that could be modified to reduce the amount of wasted food at minimal increase in shortfalls (or, alternatively, to reduce the amount of shortfalls at minimal increase in waste). We illustrate our approach with an application to empirical data from Campus Dining Services operations at the University of Missouri. Our analysis suggests that targeted production level modifications, rather than blanket increases or decreases, can allow food service providers to reduce overproduction food waste without significant increases in demand shortfalls.

OBJECTIVE This study seeks to evaluate the efficacy and safety of intranasal (IN) dexmedetomidine as a sedative medication for non-invasive procedural sedation. METHODS Subjects 6 months to 18 years of age undergoing non-invasive elective procedures were included. Dexmedetomidine (3 mcg/kg) was administered IN 40 minutes before the scheduled procedure time. The IN dexmedetomidine cohort was matched and compared to a cohort of 690 subjects who underwent sedation for similar procedures without the use of dexmedetomidine to evaluate for observed events/interventions and procedural times. RESULTS One hundred (92%) of the 109 included subjects were successfully sedated with IN dexmedetomidine. There were no significant differences in the rate of observed events/interventions in comparison to the non-dexmedetomidine cohort. However, the IN dexmedetomidine group had a longer postprocedure sleep time when compared to the non-dexmedetomidine cohort (p < 0.001), which had a significant effect on recovery time (p = 0.024). Also, the dexmedetomidine cohort had longer procedure time and total admit time (p < 0.001 and p = 0.037, respectively). CONCLUSIONS IN dexmedetomidine may be used for non-invasive pediatric procedural sedation. Subjects receiving IN dexmedetomidine had a similar rate of observed events/interventions as the subjects receiving non-dexmedetomidine sedation, with the exception of sleeping time. Also, patients sedated with IN dexmedetomidine had longer time to discharge, procedure time, and total admit time in comparison to other forms of sedation.

Collegiate sporting venues have been leading efforts toward zero-waste events in pursuit of more sustainable operations. This study audited the landfill-destined waste generated at the University of Missouri (MU) football stadium in 2014 and evaluated the life cycle greenhouse gas (GHG) and energy use associated with waste management options, including options that do and do not comply with zero-waste definitions. An estimated 47.3 metric tons (mt) of waste was generated, the majority (29.6 mt waste) came from off-site, pre-game food preparation activities; of which over 96 percent (%) was pre-consumer and un-sold food waste. The remaining 17.7 mt originated from inside the stadium; recyclable materials accounting for 43%, followed by food waste, 24%. Eleven waste management strategies were evaluated using the Waste Reduction Model (WARM). Results indicate that scenarios achieving zero waste compliance are not necessarily the most effective means of reducing GHG emissions or energy use. The two most effective approaches are eliminating edible food waste and recycling. Source reduction of edible food reduced GHGs by 103.1 mt (carbon dioxide equivalents) CO2e and generated energy savings of 448.5 GJ compared to the baseline. Perfect recycling would result in a reduction of 25.4 mt CO2e and 243.7 GJ compared to the baseline. The primary challenges to achieving these reductions are the difficulties of predicting demand for food and influencing consumer behavior.