Predictors Of Outcome In Children Research Articles

Everyday Heroes: The Personal and Economic Stressors of Early Care and Education Teachers Serving Low-Income Children

ABSTRACT Research findings This study uses newly available data on low-income children and their teachers in a mixed-delivery, publicly funded early care and education (ECE) system to document the prevalence of personal and economic stressors that ECE teachers experience. We go on to explore whether these stressors are associated with child academic, self-regulatory, and social outcomes. Results indicate that ECE teachers in our sample report a high degree of personal and economic stressors – for instance, rates of depression and food insecurity are relatively high. Yet, these stressors’ associations with child outcomes are often weak and inconsistent. Practice and policy: ECE teachers in publicly funded settings face high expectations but are paid astonishingly low wages, which may contribute to high stress. More research is needed to understand why the many stressors teachers report did not consistently predict child outcomes in this study. What enables teachers to compartmentalize or absorb their personal and economic stressors such that their students are protected from its impacts? How can this information be applied to professional development focused on improving teacher wellbeing? Regardless of associations with child outcomes, reducing stressors reported by ECE teachers is a worthy practice priority because children deserve healthy and economically secure teachers and a worthy policy priority from a human rights perspective.

Comparison of Risk-scoring Systems in Predicting Outcomes of Kawasaki Disease in a North American Cohort

Purpose: Scoring systems used to predict morbidity in children with Kawasaki disease have been developed and validated in Asian populations. The objective of this study was to assess their utility in predicting outcomes in children with Kawasaki disease …

Simultaneous Heart Rate Variability and Electroencephalographic Monitoring in Children in the Emergency Department.

Changes in heart rate variability (HRV) and electroencephalographic (EEG) background are promising tools for risk stratification and outcome prediction in children seen in the Emergency Department (ED). Novel monitoring technologies offer an opportunity for determining the clinical value of these physiologic variables, however, studies evaluating these measurements obtained in the Pediatric ED are sparse. The current study used a single center, prospective, observational cohort study of HRV and EEG as early predictors of outcome in children with acute trauma. ECG and HRV data were successfully collected in 167 subjects and simultaneous collection of ECG and EEG data using a wireless monitoring device was piloted in 17 patients with 15 patients having EEG data rated as appropriate for clinical interpretation. The mean time from ED arrival to ECG and EEG recording start was 7.5 (SD 11.6) and 34.5 (SD 15.5) minutes, respectively. The mean time required for EEG electrode placement was 9.3min (SD 5.8min). Results showed recording early HRV and EEG is feasible in children with acute injury seen in the ED. This study suggests that high consent rates are possible with the adequate research infrastructure and physiologic variables may offer an early, non-invasive marker for injury stratification and prognosis in children.

Stuck on pain? Assessing children's vigilance and awareness of pain sensations.

Attending towards pain is proposed as a key mechanism influencing the experience and chronification of pain. Persistent attention towards pain is proposed to drive poor outcomes in both adults and children with chronic pain. However, there are no validated self-report measures of pain-related attention for children. The goals of this study were to adapt the Pain Vigilance and Awareness Questionnaire (PVAQ) for use in a child sample, to preliminary examine its psychometric properties, and to assess its utility over and above a measure of general attentional capacities. We adapted the language of the PVAQ to be more easily understood by children as young as 8years. In a sample of 160 children (8-18years) with chronic pain, we examined the factor structure, internal consistency and criterion validity of the PVAQ-C. The PVAQ-C demonstrated excellent internal consistency (α=0.92) and moderate-to-strong criterion validity. A one-factor structure best fit the data. Children who reported greater attention to pain also reported greater pain catastrophizing, fear of pain, avoidance of activities and poorer physical functioning. Pain-related attention remained a significant predictor of functioning while controlling for demographics, catastrophizing and fear-avoidance. Pain-related attention also significantly predicted child outcomes independent of the child's general attention control capacities, indicating added value of a pain-specific measure of attention. The PVAQ-C shows strong indices of internal reliability and criterion validity, and indicates unique predictive utility. It will be important to study the role of pain-related attention in youth within developmental and functional-motivational frameworks. Pain-related attention is proposed as a key factor influencing fear-avoidance outcomes in both adults and youth with chronic pain, yet no self-report measures of pain-related attention have been validated for children. This paper presents a child version of the Pain Vigilance and Awareness Questionnaire (PVAQ-C), which indicates strong internal consistency, criterion validity and unique predictive validity, and provides evidence to support the Fear-Avoidance Model in youth with chronic pain.

Intervention Adherence and Self-Efficacy as Predictors of Child Outcomes in School Nurse-Delivered Interventions for Anxiety.

This study examined the association between two implementation factors, nurse-reported intervention adherence and self-efficacy, and children's outcomes in school nurse-delivered anxiety interventions. Data were collected in a pilot randomized controlled effectiveness trial with 54 children and 21 school nurses. Nurses implemented either a cognitive behavioral or relaxation-skills-only intervention. Nurse questionnaires assessed implementation factors. Independent evaluators assessed changes in children's anxiety symptoms at postintervention and at 3-month follow-up using clinical improvement and global functioning scales. Regression analyses indicated that greater intervention adherence was associated with greater anxiety symptom improvement at follow-up. Nurse self-efficacy interacted with intervention group, such that nurses with higher self-efficacy who implemented the cognitive behavioral intervention tended to have children show improvement and higher postintervention functioning. The impact of implementation factors on children's outcomes may differ depending on intervention type. Self-efficacy may be important for nurses using relatively complex interventions. Intervention adherence should be supported through training and consultation.

Comparison of the Clinical Outcomes of Guillain Barre Syndrome Based on Electrophysiological Subtypes in Pakistani Children.

ObjectiveGuillain Barre syndrome (GBS) is an autoimmune-mediated, acute, symmetrical, flaccid paralysis. Guillain Barre syndrome has different electrophysiological types that carry prognostic significance and tend to differ between adults and children. This study aims to compare the clinical outcome of Guillain Barre syndrome in Pakistani children based on their electrophysiological types to help in understanding and predicting the prognosis.Study designObservational comparative studyPlace & durationThe pediatric department, Shifa International Hospital, Islamabad; all patients with Guillain Barre syndrome seen between 2012 and 2019MethodAll children aged one to 16 years in whom Guillain Barre syndrome was diagnosed based on clinical history, examination, and electrophysiological findings. Institutional review board (IRB) approval was taken and data entered on the designed questionnaire. Chi-square and non-parametric tests were applied for significant association.ResultsTwenty-three children were included in the study. Of these, 14 were males (60.9%) while the mean age was 5.8 (+4.5) years. Acute inflammatory demyelinating polyneuropathy (AIDP) was found to be the predominant type (9; 39.1%) followed by acute motor and sensory axonal neuropathy (AMSAN) (6; 26.1%), Acute motor axonal neuropathy (AMAN) was diagnosed in four (17.4%) patients. Six (26.1%) patients needed mechanical ventilation and 10 patients (43.5%) required intensive care unit (ICU) care. The majority of the patients (18; 78.3%) received intravenous immunoglobulin (IVIG).ConclusionThe study highlights varied electrophysiological types of GBS in Pakistani children, which differ in predominance from previous studies. However, various indicators of poor outcomes that are highlighted in adults, including the older age group, need for mechanical ventilation, and electrophysiological evidence of axonal degeneration, were not significant predictors of outcome in children.

Monitoring Prenatal Exposure to Buprenorphine and Methadone.

Buprenorphine and methadone are international gold standards for managing opioid use disorders. Although they are efficacious in treating opioid dependence, buprenorphine and methadone present risks, especially during pregnancy, causing neonatal abstinence syndrome and adverse obstetrical outcomes. Buprenorphine and methadone are also abused during pregnancy, and identifying their use is important to limit unprescribed prenatal exposure. Previous studies have suggested that concentrations of buprenorphine, but not methadone markers in unconventional matrices may predict child outcomes, although currently only limited data exist. We reviewed the literature on concentrations of buprenorphine, methadone, and their metabolites in unconventional matrices to improve data interpretation. A literature search was conducted using scientific databases (PubMed, Scopus, Web of Science, and reports from international institutions) to review published articles on buprenorphine and methadone monitoring during pregnancy. Buprenorphine and methadone and their metabolites were quantified in the meconium, umbilical cord, placenta, and maternal and neonatal hair. Methadone concentrations in the meconium and hair were typically higher than those in other matrices, although the concentrations in the placenta and umbilical cord were more suitable for predicting neonatal outcomes. Buprenorphine concentrations were lower and required sensitive instrumentation, as measuring buprenorphine glucuronidated metabolites is critical to predict neonatal outcomes. Unconventional matrices are good alternatives to conventional ones for monitoring drug exposure during pregnancy. However, data are currently scarce on buprenorphine and methadone during pregnancy to accurately interpret their concentrations. Clinical studies should be conducted with larger cohorts, considering confounding factors such as illicit drug co-exposure.

Decompressive craniectomy in pediatric non-traumatic intracranial hypertension: a single center experience

Purpose: To study the clinical profile and predictors of outcome in children undergoing decompressive craniectomy (DC) for non-traumatic intracranial hypertension (ICH).Materials and methods: Mixed observational study of children, aged 1 month-12 years, who underwent DC for non-traumatic ICH in a tertiary care pediatric intensive care unit from 2012 to 2017. Data on clinical profile and outcome were retrieved retrospectively and survivors were assessed prospectively. The primary outcome was neurological outcome using Glasgow Outcome Scale-Extended (GOS-E) at minimum 6 months’ post-discharge. GOS-E of 1–4 were classified as a poor and 5–8 as a good outcome.Results: Thirty children, median (IQR) age of 6.5 (2, 50) months, underwent DC; of which 26 (86.7%) were boys. Altered sensorium (n = 26, 86.7%), seizures (n = 25, 83.3%), pallor (n = 19, 63.3%) and anisocoria (n = 14, 46.7%) were common signs and symptoms. Median (IQR) Glasgow Coma Scale at admission was 9 (6,11). Commonest etiology was intracranial bleed (n = 24; 80%). Median (IQR) time to DC was 24 (24,72) h. Eight (26.7%) children died; 2 during PICU stay and 6 during follow-up. Neurological sequelae at discharge (n = 28) were seizures (n = 25; 89.2%) and hemiparesis (n = 16; 57.1%). Twenty-one children were followed-up at median (IQR) duration of 12 (6,54) months. Good neurological outcome was seen in 14/29 (48.2%) and hemiparesis in 10/21 (47.6%) patients. On regression analysis, anisocoria at admission was an independent predictor of poor outcome [OR 7.33; 95%CI: 1.38–38.87; p = 0.019].Conclusions: DC is beneficial in children with non-traumatic ICH due to a focal pathology and midline shift. Evidence on indications and timing of DC in NTC is still evolving.

Growth trajectories of parental emotion socialization and child adjustment following a military parenting intervention: A randomized controlled trial.

Children of combat deployed parents are at risk of behavioral problems. Parental emotion socialization (PES) has been theorized to influence children's behaviors; many studies lend support to this theory. However, longitudinal studies examining PES with experimental designs are sparse. In this study, we estimated PES growth trajectories following a parenting intervention and evaluated whether intervention induced improvements in PES predict child outcomes in postdeployed military families. National Guard/Reserve families with at least one deployed parent and a child aged 4-13 years were randomized into an intervention or control group. Data from all 255 2-parent married families, who were primarily Caucasian and middle-class, were analyzed. PES was indicated by self-reported nonsupportive and supportive reactions to children's negative emotions (baseline, 1-year, and 2-year follow-up). Child behaviors were assessed through averaged mother- and father- reports (baseline and 2-year follow-up). Results of latent growth models showed that mothers and fathers assigned to the intervention condition reported greater improvements in nonsupportive PES (steeper negative slopes) over 2 years relative to controls. Both mothers' and fathers' intervention-induced improvements in nonsupportive PES were associated with decreased child internalizing behaviors. Mothers' intervention-induced improvements in nonsupportive PES were associated with decreased child externalizing behaviors. No significant findings were detected for intervention effects on supportive PES growth trajectories. Our findings supported the indirect effects of the intervention on child behaviors through nonsupportive PES over two years. PES is an important, malleable skill that can be targeted in parenting interventions for postdeployed military families. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Clinicopathologic predictors of outcomes in children with stage I germ cell tumors: A pooled post hoc analysis of trials from the Children’s Oncology Group.

418 Background: Patients with clinical stage I (CS I: cN0M0) germ cell tumors (GCT) exhibit favorable oncologic outcomes. While prognostic features can help inform treatment in adults with CS I GCT, we lack reliable means to predict relapse among pediatric patients. We sought to identify predictors of relapse in children with CS I GCT. Methods: We performed a pooled post hoc analysis on pediatric CS I GCT patients enrolled in 3 prospective trials: INT-0097 (phase II), INT-0106 (phase III), and AGCT0132 (phase III). Pathology was centrally reviewed. Patient demographics, pT stage, serum tumor markers, margin status, histology, relapse, and survival were compiled. Cox regression analyses were used to identify predictors of outcomes. Results: 88 patients were identified with histologic data available. Most patients were pT1-2 stage. Yolk sac tumor was present in 75%, while 16% had embryonal carcinoma, and 9% had choriocarcinoma. When evaluable, lymphovascular invasion (LVI) was present in 36/66 (55%) of patients. Over a median follow-up of 5.0 years, no patients died and 24 patients (27%) relapsed (median relapse-free survival not reached). Predictors of relapse included presence of choriocarcinoma (HR 4.3, p=0.004), embryonal carcinoma (HR 3.8, p=0.002), pT3 stage (HR 6.9, p=0.027), and age >12 years (HR 3.1, p=0.011). LVI (HR 2.4, p=0.072), serum tumor markers, and dominant tumor size did not reach significance. Pediatric CS I GCT patients exhibit remarkable 5-year survival. Conclusions: Using combined data from multiple prospective trials, our study identifies clinicopathologic features that predict relapse and potentially inform personalized treatment for these patients.

Epidemiology and Outcomes of Early Morning Neuroparalytic Syndrome Following Snake Bite-A Retrospective Study.

Snake envenomation has been poorly studied in developing countries. 'Early morning neuroparalytic syndrome' (EMNS), the classical clinical constellation caused by krait bites, refers to nighttime, indoor bites where nonspecific symptoms progress to neuroparalysis. Literature regarding EMNS in children is scarce. This study was planned to describe the clinical profile, intensive care needs and predictors of outcome in children with EMNS. It is a retrospective study of children below 12 years admitted with a clinical diagnosis of snake envenomation to the pediatric intensive care unit (PICU) of a tertiary care hospital in North India. Patient records were reviewed from the electronic patient database manager. Comparison was made between the EMNS group and the non-EMNS group and between survivors and nonsurvivors within the EMNS group. Of the 111 children with snake envenomation, 76 had neuroparalysis (68%) and 51 had EMNS. In the EMNS cohort, 37 (72.5%) belonged to rural areas, 46 (90.2%) had indoor bites and 39 (76.5%) were witnessed. Patients with EMNS were more likely to have absent fang marks, hypoxemia at admission, bulbar palsy and need for PICU admission. Mortality rate was 13.7% in EMNS; predictors included younger age, presence of ptosis, cardiac arrest at admission and nonavailability of PICU bed (univariable analysis) but none of them independently predicted mortality. Younger age, presence of ptosis, cardiac arrest at admission and nonavailability of intensive care beds increase the risk of mortality in children with EMNS. Timely recognition and respiratory support may reduce mortality in these children.

Predictors of Outcome in Children With Central Nervous System Tuberculosis

Background: Central Nervous system tuberculosis (CNS-Tb) is the most lethal form of extra-pulmonary tuberculosis in children. The delay in clinical suspicion and lack of markers of outcome, provides little information on the efficacy of the current treatment strategy and thus results in a higher mortality rate than other extrapulmonary manifestations of tuberculosis. This study aims to analyze clinical presentations and study the significant factors that will reliably predict the outcomes at discharge in children admitted with CNS-Tb. Methods and Material: This is a prospective observational study in children with neurotuberculosis admitted at a tertiary care hospital. Clinical presentations at the time of admission were studied. Outcomes at the end of in-patient care (completely cured, survival with some/severe disability or death) were correlated with clinical, laboratory, microbiological, and radiological parameters. Univariate and multivariate analyses were applied to study the parameters and a p-value ≤ 0·05 with a confidence interval (CI) of 95% was considered as statistically significant. Findings: The study included 100 children between 4 months to 12 years of age with a mean of 5·84 (±3·5) years. At discharge, 55% of children recovered completely, 20% had some or severe disability and 25% died. On multivariate analysis, high CSF protein (p=0·050) and drug resistance (p=0·034 ) were highly associated with fatality. Meningeal enhancements with basal exudates (p=0·021) and CSF lymphocyte count >90% were highly associated with survival with disability. Stage I disease at presentation (p<0·0001) was the only variable associated with complete recovery. Interpretation: Reliable prognostic markers for CNS-Tb can aid in predicting the efficacy of the current treatment and the anticipated outcome in the children with this disease. Funding Statement: The authors received no specific funding for this work. Declaration of Interests: The Authors declare that there is no conflict of interest. Ethics Approval Statement: After getting the required approval from the Institutional Ethics Committee (Letter number: IEC/PG/16/JAN/2018), informed and written consent was taken from all parents willing to participate.

Parents' School Involvement in Kindergarten Predicting Child Outcomes at First Grade and Third Grade

Using the Early Childhood Longitudinal Study, Kindergarten Class of 2010–11 (ECLS-K:2011; N = 18,170), the present study aimed to identify latent classes of parents’ school involvement in kindergarten and whether the latent classes of parents’ school involvement would be differentially related to children’s academic achievement and social-emotional behavioral outcomes at first grade and third grade. Latent class analysis showed three classes: School Involvement, Low Involvement, and School Contact. Parents classified as School Involvement had higher probabilities in attending school events, such as back-to-school nights and parent–teacher conferences, but not school governance. Parents classified as Low Involvement had lower probabilities in all the indicators of school involvement. Parents classified as School Contact had higher probabilities in being contacted by teachers regarding their children’s behaviors and school performance. Few significant differences in child outcomes across the three classes persisted throughout first grade and third grade. Future research and implications are discussed.

Comparison of admission serum albumin and hemoglobin as predictors of outcome in children with moderate to severe traumatic brain injury: A retrospective study: Erratum.

Comparison of admission serum albumin and hemoglobin as predictors of outcome in children with moderate to severe traumatic brain injury: A retrospective study: Erratum.

GCT-40 - Alpha-fetoprotein (AFP) as a predictor of outcome for children with germ cell tumours: A report from the Malignant Germ Cell International Consortium (MaGIC)

GCT-40 - Alpha-fetoprotein (AFP) as a predictor of outcome for children with germ cell tumours: A report from the Malignant Germ Cell International Consortium (MaGIC)

GCT-35 - Clinicopathologic predictors of outcomes in children with stage I germ cell tumours: A pooled post hoc analysis of trials from the Children’s Oncology Group

INTRODUCTION AND OBJECTIVE:Patients with clinical stage I (CS I: cN0M0) germ cell tumors (GCT) exhibit favorable oncologic outcomes. While prognostic features can help inform treatment in adults wi...

Speed and accuracy on the Hearts and Flowers task interact to predict child outcomes.

The current study tests whether accuracy and reaction time (RT) on the Hearts and Flowers (HF) task, a common assessment tool used across wide age ranges, can be leveraged as joint indicators of child executive function (EF) ability. Although previous studies have tended to use accuracy or RT, either alone or as separate indicators, one open question is whether these 2 metrics can be yoked together to enhance our measurement of EF ability. We test this question using HF data collected from first-grade children who participated in the Family Life Project. Specifically, we model the independent and interactive effects of HF accuracy and RT on several criterion outcomes representing child academic and behavioral competence. Our findings indicate that among early-elementary-aged children, accuracy and RT interact in the prediction of child outcomes, with RT being a more informative index of EF ability for children who perform at high levels of accuracy. The main effect of accuracy remained significant in the presence of these interactive effects. This pattern of findings was similar for different task blocks (i.e., mixed, flower-only) and for different child outcome domains (i.e., academic, behavioral). Our finding of an interaction between accuracy and RT contributes to a growing literature that attempts to jointly consider accuracy and RT as indicators of underlying ability, which has important implications for how EF task scores are constructed and interpreted. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

α-Fetoprotein as a predictor of outcome for children with germ cell tumors: A report from the Malignant Germ Cell International Consortium.

There are several studies describing the correlation between unsatisfactory tumor marker decline and a poor prognosis for adult patients treated for germ cell tumors. In pediatric patients, the data are limited. Therefore, this study retrospectively analyzed data from Children's Oncology Group (COG) protocol AGCT0132 to determine whether a relationship exists between α-fetoprotein (AFP) decline and outcome. One hundred thirty-one patients with germ cell tumors who were enrolled in COG protocol AGCT0132 were eligible for this analysis of AFP decline. The serum AFP half-life was calculated from levels collected postoperatively as a baseline and after the start of chemotherapy. AFP decline was defined as automatically satisfactory (AFP normalized within the first 2 AFP measures after the start of chemotherapy), calculated satisfactory (AFP half-life ≤7days after the start of chemotherapy), and unsatisfactory. The 3-year cumulative incidence of relapse was 11% (95% confidence interval [CI], 6.0%-18%) for patients with a satisfactory decline and 38% (95% CI, 13%-64%) for patients with an unsatisfactory decline (P=.006). In stratified analyses, this effect was limited to patients who were 11years of age or older and had standard risk 2 (SR2) disease (P=.004 and P=.007, respectively). Three-year overall survival (OS) for patients with a satisfactory decline versus an unsatisfactory decline was not statistically significant. This study is the first to show an association between AFP decline and the cumulative incidence of relapse in pediatric patients treated for germ cell tumors. Recognition of patients at high risk for relapse may allow for early intensification of therapy, which could affect future clinical trial design.

Alfa-feto protein (AFP) as a predictor of outcome for children with germ cell tumors: A report from the malignant germ cell international consortium.

10036 Background: There are several studies describing the correlation between unsatisfactory tumor marker decline and poor prognosis in adult patients treated for germ cell tumors. In pediatric patients the data is limited. We therefore retrospectively analyzed data collected from pediatric patients treated on the Children’s Oncology Group (COG) Protocol AGCT0132 to determine whether a relationship exists between AFP decline and outcome. Methods: One hundred and thirty-one patients with germ cell tumors enrolled on Children’s Oncology Group Protocol AGCT0132 were eligible for analysis of AFP decline. Serum AFP half-life was calculated from levels collected post-operatively and after the start of chemotherapy, excluding values in the first 7 days of chemotherapy to accommodate unpredictable increases in the initial days of treatment. AFP decline was defined as automatically satisfactory (AFP normalized within the first two AFP measures following the start of chemotherapy), calculated satisfactory (AFP half-life ≤7 days following the start of chemotherapy), and unsatisfactory. Results: The 3-year event-free survival (EFS) was 87 % (95% confidence interval-CI: 79-92 %) for patients with a satisfactory decline and 62 % (95% CI: 31-82 %) for patients with an unsatisfactory decline (p = 0.006). In stratified analyses, this effect was limited to patients ≥11 years of age and with standard risk (SR2) disease ((p = 0.002 and p = 0.004, respectively). Three-year overall survival for patients with satisfactory versus unsatisfactory decline was not statistically significant. Conclusions: This study is the first to show an association between AFP decline and EFS in pediatric patients. Although there is no statistically significant association between tumor marker decline and overall survival, recognition of patients at high-risk of relapse may allow for early intensification of therapy and impact the rationale for future clinical trial design.

Like mother, like child? Maternal determinants of children's early social-emotional development.

Social-Emotional competencies evolve early in life. For example, early emotion regulation is learned primarily in the context of mother-child interaction, which may allow for maternal influences to shape children's social-emotional development. The aim of the current study was to longitudinally examine maternal determinants of children's early social-emotional development in a community-based sample of first-time mothers (N = 61, aged 22-39 years). Specifically, we used structural equation modeling to examine how maternal emotion regulation difficulties and subclinical depression directly and indirectly, through sensitivity and postnatal bonding, assessed at 6 to 8 months predicted child outcomes at 12 to 16 months. We found that mothers' sensitivity predicted fewer social-emotional and behavioral problems and that stronger bonding predicted fewer problems and more social-emotional competencies. Emotion regulation difficulties were significantly associated with depressive symptoms; yet, when accounting for shared variances, both factors differentially predicted less positive child outcomes such that more difficulties indirectly, through poorer bonding, predicted greater delay in competencies, and more symptoms indirectly, through less sensitivity, predicted more problems. Current findings underline the significance of maternal factors impacting the quality of mother-child interaction for children's positive development. Potential implications for early prevention programs to support children who are otherwise at risk for negative emotional outcomes due to mothers' emotional state postpartum are discussed.