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Wilsterman EJ, Nellis ME, Panisello J, Al-Subu A, Breuer R, Kimura D, Krawiec C, Mallory PP, Nett S, Owen E, Parsons SJ, Sanders RC, Garcia-Marcinkiewicz A, Napolitano N, Shults J, Nadkarni VM, Nishisaki A. Evaluating Airway Management in Patients With Trisomy 21 in the PICU and Cardiac ICU: A Retrospective Cohort Study. Pediatr Crit Care Med 2024; 25:335-343. [PMID: 38059735 PMCID: PMC10994735 DOI: 10.1097/pcc.0000000000003418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
OBJECTIVES Children with trisomy 21 often have anatomic and physiologic features that may complicate tracheal intubation (TI). TI in critically ill children with trisomy 21 is not well described. We hypothesize that in children with trisomy 21, TI is associated with greater odds of adverse airway outcomes (AAOs), including TI-associated events (TIAEs), and peri-intubation hypoxemia (defined as > 20% decrease in pulse oximetry saturation [Sp o2 ]). DESIGN Retrospective database study using the National Emergency Airway Registry for Children (NEAR4KIDS). SETTING Registry data from 16 North American PICUs and cardiac ICUs (CICUs), from January 2014 to December 2020. PATIENTS A cohort of children under 18 years old who underwent TI in the PICU or CICU from in a NEAR4KIDS center. We identified patients with trisomy 21 and selected matched cohorts within the registry. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We included 8401 TIs in the registry dataset. Children with trisomy 21 accounted for 274 (3.3%) TIs. Among those with trisomy 21, 84% had congenital heart disease and 4% had atlantoaxial instability. Cervical spine protection was used in 6%. The diagnosis of trisomy 21 (vs. without) was associated with lower median weight 7.8 (interquartile range [IQR] 4.5-14.7) kg versus 10.6 (IQR 5.2-25) kg ( p < 0.001), and more higher percentage undergoing TI for oxygenation (46% vs. 32%, p < 0.001) and ventilation failure (41% vs. 35%, p = 0.04). Trisomy 21 patients had more difficult airway features (35% vs. 25%, p = 0.001), including upper airway obstruction (14% vs. 8%, p = 0.001). In addition, a greater percentage of trisomy 21 patients received atropine (34% vs. 26%, p = 0.004); and, lower percentage were intubated with video laryngoscopy (30% vs. 37%, p = 0.023). After 1:10 (trisomy 21:controls) propensity-score matching, we failed to identify an association difference in AAO rates (absolute risk difference -0.6% [95% CI -6.1 to 4.9], p = 0.822). CONCLUSIONS Despite differences in airway risks and TI approaches, we have not identified an association between the diagnosis of trisomy 21 and higher AAOs.
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Affiliation(s)
- Eric J Wilsterman
- Pediatric Critical Care, Department of Pediatrics, New York Presbyterian Weill Cornell Medical Center, New York, NY
| | - Marianne E Nellis
- Pediatric Critical Care, Department of Pediatrics, New York Presbyterian Weill Cornell Medical Center, New York, NY
| | - Josep Panisello
- Critical Care, Department of Pediatrics, Yale Medical School, New Haven, CT
| | - Awni Al-Subu
- Pediatric Critical Care Medicine, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Ryan Breuer
- Critical Care Medicine, Department of Pediatrics, Oishei Children's Hospital University at Buffalo, Buffalo, NY
| | - Dai Kimura
- Critical Care Medicine, Department of Pediatrics, Le Bonheur Children's Hospital, Heart Institute, University of Tennessee Health Science Center, Memphis, TN
| | - Conrad Krawiec
- Pediatric Critical Care Medicine, Department of Pediatrics, Penn State Health Children's Hospital, Hershey, PA
| | - Palen P Mallory
- Pediatric Critical Care Medicine, Department of Pediatrics, Duke University, Durham, NC
| | - Sholeen Nett
- Pediatric Critical Care, Department of Pediatrics, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Erin Owen
- Pediatric Critical Care Medicine, Department of Pediatrics, Norton Children's Hospital, University of Louisville, Louisville, KY
| | - Simon J Parsons
- Critical Care, Department of Pediatrics, Alberta Children's Hospital, Calgary, AB, Canada
| | - Ronald C Sanders
- Section of Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Annery Garcia-Marcinkiewicz
- General Anesthesiology, Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Natalie Napolitano
- Respiratory Therapy Department, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Justine Shults
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Vinay M Nadkarni
- Department of Anesthesiology, Critical Care and Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Akira Nishisaki
- Critical Care, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Anesthesiology, Critical Care and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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2
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Adang LA, Sevagamoorthy A, Sherbini O, Fraser JL, Bonkowsky JL, Gavazzi F, D'Aiello R, Modesti NB, Yu E, Mutua S, Kotes E, Shults J, Vincent A, Emrick LT, Keller S, Van Haren KP, Woidill S, Barcelos I, Pizzino A, Schmidt JL, Eichler F, Fatemi A, Vanderver A. Longitudinal natural history studies based on real-world data in rare diseases: Opportunity and a novel approach. Mol Genet Metab 2024; 142:108453. [PMID: 38522179 DOI: 10.1016/j.ymgme.2024.108453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 03/13/2024] [Accepted: 03/16/2024] [Indexed: 03/26/2024]
Abstract
Growing interest in therapeutic development for rare diseases necessitate a systematic approach to the collection and curation of natural history data that can be applied consistently across this group of heterogenous rare diseases. In this study, we discuss the challenges facing natural history studies for leukodystrophies and detail a novel standardized approach to creating a longitudinal natural history study using existing medical records. Prospective studies are uniquely challenging for rare diseases. Delays in diagnosis and overall rarity limit the timely collection of natural history data. When feasible, prospective studies are often cross-sectional rather than longitudinal and are unlikely to capture pre- or early- symptomatic disease trajectories, limiting their utility in characterizing the full natural history of the disease. Therapeutic development in leukodystrophies is subject to these same obstacles. The Global Leukodystrophy Initiative Clinical Trials Network (GLIA-CTN) comprises of a network of research institutions across the United States, supported by a multi-center biorepository protocol, to map the longitudinal clinical course of disease across leukodystrophies. As part of GLIA-CTN, we developed Standard Operating Procedures (SOPs) that delineated all study processes related to staff training, source documentation, and data sharing. Additionally, the SOP detailed the standardized approach to data extraction including diagnosis, clinical presentation, and medical events, such as age at gastrostomy tube placement. The key variables for extraction were selected through face validity, and common electronic case report forms (eCRF) across leukodystrophies were created to collect analyzable data. To enhance the depth of the data, clinical notes are extracted into "original" and "imputed" encounters, with imputed encounter referring to a historic event (e.g., loss of ambulation 3 months prior). Retrospective Functional Assessments were assigned by child neurologists, using a blinded dual-rater approach and score discrepancies were adjudicated by a third rater. Upon completion of extraction, data source verification is performed. Data missingness was evaluated using statistics. The proposed methodology will enable us to leverage existing medical records to address the persistent gap in natural history data within this unique disease group, allow for assessment of clinical trajectory both pre- and post-formal diagnosis, and promote recruitment of larger cohorts.
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Affiliation(s)
- Laura Ann Adang
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Anjana Sevagamoorthy
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Omar Sherbini
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jamie L Fraser
- Rare Disease Institute, Children's National Medical Center, Washington, DC, USA; Leukodystrophy and Myelin Disorders Program, Children's National Medical Center, Washington, DC, USA
| | - Joshua L Bonkowsky
- Division of Pediatric Neurology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA; Center for Personalized Medicine, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Francesco Gavazzi
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Russel D'Aiello
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nicholson B Modesti
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Emily Yu
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sylvia Mutua
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Emma Kotes
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Justine Shults
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - Ariel Vincent
- CHOP Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lisa T Emrick
- Division of Neurology and Developmental Neuroscience in Department Pediatrics, Baylor College Medicine and Texas Children's Hospital, Houston, TX, USA; Department of Human and Molecular Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Stephanie Keller
- Children's Healthcare of Atlanta Scottish Rite Hospital, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Sarah Woidill
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Isabella Barcelos
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Amy Pizzino
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Johanna L Schmidt
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Florian Eichler
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Ali Fatemi
- Moser Center for Leukodystrophies, Kennedy Krieger Institute, Baltimore, MD, USA; Departments of Neurology & Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Adeline Vanderver
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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3
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Bamat NA, Huber M, Shults J, Li Y, Zong Z, Zuppa A, Eichenwald EC, Laughon MM, DeMauro SB, McKenna KJ, Laskin B, Lorch SA. Diuretic Tolerance to Repeated-Dose Furosemide in Infants Born Very Preterm with Bronchopulmonary Dysplasia. J Pediatr 2024; 266:113813. [PMID: 37918519 PMCID: PMC10922280 DOI: 10.1016/j.jpeds.2023.113813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/27/2023] [Accepted: 10/29/2023] [Indexed: 11/04/2023]
Abstract
OBJECTIVES To assess the presence and timing of furosemide diuretic tolerance in infants with bronchopulmonary dysplasia (BPD), and to determine if tolerance is modified by thiazide co-administration. STUDY DESIGN We performed a retrospective cohort study among infants born very preterm with BPD exposed to repeated-dose furosemide for 72 hours, measuring net fluid balance (total intake minus total output) as a surrogate of diuresis in the 3 days before and after exposure. The primary comparison was the difference in fluid balance between the first and third 24 hours of furosemide exposure. We fit a general linear model for within-subject repeated measures of fluid balance over time, with thiazide co-administration as an interaction variable. Secondary analyses included an evaluation of weight trajectories over time. RESULTS In 83 infants, median fluid balance ranged between + 43.6 and + 52.7 ml/kg/d in the 3 days prior to furosemide exposure. Fluid balance decreased to a median of + 29.1 ml/kg/d in the first 24 hours after furosemide, but then increased to +47.5 ml/kg/d by the third 24-hour interval, consistent with tolerance (P < .001). Thiazides did not modify the change in fluid balance during furosemide exposure for any time-period. Weight decreased significantly in the first 24 hours after furosemide and increased thereafter (P < .001). CONCLUSIONS The net fluid balance response to furosemide decreases rapidly during repeated-dose exposures in infants with BPD, consistent with diuretic tolerance. Clinicians should consider this finding in the context of an infant's therapeutic goals. Further research efforts to identify safe and effective furosemide dosage strategies are needed.
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Affiliation(s)
- Nicolas A Bamat
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
| | - Matthew Huber
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Justine Shults
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Yun Li
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Zili Zong
- Children's Hospital of Philadelphia, Philadelphia, PA
| | - Athena Zuppa
- Adjunct Professor of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Eric C Eichenwald
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Matthew M Laughon
- Division of Neonatology, Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Sara B DeMauro
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Kristin J McKenna
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Benjamin Laskin
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Scott A Lorch
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Ducharme-Crevier L, Furlong-Dillard J, Jung P, Chiusolo F, Malone MP, Ambati S, Parsons SJ, Krawiec C, Al-Subu A, Polikoff LA, Napolitano N, Tarquinio KM, Shenoi A, Talukdar A, Mallory PP, Giuliano JS, Breuer RK, Kierys K, Kelly SP, Motomura M, Sanders RC, Freeman A, Nagai Y, Glater-Welt LB, Wilson J, Loi M, Adu-Darko M, Shults J, Nadkarni V, Emeriaud G, Nishisaki A. Safety of primary nasotracheal intubation in the pediatric intensive care unit (PICU). Intensive Care Med Paediatr Neonatal 2024; 2:7. [PMID: 38404646 PMCID: PMC10891187 DOI: 10.1007/s44253-024-00035-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 02/09/2024] [Indexed: 02/27/2024]
Abstract
Background Nasal tracheal intubation (TI) represents a minority of all TI in the pediatric intensive care unit (PICU). The risks and benefits of nasal TI are not well quantified. As such, safety and descriptive data regarding this practice are warranted. Methods We evaluated the association between TI route and safety outcomes in a prospectively collected quality improvement database (National Emergency Airway Registry for Children: NEAR4KIDS) from 2013 to 2020. The primary outcome was severe desaturation (SpO2 > 20% from baseline) and/or severe adverse TI-associated events (TIAEs), using NEAR4KIDS definitions. To balance patient, provider, and practice covariates, we utilized propensity score (PS) matching to compare the outcomes of nasal vs. oral TI. Results A total of 22,741 TIs [nasal 870 (3.8%), oral 21,871 (96.2%)] were reported from 60 PICUs. Infants were represented in higher proportion in the nasal TI than the oral TI (75.9%, vs 46.2%), as well as children with cardiac conditions (46.9% vs. 14.4%), both p < 0.001. Severe desaturation or severe TIAE occurred in 23.7% of nasal and 22.5% of oral TI (non-adjusted p = 0.408). With PS matching, the prevalence of severe desaturation and or severe adverse TIAEs was 23.6% of nasal vs. 19.8% of oral TI (absolute difference 3.8%, 95% confidence interval (CI): - 0.07, 7.7%), p = 0.055. First attempt success rate was 72.1% of nasal TI versus 69.2% of oral TI, p = 0.072. With PS matching, the success rate was not different between two groups (nasal 72.2% vs. oral 71.5%, p = 0.759). Conclusion In this large international prospective cohort study, the risk of severe peri-intubation complications was not significantly higher. Nasal TI is used in a minority of TI in PICUs, with substantial differences in patient, provider, and practice compared to oral TI.A prospective multicenter trial may be warranted to address the potential selection bias and to confirm the safety of nasal TI.
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Affiliation(s)
- Laurence Ducharme-Crevier
- Pediatric Intensive Care Unit, Department of Pediatrics, CHU Sainte-Justine Université de Montréal, Montréal, QC H3T 1C5 Canada
| | - Jamie Furlong-Dillard
- Department of Pediatric Critical Care, Norton Children's Hospital, University of Louisville, Louisville, KY USA
| | - Philipp Jung
- Department of Pediatrics, University Hospital Schleswig Holstein, Campus Luebeck, Luebeck, Germany
| | - Fabrizio Chiusolo
- Department of Anesthesia and Critical Care, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Matthew P Malone
- Division of Critical Care Medicine, Department of Pediatrics, The University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR USA
| | - Shashikanth Ambati
- Division of Pediatric Critical Care, Department of Pediatrics, Albany Medical Center, Albany, NY USA
| | - Simon J Parsons
- Section of Critical Care Medicine, Department of Pediatrics, Alberta Children's Hospital, Calgary, AB Canada
| | - Conrad Krawiec
- Pediatric Critical Care, Department of Pediatrics, College of Medicine, Penn State Health Children's Hospital, Hershey, PA USA
| | - Awni Al-Subu
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin, Madison, WI USA
| | - Lee A Polikoff
- Division of Pediatric Critical Care Medicine, Warren Alpert Medical School of Brown University, Providence, RI USA
| | - Natalie Napolitano
- Respiratory Therapy Department, Children's Hospital of Philadelphia, Philadelphia, PA USA
| | - Keiko M Tarquinio
- College of Health Professions, the Medical University of South Carolina, Charleston, SC USA
| | - Asha Shenoi
- Division of Pediatric Critical Care, Department of Pediatrics, University of Kentucky School of Medicine, Lexington, KY USA
| | - Andrea Talukdar
- Pediatric Critical Care, Medical Center/Children's Hospital and Medical Center of Omaha, University of Nebraska, Omaha, NE USA
| | - Palen P Mallory
- Division of Pediatric Critical Care Medicine, Duke University, Durham, NC USA
| | - John S Giuliano
- Department of Pediatrics (Critical Care Medicine), Yale University School of Medicine, New Haven, CT USA
| | - Ryan K Breuer
- Division of Critical Care Medicine, Department of Pediatrics, Oishei Children's Hospital, Buffalo, NY USA
| | - Krista Kierys
- Pediatric Intensive Care Unit, Penn State Health, Philadelphia, PA USA
| | - Serena P Kelly
- Division of Pediatric Critical Care, OHSU Doernbecher Children's Hospital, Portland, OR USA
| | - Makoto Motomura
- Division of Pediatric Critical Care Medicine, Aichi Children's Health and Medical Center, Obu, Aichi Japan
| | - Ron C Sanders
- Section of Critical Care, Department of Pediatrics, UAMS/Arkansas Children's Hospital, Little Rock, AR USA
| | - Ashley Freeman
- Pediatric Critical Care, Department of Pediatrics, Children's Hospital of Georgia at the Medical College of Georgia, Augusta, GA USA
| | - Yuki Nagai
- Division of Pediatric Critical Care Medicine, Kobe Children's Hospital, Kobe, Hyogo Japan
| | - Lily B Glater-Welt
- Pediatric Critical Care Medicine, Cohen Children's Medical Center of New York/Northwell, Queens, NY USA
| | - Joseph Wilson
- Pediatric Critical Care Medicine, University of Louisville, Louisville, KY USA
| | - Mervin Loi
- Department of Pediatric Subspecialties, Children's Intensive Care Unit KK Women's and Children's Hospital, Singapore, Singapore
| | - Michelle Adu-Darko
- Division of Pediatric Critical Care, Department of Pediatrics, University of Virginia Hospital, Charlottesville, VA USA
| | - Justine Shults
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Vinay Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA USA
| | - Guillaume Emeriaud
- Pediatric Intensive Care Unit, Department of Pediatrics, CHU Sainte-Justine Université de Montréal, Montréal, QC H3T 1C5 Canada
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA USA
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5
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Gladen KM, Tellez D, Napolitano N, Edwards LR, Sanders RC, Kojima T, Malone MP, Shults J, Krawiec C, Ambati S, McCarthy R, Branca A, Polikoff LA, Jung P, Parsons SJ, Mallory PP, Komeswaran K, Page-Goertz C, Toal MC, Bysani GK, Meyer K, Chiusolo F, Glater-Welt LB, Al-Subu A, Biagas K, Hau Lee J, Miksa M, Giuliano JS, Kierys KL, Talukdar AM, DeRusso M, Cucharme-Crevier L, Adu-Arko M, Shenoi AN, Kimura D, Flottman M, Gangu S, Freeman AD, Piehl MD, Nuthall GA, Tarquinio KM, Harwayne-Gidansky I, Hasegawa T, Rescoe ES, Breuer RK, Kasagi M, Nadkarni VM, Nishisaki A. Adverse Tracheal Intubation Events in Critically Ill Underweight and Obese Children: Retrospective Study of the National Emergency Airway for Children Registry (2013-2020). Pediatr Crit Care Med 2024; 25:147-158. [PMID: 37909825 PMCID: PMC10841296 DOI: 10.1097/pcc.0000000000003387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
OBJECTIVES Extremes of patient body mass index are associated with difficult intubation and increased morbidity in adults. We aimed to determine the association between being underweight or obese with adverse airway outcomes, including adverse tracheal intubation (TI)-associated events (TIAEs) and/or severe peri-intubation hypoxemia (pulse oximetry oxygen saturation < 80%) in critically ill children. DESIGN/SETTING Retrospective cohort using the National Emergency Airway for Children registry dataset of 2013-2020. PATIENTS Critically ill children, 0 to 17 years old, undergoing TI in PICUs. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Registry data from 24,342 patients who underwent TI between 2013 and 2020 were analyzed. Patients were categorized using the Centers for Disease Control and Prevention weight-for-age chart: normal weight (5th-84th percentile) 57.1%, underweight (< 5th percentile) 27.5%, overweight (85th to < 95th percentile) 7.2%, and obese (≥ 95th percentile) 8.2%. Underweight was most common in infants (34%); obesity was most common in children older than 8 years old (15.1%). Underweight patients more often had oxygenation and ventilation failure (34.0%, 36.2%, respectively) as the indication for TI and a history of difficult airway (16.7%). Apneic oxygenation was used more often in overweight and obese patients (19.1%, 19.6%) than in underweight or normal weight patients (14.1%, 17.1%; p < 0.001). TIAEs and/or hypoxemia occurred more often in underweight (27.1%) and obese (24.3%) patients ( p < 0.001). TI in underweight children was associated with greater odds of adverse airway outcome compared with normal weight children after adjusting for potential confounders (underweight: adjusted odds ratio [aOR], 1.09; 95% CI, 1.01-1.18; p = 0.016). Both underweight and obesity were associated with hypoxemia after adjusting for covariates and site clustering (underweight: aOR, 1.11; 95% CI, 1.02-1.21; p = 0.01 and obesity: aOR, 1.22; 95% CI, 1.07-1.39; p = 0.002). CONCLUSIONS In underweight and obese children compared with normal weight children, procedures around the timing of TI are associated with greater odds of adverse airway events.
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Affiliation(s)
- Kelsey M Gladen
- Pediatric Critical Care Medicine, Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ
| | - David Tellez
- Pediatric Critical Care Medicine, Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ
| | - Natalie Napolitano
- Respiratory Therapy Department, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Lauren R Edwards
- Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital and Medical Center, University of Nebraska Medical Center, Omaha, NE
| | - Ronald C Sanders
- Section of Critical Care Medicine, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR
| | - Taiki Kojima
- Department of Anesthesiology, Aichi Children's Health and Medical Center, Obu, Aichi, Japan
| | - Matthew P Malone
- Section of Critical Care Medicine, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR
| | - Justine Shults
- Department of Biostatistics, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Conrad Krawiec
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Penn State Health Children's Hospital, Hershey, PA
| | - Shashikanth Ambati
- Pediatric Critical Care Medicine, Department of Pediatrics, Albany Medical Center, Albany, NY
| | - Riley McCarthy
- Pediatric Critical Care Medicine, Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ
| | - Aline Branca
- Pediatric Critical Care Medicine, Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ
| | - Lee A Polikoff
- Division of Critical Care Medicine, Department of Pediatrics, The Warren Alpert Medical School at Brown University, Providence, RI
| | - Philipp Jung
- Department of Pediatrics, University Children's Hospital, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Simon J Parsons
- Department of Pediatrics, Section of Critical Care Medicine, Alberta Children's Hospital, Calgary, AB, Canada
| | | | | | - Christopher Page-Goertz
- Pediatric Critical Care Medicine, Department of Pediatrics, Akron Children's Hospital, Akron, OH
| | - Megan C Toal
- Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medicine, New York, NY
| | - G Kris Bysani
- Pediatric Critical Care Medicine, Department of Pediatrics, Medical City Children's Hospital, Dallas, TX
| | - Keith Meyer
- Division of Critical Care Medicine, Nicklaus Children's Hospital, Herber Wertheim College of Medicine Florida International University, Miami, FL
| | - Fabrizio Chiusolo
- Anesthesia and Critical Care Medicine, ARCO, Bambino Gesú Children's Hospital, Rome, Italy
| | - Lily B Glater-Welt
- Division of Pediatric Critical Care, Cohen Children's Medical Center of New York, Queens, NY
| | - Awni Al-Subu
- Pediatric Critical Care Medicine, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Katherine Biagas
- Pediatric Critical Care Medicine, Department of Pediatrics, The Renaissance School of Medicine at Stony Brook University, Stony Brook, NY
| | - Jan Hau Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
| | - Michael Miksa
- Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital at Montefiore, Bronx, NY
| | - John S Giuliano
- Department of Pediatrics, Section of Critical Care Medicine, Yale University School of Medicine, New Haven, CT
| | - Krista L Kierys
- Pediatric Critical Care Medicine, Department of Pediatrics, Penn State Health, Milton S. Hershey Medical Center, Hershey, PA
| | - Andrea M Talukdar
- Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital and Medical Center, University of Nebraska Medical Center, Omaha, NE
| | | | - Laurence Cucharme-Crevier
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Michelle Adu-Arko
- Division of Pediatric Critical Care, Department of Pediatrics, University of Virginia, Charlottesville, VA
| | - Asha N Shenoi
- Pediatric Critical Care Medicine, Department of Pediatrics, University of Kentucky, Lexington, KY
| | - Dai Kimura
- Critical Care Medicine, Department of Pediatrics, Orlando Health Arnold Palmer Hospital for Children, Orlando, FL
| | - Molly Flottman
- Pediatric Critical Care Medicine, Department of Pediatrics, University of Louisville, Norton Children's Hospital, Louisville, KY
| | - Shantaveer Gangu
- Critical Care Medicine, Department of Pediatrics, Orlando Health Arnold Palmer Hospital for Children, Orlando, FL
| | - Ashley D Freeman
- Pediatric Critical Care Medicine, Department of Pediatrics, Medical College of Georgia, Augusta University, Augusta, GA
| | - Mark D Piehl
- Pediatric Critical Care Medicine, Department of Pediatrics, WakeMed Children's Hospital, Raleigh, NC
| | - G A Nuthall
- Pediatric Critical Care, Department of Pediatrics, Starship Children's Hospital, Auckland, New Zealand
| | - Keiko M Tarquinio
- Pediatric Critical Care Medicine, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, GA
| | - Ilana Harwayne-Gidansky
- Pediatric Critical Care Medicine, Department of Pediatrics, Bernard and Millie Duker Children's Hospital, Albany, NY
| | - Tatsuya Hasegawa
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Aichi Children's Health and Medical Center, Obu, Aichi, Japan
| | - Erin S Rescoe
- Division of Pediatric Critical Care, Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY
| | - Ryan K Breuer
- Division of Critical Care Medicine, John R. Oishei Children's Hospital, Buffalo, NY
| | - Mioko Kasagi
- Pediatric Critical Care and Emergency Medicine, Department of Pediatrics, Tokyo Metropolitan Children's Medical Center, Fuchu, Japan
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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6
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Van Damme DM, McRae EM, Irving SY, Kelly SP, Tarquinio KM, Giuliano JS, Ruppe MD, Kierys KL, Breuer RK, Parsons SJ, Mallory PP, Shenoi AN, Swain KA, Polikoff LA, Lee A, Adu-Darko MA, Napolitano N, Shults J, Nishisaki A, Berkenbosch JW. Tracheal Intubation by Advanced Practice Registered Nurses in Pediatric Critical Care: Retrospective Study From the National Emergency Airway for Children Registry (2015-2019). Pediatr Crit Care Med 2024; 25:139-146. [PMID: 37882620 PMCID: PMC10842935 DOI: 10.1097/pcc.0000000000003386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
OBJECTIVES To describe tracheal intubation (TI) practice by Advanced Practice Registered Nurses (APRNs) in North American PICUs, including rates of TI-associated events (TIAEs) from 2015 to 2019. DESIGN/SETTING Retrospective study using the National Emergency Airway Registry for Children with all TIs performed in PICU and pediatric cardiac ICU between January 2015 and December 2019. The primary outcome was first attempt TI success rate. Secondary outcomes were TIAEs, severe TIAEs, and hypoxemia. SUBJECTS Critically ill children requiring TI in a PICU or pediatric cardiac ICU. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among 11,012 TIs, APRNs performed 1,626 (14.7%). Overall, TI by APRNs, compared with other clinicians, occurred less frequently in patients with known difficult airway (11.1% vs. 14.3%; p < 0.001), but more frequently in infants younger than 1 year old (55.9% vs. 44.4%; p < 0.0001), and in patients with cardiac disease (26.3% vs. 15.9%; p < 0.0001).There was lower odds of success in first attempt TI for APRNs vs. other clinicians (adjusted odds ratio, 0.70; 95% CI, 0.62-0.79). We failed to identify a difference in rates of TIAE, severe TIAE, and oxygen desaturation events for TIs by APRNs compared with other clinicians. The TI first attempt success rate improved with APRN experience (< 1 yr: 54.2%, 1-5 yr: 59.4%, 6-10 yr: 67.6%, > 10 yr: 63.1%; p = 0.021). CONCLUSIONS TI performed by APRNs was associated with lower odds of first attempt success when compared with other ICU clinicians although there was no appreciable difference in procedural adverse events. There appears to be a positive relationship between experience and success rates. These data suggest there is an ongoing need for opportunities to build on TI competency with APRNs.
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Affiliation(s)
- Danielle M Van Damme
- "Just For Kids" Critical Care Center, Norton Children's Hospital, Louisville, KY
| | - Emily M McRae
- "Just For Kids" Critical Care Center, Norton Children's Hospital, Louisville, KY
- School of Nursing, University of Louisville, Louisville, KY
| | - Sharon Y Irving
- School of Nursing, University of Pennsylvania, Philadelphia, PA
- Nursing and Clinical Care Services, Children's Hospital of Philadelphia, Philadelphia PA
| | - Serena P Kelly
- Doernbecher Children's Hospital, Oregon Health and Science University, Portland, OR
| | - Keiko M Tarquinio
- Pediatric Critical Care Medicine, Department of Pediatrics, Emory University/Children's Healthcare of Atlanta, Atlanta, GA
| | - John S Giuliano
- Pediatric Critical Care Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Michael D Ruppe
- "Just For Kids" Critical Care Center, Norton Children's Hospital, Louisville, KY
- Division of Pediatric Critical Care, Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY
| | | | - Ryan K Breuer
- Critical Care Medicine, Oishei Children's Hospital, University at Buffalo, Buffalo, NY
| | - Simon J Parsons
- Section of Critical Care, Alberta Children's Hospital, Calgary, AB, Canada
| | - Palen P Mallory
- Division of Pediatric Critical Care, Department of Pediatrics, Duke University, Durham, NC
| | - Asha N Shenoi
- Pediatric Critical Care, Department of Pediatrics, University of Kentucky, Lexington, KY
| | - Kelly A Swain
- Pediatric Critical Care/Pediatric Cardiac ICU, Duke University, Durham, NC
| | - Lee A Polikoff
- Pediatric Critical Care Medicine, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Anthony Lee
- Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH
| | | | - Natalie Napolitano
- Respiratory Therapy Department, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Justine Shults
- Division of Biostatistics, Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Anesthesiology, Critical Care, and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - John W Berkenbosch
- "Just For Kids" Critical Care Center, Norton Children's Hospital, Louisville, KY
- Division of Pediatric Critical Care, Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY
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7
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Loi MV, Lee JH, Huh JW, Mallory P, Napolitano N, Shults J, Krawiec C, Shenoi A, Polikoff L, Al-Subu A, Sanders R, Toal M, Branca A, Glater-Welt L, Ducharme-Crevier L, Breuer R, Parsons S, Harwayne-Gidansky I, Kelly S, Motomura M, Gladen K, Pinto M, Giuliano J, Bysani G, Berkenbosch J, Biagas K, Rehder K, Kasagi M, Lee A, Jung P, Shetty R, Nadkarni V, Nishisaki A. Ketamine Use in the Intubation of Critically Ill Children with Neurological Indications: A Multicenter Retrospective Analysis. Neurocrit Care 2024; 40:205-214. [PMID: 37160847 DOI: 10.1007/s12028-023-01734-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 04/10/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND Ketamine has traditionally been avoided for tracheal intubations (TIs) in patients with acute neurological conditions. We evaluate its current usage pattern in these patients and any associated adverse events. METHODS We conducted a retrospective observational cohort study of critically ill children undergoing TI for neurological indications in 53 international pediatric intensive care units and emergency departments. We screened all intubations from 2014 to 2020 entered into the multicenter National Emergency Airway Registry for Children (NEAR4KIDS) registry database. Patients were included if they were under the age of 18 years and underwent TI for a primary neurological indication. Usage patterns and reported periprocedural composite adverse outcomes (hypoxemia < 80%, hypotension/hypertension, cardiac arrest, and dysrhythmia) were noted. RESULTS Of 21,562 TIs, 2,073 (9.6%) were performed for a primary neurological indication, including 190 for traumatic brain injury/trauma. Patients received ketamine in 495 TIs (23.9%), which increased from 10% in 2014 to 41% in 2020 (p < 0.001). Ketamine use was associated with a coindication of respiratory failure, difficult airway history, and use of vagolytic agents, apneic oxygenation, and video laryngoscopy. Composite adverse outcomes were reported in 289 (13.9%) Tis and were more common in the ketamine group (17.0% vs. 13.0%, p = 0.026). After adjusting for location, patient age and codiagnoses, the presence of respiratory failure and shock, difficult airway history, provider demographics, intubating device, and the use of apneic oxygenation, vagolytic agents, and neuromuscular blockade, ketamine use was not significantly associated with increased composite adverse outcomes (adjusted odds ratio 1.34, 95% confidence interval CI 0.99-1.81, p = 0.057). This paucity of association remained even when only neurotrauma intubations were considered (10.6% vs. 7.7%, p = 0.528). CONCLUSIONS This retrospective cohort study did not demonstrate an association between procedural ketamine use and increased risk of peri-intubation hypoxemia and hemodynamic instability in patients intubated for neurological indications.
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Affiliation(s)
- Mervin V Loi
- Department of Pediatric Subspecialties, Children's Intensive Care Unit, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, Singapore.
| | - Jan Hau Lee
- Department of Pediatric Subspecialties, Children's Intensive Care Unit, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, Singapore
| | - Jimmy W Huh
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Palen Mallory
- Department of Pediatric Critical Care Medicine, Duke Children's Hospital and Health Center, Durham, NC, USA
| | - Natalie Napolitano
- Respiratory Therapy Department, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Justine Shults
- Department of Biostatistics, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Conrad Krawiec
- Departments of Pediatric Critical Care Medicine and Pediatrics, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Asha Shenoi
- Department of Pediatrics, University of Kentucky, Lexington, KY, USA
| | - Lee Polikoff
- Department of Pediatric Critical Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Awni Al-Subu
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Wisconsin, School of Medicine and Public Health, Madison, WI, USA
| | - Ronald Sanders
- Division of Critical Care Medicine, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Megan Toal
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Aline Branca
- Department of Pediatric Critical Care Medicine, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Lily Glater-Welt
- Department of Pediatric Critical Care Medicine, Cohen Children's Medical Center of New York, New Hyde Park, NY, USA
| | - Laurence Ducharme-Crevier
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Canada
| | - Ryan Breuer
- Division of Critical Care Medicine, Department of Pediatrics, John R. Oishei Children's Hospital, Buffalo, NY, USA
| | - Simon Parsons
- Section of Critical Care Medicine, Alberta Children's Hospital, Calgary, Canada
| | - Ilana Harwayne-Gidansky
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Albany Medical College, Albany, NY, USA
| | - Serena Kelly
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Oregon Health and Science University Doernbecher Children's Hospital, Portland, OR, USA
| | - Makoto Motomura
- Division of Pediatric Critical Care Medicine, Aichi Children's Health and Medical Center, Aichi, Japan
| | - Kelsey Gladen
- Department of Pediatric Critical Care Medicine, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Matthew Pinto
- Department of Pediatrics, New York Medical College, Valhalla, NY, USA
| | - John Giuliano
- Section of Pediatric Critical Care, Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Gokul Bysani
- Department of Pediatrics, Medical City Children's Hospital, Dallas, TX, USA
| | - John Berkenbosch
- Department of Pediatric Critical Care, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
| | - Katherine Biagas
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Renaissance School of Medicine at Stony, Brook University, Stony Brook, NY, USA
| | - Kyle Rehder
- Division of Pediatric Critical Care, Duke Children's Hospital, Durham, NC, USA
| | - Mioko Kasagi
- Division of Pediatric Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Anthony Lee
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Philipp Jung
- Department of Pediatrics, University Hospital Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Rakshay Shetty
- Pediatric Intensive Care, Rainbow Children's Hospital, Bengaluru, India
| | - Vinay Nadkarni
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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8
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Zamalin D, Hamlin I, Shults J, Katherine Henry M, Campbell KA, Anderst JD, Bachim AN, Berger RP, Frasier LD, Harper NS, Letson MM, Melville JD, Lindberg DM, Wood JN. Predictors of Making a Referral to Child Protective Services Prior to Expert Consultation. Acad Pediatr 2024; 24:78-86. [PMID: 37178908 PMCID: PMC10638459 DOI: 10.1016/j.acap.2023.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/24/2023] [Accepted: 05/02/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVE Suspicion for child abuse is influenced by implicit biases. Evaluation by a Child Abuse Pediatrician (CAP) may reduce avoidable child protective services (CPS) referrals. Our objective was to investigate the association of patient demographic, social and clinical characteristics with CPS referral before consultation by a CAP (preconsultation referral). METHODS Children<5years-old undergoing in-person CAP consultation for suspected physical abuse from February 2021 through April 2022 were identified in CAPNET, a multicenter child abuse research network. Marginal standardization implemented with logistic regression analysis examined hospital-level variation and identified demographic, social, and clinical factors associated with preconsultation referral adjusting for CAP's final assessment of abuse likelihood. RESULTS Among the 61% (1005/1657) of cases with preconsultation referral, the CAP consultant had low concern for abuse in 38% (384/1005). Preconsultation referrals ranged from 25% to 78% of cases across 10 hospitals (P < .001). In multivariable analyses, preconsultation referral was associated with public insurance, caregiver history of CPS involvement, history of intimate partner violence, higher CAP level of concern for abuse, hospital transfer, and near-fatality (all P < .05). The difference in preconsultation referral prevalence for children with public versus private insurance was significant for children with low CAP concern for abuse (52% vs 38%) but not those with higher concern for abuse (73% vs 73%), (P = .023 for interaction of insurance and abuse likelihood category). There were no differences in preconsultation referral based on race or ethnicity. CONCLUSIONS Biases based on socioeconomic status and social factors may impact decisions to refer to CPS before CAP consultation.
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Affiliation(s)
- Danielle Zamalin
- Department of Pediatrics (D Zamalin), Kravis Children's Hospital, Icahn School of Medicine, Mount Sinai Hospital, New York, NY.
| | - Irene Hamlin
- Perelman School of Medicine (I Hamlin), University of Pennsylvania, Philadelphia, Pa.
| | - Justine Shults
- Department of Biostatistics, Epidemiology (J Shults), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa.
| | - M Katherine Henry
- Division of General Pediatrics, Clinical Futures, and PolicyLab (M Katherine Henry), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa.
| | - Kristine A Campbell
- Department of Pediatrics (KA Campbell), University of Utah, Center for Safe and Healthy Families, Primary Children's Hospital, Salt Lake City, Utah.
| | - James D Anderst
- Children's Mercy Kansas City (JD Anderst), University of Missouri Kansas City School of Medicine.
| | - Angela N Bachim
- Division of Public Health Pediatrics, Department of Pediatrics (AN Bachim), Baylor College of Medicine, Texas Children's Hospital, Houston, Tex.
| | - Rachel P Berger
- Department of Pediatrics (RP Berger), UPMC Children's Hospital of Pittsburgh, Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pa.
| | - Lori D Frasier
- Department of Pediatrics (LD Frasier), Penn State Children's Hospital, Penn State Hershey College of Medicine, Hershey, Pa; Penn State Hershey Medical Center (LD Frasier), Center for the Protection of Children, Hershey, Pa.
| | - Nancy S Harper
- University of Minnesota School of Medicine (NS Harper), Center for Safe and Healthy Children, Minneapolis, Minn.
| | - Megan M Letson
- Nationwide Children's Hospital (MM Letson), The Ohio State University College of Medicine, Columbus, Ohio.
| | - John D Melville
- Division of Child Abuse Pediatrics (JD Melville), Medical University of South Carolina, Charleston, SC.
| | - Daniel M Lindberg
- Department of Emergency Medicine (DM Lindberg), The Kempe Center for the Prevention & Treatment of Child Abuse & Neglect, University of Colorado School of Medicine, Aurora, Colo.
| | - Joanne N Wood
- Division of General Pediatrics and PolicyLab (JN Wood), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa.
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9
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Mittal S, Bax A, Blum NJ, Shults J, Barbaresi W, Cacia J, Deavenport-Saman A, Friedman S, LaRosa A, Loe IM, Tulio S, Vanderbilt D, Harstad E. Receipt of Behavioral Therapy in Preschool-Age Children with ADHD and Coexisting Conditions: A DBPNet Study. J Dev Behav Pediatr 2023; 44:e651-e656. [PMID: 37751569 DOI: 10.1097/dbp.0000000000001216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 07/26/2023] [Indexed: 09/28/2023]
Abstract
OBJECTIVE Practice guidelines from the American Academy of Pediatrics and Society for Developmental and Behavioral Pediatrics recommend evidence-based behavioral therapy (BT) as first-line treatment for preschool-age children with ADHD, prior to medication initiation. Thus, this study's objective is to present the frequency of physician-documented receipt of BT in preschool-age children with ADHD prior to medication initiation and to determine factors associated with receipt BT receipt. METHODS This retrospective medical record review was conducted across 7 Developmental Behavioral Pediatrics Research Network (DBPNet) sites. Data were abstracted for children <72 months old seen by a DBP clinician and initiated on ADHD medication between 1/1/2013-7/1/2017. From narrative text of the medical records, BT receipt was coded as: parent training in behavior management (PTBM), Applied Behavior Analysis (ABA), other, or did not receive. RESULTS Of the 497 children in this study; 225 children (45%) had reported receipt of any BT prior to ADHD medication initiation, with 15.9% (n = 79) receiving PTBM. Children with co-existing diagnoses of ASD or disruptive behavior disorder were more likely to receive BT than children without co-existing conditions (59.3% vs 69.0% vs 30.6%). There was significant site variability in reported receipt of BT, ranging from 22.4% to 74.1%, and sex and insurance were not associated with BT rates. CONCLUSION The percentage of children with documented receipt of any BT, and particularly PTBM, was low across all sites and co-existing conditions. These findings highlight the universal need to increase receipt of evidence-based BT for all young children with ADHD.
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Affiliation(s)
- Shruti Mittal
- Developmental and Behavioral Pediatrics of the Carolinas, Atrium Health, Charlotte, NC
| | - Ami Bax
- University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Nathan J Blum
- Division of Developmental and Behavioral Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Justine Shults
- Division of Developmental and Behavioral Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - William Barbaresi
- Division of Developmental Medicine, Boston Children's Hospital, Boston, MA
| | - Jaclyn Cacia
- Division of Developmental and Behavioral Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Alexis Deavenport-Saman
- Keck School of Medicine, University of Southern California, Children's Hospital Los Angeles, Los Angeles, CA
| | - Sandra Friedman
- University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
| | - Angela LaRosa
- Division of Developmental and Behavioral Pediatrics, Medical University of South Carolina, Charleston, SC; and
| | | | - Shelby Tulio
- University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Douglas Vanderbilt
- Keck School of Medicine, University of Southern California, Children's Hospital Los Angeles, Los Angeles, CA
| | - Elizabeth Harstad
- Division of Developmental Medicine, Boston Children's Hospital, Boston, MA
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10
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Agawu A, Kanagawa C, Wong J, Shults J, Feudtner C, Bewtra M. Pediatric Cholelithiasis in the United States: National Hospitalization Trends, 2006 to 2019. J Pediatr Gastroenterol Nutr 2023; 77:741-747. [PMID: 37755879 DOI: 10.1097/mpg.0000000000003959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
OBJECTIVES Previous studies have shown increasing hospitalizations for pediatric cholelithiasis, but recent trends are unknown. We conducted a national study of pediatric cholelithiasis to characterize recent hospitalization rate trends. METHODS Retrospective repeated cross-sectional analysis of pediatric (age < 18 years) cholelithiasis-associated hospitalizations combining data from the 2006 through 2019 Kids' Inpatient Database releases. The primary outcome of interest was the national hospitalization rate (per 100,000 children). We examined rates stratified by age group and sex and characterized hospitalization outcomes and characteristics for pediatric cholelithiasis. RESULTS Twenty-nine thousand one hundred two hospital records representing 42,282 gallstone-associated hospitalizations were identified. The hospitalization rate declined from 12.9 [95% confidence interval (CI): 12.6-13.2] in 2006 to 9.1 (95% CI: 8.8-9.3) in 2019. Consistent with the literature, hospitalizations occurred most often among teenagers (71%) and individuals with female sex (72%). The proportion of hospitalizations at freestanding children's hospitals increased significantly (from 18.2% to 35.1%). Finally, the proportion of hospitalizations involving a potentially medical predisposing condition increased significantly. CONCLUSIONS The estimated US hospitalization rate for pediatric cholelithiasis declined by 30% between 2006 and 2019. Female patients and teenagers had the largest decline, and hospitalizations increasingly occurred at freestanding children's hospitals. Potential explanations include potential changes in delivery of care as well as changes in population disease burden.
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Affiliation(s)
- Atu Agawu
- From the Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, the
| | | | - Janeline Wong
- the Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Justine Shults
- From the Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, the
- the Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Chris Feudtner
- From the Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, the
| | - Meenakshi Bewtra
- the Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- the Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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11
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Bruce MM, Robinson AJ, Wiebe DJ, Shults J, Richmond TS. The Contribution of Neighborhood Characteristics to Psychological Symptom Severity in a Cohort of Injured Black Men. J Racial Ethn Health Disparities 2023; 10:2284-2293. [PMID: 36085354 PMCID: PMC10454987 DOI: 10.1007/s40615-022-01407-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 08/27/2022] [Accepted: 08/30/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Traumatic injury is not evenly distributed by race and class in the USA. Black men are marginalized in the society, often reside in disadvantaged neighborhoods, and are at higher risk for injury mortality and ongoing physical and psychological problems following injury. Post-traumatic stress disorder (PTSD) and depressive symptom severity are among several problematic and disabling conditions faced by injury survivors. While much research has examined individual factors that lead to increased post-injury psychological symptom severity, the contribution of the social and physical environment has been relatively understudied. OBJECTIVE To examine the contribution of neighborhood characteristics to PTSD and depressive symptom severity in Black men following traumatic injury. DESIGN Prospective cohort study. Participant data were linked via GIS to neighborhood characteristics (constructs established by factor analysis) to spatially model factors associated with increased post-injury psychological symptom severity using a GEE regression analysis, adjusting for injury mechanism and severity, age, and insurance. PARTICIPANTS Four hundred fifty-one adult Black males hospitalized for traumatic injury. RESULTS The 4 constructs were neighborhood disconnectedness, concentrated disadvantage/deprivation, crime/violence/vacancy, and race/ethnicity. High depressive and PTSD symptom severity was reported by 36.8% and 30.4% of participants, respectively. Higher PTSD symptom severity was associated with crime/violence/vacancy, and higher depressive symptom severity was associated with neighborhood disconnectedness. PTSD and depressive symptom severity were associated with intentional injury mechanisms and Medicaid/no insurance. Higher injury severity was associated with depressive symptoms. CONCLUSION Neighborhood characteristics are associated with psychological symptom severity after injury.
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Affiliation(s)
- Marta M Bruce
- University of Pennsylvania School of Nursing, Claire Fagin Hall, Room 418 Curie Blvd, Philadelphia, PA, 19104, USA
- Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Andrew J Robinson
- University of Pennsylvania School of Nursing, Claire Fagin Hall, Room 418 Curie Blvd, Philadelphia, PA, 19104, USA
| | - Douglas J Wiebe
- Department of Biostatistics, Epidemiology & Informatics, University of Pennsylvania Perelman School of Medicine, Blockley Hall, 423 Guardian Dr, Philadelphia, PA, 19104, USA
- Penn Injury Science Center, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Justine Shults
- Department of Biostatistics, Epidemiology & Informatics, University of Pennsylvania Perelman School of Medicine, Blockley Hall, 423 Guardian Dr, Philadelphia, PA, 19104, USA
| | - Therese S Richmond
- University of Pennsylvania School of Nursing, Claire Fagin Hall, Room 418 Curie Blvd, Philadelphia, PA, 19104, USA.
- Penn Injury Science Center, University of Pennsylvania, Philadelphia, PA, 19104, USA.
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12
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Blum NJ, Shults J, Barbaresi W, Bax A, Cacia J, Deavenport-Saman A, Friedman S, Loe IM, Mittal S, Vanderbilt D, LaRosa A, Harstad E. Do Externalizing and Internalizing Symptoms Moderate Medication Response in Preschool Attention-Deficit/Hyperactivity Disorder? A DBPNet Study. J Dev Behav Pediatr 2023; 44:e447-e454. [PMID: 37696030 DOI: 10.1097/dbp.0000000000001209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 06/08/2023] [Indexed: 09/13/2023]
Abstract
OBJECTIVES This study aimed to determine whether parent ratings of attention-deficit/hyperactivity disorder (ADHD) symptom severity or externalizing symptoms (EXT) or internalizing symptoms (INT) moderate response to stimulants (STIM) and alpha-2 adrenergic agonists (A2As) in preschool ADHD. METHODS Health records for children treated with medication for ADHD and with parent rating scale data available (N = 309; age <72 months) were reviewed at 7 Developmental-Behavioral Pediatric Research Network sites. Severity of ADHD was defined as the number of ADHD symptoms occurring often or very often on DSM-IV-based parent rating scales. EXT or INT from standardized rating scales were categorized as T score <60, 60 to <70, or ≥70. Ordinal logistic regression models predicting response to medication were calculated. RESULTS The median (interquartile range) age at ADHD diagnosis was 59 (54-65) months. One hundred eighty-three participants had ADHD symptom severity, and 195 had EXT or INT data. ADHD severity was not associated with medication response. Both EXT and INT were associated with medication response but with significant medication class by EXT/INT interactions. Children with higher EXT were less likely to respond to STIM, with percentage of nonresponders for T-score categories <60, 60 to <70, and ≥70 being 3.6%, 25.7%, and 33.3% (p = 0.016) and, for A2As, being 60%, 50%, and 33.3% (p = 0.55), respectively. A similar pattern was observed for INT categories: STIM 19.4%, 22.5%, and 50.0% (p = 0.002) and A2As 42.3%, 30%, and 42.3% (p = 0.48), respectively. CONCLUSION For preschool ADHD, low ratings of EXT or INT are associated with a high likelihood of response to STIM. By contrast, response rates to STIM and A2As are more similar for children with high levels of EXT or INT.
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Affiliation(s)
- Nathan J Blum
- Division of Developmental and Behavioral Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Justine Shults
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - William Barbaresi
- Division of Developmental Medicine, Boston Children's Hospital, Boston, MA
| | - Ami Bax
- University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Jaclyn Cacia
- Children's Hospital of Philadelphia, Philadelphia, PA
| | - Alexis Deavenport-Saman
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Children's Hospital Los Angeles, Los Angeles, CA
| | - Sandra Friedman
- University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
| | | | - Shruti Mittal
- Atrium Health-Levine's Children's Hospital, Charlotte, NC; and
| | - Douglas Vanderbilt
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Children's Hospital Los Angeles, Los Angeles, CA
| | - Angela LaRosa
- Medical University of South Carolina, Charleston, SC
| | - Elizabeth Harstad
- Division of Developmental Medicine, Boston Children's Hospital, Boston, MA
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Jenssen BP, Kelly MK, Faerber JA, Asch DA, Shults J, Schnoll RA, Fiks AG. Pediatrician-Delivered Smoking-Cessation Messages for Parents: An Update. Acad Pediatr 2023; 23:1140-1141. [PMID: 37244523 PMCID: PMC10524647 DOI: 10.1016/j.acap.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 05/13/2023] [Accepted: 05/21/2023] [Indexed: 05/29/2023]
Affiliation(s)
- Brian P Jenssen
- Department of Pediatrics (BP Jenssen, J Shults and AG Fiks), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Clinical Futures and PolicyLab (BP Jenssen, MK Kelly and AG Fiks), Children...s Hospital of Philadelphia, Pa.
| | - Mary Kate Kelly
- Clinical Futures and PolicyLab (BP Jenssen, MK Kelly and AG Fiks), Children...s Hospital of Philadelphia, Pa
| | - Jennifer A Faerber
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics (JA Faerber), Children...s Hospital of Philadelphia, Pa
| | - David A Asch
- Department of Medicine (DA Asch), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Justine Shults
- Department of Pediatrics (BP Jenssen, J Shults and AG Fiks), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Biostatistics (J Shults), Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Robert A Schnoll
- Department of Psychiatry and Abramson Cancer Center (RA Schnoll), Perelman School of Medicine University of Pennsylvania, Philadelphia
| | - Alexander G Fiks
- Department of Pediatrics (BP Jenssen, J Shults and AG Fiks), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Clinical Futures and PolicyLab (BP Jenssen, MK Kelly and AG Fiks), Children...s Hospital of Philadelphia, Pa
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Gavazzi F, Patel V, Charsar B, Glanzman A, Erler J, Sevagamoorthy A, McKenzie E, Kornafel T, Ballance E, Pierce SR, Teng M, Formanowski B, Woidill S, Shults J, Wassmer E, Tonduti D, Magrinelli F, Bernard G, Van Der Knaap M, Wolf N, Adang L, Vanderver A. Gross Motor Function in Pediatric Onset TUBB4A-Related Leukodystrophy: GMFM-88 Performance and Validation of GMFC-MLD in TUBB4A. J Child Neurol 2023; 38:498-504. [PMID: 37461315 PMCID: PMC10527384 DOI: 10.1177/08830738231188159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
TUBB4A pathogenic variants are associated with a spectrum of neurologic impairments including movement disorders and leukodystrophy. With the development of targeted therapies, there is an urgent unmet need for validated tools to measure mobility impairment. Our aim is to explore gross motor function in a pediatric-onset TUBB4A-related leukodystrophy cohort with existing gross motor outcome tools. Gross Motor Function Measure-88 (GMFM-88), Gross Motor Function Classification System (GMFCS-ER), and Gross Motor Function Classification-Metachromatic Leukodystrophy (GMFC-MLD) were selected through face validity. Subjects with a confirmed clinical and molecular diagnosis of TUBB4A-related leukodystrophy were enrolled. Participants' sex, age, genotype, and age at disease onset were collected, together with GMFM-88 and concurrent GMFCS-ER and GMFC-MLD. Performances on each measure were compared. GMFM-88 floor effect was defined as total score below 20%. A total of 35 subjects participated. Median performance by GMFM-88 was 16.24% (range 0-97.31), with 42.9% (n = 15) of individuals performing above the floor. GMFM-88 Dimension A (Lying and Rolling) was the best-performing dimension in the GMFM-88 (n = 29 above the floor). All levels of the Classification Scales were represented, with the exception of the GMFC-MLD level 0. Evaluation by GMFM-88 was strongly correlated with the Classification Scales (Spearman correlations: GMFCS-ER:GMFM-88 r = 0.90; GMFC-MLD:GMFM-88 r = 0.88; GMFCS-ER:GMFC-MLD: r = 0.92). Despite overall observation of a floor effect, the GMFM-88 is able to accurately capture the performance of individuals with attenuated phenotypes. GMFM-88 Dimension A shows no floor effect. GMFC-MLD shows a strong correlation with GMFCS-ER and GMFM-88, supporting its use as an age-independent functional score in TUBB4A-related leukodystrophy.
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Affiliation(s)
- Francesco Gavazzi
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Virali Patel
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Brittany Charsar
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Allan Glanzman
- Department of Physical Therapy, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jacqueline Erler
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Anjana Sevagamoorthy
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Emma McKenzie
- Department of Physical Therapy, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Tracy Kornafel
- Department of Physical Therapy, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Elizabeth Ballance
- Department of Physical Therapy, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Samuel R. Pierce
- Department of Physical Therapy, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michelle Teng
- Synaptixbio Ltd, Fermi Avenue, Harwell, Oxfordshire OX11 0QX
| | - Brielle Formanowski
- Division of Neonatology, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Sarah Woidill
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Justine Shults
- Synaptixbio Ltd, Fermi Avenue, Harwell, Oxfordshire OX11 0QX
| | - Evangeline Wassmer
- Neurology Department, Birmingham Children’s Hospital, Institute of Health and Neurodevelopment, Aston University, Birmingham, United Kingdom
| | - Davide Tonduti
- Unit of Pediatric Neurology, C.O.A.L.A (Center for Diagnosis and Treatment of Leukodystrophies), V. Buzzi Children’s Hospital, Milan, Italy
- Department of Biomedical and Clinical Sciences, L. Sacco University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Francesca Magrinelli
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
| | - Geneviève Bernard
- Departments of Neurology and Neurosurgery, Pediatrics and Human Genetics, McGill University, Montreal, Quebec, Canada
- Department Specialized Medicine, Division of Medical Genetics, McGill University Health Centre, Montreal, Quebec, Canada
- Child Health and Human Development Program, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Marjo Van Der Knaap
- Department of Child Neurology, Amsterdam Leukodystrophy Center, Emma Children’s Hospital, Amsterdam University Medical Centers, and Amsterdam Neuroscience, Cellular & Molecular Mechanisms, Vrije Universiteit, Amsterdam, The Netherlands
- Department of Integrative Neurophysiology, Center for Neurogenomics and Cognitive Research, Vrije Universiteit Amsterdam, The Netherlands
| | - Nicole Wolf
- Department of Child Neurology, Amsterdam Leukodystrophy Center, Emma Children’s Hospital, Amsterdam University Medical Centers, and Amsterdam Neuroscience, Cellular & Molecular Mechanisms, Vrije Universiteit, Amsterdam, The Netherlands
| | - Laura Adang
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Adeline Vanderver
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Lesiapeto M, Shults J, Mmunyane M, Matshaba M, Lowenthal ED. Stunted Growth Is Associated With Dyslipidemia in Young Adults With Perinatal HIV Infection. J Acquir Immune Defic Syndr 2023; 93:343-350. [PMID: 37071712 PMCID: PMC10625796 DOI: 10.1097/qai.0000000000003209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 03/27/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND HIV increases the risk of atherosclerosis and cardiovascular diseases (CVD). This risk maybe even higher in adult survivors of perinatal HIV infection because of prolonged exposure to HIV and its treatments. Nutritional deprivation in early life may further increase CVD risk. SETTING Botswana-Baylor Children's Clinical Centre of Excellence, Gaborone. METHODS This study examined dyslipidemia in 18- to 24-year olds with perinatally-acquired HIV with and without linear growth retardation ("stunting"). Anthropometry and lipid profiles were measured following a minimum 8-hour fast. Stunting was defined by a height-for-age z-score of <2 SDs below the mean. Dyslipidemia was defined by non-high-density lipoprotein cholesterol (HDL-C) of ≥130 mg/dL, low-density lipoprotein cholesterol (LDL-C) of ≥100 mg/dL, or HDL of <40 mg/dL for male subjects and <50 mg/dL for female subjects. We used logistic regression to determine whether dyslipidemia was associated with stunting while adjusting for demographic and HIV treatment variables. RESULTS Of 107 young adults (46 males; 61 females) enrolled, 36 (33.6%) were stunted. Prevalence of dyslipidemia was 11.2%, 24.3%, and 65.4% for high non-HDL-C, high LDL-C, and low HDL-C, respectively. In univariable analysis, being stunted was associated with elevated LDL-C (odds ratio [OR], 2.52; 95% confidence interval [CI] =1.02 to 6.25) but not with elevated non-HDL-C (OR = 2.17; 95% CI: = 0.65 to 7.28) or with low HDL-C (OR = 0.75; 95% CI: = 0.33 to 1.73). The association between stunting and elevated LDL-C (OR = 4.40; 95% CI: = 1.49 to 12.98) remained significant after controlling for measured confounders. CONCLUSION Dyslipidemia was common among perinatally HIV-infected youth and those with evidence of early nutritional deprivation who were more likely to have elevated LDL-C.
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Affiliation(s)
- Maemo Lesiapeto
- Centre for Child and Adolescent Nutrition, Princess Marina Hospital, Gaborone, Botswana
- University of Pennsylvania, Philadelphia, US
| | - Justine Shults
- University of Pennsylvania, Philadelphia, US
- The Children’s Hospital of Philadelphia
| | - Mogakolodi Mmunyane
- Botswana-Baylor Children’s Clinical Centre of Excellence (BBCCCOE), Gaborone, Botswana
| | - Mogomotsi Matshaba
- Botswana-Baylor Children’s Clinical Centre of Excellence (BBCCCOE), Gaborone, Botswana
- Baylor College of Medicine, Houston, Texas, US
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16
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Hernandez-Con P, Shults J, Willis AW, Yang YX. Dopamine agonists and risk of lung cancer in patients with restless legs syndrome. Pharmacoepidemiol Drug Saf 2023; 32:726-734. [PMID: 36760024 PMCID: PMC10766437 DOI: 10.1002/pds.5596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 01/20/2023] [Accepted: 01/28/2023] [Indexed: 02/11/2023]
Abstract
PURPOSE To examine the association between long-term use of dopamine agonists (DAs) and the risk of lung cancer in patients with restless legs syndrome (RLS). METHODS We conducted a retrospective cohort study using Optum Clinformatics® database. We included adults ≥40 years diagnosed with RLS during the study period (1/2006-12/2016). Follow-up started with the first RLS diagnosis and ended on the earliest of: incident diagnosis of lung cancer, end of enrollment in the database or end of the study period. The exposure of interest was cumulative duration of DAs use, measured in a time-varying manner. We constructed a multivariable Cox regression model to estimate HRs and 95% CIs for the association between lung cancer and cumulative durations of DA use, adjusting for potential confounding variables. RESULTS We identified 295 042 patients with a diagnosis of RLS. The mean age of the cohort was 62.9; 66.6% were women and 82.3% were white. The prevalence of any DA exposure was 40.3%. Compared to the reference group (no use and ≤1 year), the crude HRs for lung cancer were 1.16 (95% CI 0.99-1.36) and 1.14 (95% CI 0.86-1.51) for 1-3 years and >3 years of cumulative DA use, respectively. The adjusted HR for lung cancer was 1.05 (95% CI 0.88-1.25) for 1-3 years and 1.02 (95% CI 0.76-1.37) for >3 years of cumulative DA use, respectively. CONCLUSIONS At typical doses for the clinical management of RLS, long-term DA use was not associated with risk of lung cancer.
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Affiliation(s)
- Pilar Hernandez-Con
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Justine Shults
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Roberts Center for Pediatric Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Allison W Willis
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Neurology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Yu-Xiao Yang
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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17
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Giuliano J, Krishna A, Napolitano N, Panisello J, Shenoi A, Sanders RC, Rehder K, Al-Subu A, Brown C, Edwards L, Wright L, Pinto M, Harwayne-Gidansky I, Parsons S, Romer A, Laverriere E, Shults J, Yamada NK, Walsh CM, Nadkarni V, Nishisaki A. Implementation of Video Laryngoscope-Assisted Coaching Reduces Adverse Tracheal Intubation-Associated Events in the PICU. Crit Care Med 2023; 51:936-947. [PMID: 37058348 DOI: 10.1097/ccm.0000000000005847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
OBJECTIVES To evaluate implementation of a video laryngoscope (VL) as a coaching device to reduce adverse tracheal intubation associated events (TIAEs). DESIGN Prospective multicenter interventional quality improvement study. SETTING Ten PICUs in North America. PATIENTS Patients undergoing tracheal intubation in the PICU. INTERVENTIONS VLs were implemented as coaching devices with standardized coaching language between 2016 and 2020. Laryngoscopists were encouraged to perform direct laryngoscopy with video images only available in real-time for experienced supervising clinician-coaches. MEASUREMENTS AND MAIN RESULTS The primary outcome was TIAEs. Secondary outcomes included severe TIAEs, severe hypoxemia (oxygen saturation < 80%), and first attempt success. Of 5,060 tracheal intubations, a VL was used in 3,580 (71%). VL use increased from baseline (29.7%) to implementation phase (89.4%; p < 0.001). VL use was associated with lower TIAEs (VL 336/3,580 [9.4%] vs standard laryngoscope [SL] 215/1,480 [14.5%]; absolute difference, 5.1%; 95% CI, 3.1-7.2%; p < 0.001). VL use was associated with lower severe TIAE rate (VL 3.9% vs SL 5.3%; p = 0.024), but not associated with a reduction in severe hypoxemia (VL 15.7% vs SL 16.4%; p = 0.58). VL use was associated with higher first attempt success (VL 71.8% vs SL 66.6%; p < 0.001). In the primary analysis after adjusting for site clustering, VL use was associated with lower adverse TIAEs (odds ratio [OR], 0.61; 95% CI, 0.46-0.81; p = 0.001). In secondary analyses, VL use was not significantly associated with severe TIAEs (OR, 0.72; 95% CI, 0.44-1.19; p = 0.20), severe hypoxemia (OR, 0.95; 95% CI, 0.73-1.25; p = 0.734), or first attempt success (OR, 1.28; 95% CI, 0.98-1.67; p = 0.073). After further controlling for patient and provider characteristics, VL use was independently associated with a lower TIAE rate (adjusted OR, 0.65; 95% CI, 0.49-0.86; p = 0.003). CONCLUSIONS Implementation of VL-assisted coaching achieved a high level of adherence across the PICUs. VL use was associated with reduced adverse TIAEs.
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Affiliation(s)
- John Giuliano
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Yale University School of Medicine, New Haven, CT
| | - Ashwin Krishna
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Kentucky College of Medicine, Lexington, KY
| | - Natalie Napolitano
- Respiratory Therapy Department, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Josep Panisello
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Yale School of Medicine, New Haven, CT
| | - Asha Shenoi
- Department of Pediatrics and Critical Care Medicine, University of Kentucky College of Medicine, Kentucky Children's Hospital, Lexington, KY
| | - Ronald C Sanders
- Section of Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Kyle Rehder
- Division of Pediatric Critical Care, Duke Children's Hospital, Durham, NC
| | - Awni Al-Subu
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, UW Health American Family Children's Hospital, University of Wisconsin-Madison, Madison, WI
| | - Calvin Brown
- Department of Emergency Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Lauren Edwards
- Section of Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, AR
| | - Lisa Wright
- Department of Pediatrics and Critical Care Medicine, University of Kentucky College of Medicine, Kentucky Children's Hospital, Lexington, KY
| | - Matthew Pinto
- Pediatric Critical Care Medicine, Department of Pediatrics, Maria Fareri Children's Hospital, Valhalla, NY
| | - Ilana Harwayne-Gidansky
- Department of Pediatrics, Bernard and Millie Duker Children's Hospital at Albany Medical Center, Albany, NY
| | - Simon Parsons
- Division of Critical Care, Alberta Children's Hospital, Calgary, AB, Canada
| | - Amy Romer
- Division of Cardiac Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Elizabeth Laverriere
- Division of Critical Care Medicine and Division of General Anesthesiology at Children's Hospital of Philadelphia, Philadelphia, PA
| | - Justine Shults
- Division of Biostatistics, Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Nicole K Yamada
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Catharine M Walsh
- Division of Gastroenterology, Hepatology and Nutrition and the Research and Learning Institutes, The Hospital for Sick Children, Department of Paediatrics and the Wilson Centre, University of Toronto, Toronto, ON, Canada
| | - Vinay Nadkarni
- Department of Anesthesiology, Critical Care, and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Akira Nishisaki
- Department of Anesthesiology, Critical Care, and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Wynn CS, Fiks AG, Localio R, Shults J, Nekrasova E, Shone LP, Torres A, Griffith M, Unger R, Ware LA, Kelly MK, Stockwell MS. Examination of Text Message Plans and Baseline Usage of Families Enrolled in a Text Message Influenza Vaccine Reminder Trial: Survey Study. JMIR Form Res 2023; 7:e39576. [PMID: 37389945 PMCID: PMC10365607 DOI: 10.2196/39576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 03/08/2023] [Accepted: 03/09/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Mobile health (mHealth) is quickly expanding as a method of health promotion, but some interventions may not be familiar or comfortable for potential users. SMS text messaging has been investigated as a low-cost, accessible way to provide vaccine reminders. Most (97%) US adults own a cellphone and of those adults most use SMS text messaging. However, understanding patterns of SMS text message plan type and use in diverse primary care populations needs more investigation. OBJECTIVE We sought to use a survey to examine baseline SMS text messaging and data plan patterns among families willing to accept SMS text message vaccine reminders. METHODS As part of a National Institutes of Health (NIH)-funded national study (Flu2Text) conducted during the 2017-2018 and 2018-2019 influenza seasons, families of children needing a second seasonal influenza vaccine dose were recruited in pediatric primary care offices at the time of their first dose. Practices were from the American Academy of Pediatrics' (AAP) Pediatric Research in Office Settings (PROS) research network, the Children's Hospital of Philadelphia, and Columbia University. A survey was administered via telephone (Season 1) or electronically (Season 2) at enrollment. Standardized (adjusted) proportions for SMS text message plan type and texting frequency were calculated using logistic regression that was adjusted for child and caregiver demographics. RESULTS Responses were collected from 1439 participants (69% of enrolled). The mean caregiver age was 32 (SD 6) years, and most children (n=1355, 94.2%) were aged 6-23 months. Most (n=1357, 94.3%) families were English-speaking. Most (n=1331, 92.8%) but not all participants had an unlimited SMS text messaging plan and sent or received texts at least once daily (n=1313, 91.5%). SMS text messaging plan type and use at baseline was uniform across most but not all subgroups. However, there were some differences in the study population's SMS text messaging plan type and usage. Caregivers who wanted Spanish SMS text messages were less likely than those who chose English to have an unlimited SMS text messaging plan (n=61, 86.7% vs n=1270, 94%; risk difference -7.2%, 95% CI -27.1 to -1.8). There were no significant differences in having an unlimited plan associated with child's race, ethnicity, age, health status, insurance type, or caregiver education level. SMS text messaging use at baseline was not uniform across all subgroups. Nearly three-quarters (n=1030, 71.9%) of participants had received some form of SMS text message from their doctor's office; most common were appointment reminders (n=1014, 98.4%), prescription (n=300, 29.1%), and laboratory notifications (n=117, 11.4%). Even the majority (n=64, 61.5%) of those who did not have unlimited plans and who texted less than daily (n=72, 59%) reported receipt of these SMS text messages. CONCLUSIONS In this study, most participants had access to unlimited SMS text messaging plans and texted at least once daily. However, infrequent texting and lack of access to an unlimited SMS text messaging plan did not preclude enrolling to receive SMS text message reminders in pediatric primary care settings.
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Affiliation(s)
- Chelsea S Wynn
- Division of Child and Adolescent Health, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States
| | - Alexander G Fiks
- Department of Pediatrics, Clinical Futures & PolicyLab, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Russell Localio
- Department of Biostatistics, Epidemiology & Informatics, University of Pennsylvania, Philadelphia, PA, United States
| | - Justine Shults
- Department of Biostatistics, Epidemiology & Informatics, University of Pennsylvania, Philadelphia, PA, United States
| | - Ekaterina Nekrasova
- Department of Pediatrics, Clinical Futures & PolicyLab, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Laura P Shone
- Primary Care Research, American Academy of Pediatrics, Itasca, IL, United States
| | - Alessandra Torres
- Primary Care Research, American Academy of Pediatrics, Itasca, IL, United States
| | - Miranda Griffith
- Primary Care Research, American Academy of Pediatrics, Itasca, IL, United States
| | - Rebecca Unger
- Northwestern Children's Practice, Chicago, IL, United States
| | - Leigh Ann Ware
- Building Blocks Pediatrics, Pleasanton, TX, United States
| | - Mary Kate Kelly
- Department of Pediatrics, Clinical Futures & PolicyLab, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Melissa S Stockwell
- Division of Child and Adolescent Health, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States
- Department of Population and Family Health, Columbia University Mailman School of Public Health, New York, NY, United States
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Herrick HM, O'Reilly M, Lee S, Wildenhain P, Napolitano N, Shults J, Nishisaki A, Foglia EE. Providing Oxygen during Intubation in the NICU Trial (POINT): study protocol for a randomised controlled trial in the neonatal intensive care unit in the USA. BMJ Open 2023; 13:e073400. [PMID: 37055198 PMCID: PMC10106049 DOI: 10.1136/bmjopen-2023-073400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 03/28/2023] [Indexed: 04/15/2023] Open
Abstract
INTRODUCTION Nearly half of neonatal intubations are complicated by severe desaturation (≥20% decline in pulse oximetry saturation (SpO2)). Apnoeic oxygenation prevents or delays desaturation during intubation in adults and older children. Emerging data show mixed results for apnoeic oxygenation using high-flow nasal cannula (NC) during neonatal intubation. The study objective is to determine among infants ≥28 weeks' corrected gestational age (cGA) who undergo intubation in the neonatal intensive care unit (NICU) whether apnoeic oxygenation with a regular low-flow NC, compared with standard of care (no additional respiratory support), reduces the magnitude of SpO2 decline during intubation. METHODS AND ANALYSIS This is a multicentre, prospective, unblinded, pilot randomised controlled trial in infants ≥28 weeks' cGA who undergo premedicated (including paralytic) intubation in the NICU. The trial will recruit 120 infants, 10 in the run-in phase and 110 in the randomisation phase, at two tertiary care hospitals. Parental consent will be obtained for eligible patients prior to intubation. Patients will be randomised to 6 L NC 100% oxygen versus standard of care (no respiratory support) at time of intubation. The primary outcome is magnitude of oxygen desaturation during intubation. Secondary outcomes include additional efficacy, safety and feasibility outcomes. Ascertainment of the primary outcome is performed blinded to intervention arm. Intention-to-treat analyses will be conducted to compare outcomes between treatment arms. Two planned subgroup analyses will explore the influence of first provider intubation competence and patients' baseline lung disease using pre-intubation respiratory support as a proxy. ETHICS AND DISSEMINATION The Institutional Review Boards at the Children's Hospital of Philadelphia and the University of Pennsylvania have approved the study. Upon completion of the trial, we intend to submit our primary results to a peer review forum after which we plan to publish our results in a peer-reviewed paediatric journal. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT05451953).
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Affiliation(s)
- Heidi M Herrick
- Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Mackenzie O'Reilly
- Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sura Lee
- Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Paul Wildenhain
- Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Natalie Napolitano
- Respiratory Therapy, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Justine Shults
- Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Division of Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Akira Nishisaki
- Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Elizabeth E Foglia
- Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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20
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Cielo CM, Shults J, Tapia IE. Response. Chest 2023; 163:e149-e150. [PMID: 36894274 DOI: 10.1016/j.chest.2022.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 11/11/2022] [Indexed: 03/09/2023] Open
Affiliation(s)
- Christopher M Cielo
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Justine Shults
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ignacio E Tapia
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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21
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Napolitano N, Polikoff L, Edwards L, Tarquinio KM, Nett S, Krawiec C, Kirby A, Salfity N, Tellez D, Krahn G, Breuer R, Parsons SJ, Page-Goertz C, Shults J, Nadkarni V, Nishisaki A. Effect of apneic oxygenation with intubation to reduce severe desaturation and adverse tracheal intubation-associated events in critically ill children. Crit Care 2023; 27:26. [PMID: 36650568 PMCID: PMC9847056 DOI: 10.1186/s13054-023-04304-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 01/06/2023] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Determine if apneic oxygenation (AO) delivered via nasal cannula during the apneic phase of tracheal intubation (TI), reduces adverse TI-associated events (TIAEs) in children. METHODS AO was implemented across 14 pediatric intensive care units as a quality improvement intervention during 2016-2020. Implementation consisted of an intubation safety checklist, leadership endorsement, local champion, and data feedback to frontline clinicians. Standardized oxygen flow via nasal cannula for AO was as follows: 5 L/min for infants (< 1 year), 10 L/min for young children (1-7 years), and 15 L/min for older children (≥ 8 years). Outcomes were the occurrence of adverse TIAEs (primary) and hypoxemia (SpO2 < 80%, secondary). RESULTS Of 6549 TIs during the study period, 2554 (39.0%) occurred during the pre-implementation phase and 3995 (61.0%) during post-implementation phase. AO utilization increased from 23 to 68%, p < 0.001. AO was utilized less often when intubating infants, those with a primary cardiac diagnosis or difficult airway features, and patient intubated due to respiratory or neurological failure or shock. Conversely, AO was used more often in TIs done for procedures and those assisted by video laryngoscopy. AO utilization was associated with a lower incidence of adverse TIAEs (AO 10.5% vs. without AO 13.5%, p < 0.001), aOR 0.75 (95% CI 0.58-0.98, p = 0.03) after adjusting for site clustering (primary analysis). However, after further adjusting for patient and provider characteristics (secondary analysis), AO utilization was not independently associated with the occurrence of adverse TIAEs: aOR 0.90, 95% CI 0.72-1.12, p = 0.33 and the occurrence of hypoxemia was not different: AO 14.2% versus without AO 15.2%, p = 0.43. CONCLUSION While AO use was associated with a lower occurrence of adverse TIAEs in children who required TI in the pediatric ICU after accounting for site-level clustering, this result may be explained by differences in patient, provider, and practice factors. Trial Registration Trial not registered.
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Affiliation(s)
- Natalie Napolitano
- grid.239552.a0000 0001 0680 8770Respiratory Therapy Department, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Lee Polikoff
- grid.40263.330000 0004 1936 9094Division of Pediatric Critical Care Medicine, The Warren Alpert School of Medicine at Brown University, Providence, RI USA
| | - Lauren Edwards
- grid.266813.80000 0001 0666 4105Division of Critical Care, Department of Pediatrics, Children’s Healthcare of Atlanta, University of Nebraska Medical Center and Children’s Hospital and Medical Center, Omaha, NE USA
| | - Keiko M. Tarquinio
- grid.189967.80000 0001 0941 6502Division of Pediatric Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA USA
| | - Sholeen Nett
- grid.413480.a0000 0004 0440 749XDivision of Pediatric Critical Care, Department of Pediatrics, Dartmouth Hitchcock Medical Center, Lebanon, NH USA
| | - Conrad Krawiec
- grid.29857.310000 0001 2097 4281Division of Pediatric Critical Care Medicine, Penn State Health Children’s Hospital, Hershey, PA USA
| | - Aileen Kirby
- grid.5288.70000 0000 9758 5690Division of Pediatric Critical Care Medicine, Department of Pediatrics, Doernbecher Children’s Hospital, Oregon Health and Science University, Portland, OR USA
| | - Nina Salfity
- grid.417276.10000 0001 0381 0779Department of Critical Care, Phoenix Children’s Hospital, Phoenix, AZ USA
| | - David Tellez
- grid.417276.10000 0001 0381 0779Department of Critical Care, Phoenix Children’s Hospital, Phoenix, AZ USA
| | - Gordon Krahn
- grid.17091.3e0000 0001 2288 9830Division of Pediatric Critical Care, University of British Columbia, Vancouver, BC Canada
| | - Ryan Breuer
- grid.413993.50000 0000 9958 7286Division of Pediatric Critical Care, Oishei Children’s Hospital, Buffalo, NY USA
| | - Simon J. Parsons
- grid.413571.50000 0001 0684 7358Division of Critical Care, Alberta Children’s Hospital, Calgary, Canada
| | - Christopher Page-Goertz
- grid.413473.60000 0000 9013 1194Division of Critical Care Medicine, Akron Children’s Hospital, Akron, OH USA
| | - Justine Shults
- grid.239552.a0000 0001 0680 8770Division of Anesthesia and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Vinay Nadkarni
- grid.239552.a0000 0001 0680 8770Division of Anesthesia and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Akira Nishisaki
- grid.239552.a0000 0001 0680 8770Division of Anesthesia and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA USA
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22
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Loe IM, Blum NJ, Shults J, Barbaresi W, Bax A, Cacia J, Deavenport-Saman A, Friedman S, LaRosa A, Mittal S, Vanderbilt D, Harstad E. Adverse Effects of α-2 Adrenergic Agonists and Stimulants in Preschool-age Attention-deficit/Hyperactivity Disorder: A Developmental-Behavioral Pediatrics Research Network Study. J Pediatr 2023:S0022-3476(23)00021-5. [PMID: 36649794 DOI: 10.1016/j.jpeds.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 12/16/2022] [Accepted: 01/11/2023] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To characterize and compare the type and frequency of a range of common and uncommon adverse effects (AEs) associated with α-2 adrenergic agonist (A2A) and stimulant treatment of attention-deficit/hyperactivity disorder at preschool-age as well as to evaluate the impact of age on common AEs. STUDY DESIGN This was a retrospective electronic medical record review of children <72 months of age (n = 497) evaluated at outpatient developmental-behavioral pediatric practices at 7 US academic medical centers within the Developmental-Behavioral Pediatrics Research Network. Data on AEs were abstracted for children who had treatment initiated by a developmental-behavioral pediatrician with an A2A or stimulant medication between January 2013 and July 2017; follow-up was complete by February 2019. RESULTS A2A and stimulants had distinctive AE profiles. A2A compared with stimulants had a greater proportion with daytime sleepiness and headaches; stimulants had significantly greater proportions for most other AE, including moodiness/irritability, difficulty with sleep, appetite suppression, stomachaches, skin picking/repetitive behaviors, withdrawn behavior, and weight loss. Younger age was associated with disruptive behavior and difficulty with sleep. CONCLUSIONS Stimulants had a greater rate of most AEs compared with A2A. AE profiles, together with efficacy, should inform clinical decision-making. Prospective randomized clinical trials are needed to fully compare efficacy and AE profiles of A2A and stimulants.
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Affiliation(s)
- Irene M Loe
- Department of Pediatrics, Stanford University, Stanford, CA.
| | - Nathan J Blum
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA
| | - Justine Shults
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA
| | - William Barbaresi
- Division of Developmental Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Ami Bax
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Jaclyn Cacia
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Alexis Deavenport-Saman
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA; Division of General Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA
| | - Sandra Friedman
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
| | - Angela LaRosa
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Shruti Mittal
- Department of Pediatrics, Atrium Health, Concord, NC
| | - Douglas Vanderbilt
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA; Division of General Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA
| | - Elizabeth Harstad
- Division of Developmental Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
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23
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Daigle CH, Laverriere EK, Bruins BB, Lockman JL, Fiadjoe JE, McGowan N, Napolitano N, Shults J, Nadkarni VM, Nishisaki A. Mitigation and Outcomes of Difficult Bag-Mask Ventilation in Critically Ill Children. J Pediatr Intensive Care 2023. [DOI: 10.1055/s-0042-1760413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
AbstractDifficult bag-mask ventilation (BMV) occurs in 10% of pediatric intensive care unit (PICU) tracheal intubations (TI). The reasons clinicians identify difficult BMV in the PICU and the interventions used to mitigate that difficulty have not been well-studied. This is a prospective, observational, single-center study. A patient-specific data form was sent to PICU physicians supervising TIs from November 2019 through December 2020 to identify the presence of difficult BMV, attempted interventions used, and perceptions about intervention success. The dataset was linked and merged with the local TI quality database to assess safety outcomes. Among 305 TIs with response (87% response rate), 267 (88%) clinicians performed BMV during TI. Difficult BMV was reported in 28 of 267 patients (10%). Commonly reported reasons for difficult BMV included: facial structure (50%), high inspiratory pressure (36%), and improper mask fit (21%). Common interventions were jaw thrust (96%) and an airway adjunct (oral airway 50%, nasal airway 7%, and supraglottic airway 11%), with ventilation improvement in 44% and 73%, respectively. Most difficult BMV was identified before neuromuscular blockade (NMB) administration (96%) and 67% (18/27) resolved after NMB administration. The overall success in improving ventilation was 27/28 (96%). TI adverse outcomes (hemodynamic events, emesis, and/or hypoxemia <80%) are associated with the presence of difficult BMV (10/28, 36%) versus non-difficult BMV (20/239, 8%, p< 0.001). Difficult BMV is common in critically ill children and is associated with increased TI adverse outcomes. Airway adjunct placement and NMB use are often effective in improving ventilation.
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Affiliation(s)
- C. Hunter Daigle
- Division of Critical Care Medicine, Department of Pediatrics, University of Texas at Austin, Dell Children's Medical Center, Austin, Texas, United States
| | - Elizabeth K. Laverriere
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Benjamin B. Bruins
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Justin L. Lockman
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - John E. Fiadjoe
- Department of Anesthesiology, Critical Care, and Pain Medicine. Boston Children's Hospital. Boston, Massachusetts, United States
| | - Nancy McGowan
- Department of Respiratory Therapy, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Natalie Napolitano
- Department of Respiratory Therapy, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Justine Shults
- Division of Biostatistics, Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Vinay M. Nadkarni
- Center for Simulation, Advanced Education and Innovation, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Akira Nishisaki
- Center for Simulation, Advanced Education and Innovation, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
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24
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Nekrasova E, Fiks AG, Wynn C, Torres A, Griffith M, Shone LP, Localio R, Shults J, Unger R, Ware LA, Stockwell MS. Pediatric Practices' Perceptions of Text Message Communication with Families: An American Academy of Pediatrics (AAP), Pediatric Research in Office Settings (PROS) Study. ACI open 2023; 7:e8-e15. [PMID: 38389868 PMCID: PMC10882477 DOI: 10.1055/s-0043-1763270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
Background Text messages can be an effective and low-cost mechanism for patient reminders; however, they are yet to be consistently integrated into pediatric primary care. Objective The aim of this study was to explore pediatric primary care clinician and staff perceptions of pediatric office text message communication with families. Methods As part of the National Institutes of Health-funded Flu2Text randomized controlled trial of second-dose influenza vaccine text message reminders, we conducted 7 focus groups and 4 individual interviews in July-August 2019 with primary care pediatric clinicians and staff (n = 39). Overall, 10 Pediatric Research in Office Settings (PROS) pediatric practices in 10 states were selected using stratified sampling. Semi-structured discussion guides included perspectives on possible uses, perceived usefulness, and ease of use of text messages; practices' current text messaging infrastructure; and perceived barriers/facilitators to future use of texting. Two investigators independently coded and analyzed transcripts based on the technology acceptance model using NVIVO 12 Plus (intercoder reliability, K = 0.86). Results Overall, participants were supportive of text reminders for the second-dose influenza vaccine, other vaccines, and appointments and perceived texting as a preferred method of communication for caregivers. Health information privacy and patient confidentiality were the main concerns cited. Only respondents from practices with no internal appointment text message reminder system prior to the study expressed concerns about technology implementation logistics, time, and cost. Conclusion Text message reminders, for various uses, appear to be well accepted among a group of geographically widespread pediatric practices after participation in a trial of influenza vaccine text message reminders. Privacy, confidentiality, and resource barriers need to be addressed to facilitate successful implementation.
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Affiliation(s)
- Ekaterina Nekrasova
- Clinical Futures & Department of Pediatrics, The Children's Hospital of Philadelphia, Pennsylvania, United States
| | - Alexander G Fiks
- Clinical Futures & Department of Pediatrics, The Children's Hospital of Philadelphia, Pennsylvania, United States
| | - Chelsea Wynn
- Division of Child and Adolescent Health, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York City, New York, United States
| | - Alessandra Torres
- Department of Research, American Academy of Pediatrics, Itasca, Illinois, United States
| | - Miranda Griffith
- Department of Research, American Academy of Pediatrics, Itasca, Illinois, United States
| | - Laura P Shone
- Department of Research, American Academy of Pediatrics, Itasca, Illinois, United States
| | - Russell Localio
- Department of Biostatistics, Epidemiology & Informatics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Justine Shults
- Department of Biostatistics, Epidemiology & Informatics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Rebecca Unger
- Northwestern Children's Practice, Chicago, Illinois, United States
| | - Leigh Ann Ware
- Building Blocks Pediatrics, Pleasanton, Texas, United States
| | - Melissa S Stockwell
- Division of Child and Adolescent Health, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York City, New York, United States
- Department of Population and Family Health, Columbia University Irving Medical Center, New York City, New York, United States
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25
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Takanohashi A, Alameh MG, Woidill S, Hacker J, Davis B, Helman G, Gavazzi F, Adang L, D'Aiello R, Winters P, Cordova D, Khandaker T, Ni H, Tam Y, Lin P, Weissman D, Shults J, Vanderver A. SARS-CoV-2 mRNA-based vaccines in the Aicardi Goutières Syndrome. Mol Genet Metab 2022; 137:320-327. [PMID: 36334423 PMCID: PMC9550281 DOI: 10.1016/j.ymgme.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 10/05/2022] [Accepted: 10/06/2022] [Indexed: 12/14/2022]
Abstract
Aicardi Goutières Syndrome (AGS) is an autoinflammatory disorder resulting in sustained interferon activation through defects in nucleic acid modification and sensing pathways. Thus, mRNA-based vaccination used against SARS-CoV-2, raise disease-specific safety concerns. To assess interferon signaling, we tested mRNA SARS-CoV-2 vaccines in AGS whole blood samples. Interferon activation is measured through quantitation of interferon signaling gene (ISG) expression and is increased in AGS patients. There was no increase in ISG scores from baseline following treatment with the nucleoside modified mRNA formulation compared to an increase with unmodified. A patient-family survey reported that the vaccines were well tolerated. These findings suggest that COVID vaccination using nucleoside-modified forms of mRNA vaccines are unlikely to directly stimulate ISG expression in response to mRNA internalization in AGS tissues. With continued community spread, we recommend vaccination using nucleoside-modified mRNA vaccines in this rare disease group in individuals for whom vaccines were previously well tolerated.
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Affiliation(s)
- Asako Takanohashi
- Department of Neurology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Mohamad-Gabriel Alameh
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Sarah Woidill
- Department of Neurology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Julia Hacker
- Department of Neurology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Benjamin Davis
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Guy Helman
- Department of Neurology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Francesco Gavazzi
- Department of Neurology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Laura Adang
- Department of Neurology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Russell D'Aiello
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Patrick Winters
- Aicardi-Goutières Syndrome Advocacy Association, Crested Butte, USA
| | - Devon Cordova
- Aicardi-Goutières Syndrome Advocacy Association, Crested Butte, USA
| | | | - Houping Ni
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Ying Tam
- Acuitas Therapeutics, Vancouver, Canada
| | - Paulo Lin
- Acuitas Therapeutics, Vancouver, Canada
| | - Drew Weissman
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Justine Shults
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine University of Pennsylvania, Philadelphia, USA; Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Adeline Vanderver
- Department of Neurology, Children's Hospital of Philadelphia, Philadelphia, USA; Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.
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26
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Agawu A, Shults J, Smith-Whitley K, Feudtner C. Age- and sex-specific rates of gall bladder disease in children with sickle cell disease. Pediatr Blood Cancer 2022; 69:e29863. [PMID: 35997530 DOI: 10.1002/pbc.29863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 05/28/2022] [Accepted: 06/10/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Children with sickle cell disease (SCD) have an increased risk for gallstones due to chronic hyperbilirubinemia from hemolysis. Although gallstones are a known complication, there is variability in estimates of disease burden and uncertainty in the association between sex and gall bladder disease (GBD). METHODS This was a retrospective cohort study of children with SCD using administrative claims data (January 1, 2014-December 31, 2018). Population-averaged multivariable panel-data logistic regression models were used to evaluate the association between GBD clinical encounters (outcome) and two exposures (age and sex). Annual GBD risk was calculated using predictive margins, adjusting for disease severity, transfusion frequency, and hydroxyurea exposure. RESULTS A total of 13,745 individuals (of 21,487 possible) met inclusion criteria. The population was evenly split across sex (49.5% female) with predominantly Medicaid insurance (69%). A total of 946 individuals (6.9%) had GBD, 432 (3.1%) had a gallstone complication, and 487 (3.5%) underwent cholecystectomy. The annual risk of GBD rose nonlinearly from 1 to 5% between ages 1 and 19 years with no difference between males and females. Cholecystectomy occurred primarily in individuals with GBD (87%), and neither age nor sex was associated with cholecystectomy in this population. High disease severity (compared with low) more than doubled the annual risk of GBD at all ages. CONCLUSIONS GBD is associated with age but not sex in children with SCD. Neither age nor sex is associated with risk of cholecystectomy. High disease severity increases the rate of GBD at all ages.
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Affiliation(s)
- Atu Agawu
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children's Hospital of Philadelphia, Pennsylvania, USA.,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania, USA
| | - Justine Shults
- Division of Biostatistics, Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Pennsylvania, USA
| | - Kim Smith-Whitley
- Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Chris Feudtner
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania, USA.,Division of General Pediatrics, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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27
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Mitchell OJL, Neefe S, Ginestra JC, Schweickert WD, Falk S, Weissman GE, Covin D, Shults J, Abella BS, Shashaty MGS. Association of Time to Rapid Response Team Activation With Patient Outcomes Using a Range of Physiologic Deterioration Thresholds. Crit Care Explor 2022; 4:e0786. [PMID: 36349290 PMCID: PMC9635041 DOI: 10.1097/cce.0000000000000786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Clinical deterioration of hospitalized patients is common and can lead to critical illness and death. Rapid response teams (RRTs) assess and treat high-risk patients with signs of clinical deterioration to prevent further worsening and subsequent adverse outcomes. Whether activation of the RRT early in the course of clinical deterioration impacts outcomes, however, remains unclear. We sought to characterize the relationship between increasing time to RRT activation after physiologic deterioration and short-term patient outcomes. DESIGN Retrospective multicenter cohort study. SETTING Three academic hospitals in Pennsylvania. PATIENTS We included the RRT activation of a hospitalization for non-ICU inpatients greater than or equal to 18 years old. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary exposure was time to RRT activation after physiologic deterioration. We selected four Cardiac Arrest Risk Triage (CART) score thresholds a priori from which to measure time to RRT activation (CART score ≥ 12, ≥ 16, ≥ 20, and ≥ 24). The primary outcome was 7-day mortality-death or discharge to hospice care within 7 days of RRT activation. For each CART threshold, we modeled the association of time to RRT activation duration with 7-day mortality using multivariable fractional polynomial regression. Increased time from clinical decompensation to RRT activation was associated with higher risk of 7-day mortality. This relationship was nonlinear, with odds of mortality increasing rapidly as time to RRT activation increased from 0 to 4 hours and then plateauing. This pattern was observed across several thresholds of physiologic derangement. CONCLUSIONS Increasing time to RRT activation was associated in a nonlinear fashion with increased 7-day mortality. This relationship appeared most marked when using a CART score greater than 20 threshold from which to measure time to RRT activation. We suggest that these empirical findings could be used to inform RRT delay definitions in further studies to determine the clinical impact of interventions focused on timely RRT activation.
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Affiliation(s)
- Oscar J L Mitchell
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Emergency Medicine, Center for Resuscitation Science, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Stacie Neefe
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jennifer C Ginestra
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA
| | - William D Schweickert
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Scott Falk
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA
| | - Gary E Weissman
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA
- Penn Institute for Biomedical Informatics, University of Pennsylvania, Philadelphia, PA
| | - Donna Covin
- Penn Medicine Princeton Health, Plainsboro, NJ
| | - Justine Shults
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
- Children's Hospital of Philadelphia, Philadelphia, PA
| | - Benjamin S Abella
- Department of Emergency Medicine, Center for Resuscitation Science, Philadelphia, PA
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA
| | - Michael G S Shashaty
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
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Tapia IE, Shults J, Cielo CM, Kelly AB, Elden LM, Spergel JM, Bradford RM, Cornaglia MA, Sterni LM, Radcliffe J. A Trial of Intranasal Corticosteroids to Treat Childhood OSA Syndrome. Chest 2022; 162:899-919. [PMID: 35779610 PMCID: PMC9633812 DOI: 10.1016/j.chest.2022.06.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 06/03/2022] [Accepted: 06/14/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Intranasal corticosteroids (INCS) are frequently used to treat OSA syndrome (OSAS) in children. However, their efficacy has not been rigorously tested. RESEARCH QUESTION Do INCS result in improved OSAS symptoms, polysomnography findings, behavior, and quality of life compared with placebo? STUDY DESIGN AND METHODS In this randomized, double-blind, placebo-controlled trial, children with OSAS aged 5 to 12 years (N = 134) were randomized 2:1 to receive 3 months of INCS or placebo. Children in the INCS arm were then re-randomized to receive 9 months of INCS or placebo. Polysomnography, symptoms, and neurobehavioral findings were measured at baseline, 3 months, and 12 months. The primary outcome was change in obstructive apnea hypopnea index (OAHI) at 3 months, available for 122 children. The secondary outcome was OAHI change at 12 months, available for 70 children. RESULTS Median (interquartile range) age and OAHI at baseline for the entire group were 7.9 (6.3 to 9.9) years and 5.8 (3.6 to 9.7) events per hour. OAHI changes at 3 months (-1.72 [-3.91 to 1.92] events per hour) and 12 months (-1.2 [-4.22 to 1.71] events per hour) were not different between the two groups (P = not significant). OSAS symptoms and neurobehavioral results did not differ between the INCS and placebo groups at 3 and 12 months. The 38 children who received INCS for 12 months reported a significant OAHI decrease from 7.2 (3.62 to 9.88) events per hour to 3.7 (1.56 to 6.4) events per hour (P = .039). INTERPRETATION In children with OSAS, treatment with INCS did not result in significant polysomnography, neurobehavioral, or symptom changes at 3 and 12 months of treatment. Twelve months of INCS treatment resulted in a statistically significant but not clinically relevant OAHI reduction. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov; No.: NCT02180672; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
- Ignacio E Tapia
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA.
| | - Justine Shults
- Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Christopher M Cielo
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Andrea B Kelly
- Department of Pediatrics, Division of Endocrinology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Lisa M Elden
- Department of Surgery, Division of Otolaryngology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Jonathan M Spergel
- Department of Pediatrics, Division of Allergy and Immunology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Ruth M Bradford
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Mary Anne Cornaglia
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Laura M Sterni
- Department of Pediatrics, Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins University, Baltimore, MD
| | - Jerilynn Radcliffe
- Department of Pediatrics, Division of Developmental and Behavioral Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA
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Stockwell MS, Shone LP, Nekrasova E, Wynn C, Torres A, Griffith M, Shults J, Unger R, Ware LA, Kolff C, Harris D, Berrigan L, Montague H, Localio AR, Fiks AG. Text Message Reminders for the Second Dose of Influenza Vaccine for Children: An RCT. Pediatrics 2022; 150:e2022056967. [PMID: 35965283 PMCID: PMC9592065 DOI: 10.1542/peds.2022-056967] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/17/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Among children requiring 2 influenza doses in a given season, second dose receipt nearly halves the odds of influenza. Nationally, many children do not receive both needed doses. This study sought to compare the effectiveness of text message reminders with embedded interactive educational information versus usual care on receipt and timeliness of the second dose of influenza vaccine. METHODS This trial took place over the 2017 to 2018 and 2018 to 2019 influenza seasons among 50 pediatric primary care offices across 24 states primarily from the American Academy of Pediatrics' Pediatric Research in Office Settings practice-based research network. Caregiver-child dyads of children 6 months to 8 years in need of a second influenza vaccination that season were individually randomized 1:1 into intervention versus usual care, stratified by age and language within each practice. Intervention caregivers received automated, personalized text messages, including educational information. Second dose receipt by April 30 (season end) and by day 42 (2 weeks after second dose due date) were assessed using Mantel Haenszel methods by practice and language. Analyses were intention to treat. RESULTS Among 2086 dyads enrolled, most children were 6 to 23 months and half publicly insured. Intervention children were more likely to receive a second dose by season end (83.8% versus 80.9%; adjusted risk difference (ARD) 3.8%; 95% confidence interval [0.1 to 7.5]) and day 42 (62.4% versus 55.7%; ARD 8.3% [3.6 to 13.0]). CONCLUSIONS In this large-scale trial of primary care pediatric practices across the United States, text message reminders were effective in promoting increased and timelier second dose influenza vaccine receipt.
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Affiliation(s)
- Melissa S Stockwell
- Division of Child and Adolescent Health, Department of Pediatrics, Columbia University, New York, NY
- Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY
| | - Laura P Shone
- Primary Care Research, American Academy of Pediatrics, Itasca, IL
| | - Ekaterina Nekrasova
- Department of Pediatrics, Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Chelsea Wynn
- Division of Child and Adolescent Health, Department of Pediatrics, Columbia University, New York, NY
| | | | - Miranda Griffith
- Primary Care Research, American Academy of Pediatrics, Itasca, IL
| | - Justine Shults
- Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | | | - Chelsea Kolff
- Division of Child and Adolescent Health, Department of Pediatrics, Columbia University, New York, NY
- Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY
| | - Donna Harris
- Primary Care Research, American Academy of Pediatrics, Itasca, IL
| | - Lindsay Berrigan
- Department of Pediatrics, Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Heather Montague
- Primary Care Research, American Academy of Pediatrics, Itasca, IL
- American Academy of Dental Sleep Medicine, Lisle, IL
| | - A Russell Localio
- Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Alexander G Fiks
- Department of Pediatrics, Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, PA
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Campbell EA, Maltenfort MG, Shults J, Forrest CB, Masino AJ. Characterizing clinical pediatric obesity subtypes using electronic health record data. PLOS Digit Health 2022; 1:e0000073. [PMID: 36812554 PMCID: PMC9931247 DOI: 10.1371/journal.pdig.0000073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 06/07/2022] [Indexed: 11/19/2022]
Abstract
In this work, we present a study of electronic health record (EHR) data that aims to identify pediatric obesity clinical subtypes. Specifically, we examine whether certain temporal condition patterns associated with childhood obesity incidence tend to cluster together to characterize subtypes of clinically similar patients. In a previous study, the sequence mining algorithm, SPADE was implemented on EHR data from a large retrospective cohort (n = 49 594 patients) to identify common condition trajectories surrounding pediatric obesity incidence. In this study, we used Latent Class Analysis (LCA) to identify potential subtypes formed by these temporal condition patterns. The demographic characteristics of patients in each subtype are also examined. An LCA model with 8 classes was developed that identified clinically similar patient subtypes. Patients in Class 1 had a high prevalence of respiratory and sleep disorders, patients in Class 2 had high rates of inflammatory skin conditions, patients in Class 3 had a high prevalence of seizure disorders, and patients in Class 4 had a high prevalence of Asthma. Patients in Class 5 lacked a clear characteristic morbidity pattern, and patients in Classes 6, 7, and 8 had a high prevalence of gastrointestinal issues, neurodevelopmental disorders, and physical symptoms respectively. Subjects generally had high membership probability for a single class (>70%), suggesting shared clinical characterization within the individual groups. We identified patient subtypes with temporal condition patterns that are significantly more common among obese pediatric patients using a Latent Class Analysis approach. Our findings may be used to characterize the prevalence of common conditions among newly obese pediatric patients and to identify pediatric obesity subtypes. The identified subtypes align with prior knowledge on comorbidities associated with childhood obesity, including gastro-intestinal, dermatologic, developmental, and sleep disorders, as well as asthma.
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Affiliation(s)
- Elizabeth A. Campbell
- Department of Information Science, College of Computing & Informatics, Drexel University, Philadelphia, Pennsylvania, United States of America
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
- * E-mail:
| | - Mitchell G. Maltenfort
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
| | - Justine Shults
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
| | - Christopher B. Forrest
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
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Deavenport-Saman A, Vanderbilt DL, Harstad E, Shults J, Barbaresi W, Bax A, Cacia J, Friedman S, LaRosa A, Loe I, Mittal S, Blum N. Association of Coexisting Conditions, Attention-Deficit/Hyperactivity Disorder Medication Choice, and Likelihood of Improvement in Preschool-Age Children: A Developmental Behavioral Pediatrics Research Network Study. J Child Adolesc Psychopharmacol 2022; 32:328-336. [PMID: 35787014 DOI: 10.1089/cap.2022.0009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objectives: To determine whether conditions coexisting with attention-deficit/hyperactivity disorder (ADHD) in preschool-age children are associated with choice of stimulants or alpha-2 adrenergic agonists (A2As) and/or likelihood of improvement in ADHD symptoms. Methods: A retrospective electronic health record review of 497 children from 7 Developmental Behavioral Pediatrics Research Network (DBPNet) sites. Children were <72 months when treated with medication for ADHD from January 1, 2013 to July 1, 2017. We abstracted coexisting conditions, initial medication prescribed, and whether the medication was associated with improvement in symptoms. Analysis of improvement was adjusted for clustering by clinician and site. Results: The median (interquartile range) child age at the time of initiation of ADHD medication was 62 (54-67) months. The most common coexisting conditions included language disorders (40%), sleep disorders (28%), disruptive behavior disorders (22.7%), autism spectrum disorder (ASD; 21.8%), and motor disorders (19.9%). No coexisting conditions were present in 17.1%; 1 in 36.8%, 2 in 26.8%, and ≥3 in 19.3%. Stimulants were initially prescribed for 322 (64.8%) and A2A for 175 (35.2%) children. Children prescribed stimulants were more likely to have no coexisting conditions than those prescribed A2A (22.3% vs. 7.4%; p < 0.001). Coexisting ASD and sleep disorder were associated with increased likelihood of starting A2As versus stimulants (p < 0.0005; p = 0.002). The association between medication treatment and improvement varied by number of coexisting conditions for 0, 1, 2, or ≥3, respectively (84.7%, 73.8%, 72.9%, 64.6%; p = 0.031). Children with ≥3 coexisting conditions were less likely to respond to stimulants than children with no coexisting conditions (67.4% vs. 79.9%; p = 0.037). Conclusions: Among preschool-age children with ADHD, those with ≥3 coexisting conditions were less likely to respond to stimulants than those with no coexisting conditions. This was not found for A2A, but further research is needed as very few children with no coexisting conditions were treated with A2A.
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Affiliation(s)
- Alexis Deavenport-Saman
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California, USA.,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Douglas L Vanderbilt
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California, USA.,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | | | - Justine Shults
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Ami Bax
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Jaclyn Cacia
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sandra Friedman
- Children's Hospital Colorado, Aurora, Colorado, USA.,Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Angela LaRosa
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Irene Loe
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | | | - Nathan Blum
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Adang LA, Gavazzi F, D'Aiello R, Isaacs D, Bronner N, Arici ZS, Flores Z, Jan A, Scher C, Sherbini O, Behrens EM, Goldbach-Mansky R, Olson TS, Lambert MP, Sullivan KE, Teachey DT, Witmer C, Vanderver A, Shults J. Hematologic abnormalities in Aicardi Goutières Syndrome. Mol Genet Metab 2022; 136:324-329. [PMID: 35786528 PMCID: PMC9357135 DOI: 10.1016/j.ymgme.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/08/2022] [Accepted: 06/09/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Because of the broad clinical spectrum, heritable autoinflammatory diseases present a management and therapeutic challenge. The most common genetic interferonopathy, Aicardi Goutières Syndrome (AGS), is associated with early onset neurologic disability and systemic inflammation. The chronic inflammation of AGS is the result of dysregulation of interferon (IFN) expression by one of nine genes within converging pathways. While each AGS subtype shares common features, distinct patterns of severity and potential for systemic complications amongst the genotypes are emerging. Multilineage cytopenias are a potentially serious, but poorly understood, complication of AGS. As immunomodulatory treatment options are developed, it is important to characterize the role of the disease versus treatment in hematologic abnormalities. This will allow for better understanding and management of cytopenia. METHODS In total, 142 individuals with molecularly-confirmed AGS were included. Information on genotype, demographics, and all available hematologic laboratory values were collected from existing medical records. As part of a clinical trial, a subset of this cohort (n = 52) were treated with a janus kinase inhibitor (baricitinib), and both pre- and post-treatment values were included. Abnormal values were graded based on Common Terminology Criteria for Adverse Events (CTCAE v5.0), supplemented with grading definitions for thrombocytosis, and were compared across genotypes and baricitinib exposure. RESULTS In total, 11,184 laboratory values were collected over a median of 2.54 years per subject (range 0-22.68 years). To reduce bias from repeated sampling within a limited timeframe, laboratory results were restricted to the most abnormal value within a month (n = 8485). The most common abnormalities were anemia (noted in 24% of subjects prior to baricitinib exposure), thrombocytopenia (9%), and neutropenia (30%). Neutropenia was most common in the SAMHD1 cohort and increased with baricitinib exposure (38/69 measurements on baricitinib versus 14/121 while not on baricitinib). Having an abnormality prior to treatment was associated with having an abnormality on treatment for neutropenia and thrombocytopenia. CONCLUSION By collecting available laboratory data throughout the lifespan, we were able to identify novel patterns of hematologic abnormalities in AGS. We found that AGS results in multilineage cytopenias not limited to the neonatal period. Neutropenia, anemia, and thrombocytopenia were common. Moderate-severe graded events of neutropenia, anemia, and leukopenia were more common on baricitinib, but rarely of clinical consequence. Based on these results, we would recommend careful monitoring of hematologic parameters of children affected by AGS throughout the lifespan, especially while on therapy, and consideration of AGS as a potential differential diagnosis in children with neurologic impairment of unclear etiology with hematologic abnormalities. Trial registration ClinicalTrials.gov Identifier: NCT01724580 ClinicalTrials.gov Identifier: NCT03921554.
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Affiliation(s)
- Laura A Adang
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Francesco Gavazzi
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Russell D'Aiello
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - David Isaacs
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nowa Bronner
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Zehra Serap Arici
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Zaida Flores
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Amanda Jan
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Carly Scher
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Omar Sherbini
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Edward M Behrens
- Division of Rheumatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Raphaela Goldbach-Mansky
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Timothy S Olson
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michele P Lambert
- Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kathleen E Sullivan
- Division of Immunology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - David T Teachey
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Char Witmer
- Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Adeline Vanderver
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Justine Shults
- Department of Statistics, University of Pennsylvania, Philadelphia, PA, Philadelphia, PA, USA
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Chung ST, Katz LEL, Stettler-Davis N, Shults J, Sherman A, Ha J, Stefanovski D, Boston RC, Rader DJ, Magge SN. The Relationship Between Lipoproteins and Insulin Sensitivity in Youth With Obesity and Abnormal Glucose Tolerance. J Clin Endocrinol Metab 2022; 107:1541-1551. [PMID: 35240684 PMCID: PMC9113822 DOI: 10.1210/clinem/dgac113] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Indexed: 02/13/2023]
Abstract
CONTEXT Youth with obesity and abnormal glucose tolerance have an increased risk for atherosclerosis but the relative contributions of insulin resistance and hyperglycemia to dyslipidemia and the development of subclinical atherosclerosis are unknown. OBJECTIVE This work aims to determine the association between insulin resistance, dyslipidemia, and carotid intimal thickness (cIMT) in adolescents with normal and abnormal glucose tolerance. METHODS An observational cohort study in 155 youth: 44 obese insulin sensitive (OIS; fasting insulin ≤ 20 µM/mL, body mass index [BMI] ≥ 95th percentile), 35 obese insulin resistant (OIR; fasting insulin > 20 µM/mL, BMI ≥ 95th percentile), 34 obese abnormal glucose tolerant (AGT; BMI ≥ 95th percentile), and 42 Lean (BMI 5th-85th percentile). Lipids, lipoprotein particle size and concentration (-P), insulin sensitivity (SI an intravenous glucose test), and CMIT were compared using linear models adjusted for age, race/ethnicity, biological sex, and Tanner stage. Lipid/lipoprotein profile and CMIT were reevaluated in a subset after 2 years. RESULTS Compared to OIS and Lean, OIR and AGT had elevated triglycerides and low high-density lipoprotein cholesterol (HDL-C) but similar total cholesterol and low-density lipoprotein cholesterol (LDL-C). Among OIS, OIR, AGT, lower SI was associated with atherogenic lipids (higher triglycerides, LDL-C, non-HDL-C, and lower HDL-C) and lipoproteins (higher total LDL-P and small HDL-P, and lower large HDL-P). There was a steeper decline in the association of SI with HDL-C and large HDL-P in AGT compared with OIR and OIS. cIMT was comparable across groups and inversely correlated with SI, with no change after 2 years. CONCLUSION Among youth with obesity, insulin resistance was associated with an atherogenic lipoprotein/lipid profile and cIMT, regardless of glucose tolerance status. Insulin resistance in AGT youth was associated with a shift to smaller HDL-P compared to normoglycemic youth with obesity. Alterations in HDL-P metabolism may be early adverse manifestations of hyperglycemia in youth with obesity.
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Affiliation(s)
- Stephanie T Chung
- Section on Pediatric Diabetes, Obesity, and Metabolism, Diabetes, Endocrinology, and Obesity Branch, National Institute of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Lorraine E Levitt Katz
- Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Justine Shults
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Arthur Sherman
- Laboratory of Biological Modeling, National Institute of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Joon Ha
- Department of Mathematics, Howard University, Washington, DC, USA
| | - Darko Stefanovski
- Department of Clinical Studies, New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ray C Boston
- Department of Clinical Studies, New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, St. Vincent Hospital, University of Melbourne, Melbourne, Australia
| | - Daniel J Rader
- Departments of Medicine and Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sheela N Magge
- Division of Pediatric Endocrinology and Diabetes, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Adang LA, Gavazzi F, Jawad AF, Cusack SV, Kopin K, Peer K, Besnier C, De Simone M, De Giorgis V, Orcesi S, Fazzi E, Galli J, Shults J, Vanderver A. Corrigendum to "Development of a neurologic severity scale for Aicardi Goutières Syndrome" [Mol Genet Metab. 2020 Jun;130(2):153-160. PMID: 32279991]. Mol Genet Metab 2022; 136:81. [PMID: 35422341 DOI: 10.1016/j.ymgme.2022.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Laura A Adang
- Division of Neurology, Children's Hospital of Philadelphia, United States.
| | - Francesco Gavazzi
- Division of Neurology, Children's Hospital of Philadelphia, United States
| | - Abbas F Jawad
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, United States
| | - Stacy V Cusack
- Division of Occupational Therapy, Children's Hospital of Philadelphia, United States
| | - Kimberly Kopin
- Division of Physical Therapy, Children's Hospital of Philadelphia, United States
| | - Kyle Peer
- Division of Neurology, Children's Hospital of Philadelphia, United States
| | - Constance Besnier
- Division of Neurology, Children's Hospital of Philadelphia, United States
| | - Micaela De Simone
- Child Neurology and Psychiatry Unit, ASST Spedali Civili of Brescia, Italy
| | - Valentina De Giorgis
- Department of Child Neurology and Psychiatry, IRCCS Mondino Foundation, Pavia, Italy
| | - Simona Orcesi
- Department of Child Neurology and Psychiatry, IRCCS Mondino Foundation, Pavia, Italy
| | - Elisa Fazzi
- Child Neurology and Psychiatry Unit, ASST Spedali Civili of Brescia, Italy
| | - Jessica Galli
- Child Neurology and Psychiatry Unit, ASST Spedali Civili of Brescia, Italy
| | - Justine Shults
- Department of Biostatistics, Perelman School of Medicine at University of Pennsylvania, United States
| | - Adeline Vanderver
- Division of Neurology, Children's Hospital of Philadelphia, United States
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Henry MK, Schilling S, Shults J, Feudtner C, Katcoff H, Egbe TI, Johnson MA, Andronikou S, Wood JN. Practice Variation in Use of Neuroimaging Among Infants With Concern for Abuse Treated in Children's Hospitals. JAMA Netw Open 2022; 5:e225005. [PMID: 35442455 PMCID: PMC9021910 DOI: 10.1001/jamanetworkopen.2022.5005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE Infants who appear neurologically well and have fractures concerning for abuse are at increased risk for clinically occult head injuries. Evidence of excess variation in neuroimaging practices when abuse is suspected may indicate opportunity for quality and safety improvement. OBJECTIVE To quantify neuroimaging practice variation across children's hospitals among infants with fractures evaluated for abuse, with the hypothesis that hospitals would vary substantially in neuroimaging practices. As a secondary objective, factors associated with neuroimaging use were identified, with the hypothesis that age and factors associated with potential biases (ie, payer type and race or ethnicity) would be associated with neuroimaging use. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included infants with a femur or humerus fracture or both undergoing abuse evaluation at 44 select US children's hospitals in the Pediatric Health Information System (PHIS) from January 1, 2016, through March 30, 2020, including emergency department, observational, and inpatient encounters. Included infants were aged younger than 12 months with a femur or humerus fracture or both without overt signs or symptoms of head injury for whom a skeletal survey was performed. To focus on infants at increased risk for clinically occult head injuries, infants with billing codes suggestive of overt neurologic signs or symptoms were excluded. Multivariable logistic regression was used to investigate demographic, clinical, and temporal factors associated with use of neuroimaging. Marginal standardization was used to report adjusted percentages of infants undergoing neuroimaging by hospital and payer type. Data were analyzed from March 2021 through January 2022. EXPOSURES Covariates included age, sex, race and ethnicity, payer type, fracture type, presentation year, and hospital. MAIN OUTCOMES AND MEASURES Use of neuroimaging by CT or MRI. RESULTS Of 2585 infants with humerus or femur fracture or both undergoing evaluations for possible child abuse, there were 1408 (54.5%) male infants, 1726 infants (66.8%) who were publicly insured, and 1549 infants (59.9%) who underwent neuroimaging. The median (IQR) age was 6.1 (3.2-8.3) months. There were 748 (28.9%) Black non-Hispanic infants, 426 (16.5%) Hispanic infants, 1148 (44.4%) White non-Hispanic infants. In multivariable analyses, younger age (eg, odds ratio [OR] for ages <3 months vs ages 9 to <12 months, 13.2; 95% CI, 9.54-18.2; P < .001), male sex (OR, 1.47; 95% CI, 1.22-1.78; P < .001), payer type (OR for public vs private insurance, 1.48; 95% CI, 1.18-1.85; P = .003), fracture type (OR for femur and humerus fracture vs isolated femur fracture, 5.36; 95% CI, 2.11-13.6; P = .002), and hospital (adjusted range in use of neuroimaging, 37.4% [95% CI 21.4%-53.5%] to 83.6% [95% CI 69.6%-97.5%]; P < .001) were associated with increased use of neuroimaging, but race and ethnicity were not. Publicly insured infants were more likely to undergo neuroimaging (62.0%; 95% CI, 60.0%-64.1%) than privately insured infants (55.1%; 95% CI, 51.8%-58.4%) (P = .001). CONCLUSIONS AND RELEVANCE This study found that hospitals varied in neuroimaging practices among infants with concern for abuse. Apparent disparities in practice associated with insurance type suggest opportunities for quality, safety, and equity improvement.
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Affiliation(s)
- M. Katherine Henry
- Safe Place: Center for Child Protection and Health, Division of General Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Samantha Schilling
- Division of General Pediatrics and Adolescent Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill
| | - Justine Shults
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Chris Feudtner
- Division of General Pediatrics, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Medical Ethics, Children's Hospital of Philadelphia
| | - Hannah Katcoff
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Teniola I. Egbe
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mitchell A. Johnson
- Division of Orthopaedics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Savvas Andronikou
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Joanne N. Wood
- Safe Place: Center for Child Protection and Health, Division of General Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Policy Lab, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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Capone CA, Emerson B, Sweberg T, Polikoff L, Turner DA, Adu‐Darko M, Li S, Glater‐Welt LB, Howell J, Brown CA, Donoghue A, Krawiec C, Shults J, Breuer R, Swain K, Shenoi A, Krishna AS, Al‐Subu A, Harwayne‐Gidansky I, Biagas KV, Kelly SP, Nuthall G, Panisello J, Napolitano N, Giuliano JS, Emeriaud G, Toedt‐Pingel I, Lee A, Page‐Goertz C, Kimura D, Kasagi M, D'Mello J, Parsons SJ, Mallory P, Gima M, Bysani GK, Motomura M, Tarquinio KM, Nett S, Ikeyama T, Shetty R, Sanders RC, Lee JH, Pinto M, Orioles A, Jung P, Shlomovich M, Nadkarni V, Nishisaki A. Intubation practice and outcomes among pediatric emergency departments: A report from National Emergency Airway Registry for Children (NEAR4KIDS). Acad Emerg Med 2022; 29:406-414. [PMID: 34923705 DOI: 10.1111/acem.14431] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 10/23/2021] [Accepted: 11/22/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Tracheal intubation (TI) practice across pediatric emergency departments (EDs) has not been comprehensively reported. We aim to describe TI practice and outcomes in pediatric EDs in contrast to those in intensive are units (ICUs) and use the data to identify quality improvement targets. METHODS Consecutive TI encounters from pediatric EDs and ICUs in the National Emergency Airway Registry for Children (NEAR4KIDS) database from 2015 to 2018 were analyzed for patient, provider, and practice characteristics and outcomes: adverse TI-associated events (TIAEs), oxygen desaturation (SpO2 < 80%), and procedural success. A multivariable model identified factors associated with TIAEs in the ED. RESULTS A total of 756 TIs in 13 pediatric EDs and 12,512 TIs in 51 pediatric/cardiac ICUs were reported. Median (interquartile range [IQR]) patient age for ED TIs was higher (32 [7-108] months) than that for ICU TIs (15 [3-91] months; p < 0.001). Proportion of TIs for respiratory decompensation (52% of ED vs. 64% ICU), shock (26% vs. 14%), and neurologic deterioration (30% vs. 11%) also differed by location. Limited neck mobility was reported more often in the ED (16% vs. 6%). TIs in the ED were performed more often via video laryngoscopy (64% vs. 29%). Adverse TIAE rates (15.6% ED, 14% ICU; absolute difference = 1.6%, 95% confidence interval [CI] = -1.1 to 4.2; p = 0.23) and severe TIAE rates (5.4% ED, 5.8% ICU; absolute difference = -0.3%, 95% CI = -2.0 to 1.3; p = 0.68) were not different. Oxygen desaturation was less commonly reported in ED TIs (13.6%) than ICU TIs (17%, absolute difference = -3.4%, 95% CI = -5.9 to -0.8; p = 0.016). Among ED TIs, shock as an indication (adjusted odds ratio [aOR] = 2.15, 95% CI = 1.26 to 3.65) and limited mouth opening (aOR = 1.74, 95% CI = 1.04 to 2.93) were independently associated with TIAEs. CONCLUSIONS While TI characteristics vary between pediatric EDs and ICUs, outcomes are similar. Shock and limited mouth opening were independently associated with adverse TI events in the ED.
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Affiliation(s)
- Christine A. Capone
- Division of Pediatric Critical Care Medicine, Department of Pediatrics Steven and Alexandra Cohen Children's Medical Center New Hyde Park New York USA
| | - Beth Emerson
- Department of Pediatrics Yale University School of Medicine New Haven Connecticut USA
| | - Todd Sweberg
- Division of Pediatric Critical Care Medicine, Department of Pediatrics Steven and Alexandra Cohen Children's Medical Center New Hyde Park New York USA
| | - Lee Polikoff
- Division of Critical Care Medicine, Department of Pediatrics The Warren Alpert Medical School of Brown University Providence Rhode Island USA
| | - David A. Turner
- Division of Pediatric Critical Care, Department of Pediatrics Duke Children's Hospital and Health Center Durham North Carolina USA
| | - Michelle Adu‐Darko
- Division of Pediatric Critical Care Medicine Department of Pediatrics University of Virginia Children's Hospital Charlottesville Virginia USA
| | - Simon Li
- Department of Pediatrics Robert Wood Johnson University New Brunswick New Jersey USA
| | - Lily B. Glater‐Welt
- Division of Pediatric Critical Care Medicine, Department of Pediatrics Steven and Alexandra Cohen Children's Medical Center New Hyde Park New York USA
| | - Joy Howell
- Pediatric Critical Care Medicine Department of Pediatrics New York Presbyterian Hospital/Weill Cornell Medical Center New York New York USA
| | - Calvin A. Brown
- Department of Emergency Medicine Brigham and Women’s Hospital Harvard Medical School Boston Massachusetts USA
| | - Aaron Donoghue
- Division of Emergency Medicine Department of Pediatrics Children’s Hospital of Philadelphia Philadelphia Pennsylvania USA
- Division of Critical Care Medicine Department of Anesthesiology and Critical Care Medicine Children’s Hospital of Philadelphia Philadelphia Pennsylvania USA
| | - Conrad Krawiec
- Department of Pediatrics, Pediatric Critical Care Penn State Health Children's Hospital Hershey Pennsylvania USA
| | - Justine Shults
- Division of Biostatistics Department of Biostatistics and Epidemiology University of Pennsylvania Perelman School of Medicine Philadelphia Pennsylvania USA
| | - Ryan Breuer
- Department of Pediatrics John R. Oishei Children's Hospital Buffalo New York USA
| | - Kelly Swain
- Pediatric and Cardiac Critical Care Duke University Medical Center Durham North Carolina USA
| | - Asha Shenoi
- Department of Pediatrics and Critical Care Medicine University of Kentucky College of Medicine Kentucky Children's Hospital Lexington Kentucky USA
| | - Ashwin S. Krishna
- Department of Pediatrics and Critical Care Medicine University of Kentucky College of Medicine Kentucky Children's Hospital Lexington Kentucky USA
| | - Awni Al‐Subu
- Division of Pediatric Critical Care Medicine Department of Pediatrics UW Health American Family Children's Hospital University of Wisconsin‐Madison Madison Wisconsin USA
| | - Ilana Harwayne‐Gidansky
- Department of Pediatrics Stony Brook Children's Hospital, Stony Brook University, Renaissance School of Medicine Stony Brook New York USA
| | - Katherine V. Biagas
- Department of Pediatrics Stony Brook Children's Hospital, Stony Brook University, Renaissance School of Medicine Stony Brook New York USA
| | - Serena P. Kelly
- Department of Pediatrics Oregon Health & Science University Doernbecher Children's Hospital Portland Oregon USA
| | - Gabrielle Nuthall
- Pediatric Critical Care Medicine Starship Children's Hospital Auckland New Zealand
| | - Josep Panisello
- Section of Pediatric Critical Care Medicine Department of Pediatrics Yale School of Medicine New Haven Connecticut USA
| | - Natalie Napolitano
- Respiratory Care Department The Children’s Hospital of Philadelphia Philadelphia Pennsylvania USA
| | - John S. Giuliano
- Section of Pediatric Critical Care Medicine Department of Pediatrics Yale School of Medicine New Haven Connecticut USA
| | - Guillaume Emeriaud
- Pediatric Critical Care Medicine CHU Sainte Justine Université de Montréal Montreal Quebec Canada
| | - Iris Toedt‐Pingel
- Division of Pediatric Critical Care University of Vermont Children's Hospital Burlington Vermont USA
| | - Anthony Lee
- Division of Critical Care Medicine Nationwide Children's Hospital Ohio State University College of Medicine Columbus Ohio USA
| | | | - Dai Kimura
- Department of Pediatrics University of Tennessee Health Science Center Le Bonheur Children's Hospital Memphis Tennessee USA
| | - Mioko Kasagi
- Pediatric Critical Care & Emergency Medicine Tokyo Metropolitan Children's Medical Center Tokyo Japan
| | - Jenn D'Mello
- Section of Pediatric Emergency Medicine Department of Pediatrics University of Calgary Calgary Alberta Canada
| | - Simon J. Parsons
- Section of Critical Care Medicine Department of Pediatrics University of Calgary Calgary Alberta Canada
| | - Palen Mallory
- Department of Pediatrics Duke University Durham North Carolina USA
| | - Masafumi Gima
- Critical Care Medicine National Center for Child Health and Development Tokyo Japan
| | | | - Makoto Motomura
- Division of Pediatric Critical Care Medicine Aichi Children's Health and Medical Center Aichi Japan
| | - Keiko M. Tarquinio
- Division of Critical Care Medicine Department of Pediatrics Emory University School of Medicine Children's Healthcare of Atlanta Egleston Georgia USA
| | - Sholeen Nett
- Section of Pediatric Critical Care Medicine Children's Hospital at Dartmouth, Dartmouth‐Hitchcock Medical Center Lebanon New Hampshire USA
| | - Takanari Ikeyama
- Division of Pediatric Critical Care Medicine Aichi Children's Health and Medical Center Aichi Japan
| | - Rakshay Shetty
- Department of Pediatrics Rainbow Children's Hospital Bangalore India
| | - Ronald C. Sanders
- Section of Critical Care University of Arkansas for Medical Sciences Little Rock Arkansas USA
| | - Jan Hau Lee
- Children's Intensive Care Unit KK Women's and Children's Hospital Singapore Singapore
| | - Matthew Pinto
- Pediatric Critical Care Medicine Maria Fareri Children's Hospital Valhalla New York USA
| | - Alberto Orioles
- Division of Critical Care Children's Hospitals and Clinics of Minnesota Minneapolis Minnesota USA
| | - Philipp Jung
- Paediatric Department University Hospital Schleswig‐Holstein Campus Lübeck Germany
| | - Mark Shlomovich
- Division of Pediatric Critical Care Medicine Albert Einstein College of Medicine Children's Hospital at Montefiore Bronx New York USA
| | - Vinay Nadkarni
- Division of Critical Care Medicine Department of Anesthesiology and Critical Care Medicine Children’s Hospital of Philadelphia Philadelphia Pennsylvania USA
| | - Akira Nishisaki
- Division of Critical Care Medicine Department of Anesthesiology and Critical Care Medicine Children’s Hospital of Philadelphia Philadelphia Pennsylvania USA
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Madrigal VN, Hill DL, Shults J, Feudtner C. Trust in Physicians, Anxiety and Depression, and Decision-Making Preferences among Parents of Children with Serious Illness. J Palliat Med 2022; 25:428-436. [PMID: 34516933 PMCID: PMC8968833 DOI: 10.1089/jpm.2021.0063] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Objective: To assess parental decision-making preferences when caring for a child with serious illness and to evaluate for an association between preferences and parental trust in physicians, and potential modification of this association by parental anxiety or depression. Methods: We analyzed cross-sectional data from 200 parents of 158 children in the United States who had life-threatening illnesses and whose attending physicians thought that the parents would have to make major medical decision in the next 12 to 24 months. Parents completed measures of decision-making preferences, trust in physicians, anxiety, and depression. Results: Higher reported levels of trust were associated with lower preferences for autonomous decision making (Spearman correlation = -0.24; 95% confidence interval [CI] = -0.36 to -0.01; p < 0.008). Among parents with higher levels of trust, increasing anxiety scores were associated with decreasing preference for autonomy, whereas among parents with lower levels of trust, increasing anxiety scores showed an increasing preference for autonomy (regression coefficient = -0.01; 95% CI = -0.02 to -0.001; p ≤ 0.03). Conclusions: Decreasing trust in physicians is associated with a higher preference for autonomous decision making. Parents who have higher levels of anxiety exhibit this association more strongly. Decision support for parents of children with serious illness should use strategies to respect parental decision-making preferences, address potential distrust, and provide mental health support to parents who are anxious or depressed.
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Affiliation(s)
- Vanessa N. Madrigal
- Division Critical Care Medicine, Department of Pediatrics, George Washington University, Washington, DC, USA.,Pediatric Ethics Program, Children's National Hospital, Washington, DC, USA
| | - Douglas L. Hill
- Department of Medical Ethics, Roberts Center for Pediatric Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Justine Shults
- Department of Biostatistics, Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Chris Feudtner
- Department of Medical Ethics, Roberts Center for Pediatric Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Medical Ethics and Health Policy, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Address correspondence to: Chris Feudtner, MD, PhD, MPH, Department of Medical Ethics, Roberts Center for Pediatric Research, The Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA 19146, USA
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Gavazzi F, Adang L, Waldman A, Jan AK, Liu G, Lorch SA, DeMauro SB, Shults J, Pierce SR, Ballance E, Kornafel T, Harrington A, Glanzman AM, Vanderver A. Reliability of the Telemedicine Application of the Gross Motor Function Measure-88 in Patients With Leukodystrophy. Pediatr Neurol 2021; 125:34-39. [PMID: 34624609 PMCID: PMC8629609 DOI: 10.1016/j.pediatrneurol.2021.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 09/16/2021] [Accepted: 09/18/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Leukodystrophies are a rare class of disorders characterized by severe neuromotor disability. There is a strong need for research regarding the functional status of people with leukodystrophy which is limited by the need for in-person assessments of mobility. The purpose of this study is to assess the reliability of the Gross Motor Function Measure-88 (GMFM-88) using telemedicine compared with standard in-person assessments in patients with leukodystrophy. METHODS A total of 21 subjects with a diagnosis of leukodystrophy (age range = 1.79-52.82 years) were evaluated by in-person and by telemedicine evaluations with the GMFM-88 by physical therapists. Inter-rater reliability was assessed through evaluation of the same subject by two independent raters within a three-week period (n = 10 encounters), and intrarater reliability was assessed through blinded rescoring of video-recorded assessments after a one-week time interval (n = 6 encounters). RESULTS Remote assessments were performed by caregivers in all 21 subjects using resources found in the home with remote guidance. There was agreement between all paired in-person and remote measurements (Lin's concordance correlation ≥0.995). The Bland-Altman analysis indicated that the paired differences were within ±5%. Intrarater and inter-rater reliability demonstrated an intraclass correlation coefficient of >0.90. CONCLUSIONS These results support that remote application of the GMFM-88 is a feasible and reliable approach to assess individuals with leukodystrophy. Telemedicine application of outcome measures may be of particular value in rare diseases and those with severe neurologic disability that impacts the ability to travel.
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Affiliation(s)
- Francesco Gavazzi
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy.
| | - Laura Adang
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Amy Waldman
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Amanda K. Jan
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Geraldine Liu
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Scott A. Lorch
- Department of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Sara B. DeMauro
- Department of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Justine Shults
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA,Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Samuel R. Pierce
- Departmen of Physical Therapy, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Elizabeth Ballance
- Departmen of Physical Therapy, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Tracy Kornafel
- Departmen of Physical Therapy, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Ann Harrington
- Departmen of Physical Therapy, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Allan M. Glanzman
- Departmen of Physical Therapy, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Adeline Vanderver
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Gavazzi F, Cross ZM, Woidill S, McMann JM, Rand EB, Takanohashi A, Ulrick N, Shults J, Vanderver AL, Adang L. Hepatic Involvement in Aicardi-Goutières Syndrome. Neuropediatrics 2021; 52:441-447. [PMID: 33445189 PMCID: PMC8992010 DOI: 10.1055/s-0040-1722673] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Aicardi-Goutières syndrome (AGS) is a monogenic type-I interferonopathy that results in neurologic injury. The systemic impact of sustained interferon activation is less well characterized. Liver inflammation is known to be associated with the neonatal form of AGS, but the incidence of AGS-related hepatitis across lifespan is unknown.We compared natural history data including liver enzyme levels with markers of inflammation, (liver-specific autoantibodies and interferon signaling gene expression[ISG] scores). Liver enzymes were classified as normal or elevated by the fold increase over the upper limit of normal (ULN). The highest increases were designated as hepatitis, defined as aspartate-aminotransferase or alanine-aminotransferase threefold ULN, or gamma-glutamyl transferase 2.5-fold ULN. A larger cohort was used to further characterize the longitudinal incidence of liver abnormalities and the association with age and genotype.Across the AGS cohort (n = 102), elevated liver enzymes were identified in 76 individuals (74.5%) with abnormalities at a level consistent with hepatitis in 29 individuals (28.4%). SAMHD1 mutations were less likely to be associated with hepatitis (log-rank test; p = 0.011). Hepatitis was associated with early-onset disease and microcephaly (log-rank test; microcephaly p = 0.0401, age onset p = 0.0355). While most subjects (n = 20/33) were found to have liver-specific autoantibodies, there was no association between the presence of autoantibodies or ISG scores with hepatitis-level enzyme elevations.In conclusion, all genotypes of AGS are associated with transient elevations of liver enzymes and the presence of liver-associated autoantibodies. This adds to our growing understanding of the systemic pathology AGS.
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Affiliation(s)
- Francesco Gavazzi
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States,Department of Molecular and Translational Medicine, University of Brescia, Italy
| | - Zachary M. Cross
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Sarah Woidill
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Joseph M. McMann
- Division of Pathology and Laboratory Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Elizabeth B. Rand
- Division of Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Asako Takanohashi
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Nicole Ulrick
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Justine Shults
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States,Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Adeline L. Vanderver
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States,Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Laura Adang
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States,Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
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Bryant-Stephens T, Williams Y, Kanagasundaram J, Apter A, Kenyon CC, Shults J. The West Philadelphia asthma care implementation study (NHLBI# U01HL138687). Contemp Clin Trials Commun 2021; 24:100864. [PMID: 34926863 PMCID: PMC8649219 DOI: 10.1016/j.conctc.2021.100864] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 10/05/2021] [Accepted: 11/09/2021] [Indexed: 11/28/2022] Open
Abstract
Asthma is the most common chronic condition among children, with low-income families living in urban areas experiencing significantly higher rates. Evidence based interventions for asthma are routinely implemented in either the home, school, or primary care setting. However, even when caregivers of poor children are engaged in asthma interventions in one setting, they often have to navigate challenges in another setting, such as an under-resourced home, non-supportive school, or disengaged health care provider. The West Philadelphia Asthma Care Implementation Plan aims to compare the effectiveness of a primary care-based intervention, school-based intervention, and combined primary care and school intervention to usual care for improving asthma control in school-age children to explore if the synergistic effect of Community Health Worker (CHW) support in the home, school, and health care environments will result in improved asthma control. Children ages 5-13 with uncontrolled asthma from four West Philadelphia recruitment sites will be eligible for enrollment. The families of school age children interested in participating will be randomized to receive a primary care CHW or usual care. Those identified as attending a participating school will have a CHW-led school intervention or usual care in school. If proven effective, this care coordination program will assist caregivers in assessing resources, improving self-management skills, and ultimately reducing asthma-related ED visits and hospitalizations as well as provide additional information for healthcare systems and policy makers to inform their decisions about how and where to focus additional resources and investments in childhood asthma care to improve health outcomes.
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Key Words
- ACQ, Asthma Control Questionnaire
- Asthma
- Asthma in children
- CAPP, Communitiy Asthma Prevention Program
- CHOP, Children's Hospital of Philadelphia
- CHW, Community Health Worker
- Community research
- EBI, Evidence-based intervention
- ED, emergency department
- EHR, electronic health record
- IRB, institutional review board
- Implementation science
- OAS, Open Airways for Schools
- SAMPRO, School-based Asthma Management Program
- SBAT, School-based Asthma Therapy
- WEPACC, West Philadelphia Asthma Care Collaborative
- pCHW, primary care community health worker
- sCHW, school-based community health worker
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Affiliation(s)
- Tyra Bryant-Stephens
- Community Asthma Prevention Program, Sr Director, Center for Health Equity, Associate Professor of Pediatrics, United States
| | | | | | - Andrea Apter
- Perelman School of Medicine at the University of Pennsylvania, United States
| | - Chén C. Kenyon
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, United States
| | - Justine Shults
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, United States
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Sawinski D, Lindner H, Fitzsimmons R, Shults J, Locke JE, Cohen JB, MacLennan PA, Reese PP. Dialysis Nonadherence and Kidney Transplant Outcomes: A Retrospective Cohort Study. Am J Kidney Dis 2021; 80:46-54. [PMID: 34673160 DOI: 10.1053/j.ajkd.2021.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 09/16/2021] [Indexed: 11/11/2022]
Abstract
RATIONALE AND OBJECTIVE Concerns about non-adherent behaviors often prevent dialysis patients from entering waitlists for transplantation, despite an inconsistent association with posttransplant outcomes. We examined the association between plausible metrics of non-adherence related to dialysis treatment and posttransplant outcomes. STUDY DESIGN Retrospective cohort. We linked national dialysis treatment data with transplant registry data. SETTING AND PARTICIPANTS Adult patients on maintenance hemodialysis from 1/1/2004-12/31/2014 who received a kidney transplant at US centers. EXPOSURES We examined five nonadherence metrics: serum potassium (≥5.2 mEq/L), serum phosphorus (>5.5 mg/dL), intradialytic weight gain (IDWG, ≥5 L), shortened treatments (≥30 minutes) and missed treatments (≥1); missed treatment data was only available for 2004-2009. These metrics were characterized as the proportion of time under observation. Dialysis observation time was divided into 3-month intervals (quarters) and the number of "non-adherent" measurements in each domain was calculated for each quarter. OUTCOMES Allograft loss; mortality; and acute rejection in the first posttransplant year. ANALYTICAL APPROACH Using Cox proportional hazards and logistic regression, we estimated the hazard ratios (HRs) for graft loss and mortality, and odds ratios (OR) for rejection. RESULTS 9543 patients met inclusion criteria. In our primary model, hyperphosphatemia (aHR 1.27, 05% CI 1.08-1.49), IDWG (aHR 1.39, 95% CI 1.23-1.59) and shortened treatments (aHR 1.54, 95% CI 1.12-2.13) were associated with greater rates of allograft loss but hyperkalemia was not. IDWG (aHR 1.49, 95% CI 1.29-1.73) and shortened treatments (aHR 1.34, 95% CI 1.13-1.58) were associated with mortality while hyperkalemia and hyperphosphatemia were not. Only shortened treatments was associated with an increased risk of acute rejection (aOR 3.88, 95% CI 1.98-7.58). In models limited to the years 2004 to 2009 that included missed treatments, missed treatments were only associated with mortality. LIMITATIONS Unmeasured confounding (e.g., dietary data); adherence metrics used may have multiple, complex causes. CONCLUSIONS Plausible measures of dialysis nonadherence have long-term associations with allograft and patient survival. Behavioral metrics were more closely associated with outcomes than laboratory markers. The implications of non-adherent behaviors for dialysis patients must be carefully considered before excluding patients from transplantation.
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Affiliation(s)
- Deirdre Sawinski
- Department of Medicine, Renal Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia PA.
| | - Hanna Lindner
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Robert Fitzsimmons
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Jayme E Locke
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham AL
| | - Jordana B Cohen
- Department of Medicine, Renal Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia PA; Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Paul A MacLennan
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham AL
| | - Peter P Reese
- Department of Medicine, Renal Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia PA; Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Gavazzi F, Charsar BA, Williams C, Shults J, Alves CA, Adang L, Vanderver A. Acquisition of Developmental Milestones in Hypomyelination With Atrophy of the Basal Ganglia and Cerebellum and Other TUBB4A-Related Leukoencephalopathy. J Child Neurol 2021; 36:805-811. [PMID: 34514881 PMCID: PMC8505576 DOI: 10.1177/08830738211000977] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Mutations in TUBB4A are associated with a spectrum of neurologic disorders categorized as TUBB4A-related leukoencephalopathy. Affected children can present with global developmental delay or normal early development, followed by a variable loss of skills over time. Further research is needed to characterize the factors associated with the divergent developmental trajectories in this rare monogenic disorder because this phenotypic spectrum is not fully explained by genotype alone.To characterize early psychomotor features, developmental milestones and age of disease onset were collected from medical records (n=54 individuals). Three subcohorts were identified: individuals with the common p.Asp249Asn variant vs all other genotypes with either early (<12 months of age) or late onset of presentation. Individuals with the p.Asp249Asn variant or those with non-p.Asp249Asn genotypes with later disease onset attained key milestones, including head control, sitting, and independent walking. Subjects with early-onset, non-p.Asp249Asn-associated disease were less likely to achieve developmental milestones. Next, we defined the developmental severity as the percentage of milestones attained by age 2 years. The mild form was defined as attaining at least 75% of key developmental milestones. Among cohort categorized as mild, individuals with p.Asp249Asn variant were more likely to lose acquired abilities when compared with non-p.Asp249Asn individuals.Our results suggest multiple influences on developmental trajectory, including a strong contribution from genotype and age of onset. Further studies are needed to identify additional factors that influence overall outcomes to better counsel families and to design clinical trials with appropriate clinical endpoints.
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Affiliation(s)
- Francesco Gavazzi
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Department of Molecular and Translational Medicine, University of Brescia, Italy
| | | | - Catherine Williams
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Justine Shults
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA,Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Cesar A. Alves
- Division of Neuroradiology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Laura Adang
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Adeline Vanderver
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Dienemann T, Ziolkowski SL, Bender S, Goral S, Long J, Baker JF, Shults J, Zemel BS, Reese PP, Wilson FP, Leonard MB. Changes in Body Composition, Muscle Strength, and Fat Distribution Following Kidney Transplantation. Am J Kidney Dis 2021; 78:816-825. [PMID: 34352286 DOI: 10.1053/j.ajkd.2020.11.032] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 11/20/2020] [Indexed: 11/11/2022]
Abstract
RATIONALE AND OBJECTIVE Low muscle mass relative to fat mass (relative sarcopenia) has been associated with mortality and disability but has not been examined following transplantation. We studied how measures of body composition change after receipt of a kidney allograft. STUDY DESIGN Prospective longitudinal cohort study. SETTING AND PARTICIPANTS 60 kidney transplant recipients (ages 20-60 years) at the University of Pennsylvania. EXPOSURE Kidney transplantation. OUTCOMES DXA measures of fat mass index (FMI) and appendicular lean mass index (ALMI; representing muscle mass), CT measures of muscle density (low density represents increased intramuscular adipose tissue), dynamometer measures of leg muscle strength, and physical activity. ALMI relative to FMI (ALMFMI) is an established index of relative sarcopenia. ANALYTICAL APPROACH Measures expressed as age, sex, and race-specific Z-scores for transplant recipients were compared to 327 healthy controls. Regression models were used to identify correlates of change in outcome Z-scores and compare transplant recipients to controls. RESULTS At transplantation, ALMI, ALMIFMI, muscle strength and muscle density Z-scores were lower vs. controls (all p≤0.001). Transplant recipients received glucocorticoids throughout. The prevalence of obesity increased from 18 to 45%. Although ALMI increased following transplantation (p<0.001) and was comparable to controls from 6 months onward, gains were outpaced by increases in FMI, resulting in persistent ALMIFMI deficits (mean Z-score -0.31 at 24 months, p=0.02 vs controls). Muscle density improved following transplantation despite gains in FMI (p = 0.02). Muscle strength relative to ALMI also improved (p = 0.04) but remained low compared with controls (p=0.01). Exercise increased in the early months following transplantation (p<0.05) but remained lower than controls (p=0.02). LIMITATIONS Lack of muscle biopsies precluded assessment of muscle histology and metabolism. CONCLUSIONS The two-year interval following kidney transplantation was characterized by gains in muscle mass and strength that were outpaced by gains in fat mass resulting in persistent relative sarcopenia.
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Affiliation(s)
- Thomas Dienemann
- Department of Surgery, University Hospital of Regensburg, Regensburg, Germany.
| | - Susan L Ziolkowski
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Shaun Bender
- Boehringer Ingelheim Pharmaceuticals Inc., CT, USA
| | - Simin Goral
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jin Long
- Departments of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Joshua F Baker
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Justine Shults
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Babette S Zemel
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Peter P Reese
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - F Perry Wilson
- Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - Mary B Leonard
- Department of Medicine, Stanford University School of Medicine, Stanford, CA; Departments of Pediatrics, Stanford University School of Medicine, Stanford, CA
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Harstad E, Shults J, Barbaresi W, Bax A, Cacia J, Deavenport-Saman A, Friedman S, LaRosa A, Loe I, Mittal S, Vanderbilt D, Blum N. Preschool Attention-Deficit/Hyperactivity Disorder and Telephone Medication Management at Developmental-Behavioral Pediatric Network Sites. J Dev Behav Pediatr 2021; 42:481-484. [PMID: 33929397 DOI: 10.1097/dbp.0000000000000919] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 11/01/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To understand developmental-behavioral pediatricians' (DBPs') use of clinic versus telephone encounters for preschool attention-deficit/hyperactivity disorder (ADHD) medication management. Understanding use of telephone encounters for pharmacologic management of ADHD in preschoolers may inform care for children with ADHD. METHODS DBP investigators within Developmental Behavioral Pediatrics Research Network abstracted data from medical records of 503 children aged younger than 72 months treated for ADHD with medication by a DBP clinician between January 1, 2013, and July 1, 2017, across 7 sites. We abstracted data about medication treatment episodes (defined as start and end/change of a specific type, dose, and frequency of ADHD medication) and encounter type (clinic vs telephone). We present descriptive statistics related to encounter types and χ2 analyses to compare frequencies across reasons for the end of treatment episode and across sites. RESULTS The study included 503 participants with a total of 1734 treatment episodes. The initial medication was started via a clinic encounter 85.9% of the time and via telephone encounters 14.1% of the time. When evaluating reasons for end of treatment episode, decreases in dose/frequency of medication were less common for clinic versus telephone encounters (27% vs 73%; p < 0.001) and adding an additional medication was more common at clinic versus telephone encounters (64% vs 36% p < 0.001). Sites varied significantly in frequency of telephone encounters, ranging from 16.9% to 68.9% (mean 45.7%). CONCLUSION Telephone encounters were used for pharmacologic management of ADHD in preschoolers to varying degrees across 7 DBP sites. These findings suggest that telephone management serves an important role in ADHD care.
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Affiliation(s)
- Elizabeth Harstad
- Division of Developmental Medicine, Boston Children's Hospital, Boston, MA
| | | | - William Barbaresi
- Division of Developmental Medicine, Boston Children's Hospital, Boston, MA
| | - Ami Bax
- University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Jaclyn Cacia
- Children's Hospital of Philadelphia, Philadelphia, PA
| | - Alexis Deavenport-Saman
- Department of Pediatrics, Keck School of Medicine, University of Southern California Los Angeles, CA
- Division of General Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA
| | - Sandra Friedman
- University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
| | - Angela LaRosa
- Medical University of South Carolina, Charleston, SC
| | - Irene Loe
- Lucile Salter Packard Children's Hospital/Stanford University, Palo Alto, CA
| | | | - Douglas Vanderbilt
- Department of Pediatrics, Keck School of Medicine, University of Southern California Los Angeles, CA
- Division of General Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA
| | - Nathan Blum
- Children's Hospital of Philadelphia, Philadelphia, PA
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45
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Evans P, Shults J, Weinberg DD, Napolitano N, Ades A, Johnston L, Levit O, Brei B, Krick J, Sawyer T, Glass K, Wile M, Hollenberg J, Rumpel J, Moussa A, Verreault A, Abou Mehrem A, Howlett A, McKanna J, Nishisaki A, Foglia EE. Intubation Competence During Neonatal Fellowship Training. Pediatrics 2021; 148:peds.2020-036145. [PMID: 34172556 PMCID: PMC8290971 DOI: 10.1542/peds.2020-036145] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/12/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To characterize neonatal-perinatal medicine fellows' progression toward neonatal intubation procedural competence during fellowship training. METHODS Multi-center cohort study of neonatal intubation encounters performed by neonatal-perinatal medicine fellows between 2014 through 2018 at North American academic centers in the National Emergency Airway Registry for Neonates. Cumulative sum analysis was used to characterize progression of individual fellows' intubation competence, defined by an 80% overall success rate within 2 intubation attempts. We employed multivariable analysis to assess the independent impact of advancing quarter of fellowship training on intubation success. RESULTS There were 2297 intubation encounters performed by 92 fellows in 8 hospitals. Of these, 1766 (77%) were successful within 2 attempts. Of the 40 fellows assessed from the start of training, 18 (45%) achieved procedural competence, and 12 (30%) exceeded the deficiency threshold. Among fellows who achieved competence, the number of intubations to meet this threshold was variable, with an absolute range of 8 to 46 procedures. After adjusting for patient and practice characteristics, advancing quarter of training was independently associated with an increased odds of successful intubation (adjusted odds ratio: 1.10; 95% confidence interval 1.07-1.14). CONCLUSIONS The number of neonatal intubations required to achieve procedural competence is variable, and overall intubation competence rates are modest. Although repetition leads to skill acquisition for many trainees, some learners may require adjunctive educational strategies. An individualized approach to assess trainees' progression toward intubation competence is warranted.
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Affiliation(s)
- Peter Evans
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Justine Shults
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Danielle D. Weinberg
- Division of Neonatology, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Natalie Napolitano
- Respiratory Care, Nursing and Clinical Care Services, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Anne Ades
- Division of Neonatology, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Lindsay Johnston
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Orly Levit
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Brianna Brei
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington,Division of Neonatology, Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska
| | - Jeanne Krick
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington
| | - Taylor Sawyer
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington
| | - Kristen Glass
- Penn State Children’s Hospital and College of Medicine, Pennsylvania State University, Hershey, Pennsylvania
| | - Michelle Wile
- Penn State Children’s Hospital and College of Medicine, Pennsylvania State University, Hershey, Pennsylvania
| | - Janice Hollenberg
- Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Jennifer Rumpel
- Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | - Alexandra Verreault
- Research Centre, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
| | - Ayman Abou Mehrem
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta
| | - Alexandra Howlett
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta
| | - Julie McKanna
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elizabeth E. Foglia
- Division of Neonatology, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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46
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Brei BK, Sawyer T, Umoren R, Gray MM, Krick J, Foglia EE, Ades A, Glass K, Kim JH, Singh N, Jung P, Johnston L, Moussa A, Napolitano N, Barry J, Zenge J, Quek B, DeMeo SD, Shults J, Unrau J, Nadkarni V, Nishisaki A. Associations between family presence and neonatal intubation outcomes: a report from the National Emergency Airway Registry for Neonates: NEAR4NEOS. Arch Dis Child Fetal Neonatal Ed 2021; 106:392-397. [PMID: 33478956 PMCID: PMC8237190 DOI: 10.1136/archdischild-2020-319709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 11/21/2020] [Accepted: 12/02/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Describe the current practice of family presence during neonatal tracheal intubations (TIs) across neonatal intensive care units (NICUs) and examine the association with outcomes. DESIGN Retrospective analysis of TIs performed in NICUs participating in the National Emergency Airway Registry for Neonates (NEAR4NEOS). SETTING Thirteen academic NICUs. PATIENTS Infants undergoing TI between October 2014 and December 2017. MAIN OUTCOME MEASURES Association of family presence with TI processes and outcomes including first attempt success (primary outcome), success within two attempts, adverse TI-associated events (TIAEs) and severe oxygen desaturation ≥20% from baseline. RESULTS Of the 2570 TIs, 242 (9.4%) had family presence, which varied by site (median 3.6%, range 0%-33%; p<0.01). Family member was more often present for older infants and those with chronic respiratory failure. Fewer TIs were performed by residents when family was present (FP 10% vs no FP 18%, p=0.041). Among TIs with family presence versus without family presence, the first attempt success rate was 55% vs 49% (p=0.062), success within two attempts was 74% vs 66% (p=0.014), adverse TIAEs were 18% vs 20% (p=0.62) and severe oxygen desaturation was 49% vs 52%, (p=0.40). In multivariate analyses, there was no independent association between family presence and intubation success, adverse TIAEs or severe oxygen desaturation. CONCLUSION Family are present in less than 10% of TIs, with variation across NICUs. Even after controlling for important patient, provider and site factors, there were no significant associations between family presence and intubation success, adverse TIAEs or severe oxygen desaturation.
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Affiliation(s)
- Brianna K Brei
- Pediatrics, Division of Neonatology, University of Nebraska Medical Center, Omaha, Nebraska, USA .,Pediatrics, Division of Neonatology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Taylor Sawyer
- Pediatrics, Division of Neonatology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Rachel Umoren
- Pediatrics, Division of Neonatology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Megan M Gray
- Pediatrics, Division of Neonatology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Jeanne Krick
- Department of Pediatrics, Madigan Army Medical Center, Tacoma, Washington, USA
| | - Elizabeth E Foglia
- Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Anne Ades
- Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kristen Glass
- Department of Pediatrics, Division of Neonatology, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Jae H Kim
- Perinatal Institute, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA,Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Neetu Singh
- Neonatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Philipp Jung
- Pediatrics, Universitatsklinikum Schleswig-Holstein, Kiel, Schleswig-Holstein, Germany
| | - Lindsay Johnston
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut, USA
| | - Ahmed Moussa
- Pediatrics- Neonatology, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Québec, Canada
| | - Natalie Napolitano
- Nursing and Respiratory Care, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - James Barry
- Pediatrics, Section of Neonatology, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Jeanne Zenge
- Pediatrics, Section of Neonatology, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Binhuey Quek
- Department of Neonatology, KK Women's and Children's Hospital, Singapore
| | - Stephen D DeMeo
- Pediatrics, WakeMed Health and Hospitals, Raleigh, North Carolina, USA
| | - Justine Shults
- Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jennifer Unrau
- Pediatrics, Section of Neonatology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Vinay Nadkarni
- Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA,Center for Simulation, Advanced Education, and Innovation, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Akira Nishisaki
- Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA,Center for Simulation, Advanced Education, and Innovation, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Johnston L, Sawyer T, Ades A, Moussa A, Zenge J, Jung P, DeMeo S, Glass K, Singh N, Howlett A, Shults J, Barry J, Brei B, Foglia E, Nishisaki A. Impact of Physician Training Level on Neonatal Tracheal Intubation Success Rates and Adverse Events: A Report from National Emergency Airway Registry for Neonates (NEAR4NEOS). Neonatology 2021; 118:434-442. [PMID: 34111869 PMCID: PMC8376802 DOI: 10.1159/000516372] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/07/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Neonatal tracheal intubation (TI) outcomes have been assessed by role, but training level may impact TI success and safety. Effect of physician training level (PTL) on the first-attempt success, adverse TI-associated events (TIAEs), and oxygen desaturation was assessed. METHODS Prospective cohort study in 11 international NEAR4NEOS sites between October 2014 and December 2017. Primary TIs performed by pediatric/neonatal physicians were included. Univariable analysis evaluated association between PTL, patient/practice characteristics, and outcomes. Multivariable analysis with generalized estimating equation assessed for independent association between PTL and outcomes (first-attempt success, TIAEs, and oxygen desaturation ≥20%; attending as reference). RESULTS Of 2,608 primary TIs, 1,298 were first attempted by pediatric/neonatal physicians. PTL was associated with patient age, weight, comorbidities, TI indication, difficult airway history, premedication, and device. First-attempt success rate differed across PTL (resident 23%, fellow 53%, and attending 60%; p < 0.001). There was no statistically significant difference in TIAEs (resident 22%, fellow 20%, and attending 25%; p = 0.34). Desaturation occurred more frequently with residents (60%), compared to fellows and attendings (46 and 53%; p < 0.001). In multivariable analysis, adjusted odds ratio of the first-attempt success was 0.18 (95% CI: 0.11-0.30) for residents and 0.80 (95% CI: 0.51-1.24) for fellows. PTL was not independently associated with adjusted odds of TIAEs or severe oxygen desaturation. CONCLUSION Higher PTL was associated with increased first-attempt success but not TIAE/oxygen desaturation. Identifying strategies to decrease adverse events during neonatal TI remains critical.
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Affiliation(s)
- Lindsay Johnston
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | - Taylor Sawyer
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Anne Ades
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Ahmed Moussa
- Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, Canada
| | - Jeanne Zenge
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Philipp Jung
- Department of Pediatrics, University Hospital Schleswig Holstein, Luebeck, Germany
| | - Stephen DeMeo
- Department of Pediatrics, WakeMed Health and Hospitals, Raleigh, NC, USA
| | - Kristen Glass
- Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - Neetu Singh
- Department of Pediatrics, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | | | - Justine Shults
- Department of Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - James Barry
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Brianna Brei
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE, USA
| | - Elizabeth Foglia
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Akira Nishisaki
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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48
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Shirley M, Bittinger K, Li Y, Ford E, Friedman E, Gerber J, Elovitz M, Kelly A, DeRusso P, Albenberg L, Drigo D, Shults J, Walega R, Li H, Wu G, Zemel B. Dietary Patterns and Growth From 12 to 24 Months of Age in African American Infants. Curr Dev Nutr 2021. [DOI: 10.1093/cdn/nzab038_066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objectives
To identify dietary patterns in 12-month-old African American infants and investigate their association with change in infant BMI z-score (BMIz) from 12 to 24 months.
Methods
The prospective longitudinal Infant Growth and Microbiome Study (IGram) enrolled African American women in their 3rd trimester of pregnancy who had a pre-pregnancy BMI >30 or <25 and followed them and their infants from birth to 24 months of age. At 12 months, mothers reported infant intake of 32 food items in the past 7 days using the CDC Infant Feeding Practices Study II questionnaire. With these data we employed principal component analysis to derive dietary patterns for infants aged 12 months. We used multiple regression to test associations of dietary pattern scores with change in infant BMIz between 12 and 24 months.
Results
IGram enrolled 368 infants at birth; 320 and 283 infants completed 12- and 24-month visits, respectively. The prevalence of BMIz > 2SD was 7.8% at 12 months and 6% at 24 months. We derived three dietary patterns which together explained 36% of the variation in the dataset. Based on the highest factor loadings for each pattern, they were named “Transitional/table food,” “Formula/baby cereal,” and “Fruit and vegetable/breast milk.” The former pattern included pancakes, pasta, rice, french fries, meat, eggs, and snack and sweet foods. Regression results suggested that, accounting for maternal pre-pregnancy obesity status, the “Fruit and vegetable/breast milk” pattern explained a small portion of the variance in BMIz increase from 12 to 24 months of age (β = 0.07, 95% CI = 0.01, 0.13, P = 0.03).
Conclusions
Preliminary findings of three distinct dietary patterns in African American infants at 12 months of age are an important first step in characterizing infant feeding patterns across the rich, longitudinal IGram dataset. A positive association of the “Fruit and vegetable/breast milk” pattern with change in infant BMIz from 12 to 24 months was unexpected and requires further investigation.
Funding Sources
An unrestricted donation from the American Beverage Foundation for a Healthy America to support the Children's Hospital of Philadelphia's Healthy Weight Program; the Research Institute of the Children's Hospital of Philadelphia; the National Center for Advancing Translational Sciences; the NIH NIDDK.
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Affiliation(s)
| | | | - Yun Li
- University of Pennsylvania Perelman School of Medicine
| | | | | | | | | | | | | | | | | | | | | | - Hongzhe Li
- University of Pennsylvania Perelman School of Medicine
| | - Gary Wu
- University of Pennsylvania Perelman School of Medicine
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49
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Harstad E, Shults J, Barbaresi W, Bax A, Cacia J, Deavenport-Saman A, Friedman S, LaRosa A, Loe IM, Mittal S, Tulio S, Vanderbilt D, Blum NJ. α2-Adrenergic Agonists or Stimulants for Preschool-Age Children With Attention-Deficit/Hyperactivity Disorder. JAMA 2021; 325:2067-2075. [PMID: 33946100 PMCID: PMC8097628 DOI: 10.1001/jama.2021.6118] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Attention-deficit/hyperactivity disorder (ADHD) is diagnosed in approximately 2.4% of preschool-age children. Stimulants are recommended as first-line medication treatment. However, up to 25% of preschool-age children with ADHD are treated with α2-adrenergic agonist medications, despite minimal evidence about their efficacy or adverse effects in this age range. OBJECTIVE To determine the frequency of reported improvement in ADHD symptoms and adverse effects associated with α2-adrenergic agonists and stimulant medication for initial ADHD medication treatment in preschool-age children. DESIGN, SETTING, AND PARTICIPANTS Retrospective electronic health record review. Data were obtained from health records of children seen at 7 outpatient developmental-behavioral pediatric practices in the Developmental Behavioral Pediatrics Research Network in the US. Data were abstracted for 497 consecutive children who were younger than 72 months when treatment with an α2-adrenergic agonist or stimulant medication was initiated by a developmental-behavioral pediatrician for ADHD and were treated between January 1, 2013, and July 1, 2017. Follow-up was complete on February 27, 2019. EXPOSURES α2-Adrenergic agonist vs stimulant medication as initial ADHD medication treatment. MAIN OUTCOMES AND MEASURES Reported improvement in ADHD symptoms and adverse effects. RESULTS Data were abstracted from electronic health records of 497 preschool-age children with ADHD receiving α2-adrenergic agonists or stimulants. Median child age was 62 months at ADHD medication initiation, and 409 children (82%) were males. For initial ADHD medication treatment, α2-adrenergic agonists were prescribed to 175 children (35%; median length of α2-adrenergic agonist use, 136 days) and stimulants were prescribed to 322 children (65%; median length of stimulant use, 133 days). Improvement was reported in 66% (95% CI, 57.5%-73.9%) of children who initiated α2-adrenergic agonists and 78% (95% CI, 72.4%-83.4%) of children who initiated stimulants. Only daytime sleepiness was more common for those receiving α2-adrenergic agonists vs stimulants (38% vs 3%); several adverse effects were reported more commonly for those receiving stimulants vs α2-adrenergic agonists, including moodiness/irritability (50% vs 29%), appetite suppression (38% vs 7%), and difficulty sleeping (21% vs 11%). CONCLUSIONS AND RELEVANCE In this retrospective review of health records of preschool-age children with ADHD treated in developmental-behavioral pediatric practices, improvement was noted in the majority of children who received α2-adrenergic agonists or stimulants, with differing adverse effect profiles between medication classes. Further research, including from randomized clinical trials, is needed to assess comparative effectiveness of α2-adrenergic agonists vs stimulants.
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Affiliation(s)
- Elizabeth Harstad
- Division of Developmental Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Justine Shults
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine at University of Pennsylvania
| | - William Barbaresi
- Division of Developmental Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Ami Bax
- University of Oklahoma Health Sciences Center, Oklahoma City
| | - Jaclyn Cacia
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alexis Deavenport-Saman
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles
- Division of General Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| | - Sandra Friedman
- University of Colorado School of Medicine, Children's Hospital Colorado, Aurora
| | | | | | | | - Shelby Tulio
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Douglas Vanderbilt
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles
| | - Nathan J. Blum
- Perelman School of Medicine at University of Pennsylvania
- Division of Developmental and Behavioral Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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50
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Gavazzi F, Charsar BA, Williams C, Shults J, Alves CA, Adang L, Vanderver A. Acquisition of Developmental Milestones in Hypomyelination With Atrophy of the Basal Ganglia and Cerebellum and Other TUBB4A-Related Leukoencephalopathy. J Child Neurol 2021. [PMID: 33843299 DOI: 10.1177/0883073821000977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Mutations in TUBB4A are associated with a spectrum of neurologic disorders categorized as TUBB4A-related leukoencephalopathy. Affected children can present with global developmental delay or normal early development, followed by a variable loss of skills over time. Further research is needed to characterize the factors associated with the divergent developmental trajectories in this rare monogenic disorder because this phenotypic spectrum is not fully explained by genotype alone.To characterize early psychomotor features, developmental milestones and age of disease onset were collected from medical records (n=54 individuals). Three subcohorts were identified: individuals with the common p.Asp249Asn variant vs all other genotypes with either early (<12 months of age) or late onset of presentation. Individuals with the p.Asp249Asn variant or those with non-p.Asp249Asn genotypes with later disease onset attained key milestones, including head control, sitting, and independent walking. Subjects with early-onset, non-p.Asp249Asn-associated disease were less likely to achieve developmental milestones. Next, we defined the developmental severity as the percentage of milestones attained by age 2 years. The mild form was defined as attaining at least 75% of key developmental milestones. Among cohort categorized as mild, individuals with p.Asp249Asn variant were more likely to lose acquired abilities when compared with non-p.Asp249Asn individuals.Our results suggest multiple influences on developmental trajectory, including a strong contribution from genotype and age of onset. Further studies are needed to identify additional factors that influence overall outcomes to better counsel families and to design clinical trials with appropriate clinical endpoints.
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Affiliation(s)
- Francesco Gavazzi
- Division of Neurology, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Brittany A Charsar
- Sidney Kimmel Medical College, 23217Jefferson University, Philadelphia, PA, USA
| | - Catherine Williams
- Division of Neurology, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Justine Shults
- Department of Pediatrics, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Cesar A Alves
- Division of Neuroradiology, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Laura Adang
- Division of Neurology, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Adeline Vanderver
- Division of Neurology, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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