National Characteristics of Emergency Care for Children with Neurologic Complex Chronic Conditions

Introduction

Most pediatric emergency care occurs in general emergency departments (GED), where less pediatric experience and lower pediatric emergency readiness may compromise care. Medically vulnerable pediatric patients, such as those with chronic, severe, neurologic conditions, are likely to be disproportionately affected by suboptimal care in GEDs; however, little is known about characteristics of their care in either the general or pediatric emergency setting. In this study our objective was to compare the frequency, characteristics, and outcomes of ED visits made by children with chronic neurologic diseases between general and pediatric EDs (PED).

Methods

We conducted a retrospective analysis of the 2011-2014 Nationwide Emergency Department Sample (NEDS) for ED visits made by patients 0-21 years with neurologic complex chronic conditions (neuro CCC). We compared patient, hospital, and ED visits characteristics between GEDs and PEDs using descriptive statistics. We assessed outcomes of admission, transfer, critical procedure performance, and mortality using multivariable logistic regression.

Results

There were 387,813 neuro CCC ED visits (0.3% of 0-21-year-old ED visits) in our sample. Care occurred predominantly in GEDs, and visits were associated with a high severity of illness (30.1% highest severity classification score). Compared to GED visits, PED neuro CCC visits were comprised of individuals who were younger, more likely to have comorbid conditions (32.9% vs 21%, P < 0.001), and technology assistance (65.4% vs. 45.9%) but underwent fewer procedures and had lower ED charges ($2,200 vs $1,520, P < 0.001). Visits to PEDs had lower adjusted odds of critical procedures (adjusted odds ratio [aOR] 0.74, 95% confidence interval [CI] 0.62-0.87), transfers (aOR 0.14, 95% CI 0.04-0.56), and mortality (aOR 0.38, 95% CI 0.19-0.75) compared to GEDs.

Conclusion

Care for children with neuro CCCs in a pediatric ED is associated with less resource utilization and lower rates of transfer and mortality. Identifying features of PED care for neuro CCCs could lead to lower costs and mortality for this population.

The social drivers of health for Native Hawaiian and Pacific Islander youth in the United States

Objectives

To describe the social drivers of health and health status of Native Hawaiian and Pacific Islander (NHPI) youth in the US.

Methods

This is a cross-sectional analysis of the 2014 NHPI National Health Interview Survey (NHIS) which surveyed about 3,000 NHPI households, including 1,428 NHPI youth (884 0-12 yo, 421 13-17 yo, and 123 18-21 yo). We described domains of social drivers of health (SDoH), health conditions, and associations of income and food insecurity with body mass index (BMI) for NHPI youth.

Results

NHPI youth come from households with a wide range in income. Approximately 20% of the cohort were food insecure. Among 18-21 yo, 10% report chronic medical conditions (5% with prediabetes). 33% of 13-17 yo and 52% of 18-21 yo were overweight/ obese. For 13-17 yo, lower income was associated with higher BMI. There was no association between food insecurity and BMI for any age group.

Conclusions

Overweight/ obesity are highly prevalent among NHPI youth which is concerning for development of diabetes, hypertension, cardiovascular and kidney disease. Health efforts should focus on SDoH, obesity prevention and management for NHPI youth.

Serum Hormone Concentrations in Transgender Youth Receiving Estradiol

OBJECTIVE

This study aimed to evaluate the serum estradiol levels in gender-diverse youth to compare the efficacy of different estradiol routes in achieving therapeutic blood levels and suppressing serum testosterone levels.

METHODS

This was a retrospective chart review of patients who initiated estradiol at an adolescent gender clinic between 2010 and 2019. Data on the route of estradiol administration and antiandrogen use (spironolactone or gonadotropin-releasing hormone agonist) were collected, and laboratory data were analyzed. Scatterplots were used to visualize the relationship between the estradiol dose and testosterone and estradiol laboratory values.

RESULTS

A total of 118 patients were included, with a mean (standard deviation [SD]) age of 17.2 (1.6) years. The most common route of estradiol administration was oral only (62.7%), followed by transdermal only (23.7%), multiple routes excluding subcutaneous (8.5%), and any subcutaneous (5.1%). Notable variability was observed in the serum estradiol levels, with means (SDs) of 131.9 (120.4) pg/mL for those on oral estrogen 6 to 8 mg per day, 62.6 (40.3) pg/mL for those on transdermal estrogen 0.1 to 0.15 mg every 24 hours, and 53.6 (42.4) pg/mL for those on subcutaneous estradiol. In patients who received spironolactone, transdermal estradiol was associated with lower testosterone levels than estradiol administered orally or subcutaneously.

CONCLUSION

Oral, transdermal, and subcutaneous administrations of estrogen all lead to increased serum estradiol levels and are effective for use in gender-affirming care for youth. Patients on transdermal estrogen tended to have lower serum estradiol levels but also had more suppression of serum testosterone levels.

Solving the Autism Puzzle: Creating a Broad-Spectrum Tool to Improve Care Delivery in the Clinical Setting

PURPOSE

The purpose of this quality improvement (QI) project was to develop and implement an assessment tool to identify a patient's specific needs due to autism spectrum disorder (ASD). The use of an individualized plan of care related to sensory and behavioral differences correlates with improved experiences in the perioperative setting for patients with ASD.

DESIGN

Mixed methods, pre-post survey, retrospective data comparison.

METHODS

Metrics planned to evaluate intervention outcomes included: (1) Comparison of pre and postsurvey data obtained from perioperative staff members following ASD education, (2) Evaluation of the number of behavior response team calls made compared to retrospective data, and (3) Survey response data from families assessing the perceived experience of perioperative stay.

FINDINGS

Two hundred and fifty staff members responded to the learning needs survey; 164 in the preperiod and 86 in the postperiod. The perioperative process for these patients improved from the pre- to the postperiod in its ability to meet the needs of patients with autism (P < .001). Overall, respondents rated the sensory aids and the behavioral and sensory assessment tool as very useful (Median = 5, IQR = 2) and stated that they are likely to continue to use the tools in the future when caring for patients with autism (Median = 5, IQR = 1).

CONCLUSIONS

The caregivers of study patients felt they had a high level of satisfaction with their surgery or procedure experience. Health care providers also reported increased confidence working with individuals with ASD in the perioperative environment and satisfaction with the intervention program.

Low Pretreatment Bone Mineral Density in Gender Diverse Youth

Gender diverse adolescents have low pretreatment bone mineral density (BMD), with variable changes in BMD after initiation of gender-affirming treatment. We aimed to assess factors associated with low BMD in gender diverse youth. Sixty-four patients were included in our analysis (73% assigned male at birth). Subtotal whole-body BMD Z-scores were low in 30% of patients, and total lumbar spine BMD Z-scores low in 14%. There was a positive association with body mass index, and no association with vitamin D level. Male sex assigned at birth was associated with lower pretreatment BMD, with lower average BMD Z-scores compared to previous studies.

Improving and Sustaining Interpreter Use Over 5 Years in a Pediatric Emergency Department

BACKGROUND

Patients with a language for care other than English (LOE) face communication barriers and inequitable outcomes in health care. Professional interpretation can improve outcomes but is underutilized. Our pediatric emergency department (ED) implemented quality improvement (QI) interventions over a 5-year period with an aim to increase interpreter use to 80% of patient encounters with LOE.

METHODS

Overall interpreter use for ED encounters was measured over time, with a baseline period of October 2015 to December 2016 and during 5 years of QI interventions from January 2017 to August 2021. Interventions included staff education, data feedback, reducing barriers to interpreter use, and improving identification of language for care with plan-do-study-act cycles. Outcomes were analyzed by using statistical process control charts and standard rules for special cause variation.

RESULTS

We analyzed a total of 277 309 ED encounters during the study period, 12.2% with LOE. The overall use of interpretation increased from a baseline of 53% to 82% of encounters. Interpretation throughout the ED visit and the number of interpreted interactions per hour also increased. There was improvement across language types, patient age groups, acuity levels, and during different times of day. Special cause variation was associated with multiple QI interventions.

CONCLUSION

We reached our primary aim of providing professional interpretation for 80% of patient encounters with LOE. There were several QI interventions associated with improvements, including staff education, data feedback, improved access to interpretation, and improved identification and visualization of language for care. Efforts to improve interpreter use may benefit from a similar multifaceted approach.

Association between iron deficit repletion with ferric carboxymaltose relative to iron sucrose in children with inflammatory bowel disease: a retrospective cohort study

BACKGROUND

Iron deficiency and iron deficiency anemia are common in pediatric inflammatory bowel disease and often require supplementation with iron. There is a paucity of literature regarding optimal iron formulation. The aim of this study is to compare outcomes in pediatric patients with inflammatory bowel disease receiving either iron sucrose or ferric carboxymaltose during inpatient hospitalizations.

METHODS

This was a single-center retrospective study of pediatric patients with inflammatory bowel disease admitted for newly diagnosed disease or flare who received either iron sucrose or ferric carboxymaltose. Linear regression was used to assess differences in iron repletion. Longitudinal linear mixed-effects models and generalized estimating equations compared hematologic and iron outcomes six months post iron repletion.

RESULTS

Thirty patients received ferric carboxymaltose. Sixty-nine patients received iron sucrose. Baseline hemoglobin and iron deficits were similar in both groups. A larger percentage of iron deficit was repleted in the ferric carboxymaltose group (81.4%) compared to iron sucrose (25.9%) (p<0.001) with fewer infusions. Cumulative doses of ferric carboxymaltose administered (18.7 mg/kg) were higher than iron sucrose (6.1 mg/kg) (p<0.001). Hemoglobin increased more quickly with ferric carboxymaltose compared to iron sucrose (p=0.04 and p=0.02, respectively). Total iron binding capacity and red cell distribution width levels decreased more over time with ferric carboxymaltose versus iron sucrose (p<0.01 and p=0.01, respectively). No adverse effects were seen.

CONCLUSIONS

Hematologic and iron parameters responded more quickly with fewer infusions in patients who received ferric carboxymaltose versus iron sucrose. Patients who received ferric carboxymaltose achieved a higher percentage of iron deficit repleted. This article is protected by copyright. All rights reserved.

COVID-19 Pandemic Emergency Department Utilization for Pediatric Dental

PURPOSE

Early in the COVID-19 pandemic, restrictions from mid-March to mid-May 2020 curtailed community dental practice. The study purpose was to analyze the utilization of a pediatric hospital emergency department (ED) for dental emergencies over six months of practice disruption compared to two previous years.

METHODS

Records of patients presenting to the ED were analyzed for volume, demographics, dental emergency type/acuity, and treatment. Study patients presented between March and September 2020; controls presented between March and September 2018 and March and September 2019.

RESULTS

A total of 138 study patients (mean age equals 6.4 years) and 171 controls (mean age equals 7.0 years) were assessed. Emergency types were trauma (68 percent), caries (25 percent), and "other" (seven percent) for both periods (P=0.997). Nearly all patients triaged as "urgent." Medical radiology (P<0.001), laboratory tests (P<0.001), medication administration (P=0.016), ketamine sedation (P=0.014), and procedures by the medical team (P=0.014) increased for trauma patients in the study versus control period. Significantly more study patients with caries identified as persons of color: 69.7 percent versus 36.8 percent of controls (P=0.006).

CONCLUSIONS

The emergency department medical and dental teams served as a safety net for both public health and the private practice dental community during the early pandemic. The effect on tertiary medical facilities should be considered when closing venues for the management of routine emergencies; it is more time-efficient and cost-effective and less resource-intensive to manage patients with dental emergencies in dental clinics.

Effect of Race and Geography on Patient- and Parent-Reported Quality of Life for Children With Congenital Upper Limb Differences

PURPOSE

Patient beliefs about health and disability are shaped by many social factors and are a key determinant in their ultimate outcome. We hypothesized that pediatric and parent-reported outcome measures regarding a child's congenital upper limb difference will be affected by geographic location, parent education, sex, ethnicity, race, age, and presence of additional medical comorbidities.

METHODS

Patients enrolled in the multicenter Congenital Upper Limb Difference registry were included. Age, sex, race, ethnicity, medical comorbidities, highest level of parental education, area deprivation index, and geographic region were recorded. Patient-Reported Outcomes Measurement Information System (PROMIS) in the pediatric and parent-reported domains of upper extremity, anxiety, pain interference, peer relationships, and depressive symptoms were collected.

RESULTS

The only difference between geographic regions in the United States in pediatric and parent-reported PROMIS was that parents in the Midwest reported higher upper extremity function scores in children with upper limb differences than the West. Black patients demonstrated higher scores in parent and child-reported domains of depression, pain, and anxiety, and lower scores in upper extremity function than White and Asian peers. Additionally, children with medical comorbidities also demonstrated worse outcomes in multiple PROMIS domains. There was no difference in scores based on sex, parent education, and ethnicity.

CONCLUSIONS

In children with congenital upper limb differences, race and additional medical comorbidities have an impact on patient- and parent-reported PROMIS outcome measures in multiple domains, with Black children and those with additional medical comorbidities scoring lower than their peers.

CLINICAL RELEVANCE

As we strive to develop a health care system that provides equitable care to all patients, providers who care for children with upper limb differences should be aware that race and additional medical comorbidities can negatively affect patient- and parent-reported PROMIS outcome measures.

Cardiovascular Risk Factors and Target Organ Damage in Adolescents: The SHIP AHOY Study

BACKGROUND

Development of cardiovascular disease in adults has been directly linked to an adverse metabolic phenotype. While there is evidence that development of these risk factors in childhood persists into adulthood and the development of cardiovascular disease, less is known about whether these risk factors are associated with target organ damage during adolescence.

METHODS

We collected data from 379 adolescents (mean age 15.5, 60% male) with blood pressure between the 75th and 95th percentile to determine if there is a metabolic phenotype that predicts cardiovascular changes (left ventricular mass, systolic and diastolic function, pulse wave velocity, and renal function). We determined the number of risk factors for cardiovascular disease (hypertension, dyslipidemia, obesity, and insulin resistance) present in each participant. Generalized linear models were constructed to determine if the number of cardiovascular risk factors (CVRFs) were associated with measures of target organ damage.

RESULTS

The number of CVRFs present were associated with statistically significant differences in increased left ventricular mass index, increased pulse wave velocity, decreased peak longitudinal strain, urine albumin to creatine ratio and echocardiographic parameters of diastolic dysfunction. Generalized linear models showed that dyslipidemia and insulin resistance were independently associated with markers of diastolic dysfunction (P ≤ .05) while increased blood pressure was associated with all makers of target organ damage (P ≤ .03).

CONCLUSIONS

These data suggest the of the number of CVRFs present is independently associated with early changes in markers of target organ damage during adolescence.

Analysis of Transition from Intravenous Iron Sucrose to Ferric Carboxymaltose Infusions in Pediatric Intestinal Failure Patients

BACKGROUND

Iron supplementation is required for pediatric patients with intestinal failure (IF). There is a paucity of literature on optimal iron formulation and outcomes in this patient population that requires ongoing supplementation. The aim of this study was to assess outcomes in pediatric patients with IF receiving iron sucrose (IS) versus ferric carboxymaltose (FCM) iron infusions.

METHODS

This was a single-center observational cohort study of pediatric patients with IF requiring ongoing intravenous iron supplementation. Patients were transitioned from IS to FCM as iron therapy. Longitudinal linear mixed-effects models and generalized estimating equations were used to compare outcomes including hematologic, iron, and growth parameters for 12 months treatment duration on each iron formulation. Adverse effects were descriptively summarized.

RESULTS

Twenty-three patients were included. Sixteen received IS and later switched to FCM, 5 received IS only, and 2 received FCM only. Most patients' etiology of IF was short bowel syndrome (FCM: 81%, IS: 83%). No differences were seen over time for iron, hematologic, and growth metrics between IS and FCM. The median number of infusions over 12 months for those taking IS was 15 (IQR = 13 - 26) and 2 for FCM (IQR = 1 - 2). Asymptomatic hypophosphatemia was noted in both groups. Similar central line associated blood steam infection rates were noted.

CONCLUSIONS

IS and FCM infusions both maintained hematologic and iron parameters with no significant difference noted between the two types of iron though the number of FCM infusions was significantly less. No significant adverse effects were noted.

CLINICAL RELEVANCY STATEMENT

Pediatric patients with intestinal failure dependent on parenteral nutrition require ongoing iron supplementation. Though there are a variety of iron formulations available, there is a paucity of literature on how iron should be administered in this patient population. Practice varies widely among different institutions. In this study, pediatric patients with intestinal failure were transitioned from iron sucrose to ferric carboxymaltose infusions, and laboratory and clinical outcomes were compared. We found that patients had comparable hematologic and iron parameters with significantly fewer infusions needed in the ferric carboxymaltose group. No significant adverse effects were noted in either group. This article is protected by copyright. All rights reserved.

Association of parent demographic and psychophysical characteristics and pediatric hospital falls: A pilot and feasibility study

PURPOSE

This pilot project evaluated the feasibility of conducting a study describing parental characteristics associated with pediatric hospital falls.

DESIGN AND METHODS

This observational case-control study enrolled parent-child dyads of children who fell in the hospital and age-matched controls. Parents completed demographic, anxiety, depression, fatigue, sleep disturbance and stress questionnaires.

RESULTS

Four of 14 (28.6%) eligible faller dyads were recruited. Stress scores were correlated with anxiety and depression scores. Power calculations indicated a need for 392 fallers for a future study to identify associations of parent characteristics and pediatric hospital falls.

CONCLUSIONS

Parents should be informed the ultimate goal of the research is to understand additional ways to prevent pediatric hospital falls. To decrease parental distraction during recruitment, researchers should engage volunteers or child life specialists to entertain younger children. Future studies should consider inclusion of non-English speaking subjects and children discharged within the post-fall eligibility time frame. To decrease multicollinearity concerns, the parent stress tool should be omitted. Due to the large number of fallers needed for an adequately powered sample, a multi-site study will be needed.

PRACTICE IMPLICATIONS

A parent is often present when their child falls in the hospital. Fall risk assessment focuses on patient characteristics, neglecting parental psychophysical characteristics which may be associated with risk of falling in the hospital. Associations of parent psychophysical characteristics and pediatric hospital falls needs to be studied further. This pilot study supports the feasibility of and provides recommendations for conducting a study to describe parent characteristics associated with pediatric hospital falls.

Changes in Rates and Modality of Interpreter Use for Pediatric Emergency Department Patients in the COVID-19 Era

Background

As the COVID-19 pandemic continues, health care systems around the world have changed care delivery in significant ways. Racial and ethnic disparities have emerged for COVID-19 infection rates, morbidity, and mortality. Inequities in care and underutilization of interpretation for patients who use a language other than English (LOE) for care existed prior to this era. This study sought to evaluate interpreter use in a pediatric emergency department (ED) as changes associated with COVID-19 were implemented.

Methods

ED records were reviewed from December 1, 2019, to July 31, 2020. Patients were classified as having LOE if they preferred a language other than English and consented to interpretation. Statistical process control was used to analyze changes in interpreter use over time, relative to the onset of COVID-19–related operational changes. Beginning March 1, 2020, in-person interpreters were no longer available and staff were encouraged to communicate from outside the patient room when possible; this change served as the exposure of interest. Interpreter use for LOE patients, overall and by triage acuity level, was the study outcome.

Results

A total of 26,787 encounters were included. The weekly mean proportion of encounters that used interpretation for patients with LOE increased from 59% to 73% after the onset of COVID-19. This increase met criteria for special cause variation. Interpretation modality changed to being mostly by phone from previously by video or in-person.

Conclusion

Operational changes in the ED related to COVID-19 were associated with increased interpreter use. Possible explanations include lower patient volumes or changes in model of care that encouraged interpreter use by a variety of modalities.

Transplacental Respiratory Syncytial Virus and Influenza Virus Antibody Transfer in Alaska Native and Seattle Mother-Infant Pairs

BACKGROUND

Alaska Native (AN) infants are at risk for severe disease due to respiratory syncytial virus (RSV) and influenza. Maternal immunization protects young infants through transplacental antibody transfer. RSV- and influenza-specific transplacental antibody transfer in mother-infant pairs has not previously been evaluated in the AN population.

METHODS

Serum samples collected during pregnancy and at birth from AN mother-infant pairs in the Yukon-Kuskokwim Delta region (YKD) of Alaska (2000-2011; n = 75) and predominantly white pairs in Seattle, Washington (2014-2016; n = 57), were tested for RSV and influenza antibody using a microneutralization and hemagglutination inhibition assay, respectively, and compared between sites.

RESULTS

Mean RSV antibody concentrations in pregnant women in YKD and Seattle were similar (log2 RSV antibody 10.6 vs 10.7, P = .86), but cord blood RSV antibody concentrations were significantly lower in infants born to mothers in YKD compared with Seattle (log2 RSV antibody 11.0 vs 12.2, P < .001). Maternal and cord blood influenza antibody concentrations were lower for women and infants in YKD compared with Seattle for all 4 influenza antigens tested (all P < .05). The mean cord to maternal RSV antibody transfer ratio was 1.15 (standard deviation [SD], 0.13) in mother-infant pairs in Seattle compared with 1.04 (SD, 0.08) in YKD. Mean cord blood to maternal antibody transfer ratios for influenza antigens ranged from 1.22 to 1.42 in Seattle and from 1.05 to 1.59 in YKD.

CONCLUSIONS

Though the transplacental antibody transfer ratio was high (>1.0) for both groups, transfer ratios for RSV antibody were significantly lower in AN mother-infant pairs. Further studies are needed to elucidate the impact of lower transplacental antibody transfer on infant disease risk in rural Alaska.Alaska Native and continental US mother-infant pairs have high transplacental antibody transfer ratios (>1.0) for influenza and respiratory syncytial virus, but anti-respiratory syncytial virus antibody levels are significantly lower in Alaska Native pairs than in those from the continental US.

Risk Factors and Inadequacy of Screening for Sleep-Disordered Breathing in Children with Marfan Syndrome

The prevalence of obstructive sleep apnea (OSA) is increased in children and adults with Marfan syndrome (MFS) compared to the general population and has been shown to be associated with rapid aortic root dilation and dissection in adults. Early diagnosis and treatment of OSA may decrease long-term cardiac morbidity. We therefore studied the utility of noninvasive OSA screening tools in children with MFS. We hypothesized that youth with MFS would have higher OSA screening scores than the general pediatric population. Subjects with confirmed MFS were recruited from a single pediatric center. Data collected included cardiac history, retrospective polysomnogram (PSG) data, and prospectively collected Pediatric Sleep Questionnaire (SRBD-PSQ) and Epworth Sleepiness Scale (ESS-CHAD) scores. Fifty-one individuals aged 2-21 years old were identified. Nineteen subjects completed the surveys, 53% female, median age 16 years. Of those that completed the survey, mean SRBD-PSQ score was 0.24 ± 0.21 and mean ESS-CHAD was 6.4 ± 3.7. Comparatively, published normative data for pediatric control subjects were 0.24 ± 0.21 for SRBD-PSQ and 5.4 ± 3.7 for ESS-CHAD. In conclusions, youth with MFS had similar OSA screening scores compared to published pediatric controls. Given these findings and high prevalence of OSA in MFS youth, standard questionnaires may not be an appropriate tool for identifying children at risk for OSA in this population. In the absence of evidence-based guidelines, physicians caring for children with MFS should consider referral for PSG, even in the absence of classic symptoms.

Comparison of longitudinal and radial characteristics of intra-anal pressures using 3D high-definition anorectal manometry between children with anoretal malformations and functional constipation

BACKGROUND

Pathophysiology of fecal incontinence (FI) in children with anorectal malformations (AM) is not well understood. Standard or high-resolution anorectal manometry (ARM) does not identify radial asymmetry or localize abnormal sphincter function. 3D high-definition anorectal manometry (HDARM) provides detailed topographic and 3D pressure gradient representation of anal canal.

AIMS

To compare intra-anal pressure profiles between children with AM and controls using HDARM and to determine the association between manometric properties and reported predictors of fecal continence (AM type, spinal anomaly, and sacral integrity).

METHODS

HDARM tracings of 30 children with AM and FI referred for ARM were compared with 30 age and sex-matched children with constipation. 2D pressure profiles were used to measure length of high-pressure zone (HPZ). Longitudinal and radial measurements of sphincter pressure at rest and squeeze were taken along each segment in 3D topographic views and compared between groups.

KEY RESULTS

3D measurements demonstrated longitudinal and radial differences between groups along all quadrants of HPZ. At rest, intra-anal pressures were lower along the four segments longitudinally across the anal canal and radially along the quadrants in AM group (P < .01). At squeeze, all quadrant pressures were lower in segments 1-4 in AM group (P < .01). Sensation was abnormal in AM group (P < .01). Intra-anal pressures longitudinally and radially were not associated with predictors of fecal continence.

CONCLUSIONS AND INFERENCES

Children with AM had abnormal sensation and lower pressures longitudinally and radially along all quadrants of anal canal. Manometric properties at rest were not associated with reported predictors of fecal continence.

Decreased Incidence of Hepatic Artery Thrombosis in Pediatric Liver Transplantation Using Technical Variant Grafts: Report of the Society of Pediatric Liver Transplantation Experience

OBJECTIVE

To evaluate risk factors for hepatic artery thrombosis (HAT) and examine the long-term outcomes of graft and patient survival after HAT in pediatric recipients of liver transplantation.

STUDY DESIGN

Using multicenter data from the Society of Pediatric Liver Transplantation, Kaplan-Meier and Cox regression analyses were performed on first-time pediatric (aged <18 years) liver transplant recipients (n = 3801) in the US and Canada between 1995 and 2016.

RESULTS

Of children undergoing their first liver transplantation, 7.4% developed HAT within the first 90 days of transplantation and, of those who were retransplanted, 20.7% developed recurrent HAT. Prolonged warm ischemia times increased the odds of developing HAT (OR, 1.11; P = .02). Adolescents aged 11-17 years (OR, 0.53; P = .03) and recipients with split, reduced, or living donor grafts had decreased odds of HAT (OR, 0.59; P < .001 compared with whole grafts). Fifty percent of children who developed HAT developed graft failure within the first 90 days of transplantation (adjusted hazard ratio, 11.87; 95% CI, 9.02-15.62) and had a significantly higher post-transplant mortality within the first 90 days after transplantation (adjusted hazard ratio, 6.18; 95% CI, 4.01-9.53).

CONCLUSIONS

These data from an international registry demonstrate poorer long-term graft and patient survival in pediatric recipients whose post-transplant course is complicated by HAT. Notably, recipients of technical variant grafts had lower odds of HAT compared with whole liver grafts.

Effects of polysubstance exposure on neonatal outcomes for infants with intrauterine opioid exposure

OBJECTIVE

Quantify the effect of prenatal polysubstance exposure on neonatal outcomes compared to methadone exposure alone.

STUDY DESIGN

This retrospective cohort study compared infants with methadone-only exposure to methadone with additional psychoactive substances. Outcomes included time to maximum Finnegan scores, proportion requiring scheduled morphine, and length of stay (LOS).

RESULTS

We identified 323 subjects. The median time to maximum Finnegan score was 38.0 h with 94% peaking within 96 h. Forty-five percent of methadone-only infants were started on scheduled morphine compared to 54% of polysubstance infants (p = 0.10). LOS for polysubstance-exposed infants was 1.30 times longer than infants with methadone-only exposure (95% confidence interval: 1.05, 1.60).

CONCLUSIONS

Exposure to methadone with additional psychoactive substances is associated with longer LOS, but not postnatal morphine use or peak withdrawal symptoms. Most infants experience peak withdrawal symptoms within 4 days and may not benefit from longer observation.

Abstract MP16: Metabolic Predictors Of Target Organ Damage In Adolescents: The SHIP AHOY Study

The development of cardiovascular disease in adults has been directly linked to a metabolic phenotype that includes hypertension, obesity and dyslipidemia. While there is evidence that the development of these risk factors in childhood is linked with persistence into adulthood and eventual development of cardiovascular disease, less is known about whether these risk factors contribute to target organ damage during childhood. We collected data from 379 otherwise healthy adolescents (mean age 15.5 +/- 1.8, 60% male, 37% Non-White) across the blood pressure spectrum to determine if there is a metabolic phenotype that predicts target organ damage in adolescents. A cardiovascular risk score was calculated (1 point each for: LDL >155 or HDL <40 or TG >150; BMI > 95%; fasting glucose >100; HOMA-IR > 2.5). Generalized linear models were constructed to determine if the cardiovascular risk score was independently associated with measures of target organ damage. Cardiovascular risk score was significantly associated increased left ventricular mass index (β = 1.64, R 2 0.19) , increased pulse wave velocity (β = 0.05, R 2 0.21) and several echocardiographic parameters of diastolic dysfunction (e’/a’: β = -0.07 R 2 0.27; E/A: β = -0.04, R 2 0.11; E/e’: β =0.03, R 2 0.13) after correction for age, sex, race, HR, creatinine, uric acid and log CRP (all models P<0.0009). We found no association with peak longitudinal strain or microalbuminuria. Our study suggests that presence of cardiovascular risk factors in adolescence predicts target organ damage at a young age and could potentially be modified to prevent progression of disease.

Abstract P174: Value Of Six Minute Walk Test In The Evaluation Of Children With Elevated Blood Pressures

Lifestyle modifications, a mainstay of hypertension (HTN) therapy, include recommendations for regular physical activity. However, fitness is not typically assessed. In the HTN clinic at Seattle Children’s, we conduct the 6-minute walk test (6MWT) in children > 6 yrs referred for HTN. We sought to assess whether children referred for HTN underperform on the 6MWT.

Methods: We performed a retrospective chart review of patients seen from 9/1/18 - 9/30/19 who completed an ambulatory blood pressure monitor (ABPM) and 6MWT. Chart review included ABPM results, age, sex, BMI z-score, self-reported physical activity (RepPA) levels, rating of perceived exertion (RPE) and comorbid conditions. Exclusion criteria included lack of ABPM, 6MWT or compromised exercise capacity. ABPM was classified according to the 2014 AHA guidelines and 6MWT was compared to normative datasets. Fisher’s Exact test was used to compare the distributions of distance from mean values for the 6MWT and ANOVA was used to compare mean BMI z-score and RPE among groups. Linear regression assessed 6MWT with HTN status, adjusted for age, sex, and BMI z-score.

Results: Demographics and clinical measures are summarized in Table 1. RepPA, 6MWT and RPE did not differ significantly. Most children underachieved regardless of group; the distance walked was > 2 SD below mean in 31 of 52 (60%). BMI z-score was significantly higher in the abnormal ABPM group. Linear regression showed no effect of HTN status.

Conclusion: Most children underperformed on the 6MWT and results did not differ based on HTN status. This study suggests the 6MWT is useful to assess fitness in this population and serves as baseline for comparison.

Blood Pressure Measurement Error in Children: Lessons in Measurement Reliability

BACKGROUND AND PURPOSE

Blood pressure measurement represents the pressure exerted during heart ejection and filling. There are several ways to measure blood pressure and a valid measure is essential. The purpose of this study was to evaluate the approach to noninvasive blood pressure measurement in children.

METHODS

Blood pressure measurements were taken using the automatic Phillips MP30 monitor and compared against Welch Allyn blood pressure cuffs with Medline manual sphygmomanometers.

RESULTS

A total of 492 measurements were taken on 82 subjects, and they demonstrated comparability between automatic and manual devices.

CONCLUSIONS

Although our study indicated acceptable agreement between automatic and manual blood pressure measurement, it also revealed measurement error remains a concern, with sample size, study protocol, training, and environment all playing a role.

Hypoglycaemia avoidance behaviour and exercise levels in active youth with type 1 diabetes

AIMS

The primary goal of this exploratory study was to examine the association between fear of hypoglycaemia (FOH), hypoglycaemia avoidance behaviours and exercise in active youth with type 1 diabetes (T1D).

METHODS

30 youth with T1D who participate in some physical activity (PA), age 15.0 ± 2.4 years, on insulin pump therapy completed the 'Type 1 Diabetes Report of Exercise Practices Survey (T1D-REPS)' and parent and child hypoglycaemia fear surveys (HFS). Twenty-eight participants completed the 3-day PA recall survey. Clinical data and pump downloads were obtained at the time of the survey collection.

RESULTS

Higher child HFS behaviour and total scores were associated with higher PA levels (P = .003, P = .027), and higher parent HFS behaviour score was associated with higher youth PA levels (P = .031), after adjusting for age, sex, duration of diabetes and BMI. Higher child HFS behaviour score was associated with a higher exercise hypoglycaemia avoidance score on T1D-REPS (r = .38, P = .043). Higher child HFS worry and total scores were associated with higher HbA1c (r = .48, P = .008; r = .46, P = .012).

CONCLUSIONS

This study demonstrated that, in a generally active cohort of youth with T1D, increased hypoglycaemia avoidance behaviour was associated with higher PA levels. Higher overall FOH scores were associated with PA level, driven by higher behaviour subscale scores, while worry subscales were not correlated with PA level. Those with more FOH intervene more to specifically avoid exercise-associated hypoglycaemia and appear to have worse overall glycaemic control. Thus, improved education is required to improve glycaemic control around exercise while maintaining avoidance of hypoglycaemia.

OR27-04 Risk Factors For Low Baseline Bone Mineral Density In Gender Diverse Youth

Background

Sex steroids such as testosterone and estrogen are necessary for accumulation of bone mass. Transgender youth treated with gonadotropin releasing hormone analogues (GnRHa) to block natal puberty for gender-affirming care are at risk of low bone mineral density (BMD). Previous studies indicate that transfemale patients assigned male at birth (AMAB) have low BMD at baseline, during and after GnRHa treatment despite cross hormone treatment. Transmales assigned female at birth (AFAB), however, have normal BMD at baseline that decreases upon GnRHa treatment, with normalization upon cross hormone therapy. The reason(s) for the low baseline BMD in transfemales is unclear. We aimed to assess the baseline characteristics of transgender youth at a single multidisciplinary gender clinic prior to medical intervention and determine factors associated with BMD.

Methods

This is a retrospective chart review of patients <19 years old evaluated in the gender clinic. Dual-energy x-ray absorptiometry (DXA) scans were obtained prior to initiation of GnRHa or cross-hormone therapy per Endocrine Society guidelines for the treatment of gender dysphoria. We included patients with DXA scans completed prior to initiation of treatment with GnRHa or cross gender hormones and excluded those with concurrent medical diagnoses that may affect bone density. Data collected were bone mineral density (BMD) Z-scores, anthropometric data, vitamin D and calcium levels, and calcium intake. Multivariable linear regression models were used to assess the impact of vitamin D levels, height Z-score, weight Z-score, and BMI Z-score on subtotal body BMD Z-score, adjusted for sex assigned at birth and age.

Results

Sixty-four patients were included in our analysis. Of these, 73% were AMAB and 27% AFAB. Gender identity was male in 14%, female in 44%, and non-binary in 42%. Average height Z-score was 0.12, weight Z-score 0.27, and BMI Z-score 0.22 (using sex assigned at birth). Subtotal body BMD Z-scores were greater than zero in 11%, between zero and greater than -2 in 59%, and less than or equal to -2 in 30% of tested patients. AMAB patients had lower BMD Z-scores compared to those AFAB (p<0.05 for all Z-scores). There was a positive association with BMI, height, and weight Z-scores and increasing BMD Z-scores after adjusting for sex assigned at birth and age (p<0.05 for all Z-scores). Patients who consumed <2 servings of calcium per day had lower BMD Z-scores (p<0.05 for all Z-scores). Average vitamin D level was 24 ng/ml (+/- 9.5 SD) with no significant association with BMD Z-scores (adjusted for sex assigned at birth).

Conclusions

Patients AMAB and patients with calcium intake of < 2 servings/day are associated with lower baseline BMD in a cohort of adolescents seen in a multidisciplinary gender clinic. Height, weight, and BMI are associated linearly with BMD Z-score, following patterns previously described in other populations.

Interaction of Critical Care Practitioners With a Decision Support Tool for Weaning Mechanical Ventilation in Children

BACKGROUND

There is evidence that ventilator weaning protocols provide benefit to children receiving mechanical ventilation, but many protocols do not include explicit instructions for decreasing ventilator support from maximal settings. We evaluated care provider opinions on ventilator weaning recommendations made by a computerized decision support tool.

METHODS

Recommendations for ventilator adjustment were generated using a computerized decision support tool based on the ARDSNet protocol using data from children with acute hypoxemic respiratory failure admitted to the pediatric ICU (PICU). Attending physicians, fellows, nurse practitioners, and respiratory therapists (RTs) caring for these patients answered a brief survey to assess whether recommendations were reasonable and whether the practitioner believed they could be implemented.

RESULTS

RTs completed 99 surveys and ICU providers completed 96 surveys based on data from 10 patients. RTs and ICU providers found 63.9% and 65.3% of recommendations reasonable, respectively. There were 5 instances of disagreement between RTs and ICU providers. The percent of recommendations that RTs thought could be implemented was 29.9%, whereas this figure for ICU providers was 26.3%, with 4 instances of disagreement. Free-text responses indicated that many RTs and ICU providers were concerned about disrupting current patient stability and low tidal volumes.

CONCLUSIONS

On initial evaluation, the decision support tool did not appear to be highly acceptable to RTs and ICU providers in our setting because recommendations were rarely implemented. In addition, acceptability did not increase over time as patients generally improved. Most respondents preferred to make no ventilator changes and felt the recommendations were too aggressive. The notable barrier to use was a perception of potential patient instability with weaning.

Implementation of the m-ISHAPED Tool for Nursing Interdepartmental Handoffs

BACKGROUND

Handoffs can pose risks to patients.

LOCAL PROBLEM

Nurses throughout a children's hospital understood patient handoffs differently, resulting in handoff errors (failures) across departments.

METHODS

Lean principles were used to modify and implement the ISHAPED (Introduction, Story, History, Assessment, Plan, Error Prevention, and Dialogue) tool.

INTERVENTIONS

The team implemented a modified ISHAPED (m-ISHAPED) tool to align the content shared and the expectations for interdepartmental handoff.

RESULTS

Improvements were seen in reported patient safety events from 6.84 to 1.57 per 100 patient days (P < .001) and nurse satisfaction from 81.1% to 90.6% (P < .001).

CONCLUSIONS

A standardized process for interdepartmental nursing handoff was successfully implemented.

Impact of Sampling and Storage Techniques on Beef Muscle Measurements During Aging

ObjectivesThis objective was to determine if variations in beef sampling techniques utilized by meat researchers have a significant impact on beef muscle measurements during aging.Materials and MethodsTen beef short loins (IMPS 180) were purchased from a commercial packing plant within 48 h of slaughter. Loins were transported to the NDSU Meat Science laboratory where they were mapped into four sections from most anterior (1) to most posterior (4). Within sections, two, 40-g samples were removed; one sample was vacuum packaged (SMALL-VAC) and the other sample was stored in a wire-closure sealed bag (SMALL-BAG). The remaining whole short loin was vacuum packaged. All samples and whole short loins were stored at 4°C for 10 d. At 10 d, the short loins were sampled again where one, 40-g sample was removed from each mapped section (WHOLE-VAC). Purge loss was measured by weighing each sample prior to packaging treatment and at the end of the 10-d aging period; percentage change in weight was calculated. Troponin-T degradation was determined by western blot. Briefly, protein was extracted in an SDS-phosphate buffer, separated by SDS-PAGE under reducing conditions, and transferred to PVDF membranes. Western analysis was done using an anti-troponin-T antibody (clone JLT 12), and immunoreactive bands (Band 1 = doublet ∼42 to 45 kDa; Band 2 = doublet ∼ 36 to 38 kDa, Band 3 = 30 kDa) were analyzed for differences in density. Sarcomere length was determined using HeNe laser diffraction. Thinly sliced samples (∼50 to 100 mg) were placed in a sucrose-phosphate buffer and subjected to beadmill homogenization. A drop of the homogenate was placed on a glass slide, diffraction patterns were measured, and sarcomere length was calculated. Thiobarbituric acid reactive substances (TBARS) were assessed using a colorimetric assay. Analysis was conducted using Proc Mixed procedure of SAS where storage type, section location, and their interaction were used as fixed effects.ResultsThere was a storage type by section interaction (P = 0.017) that occurred with purge loss. SMALL-VAC samples released more purge than SMALL-BAG from the more posterior samples. Troponin-T Band 1 tended to be less (P = 0.07) in WHOLE-VAC samples compared with SMALL-VAC and SMALL-BAG. There was a storage type by section interaction (P = 0.02) where the most posterior SMALL-BAG samples had greater Band 2. There were no differences (P ≥ 0.25) in Band 3 between treatments. There was no difference (P = 0.29) in sarcomere length due storage type. However, there was a difference (P = 0.01) in sarcomere length between sections, where the shortest sarcomeres were in the center of the strip loin and longest sarcomeres on either end. There was a storage type by section interaction (P = 0.02) for TBARS where concentration was greatest in the most posterior portion of SMALL-BAG compared with WHOLE-VAC.ConclusionCollection of smaller samples for aging studies may not be representative of samples aged in a whole primal cut and may influence research outcomes.

Effect of Feeding a Low Vitamin a Diet to Beef Steers on Calpain 1 Activation during Meat Aging

ObjectivesThe objective of the study was to determine if a vitamin A deficient diet during beef finishing influences calpain 1 activation during meat aging.Materials and MethodsSixty-four steers of approximately 7 mo of age were subjected to a 14-d acclimation period followed by a 95-d growing period on a low vitamin A diet (1017 IU vitamin A/kg DM) designed to deplete liver vitamin A stores. Steers were assigned to a randomized complete blocked design with a 2 × 2 arrangement of treatments (breed: commercial Angus, n = 32, and purebred Simmental, n = 32; and a Low Vitamin A diet or a control diet). The low Vitamin A (LVA) treatment was a finishing diet with no supplemental vitamin A (723 IU vitamin A/kg DM). The control (CON) treatment was the LVA diet plus supplementation with 2200 IU vitamin A/kg DM for a total of 2923 IU vitamin A/kg DM. Serum retinol concentrations were monitored at the beginning and end of treatment. Upon completion of finishing, steers were slaughtered in two groups at a commercial plant. After fabrication, boneless strip loins (IMPS 180) were collected and transported to NDSU. Samples (approximately 40 g) were collected from the anterior portion of the strip loin on d-2 and d-7 of aging and immediately frozen. Protein was extracted from meat samples in fractionation buffers to yield sarcoplasmic and myofibrillar portions, separated by SDS-PAGE, and transferred to PVDF membranes. Immunoblot analysis was done using anti-desmin (d-2 and d-7) and anti-calpain 1 (d-2) antibodies, and results were visualized and documented. A pooled control was run on all membranes and set to a value of one for normalizing results. All experimental data were analyzed using the Proc Mixed procedure of SAS with breed of steers, dietary treatments, their interaction and slaughter date used as a fixed effect.ResultsCalpain 1 autolysis in the sarcoplasmic protein fraction of the d-2 aged loin samples were not affected by treatment or breed. The myofibrillar protein fraction from Angus loins had greater (P = 0.02) accumulation of the 76 kDa calpain 1 autolysis product than that from the Simmental loins; the myofibrillar fraction of the loins from the LVA treatment tended (P = 0.07) to have more 76 kDa calpain 1 autolysis product than that from the CON. There were not any differences (P > 0.19) in the 80 kDa calpain 1 band or the 78 kDa calpain 1 intermediate autolysis product in the myofibrillar fraction. There was a treatment by breed interaction (P = 0.01) for desmin in the d-7 aged loins where Angus loins from the CON treatment had less accumulation of the 46 kDa band than Angus loins on the LVA treatment and Simmental loins from either treatment.ConclusionVitamin A restriction increased protein proteolysis in Angus but not in Simmental steers. The increased calpain 1 autolysis in Angus vs. Simmental, regardless of Vitamin A treatment, indicates a genetic difference that may be the driver for the increased protein degradation in steers a restricted vitamin A diet.

Analysis of rabbit anti-thymocyte globulin vs basiliximab induction in pediatric liver transplant recipients

Literature is limited comparing induction immunosuppression in pediatric liver transplant (LTx) recipients. This is a single-center, retrospective cohort study of primary pediatric liver transplants at our center between 2005 and 2016 who received either basiliximab (BSX) or rabbit anti-thymocyte globulin (rATG) induction. Maintenance immunosuppression consisted of tacrolimus ± a corticosteroid taper. Exclusions included receipt of an ABO-incompatible graft, retransplantation, and multi-organ transplantation. Primary outcomes were incidence of treated biopsy-proven acute rejection (tBPAR) and PTLD within the first year and infections within 90 days of LTx. Secondary outcomes included graft and patient survival, time to first tBPAR, and incidence of steroid-resistant rejection (SRR) within the first year post-LTx. A total of 136 patients were included in the final analysis of which 57 patients (42%) received BSX induction. Patients who received rATG induction with or without a 2-week corticosteroid taper experienced significantly more tBPAR compared to those who received BSX induction with a 6-month corticosteroid taper (55.7% vs 33.3%, P = .01). There were no differences in the incidence of PTLD, infections, SRR, graft or patient survival, or time to first tBPAR between the two groups. Induction with rATG either with or without a short corticosteroid taper was associated with significantly more tBPAR in primary pediatric LTx recipients when compared to BSX induction with a prolonged corticosteroid taper in the setting of maintenance immunosuppression with tacrolimus.

Effectiveness of the Adolescent Medicine Rotation in Improving Pediatric Residents Self-Assessed Skill and Confidence Caring for Youth

PURPOSE

Practicing and resident pediatricians report inadequate skill in caring for adolescents, despite adolescents comprising roughly one-quarter of most general and subspecialty practices. This study examined the effectiveness of participation in an adolescent medicine rotation at improving pediatric residents' self-perceived skills and confidence across nine key adolescent health domains. We also evaluated the impact of didactic instruction during the rotation.

METHODS

Resident and recent-graduate participants (n = 34) completed milestone-based self-assessment of their skill and confidence caring for adolescent patients in nine key adolescent health-related domains. This study employed a post-test then retrospective pretest, an educational study design used to minimize response-shift bias whereby participants rate their skill and confidence at the end of the intervention (post-test), and then reflect back to retrospectively rate their preintervention skill (retrospective pretest). Additionally, differences in gains between those who did and did not participate in didactic instruction were evaluated. Didactic instruction was delivered during the adolescent medicine rotation utilizing a flipped-classroom model; participants received standardized preparatory materials and participated in active-learning workshops.

RESULTS

Participants demonstrated a significant (p ≤ .0001) increase in self-perceived skill levels for all assessed domains after the rotation as compared to before the rotation, whether or not they received didactic instruction. Participation in didactic instruction did not yield significant (p ≤ .05) additional benefit for any of the assessed domains.

CONCLUSIONS

Participation in an adolescent medicine rotation is of value to pediatric resident trainees and leads to increased self-assessed skill and confidence in caring for youth.

Disparities in Insulin Pump Therapy Persist in Youth With Type 1 Diabetes Despite Rising Overall Pump Use Rates

PURPOSE

This study sought to determine if disparities in insulin pump therapy among youth with type 1 diabetes (T1DM) persist despite recent increases in overall pump use rates.

DESIGN AND METHODS

All patients aged 6 months-17 years, diagnosed with T1DM, and completed 4+ outpatient diabetes visits at an academically-affiliated pediatric health care center from 2011 to 2016 were identified (n = 2131). Data were collected from existing electronic medical records and a multivariable logistic regression model was used to identify factors associated with insulin pump therapy.

RESULTS

Findings revealed one novel factor (patients/families whose primary language is Spanish [OR 0.47, p = 0.038] or other non-English languages [OR 0.47, p = 0.028]) and confirmed several previously known factors associated with lower insulin pump use: patients who were older (10-14 years OR 0.38, p < 0.0001; 15+ years OR 0.15, p < 0.0001), male (OR 0.80, p = 0.021), non-Hispanic black (OR 0.59, p = 0.009), American Indian/Alaska Native (OR 0.19, p = 0.023), had either government (OR 0.42, p < 0.0001) or no insurance (OR 0.52, p = 0.004) and poor glycemic control (at least one HbA1c ≥ 8.5%; OR 0.54, p < 0.0001).

CONCLUSION

Significant disparities in insulin pump use in youth with T1DM persist despite known benefits associated with pump therapy and underlying causes remain unclear.

PRACTICE IMPLICATIONS

Health care providers should explore barriers to insulin pump therapy, including limited English language proficiency.

Measles and Rubella Seroprevalence in Mother-Infant Pairs in Rural Nepal and the United States: Pre- and Post-Elimination Populations

We sought to compare seroprevalence of protective measles and rubella-specific antibody in mother-infant pairs across two populations: a pre-disease elimination Nepal population with recently introduced rubella vaccine and post-disease elimination U.S. population. Qualitative measles and rubella immunoglobulin G was assessed in maternal serum and cord blood from 258 pairs in Nepal, 2012-2013 and 49 pairs in Seattle, WA, 2014-2015. High rates of protective antibody were observed in both populations. Two hundred and forty-four (95%) pregnant women in Nepal had protective measles antibody versus 44 (92%) in Seattle (P = 0.42). Ninety-six percent of infants in Nepal (N = 246) and Seattle (N = 43) had protective measles antibody (P = 0.75). Ninety-four percentage of pregnant women in Nepal (N = 242) and Seattle (N = 45) had protective rubella antibody (P = 0.23). Two hundred and thirty-eight (93%) infants in Nepal had protective rubella antibody versus 44 (98%) in Seattle (P = 0.12). Continued surveillance will be necessary to ensure protective immunity, inform progress toward disease elimination in Nepal and avoid reemergence in the United States.

Predicting Pediatric Emergency Severity Index Level Based on Emergency Department Pre-Arrival Information

PURPOSE

This study examines the use of phone referral information to predict Emergency Severity Index triage levels as a proxy to anticipate emergency department nursing resource allocation in a pediatric hospital. It also assesses the relationship between these pre-arrival triage levels and hospital admission.

DESIGN AND METHODS

Emergency nurses with specialized training used standardized phone referral information to assign triage levels to 481 patients before their arrival. Upon patient arrival, independent triage levels were assigned. The two levels were then compared and patient disposition was collected. Descriptive statistics and Cohen's kappa were used to assess agreement between the two emergency severity index levels.

RESULTS

Moderate agreement was found between the pre-arrival and arrival triage levels. The majority of patients (71.3%) with a pre-arrival triage level of 1 or 2 (the most acute levels) were admitted to the hospital. These patients were also more likely to be admitted to the intensive care unit than were patients with a pre-arrival triage level≥3.

CONCLUSIONS AND PRACTICE IMPLICATIONS

The ability to predict triage levels for incoming patients could give the emergency department charge nurse the ability to plan ahead so that appropriate nursing staffing is available upon arrival. The knowledge that patients assigned a pre-arrival triage level of 1 or 2 are more likely to be admitted gives the emergency department the ability to plan for bed placement and inpatient nursing resources earlier, potentially resulting in decreased emergency department length of stay. More study on these potential benefits is needed.

Human Herpesvirus-6B Reactivation Is a Risk Factor for Grades II to IV Acute Graft-versus-Host Disease after Hematopoietic Stem Cell Transplantation: A Systematic Review and Meta-Analysis

Graft-versus-host disease (GVHD) is an important cause of morbidity and mortality after allogeneic hematopoietic cell transplantation (HCT). Many studies have suggested that human herpesvirus-6B (HHV-6B) plays a role in acute GVHD (aGVHD) after HCT. Our objective was to systematically summarize and analyze evidence regarding HHV-6B reactivation and development of aGVHD. PubMed and EMBASE databases were searched using terms for HHV-6, HCT, and aGVHD, yielding 865 unique results. Case reports, reviews, articles focusing on inherited chromosomally integrated HHV-6, poster presentations, and articles not published in English were excluded. The remaining 467 articles were reviewed for the following requirements: a statistical analysis of HHV-6B reactivation and a GVHD was described, HHV-6B reactivation was defined by PCR, and blood (plasma, serum, or peripheral blood mononuclear cells) was used for HHV-6B PCR. Data were abstracted from publications that met these criteria (n = 33). Publications were assigned to 1 of 3 groups: (1) HHV-6B reactivation was analyzed as a time-dependent risk factor for subsequent aGVHD (n = 14), (2) aGVHD was analyzed as a time-dependent risk factor for subsequent HHV-6B reactivation (n = 1), and (3) analysis without temporal specification (n = 18). A statistically significant association (P < .05) between HHV-6B reactivation and aGVHD was observed in 10 of 14 studies (71%) in group 1, 0 of 1 study (0%) in Group 2, and 8 of 18 studies (44.4%) in Group 3. Of the 14 studies that analyzed HHV-6B as a risk factor for subsequent aGVHD, 11 performed a multivariate analysis and reported a hazard ratio, which reached statistical significance in 9 of these s tudies. Meta-analysis of these 11 studies demonstrated a statistically significant association between HHV-6B and subsequent grades II to IV aGVHD (hazard ratio, 2.65; 95% confidence interval, 1.89 to 3.72; P < .001).HHV-6B reactivation is associated with aGVHD, and when studies have a temporal component to their design, HHV-6B reactivation is associated with subsequent aGVHD. Further research is needed to investigate whether antiviral prophylaxis reduces incidence or severity of aGVHD.

A clinical pathway for the postoperative management of hypocalcemia after pediatric thyroidectomy reduces blood draws

OBJECTIVES

Postoperative calcium management is challenging following pediatric thyroidectomy given potential limitations in self-reporting symptoms and compliance with phlebotomy. A protocol was created at our tertiary children's institution utilizing intraoperative parathyroid hormone (PTH) levels to guide electrolyte management during hospitalization. The objective of this study was to determine the effect of a new thyroidectomy postoperative management protocol on two primary outcomes: (1) the number of postoperative calcium blood draws and (2) the length of hospital stay.

STUDY DESIGN

Institutional review board approved retrospective study (2010-2016).

METHODS

Consecutive pediatric total thyroidectomy and completion thyroidectomy ± neck dissection cases from 1/1/2010 through 8/5/2016 at a single tertiary children's institution were retrospectively reviewed before and after initiation of a new management protocol. All cases after 2/1/2014 comprised the experimental group (post-protocol implementation). The pre-protocol control group consisted of cases prior to 2/1/2014. Multivariable linear and Poisson regression models were used to compare the control and experimental groups for outcome measure of number of calcium lab draws and hospital length of stay.

RESULTS

53 patients were included (n = 23, control group; n = 30 experimental group). The median age was 15 years. 41 patients (77.4%) were female. Postoperative calcium draws decreased from a mean of 5.2 to 3.6 per day post-protocol implementation (Rate Ratio = 0.70, p < .001), adjusting for covariates. The mean number of total inpatient calcium draws before protocol initiation was 13.3 (±13.20) compared to 7.2 (±4.25) in the post-protocol implementation group. Length of stay was 2.1 days in the control group and 1.8 days post-protocol implementation (p = .29). Patients who underwent concurrent neck dissection had a longer mean length of stay of 2.32 days compared to 1.66 days in those patients who did not undergo a neck dissection (p = .02). Hypocalcemia was also associated with a longer mean length of stay of 2.41 days compared to 1.60 days in patients who did not develop hypocalcemia (p < .01).

CONCLUSIONS

The number of calcium blood draws was significantly reduced after introduction of a standardized protocol based on intraoperative PTH levels. The hospital length of stay did not change. Adoption of a standardized postoperative protocol based on intraoperative PTH levels may reduce the number of blood draws in children undergoing thyroidectomy.

Pediatric airway study: Endoscopic grading system for quantifying tonsillar size in comparison to standard adenotonsillar grading systems

SIGNIFICANCE

Current grading systems may not allow clinicians to reliably document and communicate adenotonsillar size in the clinical setting. A validated endoscopic grading system may be useful for reporting tonsillar size in future clinical outcome studies. This is especially important as tonsillar enlargement is the cause of a substantial health care burden on children.

OBJECTIVE

To propose and validate an easy-to-use flexible fiberoptic endoscopic grading system that provides physicians with a more accurate sense of the three-dimensional relationship of the tonsillar fossa to the upper-airway.

METHODS

50 consecutive pediatric patients were prospectively recruited between February 2015 and February 2016 at a pediatric otolaryngology outpatient clinic. The patients had no major craniofacial abnormalities and were aged 1 to 16years. Each patient had data regarding BMI, Friedman palate position, OSA-18 survey results collected. For each child, digital video clips of fiberoptic nasopharyngeal, oropharyngeal and laryngeal exams were presented to 2 examiners. Examiners were asked to independently use the proposed Endoscopic tonsillar grading system, the Brodsky tonsillar grading scale, the Modified Brodsky tonsillar grading scale with a tongue depressor, and the Parikh adenoid grading system to rate adenotonsillar hypertrophy. Cohen's Kappa and weighted Kappa scores were used to assess interrater reliability for each of the four grading scales. The Spearman correlation was used to test the associations between each scale and OSA-18 scores, as well as Body Mass Index (BMI).

RESULTS

50 pediatric patients were included in this study (mean age 6.1years, range of 1year to 16years). The average BMI was 20. The average OSA-18 score was 61.7. The average Friedman palate position score was 1.34. Twelve percent of the patients had a Friedman palate position score≥3, which made traditional Brodsky grading of their tonsils impossible without a tongue depressor. All four scales showed strong agreement between the two raters. The weighted Kappa was 0.83 for the Modified Brodsky scale, 0.89 for the Brodsky scale, 0.94 for the Parikh scale to 0.98 for the Endoscopic scale (almost perfect agreement). The Endoscopic scale showed the most consistent agreement between the raters during the study. There was a moderate association between the Parikh adenoid grading system with OSA-18 scores (Spearman's ρ=0.58, p<0.001) compared to a low association of the tonsillar grading systems with OSA- 18 scores. None of the scales correlated with patient BMI.

CONCLUSIONS

The proposed Endoscopic tonsillar grading system is as reliable of a method of grading tonsillar size as conventional grading systems. It offers the advantage of allowing for critical evaluation of the tonsils without any anatomic distortion which may occur with the use of a tongue blade. This new validated endoscopic grading system provides a tool for communicating the degree of airway obstruction at the level of the oropharynx regardless of Friedman palate position and may be used in future outcomes projects.

Prophylactic Sacral Dressing for Pressure Ulcer Prevention in High-Risk Patients

BACKGROUND

Patients in intensive care units are likely to have limited mobility owing to hemodynamic instability and activity orders for bed rest. Bed rest is indicated because of the severity of the disease process, which often involves intubation, sedation, paralysis, surgical procedures, poor nutrition, low flow states, and poor circulation. These patients are predisposed to the development and/or the progression of pressure ulcers not only because of their underlying diseases, but also because of limited mobility and deconditioned states of health.

OBJECTIVE

To assess whether treating high-risk patients with a prophylactic sacral dressing decreases the incidence of unit-acquired sacral pressure ulcers.

METHODS

An evidence-based tool for identifying patients at high risk for pressure ulcers was used in 3 intensive care units at an urban tertiary care hospital and academic medical center. Those patients deemed at high risk had a prophylactic sacral dressing applied. Incidence rates were collected and compared for the 7 months preceding use of the dressings and for 7 months during the trial period when the dressing was used.

RESULTS

After the sacral dressing began being used, the number of unit-acquired sacral pressure ulcers decreased by 3.4 to 7.6 per 1000 patient days depending on the unit.

CONCLUSIONS

A prophylactic sacral dressing may help prevent unit-acquired sacral pressure ulcers. Implementation of an involved care team with heightened awareness and increased education along with a prophylactic sacral dressing in patients deemed high risk for skin breakdown are all essential for success.

Competency assessments: perceptions at follow-up

OBJECTIVES

To report on the perceptions of assessment of competency and its consequences on a group of clients and significant others at follow-up.

METHODS

Ninety-five interviews were conducted using a carefully developed semistructured telephone interview of 24 clients and 71 family/caregivers, representing the perceptions of about 80 clients.

RESULTS

There was general satisfaction in the competency assessment process. There was a perception that interests and rights were protected. Clients were seen to be less involved in all spheres of decision making regardless of capacity outcome. Clients and families were satisfied with how decisions were made.

CONCLUSIONS

Follow-up study of competency assessment does not support the conclusions previously drawn based on court record studies that assessments are deleterious and frequently result in violations of rights.

Genesis and acid/base

Perhaps the enigmatic etiology of cell specialization ultimately leading to organogenesis can be explained by the unusual combine application of some common mechanisms. Perhaps the combination of control of variable pH through compartmentalization, dialysis/diffusion gradients, and an electrophoresis plane impacts cells in zones causing the developmental patterns. Possibly pH is even manipulated at times to change the charge on molecules in order that attraction of opposite charges can be utilized.

A possible explanation for growth hormone resistance in chronic renal failure

Perhaps the liver in renal failure significantly alters its pH in order to attempt to maintain homeostasis. This alteration might explain the growth hormone resistance found in children with chronic renal failure.