Variation in pediatric medical care is common and contributes to differences in patient outcomes. Site-to-site variation in the characteristics and care of infants with neonatal opioid withdrawal ...syndrome (NOWS) has yet to be quantified. Our objective was to describe site-to-site variation in maternal-infant characteristics, infant management, and outcomes for infants with NOWS.
Cross-sectional study of 1377 infants born between July 1, 2016, and June 30, 2017, who were ≥36 weeks' gestation, with NOWS (evidence of opioid exposure and NOWS scoring within the first 120 hours of life) born at or transferred to 1 of 30 participating hospitals nationwide. Site-to-site variation for each parameter within the 3 domains was measured as the range of individual site-level means, medians, or proportions.
Sites varied widely in the proportion of infants whose mothers received adequate prenatal care (31.3%-100%), medication-assisted treatment (5.9%-100%), and prenatal counseling (1.9%-75.5%). Sites varied in the proportion of infants with toxicology screening (50%-100%) and proportion of infants receiving pharmacologic therapy (6.7%-100%), secondary medications (1.1%-69.2%), and nonpharmacologic interventions including fortified feeds (2.9%-90%) and maternal breast milk (22.2%-83.3%). The mean length of stay varied across sites (2-28.8 days), as did the proportion of infants discharged with their parents (33.3%-91.1%).
Considerable site-to-site variation exists in all 3 domains. The magnitude of the observed variation makes it unlikely that all infants are receiving efficient and effective care for NOWS. This variation should be considered in future clinical trial development, practice implementation, and policy development.
Antibiotic resistance is a growing problem facing global societies today. Many new antibiotics are derivatized versions of already existing antibiotics, which allows for antibiotic resistance to ...arise. To combat this issue, new antibiotics with different core structures need to be elucidated. Asymmetrical polyacetylenes have been isolated from natural products and they have previously been demonstrated to exhibit antimicrobial and antibacterial activity; however, their synthetic preparation has not made them easily amenable to rapid derivatization for SAR studies. Using a combination of solution and solid‐supported chemistries, an array of diynes inspired by a known natural product were prepared and assessed for antibacterial activity. Ultimately, several compounds were identified with improved activity in bacterial viability assays. Moreover, some compounds were discovered that displayed a degree of specificity for E. coli over P. fluorescens and vice versa. These new compounds show promise, and further investigation is needed to pinpoint the specific structural components that elicit biological activity.
A series of conjugated diynes were prepared via both solution phase and solid‐supported Glaser Hay couplings and screened for selective antibacterial activities. A focused structure–activity relationship screen was performed to identify key components of natural product derivatives that were essential for biological activity.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Objectives
(1) To evaluate the direct (un-mediated) and indirect (mediated) relationship between antenatal exposure to opioid agonist medication as treatment for opioid use disorder (MOUD) and the ...severity of neonatal opioid withdrawal syndrome (NOWS), and (2) to understand the degree to which mediating factors influence the direct relationship between MOUD exposure and NOWS severity.
Methods
This cross-sectional study includes data abstracted from the medical records of 1294 opioid-exposed infants (859 MOUD exposed and 435 non-MOUD exposed) born at or admitted to one of 30 US hospitals from July 1, 2016, to June 30, 2017. Regression models and mediation analyses were used to evaluate the relationship between MOUD exposure and NOWS severity (i.e., infant pharmacologic treatment and length of newborn hospital stay (LOS)) to identify potential mediators of this relationship in analyses adjusted for confounding factors.
Results
A direct (un-mediated) association was found between antenatal exposure to MOUD and both pharmacologic treatment for NOWS (aOR 2.34; 95%CI 1.74, 3.14) and an increase in LOS (1.73 days; 95%CI 0.49, 2.98). Delivery of adequate prenatal care and a reduction in polysubstance exposure were mediators of the relationship between MOUD and NOWS severity and as thus, were indirectly associated with a decrease in both pharmacologic treatment for NOWS and LOS.
Conclusions for Practice
MOUD exposure is directly associated with NOWS severity. Prenatal care and polysubstance exposure are potential mediators in this relationship. These mediating factors may be targeted to reduce the severity of NOWS while maintaining the important benefits of MOUD during pregnancy.
Significance
What is already known on this subject?
The use of MOUD during pregnancy improves fetal outcomes, while antenatal exposure to MOUD increases the risk of NOWS. The severity of NOWS is influenced by MOUD type, co-exposures, adequacy of prenatal care, and the infant’s gestational age.
What this study adds?
This study identifies factors that mediate the direct influence of antenatal MOUD exposure on the severity of NOWS and quantifies the degree to which this mediation influences outcomes in a large and geographically diverse population. Thus, providing clinicians with potential targets to improve care for this vulnerable population.
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DOBA, EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, IZUM, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UILJ, UKNU, UL, UM, UPUK, VKSCE, VSZLJ, ZAGLJ
Background
Tibial stress fractures are not uncommon in pediatric athletes. The severity of injury may be graded using magnetic resonance imaging (MRI).
Objective
To determine whether Fredericson MRI ...grading of tibial stress fractures can differentiate times to recovery across different grades in pediatric athletes.
Materials and methods
A medical record search identified all athletes younger than 19 years old who had tibial stress fractures confirmed by MRI and were treated by sports medicine specialists in our clinic system over a 5-year period. Two pediatric radiologists graded MRI exams using the Fredericson system. Time to recovery (in days) was defined in four ways: pain onset to full participation, pain onset to zero pain, first treatment to full sport participation and first treatment to zero pain. Recovery times were compared to tibial stress fracture Fredericson MRI grade and to the use of a recovery device.
Results
Thirty-eight pediatric athletes (age range: 7–18 years, mean: 15.4±2.2 years) had 42 tibial stress fractures while participating in 12 different sports. About half (55%) were track and/or cross-country athletes. The mean time from diagnosis to report of no pain for all patients was 55.6±5.0 days. We found no significant difference in time to recovery across stress fracture grade or with the use of a recovery device.
Conclusion
No differences were noted between Fredericson stress fracture grades and different time periods to recovery or between differences in recovery time and the return to full participation in sports, regardless of the use of assistive devices.
The incidence of neonatal opioid withdrawal syndrome (NOWS) has increased fivefold over the last 10 years. Standardized NOWS care protocols have revealed many improved patient outcomes. Our objective ...for this study is to describe results of a clinical practice survey of NOWS management practices designed to inform future clinical studies in the diagnosis and management of NOWS.
A cross-sectional survey was administered to medical unit directors at 32 Institutional Development Award States Pediatric Clinical Trial Network and 22 Neonatal Research Network sites in the fall of 2017. Results are presented as both the number and percentage of positive responses. Ninety-five percent Wilson confidence intervals (CIs) were generated around estimates, and χ
and Fisher's exact tests were used to compare the association between unit type and reporting of each protocol.
Sixty-two responses representing 54 medical centers were received. Most participating NICU and non-ICU sites reported protocols for NOWS management, including NOWS scoring (98% NICU; 86% non-ICU), pharmacologic treatment (92% NICU; 64% non-ICU), and nonpharmacologic care (79% NICU; 79% non-ICU). Standardized protocols for pharmacologic care and weaning were reported more frequently in the NICU (92% 95% CI: 80%-97% and 94% 95% CI: 83%-98%, respectively) compared with non-ICU settings (64% 95% CI: 39%-84% for both) (
< .05 for both comparisons). Most medical centers reported morphine as first-line therapy (82%; 95% CI: 69%-90%) and level 3 and level 4 NICUs as the location of pharmacologic treatment (83%; 95% CI: 71%-91%).
Observed variations in care between NICUs and non-ICUs revealed opportunities for targeted interventions in training and standardized care plans in non-ICU sites.
Background
The subtalar joint is commonly affected in children with juvenile idiopathic arthritis and is challenging to treat percutaneously.
Objective
To describe the technique for treating the ...subtalar joint with US-guided corticosteroid injections in children and young adults with juvenile idiopathic arthritis and to evaluate the safety of the treatment.
Materials and methods
We retrospectively analyzed 122 patients (age 15 months–29 years) with juvenile idiopathic arthritis who were referred by a pediatric rheumatologist for corticosteroid injection therapy for symptoms related to the hindfoot or ankle. In these patients the diseased subtalar joint was targeted for therapy, often in conjunction with adjacent affected joints or tendon sheaths of the ankle. We used a protocol based on age, weight and joint for triamcinolone hexacetonide or triamcinolone acetonide dose prescription. We describe the technique for successful treatment of the subtalar joint.
Results
A total of 241 subtalar joint corticosteroid injections were performed under US guidance, including 68 repeat injections for recurrent symptoms in 26 of the 122 children and young adults. The average time interval between repeat injections was 24.8 months (range 2.2–130.7 months, median 14.2 months). Subcutaneous tissue atrophy and skin hypopigmentation were the primary complications observed. These complications occurred in 3.9% of the injections.
Conclusion
With appropriate training and practice, the subtalar joint can be reliably and safely targeted with US-guided corticosteroid injection to treat symptoms related to juvenile idiopathic arthritis.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, VSZLJ, ZAGLJ
Background
Intra-articular corticosteroid injections are a safe and effective treatment for patients with juvenile idiopathic arthritis. The potential scope of care in ultrasound-guided ...corticosteroid therapy in children and a joint-based corticosteroid dose protocol designed to optimize interdisciplinary care are not found in the current literature.
Objective
The purpose of this study was to report the spectrum of care, technique and safety of ultrasound-guided corticosteroid injection therapy in patients with juvenile idiopathic arthritis and to propose an age-weight-joint-based corticosteroid dose protocol.
Materials and methods
A retrospective analysis was performed of 198 patients (ages 21 months to 28 years) referred for treatment of juvenile idiopathic arthritis with corticosteroid therapy. Symptomatic joints and tendon sheaths were treated as prescribed by the referring rheumatologist. An age-weight-joint-based dose protocol was developed and utilized for corticosteroid dose prescription.
Results
A total of 1,444 corticosteroid injections (1,340 joints, 104 tendon sheaths) were performed under US guidance. Injection sites included small, medium and large appendicular skeletal joints (upper extremity 497, lower extremity 837) and six temporomandibular joints. For patients with recurrent symptoms, 414 repeat injections were performed, with an average time interval of 17.7 months (range, 0.5–101.5 months) between injections. Complications occurred in 2.6% of injections and included subcutaneous tissue atrophy, skin hypopigmentation, erythema and pruritis.
Conclusion
US-guided corticosteroid injection therapy provides dynamic, precise and safe treatment of a broad spectrum of joints and tendon sheaths throughout the entire pediatric musculoskeletal system. An age-weight-joint-based corticosteroid dose protocol is effective and integral to interdisciplinary care of patients with juvenile idiopathic arthritis.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, VSZLJ, ZAGLJ
Importance The ability of computed tomography (CT) to distinguish between benign congenital lung malformations and malignant cystic pleuropulmonary blastomas (PPBs) is unclear. Objective To assess ...whether chest CT can detect malignant tumors among postnatally detected lung lesions in children. Design, Setting, and Participants This retrospective multicenter case-control study used a consortium database of 521 pathologically confirmed primary lung lesions from January 1, 2009, through December 31, 2015, to assess diagnostic accuracy. Preoperative CT scans of children with cystic PPB (cases) were selected and age-matched with CT scans from patients with postnatally detected congenital lung malformations (controls). Statistical analysis was performed from January 18 to September 6, 2020. Preoperative CT scans were interpreted independently by 9 experienced pediatric radiologists in a blinded fashion and analyzed from January 24, 2019, to September 6, 2020. Main Outcomes and Measures Accuracy, sensitivity, and specificity of CT in correctly identifying children with malignant tumors. Results Among 477 CT scans identified (282 boys 59%; median age at CT, 3.6 months IQR, 1.2-7.2 months; median age at resection, 6.9 months IQR, 4.2-12.8 months), 40 cases were extensively reviewed; 9 cases (23%) had pathologically confirmed cystic PPB. The median age at CT was 7.3 months (IQR, 2.9-22.4 months), and median age at resection was 8.7 months (IQR, 5.0-24.4 months). The sensitivity of CT for detecting PPB was 58%, and the specificity was 83%. High suspicion for malignancy correlated with PPB pathology (odds ratio, 13.5; 95% CI, 2.7-67.3;P = .002). There was poor interrater reliability (κ = 0.36 range, 0.06-0.64;P < .001) and no significant difference in specific imaging characteristics between PPB and benign cystic lesions. The overall accuracy rate for distinguishing benign vs malignant lesions was 81%. Conclusions and Relevance This study suggests that chest CT, the current criterion standard imaging modality to assess the lung parenchyma, may not accurately and reliably distinguish PPB from benign congenital lung malformations in children. In any cystic lung lesion without a prenatal diagnosis, operative management to confirm pathologic diagnosis is warranted.
Objective
We previously demonstrated that allogeneic cardiosphere‐derived cells (CDCs) improve myocardial function after infarction via paracrine effects when animals are pretreated with oral ...cyclosporine (CsA) prior to injury. The present study directly compared the efficacy of CDCs with and without CsA administered at the time of reperfusion after acute myocardial infarction (AMI) in a 3‐armed, blinded pre‐clinical study.
Methods
Studies were completed in closed‐chest, propofol‐anesthetized swine (n=29). After assessing baseline hemodynamics, the LAD artery was occluded with a balloon catheter for 90 minutes and contrast‐enhanced cardiac CT performed to assess the area‐at‐risk (AAR). Thirty minutes after reperfusion, animals were randomized to receive a global intracoronary infusion of saline, CDCs (20×106 cells), or CDCs with CsA (2.5 mg/kg, iv; 200 mg, po qd). LV function and TTC infarct size (IS) were assessed 1 month later.
Results
Baseline hemodynamics and LV function were similar between groups. There was no difference between the CT AAR (% of LV mass; Saline: 22.2±1.0%, CDC: 23.7±0.7%, CDC+CsA: 24.7±1.4%, p=0.26). Infarct size was not different between groups (% of LV mass; Saline: 6.7±0.7%, CDC: 6.7±0.3%, CDC+CsA: 6.9±0.6%, p=0.95), or when normalized to risk area (% of AAR; Saline: 46.2±4.0%, CDC: 46.4±2.1%, CDC+CsA: 49.2±3.1%, p=0.79). There was no difference in CT ejection fraction (Saline: 49±2% vs. CDC: 46±2% vs. CDC+CsA: 47±2%, p=0.72). Wall thickening by echocardiography in the LAD‐perfused (Saline: 26±8% vs. CDC: 18±4% vs. CDC+CsA: 18±5%, p=0.56) and the remote, non‐infarcted (Saline: 100±7% vs. CDC: 111±10% vs. CDC+CsA: 119±11%, p=0.40) areas of the LV were also similar between groups.
Conclusion
Global infusion of allogeneic CDCs in the absence of CsA immunosuppression does not reduce chronic myocardial infarct size nor improve global or regional measures of LV function. Surprisingly, CDC therapy with IV CsA administered at the time of reperfusion does not appear to elicit previously demonstrated reparative effects. These data indicate that oral CsA pretreatment may be required to effect improved LV function with global intracoronary CDC therapy.
Support or Funding Information
Supported by the National Heart Lung and Blood Institute (HL‐061610), the American Heart Association (17SDG33660200), the National Center for Advancing Translational Sciences (UL1TR001412), the Department of Veterans Affairs (1IO1BX002659), the New York State Department of Health (NYSTEM CO24351), and the Albert and Elizabeth Rekate Fund in Cardiovascular Medicine.
This is from the Experimental Biology 2019 Meeting. There is no full text article associated with this published in The FASEB Journal.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Background:
Ankle fracture surgeries are generally safe and effective procedures; however, as quality-based reimbursement models are increasingly affected by postoperative readmission, we aimed to ...determine the causes and risk factors for readmission following ankle fracture surgery.
Methods:
Ankle fracture cases were identified from the prospectively collected American College of Surgeons National Surgical Quality Improvement Program from 2013 to 2014. Demographics, comorbidities, and fracture characteristics were collected. Rates of 30-day adverse events and readmissions were determined as well as the causes for readmission. Multivariable logistic regression analyses were performed to identify risk factors associated with having any adverse events and being readmitted within 30 days of surgery.
Results:
There were 5056 patients included; 167 (3.3%) were open fractures. The rate of any postoperative adverse event was 5.2%. There were 116 unplanned readmissions, with a readmission rate of 2.3%. Of the 116 unplanned readmissions, 49 (42.2%) were for reasons related to the surgery or surgical site, with the most common causes being deep surgical site/hardware infections (12.9%), superficial site infections (11.2%), and wound disruption (6.9%). Most readmissions were for reasons unrelated to the surgical site (51.7%), including cardiac disorders (8.6%), pulmonary disorders (7.8%), and neurological/psychiatric disorders (6.9%). The cause of readmission was unknown for 6% of readmissions. With multivariable logistic regression, the strongest risk factors for readmission were a history of pulmonary disease (odds ratio OR, 2.29), American Society of Anesthesiologists (ASA) class ≥3 (OR, 2.28), and open fractures (OR, 2.04) (all P < .05).
Conclusion:
In this cohort of 5056 ankle fracture cases, 2.3% of patients were readmitted within 30 days, with at least 51.7% of all unplanned readmissions due to causes unrelated to the surgery or surgical site. Predictors of readmission included a history of pulmonary disease, higher ASA class, and open fractures. Based on these findings, we advocate close medical follow-up with nonorthopaedic providers after discharge for high-risk patients.
Level of Evidence:
Level III.
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