ABSTRACT
Background:
Ileocolonoscopy (IC) detects mucosal inflammation and magnetic resonance enterography (MRE) detects transmural inflammation in Crohn disease (CD). We aimed to evaluate the ...relationship between the simplified magnetic resonance index of activity (MARIAs) and measures of inflammation by IC in children with newly diagnosed CD.
Methods:
Retrospective review of 140 patients 6–18 years of age with CD who had baseline IC and MRE within 5 weeks of diagnosis. MARIAs was calculated for each intestinal segment (terminal ileum TI, ascending colon, transverse colon, descending colon, sigmoid colon, rectum), defined as (1 × thickness > 3 mm) + (1 × edema) + (1 × fat stranding) + (2 × ulcers). Sensitivity and specificity were derived using receiver operating characteristic (ROC) curves to compare MARIAs to IC findings.
Results:
Using IC as the reference standard, the cutoff MARIAs ≥1 identified TI segments with active inflammation with 84% sensitivity, 73% specificity, 85% positive predictive value (PPV), 70% negative predictive value (NPV), and area under the curve (AUC) 0.782 (95% confidence interval CI 0.689–0.876). The cutoff MARIAs ≥2 identified TI segments with severe lesions with 87% sensitivity, 76% specificity, 87% PPV, 76% NPV, and AUC 0.814 (95% CI 0.712–0.916). There was poor sensitivity for all colonic segments.
Conclusion:
The MARIAs is feasible and accurate in reflecting disease activity in the TI, but not in the colon, in children with newly diagnosed CD. Although the MARIAs may be useful for monitoring TI disease activity over time, full assessment continues to require both IC and MRE.
Posterior urethral valve is the most common cause of bladder outlet obstruction in infants. We aimed to describe the rate and timing of kidney-related and survival outcomes for children diagnosed ...with posterior urethral valves in United States children's hospitals using the Pediatric Health Information System database.
This retrospective cohort study included children hospitalized between January 1, 1992 and December 31, 2006, who were in their first year of life, had a diagnosis of congenital urethral stenosis, and underwent endoscopic valve ablation or urinary drainage intervention, or died. Records were searched up to December 31, 2018 for kidney-related mortality, placement of a dialysis catheter, and kidney transplantation. Cox regression analysis was used to identify risk factors, and Kaplan-Meier survival analysis used to determine time-to-event probability. Subgroup survival analysis was performed with outcomes stratified by the strongest identified risk factor.
Included were 685 children hospitalized at a median age of 7 (interquartile range, 1-37) days. Thirty four children (5%) died, over half during their initial hospitalization. Pulmonary hypoplasia was the strongest risk factor for death (hazard ratio, 7.5; 95% confidence interval 95% CI, 3.3 to 17.0). Ten-year survival probability was 94%. Fifty-nine children (9%) underwent one or more dialysis catheter placements. Children with kidney dysplasia had over four-fold risk of dialysis catheter placement (hazard ratio, 4.6; 95% CI, 2.6 to 8.1). Thirty-six (7%) children underwent kidney transplant at a median age of 3 (interquartile range, 2-8) years. Kidney dysplasia had a nine-fold higher risk of kidney transplant (hazard ratio, 9.5; 95% CI, 4.1 to 22.2).
Patients in this multicenter cohort with posterior urethral valves had a 5% risk of death, and were most likely to die during their initial hospitalization. Risk of death was higher with a diagnosis of pulmonary hypoplasia. Kidney dysplasia was associated with a higher risk of need for dialysis/transplant.
This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2019_10_03_CJN04350419.mp3.
To implement a surgeon led initiative for tracheostomy education for non-surgical pediatric first responders in the hospital setting and to assess its efficacy.
A prospective, observational study ...conducted from September 2018 to March 2019. All pediatric residents at a tertiary care children's hospital were invited to participate. An objective knowledge test and self-assessment comfort questionnaire was completed before and after the intervention and at 6-month follow up. Educational sessions involved a targeted, interactive program with a didactic presentation and case-based simulation.
Forty-four pediatric residents participated. Residents had limited experience with tracheostomy intervention with only one reporting personally resolving a tracheostomy issue. However, tracheostomy complications were relatively common with 43% reporting having watched another specialty intervene on a tracheostomy issue during an airway related emergency. The objective knowledge test results significantly increased; from pre-knowledge test percent mean of 61.25 (SD = 13.52) to post-knowledge test percent mean of 81.25 (SD = 10.57) t(39) = -8.144, p < 0.001. Comfort levels questionnaire median (IQR) results were also significantly higher than pre-intervention 3.70 (3.20–3.88) vs. 2.65 (2.13–3.00), Z = 780, p < .001.
We demonstrated improved knowledge among pediatric residents after a surgeon-led module for tracheostomy care and emergency management. A targeted tracheostomy education program may fill a gap in pediatric resident emergency resuscitation education.
In the wake of the COVID-19 pandemic, telemedicine has become rapidly adopted by the neurosurgical community; however, few studies have examined predictors of telemedicine utilization. Here, we ...analyze patient variables associated with the acceptance of a telemedicine encounter by a pediatric neurosurgical population during the early phases of the COVID-19 pandemic.
All patients seen in a single institution's outpatient pediatric neurosurgery clinic between April 1, 2020 and July 31, 2020 were retrospectively reviewed. Demographic variables were collected for each patient's first completed encounter. Patients participating in telemedicine were compared with those seen in person. Univariate analysis was performed using the Wilcoxon rank sum test for continuous variables and Fischer exact test for categorical variables. A logistic regression multivariable analysis was then performed.
We included 682 patients (374 telemedicine and 308 in person). Univariate analysis demonstrated that telemedicine visits were more likely to occur at earlier study dates (P < 0.001) and that patients participating in telemedicine visits were more likely to be established rather than new patients (P < 0.001), White or Caucasian (P < 0.001), not Hispanic or Latino (P < 0.001), English-speaking (P < 0.001), non-Medicare/Medicaid recipients (P < 0.001), have lower no-show rates (P = 0.006), and live farther from the hospital (P = 0.005). Multivariable analysis demonstrated older age (P = 0.031), earlier appointment date (P < 0.01), established patient status (P < 0.001), English-speaking (P < 0.02), and non-Medicare/Medicaid insurance (P < 0.05) were significant predictors of telemedicine utilization.
Significant demographic differences exist among pediatric patients who participated in telemedicine versus those who requested an in-person visit at our institution. Addressing barriers to access will be crucial for promoting health equity in continued utilization of telemedicine.
Abstract
Background
The increasing incidence of pediatric inflammatory bowel disease (IBD), along with more extensive and severe disease in children, raises concern for related health care ...expenditures.
Aim
The aim of this study was to quantify and characterize costs of pediatric IBD in the year following diagnosis.
Methods
We identified all patients diagnosed with IBD at Connecticut Children’s Medical Center in 2016 with a minimum of 1 year follow-up. Clinical and demographic factors were recorded at diagnosis. We examined paid service and professional costs related to outpatient medications and infusions, outpatient procedures and radiology imaging, inpatient services, and outpatient visits. Actual dollar reimbursements were from private and public payers. Data is reported as mean ± SD and median (IQR).
Results
First-year cost data were collected on 67 patients (43 Crohn’s disease CD, 24 ulcerative colitis UC, mean age 13 years SD 3.22) revealing a mean cost of $45,753 (SD $37,938), with $43,095 (SD $30,828) for CD and $50,516 (SD $48,557) for UC. Severe CD (n = 11) had a mean cost of $71,176 (SD $43,817) and severe UC (n = 5) $134,178 (SD $40,920). Patients receiving infusion therapy had a mean cost of $59,376 (SD $38,724) compared with $27,903 (SD $28,795) for those not receiving infusions. Overall cost distribution showed 37% from infusion costs, 25% hospital costs, 18% outpatient procedures, 10% outpatient oral medications, 7% outpatient imaging, and 3% outpatient visits.
Conclusions
Infusion therapy is a key driver of first-year costs for children newly diagnosed with IBD. Understanding cost distribution in relation to disease presentation can be helpful to anticipate future related costs.
Pediatric inflammatory bowel disease is increasing in incidence and severity, which raises concern for related health care expenditures. Severity of disease at time of diagnosis and use of biologic infusion therapy dramatically increase costs in the first year after diagnosis.
Background The purpose of this study was to determine the effect of a 1-day evidence-based pediatric palliative care continuing professional development program on nurses' and advanced practice ...registered nurses' perceived self-efficacy regarding palliative care. Method The revised Pediatric Palliative Care Questionnaire was administered to participants before and after a 7½-hour program. A multimodal approach was used to teach topics specific to pediatric palliative care. Results Thirty-one participants completed questionnaires. Notably, most of the participants had provided palliative or end-of-life care, but few had previous education specific to pediatrics. The self-efficacy scores of the participants significantly increased after program attendance (
= 3.53,
< .001). Conclusion Continuing professional development in pediatric palliative care improves nurses' and advanced practice registered nurses' confidence in their skills to provide this care. Findings of this study support the need for pediatric-specific education in nursing training programs and continuing professional development offerings. Continuing education may be the key to improving access to high-quality care for children living with serious illness and their families.
.
Limited data are available for long-term outcomes of pediatric patients with abdominal abscess or phlegmon at diagnosis of Crohn disease.
We performed a retrospective chart review of such children ...over a recent 6-year period at 5 pediatric inflammatory bowel diseases.
Fifty-two patients (mean age 15.9 ± 1.8 years) were reviewed. Thirty-six had an abscess and 27 (75%) required resectional therapy compared to 16 with phlegmon which 10 (63%) requiring surgery. Overall (37/52) 71% had surgery which was performed within 6 months in 32 (86%).
A similar high surgical rate exists whether pediatric patients with Crohn disease present with abscess or phlegmon.
PDF
