To identify factors associated with continuous positive airway pressure (CPAP) and/or intubation for children with bronchiolitis.
We performed a 16-center, prospective cohort study of hospitalized ...children aged <2 years with bronchiolitis. For 3 consecutive years from November 1 until March 31, beginning in 2007, researchers collected clinical data and a nasopharyngeal aspirate from study participants. We oversampled children from the ICU. Samples of nasopharyngeal aspirate were tested by polymerase chain reaction for 18 pathogens.
There were 161 children who required CPAP and/or intubation. The median age of the overall cohort was 4 months; 59% were male; 61% white, 24% black, and 36% Hispanic. In the multivariable model predicting CPAP/intubation, the significant factors were: age <2 months (odds ratio OR 4.3; 95% confidence interval CI 1.7-11.5), maternal smoking during pregnancy (OR 1.4; 95% CI 1.1-1.9), birth weight <5 pounds (OR 1.7; 95% CI 1.0-2.6), breathing difficulty began <1 day before admission (OR 1.6; 95% CI 1.2-2.1), presence of apnea (OR 4.8; 95% CI 2.5-8.5), inadequate oral intake (OR 2.5; 95% CI 1.3-4.3), severe retractions (OR 11.1; 95% CI 2.4-33.0), and room air oxygen saturation <85% (OR 3.3; 95% CI 2.0-4.8). The optimism-corrected c-statistic for the final model was 0.80.
In this multicenter study of children hospitalized with bronchiolitis, we identified several demographic, historical, and clinical factors that predicted the use of CPAP and/or intubation, including children born to mothers who smoked during pregnancy. We also identified a novel subgroup of children who required mechanical respiratory support <1 day after respiratory symptoms began.
Objectives
The objectives were to assess the test characteristics of ultrasound (US) in diagnosing appendicitis in children and to evaluate site‐related variations based on the frequency of its use. ...Additionally, the authors assessed the test characteristics of US when the appendix was clearly visualized.
Methods
This was a secondary analysis of a prospective, 10‐center observational study. Children aged 3 to 18 years with acute abdominal pain concerning for appendicitis were enrolled. US was performed at the discretion of the treating physician.
Results
Of 2,625 patients enrolled, 965 (36.8%) underwent abdominal US. US had an overall sensitivity of 72.5% (95% confidence interval CI = 58.8% to 86.3%) and specificity 97.0% (95% CI = 96.2% to 97.9%) in diagnosing appendicitis. US sensitivity was 77.7% at the three sites (combined) that used it in 90% of cases, 51.6% at a site that used it in 50% of cases, and 35% at the four remaining sites (combined) that used it in 9% of cases. US retained a high specificity of 96% to 99% at all sites. Of the 469 (48.6%) cases across sites where the appendix was clearly visualized on US, its sensitivity was 97.9% (95% CI = 95.2% to 99.9%), with a specificity of 91.7% (95% CI = 86.7% to 96.7%).
Conclusions
Ultrasound sensitivity and the rate of visualization of the appendix on US varied across sites and appeared to improve with more frequent use. US had universally high sensitivity and specificity when the appendix was clearly identified. Other diagnostic modalities should be considered when the appendix is not definitively visualized by US.
Resumen
La Realización de Ecografía en el Diagnóstico de Apendicitis en Niños en una Cohorte Multicéntrica
Objetivos
Valorar las características diagnósticas de la ecografía (ECO) en el diagnóstico de la apendicitis en niños y evaluar las variaciones relacionadas con el hospital en base a la frecuencia de su uso. Adicionalmente, valorar las características diagnósticas de la ECO cuando el apéndice fue claramente visualizado.
Metodología
Análisis secundario de un estudio observacional prospectivo de 10 hospitales. Se incluyeron los niños de 3 a 18 años de edad con dolor abdominal agudo y sospecha de apendicitis. La ECO se realizó a criterio del médico que atendió al paciente.
Resultados
De los 2.625 pacientes incluidos, en 965 (36,8%) se realizó una ECO abdominal. La ECO tuvo una sensibilidad global del 72,5% (IC 95% = 58,8% a 86,3%) y una especificidad del 97,0% (IC 95% = 96,2% a 97,9%) en el diagnóstico de apendicitis. La sensibilidad de la ECO fue del 77,7% en los tres hospitales (combinada) que la usaron en el 90% de los casos, del 51,6% en un hospital que la usó en el 50% de los casos, y del 35% en los cuatro hospitales restantes (combinada) que la usaron en el 9% de los casos. La ECO tiene una alta especificidad, del 96% al 99%, en todos los centros. De los 469 (48,6%) casos donde la apéndice se visualizó claramente en la ECO, su sensibilidad fue del 97,9% (IC 95% = 95,2% a 99,9%), con una especificidad del 91,7% (IC 95% = 86,7% a 96,7%).
Conclusiones
La sensibilidad de la ECO y el porcentaje de visualización del apéndice en la ECO variaron entre los diferentes hospitales y parece mejorar cuanto más frecuente es su uso. La ECO tiene una alta sensibilidad y especificidad de forma universal cuando el apéndice se identifica claramente. Otras modalidades diagnósticas deberían ser consideradas cuando el apéndice no se visualiza de forma definitiva por la ECO.
Background Recent genetic evidence supports that an underlying defect in skin barrier function contributes to the pathogenesis of atopic dermatitis (AD). The integrity of the skin barrier can be ...assessed objectively by measuring transepidermal water loss (TEWL). Previous investigations of TEWL as a biomarker of skin barrier function have been limited by small sample size, and studies including African American subjects are lacking. Objective We sought to determine whether children with AD have inherently altered skin barrier function by comparing TEWL as a measure of skin barrier function in African American and white children with AD with that in control subjects without AD. Methods TEWL was measured on nonlesional normal-appearing skin at 4 sites (the volar forearm, dorsal arm, lower leg, and cheek) in (1) children with AD (cases), (2) children with asthma or allergic rhinitis but without AD (allergic control subjects), and (3) nonatopic control subjects. AD severity was assessed by using the objective SCORAD index. Results TEWL was increased in children with AD compared with that seen in both control groups at most of the anatomic sites tested ( P < .05). TEWL also correlated with objective SCORAD score. The presence of allergic sensitization or other allergic conditions did not affect TEWL among children with AD. TEWL was higher in white than in African American children. Conclusion Skin barrier function as assessed by TEWL is intrinsically compromised in children with AD but not in children with other allergic conditions. The magnitude of skin barrier dysfunction correlates with AD disease severity.
The educational requirements for pediatric fellows include at least 12 months of scholarly activity and generation of a work product. Yet there lacks detailed guidance on how programs can best ...integrate scholarly activity training into fellowships. Our objectives were to understand the resources and barriers to training and identify factors associated with productivity.
We surveyed pediatric fellowship program directors (FPDs) nationally in 2019. Data analysis included descriptive statistics, χ
and Fisher's exact tests, and multivariable modeling to identify factors associated with high productivity (>75% of fellows in the past 5 years had an article from their fellowship accepted).
A total of 499 of 770 FPDs responded (65%). A total of 174 programs (35%) were highly productive. The most frequent major barriers were a lack of funding for fellows to conduct scholarship (21%,
= 105) and lack of sufficient divisional faculty mentorship (16%,
= 79). The median number of months for scholarship with reduced clinical obligations scholarship was 17. A total of 40% (
= 202) of FPDs believed training should be shortened to 2 years for clinically oriented fellows. Programs with a T32 and a FPD with >5 publications in the past 3 years were twice as likely to be productive. Not endorsing lack of adequate Scholarship Oversight Committee expertise and a research curriculum as barriers was associated with increased productivity (odds ratio = 1.83-1.65).
Despite significant protected fellow research time, most fellows do not publish. Ensuring a program culture of research may provide the support needed to take projects to publication. The fellowship community may consider reevaluating the fellowship duration, particularly for those pursing nonresearch focused careers.
Study objective Advanced imaging with computed tomography (CT) or ultrasonography is frequently used to evaluate for appendicitis. The duration of the abdominal pain may be related to the stage of ...disease and therefore the interpretability of radiologic studies. Here, we investigate the influence of the duration of pain on the diagnostic accuracy of advanced imaging in children being evaluated for acute appendicitis. Methods A secondary analysis of a prospective multicenter observational cohort of children aged 3 to 18 years with suspected appendicitis who underwent CT or ultrasonography was studied. Outcome was based on histopathology or telephone follow-up. Treating physicians recorded the duration of pain. Imaging was coded as positive, negative, or equivocal according to an attending radiologist's interpretation. Results A total of 1,810 children were analyzed (49% boys, mean age 10.9 years SD 3.8 years); 1,216 (68%) were assessed by CT and 832 (46%) by ultrasonography (238 13% had both). The sensitivity of ultrasonography increased linearly with increasing pain duration (test for trend: odds ratio=1.39; 95% confidence interval 1.14 to 1.71). There was no association between the sensitivity of CT or specificity of either modality with pain duration. The proportion of equivocal CT readings significantly decreased with increasing pain duration (test for trend: odds ratio=0.76; 95% confidence interval 0.65 to 0.90). Conclusion The sensitivity of ultrasonography for appendicitis improves with a longer duration of abdominal pain, whereas CT demonstrated high sensitivity regardless of pain duration. Additionally, CT results (but not ultrasonographic results) were less likely to be equivocal with longer duration of abdominal pain.
Background: Disparities in outcomes for children with type 1 diabetes (T1DM) are associated with poverty and race. However, little is known regarding the impact of systemic racism.
Objective: This ...aim of this study is to determine if neighborhood concentrated disadvantage index (NCDI) or Childhood Opportunity Index (COI) are associated with HbA1c and diabetes ketoacidosis (DKA) in children ≤ 18 years of age with type 1 diabetes.
Methods: The retrospective secondary data analysis included data from children ≤ 18 years of age with a diagnosis of T1DM for ≥ 6 months seen in 2017 who reside in Kentucky (n=675) . NCDI scores were calculated based on the NIH PhenX Toolkit protocol. The tool was developed from a principal components analysis of six variables at the census tract level. COI was obtained from diversitydatakids.org. Univariate analyses were performed using Kruskal-Wallis test or Pearson’s correlation. Multiple linear regression analysis was conducted to to evaluate HbA1C and multivariate Poisson model was used for DKA.
Results: Prior to controlling for age, race, and insurance type, NCDI (p<0.001) and COI (p< 0.001) were significant predictors for HbA1c. For every 1 unit increase in COI, the predicted value of AIc level decreased by 8.66 (p=0.0004) . NCDI and COI were not significant when controlling for age, race, and insurance. NCDI and COI were not significant predictors of DKA episodes.
Conclusions: This study identified NCDI and COI as predictors of HbA1c in children and adolescents with T1DM only in univariate analysis. While NCDI and COI have been shown to correlate with structural racism, these findings suggest that more research is needed in larger and more diverse samples to disentangle the complex relationships among race, racism, and poverty. Understanding the mechanisms through which racism impacts outcomes for children with T1DM is essential to improving health equity.
Disclosure
M.B.Coriell: None. K.S.Jawad: None. Y.B.Feygin: None. S.Watson: None. M.D.Stevenson: None. B.A.Wattles: Research Support; Merck & Co., Inc. V.F.Jones: None. J.Porter: None. D.W.Davis: None.
Abstract Objective Among children hospitalized with bronchiolitis, we examined the associations between in utero exposure to maternal cigarette smoking, postnatal tobacco smoke exposure, and risk of ...admission to the intensive care unit (ICU). Methods We performed a 16-center, prospective cohort study of hospitalized children aged <2 years with a physician admitting diagnosis of bronchiolitis. For 3 consecutive years, from November 1, 2007 until March 31, 2010, site teams collected data from participating families, including information about prenatal maternal smoking and postnatal tobacco exposure. Analyses used chi-square, Fisher's exact, and Kruskal-Wallis tests and multivariable logistic regression. Results Among 2207 enrolled children, 216 (10%) had isolated in utero exposure to maternal smoking, 168 (8%) had isolated postnatal tobacco exposure, and 115 (5%) experienced both. Adjusting for age, sex, race, birth weight, viral etiology, apnea, initial severity of retractions, initial oxygen saturation, oral intake, and postnatal tobacco exposure, children with in utero exposure to maternal smoking had greater odds of being admitted to the ICU (adjusted odds ratio aOR 1.51, 95% confidence interval CI 1.14–2.00). Among children with in utero exposure to maternal smoking, those with additional postnatal tobacco exposure had a greater likelihood of ICU admission (aOR 1.95, 95% CI 1.13–3.37) compared to children without postnatal tobacco smoke exposure (aOR 1.47, 95% CI 1.05–2.04). Conclusions Maternal cigarette smoking during pregnancy puts children hospitalized with bronchiolitis at significantly higher risk of intensive care use. Postnatal tobacco smoke exposure may exacerbate this risk. Health care providers should incorporate this information into counseling messages.
IMPORTANCE: Influenza is a significant public health burden, causing morbidity and mortality in children, yet vaccination rates remain low. Vaccination in the pediatric emergency department (PED) ...setting may be beneficial but, to date, has not been proven to be cost-effective. OBJECTIVE: To compare the cost-effectiveness of 4 strategies for PED-based influenza vaccine: offering vaccine to all patients, only to patients younger than 5 years, only to high-risk patients (all ages), or to no patients. DESIGN, SETTING, AND PARTICIPANTS: Using commercial decision analysis software, a cost-effectiveness analysis was performed from January 1, 2016, to June 1, 2017, to compare influenza vaccine strategies at a tertiary, urban, freestanding PED with an estimated 60 000 visits per year among a hypothetical cohort of children visiting the above PED during influenza season. Sensitivity analyses estimated the effect of uncertainties across a variety of input variables (eg, influenza prevalence, vaccine price and effectiveness, and costs of complications). MAIN OUTCOMES AND MEASURES: The primary outcomes were cost and incremental cost-effectiveness ratio in dollars per influenza case averted. Secondary outcomes included total societal costs, hospitalizations and deaths averted, and quality-adjusted life-years gained. RESULTS: Offering influenza vaccine to all eligible patients has the lowest cost, at $114.45 (95% CI, $55.48-$245.45) per case of influenza averted. This strategy saves $33.51 (95% CI, $18-$62) per case averted compared with no vaccination, and averages 27 fewer cases of influenza per 1000 patients. Offering vaccine to all patients resulted in 0.72 days (95% CI, 0.18-1.78 days) of quality-adjusted life-years lost, whereas offering to none resulted in 0.91 days (95% CI, 0.25-2.2 days) of quality-adjusted life-years lost. In sensitivity analyses, this strategy remains robustly cost-effective across a wide range of assumptions. In addition to being the most cost-effective strategy regardless of age or risk status, routine vaccination in the PED results in a net societal monetary benefit under many circumstances. In Monte Carlo analysis, offering vaccine to all patients was superior to other strategies in at least 99.8% of cases. CONCLUSIONS AND RELEVANCE: Although few PEDs routinely offer influenza vaccination, doing so appears to be cost-effective, with the potential to significantly reduce the economic (and patient) burden of pediatric influenza.
Background
Scholarly activity training is a required component of pediatric pulmonology fellowship programs. However, there are no data on resources and barriers to training and factors associated ...with fellow productivity.
Methods
We surveyed US pediatric pulmonology fellowship program directors (FPDs) between March and October 2019. Our primary outcome was fellow productivity (>75% of fellows in the past 5 years had a manuscript accepted in a peer‐reviewed journal). Analyses included descriptive statistics, χ2 and Fisher's exact tests for categorical values, and t‐test or Wilcoxon rank‐sum test for numerical values.
Results
Sixty‐one percent (33/54) of FPDs completed the survey. Seventy‐nine percent reported that most fellows completed clinical, basic science, or translational research. However, only 21% reported that most fellows pursued research positions after graduation; academic clinical positions were more common. For 21%, lack of funding and competing clinical responsibilities were barriers to completing the scholarly activity. Only 39% had highly productive programs; those FPDs were more likely to be highly satisfied with fellow scholarly activity products (p = 0.049) and have >6 publications in the previous 3 years (p = 0.03). Fifty‐two percent of FPDs believed that pediatric pulmonary training should be shortened to 2 years for those pursuing clinical or clinician‐educator careers.
Conclusions
Barriers to scholarly activity training in pediatric pulmonology programs threaten the pipeline of academic pediatric pulmonologists and physician‐investigators. Aligning fellow scholarly activity and clinical training with the skills required in their postgraduate positions could optimize the utilization of limited resources and better support career development.
OBJECTIVESTo determine rates of influenza immunization among children treated in a pediatric emergency department (ED) and to ascertain parent willingness for children to receive influenza vaccine ...(IV) in the ED.
METHODSInterviews were conducted with parents of children 6 months or older evaluated in the ED for minor illness or injury. Demographic data, IV history, and intent and willingness to receive future IV were recorded during the summer of 2013. Participants were contacted in March 2014 to assess IV status, barriers to obtaining IV, and willingness to obtain IV in the ED. Chart review determined number of patients who were at high risk.
RESULTSOf 457 families approached, 285 (62%) were enrolled. Two hundred forty-two (85%) intended to vaccinate; 83% reported willingness to receive IV at a future ED visit. Common reasons for not receiving IV were concerns about adverse effects (31%) and lack of time or interest (24%). Of the 224 participants (79%) reached in follow-up, 112 (50%) had received IV in the prior season. Among those who did not receive IV, 65 (66%) had intended to vaccinate, and 54 (55%) indicated they would have accepted IV in the ED. Fifty-three (54%) of unvaccinated patients at follow-up had high risk of influenza complications.
CONCLUSIONSOur data support an IV program in the pediatric ED as a means of increasing vaccination rates, particularly among high-risk patients. Parents are often concerned about adverse effects of IV, and providers should target education in this area.
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