Prevalence and impact of psychiatric disorders on hospitalized pediatric patients with chronic pancreatitis

BACKGROUND

Patients with chronic pancreatitis (CP) often have a debilitating clinical course characterized by high disease burden, and poor quality of life and these factors adversely affect mental health. However, there is paucity of literature on the prevalence and impact of psychiatric disorders on hospitalized pediatric patients with CP.

METHOD

ology: We analyzed the Kids Inpatient Database, and National Inpatient Sample, between 2003 and 2019 and included patients up to 21 years of age. Pediatric CP patients with psychiatric disorders were compared with patients without any of the psychiatric disorders using the ICD diagnostic codes. Various demographic and clinical factors were compared between the groups. Length of hospitalization and total hospital charges were used as surrogates to compare the hospital resource utilization between the groups.

RESULTS

We analyzed a total of 9,808 hospitalizations with CP and the overall prevalence rate of psychiatric disorders was 19.8%. The prevalence rate increased from 19.1% in 2003 to 23.4% in 2019, p = 0.006. The peak prevalence rate of 37.2% was noted at 20 years of age. Depression was noted at 7.6% of the total hospitalizations followed by substance abuse (6.5%), and anxiety (4.4%). Multivariate linear regression analysis showed that among CP patients, psychiatric disorders were independently associated with 1.3 additional days of stay and incurred $15,965 higher charges.

CONCLUSIONS

The prevalence of psychiatric disorders is increasing in pediatric CP. The concomitant presence of psychiatric disorders was found to be associated with prolonged hospital stay and incurred higher healthcare charges than those CP patients without psychiatric disorders.

Cytomegalovirus Infection Is Associated With Adverse Outcomes Among Hospitalized Pediatric Patients With Inflammatory Bowel Disease

Background

Adults with inflammatory bowel disease (IBD) are at increased risk of developing cytomegalovirus (CMV) colitis, which is associated with adverse outcomes. Similar studies in pediatric IBD patients are lacking.

Methods

We analyzed non-overlapping years of National Inpatient Sample (NIS) and Kids Inpatient Database (KID) between 2003 and 2016. We included all patients < 21 years with a diagnosis of Crohn's disease (CD) or ulcerative colitis (UC). Patients with coexisting CMV infection during that admission were compared with patients without CMV infection for outcome measures such as in-hospital mortality, disease severity, and healthcare resource utilization.

Results

We analyzed a total of 254,839 IBD-related hospitalizations. The overall prevalence rate of CMV infection was 0.3% with an overall increasing prevalence trend, P < 0.001. Approximately two-thirds of patients with CMV infection had UC, which was associated with almost 3.6 times increased risk of CMV infection (confidence interval (CI): 3.11 to 4.31, P < 0.001). IBD patients with CMV had more comorbid conditions. CMV infection was significantly associated with increased odds of in-hospital mortality (odds ratio (OR): 3.58; CI: 1.85 to 6.93, P < 0.001) and severe IBD (OR: 3.31; CI: 2.54 to 4.32, P < 0.001). CMV-related IBD hospitalizations had increased length of stay by 9 days while incurring almost $65,000 higher hospitalization charges, P < 0.001.

Conclusions

The prevalence of CMV infection is increasing in pediatric IBD patients. CMV infections significantly corelated with increased risk of mortality and severity of IBD leading to prolonged hospital stay and higher hospitalization charges. Further prospective studies are needed to better understand the factors leading to this increasing CMV infection.

Increasing incidence of acute kidney injury in pediatric severe sepsis and related adverse hospital outcomes

BACKGROUND

Pediatric severe sepsis (PSS) is associated with increased mortality, and acute kidney injury (AKI) is an independent risk factor of mortality in PSS. However, there is little data on impact of AKI on hospital outcomes in PSS.

METHODS

We analyzed non-overlapping years of the Kids' Inpatient Database (KID) and National Inpatient Sample (NIS) database between 2003 and 2019 of all pediatric patients with severe sepsis between 1 and 18 years of age. Using ICD diagnosis codes, patients were divided into two groups based on AKI status and compared for outcomes measures including in-hospital mortality and healthcare resource utilization using length of stay and inflation-adjusted hospitalization charges.

RESULTS

We analyzed 192,712 hospitalizations due to PSS during the 17-year period. Prevalence of AKI was 23.6% with overall increasing trend, P<0.001. Prevalence of AKI was significantly increased in patients with diabetes mellitus, organ transplantation, HIV, urinary tract anomalies, and malnutrition, P<0.001. Mortality rate was significantly higher among patients with AKI (19.8% vs. 8.1%, P<0.001). PSS with AKI had significantly higher median length of stay (14 vs. 11 days) and total hospitalization charges ($168,106 vs. 100,906), P<0.001. Multivariate logistic regression analysis showed that AKI without kidney replacement therapy (KRT) was associated with 3.02 times increased odds of mortality (95% CI 2.99-3.17, P<0.001) and those requiring KRT had 6.4 times increased odds of mortality (95%CI 6.1-6.7, P<0.001). AKI without KRT was associated with 7.7 (95% CI 7.3-8.05) additional days of hospitalization and 154,536 (95% CI 149,500-159,572) additional US dollars in hospitalization charges.

CONCLUSION

Almost 1 in 4 hospitalizations with PSS had AKI and was associated with >3 times increased risk of mortality and need for KRT further adversely impacts mortality and healthcare utilization. A higher resolution version of the Graphical abstract is available as Supplementary information.

Rising Burden of Psychiatric and Behavioral Disorders and Their Adverse Impact on Health Care Expenditure in Hospitalized Pediatric Patients with Inflammatory Bowel Disease

PURPOSE

The incidence and prevalence of inflammatory bowel disease (IBD) are increasing along with an increasing number of patients with comorbid conditions like psychiatric and behavioral disorders, which are independent predictors of quality of life.

METHODS

Non-overlapping years (2003-2016) of National Inpatient Sample and Kids Inpatient Database were analyzed to include all IBD-related hospitalizations of patients less than 21 years of age. Patients were analyzed for a concomitant diagnosis of psychiatric/behavioral disorders and were compared with IBD patients without psychiatric/behavioral disorder diagnoses for outcome variables: IBD severity, length of stay and inflation-adjusted hospitalization charges.

RESULTS

Total of 161,294 IBD-related hospitalizations were analyzed and the overall prevalence rate of any psychiatric and behavioral disorders was 15.7%. Prevalence rate increased from 11.3% (2003) to 20.6% (2016), p<0.001. Depression, substance use, and anxiety were the predominant psychiatric disorders. Regression analysis showed patients with severe IBD (odds ratio [OR], 1.57; confidence interval [CI], 1.47-1.67; p<0.001) and intermediate IBD (OR, 1.14; CI, 1.10-1.28, p<0.001) had increased risk of associated psychiatric and behavioral disorders than patients with a low severity IBD. Multivariate analysis showed that psychiatric and behavioral disorders had 1.17 (CI, 1.07-1.28; p<0.001) mean additional days of hospitalization and incurred additional $8473 (CI, 7,520-9,425; p<0.001) of mean hospitalization charges, independent of IBD severity.

CONCLUSION

Prevalence of psychiatric and behavioral disorders in hospitalized pediatric IBD patients has been significantly increasing over the last two decades, and these disorders were independently associated with prolonged hospital stay, and higher total hospitalization charges.

Prevalence of Metabolic Syndrome in Young Adults With Congenital Heart Disease

Adults with congenital heart disease (ACHD) are at risk of developing metabolic syndrome (MetS) at a younger age. We sought to obtain the prevalence of MetS in ACHD from a large population-based database in the United States. We conducted a retrospective cohort study of patients with ACHD in Explorys (IBM Inc., Armonk, New York) database from 2008 to 2019. The ACHD cohort included patients aged 20 to 39 years, with moderate and severe congenital heart disease, as defined by ACHD anatomic and physiologic classification. Patients were diagnosed with MetS using the modified International Diabetes Federation's diagnostic criteria. Logistic regression analysis was performed to compare the risk of MetS in the ACHD cohort. MetS was diagnosed in 1,860 of 6,720 patients with ACHD (27.6%). Among 7,359,470 controls, MetS was seen in 742,010 (10.1%). The average age of MetS in ACHD was 31.5 and 32.7 years in controls (p <0.001). The risk of MetS was higher in ACHD versus controls (odds ratio [OR] 2.75 [2.61 to 2.89], p <0.001). The risk of MetS in ACHD was higher in men (OR 3.01 [2.78 to 3.26], p <0.001) and those aged <25 years (men OR 7.57 [6.31 to 9.07], women OR 4.66 [3.85 to 5.63]; p <0.001). The risk of MetS was higher in patients with severe versus moderate ACHD (OR 1.4 [1.56 to 1.74], p <0.001). In conclusion, MetS and its risk factors are more common in young ACHD than in the general population.

Acute Pancreatitis Is Associated with Increased Risk of In-Hospital Mortality and Health Care Utilization Among Pediatric Patients with Hematopoietic Stem Cell Transplantation

OBJECTIVE

To analyze the impact of acute pancreatitis on mortality and hospital outcomes among the pediatric population following hematopoietic stem cell transplantation (HSCT).

STUDY DESIGN

We analyzed nationally representative, nonoverlapping years of the National Inpatient Sample and Kids Inpatient Database between 2003 and 2016, including all pediatric patients who had HSCT. Patients were divided into those with and without a diagnosis of acute pancreatitis and compared for demographics, clinical characteristics, comorbid conditions related to both HSCT and acute pancreatitis, and outcome measures such as in-hospital mortality and health care resource use (length of hospital stay and total hospitalization charges).

RESULTS

We analyzed a total of 128 772 hospitalizations of children and adolescents with HSCT. The overall incidence rate of acute pancreatitis was approximately 1%, with an overall increasing trend between 2003 and 2016, P < .001. The overall mortality rate was significantly greater among patients with acute pancreatitis (14.9% vs 3.6%, P < .001). Multivariate regression analysis showed that acute pancreatitis was independently associated with 3.4 times (95% CI 2.86-4.02, P < .001) increased risk of in-hospital mortality. Patients with acute pancreatitis who underwent HSCT had a greater incidence of end-organ damage and thrombotic events. Pediatric acute pancreatitis was associated with 24.3 additional days of hospitalization (95% CI 22.9-25.7, P < .001) and incurred additional $213 496 in hospitalization charges (95% CI 193 768-233 063, P < .001).

CONCLUSIONS

Pediatric recipients of HSCT who develop acute pancreatitis have adverse outcomes with increased in-hospital mortality, end-organ damage, prolonged hospital stay, and greater hospitalization charges.

Cystic fibrosis-related liver disease is an independent risk factor for mortality and increased health care resource utilization in hospitalized pediatric patients with cystic fibrosis

BACKGROUND

Cystic fibrosis-related liver disease (CFLD) is more prevalent in recent decades due to the increasing life expectancy of patients with cystic fibrosis (CF). There is paucity of population-level data on the impact of CFLD on hospital outcomes.

METHODS

We interrogated nonoverlapping years (2003-2016) of the National Inpatient Sample and Kids' Inpatient Database to include all hospitalized patients <21 years of age with a primary diagnosis of CF within the United States. A concomitant diagnosis of cirrhosis, liver fibrosis, chronic liver disease, portal hypertension, hepatomegaly, splenomegaly, hypersplenism, and liver transplant status was considered as surrogates for the diagnosis of CFLD and was compared with CF-related hospitalizations without these diagnoses (controls) for demographics, comorbid conditions, in-hospital mortality, length-of-stay, and hospital charges.

RESULTS

We evaluated 94,374 CF-related hospitalizations. The prevalence of CFLD was 5.8%. The prevalence increased from 3.1% (2003) to a peak of 7.3% (2014) with an overall increasing trend, p < 0.001. Hospitalizations with CFLD had an increased prevalence of significant comorbidities: respiratory failure,lung transplant, pulmonary hypertension, diabetes mellitus, malnutrition, Clostridioides difficile infection, cholelithiasis, anemia, and need for parenteral nutrition, p < 0.001. Multivariate regression models showed CFLD as independently associated with 2.1 (95% confidence interval [CI]: 1.5 to 2.8) times increased risk of inpatient mortality, contributed to 1.1 (95% CI: 0.89 to 1.37) additional days of hospitalization, and incurring $14,852 (95% CI: 12,204 to 17,501) excess hospital charges, p < 0.001.

CONCLUSION

CFLD is associated with multiple comorbidities and is independently associated with increased risk of mortality and increased health care resource utilization in pediatric CF-related hospitalizations.

A Novel Patent Ductus Arteriosus Severity Score to Predict Clinical Outcomes in Premature Neonates

Background: Patent Ductus Arteriosus (PDA) in premature neonates has been associated with comorbidities including chronic lung disease (CLD), and death. However, the treatment of PDA remains controversial. There have been several echocardiographic variables previously used to determine the hemodynamic significance of PDA but their utility in early prediction of clinical outcomes is not well studied. Objective: The objective of our study was to evaluate the use of a severity scoring system incorporating markers of systemic under perfusion, pulmonary over perfusion and left ventricular (LV) function in predicting clinical outcomes in premature neonates. Methods: It is a single center prospective observational study involving newborns < 32 weeks’ gestation. An echocardiogram was done within seven days of life to measure variables previously known to predict severity of shunting in PDA including pulmonary perfusion index (PPI). Predictors of CLD/death were identified using multivariate logistic regression. A severity score was derived and its ability to predict clinical outcomes was tested using a receiver operating characteristic curve. Results: We studied 98 infants with a mean (SD) gestation of 28.9 ± 1.91 weeks and birth weight of 1228.06 ± 318.94 g, respectively. We identified five echocardiographic variables along with gestational age that was independently associated with the outcome variable (PPI, LV output, Superior Mesenteric Artery [SMA] Velocity Time Integral [VTI], Peak diastolic flow velocity in Pulmonary Vein [PV Vd], and reversal of flow in diastole in descending aorta [DFR]). The range of severity score was 0 (low risk) to 12 (high risk). A higher score was associated with the primary outcome variable of CLD/death (7.5 [1.2] vs. 3.6 [1.5], p < 0.001). Our severity score had an area under the curve of 0.97 (95% CI 0.93−0.99, p < 0.001) for predicting CLD/death. Conclusion: Our new PDA severity score of 5.5 has a sensitivity and specificity of 94% and 93%, and positive and negative predictive values of 94% and 93%, respectively.

Cancer Incidence, Mortality, Years of Life Lost, Years Lived With Disability, and Disability-Adjusted Life Years for 29 Cancer Groups From 2010 to 2019: A Systematic Analysis for the Global Burden of Disease Study 2019

IMPORTANCE

The Global Burden of Diseases, Injuries, and Risk Factors Study 2019 (GBD 2019) provided systematic estimates of incidence, morbidity, and mortality to inform local and international efforts toward reducing cancer burden.

OBJECTIVE

To estimate cancer burden and trends globally for 204 countries and territories and by Sociodemographic Index (SDI) quintiles from 2010 to 2019.

EVIDENCE REVIEW

The GBD 2019 estimation methods were used to describe cancer incidence, mortality, years lived with disability, years of life lost, and disability-adjusted life years (DALYs) in 2019 and over the past decade. Estimates are also provided by quintiles of the SDI, a composite measure of educational attainment, income per capita, and total fertility rate for those younger than 25 years. Estimates include 95% uncertainty intervals (UIs).

FINDINGS

In 2019, there were an estimated 23.6 million (95% UI, 22.2-24.9 million) new cancer cases (17.2 million when excluding nonmelanoma skin cancer) and 10.0 million (95% UI, 9.36-10.6 million) cancer deaths globally, with an estimated 250 million (235-264 million) DALYs due to cancer. Since 2010, these represented a 26.3% (95% UI, 20.3%-32.3%) increase in new cases, a 20.9% (95% UI, 14.2%-27.6%) increase in deaths, and a 16.0% (95% UI, 9.3%-22.8%) increase in DALYs. Among 22 groups of diseases and injuries in the GBD 2019 study, cancer was second only to cardiovascular diseases for the number of deaths, years of life lost, and DALYs globally in 2019. Cancer burden differed across SDI quintiles. The proportion of years lived with disability that contributed to DALYs increased with SDI, ranging from 1.4% (1.1%-1.8%) in the low SDI quintile to 5.7% (4.2%-7.1%) in the high SDI quintile. While the high SDI quintile had the highest number of new cases in 2019, the middle SDI quintile had the highest number of cancer deaths and DALYs. From 2010 to 2019, the largest percentage increase in the numbers of cases and deaths occurred in the low and low-middle SDI quintiles.

CONCLUSIONS AND RELEVANCE

The results of this systematic analysis suggest that the global burden of cancer is substantial and growing, with burden differing by SDI. These results provide comprehensive and comparable estimates that can potentially inform efforts toward equitable cancer control around the world.

Cyclic Vomiting Syndrome-Related Hospitalizations Trends, Comorbidities & Health Care Costs in Children: A Population Based Study

Aim: To analyze the clinical characteristics, trends in hospitalization and health care resource utilization of pediatric patients with cyclical vomiting syndrome (CVS). Methods: We analyzed the latest 5 Healthcare Cost and Utilization Project-Kids Inpatient Database (HCUP-KID) datasets including years 2003, 2006, 2009, 2012 and 2016 for patients aged 1–20 years with a primary diagnosis of CVS and were compared with Age/gender-matched controls for comorbidities, clinical outcomes, and healthcare resource utilization. Results: A total of 12,396 CVS-related hospitalizations were analyzed. The mean age of CVS patients was 10.4 ± 6.7 years. CVS was associated with dysautonomia (OR: 12.1; CI: 7.0 to 20.8), dyspepsia (OR: 11.9; CI: 8.8 to 16.03), gastroesophageal reflux disease (OR: 6.9; Confidence Interval (CI): 6.4 to 7.5), migraine headaches (OR: 6.8; CI: 5.9 to 7.7) and irritable bowel syndrome (OR: 2.08; CI: 1.2 to 4.3) (all p < 0.001). CVS was also associated with increased cannabis use (OR: 5.26, 4.6 to 5.9; p < 0.001), anxiety disorder (OR: 3.9; CI: 3.5 to 4.4) and stress reaction (OR: 3.6; CI: 2.06 to 6.3), p < 0.001. Mean CVS-related hospitalization costs (inflation adjusted) more than doubled from $3199 in 2003 to $6721 in 2016, incurring $84 million/year in total costs. Conclusion: Hospitalized CVS patients have increased prevalence of DGBIs, dysautonomia, psychiatric conditions and cannabis use compared to non-CVS controls. CVS-related hospitalizations in U.S. is associated with increasing health care costs. Better management of CVS and comorbid conditions is warranted to reduce health care costs and improve outcomes.

Clostridioides difficile Infection Is Associated with Adverse Outcomes among Hospitalized Pediatric Patients with Acute Pancreatitis

PURPOSE

Studies in adults have shown an increasing incidence of Clostridioides difficile infection (CDI) in patients hospitalized with acute pancreatitis (AP). There is lack of epidemiological data on CDI and its impact on hospitalized pediatric patients with AP.

METHODS

We analyzed the National Inpatient Sample and Kids' Inpatient Database between the years 2003 and 2016 and included all patients (age <21 years) with a primary diagnosis of AP using specific International Classification of Diseases codes. We compared clinical outcomes between children with CDI and those without CDI. Our primary outcome was severe AP and secondary outcomes included length of stay and hospital charges.

RESULTS

A total of 123,240 hospitalizations related to AP were analyzed and CDI was noted in 0.6% of the hospital. The prevalence rate of CDI doubled from 0.4% (2003) to 0.8% (2016), p=0.03. AP patients with CDI had increased comorbidities, and also underwent more invasive surgical procedures, p<0.05. AP patients with CDI had a higher in-hospital mortality rate and increased prevalence of severe AP, p<0.001. Multivariate regression models showed that CDI was associated with 2.4 times (confidence interval [CI]: 1.91 to 3.01, p<0.001) increased odds of severe AP. CDI patients had 7.24 (CI: 6.81 to 7.67, p<0.001) additional hospital days while incurring $59,032 (CI: 54,050 to 64,014, p<0.001) additional hospitalization charges.

CONCLUSION

CDI in pediatric patients with AP is associated with adverse clinical outcomes and increased healthcare resource utilization. Further studies are needed to elucidate this association to prevent the development of CDI and to improve outcomes.

The global burden of adolescent and young adult cancer in 2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

In estimating the global burden of cancer, adolescents and young adults with cancer are often overlooked, despite being a distinct subgroup with unique epidemiology, clinical care needs, and societal impact. Comprehensive estimates of the global cancer burden in adolescents and young adults (aged 15-39 years) are lacking. To address this gap, we analysed results from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, with a focus on the outcome of disability-adjusted life-years (DALYs), to inform global cancer control measures in adolescents and young adults.

METHODS

Using the GBD 2019 methodology, international mortality data were collected from vital registration systems, verbal autopsies, and population-based cancer registry inputs modelled with mortality-to-incidence ratios (MIRs). Incidence was computed with mortality estimates and corresponding MIRs. Prevalence estimates were calculated using modelled survival and multiplied by disability weights to obtain years lived with disability (YLDs). Years of life lost (YLLs) were calculated as age-specific cancer deaths multiplied by the standard life expectancy at the age of death. The main outcome was DALYs (the sum of YLLs and YLDs). Estimates were presented globally and by Socio-demographic Index (SDI) quintiles (countries ranked and divided into five equal SDI groups), and all estimates were presented with corresponding 95% uncertainty intervals (UIs). For this analysis, we used the age range of 15-39 years to define adolescents and young adults.

FINDINGS

There were 1·19 million (95% UI 1·11-1·28) incident cancer cases and 396 000 (370 000-425 000) deaths due to cancer among people aged 15-39 years worldwide in 2019. The highest age-standardised incidence rates occurred in high SDI (59·6 [54·5-65·7] per 100 000 person-years) and high-middle SDI countries (53·2 [48·8-57·9] per 100 000 person-years), while the highest age-standardised mortality rates were in low-middle SDI (14·2 [12·9-15·6] per 100 000 person-years) and middle SDI (13·6 [12·6-14·8] per 100 000 person-years) countries. In 2019, adolescent and young adult cancers contributed 23·5 million (21·9-25·2) DALYs to the global burden of disease, of which 2·7% (1·9-3·6) came from YLDs and 97·3% (96·4-98·1) from YLLs. Cancer was the fourth leading cause of death and tenth leading cause of DALYs in adolescents and young adults globally.

INTERPRETATION

Adolescent and young adult cancers contributed substantially to the overall adolescent and young adult disease burden globally in 2019. These results provide new insights into the distribution and magnitude of the adolescent and young adult cancer burden around the world. With notable differences observed across SDI settings, these estimates can inform global and country-level cancer control efforts.

FUNDING

Bill & Melinda Gates Foundation, American Lebanese Syrian Associated Charities, St Baldrick's Foundation, and the National Cancer Institute.

Prevalence and impact of acute kidney injury in hospitalized pediatric patients with acute pancreatitis

BACKGROUND

The incidence of acute pancreatitis (AP) in pediatric patients is rising with accompanying increased hospitalizations. Acute kidney injury (AKI) is associated with worse clinical outcomes in adults, and similar data in the pediatric age group is limited.

METHODS

We analyzed non-overlapping years of National Inpatient Sample (NIS) and Kids Inpatient Database (KID) to include all patients less than 21 years old with primary diagnosis of AP between 2003 and 2016. Patients with concomitant diagnosis of AKI were compared with patients without AKI for demographics, comorbid/etiologic conditions, procedures, complications, and mortality. Length of stay and inflation-adjusted hospitalization charges were used to compare health care resource utilization.

RESULTS

In total, 123,185 AP-related hospitalizations were analyzed. Overall prevalence of AKI among AP patients was 1.5% during the study period. The prevalence rate of AKI increased almost five-fold from 0.6% (2003) to a peak rate of 2.9% (2016), P < 0.001. Patients with AKI were older, more often male and had either more systemic diseases or chronic comorbid conditions such as malignancies, systemic lupus erythematosus, solid organ transplantation, hypertriglyceridemia, and hypercalcemia. Multivariate analysis demonstrated AP-related hospitalizations with AKI were 1.97 (CI 1.27-3.08, P < 0.001) times more likely to be associated with in-hospital mortality and contributed to 4.3 additional days of hospitalization (CI 4.02-4.6, P < 0.001), also incurring an additional $51,830 (CI 48571-55088, P < 0.001) in hospital charges.

CONCLUSION

The prevalence of AKI is increasing steadily among pediatric patients with AP and is associated with increased risk of mortality and higher health care resource expenditure.

Effect of obesity on mortality among hospitalized paediatric patients with severe sepsis

INTRODUCTION

Severe sepsis is one of the leading causes of mortality among children. Studies in adults have suggested a protective effect of obesity on mortality among patients hospitalized with sepsis. Paediatric studies evaluating similar relationship is lacking.

METHODS

We analysed non-overlapping years of the Kids Inpatient Database (KID) and National Inpatient Sample (NIS) database between 2003 and 2014 of all paediatric patients with severe sepsis (PSS) up to 20 years of age. PSS was defined using specific International Classification of Diseases (ICD) codes and modified Angus criteria. Using ICD-9 diagnosis codes, patients were divided into three mutually exclusive groups (obesity, morbid obesity and control groups), and these groups were compared for outcomes measures including in-hospital mortality and healthcare resource utilization using the length of stay and inflation-adjusted hospitalization charges.

RESULTS

We analysed 109 026 hospitalizations due to PSS. The prevalence rate of obesity was 1.5% (n = 1643), and morbid obesity was 1.05% (n = 1147). Multivariate regression models showed obesity was associated with 63% (OR 0.37, CI: 0.29-0.47, p < 0.001) and 54% reduction in mortality among PSS patients and patients with septic shock respectively. Contrastingly, morbid obesity was not associated with mortality among PSS patients and but was associated with 1.37 times (CI: 1.06-1.78, p = 0.01) increased risk of mortality among paediatric patients with septic shock.

CONCLUSIONS

Paediatric obesity is associated with reduced mortality among patients with PSS, with the exception of morbid obesity. Further prospective studies are needed to better understand the relationship between obesity and outcomes in PSS.

Early-Onset Cardiomyopathy After Pacemaker Implanted in a Preterm Infant With Congenital Complete Heart Block and Anti-Ro/SSA Antibodies

Congenital complete heart block is a potentially fatal complication that can occur in neonates whose mothers have autoimmune disorders; it has rarely been reported in the presence of Sjögren syndrome. Pacemaker implantation is recommended to treat rhythm abnormalities in these neonates. We report the case of a late-preterm infant with Sjögren-syndrome-antibody-induced complete heart block who underwent temporary bipolar epicardial pacing as a bridge to permanent pacemaker implantation. Soon after the pacemaker was implanted, takotsubo cardiomyopathy developed. To our knowledge, this is the first report of reversible cardiomyopathy after pacemaker implantation in an infant.

Feasibility of P wave Centric Ambulatory Electrocardiogram Monitoring in Infants and Young Children

P wave centric ambulatory electrocardiographic (ECG) monitoring has emerged as an important tool aiding the diagnosis of arrhythmias. However, their efficacy and user experience in infants and young children are not well established. A retrospective study was performed to detail clinical and user experience of ECG monitoring using the Carnation Ambulatory Monitor (CAM) patch (Bardy Diagnostics Inc., Seattle, WA) in patients less than 10 kg. Additionally, 2 different monitor locations (over the sternum and horizontal over the left axilla) were assessed to address the optimal placement in these patients. A total of 33 CAM reports from 25 patients, aged 0 to15 months were included in the study. Mean patient age was 4.2 months ± 5.0 and mean weight was 5.3 kg ± 2.4. Thirty-six percent of patients (9/25) had known congenital heart disease. Indications for monitoring included: tachyarrhythmia (15/33, 45%), bradyarrhythmia (6/33, 18%), ectopic rhythm (9/33, 27%), cardiac tumor (1/33, 1%), and prolonged QT interval (1/33, 1%). All CAM reports showed clear, identifiable P waves which were diagnostic and lead to changes in medical management for 30% of patients (e.g., medication adjustments or discharge from cardiology care). We found the upright placement over the sternum performed better than the horizontal placement over the left axilla for small infants and children less than 10 kg. A P wave centric single-lead ECG monitor is helpful in providing accurate diagnostics tracings in infants and small children aiding in their clinical management.

A Previously Healthy 18-Year-Old Male With Fever, Arrhythmia, and Shock

A male individual aged 18 years with no significant past medical history presented with fever, headache, dry cough, and chest pain. On clinical examination, he had tachycardia and hypotension needing intravenous fluid resuscitation and inotropic support. A chest radiograph revealed streaky lung opacities, and he was treated with antibiotics for suspected community-acquired pneumonia complicated by septic shock. Significant elevation of cardiac enzymes was noted, and there was a continued need for inotropes to maintain normotension. He also developed intermittent bradycardia, with serial electrocardiograms showing first-degree atrioventricular block, low-voltage QRS complexes, and ST-T wave changes and telemetry demonstrating junctional and ventricular escape rhythm. A complete workup for sepsis and acute myocarditis were performed to find the etiologic agent. Intravenous immunoglobulins were started to treat myocarditis, with eventual clinical improvement. He was eventually diagnosed with an unusual etiology for his illness. He was noted to still have intermittent ventricular escape rhythm on electrocardiograms on follow-up 2 weeks after discharge but continues to remain asymptomatic and in good health.

Prevalence of cardiac arrhythmias in cannabis use disorder related hospitalizations in teenagers from 2003 to 2016 in the United States

AIMS

Cannabis is an increasingly common recreational substance used by teenagers. However, there is limited data probing association of cardiac arrhythmias with marijuana use in this population.

METHODS AND RESULTS

We provide prevalence trends, disease burden and healthcare utilization of cardiac arrhythmias associated with cannabis use disorder (CUD) in hospitalized teenagers (13-20 years) using a large national administrative database in the United States from 2003-2016. We used partial least square regression analysis for assessing trends in prevalence of cardiac arrhythmias and multiple logistic regression to elucidate independent predictors of arrhythmias associated with CUD. Among all CUD related hospitalizations (n = 876, 431), 0.5% had arrhythmias. Prevalence trends of arrhythmias among CUD increased six-fold during the study period (P < 0.001). CUD was more prevalent in males and older teens (both P < 0.001). There was a significant risk for mortality when CUD was associated with arrhythmia (7.4% vs. 0.1%, P < 0.001). While mean length-of-stay (LOS) was shorter (4.4 vs. 5.4 days, P < 0.001) for patients with CUD, they incurred three times higher mean hospitalization charges when compared to CUD patients without arrhythmia ($45 959 vs. $18 986, P < 0.001). Both LOS and hospitalization charges showed an uptrend during the study period (P < 0.001). Congenital heart disease, congestive heart failure, hypertension, and obesity independently predicted arrhythmias in CUD while other substance abuse did not change the risk of arrhythmia in CUD.

CONCLUSION

Arrhythmia burden is increasing among teenagers with CUD, and co-occurrence of arrhythmia and CUD worsens hospital outcomes.

Undernutrition and Obesity Are Associated with Adverse Clinical Outcomes in Hospitalized Children and Adolescents with Acute Pancreatitis

Background: Adult studies demonstrated that extremes of nutritional status adversely impact clinical outcomes in acute pancreatitis (AP). With rising prevalence of undernutrition/obesity in children, we analyzed the effect of nutritional status on the clinical outcomes in children and adolescents with acute pancreatitis. Methodology: We analyzed the Kids’ Inpatient Database (KID) between 2003 and 2016 to include all patients with a primary diagnosis of AP using specific International Classification of Diseases (ICD) codes. We classified into (1) undernutrition, (2) obesity and (3) control groups, based on ICD codes, and we compared severe acute pancreatitis and healthcare utilization (length of stay and hospitalization costs). Results: Total number of AP admissions was 39,805. The prevalence of severe AP was higher in the undernutrition and obesity groups than the control group (15.7% vs. 5.8% vs. 3.5% respectively, p < 0.001). Multivariate analyses demonstrated that undernutrition and obesity were associated with 2.5 and 1.6 times increased risk of severe AP, p < 0.001. Undernutrition was associated with an additional six days of hospitalization and almost $16,000 in hospitalization costs. Obesity was associated with an additional 0.5 day and almost $2000 in hospitalization costs, p < 0.001. Conclusion: Undernutrition and obesity were associated with greater severity of AP, as well as prolonged hospitalization stay and costs. It is imperative for treating clinicians to be aware of these high-risk groups to tailor management and strive for improved outcomes.

Global Burden of Cardiovascular Diseases and Risk Factors, 1990-2019: Update From the GBD 2019 Study

Cardiovascular diseases (CVDs), principally ischemic heart disease (IHD) and stroke, are the leading cause of global mortality and a major contributor to disability. This paper reviews the magnitude of total CVD burden, including 13 underlying causes of cardiovascular death and 9 related risk factors, using estimates from the Global Burden of Disease (GBD) Study 2019. GBD, an ongoing multinational collaboration to provide comparable and consistent estimates of population health over time, used all available population-level data sources on incidence, prevalence, case fatality, mortality, and health risks to produce estimates for 204 countries and territories from 1990 to 2019. Prevalent cases of total CVD nearly doubled from 271 million (95% uncertainty interval [UI]: 257 to 285 million) in 1990 to 523 million (95% UI: 497 to 550 million) in 2019, and the number of CVD deaths steadily increased from 12.1 million (95% UI:11.4 to 12.6 million) in 1990, reaching 18.6 million (95% UI: 17.1 to 19.7 million) in 2019. The global trends for disability-adjusted life years (DALYs) and years of life lost also increased significantly, and years lived with disability doubled from 17.7 million (95% UI: 12.9 to 22.5 million) to 34.4 million (95% UI:24.9 to 43.6 million) over that period. The total number of DALYs due to IHD has risen steadily since 1990, reaching 182 million (95% UI: 170 to 194 million) DALYs, 9.14 million (95% UI: 8.40 to 9.74 million) deaths in the year 2019, and 197 million (95% UI: 178 to 220 million) prevalent cases of IHD in 2019. The total number of DALYs due to stroke has risen steadily since 1990, reaching 143 million (95% UI: 133 to 153 million) DALYs, 6.55 million (95% UI: 6.00 to 7.02 million) deaths in the year 2019, and 101 million (95% UI: 93.2 to 111 million) prevalent cases of stroke in 2019. Cardiovascular diseases remain the leading cause of disease burden in the world. CVD burden continues its decades-long rise for almost all countries outside high-income countries, and alarmingly, the age-standardized rate of CVD has begun to rise in some locations where it was previously declining in high-income countries. There is an urgent need to focus on implementing existing cost-effective policies and interventions if the world is to meet the targets for Sustainable Development Goal 3 and achieve a 30% reduction in premature mortality due to noncommunicable diseases.

Mosaic Trisomy 16 Associated with Left Lung Agenesis, Abnormal Left Arm, and Right Pulmonary Artery Stenosis: Expanding the Phenotype and Review of the Literature

Trisomy 16 is the most common autosomal trisomy found in spontaneous abortions with mosaic versions seen in survivors. However, surviving children have multiple congenital defects and are at risk of growth and developmental delay. We report an additional case of mosaic trisomy 16 diagnosed by amniocentesis and confirmed after birth. Our patient is the first documented case of living mosaic trisomy 16 with the malformation constellation of lung agenesis, left pulmonary artery agenesis, congenital heart defects, and ipsilateral radial ray and limb abnormalities, expanding the phenotype of this rare condition. Additionally, this individual's unique combination of lung and cardiac defects caused morbidities that were challenging to manage and complicated family counseling as well.

Epidemiology, Clinical and Microbiologic Profile and Risk Factors for Inpatient Mortality in Pediatric Severe Sepsis in the United States From 2003 to 2014: A Large Population Analysis

OBJECTIVE

To evaluate the national trends in pediatric severe sepsis in the United States from 2003 to 2014.

STUDY DESIGN

For this study, we included nonoverlapping years of Kids Inpatient database and National Inpatient Sample database while including hospitalizations of children between 1 and 20 years of age from more than 4200 hospitals across the United States. We identified patient hospitalizations with severe sepsis using specific ICD codes and modified Angus Criteria. Trend analysis of various factors associated with severe sepsis was calculated using the Cochrane-Armitage test. Associated foci of infection and comorbid conditions were identified using specific ICD codes, and a multivariate regression analysis with death as outcome variable was done to evaluate for in hospital predictors of mortality.

RESULTS

Totally, 109,026 episodes of severe sepsis were identified during the study period between 2003 and 2014. Incidence of severe sepsis hospitalizations increased by 2.5 times (0.64-1.57 per 10,000 population) over the study period with notable concurrent significant decrease in mortality by more than 50%. Lower age, African American, Hispanic ethnicity, complex neurologic conditions, infective endocarditis, immunodeficient states including primary immunodeficiency disorder, HIV, burns, malignancy and transplant status are associated with mortality. There is a significant increase in use of healthcare resources (P < 0.001) with mean charges of 94,966$ despite a notable decrease in mean length of stay (22 vs. 16 days, P < 0.001) over the study period.

CONCLUSION

Incidence of pediatric severe sepsis is high leading to a significant use of healthcare resources. This study provides a detailed analysis of associated inpatient factors and comorbidities associated with mortality.

The increasing prevalence and adverse impact of morbid obesity in paediatric acute pancreatitis

OBJECTIVE

Morbid obesity is proinflammatory has been associated with adverse clinical outcomes in acute pancreatitis (AP) among adults. Obesity is increasingly prevalent in children and hence, we sought to evaluate the impact of morbid obesity on the clinical outcomes of AP using a large paediatric population-based cohort.

METHODS

We analysed the US Kids' Inpatient Database between years 2003 and 2016 to include all patients (age ≤ 21 years) with a primary diagnosis of AP using specific ICD-9-CM and ICD-10-CM codes. We compared clinical outcomes between children without obesity (controls) and those with morbid obesity (cases). The primary outcome was severe AP (2012 revised Atlanta classification) and secondary outcomes included healthcare resource utilization (length of stay and hospital costs).

RESULTS

Among 36 698 paediatric AP hospitalizations, 1275 (3.5%) were found to have morbid obesity. From 2003 to 2016, the proportion of children with morbid obesity among AP patients increased from 1.3% to 5.5% (P < .001). More than half (54%) of the children with morbid obesity were presented with cholelithiasis as contributive aetiology. The prevalence of severe AP was significantly higher in morbid obesity (7.3% vs 3.8%, P < .001). Multivariate analysis revealed that morbid obesity was increasingly associated with severe AP (OR 1.79, 95% CI 1.4, 2.26), prolonged hospitalization (by 0.41 days, P = .03), and higher hospital costs (by $1596, P < .001).

CONCLUSION

Unlike adult population, there is a lack of other confounding comorbidities in children and this national-level analysis shows that morbid obesity independently prognosticates adverse clinical outcomes in paediatric AP.