Racial and Ethnic Differences in Hospital Admission and Diagnostic Evaluation for Febrile Seizures in the Emergency Department

OBJECTIVE

To examine differences in hospital admission and diagnostic evaluation for febrile seizure by race and ethnicity.

STUDY DESIGN

We conducted a cross-sectional study among children 6 months to 6 years with simple or complex febrile seizure between January 1, 2016, and December 31, 2021, utilizing data from the Pediatric Health Information System. The primary outcome was hospital admission. Secondary outcomes included the proportion of encounters with neuroimaging or lumbar puncture. We used mixed-effects logistic regression model with random intercept for hospital and patient to estimate the association between outcomes and race and ethnicity after adjusting for covariates, including seizure type.

RESULTS

In total, 94,884 encounters were included. Most encounters occurred among children of non-Hispanic White (37.0%), Black (23.9%), and Hispanic/Latino (24.6%) race and ethnicity. Black and Hispanic/Latino children had 29% (aOR 0.71; 95% CI: 0.66, 0.75) and 26% (aOR 0.74; 95% CI: 0.69, 0.80) lower odds of hospital admission compared with non-Hispanic White children, respectively. Black and Hispanic/Latino children had 21% (aOR 0.79; 95% CI: 0.73, 0.86) and 22% (aOR 0.78; 95% CI: 0.71, 0.85) lower adjusted odds of neuroimaging compared with non-Hispanic White children. For complex febrile seizure, the adjusted odds of lumbar puncture was significantly higher among Asian children (aOR 2.12; 95% CI: 1.19, 3.77) compared with non-Hispanic White children. There were no racial differences in the odds of lumbar puncture for simple febrile seizure.

CONCLUSIONS

Compared with non-Hispanic White children, Black and Hispanic/Latino children with febrile seizures are less likely to be hospitalized or receive neuroimaging.

Prenatal and postpartum depression diagnosis in a large health system: prevalence and disparities

BACKGROUND/OBJECTIVES/INTRODUCTION

Depression during pregnancy or postpartum carries the same risks as general depression as well as additional risks specific to pregnancy, infant health and maternal well-being. The purpose of this study is to document the prevalence of depression symptoms and diagnosis during pregnancy and in the first 3 months postpartum among a cohort of women receiving prenatal care in a large health system. Secondarily, we examine variability in screening results and diagnosis by race, ethnicity, language, economic status and other maternal characteristics during pregnancy and postpartum.

PATIENTS/MATERIALS AND METHODS

A retrospective study with two cohorts of patients screened for depression during pregnancy and postpartum. Out of 7807 patients with at least three prenatal care visits and a delivery in 2016, 6725 were screened for depression (87%) at least once during pregnancy or postpartum. Another 259 were excluded because of missing race data. The final sample consisted of 6523 prenatal care patients who were screened for depression; 4914 were screened for depression in pregnancy, 4619 were screened postpartum (0-3 months). There were 3010 screened during both periods who are present in both the pregnancy and postpartum cohorts. Depression screening results are from the Patient Health Questionnaire (PHQ-9) and diagnosis of depression was measured using ICD codes. For patients screened more than once during either time period, the highest score is used for analysis.

RESULTS

Approximately, 11% of women had a positive depression screen as indicated by an elevated PHQ-9 score (>10) during pregnancy (11.3%) or postpartum (10.7%). Prevalence of depression diagnosis was similar in the two periods: 12.6% during pregnancy and 13.0% postpartum. A diagnosis of depression during pregnancy was most prevalent among women who were age 24 and younger (19.7%), single (20.5%), publicly insured (17.8%), multiracial (24.1%) or Native American (23.8%), and among women with a history of depression in the past year (58.9%). Among women with a positive depression screen, Black women were less than half as likely as White women to receive a diagnosis in adjusted models (AOR 0.40, CI: 0.23-0.71, p = .002). This difference was not present postpartum.

CONCLUSIONS

Depression symptoms and diagnoses differ by maternal characteristics during pregnancy with some groups at substantially higher risk. Efforts to examine disparities in screening and diagnosis are needed to identify reasons for variability in prenatal depression diagnosis between Black and White women.Key messagesWomen who were young, single, have public insurance, and women who identify as multiracial or non-Hispanic (NH) Native American were most likely to have a positive depression screen or a diagnosis for depression.After adjustment for confounders, NH Black women with a positive depression screen were about half as likely to have a diagnosis of depression during pregnancy as NH White women.Awareness of the differing prevalence of depression risk screening results, diagnoses and potential for variation in diagnosis may identify opportunities to improve equity in the delivery of essential mental health care to all patients.

Variation in Organizational Clinical Practice Guidelines for Croup

BACKGROUND

Croup is one of the most common respiratory complaints in pediatric emergency departments (EDs), yet little is known about clinical practice guidelines (CPGs) for this condition.

OBJECTIVES

To describe variation in CPGs across US children's hospitals.

METHODS

We describe the prevalence and features of CPGs among hospitals that submit data to the Pediatric Health Information System. Each hospital was contacted between January 10, 2022, and April 25, 2022, for their most recent croup CPG and any revisions. Characteristics reported were based on the most recent CPG revision. Characteristics included treatment recommendations, utilization measures, ED observation times, and admission criteria. Interrater reliability between reviewers was reported as percentage agreement.

RESULTS

Thirty-eight hospitals (79.2%) responded to our query, of which 20 (52.6%) had croup CPGs. Interrater reliability was moderate-high for categorizing the indication for racemic epinephrine (RE) (19 of 20; 95%), the minimum number of RE doses recommended before admission (15 of 20; 75%), and ED observation time (19 of 20; 95%), and was 100% for all other characteristics. Three CPGs (15.0%) recommended 1 RE dose, 14 (70.0%) recommended 2 RE doses, and 3 (15.0%) recommended 3 RE doses before hospital admission. Thirteen (65%) CPGs recommended RE for stridor at rest, whereas 7 (30%) recommended RE for any degree of stridor. Fourteen (70%) CPGs recommended an ED observation time <2 hours, 3 (15%) recommended 2 to 4 hours, and 2 (10%) recommended >4 hours. Few CPGs (15%) recommended use of standardized croup clinical scores.

CONCLUSIONS

Substantial variation exists among croup CPGs. Our results may inform future efforts to standardize croup CPGs across centers.

Impact of Clinical Guidelines on Hospital Utilization in Children With Croup

OBJECTIVES

To assess the impact of croup guidelines on healthcare utilization and association between guideline-recommended racemic epinephrine (RE) treatments and admission.

METHODS

Cross-sectional study of children ≥3 months to ≤8 years with croup diagnosis (International Classification of Diseases, 10th Revision) from 38 hospitals within the Pediatric Health Information System between January 1, 2019 and June 30, 2022. Guidelines were categorized by minimum number of RE treatments recommended before admission. Exclusion criteria included complex chronic or croup mimicking conditions, alternate respiratory diagnoses, and direct admissions or transfers. Primary outcomes were admission rates and standardized costs. Outcomes were compared by guideline availability and different admission thresholds. Mixed effects regression was adjusted for age, sex, race, payer, previous croup encounters, and year.

RESULTS

Twenty hospitals (52.6%) had guidelines. Fourteen recommended 2 RE treatments and 3 recommended 3 RE treatment before admission. Among 121 284 croup encounters, overall mean admission rate was 5.7% (range 0.6% to 18.5%). Hospitals with guidelines demonstrated lower unadjusted admission rate (4.6% vs 6.6%; mean difference -2.0, 95% confidence interval -2.3 to -1.7) and higher costs ($704 vs $651; mean difference 53, 95% confidence interval 43 to 63) compared with hospitals without guidelines. Hospitals with guidelines recommending 3 RE treatments demonstrated similar unadjusted mean admission rate (5.1%) and lower costs ($658 vs $713) compared with hospitals with guidelines recommending 2 RE treatments. After adjustment, all above-mentioned differences were not statistically significant.

CONCLUSIONS

Many children's hospitals lack guidelines for croup. Admission rates and costs were not significantly different between hospitals with or without guidelines after adjusting for confounders.

Declining Rates of Legg-Calvé-Perthes Surgery in the United States: National Trends Using the Kids' Inpatient Database and Pediatric Health Information System

BACKGROUND

In 2004 and 2008 two large prospective, multicenter studies were published which resulted in improved understanding of operative indications for the treatment of Legg-Calvé-Perthes disease (LCPD) based on patient age, disease severity, and resultant radiographic outcomes. The primary aim of this study is to evaluate the trends in surgical management of LCPD in the United States prior, and subsequent to, the publication of these landmark studies.

METHODS

Cross-sectional retrospective analysis of US pediatric hospitalizations for the surgical management of LCPD was conducted using the Kids' Inpatient Database from 2000 to 2016. Patients 12 years of age and younger were included who had a primary admission diagnosis of LCPD and a LCPD-related procedure during the hospitalization. Data was subsequently weighted to produce national-level estimates and variables pertaining to patient age group, procedure, demographics, and hospital characteristics were analyzed. In a post hoc analysis, the results of the Kids' Inpatient Database were also corroborated with the Pediatric Health Information System database.

RESULTS

A weighted sample of 2786 LCPD surgical admissions met inclusion and exclusion criteria; 11.2% of surgical admissions were patients below 6 years of age, 35.9% were 6 to 8 years of age, and 52.9% were above 8 years of age. There was a significant decrease in admissions for surgical management of LCPD in all age groups over time, however there was no appreciable change in the proportion of LCPD surgical admissions performed among the above 8 to below 12, above 6 to below 8, or below 6 years age groups. Femoral osteotomy remained the most common surgical procedure, while other osteotomy types, including pelvic and unspecified osteotomies involving the hip, decreased over time ( P <0.001).

CONCLUSIONS

There is a decreasing rate of hospital admissions for LCPD surgery since 2000, perhaps indicating a decline in incidence of disease. Furthermore, despite evidence supporting LCPD surgical outcomes related to patient age, there has been no change in the proportion of patients undergoing surgery by age group over time.

LEVEL OF EVIDENCE

Level III-retrospective study.

Pediatric peanut aspirations before and after 2015 recommendation for early peanut exposure

OBJECTIVES

To investigate if there has been an increase in peanut foreign body aspirations (FBA) in children since the publication of the Learning Early About Peanut Allergy (LEAP) trial, which revealed that early exposure to peanut-containing foods prevented peanut allergies in children at risk of atopic disease.

METHODS

Retrospective chart reviews were conducted separately at two pediatric institutions. Institutions One and Two reviewed children less than 7 years old who underwent bronchoscopy for FBA over ten-year periods between January 2007 and September 2017 and November 2008 and May 2018, respectively. The proportion of FBAs attributed to peanuts was compared before and after the publication LEAP.

RESULTS

Out of 515 reviewed cases, there was no change in pediatric peanut aspirations prior to and following the LEAP trial and AAP guideline change (33.5% vs 31.4%, p = 0.70). At Institution One, 317 patients met inclusion criteria. When comparing FBAs before and after LEAP, there were no significant changes in the rate of peanut aspiration (53.5% vs. 45.1%, p = 0.17). Institution Two also found no significant increase in the rate of peanut aspirations before and after the Addendum Guidelines (41.4% vs. 28.6%, p = 0.65) upon review of 198 cases.

CONCLUSIONS

Multiple institutions demonstrated a non-significant change in the rate of peanut FBAs following the AAP recommendation. Given that peanuts comprise a large proportion of FBAs, it is important to continue to track peanut aspirations. Longer term data tracking is needed from more institutions to further understand how recommendations from other specialties and the media impacts pediatric aspiration outcomes.

Factors Associated With Low Procedural Pain Scores Among 1- to 5-Year-Old Patients Undergoing Facial Laceration Repair

OBJECTIVES

Our objectives were to quantify pain experienced by young children undergoing facial laceration repair and identify factors associated with low procedural pain scores.

METHODS

We conducted a prospective cohort study of children's distress among a convenience sample of children aged 1 to 5 years undergoing facial or scalp laceration repair in 2 pediatric emergency departments. We reviewed video recordings and documented pain scores at 15-second intervals using the Face, Leg, Activity, Cry, Consolability-Revised (FLACC-r) scale. We dichotomized FLACC-r into low/high scores (≤3 and >3) to evaluate practice variables.

RESULTS

We included 11,474 FLACC-r observations from 258 procedures in the analysis. Two-thirds of 3- to 5-year-olds completed their laceration repair without the use of restraint, sedation, or anxiolytics. Mean distress scores were low (≤2.5 out of 10) across all procedure phases for 2- to 5-year-old patients. One-year-old patients experienced significantly more distress than their older counterparts (mean ≤4.2 out of 10). Odds of having low FLACC scores (≤3) were greater for patients with an expert clinician (adjusted odds ratio [aOR]: 1.72; 95% confidence interval [CI], 1.05-2.84). Wound infiltration (aOR, 0.35; 95% CI, 0.13-0.93), patient observation of a needle (aOR, 0.21; 95% CI, 0.14-0.33), and restraint (aOR, 0.04; 95% CI, 0.02-0.06) were negatively associated with low FLACC score.

CONCLUSION

The majority of 3- to 5-year-old patients were able to undergo facial laceration repair without restraint, sedation, or anxiolytics and with low mean distress scores. Our findings suggest that children's risk of experiencing moderate and severe distress during facial and scalp laceration repair may be reduced by prioritizing wound closure by expert-level clinicians, ensuring effective lidocaine-epinephrine-tetracaine application, avoiding restraint, and concealing needles from patient view.

Omphalitis Hospitalizations at a US Children's Hospital

OBJECTIVES

To describe demographics, presentation, resource use, and outcomes of patients diagnosed with omphalitis.

METHODS

This was a retrospective descriptive study of infants with omphalitis at a children's hospital system between January 2006 and December 2020. Presentation, resource use, and outcomes (omphalitis complications [eg, necrotizing fasciitis], 30-day related cause revisit, and death) were described.

RESULTS

Ninety-one patients had a primary or secondary International Classification of Diseases, Ninth or 10th Revision, code for omphalitis. Seventy-eight patients were included in analysis (47 with omphalitis as primary reason for admission). Patients with omphalitis as the primary reason for admission presented with rash (44 of 47, 93.6%), fussiness/irritability (19 of 47, 40.4%), and fever (6 of 47, 12.8%). C-reactive protein was minimally elevated, with a median of 0.4 mg/dL (interquartile range 0.29-0.85).Among all patients, blood cultures were positive in 3 (3 of 78, 3.8%) and most had positive wound cultures (70 of 78, 89.7%), with primarily gram-positive organisms. Median duration of intravenous antibiotics was 5 days (interquartile range 3-7). No patients had complications of omphalitis or death. Five patients (5 of 78, 6.4%) had a 30-day revisit for a related cause.

CONCLUSIONS

We found variation in presentation and management of patients with omphalitis at our tertiary children's hospital system. Wound cultures, but not blood tests, were helpful in guiding management in the majority of cases. There were no complications of omphalitis or deaths.

Analysis of COVID-19-Related Croup and SARS-CoV-2 Variant Predominance in the US

This cross-sectional study investigates the association of dominant SARS-CoV-2 variants with COVID-19–related croup.

Association of Neighborhood Resources and Race and Ethnicity With Readmissions for Diabetic Ketoacidosis at US Children's Hospitals

Importance

The Child Opportunity Index 2.0 (COI) assesses neighborhood resources and conditions that influence health. It is unclear whether the COI scores are associated with health outcomes by race and ethnicity among children with type 1 diabetes (T1D).

Objective

To determine whether COI categories are associated with diabetes-related outcomes by race and ethnicity, including readmissions for diabetic ketoacidosis (DKA) and co-occurring acute kidney injury (AKI) or cerebral edema (CE).

Design, Setting, and Participants

This cross-sectional study included children discharged with a primary diagnosis of T1D with DKA between January 1, 2009, and December 31, 2018. Merged data were obtained from the Pediatric Health Information System and COI. Participants included children and adolescents younger than 21 years with an encounter for DKA. Data were analyzed from April 29, 2021, to January 5, 2022.

Exposures

Neighborhood opportunity, measured with the COI as an ordered, categorical score (where a higher score indicates more opportunity), and race and ethnicity.

Main Outcomes and Measures

The primary outcome was readmission for DKA within 30 and 365 days from an index visit. Secondary outcomes included the proportion of encounters with AKI or CE. Mixed-effects logistic regression was used to generate probabilities of readmission, AKI, and CE for each quintile of COI category by race and ethnicity.

Results

A total of 72 726 patient encounters were identified, including 38 924 (53.5%) for girls; the median patient age was 13 (IQR, 9-15) years. In terms of race and ethnicity, 600 (0.8%) of the encounters occurred in Asian patients, 9969 (13.7%) occurred in Hispanic patients, 16 876 (23.2%) occurred in non-Hispanic Black (hereinafter Black) patients, 40 129 (55.2%) occurred in non-Hispanic White (hereinafter White) patients, and 5152 (7.1%) occurred in patients of other race or ethnicity. The probability of readmission within 365 days was significantly higher among Black children with a very low COI category compared with Hispanic children (risk difference, 7.8 [95% CI, 6.0-9.6] percentage points) and White children (risk difference, 7.5 [95% CI, 5.9-9.1] percentage points) at the same COI category. Similar differences were seen for children with very high COI scores and across racial groups. The COI category was not associated with AKI or CE. However, race and ethnicity constituted a significant factor associated with AKI across all COI categories. The probability of AKI was 6.8% among Black children compared with 4.2% among Hispanic children (risk difference, 2.5 [95% CI, 1.7-3.3] percentage points) and 4.8% among White children (risk difference, 2.0 [95% CI, 1.3-2.6] percentage points).

Conclusions and Relevance

These results suggest that Black children with T1D experience disparities in health outcomes compared with other racial and ethnic groups with similar COI categories. Measures to prevent readmissions for DKA should include interventions that target racial disparities and community factors.

Feasibility trial of weighted blankets as an intervention for emergence delirium in postoperative pediatric patients

BACKGROUND

Emergence delirium (ED) is a significant problem in the post anesthesia care unit (PACU), resulting in dislodgement of medical devices, patient and staff injury, prolonged recovery, and parent dissatisfaction. Parental requests for the use of weighted blankets in the hospital setting have increased. However, while weighted blankets have shown potential as treatment for anxiety in adults and children, no studies have demonstrated their safe use with children in the hospital setting.

PURPOSE

To explore the safety of weighted blanket use with children in the PACU as an intervention for ED, a feasibility study was conducted.

DESIGN AND METHODOLOGY

A convenience sample of 93 participants, aged three to 10 years were recruited. Watcha scores, vital signs, length of wear time, and reason for blanket removal were recorded for all patients.

RESULTS

Eighty-five patients completed the study. Four participants experienced vital signs outside the defined safety parameters, with only one experiencing an adverse event (1.2%). This was consistent with the historic adverse event rate of 1% for the study site. Staff did not report issues with the use or cleaning of the blankets. Of interest, there was significant correlation between ED and suspected pain.

CONCLUSION

The study demonstrated weighted blanket use is safe and feasible with children in the hospital setting, Additional studies are needed to determine the effectiveness of weighted blankets as an intervention for ED and the impact pain may have on the severity and prevalence of ED.

Evaluation of a Pediatric Enoxaparin Dosing Protocol and the Impact on Clinical Outcomes

OBJECTIVES

Enoxaparin has been studied for prophylaxis and treatment of thromboembolism in the pediatric population. Dose-finding studies have suggested higher mean maintenance dose requirements in younger children; however, the current recommended dosing schema endorsed by the American College of Chest Physicians remains conservative, likely secondary to limited data on the safety and efficacy of escalated starting doses. Primary objectives of this study included the identification of patient characteristics and risk factors with associations to anti-factor Xa (anti-Xa) values. The secondary objective was to determine an association between the initial anti-Xa value and thrombus resolution. Safety outcomes related to bleeding were also assessed.

METHODS

This retrospective cohort study reviewed records of all pediatric patients ≤18 years of age who were initiated on therapeutic subcutaneous enoxaparin between October 1, 2008, and October 1, 2018, at Children's Hospitals and Clinics of Minnesota for an indication of incident thrombus (N = 283).

RESULTS

Successful resolution of thrombus was directly associated with attaining a therapeutic anti-Xa concentration upon first laboratory evaluation. Other characteristics with associations to initial anti-Xa values included age, body mass index, and certain diagnoses. The rate of composite bleeding was consistent across concentrations of anti-Xa (p = 0.4944).

CONCLUSIONS

Despite adherence to protocol, the current enoxaparin dosing nomogram is only successful at achieving a therapeutic anti-Xa concentration (0.5-1.0 unit/mL) 55.8% of the time. A more aggressive enoxaparin dosing nomogram is warranted, as delaying time to therapeutic anti-Xa values impacts clinical outcomes, specifically thrombus resolution. Further investigation into characteristics with association to anti-Xa concentrations is needed.

Analysis of longitudinal adherence data: Hitting the target with consistency

Typical descriptions of partial adherence summarize to what extent a patient follows a prescribed treatment plan. Another aspect of adherence relates to how consistently a patient behaves. We distinguish these two notions as "adherence target" and "adherence consistency." Most research on adherence focuses on the former concept, but the latter can be a useful idea in assessing patients' compliance. Quantifying these two notions goes beyond typical summaries of center and spread, because they may be related to each other. That is, the mean is often related to the standard deviation via the variance function. Our approach defines a parameter that measures consistency separate from the adherence target. For exponential dispersion or quasi-likelihood families, the parameter corresponds to the dispersion parameter. Assessing adherence consistency to medical treatment requires longitudinal data, which can be collected with new technology. Two examples from pediatric medicine demonstrate that detangling the notion of consistency from the adherence target is useful.

P2561Withdrawal of simulated obstructive sleep apnea partially reverses atrial arrhythmogenic substrate in rats

Background

Obstructive sleep apnea (OSA) is associated with structural alterations of the left atria (LA) and increased occurrence of atrial fibrillation (AF). Obstructive respiratory events lead to intermittent hypoxia (IH) and ineffective inspiration against the occluded upper airways, which result in intrathoracic and cardiac transmural pressure changes. Data on reversibility of LA-structural remodeling processes after withdrawal of OSA are still missing.

Objectives

Aim of the study was to develop a novel AF animal model mimicking intrathoracic pressure changes in addition to IH and to analyze the effect of OSA-withdrawal on atrial remodeling reversibility.

Method

In sedated rats (2% isoflurane), IH (n=9) was applied by intermittent increase in the respiratory dead volume. Standardized obstructive respiratory events were induced by defined intermittent negative upper airway pressure (INAP = inverse CPAP) applied via a customized mask connected to a negative pressure device (n=9). One minute of IH or INAP was followed by a rest period of nine minutes for four hours every second day. Rats with comparable anesthesia were used as controls (CTR). After three weeks, the animals were sacrificed. To analyze atrial structural remodeling reversibility, additional INAP-rats (n=5) were sacrificed after INAP-withdrawal of three weeks and compared to respective CTR (n=7).

Result

Blood pressure was not affected by IH or INAP. Intermittent desaturation and post-apneic hyperventilation were comparable in INAP- and IH-rats, but INAP-rats showed significantly higher breathing efforts during apneas compared to IH-rats. LA connexin43 (Cx43) protein expression assessed by quantitative immunofluorescence was reduced in both groups compared to CTR (0.77±0.07% in CTR vs. 0.45±0.06% in IH, p=0.02; CTR vs. 0.39±0.06% in INAP, p=0.005). However, LA interstitial fibrosis content (7.03±0.58% vs. CTR, p=0.01) and LA myocyte diameters (13.23±0.34μm vs. CTR, p=0.03) were increased in INAP-rats, but not in IH-rats. This was associated with longer inducible AF-durations in INAP-rats (11.65±4.43s vs. 0.72±0.33s in CTR, p=0.03) but not in IH-rats (1.28±0.33s vs. CTR, p=0.31). Three weeks of INAP-withdrawal (INAP-W) normalized interstitial fibrosis content (INAP-W vs. CTR, p=0.50) and LA-myocyte diameter (INAP-W vs. CTR, p=0.31). However, LA Cx43 protein expression remained low after three weeks of INAP withdrawal and inducible AF-episodes were still prolonged compared to respective CTR.

Conclusion

Application of INAP in rats mimics important components of OSA beyond IH and allows the study of an arrhythmogenic substrate in the atrium independent of the development of risk factors. In our model, withdrawal of INAP resulted in partial reversibility of structural LA remodeling but was not sufficient to abolish inducible AF-episodes completely. Future clinical studies are warranted to determine the anti-arrhythmic effect of isolated sleep apnea treatment in AF-patients.

Acknowledgement/Funding

Else Kröner-Fresenius-Stiftung, SFB-TRR219-M02/S-02

Rate of Airway Intervention for Croup at a Tertiary Children's Hospital 2015-2016

BACKGROUND

Croup admission decision making is challenging because the rate of further interventions after stabilization is unclear.

OBJECTIVE

We sought to describe rates of inpatient racemic epinephrine (IRE) and additional inpatient airway interventions (IAI) (oxygen or heliox therapy, intubation, or transfer to an intensive care unit) among patients presenting to a tertiary children's hospital with croup.

METHODS

This was a retrospective descriptive study including patients (3 months to 8 years of age) with an emergency department (ED)/inpatient encounter for croup from January 1, 2015 to December 31, 2016 at a tertiary children's hospital. We excluded intensive care unit direct admissions and patients with bronchiolitis/asthma/pneumonia. We compared 3 groups (a weighted random 5% sample of patients evaluated in ED only, and those admitted with or without IRE/IAI) using Kruskal-Wallis, Pearson χ², or the Fischer exact test, where appropriate. We used multivariate analysis to compare demographics and preadmission racemic epinephrine (RE) with rates of IRE/IAI in admitted patients.

RESULTS

We included 588 patients (194 discharged from the ED, 394 admitted). In admitted patients, 20.8% (82/394) had IRE/IAI, most commonly IRE (20.0%, 79/394). Three admitted patients (0.76%) had IAI. Overall, patients with 2 outside hospital/ED doses of RE had a 12.1% rate of IRE/IAI (23.5% if ≥3 RE doses). Patients with ≥3 preadmission RE doses were more likely to have IRE/IAI compared with 2 RE (adjusted odds ratio = 2.08 [95% confidence interval 1.15-3.76]; p = 0.02); there were no other significant associations.

CONCLUSIONS

We found a low rate of IRE/IAI after ED management in patients with croup and no significant associations aside from preadmission RE doses. These findings may be considered in admission decisions.

Hydroxyurea use in young infants with sickle cell disease

BACKGROUND

Hydroxyurea (HU) reduces complications and improves quality and duration of life in sickle cell disease. Evidence supports the use of HU starting after nine months of age.

PROCEDURES

We performed a retrospective study of patients starting HU at less than five years of age between January 1, 2008, and December 31, 2016. We evaluated clinical events, laboratory data, and toxicity between three different age groups: cohort 1 (0-1 year), cohort 2 (1-2 years), and cohort 3 (2-5 years).

RESULTS

Sixty-five patients were included in the analysis. The mean age was 7.2 months (n = 35), 19.5 months (n = 13), and 35.5 months (n = 17) for cohorts 1, 2, and 3, respectively. Cohort 1 had higher hemoglobin (P = 0.0003) and MCV (P = 0.0199) and lower absolute reticulocyte count (P = 0.0304) at 24 months of age compared with cohort 3. The absolute neutrophil count (ANC) was lower compared with both older cohorts (P = 0.0364, 0.0025). The mean baseline hemoglobin F in cohort 1 was 31.5% compared with 19.7% and 16.5% in cohorts 2 and 3, respectively (P = 0.002, P < 0.0001). The mean duration of therapy was 31.3 months, 57.6 months (P = 0.018), and 29.1 months (P = 0.401), respectively. Mean Hb F levels remained higher in cohort 1 (29.9%) compared with cohorts 2 and 3 (20.4%, P = 0.007; 20.6%, P = 0.003). Cohort 1 experienced fewer hospitalizations (P = 0.0025), pain crises (P = 0.0618), and transfusions (P = 0.0426). There was no difference in toxicity between groups.

CONCLUSION

HU is safe and effective in patients 5 to 12 months of age and generated a more robust response compared with initiation in older patients.

A Comparison of Pediatric Traumatic Injuries on Farms and Residences from 2009 to 2014

PURPOSE

Children injured on farms in the United States are hospitalized at 14 times the rate of children with injuries unrelated to farming. This study characterizes pediatric injuries occurring on farms compared to injuries in homes.

METHODS

We examined the National Trauma Data Bank from 2009 to 2014 to identify children ages 0-17 with ICD-9 E-codes reflecting a farm or residential place of injury occurrence. Appropriate nonparametric tests were used to compare patient, injury, and hospitalization characteristics by injury locale. Mixed effects models for binary responses were used to examine the odds of an injury occurring on a farm versus at home, and we controlled for random effects of trauma center after adjustment for potential confounding variables including age, sex, and categorical injury severity.

FINDINGS

There were 2,776 injuries on farms, and 133,119 injuries at homes. Children injured on farms had a median age of 10 years compared to 4 years at homes (P < .001). Machinery injuries were 19 times more frequent on farms (P < .001), and injuries to multiple anatomic locations were twice as frequent on farms (P < .001). Children injured on farms required helicopter transport 4 times as often as those injured at home. Additionally, children injured on farms were nearly 2.5 times more likely to have a length of stay greater than 7 days.

CONCLUSION

Injuries occur during the course of childhood; however, injuries sustained in a farming environment are more severe and require greater clinical management than injuries which occur in the home.

The Impact of Health Equity Coaching on Patient's Perceptions of Cultural Competency and Communication in a Pediatric Emergency Department: An Intervention Design

Purpose

American Indian (AI) children experience significant disparities in health-care access. As a result, they are more likely to use the emergency department (ED) for nonemergent visits than white children. In a recent study, pediatric ED providers have shown an implicit bias for white children over AI children. To combat implicit bias in an ED setting, we created a protocol for training ED providers as health equity coaches.

Methods

The intervention took place during the fall of 2016 and was composed of 4 educational lectures, 6 to 8 hours of service learning in AI communities, and the participant's dissemination of what was learned through formal presentations and informal conversations with other ED staff. We measured the impact of this intervention on the intervention participants with a group interview at the completion of the intervention.

Results

The findings from the group interview provide feedback on what was learned during the intervention, how it impacted providers, and feedback on the structure of the intervention. Overall ED providers reported the intervention improved awareness of their implicit bias and ways to improve communication and care for AI patients. Additional institutional policy and procedural changes are necessary to effectively and sustainably address health disparities affecting AI populations.

Conclusions

The participating providers identified their lack of knowledge regarding AI cultures at the start of the intervention and it became clear that their knowledge, comfort, and relationships with AI communities increased as a result of this intervention.

L-Proline transport into renal OK epithelial cells: a second renal proline transport system is induced by amino acid deprivation

Influx of [(3)H]-L-proline into renal OK cells revealed that basal transport was mediated by the transporter SIT1. When cells were submitted for 8 h to amino acid deprivation, uptake of L-proline was now dominated by a low-affinity system with an apparent K (m) of 4.4 +/- 0.6 mM and a V (max) of 10.2 +/- 0.6 nmol/mg of protein/min operating in addition to the high-affinity SIT1 system with a K (m) of 0.12 +/- 0.01 mM and a V (max) of 0.28 +/- 0.04 nmol/mg of protein/min. The low- and high-affinity proline transporting systems were sensitive to inhibitors of JNK and PI-3 kinases, whereas a GSK-3 inhibitor affected only the upregulated transport system. Ion-replacement studies and experiments assessing substrate specificities for both systems provided strong evidence that SNAT2, that showed two- to threefold increased mRNA levels, is the responsible transporter mediating the increased proline influx under conditions of amino acid deprivation.

Increased mitochondrial palmitoylcarnitine/carnitine countertransport by flavone causes oxidative stress and apoptosis in colon cancer cells

Cancer cell metabolism is characterized by limited oxidative phosphorylation in order to minimize oxidative stress. We have previously shown that the flavonoid flavone in HT-29 colon cancer cells increases the uptake of pyruvate or lactate into mitochondria, which is followed by an increase in O(2) (-.). production that finally leads to apoptosis. Similarly, a supply of palmitoylcarnitine in combination with carnitine induces apoptosis in HT-29 cells by increasing the mitochondrial respiration rate. Here we show that flavone-induced apoptosis is increased more than twofold in the presence of palmitoylcarnitine due to increased mitochondrial fatty acid transport and the subsequent metabolic generation of O(2) (-.) in mitochondria is the initiating factor for the execution of apoptosis.

alpha-Lipoic acid induces apoptosis in human colon cancer cells by increasing mitochondrial respiration with a concomitant O2-*-generation

The antioxidant alpha-lipoic acid (ALA) has been shown to affect a variety of biological processes associated with oxidative stress including cancer. We determined in HT-29 human colon cancer cells whether ALA is able to affect apoptosis, as an important parameter disregulated in tumour development. Exposure of cells to ALA or its reduced form dihydrolipoic acid (DHLA) for 24 h dose dependently increased caspase-3-like activity and was associated with DNA-fragmentation. DHLA but not ALA was able to scavenge cytosolic O2-* in HT-29 cells whereas both compounds increased O2-*-generation inside mitochondria. Increased mitochondrial O2-*-production was preceded by an increased influx of lactate or pyruvate into mitochondria and resulted in the down-regulation of the anti-apoptotic protein bcl-X(L). Mitochondrial O2-*-generation and apoptosis induced by ALA and DHLA could be prevented by the O2-*-scavenger benzoquinone. Moreover, when the lactate/pyruvate transporter was inhibited by 5-nitro-2-(3-phenylpropylamino) benzoate, ALA- and DHLA-induced mitochondrial ROS-production and apoptosis were blocked. In contrast to HT-29 cells, no apoptosis was observed in non-transformed human colonocytes in response to ALA or DHLA addition. In conclusion, our study provides evidence that ALA and DHLA can effectively induce apoptosis in human colon cancer cells by a prooxidant mechanism that is initiated by an increased uptake of oxidizable substrates into mitochondria.

Metall/Metall?eine neue (alte) Gleitpaarung k�nstlicher H�ftgelenke in der klinischen Bew�hrungsprobe

The problems of wear debris of bearing systems containing polyethylene used in hip arthroplasty have led to an increased trend to hard on hard bearing surfaces. Based on our own good experiences with the cementless Zweymüller-Alloclassic system, we implanted the same system with metal-on-metal bearing surfaces (Metasul) in 100 cases between October 1993 and November 1994. In order to record potential side effects, specific questioning and a clinical and radiological survey were carried out before surgery and in regular intervals thereafter. Up to date almost all of the patients have had good and excellent results with an average of more than 90 points in the Harris hip score (47.8 before surgery). There were no cases of revision surgery as a result of aseptic loosening. Two revisions were performed for other reasons (change of the insert, deep infection). No disadvantageous phenomena related to Metasul in the surrounding tissue were found on macroscopic and histologic investigation. The radiological examination did not show any specific signs pertaining to the use of a metal-on-metal bearing system. We also have no grounds to suppose that there are systemic reactions due to chromium or cobalt ions. Up to now, the new metal-on-metal bearing system in connection with a proven hip arthroplasty system has lived up to clinical expectations. With regard to less wear debris, it is justified to implant it in younger patients as well. Other open questions, in particular the possibly improved long-term results, have to be answered by continuation of the study.

Effect of inoculation and leaf litter amendment on establishment of nodule-forming Frankia populations in soil

High-N(2)-fixing activities of Frankia populations in root nodules on Alnus glutinosa improve growth performance of the host plant. Therefore, the establishment of active, nodule-forming populations of Frankia in soil is desirable. In this study, we inoculated Frankia strains of Alnus host infection groups I, IIIa, and IV into soil already harboring indigenous populations of infection groups (IIIa, IIIb, and IV). Then we amended parts of the inoculated soil with leaf litter of A. glutinosa and kept these parts of soil without host plants for several weeks until they were spiked with [(15)N]NO(3) and planted with seedlings of A. glutinosa. After 4 months of growth, we analyzed plants for growth performance, nodule formation, specific Frankia populations in root nodules, and N(2) fixation rates. The results revealed that introduced Frankia strains incubated in soil for several weeks in the absence of plants remained infective and competitive for nodulation with the indigenous Frankia populations of the soil. Inoculation into and incubation in soil without host plants generally supported subsequent plant growth performance and increased the percentage of nitrogen acquired by the host plants through N(2) fixation from 33% on noninoculated, nonamended soils to 78% on inoculated, amended soils. Introduced Frankia strains representing Alnus host infection groups IIIa and IV competed with indigenous Frankia populations, whereas frankiae of group I were not found in any nodules. When grown in noninoculated, nonamended soil, A. glutinosa plants harbored Frankia populations of only group IIIa in root nodules. This group was reduced to 32% +/- 23% (standard deviation) of the Frankia nodule populations when plants were grown in inoculated, nonamended soil. Under these conditions, the introduced Frankia strain of group IV was established in 51% +/- 20% of the nodules. Leaf litter amendment during the initial incubation in soil without plants promoted nodulation by frankiae of group IV in both inoculated and noninoculated treatments. Grown in inoculated, amended soils, plants had significantly lower numbers of nodules infected by group IIIa (8% +/- 6%) than by group IV (81% +/- 11%). On plants grown in noninoculated, amended soil, the original Frankia root nodule population represented by group IIIa of the noninoculated, nonamended soil was entirely exchanged by a Frankia population belonging to group IV. The quantification of N(2) fixation rates by (15)N dilution revealed that both the indigenous and the inoculated Frankia populations of group IV had a higher specific N(2)-fixing capacity than populations belonging to group IIIa under the conditions applied. These results show that through inoculation or leaf litter amendment, Frankia populations with high specific N(2)-fixing capacities can be established in soils. These populations remain infective on their host plants, successfully compete for nodule formation with other indigenous or inoculated Frankia populations, and thereby increase plant growth performance.

Horizontal escape of the novel Tc1-like lepidopteran transposon TCp3.2 into Cydia pomonella granulovirus

We characterized an insertion mutant of the baculovirus Cydia pomonella granulovirus (CpGV), which contained a transposable element of 3.2 kb. This transposon, termed TCp3.2, has unusually long inverted terminal repeats (ITRs) of 756 bp and encodes a defective gene for a putative transposase. Amino acid sequence comparison of the defective transposase gene revealed a distant relationship to a putative transposon in Caenorhabditis elegans which also shares some similarity of the ITRs. Maximum parsimony analysis of the predicted amino acid sequences of Tc1- and mariner-like transposases available from the GenBank data base grouped TCp3.2 within the superfamily of Tc1-like transposons. DNA hybridization indicated that TCp3.2 originated from the genome of Cydia pomonella, which is the natural host of CpGV, and is present in less than 10 copies in the C. pomonella genome. The transposon TCp3.2 most likely was inserted into the viral genome during infection of host larvae. TCp3.2 and the recently characterized Tc1-like transposon TC14.7 (Jehle et al. 1995), which was also found in a CpGV mutant, represent a new family of transposons found in baculovirus genomes. The occasional horizontal escape of different types of host transposons into baculovirus genomes evokes the question about the possible role of baculoviruses as an interspecies vector in the horizontal transmission of insect transposons.

TCl4.7: a novel lepidopteran transposon found in Cydia pomonella granulosis virus

After the co-infection of larvae of the lepidopteran Cryptophlebia leucotreta with the two baculoviruses C. leucotreta granulosis virus and Cydia pomonella granulosis virus (CIGV and CpGV, respectively), three CpGV mutants and one CIGV mutant carrying insertions of 0.9 to 4.7 kb have been isolated. By cloning, sequencing, and hybridization analysis, one of these insertions was identified as a transposon-like element derived from the C. leucotreta genome. This element, called TCl4.7, was found in the genome of CpGV which naturally replicates in C. pomonella. Sequence analysis suggested that TCl4.7 is 4726 bp in size, flanked by imperfect inverted terminal repeats of 29 bp, and integrated into the target dinucleotide TA. TCl4.7 encompasses an open reading frame sharing homologies to transposase genes of the Tc1-related transposable elements found in Caenorhabditis and in Drosophila species. The open reading frame might represent a pseudogene since it is missing an ATG start codon. The integration site of TCl4.7 is located in a non-protein-coding region of the CpGV genome at m.u. 9.5. In bioassays the TCl4.7-carrying virus and all the other mutants except for one showed LC50 values similar to those of CpGV and CIGV. This is the first report of the horizontal escape of a transposable element during the in vivo infection of lepidopteran larvae by granulosis viruses.

Cholic acid and ursodeoxycholic acid therapy in primary biliary cirrhosis. Changes in bile acid patterns and their correlation with liver function

We treated 6 patients with Stage II primary biliary cirrhosis with cholic acid (CA) 10 mg.kg-1 per day for 3 months and then with the same dose of ursodeoxycholic acid (UDCA). A matching group of 6 patients was observed for 3 months without any therapy. Liver function tests and serum and stool bile acids were investigated before, during and at the end of CA and UDCA therapy. The results of liver function tests deteriorated after 6-8 weeks of CA therapy and the changes were correlated (r = 0.92) with an increase in alpha-dihydroxy-bile acids (chenodeoxycholic acid and deoxycholic acid) in the serum. The 24 h excretion of DCA in 24 h faeces was markedly increased. Ursodeoxycholic acid treatment improved liver function tests; after 4 weeks glutamate dehydrogenase (GLDH) had decreased. After 8-12 weeks of therapy ursodeoxycholic acid had increased to 50-60% of the total serum bile acids whereas the more apolar bile acids were significantly decreased. No changes in liver function tests or bile acid metabolism were found in the untreated group. Since CA and UDCA are non-toxic in man, this trial indicates that the apolar bile acids chenodeoxycholic acid and deoxycholic acid may be responsible for the deterioration of liver function in primary biliary cirrhosis. However, the therapeutic effect of UDCA cannot be explained merely by the decrease in alpha-dihydroxy-bile acids in the serum, since the laboratory results had improved prior to the decrease in the serum apolar bile acids.