Vaccine Effectiveness Against Long COVID in Children

OBJECTIVES

Vaccination reduces the risk of acute coronavirus disease 2019 (COVID-19) in children, but it is less clear whether it protects against long COVID. We estimated vaccine effectiveness (VE) against long COVID in children aged 5 to 17 years.

METHODS

This retrospective cohort study used data from 17 health systems in the RECOVER PCORnet electronic health record program for visits after vaccine availability. We examined both probable (symptom-based) and diagnosed long COVID after vaccination.

RESULTS

The vaccination rate was 67% in the cohort of 1 037 936 children. The incidence of probable long COVID was 4.5% among patients with COVID-19, whereas diagnosed long COVID was 0.8%. Adjusted vaccine effectiveness within 12 months was 35.4% (95 CI 24.5-44.7) against probable long COVID and 41.7% (15.0-60.0) against diagnosed long COVID. VE was higher for adolescents (50.3% [36.6-61.0]) than children aged 5 to 11 (23.8% [4.9-39.0]). VE was higher at 6 months (61.4% [51.0-69.6]) but decreased to 10.6% (-26.8% to 37.0%) at 18-months.

CONCLUSIONS

This large retrospective study shows moderate protective effect of severe acute respiratory coronavirus 2 vaccination against long COVID. The effect is stronger in adolescents, who have higher risk of long COVID, and wanes over time. Understanding VE mechanism against long COVID requires more study, including electronic health record sources and prospective data.

A large-scale comparison of two voice synthesis techniques on intelligibility, naturalness, preferences, and attitudes toward voices banked by individuals with amyotrophic lateral sclerosis

Amyotrophic lateral sclerosis (ALS) commonly results in the inability to produce natural speech, making speech-generating devices (SGDs) important. Historically, synthetic voices generated by SGDs were neither unique, nor age- or dialect-appropriate, which depersonalized SGD use. Voices generated by SGDs can now be customized via voice banking and should ideally sound uniquely like the individual's natural speech, be intelligible, and elicit positive reactions from communication partners. This large-scale 2 x 2 mixed between- and within-participants design examined perceptions of 831 adult listeners regarding custom synthetic voices created for two individuals diagnosed with ALS via two synthesis systems in common clinical use (waveform concatenation and statistical parametric synthesis). The study explored relationships among synthesis system, dysarthria severity, synthetic speech intelligibility, naturalness, and preferences, and also provided a preliminary examination of attitudes regarding the custom synthetic voices. Synthetic voices generated via statistical parametric synthesis trained on deep neural networks were more intelligible, natural, and preferred than voices produced via waveform concatenation, and were associated with more positive attitudes. The custom synthetic voice created from moderately dysarthric speech was more intelligible than the voice created from mildly dysarthric speech. Clinical implications and factors that may have contributed to the relative intelligibilities are discussed.

Postacute Sequelae of SARS-CoV-2 in Children

The coronavirus disease 2019 (COVID-19) pandemic has caused significant medical, social, and economic impacts globally, both in the short and long term. Although most individuals recover within a few days or weeks from an acute infection, some experience longer lasting effects. Data regarding the postacute sequelae of severe acute respiratory syndrome coronavirus 2 infection (PASC) in children, or long COVID, are only just emerging in the literature. These symptoms and conditions may reflect persistent symptoms from acute infection (eg, cough, headaches, fatigue, and loss of taste and smell), new symptoms like dizziness, or exacerbation of underlying conditions. Children may develop conditions de novo, including postural orthostatic tachycardia syndrome, myalgic encephalomyelitis/chronic fatigue syndrome, autoimmune conditions and multisystem inflammatory syndrome in children. This state-of-the-art narrative review provides a summary of our current knowledge about PASC in children, including prevalence, epidemiology, risk factors, clinical characteristics, underlying mechanisms, and functional outcomes, as well as a conceptual framework for PASC based on the current National Institutes of Health definition. We highlight the pediatric components of the National Institutes of Health-funded Researching COVID to Enhance Recovery Initiative, which seeks to characterize the natural history, mechanisms, and long-term health effects of PASC in children and young adults to inform future treatment and prevention efforts. These initiatives include electronic health record cohorts, which offer rapid assessments at scale with geographical and demographic diversity, as well as longitudinal prospective observational cohorts, to estimate disease burden, illness trajectory, pathobiology, and clinical manifestations and outcomes.

Voice banking to support individuals who use speech-generating devices: development and evaluation of Singaporean-accented English synthetic voices and a Singapore Colloquial English recording inventory

Voice banking involves recording an inventory of sentences produced via natural speech. The recordings are used to create a synthetic text-to-speech voice that can be installed on speech-generating devices. This study highlights a minimally researched, clinically relevant issue surrounding the development and evaluation of Singaporean-accented English synthetic voices that were created using readily available voice banking software and hardware. Processes used to create seven unique synthetic voices that produce Singaporean-accented English, and the development of a custom Singaporean Colloquial English (SCE) recording inventory, are reviewed. The perspectives of adults who spoke SCE and banked their voices for this project are summarized and were generally positive. Finally, 100 adults familiar with SCE participated in an experiment that evaluated the intelligibility and naturalness of the Singaporean-accented synthetic voices, as well as the effect of the SCE custom inventory on listener preferences. The addition of the custom SCE inventory did not affect intelligibility or naturalness of the synthetic speech, and listeners tended to prefer the voice created with the SCE inventory when the stimulus was an SCE passage. The procedures used in this project may be helpful for interventionists who wish to create synthetic voices with accents that are not commercially available.

Vaccine Effectiveness Against Long COVID in Children: A Report from the RECOVER EHR Cohort

Objective

Vaccination reduces the risk of acute COVID-19 in children, but it is less clear whether it protects against long COVID. We estimated vaccine effectiveness (VE) against long COVID in children aged 5-17 years.

Methods

This retrospective cohort study used data from 17 health systems in the RECOVER PCORnet electronic health record (EHR) Program for visits between vaccine availability, and October 29, 2022. Conditional logistic regression was used to estimate VE against long COVID with matching on age group (5-11, 12-17) and time period and adjustment for sex, ethnicity, health system, comorbidity burden, and pre-exposure health care utilization. We examined both probable (symptom-based) and diagnosed long COVID in the year following vaccination.

Results

The vaccination rate was 56% in the cohort of 1,037,936 children. The incidence of probable long COVID was 4.5% among patients with COVID-19, while diagnosed long COVID was 0.7%. Adjusted vaccine effectiveness within 12 months was 35.4% (95 CI 24.5 - 44.5) against probable long COVID and 41.7% (15.0 - 60.0) against diagnosed long COVID. VE was higher for adolescents 50.3% [36.3 - 61.0]) than children aged 5-11 (23.8% [4.9 - 39.0]). VE was higher at 6 months (61.4% [51.0 - 69.6]) but decreased to 10.6% (-26.8 - 37.0%) at 18-months.

Discussion

This large retrospective study shows a moderate protective effect of SARS-CoV-2 vaccination against long COVID. The effect is stronger in adolescents, who have higher risk of long COVID, and wanes over time. Understanding VE mechanism against long COVID requires more study, including EHR sources and prospective data.

Article Summary

Vaccination against COVID-19 has a protective effect against long COVID in children and adolescents. The effect wanes over time but remains significant at 12 months.

What’s Known on This Subject

Vaccines reduce the risk and severity of COVID-19 in children. There is evidence for reduced long COVID risk in adults who are vaccinated, but little information about similar effects for children and adolescents, who have distinct forms of long COVID.

What This Study Adds

Using electronic health records from US health systems, we examined large cohorts of vaccinated and unvaccinated patients <18 years old and show that vaccination against COVID-19 is associated with reduced risk of long COVID for at least 12 months.

Contributors’ Statement

Drs. Hanieh Razzaghi and Charles Bailey conceptualized and designed the study, supervised analyses, drafted the initial manuscript, and critically reviewed and revised the manuscript.Drs. Christopher Forrest and Yong Chen designed the study and critically reviewed and revised the manuscript.Ms. Kathryn Hirabayashi, Ms. Andrea Allen, and Dr. Qiong Wu conducted analyses, and critically reviewed and revised the manuscript.Drs. Suchitra Rao, H Timothy Bunnell, Elizabeth A. Chrischilles, Lindsay G. Cowell, Mollie R. Cummins, David A. Hanauer, Benjamin D. Horne, Carol R. Horowitz, Ravi Jhaveri, Susan Kim, Aaron Mishkin, Jennifer A. Muszynski, Susanna Nagie, Nathan M. Pajor, Anuradha Paranjape, Hayden T. Schwenk, Marion R. Sills, Yacob G. Tedla, David A. Williams, and Ms. Miranda Higginbotham critically reviewed and revised the manuscript.All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Authorship statement

Authorship has been determined according to ICMJE recommendations.

Associations of longitudinal BMI percentile classification patterns in early childhood with neighborhood-level social determinants of health

Background

Understanding social determinants of health (SDOH) that may be risk factors for childhood obesity is important to developing targeted interventions to prevent obesity. Prior studies have examined these risk factors, mostly examining obesity as a static outcome variable.

Objectives

This study aimed to identify distinct subpopulations based on BMI percentile classification or changes in BMI percentile classifications over time and explore these longitudinal associations with neighborhood-level SDOH factors in children from 0 to 7 years of age.

Methods

Using Latent Class Growth (Mixture) Modelling (LCGMM) we identify distinct BMI% classification groups in children from 0 to 7 years of age. We used multinomial logistic regression to study associations between SDOH factors with each BMI% classification group.

Results

From the study cohort of 36,910 children, five distinct BMI% classification groups emerged: always having obesity (n=429; 1.16%), overweight most of the time (n=15,006; 40.65%), increasing BMI% (n=9,060; 24.54%), decreasing BMI% (n=5,058; 13.70%), and always normal weight (n=7,357; 19.89%). Compared to children in the decreasing BMI% and always normal weight groups, children in the other three groups were more likely to live in neighborhoods with higher rates of poverty, unemployment, crowded households, and single-parent households, and lower rates of preschool enrollment.

Conclusions

Neighborhood-level SDOH factors have significant associations with children's BMI% classification and changes in classification over time. This highlights the need to develop tailored obesity interventions for different groups to address the barriers faced by communities that can impact the weight and health of the children living within them.

Bilateral Buccal Flap Revision Palatoplasty to Correct Velopharyngeal Dysfunction in Patients with Repaired Cleft Palate: Perceptual Speech, Acoustic, and Aerodynamic Outcomes

BACKGROUND

The purpose of this study was to analyze perceptual, acoustic, and aerodynamic changes in speech and velopharyngeal function after bilateral buccal flap revision palatoplasty (BBFRP). in patients with repaired cleft palate.

METHODS

Ten consecutive patients, aged 4-18 years with velopharyngeal dysfunction (VPD) treated with BBFRP by a single surgeon, were evaluated. Using a visual analog scale (VAS), nine blinded speech-language pathologists independently rated hypernasality, hyponasality, audible nasal emission (ANE) and speech acceptability. Measurements of the acoustic speech signal were used to quantify changes in hypernasality and nasal emission. The pressure-flow technique was used to determine changes in velopharyngeal gap size.

RESULTS

Complete records were available for 8 patients. After surgery, hypernasality significantly decreased (p<.001) and speech acceptability increased (p<.001). ANE was significantly reduced (p<.001). Postoperative acoustic measures showed a reduction of nasal emission and improved nasalization. VP gap size significantly decreased after BBFRP (p<.001), correlating with lower VAS ratings of hypernasality (p=.015). Hyponasality did not significantly change after surgery (p=.964). No patient developed sleep disordered breathing.

CONCLUSIONS

BBFRP resulted in a measurable improvement in hypernasal speech, audible nasal emission, and speech acceptability without significant changes in hyponasality or risk of obstructive sleep apnea.

Assessing the effects of therapeutic combinations on SARS-CoV-2 infected patient outcomes: A big data approach

BACKGROUND

The COVID-19 pandemic has demonstrated the need for efficient and comprehensive, simultaneous assessment of multiple combined novel therapies for viral infection across the range of illness severity. Randomized Controlled Trials (RCT) are the gold standard by which efficacy of therapeutic agents is demonstrated. However, they rarely are designed to assess treatment combinations across all relevant subgroups. A big data approach to analyzing real-world impacts of therapies may confirm or supplement RCT evidence to further assess effectiveness of therapeutic options for rapidly evolving diseases such as COVID-19.

METHODS

Gradient Boosted Decision Tree, Deep and Convolutional Neural Network classifiers were implemented and trained on the National COVID Cohort Collaborative (N3C) data repository to predict the patients' outcome of death or discharge. Models leveraged the patients' characteristics, the severity of COVID-19 at diagnosis, and the calculated proportion of days on different treatment combinations after diagnosis as features to predict the outcome. Then, the most accurate model is utilized by eXplainable Artificial Intelligence (XAI) algorithms to provide insights about the learned treatment combination impacts on the model's final outcome prediction.

RESULTS

Gradient Boosted Decision Tree classifiers present the highest prediction accuracy in identifying patient outcomes with area under the receiver operator characteristic curve of 0.90 and accuracy of 0.81 for the outcomes of death or sufficient improvement to be discharged. The resulting model predicts the treatment combinations of anticoagulants and steroids are associated with the highest probability of improvement, followed by combined anticoagulants and targeted antivirals. In contrast, monotherapies of single drugs, including use of anticoagulants without steroid or antivirals are associated with poorer outcomes.

CONCLUSIONS

This machine learning model by accurately predicting the mortality provides insights about the treatment combinations associated with clinical improvement in COVID-19 patients. Analysis of the model's components suggests benefit to treatment with combination of steroids, antivirals, and anticoagulant medication. The approach also provides a framework for simultaneously evaluating multiple real-world therapeutic combinations in future research studies.

Community risks for SARS-CoV-2 infection among fully vaccinated US adults by rurality: A retrospective cohort study from the National COVID Cohort Collaborative

BACKGROUND

While COVID-19 vaccines reduce adverse outcomes, post-vaccination SARS-CoV-2 infection remains problematic. We sought to identify community factors impacting risk for breakthrough infections (BTI) among fully vaccinated persons by rurality.

METHODS

We conducted a retrospective cohort study of US adults sampled between January 1 and December 20, 2021, from the National COVID Cohort Collaborative (N3C). Using Kaplan-Meier and Cox-Proportional Hazards models adjusted for demographic differences and comorbid conditions, we assessed impact of rurality, county vaccine hesitancy, and county vaccination rates on risk of BTI over 180 days following two mRNA COVID-19 vaccinations between January 1 and September 21, 2021. Additionally, Cox Proportional Hazards models assessed the risk of infection among adults without documented vaccinations. We secondarily assessed the odds of hospitalization and adverse COVID-19 events based on vaccination status using multivariable logistic regression during the study period.

RESULTS

Our study population included 566,128 vaccinated and 1,724,546 adults without documented vaccination. Among vaccinated persons, rurality was associated with an increased risk of BTI (adjusted hazard ratio [aHR] 1.53, 95% confidence interval [CI] 1.42-1.64, for urban-adjacent rural and 1.65, 1.42-1.91, for nonurban-adjacent rural) compared to urban dwellers. Compared to low vaccine-hesitant counties, higher risks of BTI were associated with medium (1.07, 1.02-1.12) and high (1.33, 1.23-1.43) vaccine-hesitant counties. Compared to counties with high vaccination rates, a higher risk of BTI was associated with dwelling in counties with low vaccination rates (1.34, 1.27-1.43) but not medium vaccination rates (1.00, 0.95-1.07). Community factors were also associated with higher odds of SARS-CoV-2 infection among persons without a documented vaccination. Vaccinated persons with SARS-CoV-2 infection during the study period had significantly lower odds of hospitalization and adverse events across all geographic areas and community exposures.

CONCLUSIONS

Our findings suggest that community factors are associated with an increased risk of BTI, particularly in rural areas and counties with high vaccine hesitancy. Communities, such as those in rural and disproportionately vaccine hesitant areas, and certain groups at high risk for adverse breakthrough events, including immunosuppressed/compromised persons, should continue to receive public health focus, targeted interventions, and consistent guidance to help manage community spread as vaccination protection wanes.

Predicting Attrition Patterns from Pediatric Weight Management Programs

Obesity is a major public health concern. Multidisciplinary pediatric weight management programs are considered standard treatment for children with obesity who are not able to be successfully managed in the primary care setting. Despite their great potential, high dropout rates (referred to as attrition) are a major hurdle in delivering successful interventions. Predicting attrition patterns can help providers reduce the alarmingly high rates of attrition (up to 80%) by engaging in earlier and more personalized interventions. Previous work has mainly focused on finding static predictors of attrition on smaller datasets and has achieved limited success in effective prediction. In this study, we have collected a five-year comprehensive dataset of 4,550 children from diverse backgrounds receiving treatment at four pediatric weight management programs in the US. We then developed a machine learning pipeline to predict (a) the likelihood of attrition, and (b) the change in body-mass index (BMI) percentile of children, at different time points after joining the weight management program. Our pipeline is greatly customized for this problem using advanced machine learning techniques to process longitudinal data, smaller-size data, and interrelated prediction tasks. The proposed method showed strong prediction performance as measured by AUROC scores (average AUROC of 0.77 for predicting attrition, and 0.78 for predicting weight outcomes).

An ordinal severity scale for COVID-19 retrospective studies using Electronic Health Record data

Objectives

Although the World Health Organization (WHO) Clinical Progression Scale for COVID-19 is useful in prospective clinical trials, it cannot be effectively used with retrospective Electronic Health Record (EHR) datasets. Modifying the existing WHO Clinical Progression Scale, we developed an ordinal severity scale (OS) and assessed its usefulness in the analyses of COVID-19 patient outcomes using retrospective EHR data.

Materials and Methods

An OS was developed to assign COVID-19 disease severity using the Observational Medical Outcomes Partnership common data model within the National COVID Cohort Collaborative (N3C) data enclave. We then evaluated usefulness of the developed OS using heterogenous EHR data from January 2020 to October 2021 submitted to N3C by 63 healthcare organizations across the United States. Principal component analysis (PCA) was employed to characterize changes in disease severity among patients during the 28-day period following COVID-19 diagnosis.

Results

The data set used in this analysis consists of 2 880 456 patients. PCA of the day-to-day variation in OS levels over the totality of the 28-day period revealed contrasting patterns of variation in disease severity within the first and second 14 days and illustrated the importance of evaluation over the full 28-day period.

Discussion

An OS with well-defined, robust features, based on discrete EHR data elements, is useful for assessments of COVID-19 patient outcomes, providing insights on the progression of COVID-19 disease severity over time.

Conclusions

The OS provides a framework that can facilitate better understanding of the course of acute COVID-19, informing clinical decision-making and resource allocation.

Obesity Prediction with EHR Data: A deep learning approach with interpretable elements

Childhood obesity is a major public health challenge. Early prediction and identification of the children at an elevated risk of developing childhood obesity may help in engaging earlier and more effective interventions to prevent and manage obesity. Most existing predictive tools for childhood obesity primarily rely on traditional regression-type methods using only a few hand-picked features and without exploiting longitudinal patterns of children's data. Deep learning methods allow the use of high-dimensional longitudinal datasets. In this paper, we present a deep learning model designed for predicting future obesity patterns from generally available items on children's medical history. To do this, we use a large unaugmented electronic health records dataset from a large pediatric health system in the US. We adopt a general LSTM network architecture and train our proposed model using both static and dynamic EHR data. To add interpretability, we have additionally included an attention layer to calculate the attention scores for the timestamps and rank features of each timestamp. Our model is used to predict obesity for ages between 3-20 years using the data from 1-3 years in advance. We compare the performance of our LSTM model with a series of existing studies in the literature and show it outperforms their performance in most age ranges.

Flexible-Window Predictions on Electronic Health Records

Various types of machine learning techniques are available for analyzing electronic health records (EHRs). For predictive tasks, most existing methods either explicitly or implicitly divide these time-series datasets into predetermined observation and prediction windows. Patients have different lengths of medical history and the desired predictions (for purposes such as diagnosis or treatment) are required at different times in the future. In this paper, we propose a method that uses a sequence-to-sequence generator model to transfer an input sequence of EHR data to a sequence of user-defined target labels, providing the end-users with "flexible" observation and prediction windows to define. We use adversarial and semi-supervised approaches in our design, where the sequence-to-sequence model acts as a generator and a discriminator distinguishes between the actual (observed) and generated labels. We evaluate our models through an extensive series of experiments using two large EHR datasets from adult and pediatric populations. In an obesity predicting case study, we show that our model can achieve superior results in flexible-window prediction tasks, after being trained once and even with large missing rates on the input EHR data. Moreover, using a number of attention analysis experiments, we show that the proposed model can effectively learn more relevant features in different prediction tasks.

Online patient portal use by caregivers in pediatric oncology: Are we widening sociodemographic disparities?

BACKGROUND

Financial and regulatory incentives have encouraged and increased the availability of online patient portals that provide caregivers access to their child's electronic health records (EHR). Such access is believed to promote better engagement and outcomes of care. Little is known about the use of portals by caregivers of children with cancer. This study sought to examine whether sociodemographic and clinical care variables are associated with portal activation in a pediatric oncology sample.

METHODS

Sociodemographic and clinical characteristics were extracted from the EHR of pediatric oncology patients treated for their first cancer in the Nemours Center for Cancer and Blood Disorders between 2012 and 2017. A Child Opportunity Index (COI) was calculated based on home zip code. Characteristics of children whose caregivers did and did not activate the portal were compared.

RESULTS

Sixty-six percent of caregivers activated a portal account with a peak within 90 days of diagnosis. In logistic regression, caregivers with a younger aged child, spoke English, lived closer to the hospital, lived in higher COI area, with longer treatment length, and more radiology tests had greater odds of portal activation. Those with private health insurance or White race were overrepresented among those who activated an account in univariate analysis.

CONCLUSION

The majority of caregivers of children with cancer activate portal accounts; however, differences in sociodemographic and clinical variables across those who did and did not activate accounts emerged. As portals become ubiquitous, we must understand how they are used and mitigate widening inequities caused by disparate portal use.

Concurrent Imputation and Prediction on EHR data using Bi-Directional GANs: Bi-GANs for EHR imputation and prediction

Working with electronic health records (EHRs) is known to be challenging due to several reasons. These reasons include not having: 1) similar lengths (per visit), 2) the same number of observations (per patient), and 3) complete entries in the available records. These issues hinder the performance of the predictive models created using EHRs. In this paper, we approach these issues by presenting a model for the combined task of imputing and predicting values for the irregularly observed and varying length EHR data with missing entries. Our proposed model (dubbed as Bi-GAN) uses a bidirectional recurrent network in a generative adversarial setting. In this architecture, the generator is a bidirectional recurrent network that receives the EHR data and imputes the existing missing values. The discriminator attempts to discriminate between the actual and the imputed values generated by the generator. Using the input data in its entirety, Bi-GAN learns how to impute missing elements in-between (imputation) or outside of the input time steps (prediction). Our method has three advantages to the state-of-the-art methods in the field: (a) one single model performs both the imputation and prediction tasks; (b) the model can perform predictions using time-series of varying length with missing data; (c) it does not require to know the observation and prediction time window during training and can be used for the predictions with different observation and prediction window lengths, for short- and long-term predictions. We evaluate our model on two large EHR datasets to impute and predict body mass index (BMI) values and show its superior performance in both settings.

Assessment of 135 794 Pediatric Patients Tested for Severe Acute Respiratory Syndrome Coronavirus 2 Across the United States

IMPORTANCE

There is limited information on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing and infection among pediatric patients across the United States.

OBJECTIVE

To describe testing for SARS-CoV-2 and the epidemiology of infected patients.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study was conducted using electronic health record data from 135 794 patients younger than 25 years who were tested for SARS-CoV-2 from January 1 through September 8, 2020. Data were from PEDSnet, a network of 7 US pediatric health systems, comprising 6.5 million patients primarily from 11 states. Data analysis was performed from September 8 to 24, 2020.

EXPOSURE

Testing for SARS-CoV-2.

MAIN OUTCOMES AND MEASURES

SARS-CoV-2 infection and coronavirus disease 2019 (COVID-19) illness.

RESULTS

A total of 135 794 pediatric patients (53% male; mean [SD] age, 8.8 [6.7] years; 3% Asian patients, 15% Black patients, 11% Hispanic patients, and 59% White patients; 290 per 10 000 population [range, 155-395 per 10 000 population across health systems]) were tested for SARS-CoV-2, and 5374 (4%) were infected with the virus (12 per 10 000 population [range, 7-16 per 10 000 population]). Compared with White patients, those of Black, Hispanic, and Asian race/ethnicity had lower rates of testing (Black: odds ratio [OR], 0.70 [95% CI, 0.68-0.72]; Hispanic: OR, 0.65 [95% CI, 0.63-0.67]; Asian: OR, 0.60 [95% CI, 0.57-0.63]); however, they were significantly more likely to have positive test results (Black: OR, 2.66 [95% CI, 2.43-2.90]; Hispanic: OR, 3.75 [95% CI, 3.39-4.15]; Asian: OR, 2.04 [95% CI, 1.69-2.48]). Older age (5-11 years: OR, 1.25 [95% CI, 1.13-1.38]; 12-17 years: OR, 1.92 [95% CI, 1.73-2.12]; 18-24 years: OR, 3.51 [95% CI, 3.11-3.97]), public payer (OR, 1.43 [95% CI, 1.31-1.57]), outpatient testing (OR, 2.13 [1.86-2.44]), and emergency department testing (OR, 3.16 [95% CI, 2.72-3.67]) were also associated with increased risk of infection. In univariate analyses, nonmalignant chronic disease was associated with lower likelihood of testing, and preexisting respiratory conditions were associated with lower risk of positive test results (standardized ratio [SR], 0.78 [95% CI, 0.73-0.84]). However, several other diagnosis groups were associated with a higher risk of positive test results: malignant disorders (SR, 1.54 [95% CI, 1.19-1.93]), cardiac disorders (SR, 1.18 [95% CI, 1.05-1.32]), endocrinologic disorders (SR, 1.52 [95% CI, 1.31-1.75]), gastrointestinal disorders (SR, 2.00 [95% CI, 1.04-1.38]), genetic disorders (SR, 1.19 [95% CI, 1.00-1.40]), hematologic disorders (SR, 1.26 [95% CI, 1.06-1.47]), musculoskeletal disorders (SR, 1.18 [95% CI, 1.07-1.30]), mental health disorders (SR, 1.20 [95% CI, 1.10-1.30]), and metabolic disorders (SR, 1.42 [95% CI, 1.24-1.61]). Among the 5374 patients with positive test results, 359 (7%) were hospitalized for respiratory, hypotensive, or COVID-19-specific illness. Of these, 99 (28%) required intensive care unit services, and 33 (9%) required mechanical ventilation. The case fatality rate was 0.2% (8 of 5374). The number of patients with a diagnosis of Kawasaki disease in early 2020 was 40% lower (259 vs 433 and 430) than in 2018 or 2019.

CONCLUSIONS AND RELEVANCE

In this large cohort study of US pediatric patients, SARS-CoV-2 infection rates were low, and clinical manifestations were typically mild. Black, Hispanic, and Asian race/ethnicity; adolescence and young adulthood; and nonrespiratory chronic medical conditions were associated with identified infection. Kawasaki disease diagnosis is not an effective proxy for multisystem inflammatory syndrome of childhood.

Effects of age, sex, race/ethnicity, and allergy status in obesity-related pediatric asthma

RATIONALE

Obesity in children increases the risk for new asthma. How age, sex, race/ethnicity, and allergy status affect the relationship between obesity and asthma is unclear. This study describes the relationship between high body mass index (BMI) and incident asthma.

METHODS

We conducted a retrospective cohort study to compare asthma incidence among normal weight, overweight, and obese 2 to 6, 7 to 11, and 12 to 17 year olds to define the effects of sex, race/ethnicity, and allergy status. Weight status was determined at baseline and asthma incidence was defined as ≥2 asthma encounters and ≥1 asthma prescriptions. We used multivariable Poisson regression to estimate adjusted incident asthma rates and risk ratios.

RESULTS

Data from 192 843 2 to 6 year olds, 157 284 7 to 11 year olds, and 157 369 12 to 17 year olds were included. The relative risks (95% confidence interval [CI]) of new asthma among obese children in 2 to 6 year olds, 7 to 11 year olds, and 12 to 17 year olds were 1.25 (1.15, 1.37), 1.49 (1.32, 1.69) and 1.40 (1.21, 1.63), respectively. Among children with underlying allergic rhinitis, obesity did not increase the risk of new asthma. In children without allergic rhinitis, the risk for obesity-related asthma was highest in 7 to 11 year olds (risk ratio = 1.50 95% CI, 1.33, 1.60). Before age 12, females had a higher risk for obesity-related asthma; but after age 12, obese males had a higher asthma risk (interaction P-value < .05).

CONCLUSION

Obesity is a major preventable risk factor for pediatric asthma that appears to vary along the pediatric age continuum and depends on sex, race/ethnicity and atopy status.

Being Overweight or Obese and the Development of Asthma

OBJECTIVES

Adult obesity is linked to asthma cases and is estimated to lead to 250 000 new cases yearly. Similar incidence and attributable risk (AR) estimates have not been developed for children. We sought to describe the relationship between overweight and obesity and incident asthma in childhood and quantify AR statistics in the United States for overweight and obesity on pediatric asthma.

METHODS

The PEDSnet clinical data research network was used to conduct a retrospective cohort study (January 2009-December 2015) to compare asthma incidence among overweight and/or obese versus healthy weight 2- to 17-year-old children. Asthma incidence was defined as ≥2 encounters with a diagnosis of asthma and ≥1 asthma controller prescription. Stricter diagnostic criteria involved confirmation by spirometry. We used multivariable Poisson regression analyses to estimate incident asthma rates and risk ratios and accepted formulas for ARs.

RESULTS

Data from 507 496 children and 19 581 972 encounters were included. The mean participant observation period was 4 years. The adjusted risk for incident asthma was increased among children who were overweight (relative risk [RR]: 1.17; 95% confidence interval [CI]: 1.10-1.25) and obese (RR: 1.26; 95% CI: 1.18-1.34). The adjusted risk for spirometry-confirmed asthma was increased among children with obesity (RR: 1.29; 95% CI: 1.16-1.42). An estimated 23% to 27% of new asthma cases in children with obesity is directly attributable to obesity. In the absence of overweight and obesity, 10% of all cases of asthma would be avoided.

CONCLUSIONS

Obesity is a major preventable risk factor for pediatric asthma.

A cognitive approach for design of a multimedia informed consent video and website in pediatric research

OBJECTIVE

Poor participant comprehension of research procedures following the conventional face-to-face consent process for biomedical research is common. We describe the development of a multimedia informed consent video and website that incorporates cognitive strategies to enhance comprehension of study related material directed to parents and adolescents.

MATERIALS AND METHODS

A multidisciplinary team was assembled for development of the video and website that included human subjects professionals; psychologist researchers; institutional video and web developers; bioinformaticians and programmers; and parent and adolescent stakeholders. Five learning strategies that included Sensory-Modality view, Coherence, Signaling, Redundancy, and Personalization were integrated into a 15-min video and website material that describes a clinical research trial.

RESULTS

A diverse team collaborated extensively over 15months to design and build a multimedia platform for obtaining parental permission and adolescent assent for participant in as asthma clinical trial. Examples of the learning principles included, having a narrator describe what was being viewed on the video (sensory-modality); eliminating unnecessary text and graphics (coherence); having the initial portion of the video explain the sections of the video to be viewed (signaling); avoiding simultaneous presentation of text and graphics (redundancy); and having a consistent narrator throughout the video (personalization).

DISCUSSION

Existing conventional and multimedia processes for obtaining research informed consent have not actively incorporated basic principles of human cognition and learning in the design and implementation of these processes. The present paper illustrates how this can be achieved, setting the stage for rigorous evaluation of potential benefits such as improved comprehension, satisfaction with the consent process, and completion of research objectives.

CONCLUSION

New consent strategies that have an integrated cognitive approach need to be developed and tested in controlled trials.

Use of mobile devices and the internet for multimedia informed consent delivery and data entry in a pediatric asthma trial: Study design and rationale

INTRODUCTION

Phase III/IV clinical trials are expensive and time consuming and often suffer from poor enrollment and retention rates. Pediatric trials are particularly difficult because scheduling around the parent, participant and potentially other sibling schedules can be burdensome. We are evaluating using the internet and mobile devices to conduct the consent process and study visits in a streamlined pediatric asthma trial. Our hypothesis is that these study processes will be non-inferior and will be less expensive compared to a traditional pediatric asthma trial.

MATERIALS/METHODS

Parents and participants, aged 12 through 17 years, complete the informed consent process by viewing a multi-media website containing a consent video and study material in the streamlined trial. Participants are provided an iPad with WiFi and EasyOne spirometer for use during FaceTime visits and online twice daily symptom reporting during an 8-week run-in followed by a 12-week study period. Outcomes are compared with participants completing a similarly designed traditional trial comparing the same treatments within the same pediatric health-system. After 8 weeks of open-label Advair 250/50 twice daily, participants in both trial types are randomized to Advair 250/50, Flovent 250, or Advair 100/50 given 1 inhalation twice daily. Study staff track time spent to determine study costs.

RESULTS

Participants have been enrolled in the streamlined and traditional trials and recruitment is ongoing.

CONCLUSIONS

This project will provide important information on both clinical and economic outcomes for a novel method of conducting clinical trials. The results will be broadly applicable to trials of other diseases.

Piecewise Mixed Effects Model to Compare the Weight-gain Patter ns Before and After Diagnosis of Asthma in Children Younger than 5 Years

Asthma and obesity are two significant public health problems that both originate in early childhood and have shared risk factors and manifestations. Studies suggest a strong association between asthma development and subsequent accelerated weight gain. Children are diagnosed with asthma in early childhood and are often exposed to factors associated with rapid weight gain. This article intends to demonstrate an innovative application of the piecewise mixed effects model to characterize the difference in the temporal rate of change in BMIz, the standardized scores of body mass index and weight-for-length that measure weight status, before and after asthma diagnosis in children younger than 5 years. The data consist of unique sequences from 1194 children's clinic visits during the first 5 years of life. We used a knot at the time of diagnosis and detected a differential weight-gain pattern before and after asthma diagnosis. The pre- and post-asthma-diagnosis weight-gain patterns further differ by sex and race-ethnicity. After asthma diagnosis, female children showed a higher increase in the rate of change in BMIz than males. Non-Hispanic African Americans and Hispanics had higher post-diagnosis rates of change in BMIz than Caucasians. The differential weight-gain patterns between male and female children were mainly contributed by Caucasian children. These findings could have important implications in the clinical care of children after asthma diagnosis.

Using automatic alignment to analyze endangered language data: testing the viability of untrained alignment

While efforts to document endangered languages have steadily increased, the phonetic analysis of endangered language data remains a challenge. The transcription of large documentation corpora is, by itself, a tremendous feat. Yet, the process of segmentation remains a bottleneck for research with data of this kind. This paper examines whether a speech processing tool, forced alignment, can facilitate the segmentation task for small data sets, even when the target language differs from the training language. The authors also examined whether a phone set with contextualization outperforms a more general one. The accuracy of two forced aligners trained on English (hmalign and p2fa) was assessed using corpus data from Yoloxóchitl Mixtec. Overall, agreement performance was relatively good, with accuracy at 70.9% within 30 ms for hmalign and 65.7% within 30 ms for p2fa. Segmental and tonal categories influenced accuracy as well. For instance, additional stop allophones in hmalign's phone set aided alignment accuracy. Agreement differences between aligners also corresponded closely with the types of data on which the aligners were trained. Overall, using existing alignment systems was found to have potential for making phonetic analysis of small corpora more efficient, with more allophonic phone sets providing better agreement than general ones.

Academic and Clinical Training in Cleft Palate for Speech-Language Pathologists

Objective:

The purpose of this study was to obtain information about academic and clinical training of speech-language pathology students in cleft palate (CP).

Methods:

Representatives of 232 accredited graduate programs in speech-language pathology were invited via e-mail to complete a web-based 32-item questionnaire. Questions focused on the type and nature of courses offered related to CP, availability of clinical practica, and number of hours of clinical experience by students. An item-by-item analysis was conducted and descriptive statistics obtained.

Results:

A total of 127 (54.7%) of the programs responded. Sixty-seven percent offered coursework exclusively devoted to CP, and for 53% of these it was a required course. For the programs that did not offer an exclusive course on CP, 35% indicated that CP was covered in other courses such as articulation, voice, or anatomy and physiology. Fifty-four percent of the programs offered clinical practica in CP. For these, a median of five students of a median graduate speech-language pathology class of 43 were enrolled in practica involving CP (range  =  0–21), and students spent a median of 2 hours in practica involving CP (range  =  0–100).

Conclusions:

Cleft palate is a complex disorder to which many students have limited exposure and for which more graduate training is unlikely since the 1993 American Speech-Language-Hearing Association (ASHA) certification changes. As a result, there is a need to look towards alternative methods to enhance the educational and clinical experiences of students and practitioners in cleft palate.

Perceptual evaluations of spectral and temporal modifications of deaf speech

The perceptual effect of modifying speech produced by deaf talkers was investigated to discover the changes necessary for disordered speech to be judged normal. Recordings of passages read by three deaf talkers were used as material. For the first two experiments, a three-syllable word was extracted from the deaf talkers' passages and from a similar passage recorded by a hearing talker. Each of the deaf speech samples was paired with the normal speech sample to generate various continua that differed in the spectral and temporal modifications applied to them. Within each continuum, the individual stimuli varied in the shape of the spectrum envelope and were produced by linear interpolation of LPC analysis parameters between the deaf and normal speech end points. Results suggest that correcting the temporal component of deaf speech alone is not enough to make it sound normal. Spectral corrections that approximate about 70% of normal appear to be necessary for the deaf speech samples to be judged normal. A third experiment made use of a 10-syllable segment of speech in which the relative contributions of spectral and temporal adjustments were investigated. The general conclusion of these three experiments is that spectral adjustments are more important to perceptual judgments of normality than temporal adjustments.

Phonetics of intervocalic consonant perception: retrospect and prospect

This article reviews the production characteristics and perceptual cues of intervocalic consonants as a background for acoustic studies of consonant perception in fluent speech. Data show that in conversation intervocalic consonants occur much more commonly than consonants in initial or final position; all phonetic features are strongly represented. Production characteristics of intervocalic consonants are seen to depend on the tempo and rhythmic conditions of the syllables of which they are components. At a moderate tempo, consonants in syllable-final position combine with the onset consonant of the following syllable. This affects durational characteristics and may be explained by higher energy efficiency of CV units in production. Phonological phenomena are related to the shifts in syllable position and the temporal compensations of intervocalic consonant production. Studies of consonant perception in fluent context have dealt with tempo of utterance, position in word, and rhythmic pattern, as well as phonemic context. Major phenomena are effects of coarticulation, invariance in consonant perception, and cue interaction and masking. Much evidence suggests a dominance of the perceptual cues in the CV portion of VCCV and VCV sequences. We suggest that exploration of perception variables that affect consonants in fluent context would be expedited by reorienting experimental procedures to employ listener adjustment of stimuli, instead of the traditional phoneme identification and discrimination procedures with large sets of constant stimuli. Most of the relevant literature deals with stop consonants. Lateral, rhotic, and nasal consonants also deserve intensive study because of their very frequent occurrence. Theoretical issues of phoneme perceptual invariance and motor vs. auditory theory of perception are discussed in relation to proposed experiments which vary syllable tempo and stress pattern.

Perception of anticipatory coarticulation effects in vowel-stop consonant-bowel sequences

Articulatory and acoustic studies of speech production have shown that the effects of anticipatory coarticulation may extend across several segments of an utterance. The present experiments show that such effects have perceptual significance. In two experiments, a talker produced consonant (C) and vowel (V) sequences in a sentence frame (e.g., "I say pookee") of the form "I say / C V1 C V2/" in which V1 was /u, ae/ and V2 was /i, a/. Each /i, a/ sentence pair was cross-spliced by exchanging the final syllable /C V2/ so that coarticulatory information prior to the crosspoint was inappropriate for te final vowel (V2) in crossed sentences. Recognition time (RT) for V2 in crossed and intact (as spoken) sentences was obtained from practiced listeners. In both experiments RT was slower in crossed sentences; crossed sentences also attracted more false alarms. The pattern of perceptual results was mirrored in the pattern of precross acoustic differences in experimental sentences (e.g., formants F2 and F3 were higher preceding /i/ than preceding /a/). Pretarget variation in the formants jointly predicted amount of RT interference in crossed sentences. A third experiment found interference (slower RT) and also facilitation (faster RT) from exchanges of pretarget coarticulatory information in sentences. Two final experiments showed that previous results were not dependent on the use of practiced listeners.

Perception of anticipatory coarticulation effects

Articulatory and acoustic studies have shown that the effects of anticipatory coarticulation may extend across several segments in an utterance. But previous perceptual studies suggest that only the information carried by immediately adjacent segments is used in perception. To show that perception is not so limited, we persuaded ten talkers each to produce 12 sentences (e.g., "I say poozee") of the form "I say /C V1 z V2/" in which C was /p, t, k/, V1 was /u, ae/, and V2 was /i, a/. Each /i, a/ sentence pair was cross spliced by exchanging the final syllable /z V2/ so that coarticulatory information prior to the crosspoint was inappropriate for the final vowel V2 in crossed sentences. Recognition time (RT) for V2 in crossed and intact (as spoken) sentences was obtained from practiced listeners. The results were slower RT in crossed sentences, and amount of interference depended on both V1 and C context. Another experiment varied the location of crosspoints across /C V1/ and found that RT interference increased directly with amount and proximity to target of inappropriate precross acoustics. LPC analysis of the experimental sentences showed pretarget variations in F2 frequency which were jointly dependent on identity of C, V1, and V2. Pretarget F2 variations and C and V1 identity jointly predicted amount of RT interference in crossed sentences. Finally, experiments with pretarget F2 variations in synthetic speech repeated and extended the results with real speech. These studies lead to the conclusion that the perceptual significance of coarticulation is not limited to effects on immediately adjacent segments. Listeners appear to be sensitive to many acoustic effects of the mutual influence among the segments in a sequence.