Continuous renal replacement therapy and therapeutic plasma exchange in pediatric liver failure.

Patients with acute liver failure (ALF) and acute on chronic liver failure (ACLF) have significant morbidity and mortality. They require extracorporeal blood purification modalities like continuous renal replacement therapy (CRRT) and therapeutic plasma exchange (TPE) as a bridge to recovery or liver transplantation. Limited data are available on the outcomes of patients treated with these therapies. This is a retrospective single-center study of 23 patients from 2015 to 2022 with ALF/ACLF who underwent CRRT and TPE. We aimed to describe the clinical characteristics and outcomes of these patients. Median (IQR) age was 0.93 years (0.57, 9.88), range 16 days to 20 years. Ten (43%) had ALF and 13 (57%) ACLF. Most (n = 19, 82%) started CRRT for hyperammonemia and/or hepatic encephalopathy and all received TPE for refractory coagulopathy. CRRT was started at a median of 2 days from ICU admission, and TPE started on the same day in most. The liver transplant was done in 17 (74%), and 2 recovered native liver function. Four patients, all with ACLF, died prior to ICU discharge without a liver transplant. The median peak ammonia pre-CRRT was 131 µmol/L for the whole cohort. The mean (SD) drop in ammonia after 48 h of CRRT was 95.45 (43.72) µmol/L in those who survived and 69.50 (21.70) µmol/L in those who did not (p 0.26). Those who survived had 0 median co-morbidities compared to 2.5 in non-survivors (aOR (95% CI) for mortality risk of 2.5 (1.1-5.7), p 0.028). Conclusion: In this cohort of 23 pediatric patients with ALF or ACLF who received CRRT and TPE, 83% survived with a liver transplant or recovered with their native liver. Survival was worse in those who had ACLF and those with co-morbid conditions. What is Known: •  Pediatric acute liver failure is associated with high mortality. •  Patients may require extracorporeal liver assist therapies (like CRRT, TPE, MARS, SPAD) to bridge them over to a transplant or recovery of native liver function. What is New: • Standard volume plasma exhange has not been evaluated against high volume plasma exchange for ALF. • The role, dose, and duration of therapeutic plasma exchange in patients with acute on chronic liver failure is not well described.

Serum Hormone Concentrations in Transgender Youth Receiving Estradiol.

OBJECTIVE: This study aimed to evaluate the serum estradiol levels in gender-diverse youth to compare the efficacy of different estradiol routes in achieving therapeutic blood levels and suppressing serum testosterone levels. METHODS: This was a retrospective chart review of patients who initiated estradiol at an adolescent gender clinic between 2010 and 2019. Data on the route of estradiol administration and antiandrogen use (spironolactone or gonadotropin-releasing hormone agonist) were collected, and laboratory data were analyzed. Scatterplots were used to visualize the relationship between the estradiol dose and testosterone and estradiol laboratory values. RESULTS: A total of 118 patients were included, with a mean (standard deviation [SD]) age of 17.2 (1.6) years. The most common route of estradiol administration was oral only (62.7%), followed by transdermal only (23.7%), multiple routes excluding subcutaneous (8.5%), and any subcutaneous (5.1%). Notable variability was observed in the serum estradiol levels, with means (SDs) of 131.9 (120.4) pg/mL for those on oral estrogen 6 to 8 mg per day, 62.6 (40.3) pg/mL for those on transdermal estrogen 0.1 to 0.15 mg every 24 hours, and 53.6 (42.4) pg/mL for those on subcutaneous estradiol. In patients who received spironolactone, transdermal estradiol was associated with lower testosterone levels than estradiol administered orally or subcutaneously. CONCLUSION: Oral, transdermal, and subcutaneous administrations of estrogen all lead to increased serum estradiol levels and are effective for use in gender-affirming care for youth. Patients on transdermal estrogen tended to have lower serum estradiol levels but also had more suppression of serum testosterone levels.

Solving the Autism Puzzle: Creating a Broad-Spectrum Tool to Improve Care Delivery in the Clinical Setting.

PURPOSE: The purpose of this quality improvement (QI) project was to develop and implement an assessment tool to identify a patient's specific needs due to autism spectrum disorder (ASD). The use of an individualized plan of care related to sensory and behavioral differences correlates with improved experiences in the perioperative setting for patients with ASD. DESIGN: Mixed methods, pre-post survey, retrospective data comparison. METHODS: Metrics planned to evaluate intervention outcomes included: (1) Comparison of pre and postsurvey data obtained from perioperative staff members following ASD education, (2) Evaluation of the number of behavior response team calls made compared to retrospective data, and (3) Survey response data from families assessing the perceived experience of perioperative stay. FINDINGS: Two hundred and fifty staff members responded to the learning needs survey; 164 in the preperiod and 86 in the postperiod. The perioperative process for these patients improved from the pre- to the postperiod in its ability to meet the needs of patients with autism (P < .001). Overall, respondents rated the sensory aids and the behavioral and sensory assessment tool as very useful (Median = 5, IQR = 2) and stated that they are likely to continue to use the tools in the future when caring for patients with autism (Median = 5, IQR = 1). CONCLUSIONS: The caregivers of study patients felt they had a high level of satisfaction with their surgery or procedure experience. Health care providers also reported increased confidence working with individuals with ASD in the perioperative environment and satisfaction with the intervention program.

Risk factors for severe acute kidney injury after pediatric hematopoietic cell transplantation.

BACKGROUND: Acute kidney injury (AKI) is common after hematopoietic cell transplantation (HCT) and is associated with poorer outcomes. Risk factors for AKI after pediatric HCT are not fully understood. The study objective was to assess unique risk factors for AKI in the HCT population and evaluate post-HCT AKI patterns. METHODS: We conducted a retrospective cohort study of patients < 21 years of age who underwent HCT at Seattle Children's Hospital/Fred Hutchinson Cancer Center from September 2008 to July 2017 (n = 484). We defined AKI using KDIGO criteria. We collected demographics, baseline HCT characteristics, post-HCT complications, and mortality. Multinomial logistic regression was used to estimate association between AKI and potential risk factors. We used adjusted Cox proportional hazard ratios to evaluate differences in mortality. RESULTS: One hundred and eighty-six patients (38%) developed AKI. Seventy-nine (42%) had severe AKI and 27 (15%) required kidney replacement therapy. Fluid overload was common in all groups and 67% of those with severe AKI had > 10% fluid overload. Nephrology was consulted in less than 50% of those with severe AKI. In multivariable analysis, risk of severe AKI was lower in those taking a calcineurin inhibitor (CNI). Risk of death was higher in severe AKI compared to no AKI (RR 4.6, 95% CI 2.6-8.1). CONCLUSIONS: AKI and fluid overload are common in pediatric patients after HCT. Severe AKI occurred less often with CNI use and was associated with higher mortality. Future interventions to reduce AKI and its associated complications such as fluid overload are approaches to reducing morbidity and mortality after HCT. A higher resolution version of the Graphical abstract is available as Supplementary information.

Effect of Race and Geography on Patient- and Parent-Reported Quality of Life for Children With Congenital Upper Limb Differences.

PURPOSE: Patient beliefs about health and disability are shaped by many social factors and are a key determinant in their ultimate outcome. We hypothesized that pediatric and parent-reported outcome measures regarding a child's congenital upper limb difference will be affected by geographic location, parent education, sex, ethnicity, race, age, and presence of additional medical comorbidities. METHODS: Patients enrolled in the multicenter Congenital Upper Limb Difference registry were included. Age, sex, race, ethnicity, medical comorbidities, highest level of parental education, area deprivation index, and geographic region were recorded. Patient-Reported Outcomes Measurement Information System (PROMIS) in the pediatric and parent-reported domains of upper extremity, anxiety, pain interference, peer relationships, and depressive symptoms were collected. RESULTS: The only difference between geographic regions in the United States in pediatric and parent-reported PROMIS was that parents in the Midwest reported higher upper extremity function scores in children with upper limb differences than the West. Black patients demonstrated higher scores in parent and child-reported domains of depression, pain, and anxiety, and lower scores in upper extremity function than White and Asian peers. Additionally, children with medical comorbidities also demonstrated worse outcomes in multiple PROMIS domains. There was no difference in scores based on sex, parent education, and ethnicity. CONCLUSIONS: In children with congenital upper limb differences, race and additional medical comorbidities have an impact on patient- and parent-reported PROMIS outcome measures in multiple domains, with Black children and those with additional medical comorbidities scoring lower than their peers. CLINICAL RELEVANCE: As we strive to develop a health care system that provides equitable care to all patients, providers who care for children with upper limb differences should be aware that race and additional medical comorbidities can negatively affect patient- and parent-reported PROMIS outcome measures.

Observation Versus Cast Treatment of Toddler's Fractures.

BACKGROUND: Nondisplaced metaphyseal fractures of the distal tibia, or toddler's fractures, are one of the most common pediatric injuries. Healing typically occurs quickly without sequelae. Treatment ranges from long leg cast immobilization to observation. This study compares short-term clinical and radiographic outcomes of toddler's fractures treated with long leg casting versus observation. METHODS: Patients with toddler's fractures were offered enrollment and randomization at diagnosis. Because many families opposed randomization, a preference arm was added after one year. All subjects were analyzed as a prospective cohort. Radiographs were obtained at diagnosis and 4 weeks. A modified Oxford Ankle Foot Questionnaire for Children (OAFQ-C) and family satisfaction survey were collected at diagnosis, 4 and 8 weeks. Scores were analyzed using mixed effect models. Family satisfaction surveys were compared using a Wilcoxon rank sum test. RESULTS: Forty-four subjects participated in the study, 34 (77%) in the preference arm and 10 (23%) in the randomized cohort. The median patient age was comparable between the cast and the observation groups, 2.0 versus 1.8 years, respectively. Significant improvement in OAFQ-C scores was observed in both groups over 8 weeks (P<0.01). Patients in the observation group had a higher initial play score than the cast group (P=0.03). The observation group trended toward higher physical scores at all time points (P=0.11). There was no significant difference in emotional scores between groups (P=0.77). No displacement was observed in any patient. Casted patients had significantly more minor complications with 4 patients requiring cast change or removal compared with 0 in the observed group (P=0.01). At 8 weeks, 80% of parents in the cast group were likely or very likely to choose the same treatment compared with 95.6% in the observation group. Family satisfaction scores did not differ between groups (P=0.18). They demonstrated differences in perceived normal walking at 4 weeks, with 50% of casted patients walking normally compared with 92% of observed patients. Over 90% of patients in both groups were reportedly walking normally at week 8. CONCLUSION: Observation of toddler's fractures results in equivalent clinical and radiographic outcomes, high family satisfaction and fewer complications compared with treatment with a long leg cast. LEVEL OF EVIDENCE: Level II.

Association of parent demographic and psychophysical characteristics and pediatric hospital falls: A pilot and feasibility study.

PURPOSE: This pilot project evaluated the feasibility of conducting a study describing parental characteristics associated with pediatric hospital falls. DESIGN AND METHODS: This observational case-control study enrolled parent-child dyads of children who fell in the hospital and age-matched controls. Parents completed demographic, anxiety, depression, fatigue, sleep disturbance and stress questionnaires. RESULTS: Four of 14 (28.6%) eligible faller dyads were recruited. Stress scores were correlated with anxiety and depression scores. Power calculations indicated a need for 392 fallers for a future study to identify associations of parent characteristics and pediatric hospital falls. CONCLUSIONS: Parents should be informed the ultimate goal of the research is to understand additional ways to prevent pediatric hospital falls. To decrease parental distraction during recruitment, researchers should engage volunteers or child life specialists to entertain younger children. Future studies should consider inclusion of non-English speaking subjects and children discharged within the post-fall eligibility time frame. To decrease multicollinearity concerns, the parent stress tool should be omitted. Due to the large number of fallers needed for an adequately powered sample, a multi-site study will be needed. PRACTICE IMPLICATIONS: A parent is often present when their child falls in the hospital. Fall risk assessment focuses on patient characteristics, neglecting parental psychophysical characteristics which may be associated with risk of falling in the hospital. Associations of parent psychophysical characteristics and pediatric hospital falls needs to be studied further. This pilot study supports the feasibility of and provides recommendations for conducting a study to describe parent characteristics associated with pediatric hospital falls.

Impact of integrated clinical decision support systems in the management of pediatric acute kidney injury: a pilot study.

BACKGROUND: Acute kidney injury (AKI) is common but not often recognized. Early recognition and management may improve patient outcomes. METHODS: This is a prospective, nonrandomized study of clinical decision support (CDS) system [combining electronic alert and standardized care pathway (SCP)] to evaluate AKI detection and progression in hospitalized children. The study was done in three phases: pre-, intervention (CDS) and post. During CDS, text-page with AKI stage and link to SCP was sent to patient's contact provider at diagnosis of AKI using creatinine. The SCP provided guidelines on AKI management [AEIOU: Assess cause of AKI, Evaluate drug doses, Intake-Output charting, Optimize volume status, Urine dipstick]. RESULTS: In all, 239 episodes of AKI in 225 patients (97 females, 43.1%) were analyzed. Proportion of patients with decrease in the stage of AKI after onset was 71.4% for CDS vs. 64.4% for pre- and 55% for post-CDS phases (p = 0.3). Documentation of AKI was higher during CDS (74.3% CDS vs. 47.5% pre- and 57.5% post-, p < 0.001). Significantly greater proportion of patients had nephrotoxic medications adjusted, or fluid plan changed during CDS. Patients from CDS phase had higher eGFR at discharge and at follow-up. CONCLUSIONS: AKI remains under-recognized. CDS (electronic alerts and SCP) improve recognition and allow early intervention. This may improve long-term outcomes, but larger studies are needed. IMPACT: Acute kidney injury can cause significant morbidity and mortality. It is under-recognized in children. Clinical decision support can be used to leverage existing data in the electronic health record to improve AKI recognition. This study demonstrates the use of a novel, electronic health record-linked, clinical decision support tool to improve the recognition of AKI and guideline-adherent clinical care.

Risk Factors and Inadequacy of Screening for Sleep-Disordered Breathing in Children with Marfan Syndrome.

The prevalence of obstructive sleep apnea (OSA) is increased in children and adults with Marfan syndrome (MFS) compared to the general population and has been shown to be associated with rapid aortic root dilation and dissection in adults. Early diagnosis and treatment of OSA may decrease long-term cardiac morbidity. We therefore studied the utility of noninvasive OSA screening tools in children with MFS. We hypothesized that youth with MFS would have higher OSA screening scores than the general pediatric population. Subjects with confirmed MFS were recruited from a single pediatric center. Data collected included cardiac history, retrospective polysomnogram (PSG) data, and prospectively collected Pediatric Sleep Questionnaire (SRBD-PSQ) and Epworth Sleepiness Scale (ESS-CHAD) scores. Fifty-one individuals aged 2-21 years old were identified. Nineteen subjects completed the surveys, 53% female, median age 16 years. Of those that completed the survey, mean SRBD-PSQ score was 0.24 ± 0.21 and mean ESS-CHAD was 6.4 ± 3.7. Comparatively, published normative data for pediatric control subjects were 0.24 ± 0.21 for SRBD-PSQ and 5.4 ± 3.7 for ESS-CHAD. In conclusions, youth with MFS had similar OSA screening scores compared to published pediatric controls. Given these findings and high prevalence of OSA in MFS youth, standard questionnaires may not be an appropriate tool for identifying children at risk for OSA in this population. In the absence of evidence-based guidelines, physicians caring for children with MFS should consider referral for PSG, even in the absence of classic symptoms.

Decreased Incidence of Hepatic Artery Thrombosis in Pediatric Liver Transplantation Using Technical Variant Grafts: Report of the Society of Pediatric Liver Transplantation Experience.

OBJECTIVE: To evaluate risk factors for hepatic artery thrombosis (HAT) and examine the long-term outcomes of graft and patient survival after HAT in pediatric recipients of liver transplantation. STUDY DESIGN: Using multicenter data from the Society of Pediatric Liver Transplantation, Kaplan-Meier and Cox regression analyses were performed on first-time pediatric (aged <18 years) liver transplant recipients (n = 3801) in the US and Canada between 1995 and 2016. RESULTS: Of children undergoing their first liver transplantation, 7.4% developed HAT within the first 90 days of transplantation and, of those who were retransplanted, 20.7% developed recurrent HAT. Prolonged warm ischemia times increased the odds of developing HAT (OR, 1.11; P = .02). Adolescents aged 11-17 years (OR, 0.53; P = .03) and recipients with split, reduced, or living donor grafts had decreased odds of HAT (OR, 0.59; P < .001 compared with whole grafts). Fifty percent of children who developed HAT developed graft failure within the first 90 days of transplantation (adjusted hazard ratio, 11.87; 95% CI, 9.02-15.62) and had a significantly higher post-transplant mortality within the first 90 days after transplantation (adjusted hazard ratio, 6.18; 95% CI, 4.01-9.53). CONCLUSIONS: These data from an international registry demonstrate poorer long-term graft and patient survival in pediatric recipients whose post-transplant course is complicated by HAT. Notably, recipients of technical variant grafts had lower odds of HAT compared with whole liver grafts.

Hepatic Histology in Treatment-naïve Children With Chronic Hepatitis B Infection Living in the United States and Canada.

OBJECTIVES: Chronic hepatitis B virus infection is a major cause of morbidity and mortality. The aim of the study is to describe the hepatic histology in children chronically infected with hepatitis B virus living in the United States and Canada. METHODS: Liver biopsies of 134 treatment-naïve children with chronic hepatitis B virus infection were scored for inflammation, fibrosis, and other histological features, and correlated with clinical and laboratory data. RESULTS: Sixty percentage of subjects acquired the infection vertically, 51% were male, and 69% were hepatitis B e antigen-positive at the time of the biopsy. Hepatitis B DNA levels were generally high (mean 7.70 log IU/mL), as was serum alanine aminotransferase (median 120 U/L). Using the Ishak-modified histology activity index scoring system, interface hepatitis was mild in 31%, moderate in 61%, and severe in 6%. Lobular inflammation was mild in 54%, moderate in 29%, and marked in 7%. Portal inflammation was mild in 38% and moderate in 62% of subjects. Eighteen percentage had no fibrosis, 59% had portal expansion without bridging fibrosis, 19% had bridging fibrosis, and 4% had cirrhosis. Alanine aminotransferase positively correlated with inflammation and fibrosis. Neither age, duration of infection, nor Hepatitis B virus DNA levels correlated with fibrosis. Fibrosis-4 index did not correlate with fibrosis but correlated with inflammation. Aspartate aminotransferase/platelet ratio index correlated with both inflammation and fibrosis. CONCLUSIONS: Chronic hepatitis B virus infection results in significant inflammation and fibrosis during childhood. Serum alanine aminotransferase is a strong indicator of the severity and extent of hepatic inflammation and fibrosis.

Implementation of the m-ISHAPED Tool for Nursing Interdepartmental Handoffs.

BACKGROUND: Handoffs can pose risks to patients. LOCAL PROBLEM: Nurses throughout a children's hospital understood patient handoffs differently, resulting in handoff errors (failures) across departments. METHODS: Lean principles were used to modify and implement the ISHAPED (Introduction, Story, History, Assessment, Plan, Error Prevention, and Dialogue) tool. INTERVENTIONS: The team implemented a modified ISHAPED (m-ISHAPED) tool to align the content shared and the expectations for interdepartmental handoff. RESULTS: Improvements were seen in reported patient safety events from 6.84 to 1.57 per 100 patient days (P < .001) and nurse satisfaction from 81.1% to 90.6% (P < .001). CONCLUSIONS: A standardized process for interdepartmental nursing handoff was successfully implemented.

Analysis of rabbit anti-thymocyte globulin vs basiliximab induction in pediatric liver transplant recipients.

Literature is limited comparing induction immunosuppression in pediatric liver transplant (LTx) recipients. This is a single-center, retrospective cohort study of primary pediatric liver transplants at our center between 2005 and 2016 who received either basiliximab (BSX) or rabbit anti-thymocyte globulin (rATG) induction. Maintenance immunosuppression consisted of tacrolimus ± a corticosteroid taper. Exclusions included receipt of an ABO-incompatible graft, retransplantation, and multi-organ transplantation. Primary outcomes were incidence of treated biopsy-proven acute rejection (tBPAR) and PTLD within the first year and infections within 90 days of LTx. Secondary outcomes included graft and patient survival, time to first tBPAR, and incidence of steroid-resistant rejection (SRR) within the first year post-LTx. A total of 136 patients were included in the final analysis of which 57 patients (42%) received BSX induction. Patients who received rATG induction with or without a 2-week corticosteroid taper experienced significantly more tBPAR compared to those who received BSX induction with a 6-month corticosteroid taper (55.7% vs 33.3%, P = .01). There were no differences in the incidence of PTLD, infections, SRR, graft or patient survival, or time to first tBPAR between the two groups. Induction with rATG either with or without a short corticosteroid taper was associated with significantly more tBPAR in primary pediatric LTx recipients when compared to BSX induction with a prolonged corticosteroid taper in the setting of maintenance immunosuppression with tacrolimus.

Hepatic Venous Pressure Gradient Measurements in Children: Correlation With Hepatic Histology and Clinical Indicators of Portal Hypertension.

OBJECTIVES: In adults, elevated hepatic venous pressure gradients (HVPGs) are correlated with the degree of liver fibrosis on histopathology and predict worse outcomes including variceal bleeding and death. We aimed to examine the association between HVPG measurements, histopathologic findings, and clinical indicators of portal hypertension in children. METHODS: Utilizing retrospective data from 2 pediatric centers between 2006 and 2015, we identified children who underwent simultaneous HVPG measurement and transjugular liver biopsy. Medical charts were reviewed for histopathology, imaging, endoscopic, and clinical data. RESULTS: Forty-one children (median age 11 years) were included in the analysis with diagnoses of acute hepatitis (n = 15), chronic liver disease (n = 12), hepatic noncirrhotic portal hypertension (n = 4), acute liver failure (n = 3), and nonhepatic causes of portal hypertension (n = 7). Elevated mean HVPG measurements were found in children with acute liver failure (10 mmHg, range 4-12) and chronic liver disease (7 mmHg, range 1-12). HVPG measurements did not correlate with the histological severity of fibrosis (ρ = 0.23, P = 0.14) or portal inflammation (ρ = 0.24, P = 0.29), and no difference was found in HVPG when comparing children with and without a history of variceal bleeding (P = 0.43). CONCLUSIONS: HVPG measurements do not correlate significantly with the degree of hepatic fibrosis on biopsy. Furthermore, HVPG measurements are not associated with the presence of varices or history of variceal bleeding, suggesting the possibility of intrahepatic shunting in children with advanced liver disease. Therefore, unlike in adults, HVPG measurements may not accurately predict children who are at risk of complications from portal hypertension.

Determining Interrater Reliability of the Cornell Assessment of Pediatric Delirium Screening Tool Among PICU Nurses.

OBJECTIVES: To determine the interrater reliability of the Cornell Assessment of Pediatric Delirium Screening Tool amount PICU nurses. DESIGN: The design was setup as a cross-sectional study and conducted over the course of a year. SETTING: This study setting was a PICU and a pediatric cardiac ICU at Seattle Children's Hospital, a tertiary freestanding university-affiliated hospital in Seattle, Washington. PATIENTS: A total sample of 108 patients were included in this study. Patients were selected using a convenience sample. Inclusion in this study involved all patients eligible for a Cornell Assessment of Pediatric Delirium assessment, reflecting practice standards. Exclusion criteria included patients who had a Richmond Agitation and Sedation Score of (-4) or (-5), based on the Cornell Assessment of Pediatric Delirium procedure. There were 113 patients screened, but five were excluded from the final sample size due to missing information. INTERVENTIONS: The research nurse would screen the patient using the Cornell Assessment of Pediatric Delirium during the 12:00 noon hour, which coincided with the clinical nurse Cornell Assessment of Pediatric Delirium assessment. The clinical and research nurse were kept blind to each other's assessment. Scores were then analyzed to determine the kappa coefficient. MEASUREMENTS AND MAIN RESULTS: The kappa coefficient between nurses was found to be 0.60 (95% CI, 0.44-0.76), indicating moderate agreement. Age was found to have a higher association with agreement. In children 2 years old or greater, the kappa coefficient was 0.85 (95% CI, 0.68-1.00). Children whose raters did not agree on scoring were more likely to be younger than those who had raters that agreed (p < 0.01). CONCLUSIONS: Evaluating the interrater reliability of clinical tool, such as the Cornell Assessment of Pediatric Delirium, may be important to more accurately identify patients at high risk of delirium in a PICU or pediatric cardiac ICU. The evaluation of the tool's performance in practice may also be helpful to ensure ongoing consistency among the clinical nurses that complete these assessments on a daily basis.

Disparities in Insulin Pump Therapy Persist in Youth With Type 1 Diabetes Despite Rising Overall Pump Use Rates.

PURPOSE: This study sought to determine if disparities in insulin pump therapy among youth with type 1 diabetes (T1DM) persist despite recent increases in overall pump use rates. DESIGN AND METHODS: All patients aged 6 months-17 years, diagnosed with T1DM, and completed 4+ outpatient diabetes visits at an academically-affiliated pediatric health care center from 2011 to 2016 were identified (n = 2131). Data were collected from existing electronic medical records and a multivariable logistic regression model was used to identify factors associated with insulin pump therapy. RESULTS: Findings revealed one novel factor (patients/families whose primary language is Spanish [OR 0.47, p = 0.038] or other non-English languages [OR 0.47, p = 0.028]) and confirmed several previously known factors associated with lower insulin pump use: patients who were older (10-14 years OR 0.38, p < 0.0001; 15+ years OR 0.15, p < 0.0001), male (OR 0.80, p = 0.021), non-Hispanic black (OR 0.59, p = 0.009), American Indian/Alaska Native (OR 0.19, p = 0.023), had either government (OR 0.42, p < 0.0001) or no insurance (OR 0.52, p = 0.004) and poor glycemic control (at least one HbA1c ≥ 8.5%; OR 0.54, p < 0.0001). CONCLUSION: Significant disparities in insulin pump use in youth with T1DM persist despite known benefits associated with pump therapy and underlying causes remain unclear. PRACTICE IMPLICATIONS: Health care providers should explore barriers to insulin pump therapy, including limited English language proficiency.

Human Herpesvirus-6B Reactivation Is a Risk Factor for Grades II to IV Acute Graft-versus-Host Disease after Hematopoietic Stem Cell Transplantation: A Systematic Review and Meta-Analysis.

Graft-versus-host disease (GVHD) is an important cause of morbidity and mortality after allogeneic hematopoietic cell transplantation (HCT). Many studies have suggested that human herpesvirus-6B (HHV-6B) plays a role in acute GVHD (aGVHD) after HCT. Our objective was to systematically summarize and analyze evidence regarding HHV-6B reactivation and development of aGVHD. PubMed and EMBASE databases were searched using terms for HHV-6, HCT, and aGVHD, yielding 865 unique results. Case reports, reviews, articles focusing on inherited chromosomally integrated HHV-6, poster presentations, and articles not published in English were excluded. The remaining 467 articles were reviewed for the following requirements: a statistical analysis of HHV-6B reactivation and aGVHD was described, HHV-6B reactivation was defined by PCR, and blood (plasma, serum, or peripheral blood mononuclear cells) was used for HHV-6B PCR. Data were abstracted from publications that met these criteria (n = 33). Publications were assigned to 1 of 3 groups: (1) HHV-6B reactivation was analyzed as a time-dependent risk factor for subsequent aGVHD (n = 14), (2) aGVHD was analyzed as a time-dependent risk factor for subsequent HHV-6B reactivation (n = 1), and (3) analysis without temporal specification (n = 18). A statistically significant association (P < .05) between HHV-6B reactivation and aGVHD was observed in 10 of 14 studies (71%) in group 1, 0 of 1 study (0%) in Group 2, and 8 of 18 studies (44.4%) in Group 3. Of the 14 studies that analyzed HHV-6B as a risk factor for subsequent aGVHD, 11 performed a multivariate analysis and reported a hazard ratio, which reached statistical significance in 9 of these studies. Meta-analysis of these 11 studies demonstrated a statistically significant association between HHV-6B and subsequent grades II to IV aGVHD (hazard ratio, 2.65; 95% confidence interval, 1.89 to 3.72; P < .001). HHV-6B reactivation is associated with aGVHD, and when studies have a temporal component to their design, HHV-6B reactivation is associated with subsequent aGVHD. Further research is needed to investigate whether antiviral prophylaxis reduces incidence or severity of aGVHD.

Pediatric airway study: Endoscopic grading system for quantifying tonsillar size in comparison to standard adenotonsillar grading systems.

SIGNIFICANCE: Current grading systems may not allow clinicians to reliably document and communicate adenotonsillar size in the clinical setting. A validated endoscopic grading system may be useful for reporting tonsillar size in future clinical outcome studies. This is especially important as tonsillar enlargement is the cause of a substantial health care burden on children. OBJECTIVE: To propose and validate an easy-to-use flexible fiberoptic endoscopic grading system that provides physicians with a more accurate sense of the three-dimensional relationship of the tonsillar fossa to the upper-airway. METHODS: 50 consecutive pediatric patients were prospectively recruited between February 2015 and February 2016 at a pediatric otolaryngology outpatient clinic. The patients had no major craniofacial abnormalities and were aged 1 to 16years. Each patient had data regarding BMI, Friedman palate position, OSA-18 survey results collected. For each child, digital video clips of fiberoptic nasopharyngeal, oropharyngeal and laryngeal exams were presented to 2 examiners. Examiners were asked to independently use the proposed Endoscopic tonsillar grading system, the Brodsky tonsillar grading scale, the Modified Brodsky tonsillar grading scale with a tongue depressor, and the Parikh adenoid grading system to rate adenotonsillar hypertrophy. Cohen's Kappa and weighted Kappa scores were used to assess interrater reliability for each of the four grading scales. The Spearman correlation was used to test the associations between each scale and OSA-18 scores, as well as Body Mass Index (BMI). RESULTS: 50 pediatric patients were included in this study (mean age 6.1years, range of 1year to 16years). The average BMI was 20. The average OSA-18 score was 61.7. The average Friedman palate position score was 1.34. Twelve percent of the patients had a Friedman palate position score≥3, which made traditional Brodsky grading of their tonsils impossible without a tongue depressor. All four scales showed strong agreement between the two raters. The weighted Kappa was 0.83 for the Modified Brodsky scale, 0.89 for the Brodsky scale, 0.94 for the Parikh scale to 0.98 for the Endoscopic scale (almost perfect agreement). The Endoscopic scale showed the most consistent agreement between the raters during the study. There was a moderate association between the Parikh adenoid grading system with OSA-18 scores (Spearman's ρ=0.58, p<0.001) compared to a low association of the tonsillar grading systems with OSA- 18 scores. None of the scales correlated with patient BMI. CONCLUSIONS: The proposed Endoscopic tonsillar grading system is as reliable of a method of grading tonsillar size as conventional grading systems. It offers the advantage of allowing for critical evaluation of the tonsils without any anatomic distortion which may occur with the use of a tongue blade. This new validated endoscopic grading system provides a tool for communicating the degree of airway obstruction at the level of the oropharynx regardless of Friedman palate position and may be used in future outcomes projects.

Predicting Pediatric Emergency Severity Index Level Based on Emergency Department Pre-Arrival Information.

PURPOSE: This study examines the use of phone referral information to predict Emergency Severity Index triage levels as a proxy to anticipate emergency department nursing resource allocation in a pediatric hospital. It also assesses the relationship between these pre-arrival triage levels and hospital admission. DESIGN AND METHODS: Emergency nurses with specialized training used standardized phone referral information to assign triage levels to 481 patients before their arrival. Upon patient arrival, independent triage levels were assigned. The two levels were then compared and patient disposition was collected. Descriptive statistics and Cohen's kappa were used to assess agreement between the two emergency severity index levels. RESULTS: Moderate agreement was found between the pre-arrival and arrival triage levels. The majority of patients (71.3%) with a pre-arrival triage level of 1 or 2 (the most acute levels) were admitted to the hospital. These patients were also more likely to be admitted to the intensive care unit than were patients with a pre-arrival triage level≥3. CONCLUSIONS AND PRACTICE IMPLICATIONS: The ability to predict triage levels for incoming patients could give the emergency department charge nurse the ability to plan ahead so that appropriate nursing staffing is available upon arrival. The knowledge that patients assigned a pre-arrival triage level of 1 or 2 are more likely to be admitted gives the emergency department the ability to plan for bed placement and inpatient nursing resources earlier, potentially resulting in decreased emergency department length of stay. More study on these potential benefits is needed.