Advanced HIV disease in Homa Bay County, Kenya: Characteristics of newly-diagnosed and antiretroviral therapy-experienced clients.

Advanced HIV disease (AHD) remains a significant burden, despite the widespread use of antiretroviral therapy (ART) programs. Individuals with AHD are at a high risk of death even after starting ART. We characterized treatment naïve and treatment experienced clients presenting with AHD in western Kenya to inform service delivery and program improvement. We conducted a retrospective study using routinely collected program data from October 2016 to September 2019 for AHD clients in eight facilities in Homa Bay County, Kenya. Demographic and clinical data were abstracted from the medical records of AHD clients, defined as HIV-positive clients aged ≥ 5 years with documented CD4 count < 200 cells/mm3 and/or WHO clinical stage II/IV. Associations were assessed using Pearson's chi-square and Mann-Whitney Rank-Sum tests at 5% level of significance. Of the 19,427 HIV clients at the eight facilities, 6649 (34%) had a CD4 count < 200 cells/mm3 or a WHO III/IV stage. Of these, 1845 were randomly selected for analysis. Over half (991) of participants were aged 45 + years and 1040 (56%) were female. The median age was 46.0 years (interquartile range: 39.2-54.5); 1553 (84%) were in care at county and sub-county hospitals; and 1460 (79%) were WHO stage III/IV at enrollment. At ART initiation, 241 (13%) had tuberculosis, 192 (10%) had chronic diarrhea, and 94 (5%) had Pneumocystis jiroveci pneumonia. At the time of data collection, 89 (5%) participants had died and 140 (8%) were lost to follow-up. Eighteen percent (330) of participants were ART-experienced (on ART for ≥ 3 months). The proportions of ART-experienced and -naïve clients regarding age, sex and marital status were similar. However, a higher proportion of ART-experienced clients received care at primary care facilities, (93(28%) vs. 199 (13%); P < .001); were WHO stage 3/4 at AHD diagnosis, 273 (84%) vs. 1187 (79%) (P = .041); and had died or been LTFU, (124 (38%) vs. 105 (7%); P < .001). With increasing prevalence of patients on ART, the proportion of AHD treatment-experienced clients may increase without effective interventions to ensure that these patients remain in care.

Atypical Location of Oral Metastasis as the First Manifestation of Renal Carcinoma. Case Report / Localización Atípica de Metastasis Oral como Primera Manifestación de Carcinoma Renal. Reporte de Caso

Oral cavity metastatic tumors derived from primary tumors from other corporal regions are rare, representing barely 1 % of all malignant tumors. Differential diagnosis of these lesions is challenging due to the wide spectrum of lesions with similar clinical presentation and especially when the presence of a primary tumor goes undetected. We present the case of a 55-year-old male with a painless tumor in the anterior maxillary region, vestibular gingiva and palate, with a 2-month evolution. Anatomopathological diagnosis was malignant clear cell tumor, highly suggestive of clear cell renal carcinoma metastasis, and the oral lesion constituted the first sign of illness.

Los tumores metastásicos de cavidad oral derivados de tumores primarios de otras regiones corporales son raros, representando apenas el 1 % de todos los tumores malignos. El diagnóstico diferencial de estas lesiones es desafiante debido al amplio espectro de lesiones con presentación clínica similar y especialmente cuando la presencia de un tumor primario pasa desapercibida. Presentamos el caso de un varón de 55 años con una tumoración indolora en región maxilar anterior, encía vestibular y paladar, de 2 meses de evolución. El diagnóstico anatomopatológico fue de tumor maligno de células claras, altamente sugestivo de metástasis de carcinoma renal de células claras, y la lesión bucal constituyó el primer signo de enfermedad.

Optimizing antiretroviral therapy for children living with HIV: Experience from an observational cohort in Lesotho.

INTRODUCTION: We describe transition of HIV-positive children from efavirenz- or nevirapine-based antiretroviral therapy (ART) to optimal dolutegravir (DTG) or lopinavir/ritonavir (LPV/r) (solid formulation)-based ART in Lesotho. METHODS: We followed a cohort of children less than 15 years of age who were initiated on ART on or after January 1, 2018 from 21 selected health facilities in Lesotho. From March 2020 to May 2022, we collected data retrospectively through chart abstraction and prospectively through caregiver interviews to cover a period of 24 months following treatment initiation. We used a structured questionnaire to collect data on demographics, ART regimen, drug formulations and switches, viral suppression, retention, and drug administration challenges. Data were summarized as frequencies and percentages, using SAS ver.9.4. RESULTS: Of 310 children enrolled in the study, 169 (54.5%) were female, and median age at ART initiation was 5.9 years (IQR 1.1-11.1). During follow-up, 19 (6.1%) children died, 41 (13.2%) were lost to follow-up and 74 (23.9%) transferred to non-study sites. At baseline, 144 (46.4%) children were receiving efavirenz-based ART regimen, 133 (42.9%) LPV/r, 27 (8.7%) DTG, 5 (1.6%) nevirapine; 1 child had incomplete records. By study end, 143 (46.1%) children were receiving LPV/r-based ART regimen, 109 (35.2%) DTG, and 58 (18.7%) were on efavirenz or nevirapine-based regimen. Of 116 children with viral load results after six months or more on a consistent regimen, viral suppression was seen in 35/53 (66.0%) children on LPV/r, 36/38 (94.7%) children on DTG and 19/24 (79.2%) children on efavirenz. CONCLUSION: Following optimal ART introduction in Lesotho, most children in the cohort were transitioned and many attained or maintained viral suppression after transition; however, we recommend more robust viral load monitoring and patient tracking to reduce losses and improve outcomes after ART transition.

Virologic Outcomes and ARV Switch Profiles 2 Years After National Rollout of Dolutegravir to Children Less Than 15 Years in Southern Mozambique.

BACKGROUND: Dolutegravir (DTG) was scaled up globally to optimize treatment for children living with HIV. We evaluated the rollout and virological outcomes after DTG introduction in Mozambique. METHODS: Data from children 0-14 years with visits from September 2019 to August 2021 were extracted from records in 16 facilities in 12 districts. Among children ever on DTG, we report treatment switches, defined as changes in anchor drug, regardless of changes to nucleoside reverse transcriptase inhibitor (NRTI) backbones. Among those on DTG for ≥6 months, we described viral load suppression rates by children newly initiating and switching to DTG and by the NRTI backbone at the time of the DTG switch. RESULTS: Overall, 3,347 children were ever on DTG-based treatment (median age 9.5 years; 52.8% female). Most children (3,202, 95.7%) switched to DTG from another antiretroviral regimen. During the 2-year follow-up, 9.9% never switched from DTG; 52.7% had 1 regimen change, of which 97.6% were switched to DTG. However, 37.2% of children experienced ≥2 anchor drug changes. Overall median time on DTG was 18.6 months; nearly all children ≥5 years (98.6%) were on DTG at the last visit. Viral suppression was 79.7% (63/79) for children newly initiating DTG and 85.8% (1,775/2,068) for those switching to DTG. Suppression rates were 84.8% and 85.7% among children who switched and maintained NRTI backbones, respectively. CONCLUSIONS: Viral suppression rates of ≥80% with minor variations by backbone were achieved during the 2-year DTG rollout. However, there were multiple anchor drug switches for over one-third of children, which may be attributable in part to drug stockouts. Long-term pediatric HIV management will only be successful with immediate and sustainable access to optimized child-friendly drugs and formulations.

Case-control study of exclusive breast feeding and severe bronchiolitis in the United States.

BACKGROUND: Bronchiolitis is a major cause of infant illness, with few known modifiable risk factors. Breast feeding may reduce risk of severe bronchiolitis, but the association of exclusive vs. partial breast feeding with severe bronchiolitis is unclear. OBJECTIVE: To estimate the association of exclusive vs. partial breast feeding during ages 0-2.9 months with bronchiolitis hospitalisation during infancy. METHODS: We conducted a case-control study as a secondary analysis of two prospective US cohorts in the Multicenter Airway Research Collaboration. Cases were enrolled in a 17-centre study of infants hospitalised for bronchiolitis during 2011-2014 (n = 921). Controls were enrolled in a five-centre study of healthy infants during 2013-2014 and 2017 (n = 719). Breast feeding history during ages 0-2.9 months was collected by parent interview. Among breastfed infants, the association of exclusive vs. partial breast feeding with odds of bronchiolitis hospitalisation was estimated using a multivariable logistic regression model adjusted for demographic variables, parental asthma history, and early-life exposures. As a secondary analysis, we estimated the associations of exclusive, predominant, and occasional breast feeding vs. no breast feeding with the odds of bronchiolitis hospitalisation. RESULTS: Among 1640 infants, the prevalence of exclusive breast feeding was 187/921 (20.3%) among cases and 275/719 (38.3%) among controls. Exclusive vs. partial breast feeding was associated with 48% reduced odds of bronchiolitis hospitalisation (adjusted odds ratio [OR] 0.52, 95% confidence interval [CI] 0.39, 0.69). In the secondary analysis, exclusive vs. no breast feeding was associated with 58% reduced odds of bronchiolitis hospitalisation (OR 0.42, 95% CI 0.23, 0.77), whereas predominant breast feeding (OR 0.77, 95% CI 0.37, 1.57) and occasional breast feeding (OR 0.98, 95% CI 0.57, 1.69) were not associated with meaningfully reduced odds of bronchiolitis hospitalisation. CONCLUSION: Exclusive breast feeding had a strong protective association against bronchiolitis hospitalisation.

Standardized enhanced adherence counseling for improved HIV viral suppression among children and adolescents in Homa Bay and Turkana Counties, Kenya.

Viral suppression is suboptimal among children and adolescents on antiretroviral therapy (ART) in Kenya. We implemented and evaluated a standardized enhanced adherence counseling (SEAC) package to improve viral suppression in children and adolescents with suspected treatment failure in Homa Bay and Turkana. The SEAC package, implemented from February 2019 to September 2020, included: standard procedures operationalizing the enhanced adherence counseling (EAC) process; provider training on psychosocial support and communication skills for children living with HIV and their caregivers; mentorship to providers and peer educators on EAC processes; and individualized case management. We enrolled children and adolescents aged 0 to 19 years with suspected treatment failure (viral load [VL] >1000 copies/mL) who received EAC before standardization as well as those who received SEAC in a pre-post evaluation of the SEAC package conducted in 6 high-volume facilities. Pre-post standardization comparisons were performed using Wilcoxon-Mann-Whitney and Pearson's chi-square tests at a 5% level of significance. Multivariate logistic regression was performed to identify factors associated with viral resuppression. The study enrolled 741 participants, 595 pre- and 146 post-SEAC implementation. All post-SEAC participants attended at least 1 EAC session, while 17% (n = 98) of pre-SEAC clients had no record of EAC attendance. Time to EAC following the detection of high VL was reduced by a median of 8 days, from 49 (interquartile range [IQR]: 23.0-102.5) to 41 (IQR: 20.0-67.0) days pre- versus post-SEAC (P = .006). Time to completion of at least 3 sessions was reduced by a median of 12 days, from 59.0 (IQR: 36.0-91.0) to 47.5 (IQR: 33.0-63.0) days pre- versus post-SEAC (P = .002). A greater percentage of clients completed the recommended minimum 3 EAC sessions at post-SEAC, 88.4% (n = 129) versus 61.1% (n = 363) pre-SEAC, P < .001. Among participants with a repeat VL within 3 months following the high VL, SEAC increased viral suppression from 34.6% (n = 76) to 52.5% (n = 45), P = .004. Implementation of the SEAC package significantly reduced the time to initiate EAC and time to completion of at least 3 EAC sessions, and was significantly associated with viral suppression in children and adolescents with suspected treatment failure.

Cistoadenoma de glándula salival menor en paladar: Reporte de dos casos y revisión de la literatura / Cystadenoma of the minor salivary gland on the palate: Report of two cases and review of the literature

El cistoadenoma es un tumor epitelial benigno de baja frecuencia en glándulas salivales, que habitualmente se presenta como una masa de crecimiento lento. En glándulas salivales menores se localiza habitualmente en labio, paladar y mucosa yugal, cuyo diagnóstico diferencial representa un desafío desde el punto de vista clínico. El propósito de este reporte es presentar 2 casos de cistoadenoma en paladar, con énfasis en sus características clínicas y diagnóstico diferencial.

Cystadenoma is an uncommon benign epithelial tumor of the salivary glands, which usually appears as a slow-growing mass. In minor salivary glands, it is usually located in the lip, palate and buccal mucosa, whose differential diagnosis is a clinical challenge. The purpose of this report is to present 2 cases of palate cystadenoma, with emphasis on their clinical characteristics and differential diagnosis.

Promoting glycemic control in young children with type I diabetes: Results from a pilot intervention for parents.

OBJECTIVE: Nutrition and physical activity are key components of daily diabetes care in young children with type I diabetes (T1D). Normative developmental behavioral challenges related to nutrition and physical activity complicate management of T1D. The current pilot study evaluated the feasibility, acceptability, and indications of behavior change of an intervention aimed at improving nutrition and physical activity in young children with T1D. METHOD: Thirty-6 parents of young children (ages 2-5 years, M = 4.2) with T1D from 2 clinics in the Washington, DC area were randomized to receive the type One Training (TOTs) program or Usual Care (UC). Assessments included recruitment and completion rates, participant acceptability, and outcomes including glycemic variability via continuous glucose monitoring, nutritional intake via remote food photography, physical activity via accelerometers, and parental report on behavior and psychosocial functioning. RESULTS: Despite recruitment challenges, the TOTs program was feasible to administer, with high program and assessment completion rates. Acceptability ratings were very high but differed by recruitment site. Participants randomized to TOTs had an increase in percent of time in target glycemic range and reduction in behavioral feeding problems between baseline and follow-up while those randomized to UC did not. Participants in UC demonstrated a decrease in in moderate to vigorous physical activity at follow-up. CONCLUSIONS: The TOTs program demonstrated preliminary feasibility and acceptability. Future research will examine components of treatment for evidence of efficacy and target the intervention to those most likely to benefit. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Tumor Odontogénico Adenomatoide Quístico, presentación inusual. Reporte de dos casos / Cystic Adenomatoid Odontogenic Tumor, unusual presentation. Report of two cases

RESUMEN: El tumor odontogénico adenomatoide es un tumor benigno, poco común, que corresponde al 2-7% de los tumores odontogénicos. Se presenta con mayor prevalencia en la segunda década de vida y se ubica preferentemente en maxilar anterior. Es una lesión encapsulada, no agresiva, de crecimiento lento, que puede pasar desapercibida durante años. Deriva del epitelio odontogénico, y se caracteriza histológicamente por células epiteliales dispuestas en nidos, remolinos o cordones con escaso tejido conjuntivo. Puede presentar estructuras canaliculares un patrón ductiforme, con calcificaciones y presenta cápsula. El presente estudio reporta dos casos, el primero es una mujer de 30 años y el segundo el de un hombre de 36 años, ambos con un tumor odontogénico adenomatoide ubicado en zona maxilar anterior derecha, asintomático, sin asociación con diente incluido y de presentación quística a nivel imagenológico e histopatológico. Se discuten características clínicas, radiográficas, histopatológicas y terapéuticas de los casos.

ABSTRACT: Adenomatoid odontogenic tumor is a benign, rare tumor that accounts for 2-7% of odontogenic tumors. It appears with greater prevalence in the second decade of life and is located preferentially in the anterior maxilla. It is a slow-growing, non-aggressive, encapsulated lesion that can go unnoticed for years. It is derived from the odontogenic epithelium, and is characterized histologically by epithelial cells arranged in nests, eddies, or cords with little connective tissue. It may have canalicular structures and a ductiform pattern, with calcifications and it has a capsule. The present study reports two cases, the first is a 30-year-old woman and the second is a 36-year-old man, both with an adenomatoid odontogenic tumor located in the right anterior maxillary area, asymptomatic, without association with an included tooth and cystic presentation at the imaging and histopathological levels. The clinical, radiographic, histopathological and therapeutic characteristics of the cases are discussed.

Giving parents support: a randomized trial of peer support for parents after NICU discharge.

BACKGROUND: Peer support during inpatient hospitalization has been recommended for NICU parents and can improve maternal mental health. Less is known about the impact of peer support after NICU discharge on parental mental health and infant healthcare utilization. METHODS: Three hundred families of infants approaching discharge from a Level IV NICU were randomized to receive a care notebook (control) or care notebook plus peer support for 12 months (intervention). Participants reported on measures of stress, depression, anxiety, self-efficacy, and infant healthcare utilization. Analysis compared outcomes between control and treatment groups. RESULTS: Parental depression, anxiety, stress, and self-efficacy improved significantly for all participants, yet there were no differences between control and intervention groups. Infant ED visits, hospitalizations, immunization status, and developmental status at 12 months did not differ between groups. CONCLUSIONS: Peer support after NICU discharge did not improve self-reported parental mental health measures or infant healthcare utilization. CLINICAL TRIAL REGISTRATION: NCT02643472.

Blood eosinophils, specific immunoglobulin E, and bronchiolitis severity.

BACKGROUND: Bronchiolitis is the leading cause of hospitalization for United States infants. Blood eosinophil and serum specific IgE (sIgE) levels are separately linked to clinical severity but few studies have examined these biomarkers together. OBJECTIVE: Among infants hospitalized for bronchiolitis, we investigated the association between (1) blood eosinophilia and severity, (2) sIgE sensitization and severity, and (3) interaction between the two biomarkers on severity. METHODS: We enrolled 1016 infants hospitalized for bronchiolitis between 2011 and 2014 across 17 U.S. hospitals into a prospective cohort study. Of those, 873 (86%) had eosinophils measured and all had sIgE levels from blood collected at hospitalization. We investigated higher bronchiolitis severity using intensive care therapy as the outcome (i.e., intensive care unit admission, intubation, and/or receipt of continuous positive pressure ventilation). RESULTS: Among 873 infants in the analytic cohort, 18% had blood eosinophilia of ≥3%, and 20% were positive for sIgE. With regard to bronchiolitis severity, 15% received intensive care therapy. In unadjusted analyses, eosinophils ≥3% was not associated with intensive care therapy, while sIgE was associated with a significantly higher risk (odds ratio [OR]: 1.44, 95% confidence interval [CI]: 1.08-1.92; p = .01). In a multivariable model for intensive care therapy, eosinophilia remained unassociated with severity, and sIgE remained associated (OR: 1.60, 95% CI: 1.05-2.45; p = .03). Also, sIgE did not modify the association between eosinophil level and intensive care therapy (pinteraction = .14). CONCLUSION: Blood eosinophilia of ≥3% was not associated with bronchiolitis severity. By contrast, sIgE was independently associated with bronchiolitis severity and did not modify the association between eosinophil level and severity.

HEADSS Up! Missed Opportunity for Psychosocial Screening in Hospitalized Adolescents.

OBJECTIVE: To assess the frequency and completeness of adolescent psychosocial screening documentation for adolescents and young adults hospitalized to a pediatric hospitalist medicine service. METHODS: All patients 12 to 21 years old on the hospital medicine service in an urban, academic, free standing children's hospital in the Mid-Atlantic United States from January 1, 2014, to December 31, 2015, were identified. A retrospective review was conducted to assess the frequency of documentation of a complete psychosocial screening using the Home, Education, Activities, Drugs, Sex, Suicide assessment within 48 hours of admission. Differences in screening rates according to race, sex, age, patient's medical complexity, and whether they required transfer to a higher level of care were assessed through logistic regression analyses. RESULTS: Only 5.3% (24 of 435 patients) had all 6 domains of the Home, Education, Activities, Drugs, Sex, Suicide psychosocial assessment documented. Controlling for patient characteristics (demographic, medical complexity, and level of care), the odds of being screened for sensitive domains (drugs, sex, and suicide) were higher in female patients, patients ≥16 years old, and those transferred to a higher level of care. Those considered high medical complexity were screened less across all domains. CONCLUSIONS: Overall, pediatric hospitalist documentation lacked adolescent psychosocial screening. Potential opportunities exist through screening early in the hospitalization to connect youth with services that influence health outcomes.

Effects of the Pratt pouch model of dispensing nevirapine prophylaxis on HIV exposed infant completion of 6 weeks of prophylaxis in Uganda.

INTRODUCTION: The innovative Pratt pouch could optimize dispensing nevirapine prophylaxis to HIV-exposed infants in pre-measured single dose pouches to increase completion of the full 6 week infant nevirapine regimen. MATERIALS AND METHODS: Nineteen health facilities with highest HIV positivity rates among pregnant women across 9 districts in southwest and central Uganda were assigned to control and intervention groups. HIV-positive women enrolled at intervention facilities received pouches filled with premeasured single doses of nevirapine using Uganda national guidelines, which were integrated into the existing drug distribution system. During antenatal care (ANC) women received 14 pouches to cover time until the 6 day postpartum visit, with an additional 8 pouches if women were delayed in returning to the facility, and 28 pouches after delivery. Women enrolled at control facilities received standard nevirapine syrup following delivery for postnatal infant prophylaxis. In a select number of intervention facilities, during ANC, women received all 42 pouches needed to complete the 6 weeks regimen. Medical record data from enrolled women were extracted; interviews with HIV-positive women during postnatal care visits were conducted. Data were collected January to August 2018 (control sites) and October 2019 to February 2020 (intervention sites). Unadjusted and adjusted logistic regression models were used to identify factors associated with facility delivery, postnatal care follow-up visit, and completion of the full 6 weeks infant nevirapine regimen. RESULTS: Significantly more women in the intervention (n = 320) versus control (n = 340) group had facility delivery (292/316, 92.4% versus 169/340, 49.7%, p<0.0001), postnatal visits within 2 weeks postpartum (295/297, 99.3% versus 133/340, 39.1%, p<0.0001) and reported their infants completing the full 6 weeks infant prophylaxis regimen (299/313, 95.5% versus 210/242, 86.8%, p = 0.0002). Dispensing 42 versus 14 pouches during ANC did not have negative effects on these outcomes. Among out-of-facility deliveries, a higher proportion of infants received nevirapine within 72 hours of birth in the intervention versus control group, 95.8% versus 77.9%. In multivariate models, the intervention group was the only significant factor associated with facility delivery or completion of the full 6 weeks infant prophylaxis. CONCLUSIONS: Use of the Pratt pouch resulted in an increase in HIV-exposed infants completing the full 6weeks prophylaxis regimen and associated benefits including increasing facility delivery and women's adherence to postnatal care services.

Positive fluid balance is associated with death and severity of brain injury in neonates with hypoxic-ischemic encephalopathy.

OBJECTIVE: To investigate the association between fluid balance during therapeutic hypothermia (TH) and severity of brain injury on magnetic resonance imaging (MRI) in neonates with hypoxic-ischemic encephalopathy (HIE). STUDY DESIGN: This is a secondary analysis of data from a prospective observational study in neonates with HIE. Daily net positive fluid balance during TH was investigated for association with the adverse primary outcome of death or moderate-to-severe brain injury on MRI using multivariable logistic regression. RESULTS: Of the 150 neonates included, 50 suffered adverse outcome and had significantly higher net positive fluid balance (53 vs. 19 ml/kg/day, p < 0.01) during first 24 hours of TH. Neonates with a net positive fluid balance (>25 ml/kg/day) at 24 hours of TH had 3.4 (95% CI 1.3-9) times higher odds of adverse outcome. CONCLUSIONS: Positive fluid balance during TH in neonates with HIE is independently associated with death or moderate-to-severe brain injury on MRI.

Autonomic nervous system maturation in the premature extrauterine milieu.

BACKGROUND: In premature infants, we investigated whether the duration of extrauterine development influenced autonomic nervous system (ANS) maturation. METHODS: We performed a longitudinal cohort study of ANS maturation in preterm infants. Eligibility included birth gestational age (GA) < 37 weeks, NICU admission, and expected survival. The cohort was divided into three birth GA groups: Group 1 (≤29 weeks), Group 2 (30-33 weeks), and Group 3 (≥34 weeks). ECG data were recorded weekly and analyzed for sympathetic and parasympathetic tone using heart rate variability (HRV). Quantile regression modeled the slope of ANS maturation among the groups by postnatal age to term-equivalent age (TEA) (≥37 weeks). RESULTS: One hundred infants, median (Q1-Q3) birth GA of 31.9 (28.7-33.9) weeks, were enrolled: Group 1 (n = 35); Group 2 (n = 40); and Group 3 (n = 25). Earlier birth GA was associated with lower sympathetic and parasympathetic tone. However, the rate of autonomic maturation was similar, and at TEA there was no difference in HRV metrics across the three groups. The majority of infants (91%) did not experience significant neonatal morbidities. CONCLUSION: Premature infants with low prematurity-related systemic morbidity have maturational trajectories of ANS development that are comparable across a wide range of ex-utero durations regardless of birth GA. IMPACT: Heart rate variability can evaluate the maturation of the autonomic nervous system. Metrics of both the sympathetic and parasympathetic nervous system show maturation in the premature extrauterine milieu. The autonomic nervous system in preterm infants shows comparable maturation across a wide range of birth gestational ages. Preterm newborns with low medical morbidity have maturation of their autonomic nervous system while in the NICU. Modern NICU advances appear to support autonomic development in the preterm infant.

How prenatal head ultrasound reference ranges affect evaluation of possible fetal microcephaly.

OBJECTIVES: Different fetal ultrasound (US) nomograms of the head circumference (HC) have been established; however, comparisons between the detection rates of microcephaly among US nomograms are few and inconsistent. We aimed to compare the prenatal diagnostic rate of fetal microcephaly (FM) among four widely used US nomograms of the fetal HC, when applied to the same group of fetuses. METHODS: We retrospectively identified singleton pregnancies complicated by fetal HC < 5th percentile for gestational age (GA) by US, without other risk factors for FM and with normal fetal brain MRI. Raw values of HC by US were converted to z-scores using four nomograms (Chervenak = A, Hadlock = B, Gelber = C, Papageorghiou = D). Z-scores value of the HC were classified as normal, possible normal, or microcephaly if values were >-2, ≤ -2 and >-3, or ≤ -3, respectively and compared among the four nomograms. RESULTS: Fifty one fetuses at a mean (±SD) GA of 28 (±4) weeks were included. The four nomograms resulted in different z-score values of the fetal HC for the same subject (p < .001) and none of them showed 100% agreement. Reference C and D showed the highest agreement in classifying subjects as normal, possible normal, or with microcephaly (simple Kappa = 0.8915, % agreement = 94.1%), while A and B had the lowest agreement (simple Kappa = 0.0977, % agreement = 51.0%). CONCLUSIONS: Despite the use of similar prenatal cutoff z-score values of the fetal HC, the four nomograms led to different diagnostic rates of FM. More consistent diagnostic criteria are therefore needed to define FM, especially in the absence of other risk factors for FM and normal fetal brain MRI, since the prenatal diagnosis can affect pregnancy management.

Improving antibiotic prescribing in the emergency department for uncomplicated community-acquired pneumonia.

BACKGROUND: The Pediatric Infectious Disease Society (PIDS) and Infectious Disease Society of America (IDSA) published an evidence-based guideline for the treatment of uncomplicated community-acquired pneumonia (CAP) in children, recommending aminopenicillins as the first-line therapy. Poor guideline compliance with 10%-50% of patients admitted to the hospital receiving narrow-spectrum antibiotics has been reported. A new clinical practice guideline (CPG) was implemented in our emergency department (ED) for uncomplicated CAP. The aim of this study was to examine baseline knowledge and ED provider prescribing patterns pre- and post-CPG implementation. METHODS: Prior to CPG-implementation, an anonymous case-based survey was distributed to evaluate knowledge of the current PIDS/IDSA guideline. A retrospective chart review of patients treated in the ED for CAP from January 2015 to February 2017 was performed to assess prescribing patterns for intravenous (IV) antibiotics in the ED at Children's National Health System pre- and post-CPG implementation. RESULTS: ED providers were aware of the PIDS/IDSA guideline recommendations, with 86.4% of survey responders selecting ampicillin as the initial antibiotic of choice. However, only 41.2% of patients admitted to the hospital with uncomplicated CAP pre-CPG received ampicillin (P<0.01). There was no statistically significant increase in ampicillin prescribing post-CPG (P=0.40). CONCLUSIONS: Providers in the ED are aware of the PIDS/IDSA guideline regarding the first-line therapy for uncomplicated CAP; however, this knowledge does not translate into clinical practice. Implementation of a CPG in isolation did not significantly change prescribing patterns for uncomplicated CAP.

Discharge Communication Practices for Children With Medical Complexity: A Retrospective Chart Review.

OBJECTIVES: Children with medical complexity (CMC) have an increased risk of adverse events after hospital discharge. Authors of previous studies have evaluated discharge communication practices with primary care providers (PCPs) in adults and general pediatric patients. There is a lack of evidence surrounding hospitalist communication practices at discharge for CMC. In this study, we explore hospitalist-to-PCP communication for CMC at hospital discharge. METHODS: A retrospective chart review was performed at a single tertiary care children's hospital. The population included patients with ≥1 complex chronic condition who were discharged from the pediatric hospitalist team. The presence, type, and quality of discharge communication were collected. A descriptive analysis in which we used χ2, t test, Wilcoxon rank testing, and odds ratios was conducted to identify differences in communication practices in CMC. RESULTS: We identified 368 eligible patients and reviewed their electronic medical records. Discharge communication was documented for 59% of patient encounters. Communication was less likely to occur for patients with technology dependence (P = .01), older patients (P = .02), and those who were admitted to a teaching service (P = .04). The quality of discharge summaries did not change for patients with technology dependence compared with patients without technology dependence. CONCLUSIONS: Communication with the PCP at discharge was less likely to be documented in children with technology dependence. Hospitalists may encounter barriers in completion of appropriate and timely discharge communication with PCPs for CMC. Consistent handoff processes could be used to improve care for our patients with enhanced coordination needs.

The impact of intravenous opioid shortages on postoperative pain control in a pediatric cardiac intensive care unit.

BACKGROUND: The national supply of intravenous pain medications has been restricted since 2018 due to shortages. In late 2017, the ongoing shortages combined with the increased demand for alternative formulations resulted in interruptions in the supply of medications. The cascading effect of interruptions in supply caused hospitals to implement restrictive measures to extend the availability of these medications. This study aims to evaluate differences in pain control in postoperative cardiac patients due to intravenous opioid shortage at a standalone pediatric hospital. METHOD: A retrospective chart review of postoperative patients in the cardiac intensive care unit at Children's National Hospital was conducted from January to September 2017 and 2018. The objective of this study is to determine if a difference in postoperative pain scores in the period before and during the national intravenous opioid shortage exists, analyzed by differences in Face, Legs, Activity, Cry, Consolability (FLACC) scores. RESULTS: No differences were found in mean FLACC scores for the 140 patients who were evaluated. Patients in 2017 reported faster decline of pain symptoms compared with those in 2018. No differences in baseline characteristics or secondary outcomes were noted. CONCLUSION: Pain management was better controlled immediately postoperatively in 2018 compared with 2017, but the pain was better controlled for the duration of the postoperative period in 2017.