Medical Misadventures as Errors and Mistakes and Motor Vehicular Accidents in the Disproportionate Burden of Childhood Mortality among Blacks/African Americans in the United States: CDC Dataset, 1968-2015.

PURPOSE: Racial disparities in infant mortality in the United States persist after adjustment for known confounders of race and mortality association, as well as heterogeneity assessment. Epidemiologic and clinical data continue to show the survival disadvantages of Black/AA children: when Black/AAs are compared to whites, they are three times as likely to die from all-cause mortality. The persistent inability to remove the variance in race-mortality association is partly due to unobserved, unmeasured, and residual confounding, as well as implicit biases in public health and clinical medicine in health equity transformation. This current epidemiologic-perspective explanatory model study aimed to examine the possible explanation of racial differences in U.S. infant mortality using medical misadventures as errors and mistakes, and infants' involvement in motor vehicular traffic accidents. MATERIALS AND METHOD: Using CDC WONDER ecologic data from 1968 to 2015, we assessed the infant mortality-rate ratio and percent change associated with medical misadventures as well as motor vehicular accidents or trauma. The rate ratio and percent change were estimated using stratification analysis and trend homogeneity, respectively. RESULTS: There was a Black-white racial difference in medical misadventures during the study period. Relative to the years 1968-1978 (rate ratio [RR], 1.43), there was a steady increase in the mortality-rate ratio in 1979-1998 (52%, RR = 1.52), and mortality was more than two times as likely in 1999-2015 (RR = 2.37). However, with respect to motor vehicular accident/trauma mortality, the mortality ratio, although lower among Blacks in 1968-1978 (RR, 0.92), increased in 1979-1998 by 27% (RR = 1.27) but decreased in 1999-2015 (RR, 1.17), though there was still an excess of 17% mortality among Black/AAs. The percent change for medical misadventures indicated an increasing trend from 9.3% in 1998 to 52% in 2015. However, motor vehicular-related mortality indicated a positive trend in 1998 (38.5%) but a negative trend in 2015 (-8.4%). CONCLUSIONS: There were substantial race differentials or variances in infant mortality associated with medical misadventures compared to traffic accidents, and Black/AA children relative to whites experienced a survival disadvantage. These comparative findings are suggestive of medical misadventures and motor vehicular trauma as potential explanations for some of the persistent Black-white disparities in overall infant mortality in the U.S. From these findings, we recommend a national effort to address these issues, thus narrowing the observed disparities in the U.S. infant mortality burden among Black/AAs.

Survival disadvantage of male children with retinoblastoma in the United States: Surveillance Epidemiology and End Results (2000-2017) Evidence.

BACKGROUND: Retinoblastoma is a rare malignancy involving the retina, although, more common among children, with genetic inheritance explaining the incidence as well as acquired forms. The incidence varies among race and sex as well as mortality and survival. The current study aimed to assess retinoblastoma cumulative incidence (CMI), mortality, and survival by sex. METHODS: A retrospective cohort design was used to assess the CMI, mortality, and survival in this pediatric malignancy based on the Surveillance Epidemiology and End Results (SEER) data 2000-2017. The binomial regression model was used to examine sex differentials in mortality, as well as other study variables, while Cox proportional hazard model was used for the survival variability by sex. RESULTS: The CMI during this period was higher among males relative to females (males n = 249, 56.7%; females n = 190, 43.3%, χ2  = 2.90, df = 1, p = 0.089). There were sex differences in mortality, with excess mortality observed among males compared to females, risk ratio = 3.40, 95% CI [1.0-15.72]. The survival differences by sex indicated decreased survival among males relative to females, hazard ratio (HR) = 3.39, 95% CI [1.0-15.72]. After controlling for the potential confoundings, namely tumor grade, urbanity, and median income the survival disadvantage of males persisted. Compared to females', males were more than three times as likely to die, adjusted HR = 3.42, 99% CI [0.37-31.60]. CONCLUSION: In a representative sample of pediatric retinoblastoma, there was a sex differential in survival with excess risk of dying identified among males relative to females, which may be explained in part by male X-linkage.

Black-White Risk Differentials in Pediatric COVID-19 Hospitalization and Intensive Care Unit Admissions in the USA.

PURPOSE: The COVID-19 morbidity with SARS-CoV-2 as a causative pathogenic microbe remains a pandemic with children experiencing less mortality but with severe manifestations. The current study aimed to assess SARS-CoV-2 cumulative incidence, COVID-19 hospitalization, and ICU admission with respect to racial differentials. MATERIALS AND METHODS: A cross-sectional nonexperimental epidemiologic design was used to examine pediatric COVID-19 data from CDC during 2020. The variables assessed were ICU admissions, hospitalization, sex, race, and region. The Chi-Square (X2) statistic was used to examine the independence of the variables by race, while the binomial regression model was used to predict racial risk differentials in hospitalization and ICU admissions. RESULTS: The pediatric COVID-19 data observed the cumulative incidence of hospitalization to be 96,376, while ICU admission was 12,448. Racial differences were observed in hospitalization, ICU admissions, sex, and region. With respect to COVID-19 hospitalization, Black/African American (AA) children were two times as likely to be hospitalized compared to their White counterparts, prevalence risk ratio (pRR) = 2.20, 99% confidence interval (CI = 2.12-2.28). Similarly, Asians were 45% more likely to be hospitalized relative to their White counterparts, pRR = 1.45, 99% CI = 1.32-1.60. Regarding ICU admission, there was a disproportionate racial burden, implying excess ICU admission among Black/AA children relative to their White counterparts, pRR = 5.18, 99% CI = 4.44-6.04. Likewise, Asian children were 3 times as likely to be admitted to the ICU compared to their White counterparts, pRR = 3.36, 99% CI = 2.37-4.77. Additionally, American Indians/Alaska Natives were 2 times as likely to be admitted to ICU, pRR = 2.54, 99% CI = 0.82-7.85. CONCLUSION: Racial disparities were observed in COVID-19 hospitalization and ICU admission among the US children, with Black/AA children being disproportionately affected, implying health equity transformation.

Social gradient predicts survival disadvantage of African Americans/Black children with lymphoma.

BACKGROUND: Cancer is the leading cause of disease-related mortality among children, 0-14 years, and lymphoma, a malignant neoplasm of the lymphoid cells, mostly lymphatic B and T cells is common among children. The current study aimed to assess the cumulative incidence (CmI), mortality, and survival in pediatric lymphoma. MATERIALS AND METHODS: A retrospective cohort was utilized to examine children, 0-19 years with lymphoma for CmI, mortality and survival from the Surveillance, Epidemiology, and End Results (SEER) data. The variables assessed included social determinants of health, namely urbanity, median household income, and race. While chi square was used to characterize study variables by race, binomial regression was employed for mortality risk. The Cox proportional hazard model was used for survival modeling. RESULTS: The CmI was higher among white children (76.67%) relative to Black/African American (AA, 13.44%), American Indian/Alaskan Native (AI/AN, 0.67%), as well as Asian/Pacific Islander (A/PI, 7.53%). With respect to mortality, there was excess mortality among Black/AA children compared to white children, Risk Ratio (RR) = 1.54, 95% CI, 1.33-1.79. Relative to whites, Blacks were 52% more likely to die, Hazard Ratio (HR) = 1.52, 95% CI, 1.30-1.78. Survival disadvantage persisted among Blacks/AA after controlling for the other confoundings, adjusted hazard ratio (aHR) = 1.54, 99% CI, 1.24-1.91. CONCLUSION: In a large cohort of children with lymphoma, Black/AA children relative to whites presented with survival disadvantage, which was explained by urbanity and median household income, suggestive of transforming the physical and social environments in narrowing the racial differences in pediatric lymphoma survival in the US.

Predictive Effect of Helicobacter pylori in Gastric Carcinoma Development: Systematic Review and Quantitative Evidence Synthesis.

Helicobacter pylori (H. pylori) is a bacterial pathogen implicated in gastritis, gastric ulceration, and gastric carcinoma. This study aimed to synthesize literature in providing evidence on the causative role of H. pylori in gastric carcinoma development. This study is based on assessing public literature using an applied meta-analysis, namely, quantitative evidence synthesis (QES). The analytic procedure uses DerSimonian-Laird, including assessing heterogeneity. The QES also utilizes meta-regression and the environmental effect associated with H. pylori in gastric cancer development. Eighteen studies are included in the QES. There is increased prevalence of H. pylori exposure among the cases. The heterogeneity between the CES and individual effect sizes is also significant. Despite controlling for the confoundings, there is increased exposure to H. pylori among the gastric cancer cases, regardless of the differences in the geographic location. H. pylori in this synthesized literature illustrates the contributory role of this microbe in gastric carcinoma. Additionally, regardless of geographic locale, namely, South Korea or Spain, H. pylori is implicated in gastric cancer development.

Black-White Risk Differentials in COVID-19 (SARS-COV2) Transmission, Mortality and Case Fatality in the United States: Translational Epidemiologic Perspective and Challenges.

BACKGROUND: Social and health inequities predispose vulnerable populations to adverse morbidity and mortality outcomes of epidemics and pandemics. While racial disparities in cumulative incidence (CmI) and mortality from the influenza pandemics of 1918 and 2009 implicated Blacks with survival disadvantage relative to Whites in the United States, COVID-19 currently indicates comparable disparities. We aimed to: (a) assess COVID-19 CmI by race, (b) determine the Black-White case fatality (CF) and risk differentials, and (c) apply explanatory model for mortality risk differentials. METHODS: COVID-19 data on confirmed cases and deaths by selective states health departments were assessed using a cross-sectional ecologic design. Chi-square was used for CF independence, while binomial regression model for the Black-White risk differentials. RESULTS: The COVID-19 mortality CmI indicated Blacks/AA with 34% of the total mortality in the United States, albeit their 13% population size. The COVID-19 CF was higher among Blacks/AA relative to Whites; Maryland, (2.7% vs. 2.5%), Wisconsin (7.4% vs. 4.8%), Illinois (4.8% vs. 4.2%), Chicago (5.9% vs. 3.2%), Detroit (Michigan), 7.2% and St. John the Baptist Parish (Louisiana), 7.9%. Blacks/AA compared to Whites in Michigan were 15% more likely to die, CmI risk ratio (CmIRR) = 1.15, 95% CI, 1.01-1.32. Blacks/AA relative to Whites in Illinois were 13% more likely to die, CmIRR = 1.13, 95% CI, 0.93-1.39, while Blacks/AA compared to Whites in Wisconsin were 51% more likely to die, CmIRR = 1.51, 95% CI, 1.10-2.10. In Chicago, Blacks/AA were more than twice as likely to die, CmIRR = 2.24, 95% CI, 1.36-3.88. CONCLUSION: Substantial racial/ethnic disparities are observed in COVID-19 CF and mortality with Blacks/AA disproportionately affected across the United States.

Implication of Vaginal and Cesarean Section Delivery Method in Black-White Differentials in Infant Mortality in the United States: Linked Birth/Infant Death Records, 2007-2016.

Racial/ethnic disparities in infant mortality (IM) continue to persist in the United States, with Black/African Americans (AA) being disproportionally affected with a three-fold increase in mortality compared to Whites. Epidemiological data have identified maternal characteristics in IM risk such as preeclampsia, eclampsia, maternal education, smoking, maternal weight, maternal socioeconomic status (SES), and family structure. Understanding the social gradient in health including implicit bias, as inherent in the method of labor and delivery and the racial heterogeneity, may facilitate intervention mapping in narrowing the Black-White IM risk differences. We aimed to assess the temporal/racial trends and the methods of delivery, mainly vaginal vs. cesarean section (C-section) as an exposure function of IM. The United States linked birth/infant death records (2007-2016) were used with a cross-sectional ecological design. The analysis involved chi squared statistic, incidence rate estimation by binomial regression model, and period percent change. Of the 40,445,070 births between 2007 and 2016, cumulative mortality incidence was 249,135 (1.16 per 1000). The IM rate was highest among Black/AA (11.41 per 1000), intermediate among Whites (5.19 per 1000), and lowest among Asian /Pacific Islanders (4.24 per 1000). The cumulative incidence rate difference, comparing vaginal to cesarean procedure was 1.73 per 1000 infants, implying excess IM with C-section. Compared to C-section, there was a 31% decreased risk of IM among mothers with vaginal delivery, rate ratio (RR) = 0.69, 95% confidence interval (CI): 0.64-0.74. Racial disparities were observed in the method of delivery associated with IM. Black/AA mothers with vaginal delivery had a 6% decreased risk of IM compared to C-section, RR = 0.94, 95% CI: 0.92-0.95, while Whites with vaginal delivery had a 38% decrease risk of IM relative to C-section, RR= 0.68, 95% CI: 0.67-0.69, p < 0.001. Infant mortality varied by race, with Black/AA disproportionally affected, which is explained in part by labor and delivery procedures, suggestive of reliable and equitable intrapartum assessment of Black/AA mothers during labor, as well as implicit bias marginalization in the healthcare system.

DNA Methylation of Candidate Genes (ACE II, IFN-γ, AGTR 1, CKG, ADD1, SCNN1B and TLR2) in Essential Hypertension: A Systematic Review and Quantitative Evidence Synthesis.

Physical, chemical, and social environments adversely affect the molecular process and results in cell signal transduction and the subsequent transcription factor dysregulation, leading to impaired gene expression and abnormal protein synthesis. Stressful environments such as social adversity, isolation, sustained social threats, physical inactivity, and highly methylated diets predispose individuals to molecular level alterations such as aberrant epigenomic modulations that affect homeostasis and hemodynamics. With cardiovascular disease as the leading cause of mortality in the US and blacks/African Americans being disproportionately affected by hypertension (HTN) which contributes substantially to these deaths, reflecting the excess mortality and survival disadvantage of this sub-population relative to whites, understanding the molecular events, including epigenomic and socio-epigenomic modulations, is relevant to narrowing the black-white mortality risk differences. We aimed to synthesize epigenomic findings in HTN namely (a) angiotensin-converting enzyme 2 (ACE II) gene, (b) Toll-like receptor 2 (TLR2) gene, (c) interferon γ (IFN-γ) gene, and (d) Capping Actin Protein, Gelosin-Like (CAPG) gene, adducin 1(ADD1) gene, (e) Tissue inhibitor of metalloproteinase 3 (TIMP3), (f) mesoderm specific transcript (MEST) loci, (g) sodium channel epithelial 1 alpha subunit 2 (SCNN1B), (h) glucokinase (CKG) gene (i) angiotensin II receptor, type1 (AGTR1), and DNA methylation (mDNA). A systematic review and quantitative evidence synthesis (QES) was conducted using Google Scholar and PubMed with relevant search terms. Data were extracted from studies on: (a) Epigenomic modulations in HTN based on ACE II (b) TLR2, (c) IFN-γ gene, (d) CAPG, ADD1, TIMP3, MEST loci, and mDNA. The random-effect meta-analysis method was used for a pooled estimate of the common effect size, while z statistic and I^2 were used for the homogeneity of the common effect size and between studies on heterogeneity respectively. Of the 642 studies identified, five examined hypermethylation while seven studies assessed hypomethylation in association with HTN. The hypermethylation of ACE II, SCNN1B, CKG, IFN-γ gene, and miR-510 promoter were associated with hypertension, the common effect size (CES) = 6.0%, 95% CI, -0.002-11.26. In addition, the hypomethylation of TLR2, IFN-γ gene, ADD1, AGTR1, and GCK correlated with hypertension, the CES = 2.3%, 95% CI, -2.51-7.07. The aberrant epigenomic modulation of ACE II, TLR2, IFN-γ, AGTR1, and GCK correlated with essential HTN. Transforming the environments resulting from these epigenomic lesions will facilitate early intervention mapping in reducing HTN in the US population, especially among socially disadvantaged individuals, particularly racial/ethnic minorities.

Implication of Spiritual Network Support System in Epigenomic Modulation and Health Trajectory.

With challenges in understanding the multifactorial etiologies of disease and individual treatment effect heterogeneities over the past four decades, much has been acquired on how physical, chemical and social environments affect human health, predisposing certain subpopulations to adverse health outcomes, especially the socio-environmentally disadvantaged (SED). Current translational data on gene and adverse environment interaction have revealed how adverse gene-environment interaction, termed aberrant epigenomic modulation, translates into impaired gene expression via messenger ribonucleic acid (mRNA) dysregulation, reflecting abnormal protein synthesis and hence dysfunctional cellular differentiation and maturation. The environmental influence on gene expression observed in most literature includes physical, chemical, physicochemical and recently social environment. However, data are limited on spiritual or religious environment network support systems, which reflect human psychosocial conditions and gene interaction. With this limited information, we aimed to examine the available data on spiritual activities characterized by prayers and meditation for a possible explanation of the nexus between the spiritual network support system (SNSS) as a component of psychosocial conditions, implicated in social signal transduction, and the gene expression correlate. With the intent to incorporate SNSS in human psychosocial conditions, we assessed the available data on bereavement, loss of spouse, loneliness, social isolation, low socio-economic status (SES), chronic stress, low social status, social adversity (SA) and early life stress (ELS), as surrogates for spiritual support network connectome. Adverse human psychosocial conditions have the tendency for impaired gene expression through an up-regulated conserved transcriptional response to adversity (CTRA) gene expression via social signal transduction, involving the sympathetic nervous system (SNS), beta-adrenergic receptors, the hypothalamus-pituitary-adrenal (HPA) axis and the glucocorticoid response. This review specifically explored CTRA gene expression and the nuclear receptor subfamily 3 group C member 1 (NR3C1) gene, a glucocorticoid receptor gene, in response to stress and the impaired negative feedback, given allostatic overload as a result of prolonged and sustained stress and social isolation as well as the implied social interaction associated with religiosity. While more remains to be investigated on psychosocial and immune cell response and gene expression, current data on human models do implicate appropriate gene expression via the CTRA and NR3C1 gene in the SNSS as observed in meditation, yoga and thai-chi, implicated in malignant neoplasm remission. However, prospective epigenomic studies in this context are required in the disease causal pathway, prognosis and survival, as well as cautious optimism in the application of these findings in clinical and public health settings, due to unmeasured and potential confoundings implicated in these correlations.

Aberrant Epigenomic Modulation of Glucocorticoid Receptor Gene (NR3C1) in Early Life Stress and Major Depressive Disorder Correlation: Systematic Review and Quantitative Evidence Synthesis.

Early life stress (ELS) induced by psychological trauma, child maltreatment, maternal separation, and domestic violence predisposes to psycho-behavioral pathologies during adulthood, namely major depressive disorder (MDD), anxiety, and bipolar affective disorder. While environmental data are available in illustrating this association, data remain to be established on the epigenomic underpinning of the nexus between ELS and MDD predisposition. Specifically, despite the observed aberrant epigenomic modulation of the NR3C1, a glucocorticoid receptor gene, in early social adversity and social threats in animal and human models, reliable scientific data for intervention mapping in reducing social adversity and improving human health is required. We sought to synthesize the findings of studies evaluating (a) epigenomic modulations, mainly DNA methylation resulting in MDD following ELS, (b) epigenomic modifications associated with ELS, and (c) epigenomic alterations associated with MDD. A systematic review and quantitative evidence synthesis (QES) were utilized with the random effect meta-analytic procedure. The search strategy involved both the PubMed and hand search of relevant references. Of the 1534 studies identified through electronic search, 592 studies were screened, 11 met the eligibility criteria for inclusion in the QES, and 5 examined ELS and MDD; 4 studies assessed epigenomic modulation and ELS, while 2 studies examined epigenomic modulations and MDD. The dense DNA methylation of the 1F exon of the NR3C1, implying the hypermethylated region of the glucocorticoid receptor gene, was observed in the nexus between ELS and MDD, common effect size (CES) = 14.96, 95%CI, 10.06-19.85. With respect to epigenomic modulation associated with child ELS, hypermethylation was observed, CES = 23.2%, 95%CI, 8.00-38.48. In addition, marginal epigenomic alteration was indicated in MDD, where hypermethylation was associated with increased risk of MDD, CES = 2.12%, 95%CI, -0.63-4.86. Substantial evidence supports the implication of NR3C1 and environmental interaction, mainly DNA methylation, in the predisposition to MDD following ELS. This QES further supports aberrant epigenomic modulation identified in ELS as well as major depressive episodes involving dysfunctional glucocorticoid-mediated negative feedback as a result of allostatic overload. These findings recommend prospective investigation of social adversity and its predisposition to the MDD epidemic via aberrant epigenomic modulation. Such data will facilitate early intervention mapping in reducing MDD in the United States population.

Risk Differences in Disease-Specific Infant Mortality Between Black and White US Children, 1968-2015: an Epidemiologic Investigation.

PURPOSE: Black/African American (AA) infants have been persistently observed with survival disadvantage compared to White infants in the USA, implying excess mortality. While reliable epidemiologic data continue to illustrate these disparities, data are yet to provide a substantial explanation to the observed rates and risk differences over the past six decades. We aimed in this study to examine the infant mortality risk differences by temporal trends and to provide an ecologic and non-concurrent explanation for the persisted variability. METHODS: A retrospective design with aggregate data from the Center for Disease Control and Prevention (CDC) was used to access the risk difference in cause-specific mortality, while stratification analysis was utilized for the risk ratio estimation. We also estimated the percent change for mortality trends. RESULTS: The cumulative infant mortality (IM) incidence was two times as likely for Black/AA relative to White, risk ratio (RR), 2.05. There were temporal trends in IM between 1968 and 2015 with excess IM among Black/AA children. Specifically, between 1968 and 2015, the percent change (% change) for digestive system disorders (58.43%); genito-urinary tract system disorders (58.20%); muscle, skeleton, and connective tissue disorders (66.60%); congenital anomalies (23.79%); and certain perinatal causes (38.65%) indicated upward trends in infant mortality Black/AA and White risk ratio. Except for neoplasm, and the initial study period (1968-1978) for congenital anomalies, Black/AA infants indicated survival disadvantage, implying excess mortality ratio relative to their White counterparts. CONCLUSION: Disease-specific infant mortality is higher among black/AA except for neoplasm, and increasing percent changes are observed in digestive; genito-urinary; and muscle, skeleton, and connective tissue disorders. These findings are suggestive of the pressing needs to examine the cause of these disparities namely social determinants of health and social inequity for specific risk-adapted intervention in achieving health equity in US infant mortality.

Lower Regional Pediatric In-hospital Mortality Albeit Racial/ethnic Disparities.

PURPOSE: Variability in pediatric morbidity and mortality tends to be influenced by several factors including though not limited to social determinants of health, namely health inequity as an exposure function of health disparities. We aimed to assess the cumulative incidence of pediatric mortality, racial/ethnic disparities, and the predisposing factors for the disparities. METHOD: The current study retrospectively examined the Nemours/Alfred I. duPont Hospital for Children medical records of 16,121 patients diagnosed with any pediatric condition during 2009 and 2010. RESULTS: In-hospital pediatric mortality cumulative incidence was relatively low (80 deaths, 0.49%) when compared with similar settings in the U.S. (national average range, 0.8e1.1%) during the same period. Compared with whites/Caucasians, mortality was higher among blacks/African Americans, prevalence odds ratio (POR), 1.06, 95% CI, 0.77e1.45, and higher for some other race, POR, 1.48, 95% CI, 1.06e2.10. After controlling for potential confounders (severity of illness, insurance status, and length of stay), racial differences in pediatric mortality did not persist between whites and some other race, adjusted POR, 1.08, 99% CI, 0.75e1.57. CONCLUSIONS: In-hospital pediatric mortality cumulative incidence was relatively low in our region, and racial disparities exist but did not persist after controlling for confounders. These findings are suggestive of the importance of social determinants of health namely quality care, adequate medical insurance, and early detection, diagnosis in pediatric morbidity and epigenomic alterations, as well as the need to go beyond the "close medical model" to improve pediatric morbidity and survival by addressing health inequity as a function of health disparities.

Maternal Sociodemographic Characteristics, Experiences and Health Behaviors Associated with Postpartum Care Utilization: Evidence from Maryland PRAMS Dataset, 2012-2013.

Objectives Postpartum visits are increasingly recognized as a window of opportunity for health care providers to counsel new mothers and promote healthy behaviors, including increasing contraceptive use and screening for postpartum depression. In Maryland, there is a lack of research on postpartum visit (PPV) attendance and the specific risk factors associated with not receiving postpartum care. In this study, we estimated the proportion of mothers in Maryland who attended a PPV and assessed maternal sociodemographic characteristics and health behaviors associated with PPV non-attendance. Methods Data were analyzed from the 2012 and 2013 Maryland Pregnancy Risk Assessment Monitoring System (n = 2204). Bivariate and multivariable logistic regression were performed to examine the association between covariates and PPV non-attendance. Results Overall, 89.6% of women reported PPV attendance. Bivariate analyses between maternal sociodemographic and health behavior characteristics and PPV non-attendance indicated that being unmarried (OR 3.03, 95% CI 2.12-4.31), experiencing infant loss (OR 7.17, 95% CI 2.57-19.97), working during pregnancy (OR 0.44, 95% CI 0.31-0.63) and not receiving dental care (OR 2.03, 95% CI 1.43-2.88) as significant risk factors for PPV non-attendance. After controlling for known and theoretical confounders, experiencing an infant loss (aOR 5.18, 95% CI 1.54-17.4), not receiving dental care (aOR 1.54, 95% CI 1.06-2.26) and working during pregnancy (aOR 0.61, 95% CI 0.41-0.93) emerged as strong predictors of PPV non-attendance. Conclusions for Practice Mothers who recently experienced an infant death were at greatest risk for not attending a PPV, suggesting the need to establish comprehensive support networks, including grief counseling and additional service reminders for mothers who experienced an infant death.

A patient and family data domain collection framework for identifying disparities in pediatrics: results from the pediatric health equity collaborative.

BACKGROUND: By 2020, the child population is projected to have more racial and ethnic minorities make up the majority of the populations and health care organizations will need to have a system in place that collects accurate and reliable demographic data in order to monitor disparities. The goals of this group were to establish sample practices, approaches and lessons learned with regard to race, ethnicity, language, and other demographic data collection in pediatric care setting. METHODS: A panel of 16 research and clinical professional experts working in 10 pediatric care delivery systems in the US and Canada convened twice in person for 3-day consensus development meetings and met multiple times via conference calls over a two year period. Current evidence on adult demographic data collection was systematically reviewed and unique aspects of data collection in the pediatric setting were outlined. Human centered design methods were utilized to facilitate theme development, facilitate constructive and innovative discussion, and generate consensus. RESULTS: Group consensus determined six final data collection domains: 1) caregivers, 2) race and ethnicity, 3) language, 4) sexual orientation and gender identity, 5) disability, and 6) social determinants of health. For each domain, the group defined the domain, established a rational for collection, identified the unique challenges for data collection in a pediatric setting, and developed sample practices which are based on the experience of the members as a starting point to allow for customization unique to each health care organization. Several unique challenges in the pediatric setting across all domains include: data collection on caregivers, determining an age at which it is appropriate to collect data from the patient, collecting and updating data at multiple points across the lifespan, the limits of the electronic health record, and determining the purpose of the data collection before implementation. CONCLUSIONS: There is no single approach that will work for all organizations when collecting race, ethnicity, language and other social determinants of health data. Each organization will need to tailor their data collection based on the population they serve, the financial resources available, and the capacity of the electronic health record.

Dynamic Lower Extremity Deformity in Children With Pseudoachondroplasia.

BACKGROUND: Pseudoachondroplasia is a diverse group of skeletal dysplasias with a common pathway of altered cartilage oligomeric matrix protein (COMP) production. This rhizomelic dwarfism is commonly associated with deformities of the lower extremities, accelerated osteoarthritis, and ligamentous laxity. One of the most common alignment problems is coronal knee angulation which combined with tibial torsion, results in a complex deformity. The outcome of surgical correction of these deformities is variable. METHODS: This study used 3-dimensional gait analysis to describe the kinematic deformities in 12 children (aged 3 to 15 y) and compared them to the static deformities measured on standing anteroposterior radiograph. RESULTS: Both gait analysis and radiographs showed large variability in the coronal deformities but strong correlation to each other. Gait analysis showed mean varus alignment of the knee to be 13.5±13.1 degrees; that mean is not statistically different from radiographs, which showed a mean varus of 16.2±17.1 degrees. The correlation coefficient between radiographic and kinematic measurement was 0.70. The kinematic internal tibial torsion measured an average 15±19 degrees, which was moderately correlated to knee varus (r=0.45, P<0.01). CONCLUSIONS: Measurements of varus-valgus alignment correlated well between gait analysis and radiographs. Tibial torsion correlated with varus. In the absence of gait analysis, anteroposterior standing leg length radiographs with the patella facing foreward can be used to assess deformity. As this study does not correlate these measurements to postoperative results, an appropriately powered prospective study and further investigation of biological effects of altered cartilage oligomeric matrix protein production are needed to explain the variable surgical outcomes. LEVEL OF EVIDENCE: Level IV-case series without control group).

Implication of Socio-Demographics on Cognitive-Related Symptoms in Sports Concussion Among Children.

BACKGROUND: Sports-related concussion remains a public health challenge due to its morbidity and mortality. One of the consequences of concussion is cognitive impairment (CI) and cognitive-related symptoms (CRS) which determine, to some extent, physical and behavioral functioning of children who sustain concussion. Despite the high prevalence of CI and CRS associated with concussion, the risk factors are not fully understood. We aimed to characterize CRS and to examine its relationship with race, ethnicity, age, insurance, and sex in a pediatric population. METHODS: A retrospective cohort (case-only) design was used to assess CRS prevalence and its relationship with race and sex using a pediatric hospital's electronic medical records. A consecutive sample was used with 1429 cases between 2007 and 2014. Study characteristics were examined using chi-square and log binomial regression for hypothesis-specific testing. RESULTS: Of the 1429 cases, 872 (61.0 %) were boys and 557 (39.0 %) were girls. The racial distribution indicated 1146 (80.2 %) Whites, 170 (11.9 %) Blacks/African Americans, and 113 (7.9 %) others. The prevalence of CRS was 78.0 %. Whereas boys had sustained more concussions, girls were more likely to present with CRS; prevalence risk ratio = 1.07, 95 % CI 1.01-1.13, p = 0.02. The crude analysis indicated no racial disparities in CRS prevalence, but the multivariable analysis did, comparing White to Black/African American children; adjusted prevalence risk ratio (aPRR) = 1.77, 99 % CI 1.02-3.08, p = 0.008. CONCLUSIONS: Racial disparities exist in CRS among children with sports-related concussion, and Black/African American children are more likely, relative to Whites, to suffer CRS. Due to uncertainty in causal inference, we caution the interpretation and application of these data in risk-adapted concussion prevention.

Preoperative halo-gravity traction with and without thoracoscopic anterior release for skeletal dysplasia patients with severe kyphoscoliosis.

PURPOSE: Recent work has shown the safety and efficacy of halo-gravity traction as an operative adjunct. However, there are no reports specifically looking at halo-gravity traction in patients with skeletal dysplasia. Our purpose was to assess the safety and efficacy of traction in children with skeletal dysplasia who present with severe kyphoscoliosis. METHODS: We retrospectively reviewed eight consecutive children with skeletal dysplasia who were treated with halo-gravity traction preoperatively. Six of the patients had a thoracoscopic anterior release prior to the halo-gravity traction. All patients were ambulatory and presented with severe, rigid kyphoscoliosis. RESULTS: The mean duration of traction was 32 days. There were no neurologic complications with traction or after posterior spinal instrumentation. The majority of kyphoscoliosis correction was with the halo-gravity traction alone: major curve (MC) Cobb angle improved 41 %; C7-center sacral vertical line, 75 %; C7-MC apex, 21 %; and T2-T12 kyphosis, 35 %. Trunk height increased 37 % and thoracic height 44 %. An additional amount of correction was obtained with posterior spinal instrumentation (±fusion), decreasing MC Cobb angle an additional 23 %; C7-apex, 16 %; and T2-T12 kyphosis, 10 %. There was no additional correction of thoracic height. Two years after posterior spinal instrumentation (±fusion), a mild-to-moderate amount of correction was lost: MC Cobb angle decreased 23 %; compensatory Cobb angle, 28 %; C7-CSVL, 24 %; C7-S1, 22 %; regional kyphosis, 31 %; thoracic kyphosis, 29 %; and trunk height, 27 %. CONCLUSIONS: Among children with skeletal dysplasia and severe kyphosis, halo-gravity traction is well tolerated and safe. Most of the corrections in radiographic parameters were achieved with traction alone. Traction improves coronal balance, apical translation, thoracic height, and kyphosis. In this specific population, the potential for neurologic injury during corrective surgery is high. However, preoperative halo-gravity traction provides slow, progressive correction in a safe manner and avoided neurologic injury in these patients. This study did not compare patients without halo-gravity traction to patients with halo-gravity traction, therefore it cannot be concluded that going straight to instrumentation without traction will give a poorer radiographic result. LEVEL OF EVIDENCE: IV.

Effectiveness of Powered Intracapsular Tonsillectomy in Children With Severe Obstructive Sleep Apnea.

IMPORTANCE: Powered intracapsular tonsillectomy and adenoidectomy (PITA) is an increasingly common pediatric procedure. Few studies have examined its effectiveness in children with severe obstructive sleep apnea (OSA). OBJECTIVE: To assess the effectiveness of PITA in patients with severe OSA as evidenced by change in polysomnographic parameters. DESIGN, SETTING, AND PARTICIPANTS: We performed a case series study with medical record review of 70 children with severe OSA who underwent PITA at a tertiary care pediatric hospital from January 1, 2010, through December 31, 2014. MAIN OUTCOMES AND MEASURES: Preoperative and postoperative polysomnographic parameters. RESULTS: Of the 70 children with severe OSA who underwent PITA, 39 (56%) were boys, and the median age at surgery was 3.7 years. There were significant mean (SD) decreases in the postoperative apnea-hypopnea index (32.4 [28.4] vs 5.8 [9.7], P < .001), obstructive apnea index (20.4 [17.97] vs 2.55 [5.9]), obstructive apnea-hypopnea index (25.5 [22.4] vs 3.9 [7.3], P < .001), arousal index (53.7 [33.9] vs 27.4 [22.6], P < .001), percentage of total sleep time spent snoring (28.6 [30.5] vs 13.6 [20.8], P = .001), and oxygen desaturation index of 4% or more (22.9 [26.4] vs 4.5 [9.9], P < .001). Mean (SD) oxygen saturation (96.8 [2.0] vs 98.2 [1.3], P < .001) and oxygen saturation nadir (75.5 [13.1] vs 88.4 [8.1], P < .001) increased significantly. A significant decrease in time was observed with an end-tidal carbon dioxide greater than 55 mm Hg (49.67 [97.5] vs 19.1 [73.9] minutes, P = .01). CONCLUSIONS AND RELEVANCE: Powered intracapsular tonsillectomy and adenoidectomy improved OSA in this series of pediatric patients by reducing obstructive apneas and hypopneas, oxygen desaturation, arousal index, carbon dioxide level, and snoring, as well as increasing oxygen saturation nadir. Results are comparable to those described for traditional electrocautery tonsillectomy and support the use of PITA for the treatment of severe OSA in children with adenotonsillar hypertrophy.

Pamidronate Treatment to Prevent Reoccurring Fractures in Children With Cerebral Palsy.

BACKGROUND: Some children with cerebral palsy (CP) have frequent fractures due to low bone mineral density and receive treatment with pamidronate, an intravenous bisphosphonate. Our review evaluates the outcome of pamidronate treatment in these children. METHODS: A retrospective chart review was performed, and 32 patients (14 girls and 18 boys) with CP Gross Motor Function Classification System level III (2 patients), IV (3 patients), and V (27 patients) treated with 5 courses of pamidronate for low mineral density were identified. Patients with a minimum of 2 years of follow-up were included in the study. Data collection was a review of the demographics and pretreatment, peritreatment, and posttreatment fracture history. RESULTS: The mean age at treatment was 11.6 years (range, 2.9 to 19.6 y). There were 102 fractures (mean duration 2.5 y) pretreatment and 28 fractures posttreatment. With an average follow-up of 6.4 years, posttreatment rate of fracture decreased to 0.10 fractures per year from the pretreatment rate of 2.4 fractures per year (P<0.001). The femur was the most common bone fractured both pretreatment (54%) and posttreatment (61%); the major site was the distal third of the femur. There were 11 fractures during the course of pamidronate treatment at a rate of 0.33 fractures per year. Only 11 patients (34%) sustained fracture posttreatment. No correlation with fracture pattern or occurrence was found with patient age, number of pretreatment fractures, or sex. Most fractures were caused by low-energy injuries, and most were managed nonoperatively. CONCLUSIONS: In patients with CP and disuse osteoporosis, the most common fracture sustained involved the distal femur via low-velocity injury, and most fractures were treated nonoperatively. Although the fracture pattern and the treatment remained unchanged, reoccurring fractures in these children can be effectively treated medically to interrupt the fracturing tendency.

The Long-term Outcome of Early Spine Fusion for Scoliosis in Children With Cerebral Palsy.

STUDY DESIGN: Retrospective review of radiographs and charts (case-only). OBJECTIVE: The aim of this study was to describe the long-term outcomes of spine fusion for neuromuscular scoliosis in children below 10 years of age with cerebral palsy (CP). SUMMARY OF BACKGROUND DATA: Severely involved children with CP may develop early-onset scoliosis. The outcome of spine fusion is not clear and there are no studies focused on spine fusion in this young patient population. METHODS: This is a retrospective review of 33 children who underwent spine fusion with unit-rod instrumentation between 1989 and 2006 for CP neuromuscular scoliosis, aged below 10 years at spine fusion, and with follow-up >5 years. Demographic, medical, and radiographic data were retrospectively assessed. Repeated measure analysis of variance and Kaplan-Meier survival estimates were used for data assessment. RESULTS: Thirty-three of 42 patients who underwent spine fusion in this period, 19 boys and 14 girls, met the inclusion criteria. Of 9 patients who were excluded, 3 were lost to follow-up and remaining 6 died within 5 years of surgery. Mean age at surgery was 8.3 years (range, 4.4-9.9 y). Mean follow-up was 9.8 years (range, 5.5-15.8 y). Gross motor function classification system level was V in 31 patients and IV in 2 patients. Thirty-one patients (94%) had seizure disorder, 29 patients (88%) had gastric feeding tubes, and 9 patients (27%) had tracheostomy tubes. Eighty-five percent of the patients had posterior-only surgery. Mean Cobb angles preoperative, immediately postoperative, and at final follow-up were 85, 21, and 24 degrees, respectively. Mean postoperative pelvic obliquity correction was 15±9 degrees (P<0.001). At final follow-up, there was no significant change from the postoperative measurements. Complications included 1 deep wound infection and 10 other problems. Eleven patients (28.2%) died after a mean follow-up of 5.6±3.8 years. CONCLUSIONS: In our cohort with early-onset neuromuscular scoliosis, spine fusion was associated with minimal short-term and long-term morbidity, but there was 28% mortality at 10 years of follow-up and 50% predicted mortality at 15 years.