Trends in Head Computed Tomography Utilization in Children Presenting to Emergency Departments After Traumatic Head Injury.

OBJECTIVES: Although closed head injuries occur commonly in children, most do not have a clinically important traumatic brain injury (ciTBI) and do not require neuroimaging. We sought to determine whether the utilization of computed tomography of the head (CT-H) in children presenting to an emergency department (ED) with a closed head injury changed after publication of validated clinical prediction rules to identify children at risk of ciTBI by the Pediatric Emergency Care Applied Research Network (PECARN). METHODS: We used the nationwide ED sample (2008-2013) to examine children visiting an ED after a mild closed head injury. Multiple patient and hospital characteristics were assessed. RESULTS: Of the 4,552,071 children presenting to an ED with a mild closed head injury, 1,181,659 (26.0%) underwent CT-H. Care was most commonly received at metropolitan teaching hospitals (43.5%) and varied markedly by geographic region. Overall, there were no significant changes in the nationwide rates of CT-H utilization in the period immediately after publication of the PECARN prediction rules. However, compared with metropolitan teaching hospitals, CT-H utilization increased significantly for patients treated at nonteaching hospitals and at nonmetropolitan hospitals. CONCLUSIONS: There was no overall reduction in CT-H utilization after publication of the 2009 PECARN prediction rules. However, patients treated at metropolitan teaching hospitals were significantly less likely to undergo CT-H after 2009, suggesting some penetration of the PECARN tool in that setting. Further research should study patterns of CT-H utilization in nonteaching hospitals and nonmetropolitan hospitals to assess challenges for adoption of validated pediatric ciTBI prediction rules.

Hospital-Based Emergency Department Visits With Pediatric Burns: Characteristics and Outcomes.

OBJECTIVE: The objective of this study was to examine the characteristics and outcomes in children presenting to emergency departments (EDs) with burn injuries. METHODS: The Nationwide Emergency Department Sample (NEDS) for the years 2008 to 2013 was used. All patients younger than 18 years who visited a hospital-based ED with a burn injury were selected. The study focused on (1) demographics (age, sex, insurance status), (2) characteristics of burns (types, causes), (3) disposition status after ED/hospitalization, (4) charges (ED and hospital), and (5) patient outcomes. Inclusion criteria were a visit to ED in the United States with a burn. Descriptive statistics were used to summarize the findings. RESULTS: During the study period, there were 746,593 ED visits due to burn injuries. Majority were insured by Medicaid (52.8%). Most frequent injuries were burns of wrists/hands (39.5%), lower limbs (24.1%), and upper limb-except wrist/hand (20.1%). The most common causes of burns were heat from electric appliances (37.1%) or hot liquids and vapors (24.8%). Following the ED visit, 89.1% were discharged routinely, and 4.3% were admitted. Mean charge per patient per ED visit was $1117. Total ED charges across the United States was $708.7 million. When admitted, mean length of stay was 5.7 days. Total hospitalization charge across the United States was $1.7 billion. CONCLUSIONS: Pediatric burn injuries require significant resources for stabilization and treatment by EDs. The present study highlights the burden and impact of pediatric burn injuries in the United States.

Opioid Abuse and Dependence in Those Hospitalized Due to Head and Neck Cancer.

PURPOSE: In the United States, 2.1 million people develop substance abuse disorders that are associated with prescribed opioids. The objective of the present study was to identify the factors associated with opioid abuse and dependence (OAD) in those hospitalized for head and neck cancer (HNC). Although measures are being implementing to reduce opioid prescribing, the use of these drugs in individuals with HNC can be valuable. However, little is known about OAD among this cohort of individuals. MATERIALS AND METHODS: The present study was a retrospective analysis of the Nationwide Inpatient Sample for 2012 to 2014. All patients hospitalized because of any HNC were selected. The OAD prevalence was identified. The patient demographic, hospital, and geographic factors were considered independent variables and OAD was the outcome. Multivariable logistic regression model was used to identify the factors associated with OAD. RESULTS: A total of 92,055 patients were hospitalized because of HNCs. OAD was prevalent in 0.8% of the patients. The OAD rates were greatest in patients with a malignant neoplasm of ill-defined sites within the lip, oral cavity, and pharynx (1.6%). Age 30 to 44 years (odds ratio [OR] 5.19, 95% confidence interval [CI] 2.23 to 12.06; P < .01) and age 45 to 64 years (OR 4.05, 95% CI 2.15 to 7.61; P < .01) were associated with greater odds for OAD compared with age older than 64 years. Black (OR 1.76, 95% CI 1.12 to 2.78; P = .01) and Hispanic (OR 2.20, 95% CI 1.27 to 3.79; P < .01) race/ethnicity were associated with greater odds for OAD compared with white race/ethnicity. Individuals covered by Medicaid (OR 2.08, 95% CI 1.26 to 3.43; P < .01), and those who were uninsured (OR 2.27, 95% CI 1.05 to 4.89; P = .04) were associated with greater odds for OAD compared with those covered by private insurance. An increase in the comorbid burden was associated with increased odds of OAD (OR 1.57, 95% CI 1.47 to 1.68; P < .001). CONCLUSIONS: The present study identified specific anatomic sites where malignant neoplasm was associated with greater odds of OAD. Additionally, the study found that coverage by Medicaid, black and/or Hispanic race/ethnicity, lowest income households, and a greater comorbid burden were associated with greater odds of OAD.

Successful use of extracorporeal membrane oxygenation in a child with obstructive shock due to massive bilateral pulmonary embolism.

BACKGROUND: Acute massive pulmonary embolism (PE) is a very rare condition in children. We report the successful use of veno-arterial extracorporeal membrane oxygenation (VA ECMO) as a lifesaving modality in a child with acute massive PE. CASE PRESENTATION: A nine-year-old female with spinal muscular atrophy type 1, chronic respiratory failure with tracheostomy and ventilator dependence presented with tachypnea and hypoxia. She had recent coiling of her pulmonary arterio-venous malformation. A chest computerized tomography scan showed massive bilateral PE. Urgent catheter-directed thrombolysis failed. She was placed on VA-ECMO with stabilization of hemodynamics. She underwent surgical thrombo-embolectomy followed by weaning of ECMO support. DISCUSSION: The use of VA ECMO supported the cardio-respiratory status and perfusion to facilitate surgical embolectomy.

Facial Fractures in Patients With Firearm Injuries: Profile and Outcomes.

PURPOSE: Firearm injuries (FAIs) are a major public health issue in the United States. The objective of this study was to examine characteristics and outcomes of patients presenting to emergency departments (EDs) with facial fractures attributed to FAIs. MATERIALS AND METHODS: The Nationwide Emergency Department Sample for the years 2008 to 2013 was used. All patients who visited EDs with FAIs and facial fractures were selected. The study focused on the following variables: 1) demographic characteristics, 2) types of facial fractures, 3) disposition status after ED visit or subsequent hospitalization, 4) charges (ED and hospitalization), and 5) patient outcomes. The inclusion criteria were a visit to a hospital-based ED with facial fractures and an external cause of FAI. Descriptive statistics were used to summarize findings. Multivariate logistic regression analysis was used to examine the simultaneous effects of patient-related factors on ED death. RESULTS: During the study period, a total of 15,469 patients (mean age, 34 years) visited hospital-based EDs with facial fractures attributed to FAIs. Most were uninsured male patients. The most common etiology of FAIs was assault. The most common facial fractures were open mandibular fractures and open maxillary and/or malar bone fractures. Approximately 27% of patients had a concomitant intracranial injury. After the ED visit, 74% were admitted. The mean ED charge per patient was $6,403, and the total ED charge across the United States was $76.48 million. The mean hospitalization charge per patient was $167,203. The total hospitalization charge across the United States was $1.9 billion. Patients with intracranial injuries (odds ratio [OR], 21.21; 95% confidence interval [CI], 7.16 to 62.85; P < .01), uninsured patients (OR, 4.24; 95% CI, 1.44 to 12.51; P < .01), and patients residing in areas with high household incomes (OR, 5.60; 95% CI, 2.51 to 12.46; P < .01) were high-risk groups for ED death. CONCLUSIONS: FAIs require substantial resources for stabilization and treatment by EDs. This study highlights the burden and impact of facial fractures in patients with FAIs in the United States.

Adverse clinical events reported during Invisalign treatment: Analysis of the MAUDE database.

INTRODUCTION: The objectives of this study were to examine adverse clinical events after the use of the Invisalign system and to provide an overview of the actions taken by the manufacturer to address these events. METHODS: A retrospective analysis of the Manufacturer and User Facility Device Experience database of the United States Food and Drug Administration was used. All medical device reports reported to the United States Food and Drug Administration pertaining to products of Align Technology from November 1, 2006, to November 30, 2016, were analyzed. Qualitative content analysis was conducted of event descriptions and manufacturer narrative reports. RESULTS: A total of 173 medical device reports were reported in the Manufacturer and User Facility Device Experience database: 169 (97.7%) were designated as adverse event reports, and 45 (26%) were deemed by the treating doctor to be serious or life threatening. The most medical device reports that reported a serious or life-threatening event were in 2014 (50%). The most frequently reported adverse event was difficulty breathing (56 events) followed by sore throat (35 events), swollen throat (34 events), swollen tongue (31 events), hives and itchiness (31 events), anaphylaxis (30 events), swollen lips (27 events), and feeling of throat closing/tight airway/airway obstruction/laryngospasm (24 events). CONCLUSIONS: Serious or life-threatening events could be associated with use of Invisalign systems. Health care providers should be aware of these events and know how to handle them if they arise in their practices.

Impact of Periapical Abscess on Infectious Complications in Patients Undergoing Extracorporeal Circulation Auxiliary to Open-Heart Surgical Procedures.

OBJECTIVE: Extracorporeal circulation auxiliary to open-heart surgeries (ECAOHS) may exert nonphysiological stresses on periapical abscessed tissues leading to hematogenous spread of microbes. The aim of this report was to estimate risk of postoperative infectious complications in patients with periapical abscesses and undergoing ECAOHS. METHODS: A retrospective analysis of Nationwide Inpatient Sample (years 2009 and 2010) was conducted. All patients (aged 19 to 65 years) who underwent ECAOHS were selected. International Classification of Diseases-9-Clinical Modification codes were used to identify the presence of periapical abscess and infectious complications. Multivariable logistic regression models were used to examine the associations between the presence of periapical abscess and occurrence of infectious complications. RESULTS: A total of 265,235 patients underwent an ECAOH procedure. Of these, 431 patients had a periapical abscess. Septicemia developed in 16% of those with periapical abscess (compared with 4.2% in those without periapical abscess). Those with periapical abscess had higher rates of any of the infectious complications when compared with those without periapical abscess (30.2% vs 11.6%, respectively). After adjustment for multiple confounders, those with periapical abscess were associated with higher odds for developing septicemia (odds ratio = 2.51, 95% confidence interval = 1.06-5.91, P = .04) and any of the infectious complications (odds ratio = 2.23, 95% confidence interval = 1.08-4.59, P = .03) when compared with those who did not have periapical abscess. CONCLUSIONS: Those with periapical abscess are associated with higher odds for infectious complications when compared with those without periapical abscess.

Outcomes of invasive mechanical ventilation in children and adolescents hospitalized due to status asthmaticus in United States: a population based study.

OBJECTIVE: Current national estimates of and outcomes of Invasive Mechanical Ventilation (MV) in status asthmaticus (SA) are unclear. The objective of this study is to estimate the incidence and outcomes of MV in hospitalized SA children and adolescents. METHODS: We used the Nationwide Inpatient Sample (NIS, 2009-2010), the largest all-payer hospital discharge database in United States. All hospitalizations (age ≤21 years) with a primary diagnosis of SA were selected. MV was identified using ICD-9-CM procedure codes. Multivariable regression analyses were used to examine the association between MV and outcomes (Length of Stay (LOS) and Hospital Charges (HC)). RESULTS: Over the study period, of the 250 718 SA hospitalizations, MV was needed for <96 h in 0.37% hospitalizations and 0.18% had MV for ≥96 h. Complications occurred in 12.4% (30 991) of all hospitalizations with pneumonia (10.8%) being the most common. A total of 65 patients died in hospitals (the overall in-hospital mortality [IHM] rate was 0.03%). About 55 of these deaths occurred among those who had MV (4% IHM rate for those receiving MV). The mean LOS and hospital HC included without MV (2.1 d, $11 921) MV < 96 h (4.8 d, $52 201); MV > 96 h (15.6 d, $200 336). After adjustment for patient/hospital level factors, the need for MV was associated with significantly higher LOS and HC (p < 0.0001). Those who had MV<96 h (OR = 2.58, 95% CI = 1.77-3.77) or MV ≥ 96 h (OR = 6.23, 95% CI = 3.87-10.03) had higher risk of developing pneumonia. CONCLUSIONS: Although MV is infrequently needed in children and adolescents hospitalized for SA (0.55% incidence rate), it is associated with higher IHM rate and significant hospital resource utilization.

Prevalence and Predictors of Adverse Events during Procedural Sedation Anesthesia-Outside the Operating Room for Esophagogastroduodenoscopy and Colonoscopy in Children: Age Is an Independent Predictor of Outcomes.

OBJECTIVES: Procedural sedation/anesthesia outside the operating room for a variety of procedures is well described with an overall low adverse event rate in certain settings. Adverse event associated with procedural sedation/anesthesia outside the operating room for gastrointestinal procedures have been described, albeit in small, single-center studies with wide variance in outcomes. Predictors of such outcomes are unclear. We aimed to estimate the prevalence of adverse event in children undergoing procedural sedation/anesthesia outside the operating room for esophagogastroduodenoscopy, colonoscopy, or both to identify predictors of adverse event. DESIGN/SETTING/PATIENTS: Retrospective analysis of Pediatric Sedation Research Consortium database, a large data repository of pediatric patients aged 21 years old or younger undergoing procedural sedation/anesthesia outside the operating room during September 2007 to November 2011. Twenty-two of the 40 centers provided data pertaining to the procedure of interest. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Primary outcome variable is any adverse event. Independent variables include: age (five groups), sex, American Societyof Anaesthesiologists status, procedure (esophagogastroduodenoscopy, colonoscopy, or both), provider responsible, medication used, location, and presence of coexisting medical conditions. Descriptive statistics used to summarize the data. Using multivariablelogistic regression model, odds ratio, 95% CI) were computed. A total of 12,030 procedures were performed (esophagogastroduodenoscopy, 7,970; colonoscopy, 1,378; and both, 2,682). A total of 96.9% of patients received propofol. Eighty-three percent were performed in a sedation unit. Prevalence of adverse event was 4.8%. The most common adverse event were persistent desaturations (1.5%), airway obstruction (1%), cough (0.9%), and laryngospasm (0.6%). No deaths or CPR occurred. Infants and children aged 5 years old or younger had a higher adverse event rate than older children (15.8%, 7.8% vs 4%). Regression analysis revealed age 5 years old or younger, American Society of Anaesthesiologists greater than or equal to 2, esophagogastroduodenoscopy ± colonoscopy, and coexisting medical conditions of obesity and lower airway disease were independent predictors of higher adverse event. CONCLUSIONS: Overall prevalence of any adverse event was 4.8%. Independent predictors of adverse events in procedural sedation/anesthesia outside the operating room in pediatric esophagogastroduodenoscopy/colonoscopy onoscopy were identified. Recognition of such risk factors may enable optimization of procedural sedation.

Presence of gingivitis and periodontitis significantly increases hospital charges in patients undergoing heart valve surgery.

OBJECTIVE: To examine the prevalence and impact of gingivitis and periodontitis in patients having heart valve surgical procedures. METHODS: Nationwide Inpatient Sample for the years 2004-2010 was used. All patients who had heart valve surgical procedures were selected. Prevalence of gingivitis/periodontitis was examined in these patients. Impact of gingivitis/periodontitis on hospital charges, length of stay, and infectious complications was examined. RESULTS: 596,190 patients had heart valve surgical procedures. Gingivitis/periodontitis was present in 0.2 percent. Outcomes included: median hospital charges ($175,418 with gingivitis/ periodontitis versus $149,353 without gingivitis/periodontitis) and median length of stay (14 days with gingivitis/periodontitis versus 8 days without gingivitis/periodontitis). After adjusting for the effects of patient- and hospital-level confounding factors, hospital charges and length of stay were significantly higher (p < 0.001) in those with gingivitis/periodontitis compared to their counterparts. Further, patients with gingivitis/periodontitis had significantly higher odds for having bacterial infections (OR = 3.41, 95% CI = 2.33-4.98, p < 0.0001) when compared to those without gingivitis/periodontitis. CONCLUSION: Presence of gingivitis and periodontitis is associated with higher risk for bacterial infections and significant hospital resource utilization.

Poor Oral Health Linked with Increased Risk of Infectious Complications in Adults with Leukemia.

OBJECTIVE: The objective of this study is to examine the impact of the presence of gingivitis/periodontitis on the occurrence of infectious complications (including septicemia, bacterial infections, and mycoses) in hospitalized leukemic adults in the United States. METHODS: A retrospective analysis of the Nationwide Inpatient Sample (NIS) for the years 2004-2010 was performed. All hospitalized leukemic patients aged 18 to 65 years were selected. The association between occurrence of gingivitis/periodontitis and infectious complications was examined by multivariable logistic regression models. A total of 135,692 hospitalizations were due to leukemias during the study period. Among these, gingivitis/periodontitis was present in 0.6%. Septicemia occurred in 27.8% of those who had gingivitis/periodontitis (compared to 19.6% in those without gingivitis/periodontitis), bacterial infections occurred in 19.5% of those who had gingivitis/periodontitis (compared to 10.1% in those without gingivitis/periodontitis), and mycoses occurred in 20.7% of those who had gingivitis/periodontitis (compared to 10.7% in those without gingivitis/periodontitis). Patients who had gingivitis/periodontitis were associated with significantly higher odds for septicemia (OR = 1.58, 95% CI = 1.14-2.19, p = 0.01), bacterial infections (OR = 2.15, 95% CI = 1.51-3.07, p<0.01), mycoses (OR = 2.16, 95% CI = 1.43-3.28, p<0.01), or any infectious complication (OR = 2.15, 95% CI = 1.63-2.84, p<0.01) when compared to their counterparts following adjustment for multiple patient and hospital-level confounding factors. CONCLUSIONS: Poor oral health (as defined by the presence of gingivitis/periodontitis) is an independent predictor of increased risk of infectious complications in hospitalized leukemic adults in the United States.

Fatalities above 30,000 feet: characterizing pediatric deaths on commercial airline flights worldwide.

OBJECTIVES: We conducted this study to characterize in-flight pediatric fatalities onboard commercial airline flights worldwide and identify patterns that would have been unnoticed through single case analysis of these relative rare events. DESIGN: Retrospective cohort study of pediatric in-flight medical emergencies resulting in fatalities between January 2010 and June 2013. SETTING: A ground-based medical support center providing remote medical support to commercial airlines worldwide. PATIENTS: Children (age 0-18 yr) who experienced a medical emergency resulting in death during a commercial airline flight. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were a total of 7,573 in-flight medical emergencies involving children reported to the ground-based medical support center, resulting in 10 deaths (0.13% of all pediatric in-flight emergencies). The median subject age was 3.5 months with 90% being younger than 2 years, the age until which children are allowed to travel sharing a seat with an adult passenger, also known as lap infants. Six patients had no previous medical history, with one suffering cardiorespiratory arrest after developing acute respiratory distress during flight and five found asystolic (including four lap infants). Four subjects had preflight medical conditions, including two children traveling for the purpose of accessing advanced medical care. CONCLUSIONS: Pediatric in-flight fatalities are rare, but death occurs most commonly in infants and in subjects with a preexisting medical condition. The number of fatalities involving seemingly previously healthy children under the age of 2 years (lap infants) is intriguing and could indicate a vulnerable population at increased risk of death related to in-flight environmental factors, sleeping arrangements, or yet another unrecognized factor.

Emergency department visits with facial fractures among children and adolescents: an analysis of profile and predictors of causes of injuries.

PURPOSE: The objectives of this study were to provide nationally representative estimates of hospital-based emergency department (ED) visits for facial fractures in children and adolescents, examine the burden associated with such visits, identify common types of facial fracture, and examine the role of patient-related demographic factors on the causes of facial fractures. MATERIALS AND METHODS: The Nationwide Emergency Department Sample for 2008 to 2010 was used. All ED visits with a diagnosis of facial fractures in those no older than 21 years were selected. Demographic characteristics, types of facial fracture, causes of injuries, and hospital charges were examined. RESULTS: During the study period, 336,124 ED visits were for facial fractures in those no older than 21 years. Late adolescents (18 to 21 yr old) and middle adolescents (15 to 17 yr old) comprised 45.6% and 26.6% of all ED visits, respectively. Male patients comprised 74.7% of ED visits. The most common facial fractures were those of the nasal bones and mandible. Younger children were more likely to have falls, pedal cycle accidents, pedestrian accidents, and transport accidents, whereas older groups were more likely to have firearm injuries, motor vehicle traffic accidents, and assaults (P < .05). Female patients were more likely to have falls, motor vehicle traffic accidents, and transport accidents, whereas male patients were more likely to have firearm injuries, pedal cycle accidents, and assaults (P < .05). Those residing at low annual income household levels were at a high risk for having firearm injuries, motor vehicle traffic accidents, and transport accidents (P < .05). CONCLUSIONS: Late adolescents, middle adolescents, and male patients comprise a significant proportion of these ED visits. Age, gender, and household income levels are significantly associated with the causes of facial fracture injuries.

Epidemiology of hospital-based emergency department visits due to sports injuries.

BACKGROUND: Sports-related injuries in adolescents incur a significant amount of hospital resources. Sports-related injuries are not an uncommon cause of ED visit; however, national estimates of such injuries in teenagers are unknown. OBJECTIVES: The aim of this study was to identify and characterize emergency department (ED) visits that result from sports-related injuries among teenagers across the United States. This study describes the outcomes associated with sports-related injuries necessitating ED visits among teenagers at a national level. STUDY DESIGN: This is a descriptive epidemiology study. METHODS: The 2008 Nationwide Emergency Department Sample data set, the largest all-payer health care database in the United States, was used to identify ED visits with external cause of injury related to sports occurring in patients aged 13 through 19 years. Outcomes examined included discharge status after the ED visit and presence of concomitant injuries. Descriptive statistics was used to summarize the estimates. Nationwide representative estimates were computed using the discharge weight variable. RESULTS: There were 432,609 ED visits by those between the ages of 13 and 19 years who experienced sports-related injuries, with total charges close to $447.4 million, with a mean total per-visit charge of $1205. The male patients accounted for 76.8% of the total ED visits. The most frequently occurring injuries were superficial injury or contusion (n = 118,250 ED visits); sprains and strains (n = 105,476); fracture of the upper limb (n = 63,151); open wounds of the head, the neck, and the trunk (n = 46,176); as well as intracranial injury (n = 30,726). Close to 29% of all ED visits occurred among those residing in geographical areas with median household income levels of greater than $64,000. After the ED visit, 1.6% were admitted to the same hospital, with a mean length of stay of 2.4 days and a mean hospital charge for ED visit and inpatient services of $22,703. The male patients composed 87.5% of the hospitalizations. The total of hospitalization charges across the entire United States was $154.8 million. CONCLUSIONS: Sports injuries account for a substantial number of 2008 teenage ED visits in the United States. Patient- and hospital-level characteristics were analyzed and highlighted.

Children in the United States make close to 200,000 emergency department visits due to poisoning each year.

OBJECTIVE: The aim of this study was to provide nationally representative hospital-based emergency department (ED) estimate visits in children (aged ≤ 18 y) attributed to poisoning in the United States in 2008. METHODS: Nationwide Emergency Department Sample for the year 2008 was used. All ED visits among children (aged ≤ 18 y) with an external cause of injury for "poisoning" were selected for analysis. Demographic characteristics of the ED visits and outcomes examined included ED charges (EDCs), hospitalization charges (HCs), length of stay in hospital, and disposition after ED visit. RESULTS: During the year 2008, a total of 191,197 ED visits were attributed to poisoning with close to 56% of all ED visits occurring among those aged younger than 4 years. Boys comprised approximately 54% of all ED visits. After an ED visit, 87% were routinely discharged, and 7.3% were admitted into the same hospital. Forty-eight children died in the ED. The frequently reported poisonings included accidental poisoning by other drugs (44,219 ED visits); accidental poisoning by other gases and vapors (27,035 ED visits); and accidental poisoning by analgesics, antipyretics, and antirheumatics (22,334 ED visits). The mean EDC per visit was $1077. The total EDC across the entire United States was $171.8 million. Mean length of stay was 1.9 days. Among those who were hospitalized, the mean HC was $11,792. The total HC across the entire United States was $162.3 million. CONCLUSIONS: The current study provides nationally representative estimates of ED visits attributed to poisoning among children in the United States. High-risk groups and economics associated with treating these injuries are estimated.

Overview of registered studies in orthodontics: Evaluation of the ClinicalTrials.gov registry.

INTRODUCTION: The Food and Drug Administration Modernization Act of 1997 made it mandatory for all phase II through IV trials regulated by this Act to be registered. After this, the National Institutes of Health created ClinicalTrials.gov, which is a registry of publicly and privately supported clinical studies of human participants. The objective of this study was to examine the characteristics of registered studies in orthodontics. METHODS: The ClinicalTrials.gov Web site was used to query all registered orthodontic studies. The search term used was "orthodontics." No limitations were placed for the time period. All registered studies regardless of their recruitment status, study results, and study type were selected for analysis. RESULTS: A total of 64 orthodontic studies were registered as of January 1, 2014. Of these, 52 were interventional, and 12 were observational. Close to 60% of the interventional studies and 66.7% of the observational studies had sample sizes of 50 or fewer subjects. About 21.2% of the interventional studies and 16.7% of the observational studies had sample sizes greater than 100. Only 1 study was funded by the National Institutes of Health, and the rest were funded by "other" or "industry" sources. Close to 87.7% of the interventional studies were randomized. Interventional model assignments included factorial assignment (3.9%), parallel assignments (74.5%), crossover assignment (7.8%), and single-group assignment (13.7%). Most studies were treatment oriented (80.4%). The types of masking used by the interventional studies included open label (28.9%), single blind (44.2%), and double blind (26.9%). Outcome assessors were blinded in only 6 studies. CONCLUSIONS: Orthodontic studies registered in ClinicalTrials.gov are dominated by small single-center studies. There are wide variations with regard to treatment allocation approaches and randomization methods in the studies. These results also indicate the need for multicenter clinical studies in orthodontics.

Textbook Outcome for Superior Cavopulmonary Connection: A Metric for Single Ventricle Heart Surgery.

Background: To develop a more holistic measure of congenital heart center performance beyond mortality, we created a composite "textbook outcome" (TO) for the Glenn operation. We hypothesized that meeting TO would have a positive prognostic and financial impact. Methods: This was a single center retrospective study of patients undergoing superior cavopulmonary connection (bidirectional Glenn or Kawashima ± concomitant procedures) from 2005 to 2021. Textbook outcome was defined as freedom from operative mortality, reintervention, 30-day readmission, extracorporeal membrane oxygenation, major thrombotic complication, length of stay (LOS) >75th percentile (17d), and mechanical ventilation duration >75th percentile (2d). Multivariable logistic regression and Cox proportional hazards modeling were used. Results: Fifty-one percent (137/269) of patients met TO. Common reasons for TO failure were prolonged LOS (78/132, 59%) and ventilator duration (67/132, 51%). In multivariable analysis, higher weight [odds ratio, OR: 1.44 (95% confidence interval, CI: 1.15-1.84), P = .002] was a positive predictor of TO achievement while right ventricular dominance [OR 0.47 (0.27-0.81), P = .007] and higher preoperative pulmonary vascular resistance [OR 0.58 (0.40-0.82), P = .003] were negative predictors. After controlling for preoperative factors and excluding operative mortalities, TO achievement was independently associated with a decreased risk of death over long-term follow-up [hazard ratio: 0.50 (0.25-0.99), P = .049]. Textbook outcome achievement was also associated with lower direct cost of care [$137,626 (59,333-167,523) vs $262,299 (114,200-358,844), P < .0001]. Conclusion: Achievement of the Glenn TO is associated with long-term survival and lower costs and can be predicted by certain risk factors. As outcomes continue to improve within congenital heart surgery, operative mortality will become a less informative metric. Textbook outcome analysis may represent a more balanced measure of a successful outcome.

Staged repair of borderline hypoplastic heart disease with early biventricular conversion.

Objective: In select patients with borderline ventricular hypoplasia, we adopted a strategy of initial single-ventricle palliation followed by staged or direct biventricular conversion by 2 years of age. Methods: Between 2018 and 2023, 14 newborns with borderline hypoplastic heart disease deemed high risk for primary biventricular repair underwent palliative procedures as a neonate/infant, followed by staged or direct biventricular conversion. Results: Of the 14 patients, 6 had borderline left ventricles and 8 had borderline right ventricles. Index neonatal operations were performed in 12 patients and included the Norwood operation (n = 5), pulmonary artery band (n = 3), ductal stent (n = 3), and hybrid Norwood (n = 1). Five patients underwent direct biventricular conversion, and the remaining 9 patients underwent staged ventricular recruitment operations at a mean age of 6 months (range, 3-11 months). Ventricular recruitment operations included atrial septation with or without ventricular rehabilitation, atrioventricular valve repair, or outflow tract operations. At a mean duration of 8 months (range, 4-10 months) after ventricular recruitment, there was a significant increase in chamber volume, aortic valve, and mitral valve size in patients with borderline left ventricles, and a normalization of the right ventricle:left ventricle end-diastolic volume ratio in patients with borderline right ventricles. To date, 13 of 14 patients have undergone successful biventricular conversion at a mean age of 16 months (range, 4-31 months). Conclusions: In select newborns with borderline hypoplastic heart disease, single-ventricle palliation followed by staged or direct biventricular conversion may increase infant survival while allowing for early attainment of a biventricular circulation.

Factors Associated With Successful Extubation Readiness Testing in Children With Congenital Heart Disease.

BACKGROUND: In children with congenital heart disease, extubation readiness testing (ERT) is performed to evaluate the potential for liberation from mechanical ventilation. There is a paucity of data that suggests what mechanical ventilation parameters are associated with successful ERT. We hypothesized that ERT success would be associated with certain mechanical ventilator parameters. METHODS: Data on daily ERT assessments were recorded as part of a quality improvement project. In accordance with our respiratory therapist-driven ventilator protocol, patients were assessed daily for ERT eligibility and tested daily, if eligible. Mechanical ventilation parameters were categorized a priori to evaluate the differences in levels of respiratory support. The primary outcome was ERT success. RESULTS: A total of 780 ERTs from 320 subjects (median [interquartile range] age 2.5 [0.6-6.5] months and median weight [interquartile range] 4.2 [3.3-6.9] kg) were evaluated. A total of 528 ERTs (68%) were passed, 306 successful ERTs (58%) resulted in extubation, and 30 subjects (9.4%) were re-intubated. There were statistically significant differences in the ERT pass rate for ventilator mode, peak inspiratory pressure, Δ pressure, PEEP, mean airway pressure ([Formula: see text]), and dead-space-to-tidal-volume ratio (all P < .001) but not for [Formula: see text]. ERT success decreased with increases in peak inspiratory pressure, Δ pressure, PEEP, [Formula: see text], and dead-space-to-tidal-volume ratio. Logistic regression revealed neonates, Δ pressure ≥ 11 cm H2O, and [Formula: see text] > 10 cm H2O were associated with a decreased odds of ERT success, whereas children ages 1-5 years and an [Formula: see text] of 0.31-0.40 had increased odds of ERT success. CONCLUSIONS: ERT pass rates decreased as ventilator support increased; however, some subjects were able to pass ERT despite high ventilator support. We found that [Formula: see text] was associated with ERT success and that protocols should consider using [Formula: see text] instead of PEEP thresholds for ERT eligibility. Cyanotic lesions were not associated with ERT success, which suggests that patients with cyanotic heart disease can be included in ERT protocols.

Association Between Pressure Support During Extubation Readiness Testing and Time to First Extubation in Children With Congenital Heart Disease.

BACKGROUND: Extubation readiness testing (ERT) is often performed in children with congenital heart disease prior to liberation from mechanical ventilation. The ideal ERT method in this population is unknown. We recently changed our ERT method from variable (10, 8, or 6 cm H2O, depending on endotracheal tube size) to fixed (5 cm H2O) pressure support (PS). Our study assessed the association between this change and time to first extubation and need for re-intubation. METHODS: We studied 2 temporally distinct cohorts, one where ERT was conducted with variable PS and another using PS fixed at 5 cm H2O. Data were prospectively collected as part of a quality improvement project. The primary outcome was time to first extubation. Secondary outcomes were need for re-intubation and percentage of successful ERTs. We performed Poisson regression or logistic regression for the association between PS during ERT and time to first extubation or re-intubation, respectively. RESULTS: We included 320 subjects, 186 in the variable PS group and 152 in fixed PS group. In unadjusted analysis, median time to first extubation was longer in the fixed PS group compared to the variable PS group (4.1 [2.0-7.1] d vs 3.1 [1.1-5.9] d, P = .02), and there was no difference in re-intubation rate (11% vs 8%, P = .34). Subjects in the fixed PS group were significantly more likely to be mechanically ventilated after cardiac arrest, have a Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) category of 4 or 5, be extubated on day shift, receive enteral feeds at extubation, have higher respiratory support at extubation, and higher dead-space-to-tidal-volume ratio. After controlling for these variables in multivariable regression, we found no association between the choice of PS and time to first extubation or re-intubation. CONCLUSIONS: The use of a fixed PS of 5 cm H2O instead of variable PS during ERT was not associated with longer time to first extubation or extubation failure.