Parental Knowledge of Appropriate Placement of Child Restraint Systems Before and After Educational Intervention in a Pediatric Emergency Department.

OBJECTIVE: This study aimed to determine caregiver's knowledge of appropriate car restraint systems (CRSs) use and compare this with the actual use among children presenting to the pediatric emergency department (PED), and to determine the efficacy of PED-based intervention on improving knowledge. METHODS: We conducted a prospective, intervention study of children (<8 years old) during a 12-month period in the PED. Based on their height and weight, children were assigned to group 1 (rear facing), group 2 (forward facing), or group 3 (booster). Caregivers were surveyed in their baseline CRS knowledge. Certified child passenger safety technicians evaluated each CRS and gave caregivers one-on-one education. Participants were called back to answer a posttest to determine if the information given was retained. RESULTS: Of the 170 children enrolled, 64 (37.6%) were assigned to group 1, 68 (40%) to group 2, and 38 (22.3%) to group 3. Of these, 63% were not aware of the state law regarding CRS use. Among those without a CRS, 18% belonged to group 1, 36% to group 2, and 46% to group 3. Even among those who reportedly had CRS, 13% of children did not have one-on-on inspection. After inspection, 84% of group 1, 71% of group 2, and 70% of group 3 were in the appropriate one. Nearly 45% were not compliant with American Academy of Pediatrics guidelines of children riding in rear-facing CRS until 2 years of age. CONCLUSIONS: A significant proportion of children visiting the PED are not in appropriate CRS, and caretaker knowledge about correct CRS types and installation is poor. Future educational efforts should focus on rear-facing and booster seat age-group children.

What you need to know about statistics, part II: reliability of diagnostic and screening tests.

The foundation for the usefulness of any diagnostic test should be that it is both reliable and accurate in its clinical diagnosis. In this article we present the second of a two-part series on validity and reliability, discussing the assessment of reliability among raters of diagnostic tests and between diagnostics tests themselves. To examine reproducibility (reliability) among raters of diagnostic tests we present the calculation of two statistical procedures: (1) the kappa coefficient statistic when presented with categorical data for the presence or absence of a clinical diagnosis and (2) the intraclass correlation coefficient (ICC) for continuously scaled data among raters. The accuracy among diagnostic tests (i.e. their interchangeability) can be evaluated by application of (1) a Bland-Altman plot procedure (with its 95% limits of agreement) and (2) the Passing-Bablok regression procedure (for the identification and evaluation of systematic and proportional differences). When deciding whether to select a diagnostic test one must evaluate its ability to provide more precise information than a gold standard test, and whether in clinical practice it would be more beneficial for patients to adopt it.

What you need to know about statistics Part I: validity of diagnostic and screening tests.

The intent of this manuscript is to provide guidance and support to clinicians and investigators for reporting the results of screening and diagnostic tests. This article is the first of two parts addressing statistics in imaging research. In this part validity measures are discussed. In part II reliability measures will be discussed. In discussing validity, the following concepts will be introduced: (1) functions of diagnostic tests, (2) statistical characteristics of diagnostic tests and application of validity measures, (3) power and sample size for testing the sensitivity and specificity of the diagnostic test, (4) statistical versus clinical significance and (5) characteristics of a useful diagnostic test.

A comprehensive study of clinical biomarkers, use of inotropic medications and fluid resuscitation in newborns with persistent pulmonary hypertension.

Persistent pulmonary hypertension of the newborn (PPHN) is associated with high morbidity and mortality. This study evaluated clinical outcomes in PPHN in relation to echocardiographic (EC) markers, score of neonatal acute physiology, perinatal extension, version II (SNAPPE II) scores, inotropic agent use, and the amount of fluid received as boluses. In this retrospective chart analysis of 98 neonates with PPHN born at >34 weeks' gestation, we compared two cohorts of newborns: those who received inhaled nitric oxide and mechanical ventilation only, and who survived to discharge (Group 1); and those who required extracorporeal membrane oxygenation (ECMO) or who died (Group 2). Of 21 EC parameters assessed, seven were significantly different between Group 1 and Group 2. Eleven (24.4%) newborns in Group 2 had decreased left ventricular (LV) function, compared with three (5.1%) in Group 1 (p = 0.011). Median SNAPPE II scores were significantly higher in Group 2 than in Group 1 (p < 0.001). Newborns in Group 2 also received a significantly higher amount of fluid as boluses during the first 7 days of hospitalization compared with Group 1 (p = 0.018). Following logistic regression analysis, only the difference in total SNAPPE II score retained statistical significance (p < 0.001); however, the total amount of fluid administered as boluses trended higher (p = 0.087) for newborns in Group 2. Our findings show that SNAPPE II scores may help guide counseling for parents of newborns with PPHN regarding the likelihood of death or the need for ECMO. Limiting fluid boluses may improve outcomes in newborns with high SNAPPE II scores and decreased LV function.

Severe Intraventricular Hemorrhage in Extremely Premature Infants: Are high Carbon Dioxide Pressure or Fluctuations the Culprit?

OBJECTIVE: This study aims to examine the association between measures of hypercapnia and fluctuation in Pco 2 and severe intraventricular hemorrhage (IVH) and to evaluate the prevalence of hypercapnia, hypocapnia, and fluctuations in Pco 2 in the initial 72 hours of life among premature infants. STUDY DESIGN: Retrospective study of premature infants with birth weight < 1,250 g, who were receiving some respiratory support. All blood gases obtained in the first 3 days of life were collected. Univariate and multivariate analyses were performed to assess the association of hypercapnia, and fluctuations in Pco 2 with severe IVH. RESULT: Our cohort included 285 patients, of whom 84% were intubated. Only 20% patients had all blood gases in the normocapnia range; 9% had at least 1 gas with hypercapnia; 51% had at least 1 gas with hypocapnia, and 20% patients had both hypercapnia and hypocapnia at different times. Infants with severe IVH (n = 41) had significantly higher peak Pco 2 and greater fluctuations in Pco 2 within a short interval, compared with those without severe IVH (n = 227). After controlling for gestational age, gender, antenatal steroid exposure, presence of hypercapnia, and Apgar score at 5 minutes, fluctuation in Pco 2 remained significantly associated with severe IVH. CONCLUSION: Fluctuations in Pco 2 within a short period may be more significantly associated with severe IVH than the mere presence of hypercapnia.

Safety, Awareness, and Familiarity regarding Epilepsy in Teenage Years (SAFETY): understanding the adolescents' perspective about their disease.

OBJECTIVE: The objective of this study was to evaluate the understanding of adolescent patients regarding epilepsy. METHODS: The SAFETY (Safety, Awareness, and Familiarity regarding Epilepsy in Teenage Years) questionnaire (content validity index: 0.96, Flesch readability score: 66.6) was administered to 165 cognitively normal adolescents with epilepsy (85 females, mean age: 15.2 ± 1.6 years, range: 13-18 years). The first part of the questionnaire was devised to evaluate knowledge about epilepsy and antiepileptic medications (SAFETY-K: 7 questions). The second part queried lifestyle modifications and safety (SAFETY-S: 10 questions). Female participants answered 5 additional questions related to reproductive health (RH questionnaire). RESULTS: The correct response rate for the composite SAFETY questionnaire was 51.5%. The average rates of correct responses for the SAFETY-K and SAFETY-S questions were 47.9% and 53.9%, respectively. On univariate logistic regression analysis, factors which were significant predictors of correct responses included age (odds ratio: 1.8, C.I. = 1.3-2.4), race (Caucasian vs. African-American; odds ratio: 3.9, C.I. = 1.4-10.4), and employment of at least one parent in a professional occupation (odds ratio: 3.3, C.I. = 1.1-10.3). The correct response rate did not correlate with the duration of epilepsy, extent of seizure control, number of antiepileptic medications, parental educational, or (un)employment status. The mean rate of correct responses for the RH questions amongst teenage girls was 17.4%. CONCLUSIONS: There is lack of awareness about epilepsy and its associated lifestyle modifications in adolescents with epilepsy seen at our institution. This is especially true in young adolescents, African-American patients, and those whose parents are not employed in professional occupations. Teenage girls with epilepsy appear to have limited knowledge with respect to contraception and childbearing.

Impact of interhospital transport on the physiologic status of very low-birth-weight infants.

OBJECTIVES: To evaluate the change in physiologic stability of very low-birth-weight (VLBW) infants following transport using TRIPS (transport risk index of physiologic stability) score as a measure of physiologic stability and compare changes in TRIPS score in groups of VLBW infants who underwent shorter versus longer transport. STUDY DESIGN: Retrospective chart review. RESULTS: Our cohort of 106 infants, 44 (41%) of whom were females, had a mean birth weight of 777 g (standard deviation [SD] 159) and median gestational age of 26 weeks (range 23 to 32 weeks). Mean weight at transfer was 1,610 g (SD 924) and mean postnatal age at transfer was 56 days (SD 45). Median time on transport was 15 minutes (range 10 to 85 minutes). All 106 transports were ground transports. Of the 106 infants, 57 (54%) had deterioration, 20 (19%) had improvement, and 29 (27%) had no change in their physiologic status during transport. Comparison of the two transport duration groups based on median transport time as a cutoff point (i.e., ≤ 15 minutes and > 15 minutes) revealed a higher proportion of infants with deterioration in their physiologic status in the prolonged transport (>15 minutes) group (65% versus 45%; p = 0.03). Temperature change, either alone or in combination with other indices, was responsible for change in TRIPS score (deterioration or improvement) in 79% of these infants. CONCLUSIONS: Interhospital transport of VLBW infants may cause deterioration in their physiologic status, the likelihood of which is increased with longer duration of transport. Better temperature regulation during interhospital transport may decrease the chances of deterioration in physiologic status of VLBW infants.

Listeria and enterococcal infections in neonates 28 days of age and younger: is empiric parenteral ampicillin still indicated?

INTRODUCTION: Empiric parenteral ampicillin has traditionally been used to treat listeria and enterococcal serious bacterial infections (SBI) in neonates 28 days of age or younger. Anecdotal experience suggests that these infections are rare. Existing data suggest an increasing resistance to ampicillin. Guidelines advocating the routine use of empiric ampicillin may need to be revisited. OBJECTIVE: This study aimed to describe the epidemiology and ampicillin sensitivity of listeria and enterococcal infections in neonates 28 days of age and younger who presented to 2 pediatric emergency departments (ED) in Michigan. METHODS: We conducted a 2-center, retrospective chart review (2006-2010) of neonates 28 days of age or younger who were evaluated for SBI in the ED. We abstracted and compared relevant demographic, historical and physical details, laboratory test results, and antibiotic sensitivity patterns to ampicillin from the eligible patient records. RESULTS: We identified SBI in 6% (72/1192) of neonates 28 days of age or younger who were evaluated for SBI, of which 0.08% (1/1192) neonates had enterococcal bacteremia and 0.08% (1/1192) neonates had listeria bacteremia. A total of 1.4% (15/1192) of patients had enterococcal urinary tract infection (UTI). Urinalysis is less helpful as a screening tool for enterococcal UTI when compared with Escherichia coli UTI (P < 0.001). Seventy-three percent (11/15) of urine isolates had an increase of minimal inhibitory concentrations, which indicate gradual development of resistance to ampicillin. CONCLUSIONS: Listeria is an uncommon cause of neonatal SBI in febrile neonates who presented to the ED. Empiric use of ampicillin may need to be reconsidered if national data confirm very low listeria and enterococcal prevalence and high ampicillin resistance patterns.

Impact of Erenumab on Migraine Disability: A Three-Month MIDAS (Migraine Disability Assessment Scale) Score Analysis at Dubai Health Facilities.

BACKGROUND AND AIM: Migraine is a prevalent neurological disorder causing recurrent headaches that significantly impact daily life. Erenumab, a calcitonin gene-related peptide (CGRP) receptor antagonist, has emerged as a promising treatment for migraine. CGRP is thought to play a role in migraine pathophysiology, and erenumab works by blocking CGRP binding to its receptors. Erenumab has been found to be effective in reducing migraine frequency, with potential benefits for improving patient outcomes. This study investigated the impact of erenumab on migraine disability in patients treated at Dubai Health facilities. We specifically assessed changes in Migraine Disability Assessment Scale (MIDAS) scores before and after a three-month treatment period. METHODS: This retrospective analysis examined data from 26 patients diagnosed with migraine according to the established criteria. All patients received erenumab treatment for three months. MIDAS, a validated tool, was used to quantify migraine-related disability at baseline and after treatment completion. Due to potential skewness in the data distribution, the statistical analysis focused on the median change in MIDAS scores across groups based on gender and erenumab dosage. Non-parametric tests were employed to assess group differences. RESULTS: Erenumab treatment resulted in a median decrease of 13 points in MIDAS scores, suggesting a potential improvement in migraine disability at three months. Statistical analysis revealed no statistically significant group differences regarding MIDAS score changes between genders or erenumab dosage groups. However, trends toward improvement were observed in all subgroups. CONCLUSION: While not statistically significant due to the limited sample size and the absence of a control group, these findings suggest a potential benefit of erenumab in reducing migraine disability. Future research with more extensive, controlled trials is warranted to definitively assess erenumab's effectiveness and explore potential treatment regimen variations for optimal patient outcomes.

Institutional experience on the impact of glucagon-like peptide-1 agonists (GLP-1) on glycemic control and weight loss in patients with type 2 diabetes at the Dubai Diabetes Center, United Arab Emirates.

AIMS: To describe the effect of three classes of GLP1 analogues on HbA1c and weight over one year in a homogenous group of patients at the Dubai Diabetes Center in Dubai, United Arab Emirates. The specific objectives are to study the extent of change in HbA1c and weight loss on these medications as well as the sustainability of change over one year. METHODS: A retrospective audit of patients diagnosed Type 2 diabetes receiving one of the three following GLP-1 agonists (Exenatide LA 2 mg weekly, liraglutide 1.8 mg once daily, Dulaglutide 1.5 mg) over one year and documenting changes in HbA1c and weight at 3-, 6-, 9-, and 12-months intervals. RESULTS: The study shows that while there was significant reduction in HbA1c and weight in the first 3 months, this change was not clinically significant. Also, the change was not maintained at the end of the year. By the final quarter, the effect of the medication diminishes, accompanied by a partial regain of weight. CONCLUSION: GLP1 agonists favorable initial effect on HbA1c and weight may not be sustainable beyond a certain period. The exact reason and factors contributing to this need further exploration.

Knowledge, attitude and practices of insulin therapy among patients with type 2 diabetes: a cross-sectional study.

OBJECTIVES: This study aimed to assess the knowledge, attitude and practices of patients with type 2 diabetes on insulin regarding insulin therapy. DESIGN: A cross-sectional study. SETTING: This study was conducted at the Dubai Diabetes Center from 1 December 2018 to 1 March 2020. PARTICIPANTS: Face-to-face interviews were conducted for 350 participants with type 2 diabetes at the Dubai Diabetes Center. Interviews followed the structured format of a questionnaire designed to obtain demographic details and score participants on knowledge, attitude and practices. We included patients aged >18 years and receiving insulin therapy. Patients with type 1 diabetes, pregnant women with gestational diabetes, those aged <18 years or those with a history of dementia were excluded. RESULTS: The median age of participants was 61 years (first quartile, 53 years; third quartile, 67 years); 35.7% were male individuals and 64.3% were female individuals. The median percentage scores for knowledge, attitude and practices were 62.5% (62.5%, 75%), 85.7% (71.4%, 100%) and 77.7% (66.6%, 88.8%), respectively. Highly educated participants had a high level of knowledge. Significant negative correlations were found between the percentage knowledge scores and participants' age and between the participants' percentage attitude scores and haemoglobin A1C levels; Spearman's correlations were -0.182 (p<0.001) and -0.14 (p=0.008), respectively. A significant positive Spearman's correlation of 0.123 (p=0.021) was found between the percentage knowledge and percentage practice scores. No correlations were found among knowledge levels, participants' haemoglobin A1c levels and duration of insulin use. CONCLUSION: Patients with type 2 diabetes receiving insulin therapy and attending the Dubai Diabetes Center had adequate knowledge, a positive attitude and correct practice regarding insulin therapy. However, knowledge of specific facts did not always translate into correct behaviours and practices.

Reproductive and fetal toxicity studies of histamine H3 receptor antagonist DL76 used in mice to prevent maximal electroshock-induced seizure.

Introduction: Brain histamine is considered an endogenous anticonvulsant and histamine H1 receptor. H1R antagonists have, in earlier studies, been found to induce convulsions. Moreover, research during the last two decades has provided more information concerning the anticonvulsant activities of histamine H3R (H3R) antagonists investigated in a variety of animal epilepsy models. Methods: Therefore, the in vivo anticonvulsant effect of the H3R antagonist DL76, with proven high in vitro affinity, in vitro selectivity profile, and high in vivo antagonist potency in mice against maximal electroshock (MES)-induced seizures in mice, was assessed. Valproic acid (VPA) was used as a reference antiepileptic drug (AED). In addition, DL76 was tested for its reproductive and fetal toxicity in the same animal species. Results and discussion: Our observations showed that acute systemic administration (intraperitoneal; i.p.) of DL76 (7.5 mg/kg, 15 mg/kg, 30 mg/kg, and 60 mg/kg, i.p.) provided significant and dose-dependent protection against MES-induced seizures in female and male mice. Moreover, the DL76-provided protective effects were comparable to those offered by the VPA and were reversed when animals were co-administered the CNS-penetrant selective H3R agonist R-(α)-methylhistamine (RAM, 10 mg/kg, i.p.). Furthermore, the administration of single (7.5 mg/kg, 15 mg/kg, 30 mg/kg, or 60 mg/kg, i.p.) or multiple doses (3 × 15 mg/kg, i.p.) of H3R antagonist DL76 on gestation days (GD) 8 or 13 failed to affect the maternal body weight of mice when compared with the control mice group. No significant alterations were detected in the average number of implantations and resorptions between the control and DL76-treated groups at the early stages of gestation and the organogenesis period. In addition, no significant differences in the occurrence of skeletal abnormalities, urogenital abnormalities, exencephaly, exomphalos, facial clefts, and caudal malformations were observed. The only significant abnormalities witnessed in the treated groups of mice were in the length of long bones and body length. In conclusion, the novel H3R antagonist DL76 protected test animals against MES-induced seizures and had a low incidence of reproductive and fetal malformation with decreased long bone lengths in vivo, signifying the potential therapeutic value of H3R antagonist DL76 for future preclinical as well as clinical development for use in the management of epilepsy.

Hyponatremia during arginine vasopressin therapy in children following cardiac surgery.

OBJECTIVE: To describe the incidence and severity of hyponatremia after initiation of arginine vasopressin therapy in children recovering from cardiothoracic surgery, and to compare these patients with a control group with similar disease complexity and severity who did not receive arginine vasopressin. DESIGN: Retrospective chart review. SETTING: PICU at a tertiary care university hospital. PATIENTS: Twenty-nine patients who received arginine vasopressin for at least 6 hours during the first 48 postoperative hours following cardiothoracic surgery were compared with 47 patients who did not receive arginine vasopressin. After surgery, all patients received intravenous fluids consisting of dextrose and 0.22% saline for daily fluid requirements as well as isotonic colloid and blood products as needed for additional resuscitation. RESULTS: Mean initial postoperative serum sodium did not differ between groups, 144.6 ± 3.4 in those patients who received arginine vasopressin and 144.5 ± 3.7 in those who did not, p = 0.969. Mean lowest sodium in the first 72 hours, however, was 134.7 ± 3.8 in those who received arginine vasopressin as compared with 137.1 ± 4.3 in the control group, p = 0.019. Hyponatremia occurred in 14 of the patients (48%) who received arginine vasopressin but only in 8 of the patients (17%) in the control group, p = 0.004. Mean age, weight, sex, Aristotle score, and duration of cardiopulmonary bypass were not statistically different between groups. Mean volumes of hypotonic fluids administered and cumulative diuretic dosing during the first 72 hours post-surgery were also not statistically different between groups. CONCLUSIONS: Hyponatremia occurred in nearly half of the infants and children receiving arginine vasopressin therapy in this study. Clinicians should be aware of this association, monitor serum sodium values closely, and consider providing less free water to these patients before hyponatremia occurs.

Risk and predictors of severity and mortality in patients with type 2 diabetes and COVID-19 in Dubai.

BACKGROUND: Globally, patients with diabetes suffer from increased disease severity and mortality due to coronavirus disease 2019 (COVID-19). Old age, high body mass index (BMI), comorbidities, and complications of diabetes are recognized as major risk factors for infection severity and mortality. AIM: To investigate the risk and predictors of higher severity and mortality among in-hospital patients with COVID-19 and type 2 diabetes (T2D) during the first wave of the pandemic in Dubai (March-September 2020). METHODS: In this cross-sectional nested case-control study, a total of 1083 patients with COVID-19 were recruited. This study included 890 men and 193 women. Of these, 427 had T2D and 656 were non-diabetic. The clinical, radiographic, and laboratory data of the patients with and without T2D were compared. Independent predictors of mortality in COVID-19 non-survivors were identified in patients with and without T2D. RESULTS: T2D patients with COVID-19 were older and had higher BMI than those without T2D. They had higher rates of comorbidities such as hypertension, ischemic heart disease, heart failure, and more life-threatening complications. All laboratory parameters of disease severity were significantly higher than in those without T2D. Therefore, these patients had a longer hospital stay and a significantly higher mortality rate. They died from COVID-19 at a rate three times higher than patients without. Most laboratory and radiographic severity indices in non-survivors were high in patients with and without T2D. In the univariate analysis of the predictors of mortality among all COVID-19 non-survivors, significant associations were identified with old age, increased white blood cell count, lym-phopenia, and elevated serum troponin levels. In multivariate analysis, only lymphopenia was identified as an independent predictor of mortality among T2D non-survivors. CONCLUSION: Patients with COVID-19 and T2D were older with higher BMI, more comorbidities, higher disease severity indices, more severe proinflammatory state with cardiac involvement, and died from COVID-19 at three times the rate of patients without T2D. The identified mortality predictors will help healthcare workers prioritize the management of patients with COVID-19.

Nasopharyngeal airway pressures in bronchiolitis patients treated with high-flow nasal cannula oxygen therapy.

BACKGROUND: Heated, humidified, high-flow nasal cannula oxygen therapy (HHHFNC) has been used to improve ventilation in preterm infants. There are no data on airway pressures generated and efficacy in bronchiolitis. OBJECTIVE: The objective of this study was to determine nasopharyngeal (NP) pressures generated with HHHFNC therapy in bronchiolitis. METHODS: We conducted a prospective, observational study to measure NP pressures at varying flow rates of HHHFNC therapy in moderate to severe bronchiolitis. Vital signs, bronchiolitis severity scores, and oxygen saturation were also noted. RESULTS: Twenty-five patients were enrolled (mean, 78.1 [SD, 30.9] days; weight, 5.3 [SD, 1.1] kg). Nasopharyngeal pressures increased linearly with flow rates up to 6 L/min. Beyond 6 L/min, pressure increase was linear but less accelerated. On average, NP pressure increased by 0.45 cm H2O for each 1-L/min increase in flow rate. There were significant differences between pressures in open- and closed-mouth states for flow rates up to 6 L/min. At 6 L/min, the pressure in open-mouth state was 2.47 cm H2O and that in closed-mouth state was 2.74 cm H2O (P < 0.001). Linear regression analysis revealed that only flow (not weight or gender) had an effect on generated pressure. Bronchiolitis severity scores improved significantly with HHHFNC therapy (pre: 14.5 [SD, 1.4], post: 10.4 [SD, 1.2]; P < 0.001). CONCLUSIONS: Increasing flow rates of HHHFNC therapy are associated with linear increases in NP pressures in bronchiolitis patients. Larger studies are needed to assess the clinical efficacy of HHHFNC therapy in bronchiolitis.

Impact of COVID-19 Lockdown on Glycemic Control in Patients with Type 2 Diabetes Mellitus in Dubai.

OBJECTIVE: The objective of this study is to evaluate the impact of the COVID-19 lockdown on glycemic control and accompanying laboratory parameters in patients with type 2 Diabetes Mellitus. METHODS: This study is a retrospective cohort study that was done on a multicenter level. It was conducted during the lockdown in 341 individuals. HbA1c was tested to measure glycemic control immediately before and after the lockdown period that lasted for 13 weeks. RESULTS: The primary outcome was the improvement of mean HbA1C after 13 weeks of lockdown compared to the pre-lockdown HbA1C. It was found that the mean HbA1C improved from 7.5±1.5 to 7.3±1.5 with a p-value of 0.001. CONCLUSION: Our study showed that patients with type 2 diabetes mellitus exhibited an improvement in their glycemic control after the period of lockdown.

Impact of vitamin D treatment on 25 hydroxy vitamin D levels and insulin homeostasis in obese African American adolescents in a randomized trial.

BACKGROUND: Obesity is affecting children in epidemic proportions in the United States with nearly 25% of children being obese. Consequences of obesity including dyslipidemia, type 2 diabetes and cardiovascular disease are leading to morbidity at younger ages. Parallel to the obesity and diabetes epidemics, the prevalence of vitamin D deficiency has reached very high levels and has been associated with insulin resistance and dyslipidemia. Studies exploring the impact of vitamin D repletion on insulin sensitivity and dyslipidemia in children are sparse.The aim of this study was to determine the impact of treatment with vitamin D (ergocalciferol) in obese African American (AA) children on vitamin D levels and insulin secretion and sensitivity. METHODS: This pilot study was conducted in a tertiary care Pediatric Emergency Department (ED). African American obese children (n = 29; 22 female) 13-17 y, with 25-hydroxy vitamin D level [25(OH)D] <20 ng/ml, were randomized to receive either 50,000 IU vitamin D2/week or a placebo for 12 weeks. Pre- and post- oral glucose tolerance testing with glucose and insulin levels drawn at 0, 30, 60, 90 and 120 min were performed. Pre/post intervention lipid profiles and calcium levels were also evaluated. RESULTS: There was no difference in serum 25(OH)D between groups at baseline. Follow-up 25(OH)D level was greater in the treatment vs. placebo group, and significantly increased from baseline in the treatment group only. However, there was no difference between groups in baseline vs. follow-up insulin- or lipid-related parameters. Follow-up serum 25(OH)D was positively correlated with fasting insulin and high-density lipoprotein (HDL) level in the vitamin D treated group only. CONCLUSION: While serum 25(OH)D levels in obese AA teens increased adequately with vitamin treatment for 12 weeks and correlated with fasting insulin, it did not significantly impact insulin secretion or sensitivity. Larger studies are required over a longer period of time to confirm and explore the reasons for this finding.

Development and Validation of a Pediatric Endocrine Knowledge Assessment Questionnaire: Impact of ac Pediatric Endocrine Knowledge Assessment Questionnaire Intervention Study.

OBJECTIVE: While there is general agreement that patient education is essential for compliance, no objective tools exist to assess knowledge in children and parents of children with endocrine disorders. We aimed to design and validate a Pediatric Endocrine Knowledge Assessment Questionnaire (PEKAQ) for congenital hypothyroidism, Hashimoto's thyroiditis, isolated growth hormone deficiency, Graves' disease, and congenital adrenal hyperplasia. We evaluated baseline knowledge of children and parents of children with these disorders and assessed impact of educational intervention. METHODS: At baseline, 77 children (12-18 years) and 162 parents of children 1-18 years participated in this prospective intervention study. Educational handouts for five targeted disorders were designed. Following one-on-one educational intervention, 55 children and 123 parents participated. Baseline and post-intervention knowledge scores were compared using McNemar's test. RESULTS: Adequate multi-rater Kappa measure of agreement was achieved for children's (0.70) and parent's (0.75) PEKAQs. Flesch Reading Ease Score for both PEKAQs (15 questions each) was 65. Post-intervention, significantly higher proportion of parents and children answered majority of questions correctly (p<0.05). Sixteen percent more parents and 22% more children knew their diagnosis correctly (p<0.05). Significant improvement was noted among all participants regarding reason for treatment, steps to take in a situation of missed dose, exercise and diet with these disorders, and long-term prognosis. Parent's knowledge score was an independent predictor of child's score. CONCLUSIONS: To our knowledge, this is the first validated PEKAQ that can be used widely in pediatric endocrinology clinics. We noted significant improvement in knowledge of children and parents of children with endocrine disorders.

Prescription errors before and after introduction of electronic medication alert system in a pediatric emergency department.

OBJECTIVES: Prescription errors occur frequently in pediatric emergency departments (PEDs).The effect of computerized physician order entry (CPOE) with electronic medication alert system (EMAS) on these is unknown. The objective was to compare prescription errors rates before and after introduction of CPOE with EMAS in a PED. The hypothesis was that CPOE with EMAS would significantly reduce the rate and severity of prescription errors in the PED. METHODS: A prospective comparison of a sample of outpatient, medication prescriptions 5 months before and after CPOE with EMAS implementation (7,268 before and 7,292 after) was performed. Error types and rates, alert types and significance, and physician response were noted. Medication errors were deemed significant if there was a potential to cause life-threatening injury, failure of therapy, or an adverse drug effect. RESULTS: There was a significant reduction in the errors per 100 prescriptions (10.4 before vs. 7.3 after; absolute risk reduction = 3.1, 95% confidence interval [CI] = 2.2 to 4.0). Drug dosing error rates decreased from 8 to 5.4 per 100 (absolute risk reduction = 2.6, 95% CI = 1.8 to 3.4). Alerts were generated for 29.6% of prescriptions, with 45% involving drug dose range checking. The sensitivity of CPOE with EMAS in identifying errors in prescriptions was 45.1% (95% CI = 40.8% to 49.6%), and the specificity was 57% (95% CI = 55.6% to 58.5%). Prescribers modified 20% of the dosing alerts, resulting in the error not reaching the patient. Conversely, 11% of true dosing alerts for medication errors were overridden by the prescribers: 88 (11.3%) resulted in medication errors, and 684 (88.6%) were false-positive alerts. CONCLUSIONS: A CPOE with EMAS was associated with a decrease in overall prescription errors in our PED. Further system refinements are required to reduce the high false-positive alert rates.

Necessity of temporary epicardial pacing wires after surgery for congenital heart disease.

BACKGROUND: Temporary epicardial pacing wires are commonly placed in patients undergoing surgery for congenital heart disease. Though often helpful, these wires are not without risk. We aimed to identify characteristics that would obviate placement of temporary epicardial pacing wires in this patient population. METHODS: A prospective observational study was performed on patients admitted to the pediatric intensive care unit after surgery for congenital heart disease between October 2011 and October 2012. Logistic regression analysis was performed to identify independent predictors of patients in whom wires were not helpful postoperatively. RESULTS: Wires were placed in 213 of 249 patients. Wires were helpful in 50 patients; 23 for diagnostic purposes only, 17 for therapeutic purposes only, and 10 for both. On logistic regression analysis, absence of intraoperative arrhythmias (p < 0.01), lower arteriovenous O2 difference (p < 0.01), and shorter duration of cardiopulmonary bypass (p = 0.050) were significant predictors of patients in whom wires were not helpful postoperatively. Further, the predicted probability based on logistic regression model using these 3 variables correctly identified 93% of patients who did not need pacing wires. Four complications (1.9%) related to wires occurred, including 1 episode of life-threatening bleeding that was found, during emergent exploration, to be due to atrial perforation at the wire insertion site. CONCLUSIONS: Temporary epicardial pacing wires are not necessary in many patients recovering from surgery for congenital heart disease. A conservative approach to their use may therefore be warranted.