Effects of 1.5-T versus 3-T magnetic resonance imaging in fetuses: is there a difference in postnatal neurodevelopmental outcome? Evaluation in a fetal population with left-sided congenital diaphragmatic hernia.

BACKGROUND: The utilization of 3-T magnetic field strength in obstetric imaging is increasingly common. It is important to ensure that magnetic resonance (MR) imaging with higher magnetic field strength is safe for the fetus. Comparison of neurodevelopmental outcome in neonates undergoing prenatal MR imaging with 1.5-T versus 3-T is of interest but has not yet been examined. OBJECTIVE: We hypothesized no clinically meaningful difference in neurodevelopmental outcome between fetuses undergoing 1.5-T versus 3-T fetal MR imaging. As imaging a normal fetus for research purposes is illegal in Pennsylvania, this study was conducted in a population of fetuses with left congenital diaphragmatic hernia (left-CDH). MATERIALS AND METHODS: A retrospective review of neurodevelopmental outcome of fetuses with left-CDH scanned at 1.5-T (n=75) versus 3-T (n=25) magnetic field strength between July of 2012 and December of 2019 was performed. Neurodevelopmental outcomes were assessed using the Bayley Scales of Infant Development, 3rd Edition (BSID-III). RESULTS: There were no statistical differences in median age of assessment (1.5-T: 18 [12, 25] versus 3-T: 21 [11, 26], P=0.79), in mean BSID-III cognitive (1.5-T: 91 ± 14 versus 3-T: 90 ± 16, P=0.82), language (1.5-T: 92 ± 20 versus 3-T: 91 ± 20, P=0.91), and motor composite (1.5-T: 89 ± 15 versus 3-T: 87 ± 18, P=0.59) scores, subscales scores (for all, P>0.50), or in risk of abnormal neuromuscular exam (P=0.29) between neonates with left-CDH undergoing a 1.5-T versus 3-T MR imaging during fetal life. Additionally, the distribution of patients with average, mildly delayed, and severely delayed BSID-III scores was similar between the two groups (for all, P>0.50). The overall distribution of the composite scores in this CDH population was similar to the general population independent of exposure to 1.5-T or 3-T fetal MR imaging. Two 3-T patients (8%) and five 1.5-T patients (7%) scored within the significant delayed range for all BSID-III domains. Subjects with lower observed-to-expected fetal lung volume (O/E FLV) and postnatal need for ECMO had lower cognitive, language, motor, and subscales scores (for all, P<0.03) regardless of being imaged at 1.5-T versus 3-T. CONCLUSION: This preliminary study suggests that, compared to 1.5-T MR imaging, fetal exposure to 3-T MR imaging does not increase the risk of neurodevelopmental impairment in fetuses with left-CDH. Additional MR imaging studies in larger CDH cohorts and other fetal populations are needed to replicate and extend the present findings.

The Patient Dignity Inventory and Dignity-Related Distress among the Critically Ill.

CONTEXT: Critical illness confers a significant risk of psychological distress, both during and after intensive care unit (ICU) admission. The Patient Dignity Inventory is a 25-item instrument initially designed to measure psychosocial, existential and symptom-related distress in terminally ill patients. OBJECTIVES: This study was conducted to validate the inventory as a means of identifying distress in inpatient critical care settings. METHODS: Single-center prospective cohort study of adult patients admitted to one of five ICUs within the University of Pennsylvania Health System for greater than 48 hours from January 2019 to February 2020. Patients completed the inventory in addition to the Patient Health Questionnaire-9 and the Generalized Anxiety Disorder-seven questionnaires. RESULTS: The tool's internal structure was assessed via principal components analysis. 155 participants consented, completed the surveys and were included for analysis. Scores on the inventory showed evidence of internal consistency when used in critical care settings (Cronbach's α=0.95). Moreover, principal components analysis elucidated four themes prevalent in critically-ill patients: Illness-related Concerns, Interactions with Others, Peace of Mind and Dependency. Construct validity was assessed through correlational analysis with depression and anxiety questionnaires. Scores on the inventory appear to be valid for assessing dignity-related psychological concerns in the critical care setting although there is overlap among components and with anxiety and depression scores. CONCLUSIONS: This study demonstrates that the inventory can be used to assess patient distress in critical care settings. Further research may elucidate the role of dignity-based interventions in treating and preventing post-intensive care psychological symptoms.

Predicting neonatal outcomes in infants with giant omphalocele using prenatal magnetic resonance imaging calculated observed-to-expected fetal lung volumes.

OBJECTIVE: To examine the association between prenatal magnetic resonance imaging (MRI) based observed/expected total lung volume (O/E TLV) and outcome in neonates with giant omphalocele (GO). METHODS: Between 06/2004 and 12/2019, 67 cases with isolated GO underwent prenatal and postnatal care at our institution. MRI-based O/E TLVs were calculated based on normative data from Meyers and from Rypens and correlated with postnatal survival and morbidities. O/E TLV scores were grouped based on severity into <25% (severe), between 25% and 50% (moderate), and >50% (mild) for risk stratification. RESULTS: O/E TLV was calculated for all patients according to Meyers nomograms and for 49 patients according to Rypens nomograms. Survival for GO neonates with severe, moderate, and mild pulmonary hypoplasia based on Meyers O/E TLV categories was 60%, 92%, and 96%, respectively (p = 0.04). There was a significant inverse association between Meyers O/E TLV and risk of neonatal morbidities (p < 0.05). A similar trend was observed with Rypens O/E TLV, but associations were less often significant likely related to the smaller sample size. CONCLUSION: Neonatal outcomes are related to fetal lung size in isolated GO. Assessment of Meyers O/E TLV allows identification of GO fetuses at greatest risk for complications secondary to pulmonary hypoplasia.

Mortality After Adolescent Firearm Injury: Effect of Trauma Center Designation.

PURPOSE: To determine the incidence and outcomes of firearm injuries in adolescents and the effect of trauma center (TC) designation on their mortality. METHODS: The National Trauma Data Bank (2010-2016) was queried for all encounters involving adolescents aged 13-16 years with firearm injuries. Multivariable logistic regression was employed to determine the association of covariates with mortality (α = .05). Propensity score matching was also used to explore the relationship between TC designation and mortality. RESULTS: A total of 9,029 adolescents met inclusion criteria. Patients aged 15 and 16 years compromised 77.8% of the cohort and were more often male (87.9% vs. 80.6%, p < .001), black (63.8% vs. 56.1%, p < .001), injured in the abdomen (25.4% vs. 22.4%, p = .007) or extremities (62.3% vs. 56.7%, p < .001), and incurred severe injuries (54.5% vs. 50.9%, p = .004) versus 13- and 14-year-old patients. Younger patients were more often injured in the head/neck (23.8% vs. 20.5%, p = .001). Multivariable logistic regression demonstrated no difference in mortality between age groups. Poor neurologic presentation, severe injury, abdominal, chest, and head injuries were all associated with an increased odds of death. Odds of mortality were 2.88 times higher at adult TCs compared to pediatric TCs (CI: 1.55-5.36, p = .001). However, using a 1:1 propensity score matching model, no difference in mortality was found between TC types (p = NS). CONCLUSIONS: Variability exists in outcomes for adolescents after firearm injuries. Understanding and identifying the potential differences between pediatric and adult TCs managing adolescent firearm victims may improve survival in all treatment venues, but these data support patients being treated at the closest available TC.

An RCT of Fecal Immunochemical Test Colorectal Cancer Screening in Veterans Without Recent Primary Care.

INTRODUCTION: The use of screening can prevent death from colorectal cancer, yet people without regular healthcare visits may not realize the benefits of this preventive intervention. The objective of this study was to determine the effectiveness of a mailed screening invitation or mailed fecal immunochemical test in increasing colorectal cancer screening uptake in veterans without recent primary care encounters. STUDY DESIGN: Three-arm pragmatic randomized trial. SETTING/PARTICIPANTS: Participants were screening-eligible veterans aged 50-75 years, without a recent primary care visit who accessed medical services at the Corporal Michael J. Crescenz Veteran Affairs Medical Center between January 1, 2017, and July 31, 2017. All data were analyzed from March 1, 2018, to July 31, 2018. INTERVENTION: Participants were randomized to (1) usual opportunistic screening during a healthcare visit (n=260), (2) mailed invitation to screen and reminder phone calls (n=261), or (3) mailed fecal immunochemical test outreach plus reminder calls (n=61). MAIN OUTCOME MEASURES: The main outcome under investigation was the completion of colorectal cancer screening within 6 months after randomization. RESULTS: Of 782 participants in the trial, 53.9% were aged 60-75 years and 59.7% were African American. The screening rate was higher in the mailed fecal immunochemical test group (26.1%) compared with usual care (5.8%) (rate difference=20.3%, 95% CI=14.3%, 26.3%; RR=4.52, 95% CI=2.7, 7.7) or screening invitation (7.7%) (rate difference=18.4%, 95% CI=12.2%, 24.6%; RR=3.4, 95% CI=2.1, 5.4). Screening completion rates were similar between invitation and usual care (rate difference=1.9%, 95% CI= -2.4%, 6.2%; RR=1.3, 95% CI=0.7, 2.5). CONCLUSIONS: Mailed fecal immunochemical test screening promotes colorectal cancer screening participation among veterans without a recent primary care encounter. Despite the addition of reminder calls, an invitation letter was no more effective in screening participation than screening during outpatient appointments. TRIAL REGISTRATION: This study is registered at clinicaltrials.gov NCT02584998.

Therapy at 30 days of life predicts lung function at 6 to 12 months in infants with congenital diaphragmatic hernia.

INTRODUCTION: Congenital diaphragmatic hernia (CDH) is associated with variable degrees of lung hypoplasia. Pulmonary support at 30 days postnatal age was found to be the strongest predictor of inpatient mortality and morbidity among CDH infants and was also associated with higher pulmonary morbidity at 1 and 5 years. It is not known, however, if there is a relationship between the need for medical therapy at 30 days of life and subsequent abnormalities in lung function as reflected in infant pulmonary function test (iPFT) measurements. OBJECTIVE: We hypothesized that CDH infants who require more intensive therapy at 30 days would have more abnormal iPFT values at the time of their first infant pulmonary function study, reflecting the more severe spectrum of lung hypoplasia. METHODS: A single-institution chart review of all CDH survivors who were enrolled in a Pulmonary Hypoplasia Program (PHP) through July 2019, and treated from 2002 to 2019 was performed. All infants were divided into groups based on their need for noninvasive (supplemental oxygen, high flow therapy, noninvasive mechanical ventilation) or invasive (mechanical ventilation, extracorporeal membrane oxygenation) respiratory assistance, bronchodilators, diuretic use, and pulmonary hypertension (PH) therapy (inhaled and/or systemic drugs) at 30 days. Descriptive and statistical analyses were performed between groups comparing subsequent lung function measurements. RESULTS: A total of 382 infants (median gestational age [GA] 38.4 [interquartile range (IQR) = 37.1-39] weeks, 41.8% female, 70.9% Caucasian) with CDH were enrolled in the PHP through July 2019, and 118 infants underwent iPFT. The median age of the first iPFT was 6.6 (IQR = 5.3-11.7) months. Those requiring any pulmonary support at 30 days had a higher functional residual capacity (FRC) (z) (P = .03), residual volume (RV) (z) (P = .008), ratio of RV to total lung capacity (RV/TLC) (z) (P = .0001), and ratio of FRC to TLC (FRC/TLC) (z) (P = .001); a lower forced expiratory volume at 0.5 seconds (FEV0.5) (z) (P = .03) and a lower respiratory system compliance (Crs) (P = .01) than those who did not require any support. Similarly, those requiring diuretics and/or PH therapy at 30 days had higher fractional lung volumes, lower forced expiratory flows and Crs than infants who did not require such support (P < .05). CONCLUSIONS: Infants requiring any pulmonary support, diuretics and/or PH therapy at 30 postnatal days have lower forced expiratory flows and higher fractional lung volumes, suggesting a greater degree of lung hypoplasia. Our study suggests that the continued need for PH, diuretic or pulmonary support therapy at 30 days can be used as additional risk-stratification measurements for evaluation of infants with CDH.

Pediatric firearm mortality in the United States, 2010 to 2016: A National Trauma Data Bank analysis.

BACKGROUND: Pediatric firearm injury is a leading cause of death for U.S. children. We sought to further characterize children who die from these injuries using a validated national database. METHODS: The National Trauma Data Bank 2010 to 2016 was queried for patients aged 0 to 19 years old. International Classification of Diseases external cause of injury codes were used to classify patients by intent. Differences between groups were analyzed using χ or Mann-Whitney U tests. Patterns over time were analyzed using nonparametric tests for trend. Multivariable logistic regression was used to investigate associations between the above factors and mortality. RESULTS: There were a total of 45,288 children with firearm injuries, 12.0% (n = 5,412) of whom died. Those who died were younger and more often white than survivors. Mortality was associated with increased injury severity, shock on presentation, and polytrauma (p < 0.001 for all). There was an increasing trend in the proportion of self-inflicted injuries over the study period (p < 0.001), and mortality from these self-inflicted injuries increased concordantly (35.3% in 2010 to 47.8% in 2016, p = 0.001). Location of severe injuries had significant different mortality rates, ranging from 51.3% of head injuries to 3.9% in the extremities. In the multivariable model, treatment at a pediatric trauma center was protective against mortality, with odds ratios of 2.10 (confidence interval, 1.64-2.68) and 1.80 (confidence interval, 1.39-2.32) for death at adult and dual-designated trauma centers, respectively. This finding was confirmed in age-stratified cohorts. CONCLUSION: Proportions of self-inflicted pediatric firearm injury in the National Trauma Data Bank increased from 2010 to 2016, as did mortality from self-inflicted injury. Because mortality is highest in this subpopulation, prevention and treatment efforts should be prioritized in this group of firearm-injured children. LEVEL OF EVIDENCE: Epidemiological study, level V.

Defining the role of angioembolization in pediatric isolated blunt solid organ injury.

PURPOSE: To determine the incidence and outcomes of angiography in pediatric patients with blunt solid organ injury (SOI). METHODS: The National Trauma Data Bank (2010-2014) was queried for patients ≤19 years who experienced isolated blunt SOI. Multivariate logistic regression was used to evaluate characteristics associated with radiological and surgical intervention. RESULTS: Patients with isolated blunt injuries to the spleen (n = 7542), liver (n = 4549), and kidney (n = 2640) were identified. Use of angiography increased yearly from 1.6% to 3.1% of cases (p = 0.001) and was associated with older age (OR 2.61 [CI: 1.94-3.50], p < 0.001) and grade III or higher injury (OR 4.63 [CI: 3.11-6.90], p < 0.001). Odds of angiography were 4.9 times higher at adult trauma centers (TCs) than pediatric TCs overall, and almost 9 times higher for isolated splenic trauma (p < 0.001 for each). There was no improvement in splenic salvage after angiography for high grade injuries (3.5% vs. 4.8%, p = NS). Only 1.8% of cases began within 30 min of arrival (median time = 3.6 h). CONCLUSION: Variability exists in the utilization of angiography in pediatric blunt SOI between adult and pediatric TCs, with no improvement in splenic salvage. LEVEL OF EVIDENCE: Level III - Treatment study.

Life-saving interventions in pediatric trauma: A National Trauma Data Bank experience.

BACKGROUND: Emergent procedures are infrequent in pediatric trauma. We sought to determine the frequency and efficacy of life-saving interventions (LSI) performed for pediatric trauma patients within the first hour of care at a trauma center. METHODS: The National Trauma Data Bank (2010-2014) was queried for patients 19 years or younger who underwent LSIs within 1 hour of arrival to the emergency department. Life-saving interventions included emergency department thoracotomy (EDT) and emergent airway procedures (EAP). Multivariable logistic regression was used to evaluate the influence of patient and hospital characteristics on mortality. RESULTS: Of 725,284 recorded traumatic encounters, only 1,488 (0.2%) pediatric patients underwent at least one of the defined LSI during the 5-year study period (EDT, 1,323; EAP, 187). Most patients (85.6%) were 15 years or older. Mortality was high but varied by procedure type (EDT, 64.3%; EAP, 28.3%). Mortality for patients younger than 1 year undergoing EDT was 100%, decreasing to 62.6% in patients aged 15 years to 19 years. For EAP, mortality ranged from 66.7% for infants to 27.2% in 15-year-old to 19-year-old patients. Lower Glasgow Coma Scale score, higher Injury Severity Score, presence of shock, and a blunt mechanism of injury were independently associated with mortality in the EDT cohort. On average, trauma centers in this study performed approximately one LSI per year, with only 13.8% of cases occurring at a verified pediatric trauma center. CONCLUSION: Life-saving interventions in the pediatric trauma population are uncommon and outcomes variable. Novel solutions to keep proficient at such interventions should be sought, especially for younger children. Guidelines to improve identification of appropriate candidates for LSI are critical given their rare occurrence. LEVEL OF EVIDENCE: Retrospective cohort study, III.

Laparoscopic Management of Pediatric Abdominal Trauma: A National Trauma Data Bank Experience.

Purpose: To characterize injury patterns and institutional trends associated with the utilization of laparoscopy in the management of pediatric abdominal trauma. Methods: The National Trauma Data Bank (2010-2014) was queried for encounters involving patients ≤14 years who underwent an open or laparoscopic abdominal operation within 48 hours of emergency department arrival. Patient, injury, and hospital characteristics associated with each approach were identified. Multivariate logistic regression was used to evaluate the influence of patient and hospital characteristics on operative approach. Results: Laparoscopy comprised 7.8% (n = 355) of all abdominal trauma operations. Patients undergoing laparoscopy had lower injury severity scores and higher Glasgow Coma Scale scores on arrival compared with laparotomy subjects (P < .001). Laparoscopic patients also had a shorter length of hospital stay (5.0 versus 8.6 days, P < .001), but longer time to the operating room (9.2 versus 6.3 hours, P < .001) compared with their open counterparts. The proportion of cases managed laparoscopically increased from 6.2% in 2010 to 10.1% in 2014 (P = .013), with increase in utilization primarily driven by university hospitals (P = .026) and level I pediatric trauma centers (P = .043). Conversion to laparotomy was uncommon (18.6%), and mortality in the laparoscopic cohort was low (0.4%). Conclusions: Use of laparoscopy has increased in the pediatric abdominal trauma population, typically in a less injured cohort of patients. As familiarity with and availability of minimally invasive techniques increase, this trend will likely continue.

Parent and Clinician Perspectives on Sustained Behavior Change after a Prenatal Obesity Program: A Qualitative Study.

BACKGROUND: Infants of obese women are at a high risk for development of obesity. Prenatal interventions targeting gestational weight gain among obese women have not demonstrated consistent benefits for infant growth trajectories. METHODS: To better understand why such programs may not influence infant growth, qualitative semi-structured interviews were conducted with 19 mothers who participated in a prenatal nutrition intervention for women with BMI 30 kg/m2 or greater, and with 19 clinicians (13 pediatric, 6 obstetrical). Interviews were transcribed and coded with themes emerging inductively from the data, using a grounded theory approach. RESULTS: Mothers were interviewed a mean of 18 months postpartum and reported successful postnatal maintenance of behaviors that were relevant to the family food environment (Theme 1). Ambivalence around the importance of postnatal behavior maintenance (Theme 2) and enhanced postnatal healthcare (Theme 3) emerged as explanations for the failure of prenatal interventions to influence child growth. Mothers acknowledged their importance as role models for their children's behavior, but they often believed that body habitus was beyond their control. Though mothers attributed prenatal behavior change, in part, to additional support during pregnancy, clinicians had hesitations about providing children of obese parents with additional services postnatally. Both mothers and clinicians perceived a lack of interest or concern about infant growth during pediatric visits (Theme 4). CONCLUSIONS: Prenatal interventions may better influence childhood growth if paired with improved communication regarding long-term modifiable risks for children. The healthcare community should clarify a package of enhanced preventive services for children with increased risk of developing obesity.

Infant Growth following Maternal Participation in a Gestational Weight Management Intervention.

BACKGROUND: Obesity is widespread and treatment strategies have demonstrated limited success. Changes to obstetrical practice in response to obesity may support obesity prevention by influencing offspring growth trajectories. METHODS: This retrospective cohort study examined growth among infants born to obese mothers who participated in Nutrition in Pregnancy (NIP), a prenatal nutrition intervention at one urban hospital. NIP participants had Medicaid insurance and BMIs of 30 kg/m(2) or greater. We compared NIP infant growth to a historical control cohort, matched on maternal factors: age, race/ethnicity, prepregnancy BMI, parity, and history of prepregnancy hypertension or preterm birth. RESULTS: Growth data were available for 61 NIP and 145 control infants. Most mothers were African American (94%). Mean maternal BMI was 39.9 kg/m(2) (standard deviation [SD], 5.6) for NIP participants and 38.8 kg/m(2) (SD, 6.0) for controls. Pregnancy outcomes, including preterm birth, gestational diabetes, and birth weight, did not differ between groups. NIP participants were more likely to attend a postpartum visit (69% vs. 52%; p value, 0.03). At 1 year, 17% of NIP infants and 15% of controls had weight-for-length (WFL) ≥95th percentile (p value, 0.66). Other markers of accelerated infant growth, including crossing WFL percentiles and peak infant BMI, did not differ between groups. CONCLUSIONS: There was no difference in growth between infants whose mothers participated in a prenatal nutrition intervention and those whose mothers did not. Existing prenatal programs for obese women may be inadequate to prevent pediatric obesity without pediatric collaboration to promote family-centered support beyond pregnancy.

The ups and downs of early mothering.

INTRODUCTION: The maternal experience of having a young infant is often viewed through a negative lens focused on psychological distress due, in part, to a historical focus on identifying threats to prenatal, perinatal and postpartum well-being of women and infants. This report examines maternal appraisal of both positive and negative experiences during and after pregnancy and introduces a new scale that assesses both uplifts and hassles that are specific to early motherhood. METHODS: The sample included 136 women who began study participation during pregnancy and completed an existing scale designed to evaluate pregnancy-specific hassles and uplifts. When infants were 6 months old, participants completed the newly developed Maternal Experience Scale (MES) along with questionnaires related to anxiety, depression, attachment, parenting stress and infant temperament characteristics. RESULTS: In general, women with 6-month-old infants rated their maternal experiences far more positively than negatively. MES hassles and uplift scores reflected both convergent and discriminant validity with general measures of psychological well-being and parent-specific measures. Appraisal of the pregnancy experience significantly predicted appraisal of early motherhood for hassles, uplifts and a composite score reflecting emotional valence. Women became relatively more uplifted and less hassled from pregnancy to 6-month postpartum; this was particularly true for multiparous women. DISCUSSION: The maternal perception of motherhood corresponds to her perception of pregnancy. The MES provides a balanced view of motherhood by including maternal appraisal of the uplifting aspects of caring for an infant.

Residency exposures and anticipated future involvement in community settings.

OBJECTIVE: To assess how exposures to community activities in residency impact anticipated future involvement in community child health settings. METHODS: Prospective cohort study of pediatric residents from 10 programs (12 sites) who completed training between 2003 and 2009. Residents reported annual participation for ≥ 8 days in each of 7 community activities (eg, community settings, child health advocacy) in the prior year. At the start and end of residency, residents reported anticipated involvement in 10 years in 8 community settings (eg, school, shelter). Anticipated involvement was dichotomized: moderate/substantial ("high") versus none/limited ("low"). Logistic regression modeled whether residency exposures independently influenced anticipated future involvement at the end of residency. RESULTS: A total of 683 residents completed surveys at the start and end of residency (66.8% participation). More than half of trainees reported ≥ 8 days' of involvement in community settings (65.6%) or child health advocacy (53.6%) in residency. Fewer anticipated high involvement in at least 1 community setting at the end of residency than at the start (65.5% vs 85.6%, P < .001). Participation in each community activity mediated but did not moderate relations between anticipated involvement at the start and end of residency. In multivariate models, exposure to community settings in residency was associated with anticipated involvement at end of residency (adjusted odds ratio 1.5; 95% confidence interval 1.2, 2.0). No other residency exposures were associated. CONCLUSIONS: Residents who anticipate high involvement in community pediatrics at the start of residency participate in related opportunities in training. Exposure to community settings during residency may encourage community involvement after training.