Determinants of successful ictal SPECT injection in phase 1 epilepsy presurgical evaluation: Findings from the pediatric epilepsy research consortium surgery database project.

OBJECTIVES: The main goal of presurgical evaluation in drug-resistant focal epilepsy is to identify a seizure onset zone (SOZ). Of the noninvasive, yet resource-intensive tests available, ictal single-photon emission computed tomography (SPECT) aids SOZ localization by measuring focal increases in blood flow within the SOZ via intravenous peri-ictal radionuclide administration. Recent studies indicate that geographic and center-specific factors impact utilization of these diagnostic procedures. Our study analyzed successful ictal SPECT acquisition (defined as peri-ictal injection during inpatient admission) using surgery-related data from the Pediatric Epilepsy Research Consortium (PERC) surgery database. We hypothesized that a high seizure burden, longer duration of video EEG monitoring (VEEG), and more center-specific hours of SPECT availability would increase the likelihood of successful ictal SPECT. METHODS: We identified study participants (≤18 years of age) who underwent SPECT as part of their phase 1 VEEG from January 2018 to June 2022. We assessed association between ictal SPECT outcomes (success vs. failure) and variables including patient demographics, epilepsy history, and center-specific SPECT practices. RESULTS: Phase 1 VEEG monitoring with ictal SPECT injection was planned in 297 participants and successful in 255 participants (85.86%). On multivariable analysis, the likelihood of a successful SPECT injection was higher in patients of non-Hispanic ethnicity (p = 0.040), shorter duration VEEG (p = 0.004), and higher hours of available SPECT services (p < 0.001). Higher seizure frequency (p = 0.033) was significant only in bivariate analysis. Patients treated at centers with more operational hours were more likely to experience pre-admission protocols prior to VEEG (p = 0.002). SIGNIFICANCE: There is inter-center variability in protocols and SPECT acquisition capabilities. Shorter duration of EEG monitoring, non-Hispanic ethnicity (when on private insurance), extended operational hours of nuclear medicine as noted on multivariate analysis and higher seizure frequency in bivariate analysis are strongly associated with successful ictal SPECT injection. PLAIN LANGUAGE SUMMARY: In pediatric patients with drug-resistant epilepsy, single-photon emission computed tomography (SPECT) scans can be helpful in localizing seizure onset zone. However, due to many logistical challenges described below, which include not only the half-life of the technetium isotope used to inject intravenously during a seizure (called the ictal SPECT scan) but also available nuclear scanner time in addition to the unpredictability of seizures, obtaining an ictal SPECT during a planned elective inpatient hospital stay is not guaranteed. Thus, as healthcare costs increase, planning a prolonged hospital stay during which an ictal SPECT scan is not feasible is not optimal. We leveraged our prospective surgery database to look at center-specific factors and patient-specific factors associated with an ictal SPECT injection in the first, pediatric-focussed, large-scale, multicenter, prospective, SPECT feasibility study. We found that longer availability of the scanner is the most important center-specific factor in assuring ictal SPECT injection. Although seizure frequency is an important patient-specific factor on bivariate analysis, this factor lost statistical significance when other factors like patient insurance status and video EEG duration were also considered in our multivariable logistical model.

Preventing Inpatient NP Burnout: The Power of Adequate Staffing and Leadership.

BACKGROUND: Nurse practitioner (NP) burnout related to high patient-to-NP ratios needs to be addressed. OBJECTIVES: To survey inpatient pediatric NPs, assess burnout and characterize associated workload and support. DESIGN: Online cross-sectional survey conducted in three phases from March 2022 to August 2023. SUBJECTS AND SETTING: Inpatient specialty NPs from 32 hospitals. RESULTS: Fisher's exact test and logistic regression were implemented. A patient-to-provider (NP or resident) ratio of more than 5:1 was associated with NP burnout (OR = 3.5, 95% CI 1.0, 12.0 and OR = 4.1, 95% CI 1.1, 16.2, respectively, p < .05). Among NPs without burnout, 100% had organizational NP leadership (p = .012). INTERPRETATION: Though limited by a small convenience sample, a patient-to-provider ratio over 5:1 was associated with NP burnout, and NP leadership was protective. Further research of cost analysis, retention, and patient quality and safety measures are needed. CONCLUSION: Lower patient-to-NP ratios and NP leadership play a pivotal role in preventing burnout.

Adding oscillometry to spirometry in guidelines better identifies uncontrolled asthma, future exacerbations, and potential targeted therapy.

The objective of this review is to provide new advances in our understanding of the clinical importance of establishing peripheral airway impairment (PAI) by impulse oscillometry (IOS) and targeted therapy, which could result in better asthma outcomes. Data sources include PubMed and Google search, limited to English language and human disease, with key words IOS and asthma. Key findings include PAI being consistently associated with uncontrolled asthma across ethnicities, using IOS reference equations factoring Hispanic and White reference algorithms. It is noted that PAI is common even in patients considered well-controlled by asthma guidelines. In a large longitudinal analysis (Assessment of Small Airways Involved in Asthma or ATLANTIS study), a composite of R5-R20, AX, and X5 ordinal scores were independently predictive of asthma control and exacerbation in a multivariate analysis, but forced expiratory volume in 1 second was not significantly predictive of morbidities. However, combining forced expiratory volume in 1 second less than 80% with PAI resulted in greater odds of identifying uncontrolled asthma and exacerbations, than either alone. Applying an external validation method in children with asthma offers the clinician the IOS reference equations best fit for their own specific population. Several clinical phenotypes can also identify PAI with high probability, useful when IOS is not available. Poor asthma outcomes for obese patients with asthma are associated with dysanapsis and PAI, not obesity alone. Extrafine inhaled corticosteroids achieve better asthma control and improve peripheral airway function with fewer exacerbations at lower dosages than nonextrafine inhaled corticosteroid aerosols. In conclusion, these data support the benefit of adding IOS to spirometry in future asthma guidelines and suggest the potential benefit from targeted therapy.

Pediatric Patients with Tracheostomies and Its Multifacet Association with Lower Airway Infections: An 8-Year Retrospective Study in a Large Tertiary Center.

Background: Lower respiratory tract infections frequently complicate the care of children with chronic tracheostomies. Pediatric patients have significantly more risk to have tracheostomy infections than adults. Better understanding of modifiable risk factors for pulmonary exacerbations may improve the care of technology-dependent children. Methods: A retrospective single-center cohort study conducted on children with tracheostomy and chronic home ventilator to determine the incidence of pulmonary exacerbations leading to hospitalizations, emergency room (ER) visits, and antibiotic prescriptions. Oral and nebulized antibiotic prescriptions were collected and correlated to the type of exacerbation. Results: Gram-negative enteric organisms were the most common microbes seen in the lower airways, with Pseudomonas aeruginosa cultured in 86% of the subjects. P. aeruginosa presence predicted a 4-fold increased rate of pulmonary-related hospitalization. In pediatric patients with chronic respiratory failure, 64% of readmissions were pulmonary or tracheostomy related. When compared to standard care subjects on dual agent, alternating monthly nebulized antibiotic therapy (for chronic pseudomonas colonization) experienced 41% fewer hospitalizations [incidence rate ratios (IRR) 0.59 (0.18), P = 0.08], 46% fewer ER visits [IRR 0.56 (0.16), P = 0.04], and 41% fewer pulmonary-related ER visits [IRR 0.59 (0.19), P = 0.94]. Discussion: Children who require artificial airways are at an increased risk for bacterial bronchopulmonary infections. Most notable risk factors for hospitalization in tracheostomized children included neurologic impairment, dysphagia, aspiration, gastrotomy tube dependence, and gastroesophageal reflux disease. Pathogenic microbes such as P. aeruginosa species, certain gram-negative bacteria, candida, and yeast also predicted increased hospitalizations. Use of nebulized antibiotics prophylaxis in a subset of patients predicted lower rates of hospitalization or ER visits. More studies are needed to assess whether there is increased antimicrobial resistance with this strategy, and whether the benefits persist in the long-term nebulized antibiotics utilization.

Impact of COVID-19 pandemic on pediatric healthcare burnout in acute care: a longitudinal study.

BACKGROUND: COVID-19 pandemic introduced significant challenges that may have exacerbated healthcare worker (HCW) burnout. To date, assessments of burnout during COVID-19 pandemic have been cross-sectional, limiting our understanding of changes in burnout. This longitudinal study assessed change across time in pediatric HCW burnout during the COVID-19 pandemic and whether demographic and psychological factors were associated with changes in burnout. METHODS: This longitudinal study included 162 physicians, physician assistants, nurses, and medical technicians within the emergency department (ED), intensive care, perioperative, and inter-hospital transport services in a children's hospital. HCW demographics, anxiety and personality traits were reported via validated measures. HCWs completed the Maslach Burnout Inventory in April 2020 and March 2021. Data were analyzed using generalized estimating equations. RESULTS: The percentage of HCWs reporting high emotional exhaustion and/or depersonalization burnout increased significantly across time (18.5% to 28.4%, P = 0.010). Factors associated with increased emotional exhaustion included working in the ED (P = 0.011) or perioperative department (P < 0.001), being a nurse or medical technician (P's < 0.001), not having children (P < 0.001), and low conscientiousness (P < 0.001). CONCLUSIONS: Pediatric HCW burnout significantly increased over 11-months of the COVID-19 pandemic. Results suggest that certain demographic and psychological factors may represent potential area to target for intervention for future pandemics. IMPACT: This longitudinal study revealed that the COVID-19 pandemic has had a significant impact on pediatric healthcare worker burnout. The percentage of healthcare workers reporting high levels of emotional exhaustion and depersonalization burnout increased significantly over 11-months of the COVID-19 pandemic. Results suggest that certain demographic and psychological factors may represent potential targets for future interventions.

Living in environmental justice areas worsens asthma severity and control: Differential interactions with disease duration, age at onset, and pollution.

BACKGROUND: Impoverished and historically marginalized communities often reside in areas with increased air pollution. OBJECTIVE: We evaluated the association between environmental justice (EJ) track and asthma severity and control as modified by traffic-related air pollution (TRAP). METHODS: We performed a retrospective study of 1526 adult asthma patients in Allegheny County, Pa, enrolled in an asthma registry during 2007-20. Asthma severity and control were determined using global guidelines. EJ tract designation was based on residency in census tracts with ≥30% non-White and/or ≥20% impoverished populations. TRAP exposures (NO2 and black carbon) for each census tract were normalized into pollution quartiles. Generalized linear model analyses determined the effect of EJ tract and TRAP on asthma. RESULTS: TRAP exposure in the highest quartile range was more frequent among patients living in an EJ tract (66.4% vs 20.8%, P < .05). Living in an EJ tract increased the odds of severe asthma in later onset asthma. The odds of uncontrolled asthma increased with disease duration in all patients living in EJ tracts (P < .05). Living in the highest quartile of NO2 also increased the odds of uncontrolled asthma in patients with severe disease (P < .05), while there was no effect of TRAP on uncontrolled asthma in patients with less severe disease (P > .05). CONCLUSIONS: Living in an EJ tract increased the odds of severe and uncontrolled asthma and was influenced by age at onset, disease duration, and potentially by TRAP exposure. This study underscores the need to better understand the complex environmental interactions that affect lung health in groups that have been economically and/or socially marginalized.

A pilot study of multi-modal pain management for same-day discharge after minimally invasive repair of pectus excavatum (Nuss procedure) in children.

BACKGROUND: Despite advancements in minimally invasive repair of pectus excavatum (MIRPE), Nuss procedure, postoperative pain control remains challenging. This report covers a multimodal regimen using bilateral single-shot paravertebral block (PVB) and bilateral thoracoscopic intercostal nerve (T3-T7) cryoablation, leading to significant reduction in length of stay (LOS) and high rate of same-day discharge. METHODS: This is a comparative study of pain management protocols for patients undergoing the Nuss procedure at a single center from 2016 through 2020. All patients underwent the the same surgical technique for the treatment of pectus excavatum at a single center. Patients received bilateral PVB with continuous infusion (Group 1, n = 12), bilateral PVB with infusion and right-side cryoablation (Group 2, n = 9), or bilateral single-shot PVB and bilateral cryoablation (Group 3, n = 17). The primary outcome was LOS with focus on same-day discharge, and the secondary outcome was decreased opioid usage. RESULTS: Eleven of 17 patients in Group 3 (65%) (bilateral single-shot PVB and bilateral cryoablation) were discharged the same day as surgery. The remaining Group 3 patients were discharged the following day with no complications or interventions. Compared to Group 1 (no cryoablation), Group 3 had shorter LOS (median 4.4 days vs. 0.7 days, respectively, p < 0.001) and significantly decreased median opioid use on the day of surgery (0.92 mg/kg vs. 0.47 mg/kg, p = 0.006). CONCLUSION: Findings demonstrate the feasibility of multimodal pain management for same-day discharge after the Nuss procedure. Future multisite studies are needed to investigate the superiority of this approach to established methods. LEVEL OF EVIDENCE: III.

Use of COVID-19 Convalescent Plasma for Treatment of Symptomatic SARS-CoV-2 Infection at a Children's Hospital: A Contribution to a Still Inadequate Body of Evidence.

Data on COVID-19 convalescent plasma (CCP) safety and efficacy in children and young adults are limited. This single-center prospective, open-label trial evaluates CCP safety, neutralizing antibody kinetics, and outcomes in children and young adults with moderate/severe COVID-19 (April 2020-March 2021). A total of 46 subjects received CCP; 43 were included in the safety analysis (SAS); 7.0% < 2 years old, 2.3% 2-<6, 27.9% 6-<12, 39.5% 12-<19, and 23.3% > 19 years old; 28 were included in the antibody kinetic analysis (AbKS); 10.7% < 2 years old, 10.7% 6-<12, 53.8% 12-<19, and 25.0% > 19 years old. No adverse events occurred. The median COVID-19 severity score improved (5.0 pre-CCP to 1.0 by day 7; p < 0.001). A rapid increase in the median percentage of inhibition was observed in AbKS (22.5% (13.0%, 41.5%) pre-infusion to 52% (23.7%, 72%) 24 h post-infusion); a similar increase was observed in nine immune-competent subjects (28% (23%, 35%) to 63% (53%, 72%)). The inhibition percentage increased until day 7 and persisted at 21 and 90 days. CCP is well tolerated in children and young adults, providing rapid and robust increased antibodies. CCP should remain a therapeutic option for this population for whom vaccines are not fully available and given that the safety and efficacy of existing monoclonal antibodies and antiviral agents have not been established.

Single-center comparison of outcomes between laparoscopic appendectomy and transumbilical laparoscopic assisted appendectomy.

PURPOSE: Appendectomy is the most common pediatric emergency surgery performed to date. This study compared outcomes between laparoscopic appendectomy (LA) and transumbilical laparoscopic assisted appendectomy (TULAA) for 1154 uncomplicated patients across 5 years at a single institution. Primary outcomes include length of stay (LOS), post-operative complications, pain score, and operating room (OR) time. METHODS: Demographic and clinical data was collected for 1154 eligible patients treated for uncomplicated appendicitis between August 2014-October 2019, with 830 patients in the LA group, and 324 in the TULAA group. Mixed effects modeling procedure using logistic and linear regression examined the effect of surgery type on the four primary outcomes after adjustment for potential clustering effect of surgeon and confounding factors. RESULTS: Of 1154 patients, 62.7% were male, and mean (SD) age was 10.9 (3.6) years. Median [IQR] LOS was 28.0 h [22.0, 36.0], mean (SD) OR time was 29.0 (10.0) minutes, and median [IQR] pain at maximum level was 5.5 (2.7). The complication rate overall was <5.0% and did not differ between TULAA and LA groups (p > 0.05). OR time was reduced by an average of 5.2 min in the TULAA group (p < 0.001), pain did not differ between groups overall (p > 0.05), and patients were more likely to be discharged within 24 h in patients who underwent TULAA (OR = 5.3 [1.6, 17.4], p = 0.007). CONCLUSION: Retrospective analysis of 1154 pediatric appendectomies, found no difference in complications between single- and three-incision laparoscopic procedures (TULAA vs. LA). Findings suggest TULAA is a safe procedure for acute appendicitis in pediatrics. LEVEL OF EVIDENCE: IV.

In young children with asthma, obesity and uncontrolled disease are highly associated with peripheral airway impairment.

BACKGROUND: Despite the fact that impulse oscillometry (IOS)-determined peripheral airway impairment (PAI) phenotype is a major risk factor for uncontrolled asthma, IOS is seldom used clinically. OBJECTIVE: To identify clinical characteristics that can best identify the PAI phenotype. METHODS: Clinical characteristics and spirometry results were compared in 227 patients with asthma with the PAI phenotype determined by resistance and reactance values that exceeded IOS­predictive normal values using Gochicoa-Rangel equations. Logistic regression analyses determined factors associated with PAI phenotype, with risk classification based on predicted probability from the final adjusted model. RESULTS: Analysis for identifying PAI, present in 37% of our population, revealed statistically significant odds ratio (OR) for age (4-7 years), of 3.75 (1.47-9.55) (P = .006), obesity OR of 2.59 (1.36-4.96) (P = .004), uncontrolled asthma OR of 2.77 (1.34-5.74) (P = .006), and abnormal forced expiratory flow between 25% and 75% (FEF25%-75%) (<65%) OR of 4.22 (1.59-11.20) (P = .004). For identifying PAI in those considered well controlled, key characteristics were age (4-7 years), OR of 2.81 (1.10-7.18) (P = .03), and obesity, OR of 2.18 (1.09-4.39) (P = .03). For those 4 to 7 years old, who were obese and had uncontrolled disease, probability of PAI was greater than or equal to 80%, regardless of FEF 25%-75%. Probabilities from logistic regression analyses to identify PAI were associated with an area under the curve of 0.750, and applying standard threshold of greater than or equal to 0.50 probability for identification produced sensitivity at 49.4%, specificity at 85.3%, positive predictive value at 66.1%, negative predictive value at 74.4%, and accuracy at 72.1%. CONCLUSION: Clinical characteristics of age at 4 to 7 years, obesity, uncontrolled asthma, and FEF 25%-75% (<65%) identify PAI with high specificity and accuracy. This approach offers the clinician a practical method for strongly considering the presence of PAI when IOS is not available.

Ampicillin and Gentamicin Treatment for Early Onset Neonatal Sepsis: When One Size Does Not Fit All.

Based on in vitro susceptibilities and the concern for emergence of resistance and long-term safety, ampicillin plus gentamicin remains the recommended antibiotic regimen for early onset neonatal sepsis. Our objective was to identify potential limitations of this regimen based on clinical and pathogen characteristics while minimizing risks associated with prolonged antibiotic exposure. We identified 43 gram-negative pathogens in 42 patients. Escherichia coli (E coli) occurred in 50% and Streptococcus agalactiae in 23.8% of patient. Ampicillin resistance was common, particularly in E coli (85.7%). Mortality was 23.8%, all due to E coli. We found that E coli is the most frequent pathogen and has a high mortality particularly in neonates < 1500 g; mortality is high with the current dosing strategy when E coli is resistant to ampicillin even when sensitive to gentamicin; resistance to gentamicin remains low but seems to be increasing while resistance to third-generation cephalosporins remains very low.

External validation can provide the clinician with IOS equations that best predict the risk of uncontrolled asthma in their population.

BACKGROUND: Peripheral airway impairment (PAI) has been shown to have a close association to risk of uncontrolled asthma in children. However, clear methods have not been established for the clinician to select impulse oscillometry (IOS) reference equations best suited for their population. Our study aimed to develop a practical external validation analytic approach for the clinician to determine which of the available reference equations best predicts uncontrolled asthma for their patients. METHODS: This is a post hoc analyses of data collected at baseline in a randomized controlled study that occurred from March 2016 to 2018. The study population consisted of 227 children, ages 4-18 years, with moderate to severe asthma. Discrimination and calibration predictive performance of available and suitable IOS equations were assessed by using uncontrolled asthma as the criterion outcome. Discrimination statistics of accuracy, sensitivity, and specificity served as the primary performance indicators. Rank scores were determined by the number of acceptable limit thresholds met for these measures (≥60%, ≥50%, and ≥60%, respectively) across IOS metrics (R5, R5-R20, AX, and X5) resulting in a total possible score of 12. RESULTS: External validity assessment determined the rank order of best to worst equations as being Gochicoa-Rangel (rank score = 10) > Nowowiejska (rank score = 9) > Assumapcao (rank score = 6) > Amra (rank score = 2). Gochicoa-Rangel reference equations provided the best option for universal application with accuracy of 73.1%, 72.2%, 76.7%, and 66.2% for R5, R5-R20, AX, and X5, respectively. CONCLUSIONS: External validation, particularly discrimination in asthmatic children, offers the clinician a practical approach to selecting the most suitable predictive equations for their patients.

Pediatric Myopericarditis Presenting to the Emergency Department as Chest Pain: A Comparative Study With Myocarditis.

METHODS: A database query was performed and identified patients over a 9-year period, and clinical data, laboratory data, and cardiac studies were extracted and analyzed from the electronic health record. RESULTS: A total of 36 patients were identified with the discharge diagnosis of myopericarditis and 22 with myocarditis. The median age for myopericarditis patients was 16.2 years, and 97% were male. The median initial troponin was 7.1 ng/mL, the peak was at 16.6 ng/mL, and 58% had ST changes on electrocardiogram. The median length of stay for myopericarditis patients was 1.7 days, and 50% were discharged home on nonsteroidal anti-inflammatory medication. Compared with myocarditis, myopericarditis patients were older, had a higher incidence of chest pain, and were less likely to have fever, vomiting, abdominal pain, upper respiratory infection symptoms, chest radiograph abnormalities, or T-wave inversion (P < 0.05). Myopericarditis patients also had lower Pediatric Risk of Mortality version 3 scores, B-type natriuretic peptide levels, and higher left ventricular ejection fractions on admission (67% vs 41%; P < 0.05). A classification model incorporating initial left ventricular ejection fraction, B-type natriuretic peptide, electrocardiogram, and chest radiograph findings distinguished myopericarditis from myocarditis with correct classification in 95% of patients. CONCLUSIONS: Myopericarditis is a relatively common cause of chest pain for patients admitted to the pediatric intensive care unit, presents differently than true myocarditis, and carries a good prognosis.

Improved asthma outcomes among at-risk children in a pharmacist-led, interdisciplinary school-based health clinic: A pilot study of the CAReS program.

BACKGROUND: Disparities in access to care and outcomes have been identified among children with asthma living in underserved communities. The Caring for Asthma in our Region's Schoolchildren program was established to reduce disparities by providing school-based, comprehensive asthma care by a pharmacist-led, interdisciplinary team to high-risk pediatric populations in the Greater Pittsburgh area. OBJECTIVE: To investigate program impact on follow-up appointment attendance, delivery of guideline-based care, asthma control, asthma morbidity (emergency department [ED] visits, oral corticosteroid [OCS] requirement), and asthma-related knowledge and quality of life. METHODS: The study enrolled 50 children with asthma from 6 elementary schools (September 2014-December 2017). Children completed 5 visits over a 3-month period. McNemar's test assessed improvement in guideline-based controller therapy use and reduced morbidity (ED visits or OCS requirement). Generalized estimating equation analyses determined the significance of monthly improvements in asthma control, asthma knowledge, and quality of life. RESULTS: A 100% show rate was achieved in nearly all participants (92.0%). Most of the patients were African-American (56%). In children with persistent disease, only 21.4% were prescribed controller therapy at baseline, which improved to 78.5% upon enrollment (P < 0.05). Asthma control statistically significantly improved (P < 0.05), and a reduction in percentage of patients who required an ED visit or an OCS burst pre-to postintervention was also statistically significant (31.3% vs. 14.6%, P < 0.05). The goal of 100% treatment plan knowledge was achieved in 67% of caregivers within 1 month and increased from 6% to 60% in children over 3 months (P < 0.05). Asthma-related quality of life also improved statistically significantly pre-to postintervention (P < 0.05). CONCLUSIONS: Disparities in asthma outcomes owing to inadequate access to health care can be addressed. Improved asthma control, asthma medication knowledge, quality of life, and reduced morbidity in high-risk pediatric patients are achievable as demonstrated by our study. Our findings support the feasibility and value of a pharmacist-led, interdisciplinary school-based health care delivery model in providing comprehensive asthma care to at-risk pediatric populations.

Asthma prevalence and control among schoolchildren residing near outdoor air pollution sites.

INTRODUCTION: Outdoor air pollution (OAP) contributes to poor asthma outcomes and remains a public health concern in Pittsburgh. The purpose of this study was to determine the prevalence of childhood asthma and its rate of control among Pittsburgh schoolchildren residing near OAP sites. METHODS: Participants were recruited from schools near OAP sites. Asthma prevalence and control were assessed using a validated survey. Demographics and socioeconomic status were collected by survey, BMI was calculated, secondhand smoke (SHS) exposure was assessed by salivary cotinine levels, and OAP was assessed by mobile platform monitoring. Multivariate analysis adjusted for confounders. RESULTS: In 1202 Pittsburgh elementary school students surveyed, 50.9% were female, average age was 8.5 years (SD = 1.9), 52.2% were African American and 60.6% had public health insurance. SHS exposure was relatively high at 33.9%, 17.1% of students were obese, and 70% had exposure to particulate matter (PM2.5) greater than the World Health Organization standard of 10 µg/m3. Overall prevalence of asthma was 22.5% with PM2.5, nitric oxide (NOx), sulfur (S), and zinc (Zn) significantly related to odds of asthma. Among the 270 children previously diagnosed with asthma, 59.3% were not well controlled with PM2.5, black carbon, and silicon (Si) significantly related to odds of uncontrolled asthma. CONCLUSIONS: These results demonstrate that asthma prevalence and poor disease control are significantly elevated in Pittsburgh schoolchildren exposed to high levels of OAP. Future efforts need to focus on primary prevention of asthma by reducing exposure to OAP in at risk populations.

Caregiver Depressive Symptoms and Primary Medication Nonadherence in Children With Asthma.

INTRODUCTION: The purpose of this study was to identify risk factors for primary medication nonadherence among low-income minority children with persistent asthma. METHOD: Data were from an environmental control and educational intervention for children with uncontrolled asthma who were treated in the emergency department for an asthma exacerbation. Presence or absence of pharmacy records for child asthma medications was the outcome of interest. A range of sociodemographic, health, and psychosocial measures were included in the binary logistic regression. RESULTS: Of the 222 youths (mean age = 6.3 years; 93.7% Black), 25 (11.3%) lacked pharmacy records of asthma medications. For every 1-point increase in caregiver depressive symptoms, the odds of the child having a pharmacy record declined by 5% (odds ratio = 0.95; p = .012). DISCUSSION: Providers should systematically assess and monitor caregiver depressive symptoms as a potential contributing factor for primary medication nonadherence in low-income minority children with persistent, uncontrolled asthma.