Lessons Learned From a Sequential Mixed-Mode Survey Design to Recruit and Collect Data From Case-Control Study Participants: Formative Evaluation.

BACKGROUND: Sequential mixed-mode surveys using both web-based surveys and telephone interviews are increasingly being used in observational studies and have been shown to have many benefits; however, the application of this survey design has not been evaluated in the context of epidemiological case-control studies. OBJECTIVE: In this paper, we discuss the challenges, benefits, and limitations of using a sequential mixed-mode survey design for a case-control study assessing risk factors during the COVID-19 pandemic. METHODS: Colorado adults testing positive for SARS-CoV-2 were randomly selected and matched to those with a negative SARS-CoV-2 test result from March to April 2021. Participants were first contacted by SMS text message to complete a self-administered web-based survey asking about community exposures and behaviors. Those who did not respond were contacted for a telephone interview. We evaluated the representativeness of survey participants to sample populations and compared sociodemographic characteristics, participant responses, and time and resource requirements by survey mode using descriptive statistics and logistic regression models. RESULTS: Of enrolled case and control participants, most were interviewed by telephone (308/537, 57.4% and 342/648, 52.8%, respectively), with overall enrollment more than doubling after interviewers called nonresponders. Participants identifying as female or White non-Hispanic, residing in urban areas, and not working outside the home were more likely to complete the web-based survey. Telephone participants were more likely than web-based participants to be aged 18-39 years or 60 years and older and reside in areas with lower levels of education, more linguistic isolation, lower income, and more people of color. While there were statistically significant sociodemographic differences noted between web-based and telephone case and control participants and their respective sample pools, participants were more similar to sample pools when web-based and telephone responses were combined. Web-based participants were less likely to report close contact with an individual with COVID-19 (odds ratio [OR] 0.70, 95% CI 0.53-0.94) but more likely to report community exposures, including visiting a grocery store or retail shop (OR 1.55, 95% CI 1.13-2.12), restaurant or cafe or coffee shop (OR 1.52, 95% CI 1.20-1.92), attending a gathering (OR 1.69, 95% CI 1.34-2.15), or sport or sporting event (OR 1.05, 95% CI 1.05-1.88). The web-based survey required an average of 0.03 (SD 0) person-hours per enrolled participant and US $920 in resources, whereas the telephone interview required an average of 5.11 person-hours per enrolled participant and US $70,000 in interviewer wages. CONCLUSIONS: While we still encountered control recruitment challenges noted in other observational studies, the sequential mixed-mode design was an efficient method for recruiting a more representative group of participants for a case-control study with limited impact on data quality and should be considered during public health emergencies when timely and accurate exposure information is needed to inform control measures.

Competencies for Public Health Professionals and Epidemiologists Who Detect and Investigate Enteric Disease Outbreaks.

OBJECTIVE: Food safety progress depends on the ability of public health agencies to detect and investigate foodborne disease outbreaks. The Integrated Food Safety Centers of Excellence identify and implement best practices and serve as resources for public health professionals who investigate enteric disease outbreaks. To target the needs of this diverse workforce, the Integrated Food Safety Centers of Excellence developed and assessed a professional tier framework and competencies. METHODS: We described the characteristics of public health professionals who investigate enteric disease outbreaks in the epidemiology role in a conceptual tiered framework. We mapped core competencies to each tier and disseminated a survey to practitioners at local (June 2019) and state (August 2018) US public health agencies to evaluate the importance and frequency of each competency. RESULTS: We developed 15 competencies on surveillance, outbreak detection, interview skills, investigation team, specimen testing, data analysis, hypothesis generation, study design, communication, enteric disease biology, control measures, legal authority, quality improvement, environmental health, and reporting to surveillance. The 286 survey respondents selected interview skills, surveillance, control measures, and hypothesis generation as the competencies most important to their work and most frequently performed. CONCLUSION: The Integrated Food Safety Centers of Excellence created the first published workforce framework and competencies for public health professionals who detect and investigate enteric disease outbreaks in the epidemiology role, in collaboration with local, state, and federal public health agencies and national organizations. These tools have been integrated into existing programs and can be used to develop training curricula, assess workforce competency over time, and identify priorities for continuing education and training.

Community exposures among Colorado adults who tested positive for SARS-CoV-2 -A case-control study, March-December 2021.

OBJECTIVES: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, which causes coronavirus disease 2019 (COVID-19), is spread primarily through exposure to respiratory droplets from close contact with an infected person. To inform prevention measures, we conducted a case-control study among Colorado adults to assess the risk of SARS-CoV-2 infection from community exposures. METHODS: Cases were symptomatic Colorado adults (aged ≥18 years) with a positive SARS-CoV-2 test by reverse transcription-polymerase chain reaction (RT-PCR) reported to Colorado's COVID-19 surveillance system. From March 16 to December 23, 2021, cases were randomly selected from surveillance data ≤12 days after their specimen collection date. Cases were matched on age, zip code (urban areas) or region (rural/frontier areas), and specimen collection date with controls randomly selected among persons with a reported negative SARS-CoV-2 test result. Data on close contact and community exposures were obtained from surveillance and a survey administered online. RESULTS: The most common exposure locations among all cases and controls were place of employment, social events, or gatherings and the most frequently reported exposure relationship was co-worker or friend. Cases were more likely than controls to work outside the home (adjusted odds ratio (aOR) 1.18, 95% confidence interval (CI): 1.09-1.28) in industries and occupations related to accommodation and food services, retail sales, and construction. Cases were also more likely than controls to report contact with a non-household member with confirmed or suspected COVID-19 (aOR 1.16, 95% CI: 1.06-1.27). CONCLUSIONS: Understanding the settings and activities associated with a higher risk of SARS-CoV-2 infection is essential for informing prevention measures aimed at reducing the transmission of SARS-CoV-2 and other respiratory diseases. These findings emphasize the risk of community exposure to infected persons and the need for workplace precautions in preventing ongoing transmission.

Perceptions of Parental Tobacco Dependence Treatment Among a Children's Hospital Staff.

OBJECTIVES: To assess employee support for and knowledge of smoking cessation programs for patients' parents and staff and employees' level of comfort discussing smoking with patients and their families before and during a hospital-wide study of a tobacco cessation and/or exposure reduction program for inpatients' parents who smoke. METHODS: Clinical staff were invited to complete online surveys at the beginning of and 19 months into a randomized controlled trial to test the efficacy of an inpatient tobacco cessation and exposure reduction program for parents of hospitalized children. The program included educating pediatric inpatient clinical staff about available resources, such as the Colorado QuitLine, and smoking cessation interventions for the parents of hospitalized children. Clinical staff were recruited via e-mail listservs, a weekly e-mail newsletter, and posted flyers. Baseline and midstudy results were compared, and χ2 tests were performed. RESULTS: At the baseline, 192 clinical staff responded; 235 responded midstudy. At the baseline and midstudy, at least 90% of the respondents believed that the hospital should support parents in quitting smoking, although the support for free nicotine replacement therapy was low (27% at the baseline to 35% at midstudy). One-fifth of the respondents were uncomfortable discussing smoking; this proportion decreased after educational interventions. Knowledge about hospital cessation resources had also increased at midstudy. CONCLUSIONS: There was strong support for helping parents and staff quit smoking. Comfort among clinical staff in addressing tobacco dependence in patients and families and awareness of cessation resources increased over the course of the study.

Marijuana and Tobacco Coexposure in Hospitalized Children.

BACKGROUND: The impact of secondhand marijuana smoke exposure on children is unknown. New methods allow for the detection of marijuana smoke exposure in children. METHODS: We studied children who were hospitalized in Colorado and had a parent participating in a smoking cessation study; all children had urine samples remaining from the original study as well as consent for future research. Parents completed a survey and urine samples were analyzed for cotinine and marijuana metabolites, including 11-hydroxy-Δ9-tetrahydrocannabinol (COOH-THC), by using liquid chromatography-tandem mass spectrometry. RESULTS: The median age of the children was 6.0 years (range 0-17 years); 57% were boys. Half (55%) were white, 12% were African American, and 33% were of another race; 39% identified as Hispanic. Approximately 46% had detectable COOH-THC, and 11% had detectable THC. Of those with detectable THC, 3 were teenagers, and 6 were <8 years of age. There were no significant differences in urinary COOH-THC concentrations by age, sex, race and/or ethnicity, or socioeconomic status. Children with positive results for COOH-THC were more likely to have parents who use marijuana daily, smoke marijuana versus other forms of use, use daily in the home, and smoke marijuana in another room if the children are around compared with smoking outside. CONCLUSIONS: Approximately half of the children who qualified for our study had biological evidence of exposure to marijuana. Researchers in studies such as this provide valuable data on secondhand exposure to children from parents using tobacco and marijuana and can inform public health policies to reduce harm.

An Electronic Health Record Tool Designed to Improve Pediatric Hospital Discharge has Low Predictive Utility for Readmissions.

We developed an electronic health record tool to improve pediatric hospital discharge. This tool flags children with three components that might complicate discharge: home health, polypharmacy (greater than or equal to 6 medications), or nonEnglish speaking caregiver. The tool tallies components and displays them as a composite score of 0-3 points. We describe the tool's development, implementation, and an evaluation of its predictive utility for 30-day unplanned readmissions in 29,542 discharged children. Of these children, 28% had a composite score of 1, 8% a score greater than or equal to 2, and 4% were readmitted. The odds of readmission was significantly higher in children with composite score of 1 versus 0 (odds ratio [OR]: 1.7; 95% CI, 1.5-2) and greater than or equal to 2 versus 0 (OR 4.2; 95% CI 3.6-4.9). The C-statistic for this model was 0.6259. Despite the positive association of the score with readmission, the tool's discriminatory performance is low. Additional research is needed to evaluate its practical benefit for improving the quality of hospital discharge. This study was supported by an institutional Clinical and Operational Effectiveness and Patient Safety Small Grants Program.

Characteristics of Children Hospitalized for Psychogenic Nonepileptic Seizures Due to Conversion Disorder Versus Epilepsy.

OBJECTIVES: Psychogenic nonepileptic seizures (PNES) are a manifestation of conversion disorder among children but can be difficult to distinguish from epilepsy. We sought to identify characteristics that differentiate children with PNES from those with epilepsy. METHODS: We conducted a retrospective cohort study of children admitted with epilepsy or PNES to 45 children's hospitals from 2004 to 2014. Children with PNES (n = 399) versus those with epilepsy (n = 13 241) were compared on demographic and clinical characteristics, testing, treatment, and health care use. Hierarchical multivariable logistic regression was used to identify characteristics associated with PNES diagnosis. RESULTS: Children with PNES were more likely to be female (adjusted odds ratio [aOR] 2.3; 95% confidence interval [CI] 1.8-3.0), older (aOR 3.8; 95% CI 2.7-5.3 for 14-16 years old), African American (aOR 2.0; 95% CI 1.5-2.7), and have diagnosis codes for psychiatric disorders (aOR 7.1; 95% CI 5.6-9.1) and pain (aOR 2.6; 95% CI 1.9-3.4). They were also more likely to be admitted in the fall (aOR 2.0; 95% CI 1.4-2.8) or spring (aOR 1.9; 95% CI 1.4-2.6) versus summer. Total adjusted hospitalization costs were greater for children with epilepsy ($4724, 95% CI $4413-$5057 vs $5326, 95% CI $5259-$5393; P = .001); length of stay was similar. CONCLUSIONS: Demographic and clinical characteristics differed among children with PNES versus those with epilepsy, including significantly increased odds of psychiatric and pain diagnoses among children with PNES. To better inform treatment and prognostication for children with PNES, research is needed to understand reasons for these differences, seasonal admission patterns, and the relationship between PNES and other psychiatric disorders.

Comparison of Fusion Rates Based on Graft Material Following Occipitocervical and Atlantoaxial Arthrodesis in Adults and Children.

BACKGROUND: Fusion rates following rigid internal instrumentation for occipitocervical and atlantoaxial instability approach 100% in many reports. Based on this success and the morbidity that can be associated with obtaining autograft for fusion, surgeons increasingly select alternative graft materials. OBJECTIVE: To examine fusion failure using various graft materials in a retrospective observational study. METHODS: Insurance claims databases (Truven Health MarketScan® [Truven Health Analytics, Ann Arbor, Michigan] and IMS Health Lifelink/PHARMetrics [IMS Health, Danbury, Connecticut]) were used to identify patients with CPT codes 22590 and 22595. Patients were divided by age (≥18 yr = adult) and arthrodesis code, establishing 4 populations. Each population was further separated by graft code: group 1 = 20938 (structural autograft); group 2 = 20931 (structural allograft); group 3 = other graft code (nonstructural); group 4 = no graft code. Fusion failure was assigned when ≥1 predetermined codes presented in the record ≥90 d following the last surgical procedure. RESULTS: Of 522 patients identified, 419 were adult and 103 were pediatric. Fusion failure occurred in 10.9% (57/522) of the population. There was no statistically significant difference in fusion failure based on graft material. Fusion failure occurred in 18.9% of pediatric occipitocervical fusions, but in 9.2% to 11.1% in the other groups. CONCLUSION: Administrative data regarding patients who underwent instrumented occipitocervical or atlantoaxial arthrodesis do not demonstrate differences in fusion rates based on the graft material selected. When compared to many contemporary primary datasets, fusion failure was more frequent; however, several recent studies have shown higher failure rates than previously reported. This may be influenced by broad patient selection and fusion failure criteria that were selected in order to maximize the generalizability of the findings.

Pediatric versus adult meningioma: comparison of epidemiology, treatments, and outcomes using the Surveillance, Epidemiology, and End Results database.

Pediatric meningiomas, which account for < 1% of all meningiomas, are thought to have unique features, including being more aggressive than their adult counterparts. The goal of this investigation was to compare pediatric and adult meningiomas in a large head-to-head comparison. We used the Surveillance, Epidemiology, and End Result (SEER) datasets to compare meningioma demographics, first treatments, and outcomes among children/adolescents (0-21 years), young adults (22-45 years), and older adults (> 45 years). During 2004-2012, SEER contained 59148 patients age 0-107 years diagnosed with meningioma, with children/adolescents accounting for 381 (0.64%) patients. Unlike older and young adults, children/adolescents with meningioma did not demonstrate female predominance, and had an equal 1:1 male-to-female ratio. Children/adolescents also had almost three-times as many spinal tumors (13.1%) than young adults (4.2%) and older adults (4.4%). Both children/adolescents and young adults had undergone more gross total resections (both 43%) versus older adults (25%), and were treated more with radiation (14.6%, and 12.0% respectively) than their older counterparts (8.5%). In addition, both children/adolescents and young adults had significantly lower all-cause mortality (4.5% in both) than older adults (24.6%), during median 35-month follow-up. Inherent limitations of the SEER datasets restrict our ability to answer important questions regarding comparisons of tumor grading, histological diagnosis, cause-specific mortality, and neurofibromatosis status. Pediatric meningiomas appear distinct from their adult counterparts as they do not display the typical female predominance and include more clinically relevant spinal tumors. More extensive surgeries, greater use of radiation therapy, and lower all-cause mortality were seen in both children/adolescents and young adults, which raises questions regarding the perceived uniquely aggressive nature of pediatric meningiomas. However, due to the significant limitations of the SEER datasets, our results must be interpreted cautiously and stand only to foster novel questions, which would be better answered in well-designed, prospective studies.

Exploring provider and parental perceptions to influenza vaccination in the inpatient setting.

BACKGROUND: Hospitalization provides an ideal opportunity for immunization, but few studies have explored provider and parental attitudes toward pediatric inpatient vaccination against influenza. OBJECTIVES: The objectives were to determine provider and caregiver attitudes and explore potential barriers to inpatient influenza vaccination. METHODS: We developed and distributed two surveys to parents/caregivers as well as providers of general pediatric inpatients at Children's Hospital Colorado between October 2014 and March 2015 assessing attitudes toward influenza and inpatient influenza vaccination. We analyzed the Likert scale responses using univariate analyses and multiple logistic regression to assess associations between responses and vaccination status. RESULTS: The overall response rate was 95% and 58% for parents and providers, respectively. Parents of hospitalized children who agreed that flu vaccines are safe (adjusted OR 2.50 [95%CI 1.76-3.58]), and that the influenza vaccine is needed every year had higher odds of having a vaccinated child (adjusted OR 3.30 [95%CI 2.30-4.81]). Most providers (91%) agree that influenza vaccination is an important priority among inpatients, but believe that parental misconceptions and their reluctance for inpatient vaccination are the most important barriers to influenza vaccination. Providers forgetting to ask about vaccination status and order the vaccine are the next most commonly identified barriers. In contrast, most parents surveyed had favorable attitudes toward inpatient influenza vaccination and disagreed that their child was too sick to receive the vaccine during hospitalization.

Tobacco-Smoke Incursions and Satisfaction Among Residents With Children in Multiunit Housing, United States, 2013.

OBJECTIVES: Residents of multiunit housing can be exposed to tobacco smoke even if they do not permit smoking in their homes. Although even low levels of tobacco smoke exposure can cause health problems for children and adults, some landlords are reluctant to ban smoking for fear of decreased occupancy rates or tenant satisfaction. The objective of this study was to assess the impact of tobacco smoke-free policies and tobacco-smoke incursions on housing satisfaction in multiunit housing residences with children. METHODS: In 2013, 3696 randomly sampled US adult multiunit housing dwellers were invited to participate in a survey, and 3253 (88%) participated. Of these, 3128 responded to the question about having a child in the home, and 835 (27%) reported having a child in the home. We collected data on demographic characteristics, tobacco-smoke incursions, knowledge and attitudes about smoking policies, and housing satisfaction for this sample of 835 residents. RESULTS: Of the 827 residents who responded to the question, 755 (91.3%) agreed that tenants have a right to live in a tobacco smoke-free building. Although 672 of 835 (80.5%) residents were not cigarette smokers, most lived where smoking was permitted in the units (n = 463, 56.9%) or on the property (n = 571, 70.5%). Of 580 non-cigarette smoking residents who lived where no one had smoked cigarettes in the home for the past 3 months, 144 (25.2%) reported a recent tobacco-smoke incursion. Of these 144 residents, 143 (99%) were bothered. Few (36/143, 25.2%) complained to the landlord. Reasons for not complaining were reluctance to upset neighbors or concern about retaliation. Tobacco-smoke incursions and housing/landlord satisfaction were inversely related ( P < .05). CONCLUSION: Multiunit housing residents living with children in the United States strongly support smoke-free multiunit housing.

Detecting biomarkers of secondhand marijuana smoke in young children.

BACKGROUND: The impact of secondhand marijuana smoke exposure on children is unknown. New methods allow detection of secondhand marijuana smoke in children. METHODS: We studied children ages 1 mo to 2 y hospitalized with bronchiolitis in Colorado from 2013 to 2015. Parents completed a survey, and urine samples were analyzed for cotinine using LC/MS/MS (limits of detection 0.03 ng/ml) and marijuana metabolites including COOH-THC (limits of detection 0.015 ng/ml). RESULTS: A total of 43 subjects had urine samples available for analysis. Most (77%) of the subjects were male, and 52% were less than 1 y of age. COOH-THC was detectable in 16% of the samples analyzed (THC+); the range in COOH-THC concentration was 0.03-1.5 ng/ml. Two subjects had levels >1 ng/ml. Exposure did not differ by gender or age. Non-white children had more exposure than white children (44 vs. 9%; P < 0.05). 56% of children with cotinine >2.0 ng/ml were THC+, compared with 7% of those with lower cotinine (P < 0.01). CONCLUSION: Metabolites of marijuana smoke can be detected in children; in this cohort, 16% were exposed. Detectable COOH-THC is more common in children with tobacco smoke exposure. More research is needed to assess the health impacts of marijuana smoke exposure on children and inform public health policy.

Missed Opportunities for Influenza Vaccination Among Hospitalized Children With Influenza at a Tertiary Care Facility.

OBJECTIVES: To identify the extent and characteristics of missed opportunities for influenza vaccination among children hospitalized with influenza at a tertiary children's hospital. METHODS: We conducted a retrospective cohort study of hospitalized patients with polymerase chain reaction-confirmed influenza admitted to Children's Hospital Colorado from 2010 to 2014. We reviewed medical records for vaccination status and previous visits. The primary outcome was the proportion of underimmunized patients hospitalized with influenza with at least 1 missed opportunity visit (visit before influenza diagnosis in which an eligible patient did not receive the influenza vaccine). The relationship between sociodemographic characteristics and the primary outcome were examined using χ(2) tests and nonparametric tests, and variables with P < .2 were entered into a multivariate logistic regression model. RESULTS: Among 322 patients hospitalized with influenza, 199 (61%) were undervaccinated; 83 of 199 (42%) had at least 1 missed opportunity for influenza vaccination. Multivariate analysis demonstrated that high-risk status (adjusted odds ratio 6.9, 95% confidence interval 3.8-12.4) was associated with increased odds of having a missed opportunity visit. Most missed opportunity visits were to subspecialty clinics (42%), and most visits (71%) occurred from September to November. CONCLUSIONS: More than 40% of hospitalizations for influenza in children are associated with at least 1 missed opportunity visit at a tertiary center. Our findings highlight the potential role of tertiary care institutions in increasing influenza vaccination rates among children.

Enterovirus D68 in Critically Ill Children: A Comparison With Pandemic H1N1 Influenza.

OBJECTIVE: In 2014, the Unites States experienced an outbreak of enterovirus D68 associated with severe respiratory illness. The clinical characteristics associated with severe illness from enterovirus D68 during this outbreak compared with those associated with the 2009 H1N1 influenza virus outbreak are unknown. DESIGN AND SETTING: In this retrospective cohort study, we characterized the clinical features of children with enterovirus D68 admitted to the PICU between August 1, 2014, and November 1, 2014, and compared them with critically ill children infected with H1N1 influenza during the pandemic admitted between May 1, 2009, and January 31, 2010. PATIENTS: PICU patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Ninety-seven severely ill children with enterovirus D68 infections were compared with 68 children infected with H1N1 influenza during the 2009 pandemic. Children with enterovirus D68 were more likely to have asthma (62% vs 23%; p < 0.001) and present with reactive airway disease exacerbations, with greater receipt of albuterol (94% vs 49%) and steroids (89% vs 40%; p < 0.0001 for both). Although more children with enterovirus D68 were admitted to the ICU compared with those with H1N1 influenza, they had a shorter hospital length of stay (4 vs 7 d; p < 0.0001), with lower intubation rates (7% vs 44%), vasopressor use (3% vs 32%), acute respiratory distress syndrome (3% vs 24%), shock (0% vs 16%), and death (0% vs 12%; p < 0.05 for all). Compared with children with other enteroviruses and rhinoviruses, children with enterovirus D68 were more likely to have a history of asthma (64% vs 45%) or multiple prior wheezing episodes (54% vs 34%; p < 0.01 for both). CONCLUSIONS: Critically ill children with enterovirus D68 were more likely to present with reactive airway disease exacerbations, whereas children with H1N1 influenza were more likely to present with pneumonia. Compared with the pandemic H1N1 influenza outbreak, the enterovirus D68 outbreak resulted in more children requiring admission to the ICU, but was associated with less severe outcomes.

Atypical pediatric ganglioglioma is common and associated with a less favorable clinical course.

OBJECT Ganglioglioma (GG) is commonly recognized as a low-grade tumor located in the temporal lobe, often presenting with seizures. Most are amenable to complete resection and are associated with excellent oncological outcome. The authors encountered several GGs in various locations, which seem to have a less favorable clinical course than GGs in the temporal lobe. METHODS The authors performed a single-center retrospective review of all children with a histological diagnosis of GG who were treated at Children's Hospital Colorado between 1997 and 2013. Each tumor was categorized by 2 pediatric neuroradiologists as typical or atypical based on preoperative MRI appearance. Typical lesions were cortically based, within a single cerebral lobe, well-circumscribed, and solid or mixed solid/cystic. The treatment and clinical course of each patient was analyzed. RESULTS Thirty-seven children were identified, with a median age at presentation of 8.2 years and median follow-up of 38.0 months. Eighteen tumors (48.6%) were typical and 19 (51.4%) were atypical. All typical lesions presented with seizures, whereas no atypical lesions did so. Sixteen (88.9%) typical lesions were located in the temporal lobe. In the atypical group, tumor location was variable, including 11 (57.9%) in the brainstem. Death during follow-up was statistically more common in the atypical group (31.6% vs 0%, p = 0.02). Gross-total resection (GTR) was achieved for 15 of 16 typical tumors (93.8%), compared with 3 atypical tumors (15.8%, p < 0.0001). Presentation with seizure or non-brainstem location were each associated with survival (p = 0.02 and 0.004, respectively). The presence of mutation in BRAF exon 15 did not differ between the 2 groups. CONCLUSIONS Pediatric GG with typical imaging features is associated with excellent rates of GTR and overall survival. Atypical GG is commonly encountered, less amenable to GTR, and associated with a worse outcome. This may relate to anatomical or biological characteristics and merits further investigation.

Routine perioperative ketorolac administration is not associated with hemorrhage in pediatric neurosurgery patients.

OBJECT NSAIDs are effective perioperative analgesics. Many surgeons are reluctant to use NSAIDs perioperatively because of a theoretical increase in the risk for bleeding events. The authors assessed the effect of routine perioperative ketorolac use on intracranial hemorrhage in children undergoing a wide range of neurosurgical procedures. METHODS A retrospective single-institution analysis of 1451 neurosurgical cases was performed. Data included demographics, type of surgery, and perioperative ketorolac use. Outcomes included bleeding events requiring return to the operating room, bleeding seen on postoperative imaging, and the development of renal failure or gastrointestinal tract injury. Variables associated with both the exposure and outcomes (p < 0.20) were evaluated as potential confounders for bleeding on postoperative imaging, and multivariable logistic regression was performed. Bivariable analysis was performed for bleeding events. Odds ratios and 95% CIs were estimated. RESULTS Of the 1451 patients, 955 received ketorolac. Multivariate regression analysis demonstrated no significant association between clinically significant bleeding events (OR 0.69; 95% CI 0.15-3.1) or radiographic hemorrhage (OR 0.81; 95% CI 0.43-1.51) and the perioperative administration of ketorolac. Treatment with a medication that creates a known bleeding risk (OR 3.11; 95% CI 1.01-9.57), surgical procedure (OR 2.35; 95% CI 1.11-4.94), and craniotomy/craniectomy (OR 2.43; 95% CI 1.19-4.94) were associated with a significantly elevated risk for radiographically identified hemorrhage. CONCLUSIONS Short-term ketorolac therapy does not appear to be associated with a statistically significant increase in the risk of bleeding documented on postoperative imaging in pediatric neurosurgical patients and may be considered as part of a perioperative analgesic regimen. Although no association was found between ketorolac and clinically significant bleeding events, a larger study needs to be conducted to control for confounding factors, because of the rarity of these events.

Short-term mortality following surgical procedures for the diagnosis of pediatric brain tumors: outcome analysis in 5533 children from SEER, 2004-2011.

OBJECT Thirty-day mortality is increasingly a reference metric regarding surgical outcomes. Recent data estimate a 30-day mortality rate of 1.4-2.7% after craniotomy for tumors in children. No detailed analysis of short-term mortality following a diagnostic neurosurgical procedure (e.g., resection or tissue biopsy) for tumor in the US pediatric population has been conducted. METHODS The Surveillance, Epidemiology and End Results (SEER) data sets identified patients ≤ 21 years who underwent a diagnostic neurosurgical procedure for primary intracranial tumor from 2004 to 2011. One- and two-month mortality was estimated. Standard statistical methods estimated associations between independent variables and mortality. RESULTS A total of 5533 patients met criteria for inclusion. Death occurred within the calendar month of surgery in 64 patients (1.16%) and by the conclusion of the calendar month following surgery in 95 patients (1.72%). Within the first calendar month, patients < 1 year of age (n = 318) had a risk of death of 5.66%, while those from 1 to 21 years (n = 5215) had a risk of 0.88% (p < 0.0001). By the end of the calendar month following surgery, patients < 1 year (n = 318) had a risk of death of 7.23%, while those from 1 to 21 years (n = 5215) had a risk of 1.38% (p < 0.0001). Children < 1 year at diagnosis were more likely to harbor a high-grade lesion than older children (OR 1.9, 95% CI 1.5-2.4). CONCLUSIONS In the SEER data sets, the risk of death within 30 days of a diagnostic neurosurgical procedure for a primary pediatric brain tumor is between 1.16% and 1.72%, consistent with contemporary data from European populations. The risk of mortality in infants is considerably higher, between 5.66% and 7.23%, and they harbor more aggressive lesions.

A comparison of H1N1 influenza among pediatric inpatients in the pandemic and post pandemic era.

BACKGROUND: The novel influenza A H1N1 (A[H1N1]pdm09) strain emerged in 2009, contributing to significant morbidity and mortality. It is not known whether illness associated with A(H1N1) pdm09 in the post-pandemic era exhibits a similar disease profile. OBJECTIVE: The objectives of this study were to compare the burden of disease of A(H1N1) pdm09 influenza from the 2009 pandemic year to the post-pandemic years (2010-2014), and to explore potential reasons for any differences. STUDY DESIGN: We conducted a retrospective cohort study of inpatients admitted to Children's Hospital Colorado with a positive respiratory specimen for influenza from May-December, 2009 and December, 2010-April, 2014. Univariate and multivariate analyses were conducted to compare the demographics and clinical characteristics of patients with H1N1 during the two periods. RESULTS: There were 388 inpatients with influenza A(H1N1) pdm09 in 2009, and 117 during the post-pandemic years. Ninety-four percent of all H1N1 during the post-pandemic era was observed during the 2013-2014 influenza season. Patients with A(H1N1) pdm09 during the post-pandemic year were less likely to have an underlying medical condition (P<0.01). Patients admitted to the ICU during the post-pandemic year had a lower median age (5 vs 8 years, P=0.01) and a lower proportion of patients were intubated, had mental status changes, and ARDS compared with the pandemic years, (P<0.01 for all), with decreased mortality (P=0.02). CONCLUSION: Patients with influenza A(H1N1) pdm09 during the post-pandemic years appeared to have less severe disease than patients with A(H1N1) pdm09 during the pandemic year. The reasons for this difference are likely multifactorial.

Hospitalization for Community-Acquired Pneumonia in Children: Effect of an Asthma Codiagnosis.

BACKGROUND AND OBJECTIVE: Community-acquired pneumonia (CAP) is a common and expensive cause of hospitalization among US children, many of whom receive a codiagnosis of acute asthma. The objective of this study was to describe demographic characteristics, cost, length of stay (LOS), and adherence to clinical guidelines among these groups and to compare health care utilization and guideline adherence between them. METHODS: This was a multicenter retrospective cohort study using data from the Pediatric Health Information System. Children aged 2 to 18 who were hospitalized with uncomplicated CAP from July 1, 2007, to June 30, 2012 were included. Demographics, LOS, total standardized cost, and clinical guideline adherence were compared between patients with CAP only and CAP plus acute asthma. RESULTS: Among the 25,124 admissions, 57% were diagnosed with CAP only; 43% had a codiagnosis of acute asthma. The geometric mean for standardized cost was $4830; for LOS, it was 2.01 days. Eighty-four percent of patients had chest radiographs; CAP+acute asthma patients were less likely to have a blood culture performed (36% vs 62%, respectively) and more likely not to have a complete blood count performed (49% vs 27%, respectively). Greater guideline adherence was associated with higher cost at the patient-level but lower average cost per hospitalization at the hospital level. CAP+acute asthma patients had higher relative costs (11.8%) and LOS (5.6%) within hospitals and had more cost variation across hospitals, compared with patients with CAP only. CONCLUSIONS: A codiagnosis of acute asthma is common for children with CAP. This could be from misdiagnosis or co-occurrence. Diagnostic and/or management variability appears to be greater in patients with CAP+asthma, which may increase resource utilization and LOS for these patients.