Cancer worry and its impact on self-reported depressive symptoms among adult males and females in the US: a nationwide sample study.

OBJECTIVE: With cancer the second deadliest disease in the world, worry about cancer can have mental health or psychiatric implications. This study examines the prevalence, differences, and influence of cancer worry (CW), its interaction effect with age, and other confounders on self-reported depressive symptoms (SRDS) among adult males and females in the US. METHODS: We utilized a nationally representative sample data of 2,950 individuals (males = 1,276; females = 1,674) from Cycle 4 of the Health Information National Trends Survey 5 (HINTS 5) 2020. Using frequencies, bivariate chi-square test, and multivariate logistic regression, we examined the prevalence, difference, and association of CW with SRDS, adjusting for confounders. RESULTS: The prevalence rate of SRDS was found to be 32% among females and 23.5% among males. Among individuals with CW, females had a higher prevalence of SRDS compared to males (40.5% vs. 35.1%). However, there was a significant difference in the likelihood of experiencing SRDS between males and females with CW, with males having 84% increased risk compared to females. Across all age groups, the multivariate analysis of the relationship between CW and SRDS revealed that both males and females showed a significantly decreased likelihood of SRDS compared to those aged 18-34 years. However, males aged 35 years or older exhibited an even more pronounced decrease in likelihood compared to females in the same age group. Nonetheless, when examining the interaction of age and CW, we observed a significantly increased likelihood of SRDS across all age groups. Males, in particular, had a higher increased likelihood of SRDS compared to females across all ages, except for those aged 75 years and older. CONCLUSION: The findings of this study highlight the significant influence of CW on individuals' SRDS and the modifying effect of age, particularly among males. These results are important for a better understanding of the risk of CW on mental health, which can be a preventive strategy or control mechanism.

Therapeutic Plasma Exchange in Children With Thrombocytopenia-Associated Multiple Organ Failure: The Thrombocytopenia-Associated Multiple Organ Failure Network Prospective Experience.

OBJECTIVE: The objective was to compare the resolution of organ dysfunction, 28-day mortality, and biochemical markers in children with thrombocytopenia-associated multiple organ failure who received therapeutic plasma exchange versus no therapeutic plasma exchange. DESIGN: Observational longitudinal cohort study. SETTING: Nine U.S. PICUs. PATIENTS: Eighty-one children with sepsis-induced thrombocytopenia-associated multiple organ failure. INTERVENTIONS: Therapeutic plasma exchange. MEASUREMENTS AND MAIN RESULTS: Adjusted relative risk for 28-day mortality was modeled using standard multivariate regression with propensity score weighting to reduce covariate confounding. Change from baseline Pediatric Logistic Organ Dysfunction scores between therapeutic plasma exchange and no therapeutic plasma exchange differed in temporal pattern during the first week (p = 0.009). By day 4, mean Pediatric Logistic Organ Dysfunction score declined by 7.9 points (95% CI, -10.8 to -5.1) in the therapeutic plasma exchange-treated group compared with no change with no therapeutic plasma exchange. Use of therapeutic plasma exchange was associated with reduced 28-day mortality by multivariate analysis (adjusted relative risk, 0.45; 95% CI, 0.23-0.90; p = 0.02) and by propensity score weighting (adjusted relative risk, 0.46; 95% CI, 0.22-0.97; p = 0.04). CONCLUSIONS: Therapeutic plasma exchange use in thrombocytopenia-associated multiple organ failure was associated with a decrease in organ dysfunction. After accounting for several risk factors, 28-day all-cause mortality was lower in children treated with therapeutic plasma exchange compared with those receiving no therapeutic plasma exchange. A multicenter randomized clinical trial is necessary to determine a causal relationship.

Venoarterial Extracorporeal Membrane Oxygenation Versus Conventional Therapy in Severe Pediatric Septic Shock.

OBJECTIVES: The role of venoarterial extracorporeal membrane oxygenation in the treatment of severe pediatric septic shock continues to be intensely debated. Our objective was to determine whether the use of venoarterial extracorporeal membrane oxygenation in severe septic shock was associated with altered patient mortality, morbidity, and/or length of ICU and hospital stay when compared with conventional therapy. DESIGN: International multicenter, retrospective cohort study using prospectively collected data of children admitted to intensive care with a diagnosis of severe septic shock between the years 2006 and 2014. SETTING: Tertiary PICUs in Australia, New Zealand, Netherlands, United Kingdom, and United States. PATIENTS: Children greater than 30 days old and less than 18 years old. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 2,452 children with a diagnosis of sepsis or septic shock, 164 patients met the inclusion criteria for severe septic shock. With conventional therapy (n = 120), survival to hospital discharge was 40%. With venoarterial extracorporeal membrane oxygenation (n = 44), survival was 50% (p = 0.25; CI, -0.3 to 0.1). In children who suffered an in-hospital cardiac arrest, survival to hospital discharge was 18% with conventional therapy and 42% with venoarterial extracorporeal membrane oxygenation (Δ = 24%; p = 0.02; CI, 2.5-42%). Survival was significantly higher in patients who received high extracorporeal membrane oxygenation flows of greater than 150 mL/kg/min compared with children who received standard extracorporeal membrane oxygenation flows or no extracorporeal membrane oxygenation (82%, 43%, and 48%; p = 0.03; CI, 0.1-0.7 and p < 0.01; CI, 0.2-0.7, respectively). Lengths of ICU and hospital stay were significantly longer for children who had venoarterial extracorporeal membrane oxygenation. CONCLUSIONS: The use of venoarterial extracorporeal membrane oxygenation in severe pediatric sepsis is not by itself associated with improved survival. However, venoarterial extracorporeal membrane oxygenation significantly reduces mortality after cardiac arrest due to septic shock. Venoarterial extracorporeal membrane oxygenation flows greater than 150 mL/kg/min are associated with almost twice the survival rate of conventional therapy or standard-flow extracorporeal membrane oxygenation.

Recommendations on the Indications for RBC Transfusion for the Critically Ill Child Receiving Support From Extracorporeal Membrane Oxygenation, Ventricular Assist, and Renal Replacement Therapy Devices From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative.

OBJECTIVES: To present recommendations and supporting literature for RBC transfusions in critically ill children supported with extracorporeal membrane oxygenation, ventricular assist devices, or renal replacement therapy. DESIGN: Consensus conference series of international, multidisciplinary experts in RBC transfusion management of critically ill children. METHODS: The panel of 38 experts developed evidence-based, and when evidence was lacking, expert-based clinical recommendations as well as research priorities for RBC transfusions in critically ill children. The extracorporeal membrane oxygenation/ventricular assist device/renal replacement therapy subgroup included six experts. We conducted electronic searches of the PubMed, EMBASE, and Cochrane Library databases from 1980 to May 2017, using medical subject heading terms and text words to define concepts of RBC transfusion, extracorporeal membrane oxygenation, ventricular assist device, and renal replacement therapy. We used a standardized data extraction form to construct evidence tables and graded the evidence using the Grading of Recommendations Assessment, Development, and Evaluation system. Recommendations developed and supporting literature were reviewed and scored by all panel members. Agreement was obtained using the Research and Development/UCLA Appropriateness Method. RESULTS: For inpatients requiring extracorporeal membrane oxygenation, ventricular assist device, or renal replacement therapy support, there was expert agreement (> 80%) on five good practice statements aimed to improve accuracy and uniform reporting of RBC transfusion data in pediatric extracorporeal membrane oxygenation, ventricular assist device, and renal replacement therapy studies and quality improvement projects; four clinical recommendations of physiologic metrics and biomarkers of oxygen delivery, in addition to hemoglobin concentration, to guide RBC transfusion, acknowledging insufficient evidence to recommend specific RBC transfusion strategies; and eight research recommendations. CONCLUSIONS: Further research surrounding indications, risks, benefits, and alternatives to RBC transfusion in children on extracorporeal devices is clearly needed. Using a structured literature review and grading process, the Transfusion and Anemia Expertise Initiative panel concluded that there is currently insufficient evidence to recommend specific RBC transfusion variables in children requiring extracorporeal membrane oxygenation, ventricular assist device, or renal replacement therapy support.

Consensus Recommendations for RBC Transfusion Practice in Critically Ill Children From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative.

OBJECTIVES: To date, there are no published guidelines to direct RBC transfusion decision-making specifically for critically ill children. We present the recommendations from the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. DESIGN: Consensus conference series of multidisciplinary, international experts in RBC transfusion management of critically ill children. SETTING: Not applicable. INTERVENTION: None. SUBJECTS: Children with, or children at risk for, critical illness who receive or are at risk for receiving a RBC transfusion. METHODS: A panel of 38 content and four methodology experts met over the course of 2 years to develop evidence-based, and when evidence lacking, expert consensus-based recommendations regarding decision-making for RBC transfusion management and research priorities for transfusion in critically ill children. The experts focused on nine specific populations of critically ill children: general, respiratory failure, nonhemorrhagic shock, nonlife-threatening bleeding or hemorrhagic shock, acute brain injury, acquired/congenital heart disease, sickle cell/oncology/transplant, extracorporeal membrane oxygenation/ventricular assist/ renal replacement support, and alternative processing. Data to formulate evidence-based and expert consensus recommendations were selected based on searches of PubMed, EMBASE, and Cochrane Library from 1980 to May 2017. Agreement was obtained using the Research and Development/UCLA Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. MEASUREMENTS AND RESULTS: The Transfusion and Anemia Expertise Initiative consensus conference developed and reached consensus on a total of 102 recommendations (57 clinical [20 evidence based, 37 expert consensus], 45 research recommendations). All final recommendations met agreement, defined a priori as greater than 80%. A decision tree to aid clinicians was created based on the clinical recommendations. CONCLUSIONS: The Transfusion and Anemia Expertise Initiative recommendations provide important clinical guidance and applicable tools to avoid unnecessary RBC transfusions. Research recommendations identify areas of focus for future investigation to improve outcomes and safety for RBC transfusion.

Successful Use of Extracorporeal Life Support in a Hematopoietic Stem Cell Transplant Patient with Neuroblastoma.

Respiratory failure associated with hematopoietic stem cell transplantation (HSCT) has been considered a contraindication for use of extracorporeal membrane oxygenation (ECMO) at many centers. We describe a child with neuroblastoma and hypoxemic respiratory failure following HSCT who was successfully managed with veno-venous (VV) ECMO. The patient was an 18-month-old female with high-risk neuroblastoma status post tumor resection, chemotherapy, autologous HSCT, and primary site radiation. On day 113 posttransplant while receiving maintenance immunotherapy, she had an acute respiratory decompensation because of rhinovirus, aspiration pneumonia, and capillary leak syndrome. The patient was intubated and transitioned to a high frequency oscillatory ventilation and inhaled nitric oxide. Because of refractory hypoxemia, she was cannulated for VV ECMO. She was weaned and decannulated after 7.5 days on ECMO, then subsequently transferred for inpatient rehabilitation. The most recent Extracorporeal Life Support Organization registry analysis showed low survival (3/29) in patients requiring ECMO after HSCT, and 2 of 3 survivors had nononcological diagnoses. However, our patient's outcome suggests that HSCT status should not be an absolute contraindication. The presence of a reversible single organ failure and the absence of significant bleeding risk in an engrafted, neurologically intact, and non-neutropenic HSCT patient with a favorable prognosis can support the potential benefit of ECMO.

Resuscitation With Balanced Fluids Is Associated With Improved Survival in Pediatric Severe Sepsis.

OBJECTIVE: To evaluate outcomes in patients receiving balanced fluids for resuscitation in pediatric severe sepsis. DESIGN: Observational cohort review of prospectively collected data from a large administrative database. SETTING: PICUs from 43 children's hospitals. PATIENTS: PICU patients diagnosed with severe sepsis. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We reviewed data from the Pediatric Health Information System database from 2004 to 2012. Children with pediatric severe sepsis receiving balanced fluids for resuscitation in the first 24 and 72 hours of treatment were compared to those receiving unbalanced fluids. Thirty-six thousand nine hundred eight patients met entry criteria for analysis. Two thousand three hundred ninety-eight patients received exclusively balanced fluids at 24 hours and 1,641 at 72 hours. After propensity matching, the 72-hour balanced fluids group had lower mortality (12.5% vs 15.9%; p = 0.007; odds ratio, 0.76; 95% CI, 0.62-0.93), lower prevalence of acute kidney injury (16.0% vs 19.2%; p = 0.028; odds ratio, 0.82; 95% CI, 0.68-0.98), and fewer vasoactive infusion days (3.0 vs 3.3 d; p < 0.001) when compared with the unbalanced fluids group. CONCLUSIONS: In this retrospective analysis carried out by propensity matching, exclusive use of balanced fluids in pediatric severe sepsis patients for the first 72 hours of resuscitation was associated with improved survival, decreased prevalence of acute kidney injury, and shorter duration of vasoactive infusions when compared with exclusive use of unbalanced fluids.

American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock.

OBJECTIVES: The American College of Critical Care Medicine provided 2002 and 2007 guidelines for hemodynamic support of newborn and pediatric septic shock. Provide the 2014 update of the 2007 American College of Critical Care Medicine "Clinical Guidelines for Hemodynamic Support of Neonates and Children with Septic Shock." DESIGN: Society of Critical Care Medicine members were identified from general solicitation at Society of Critical Care Medicine Educational and Scientific Symposia (2006-2014). The PubMed/Medline/Embase literature (2006-14) was searched by the Society of Critical Care Medicine librarian using the keywords: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, extracorporeal membrane oxygenation, and American College of Critical Care Medicine guidelines in the newborn and pediatric age groups. MEASUREMENTS AND MAIN RESULTS: The 2002 and 2007 guidelines were widely disseminated, translated into Spanish and Portuguese, and incorporated into Society of Critical Care Medicine and American Heart Association/Pediatric Advanced Life Support sanctioned recommendations. The review of new literature highlights two tertiary pediatric centers that implemented quality improvement initiatives to improve early septic shock recognition and first-hour compliance to these guidelines. Improved compliance reduced hospital mortality from 4% to 2%. Analysis of Global Sepsis Initiative data in resource rich developed and developing nations further showed improved hospital mortality with compliance to first-hour and stabilization guideline recommendations. CONCLUSIONS: The major new recommendation in the 2014 update is consideration of institution-specific use of 1) a "recognition bundle" containing a trigger tool for rapid identification of patients with septic shock, 2) a "resuscitation and stabilization bundle" to help adherence to best practice principles, and 3) a "performance bundle" to identify and overcome perceived barriers to the pursuit of best practice principles.

Experience with the use of propofol for radiologic imaging in infants younger than 6 months of age.

BACKGROUND: There is an increased risk associated with procedural sedation of infants younger than 6 months of age. The use of propofol for radiologic imaging of this age group is not well studied. OBJECTIVE: We hypothesize that adverse events are higher in the infant population receiving propofol for radiologic imaging. MATERIALS AND METHODS: A retrospective chart review was undertaken of 304 infants younger than 6 months old who received propofol for procedural sedation from October 2012 to February 2015. Patient demographics, propofol dosing, sedation-related adverse events and interventions were collected. Serious adverse events were defined as laryngospasm, aspiration, the need for admission, cardiac arrest or death. RESULTS: Procedural sedation for radiologic imaging was successful in 301/304 (99%) of infants using propofol. Of these 304 patients, 130 (42.8%) patients were female, and 240 of the 304 (79%) were between 3 and 6 months of age. The majority of patients (172/304 [56.6%]) were American Society of Anesthesiologists-Physical Status Class II. There were 57 sedation-related, minor adverse events in 39 out of 304 (12.8%) patients. Thirteen of the 304 (4.3%) patients had 14 serious adverse events, with airway obstruction the most common. Eighty interventions were required in 56/304 (18.4%) patients. The most common interventions were continuous positive airway pressure (CPAP) in 25/304 patients (8.2%) and jaw thrust in 15/304 (4.9%). The median induction propofol dose was 4.7 mg/kg. A need for an increase in the propofol infusion rate during the procedure was noted in 162/304 (53.3%) infants. No significant predictors of sedation-related adverse events were detected. CONCLUSION: Propofol can be used for radiologic imaging of infants younger than 6 months of age with a high success rate. Practitioners should be mindful of significantly higher dosing requirements and a higher incidence of airway events, which can be easily identified and managed by a team of experienced sedation providers.

Effect of Inhaled Nitric Oxide on Outcomes in Children With Acute Lung Injury: Propensity Matched Analysis From a Linked Database.

OBJECTIVES: To evaluate the effect of inhaled nitric oxide on outcomes in children with acute lung injury. DESIGN: Retrospective study with a secondary data analysis of linked data from two national databases. Propensity score matching was performed to adjust for potential confounding variables between patients who received at least 24 hours of inhaled nitric oxide (inhaled nitric oxide group) and those who did not receive inhaled nitric oxide (no inhaled nitric oxide group). SETTING: Linked data from Virtual Pediatric Systems (LLC) database and Pediatric Health Information System. PATIENTS: Patients less than 18 years old receiving mechanical ventilation for acute lung injury at nine participating hospitals were included (2009-2014). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 20,106 patients from nine hospitals were included. Of these, 859 patients (4.3%) received inhaled nitric oxide for at least 24 hours during their hospital stay. Prior to matching, patients in the inhaled nitric oxide group were younger, with more comorbidities, greater severity of illness scores, higher prevalence of cardiopulmonary resuscitation, and greater resource utilization. Before matching, unadjusted outcomes, including mortality, were worse in the inhaled nitric oxide group (inhaled nitric oxide vs no inhaled nitric oxide; 25.7% vs 7.9%; p < 0.001; standardized mortality ratio, 2.6 [2.3-3.1] vs 1.1 [1.0-1.2]; p < 0.001). Propensity score matching of 521 patient pairs revealed no difference in mortality in the two groups (22.3% vs 20.2%; p = 0.40; standardized mortality ratio, 2.5 [2.1-3.0] vs 2.3 [1.9-2.8]; p = 0.53). However, the other outcomes such as ventilation free days (10.1 vs 13.6 d; p < 0.001), duration of mechanical ventilation (13.8 vs 10.1 d; p < 0.001), duration of ICU and hospital stay (15.5 vs 12.2 d; p < 0.001 and 28.0 vs 24.1 d; p < 0.001), and hospital costs ($150,569 vs $102,823; p < 0.001) were significantly worse in the inhaled nitric oxide group. CONCLUSIONS: This large observational study demonstrated that inhaled nitric oxide administration in children with acute lung injury was not associated with improved mortality. Rather, it was associated with increased hospital utilization and hospital costs.

Outcomes following implementation of a pediatric procedural sedation guide for referral to general anesthesia for magnetic resonance imaging studies.

BACKGROUND/AIMS: Guidelines for referral of children to general anesthesia (GA) to complete MRI studies are lacking. We devised a pediatric procedural sedation guide to determine whether a pediatric procedural sedation guide would decrease serious adverse events and decrease failed sedations requiring rescheduling with GA. METHODS: We constructed a consensus-based sedation guide by combining a retrospective review of reasons for referral of children to GA (n = 221) with published risk factors associated with the inability to complete the MRI study with sedation. An interrupted time series analysis of 11 530 local sedation records from the Pediatric Sedation Research Consortium between July 2008 and March 2013, adjusted for case-mix differences in the pre- and postsedation guide cohorts, evaluated whether a sedation guide resulted in decreased severe adverse events (SAE) and failed sedation rates. RESULTS: A significant increase in referrals to GA following implementation of a sedation guide occurred (P < 0.001), and fewer children with an ASA-PS class ≥III were sedated using procedural sedation (P < 0.001). There was no decrease in SAE (P = 0.874) or in SAE plus airway obstruction with concurrent hypoxia (P = 0.435). There was no change in the percentage of failed sedations (P = 0.169). CONCLUSIONS: More studies are needed to determine the impact of a sedation guide on pediatric procedural sedation services.

Extracorporeal therapies in pediatric severe sepsis: findings from the pediatric health-care information system.

INTRODUCTION: Pediatric severe sepsis (PSS) continues to be a major health problem. Extracorporeal therapies (ETs), defined as extracorporeal membrane oxygenation (ECMO) and RRenal replacement therapyenal replacement therapy (RRT), are becoming more available for utilization in a variety of health conditions. We aim to describe (1) rates of utilization of ET in PSS, (2) outcomes for PSS patients receiving ET, and (3) epidemiologic characteristics of patients receiving ET. METHODS: We conducted a retrospective review of a prospectively collected database. Data from the Pediatric Health Information System (PHIS) database collected by the Children's Hospital Association (CHA) from 2004-2012 from 43 US children's hospitals' pediatric intensive care units (PICUs) were used. Patients with PSS were defined by (1) International Classification of Diseases, 9th Revision (ICD-9) codes reflecting severe sepsis and septic shock and (2) ICD-9 codes of infection and organ dysfunction as defined by updated Angus criteria. Among the patients with PSS, those with a PHIS flag of ECMO or RRT were identified further as our main cohort. RESULTS: From 2004 to 2012, 636,842 patients were identified from 43 hospitals, and PSS prevalence was 7.7 % (49,153 patients). Nine point eight percent (4795 patients) received at least one form of ET, and the associated mortality rate was 39 %. Mortality rates were 47.8 % for those who received ECMO, 32.3 % in RRT, and 58.0 % in RRT + ECMO. Underlying co-morbidities were found in 3745 patients (78.1 %) who received ET (81 % for ECMO, 77.9 % in RRT, and 71.2 % in those who received both). There was a statistically significant increase in ECMO utilization in patients with at least three organ dysfunctions from 2004 to 2012 (6.9 % versus 10.3 %, P < 0.001) while RRT use declined (24.5 % versus 13.2 %, P < 0.001). After 2009, there was a significant increase in ECMO utilization (3.6 % in 2004-2008 versus 4.0 % in 2009-2012, P = 0.004). ECMO and RRT were used simultaneously in only 500 patients with PSS (1 %). CONCLUSIONS: ETs were used in a significant portion of PSS patients with multiple organ dysfunction syndrome (MODS) during this time period. Mortality was significant and increased with increasing organ failure. ECMO use in PSS patients with MODS increased from 2004 to 2012. Further evaluation of ET use in PSS is warranted.

Pediatric critical care physician-administered procedural sedation using propofol: a report from the Pediatric Sedation Research Consortium Database.

OBJECTIVE: Increasing demand for pediatric procedural sedation has resulted in a marked increase in provision of pediatric procedural sedation by pediatric critical care physicians both inside and outside of the ICU. Reported experience of pediatric critical care physicians-administered pediatric procedural sedation is limited. We used the Pediatric Sedation Research Consortium database to evaluate a multicenter experience with propofol by pediatric critical care physicians in all settings. SETTING: Review of national Pediatric Sedation Research Consortium database to identify pediatric procedural sedation provided by pediatric critical care physicians from 2007 to 2012. Demographic and clinical data were collected to describe pediatric procedural sedation selection, location, and delivery. Multivariable logistic regression analysis was performed to identify risk factors associated with pediatric procedural sedation-related adverse events and complications. MEASUREMENTS AND MAIN RESULTS: A total of 91,189 pediatric procedural sedation performed by pediatric critical care physicians using propofol were included in the database. Median age was 60.0 months (range, 0-264 months; interquartile range, 34.0-132.0); 81.9% of patients were American Society of Anesthesiologists class I or II. Most sedations were performed in dedicated sedation or radiology units (80.9%). Procedures were successfully completed in 99.9% of patients. A propofol bolus alone was used in 52.8%, and 41.7% received bolus plus continuous infusion. Commonly used adjunctive medications were lidocaine (35.3%), opioids (23.3%), and benzodiazepines (16.4%). Overall adverse event incidence was 5.0% (95% CI, 4.9-5.2%), which included airway obstruction (1.6%), desaturation (1.5%), coughing (1.0%), and emergent airway intervention (0.7%). No deaths occurred; a single cardiac arrest was reported in a 13-month-old child receiving propofol and ketamine, with no untoward neurologic sequelae. Risk factors associated with adverse event included: location of sedation, number of adjunctive medications, upper and lower respiratory diagnosis, prematurity diagnosis, weight, American Society of Anesthesiologists status, and painful procedure. CONCLUSIONS: Pediatric procedural sedation using propofol can be provided by pediatric critical care physicians effectively and with a low incidence of adverse events.

A Survey of Attitudes and Practices Regarding the Use of Steroid Supplementation in Pediatric Sepsis.

OBJECTIVE: Although corticosteroid (CS) supplementation for pediatric septic shock (PSS) is recommended by American College of Critical Care Medicine sepsis guidelines, most data are based on adult trials. Standardized protocols for stimulation testing for adrenal insufficiency (AI) and CS treatment in children have been reported, but the current state of CS use and protocols have not been evaluated in pediatric intensive care units in the United States. We surveyed a group of pediatric intensivists to assess current approaches. DESIGN: An electronic survey with 54 questions on attitudes and current use of CSs was distributed to 49 pediatric critical care and 49 pediatric endocrinology fellowship program directors. MAIN RESULTS: Twenty-one (43%) of 49 critical care recipients completed the survey. Eleven (52%) were from medical/surgical units and 10 (48%) were from medical/surgical/cardiac units, with a median of 24 beds and 1614 annual admissions. Thirteen (62%) of 21 recipients rated the importance of steroids in the management of PSS as greater than 4 or 5, with 1 being of no importance and 5 of critical importance. Nineteen (90%) of 21 recipients thought AI occurs "sometimes" or "often" in septic shock. Adrenocorticotropin stimulation testing was frequently used (19 of 21; 90%) but not in protocol. Eighteen (85%) of 21 recipients agreed that "some should" receive "steroids as it improves outcome" and 9% agreed that "most should…" Fourteen (66%) of 21 recipients reported that more than 50% of patients with vasopressor-refractory PSS receive CSs. Hydrocortisone was used in 21 (100%) of 21 recipients, but dosing and duration were variable. Concerns to limit/avoid CSs included hyperglycemia (38%), superinfections (81%), and critical illness myopathy (57%). Only 3 (14%) of 21 recipients reported that they used a CS protocol for PSS. Sixteen (76%) of 21 recipients were not comfortable drawing conclusions from adult studies for PSS. Nineteen (90%) of 21 recipients agreed that it would be important to perform a randomized trial for CS use in PSS. CONCLUSIONS: Corticosteroids are used at most centers for treatment of PSS, but significant variation in attitudes and use exists. Most centers identify AI as frequent; most report variable use of stimulation testing and dosing of CSs. Few centers currently use a standard protocol for diagnosis and treatment. Interest in performing a randomized trial for CSs remains because in part of reluctance to accept adult trial data.

Pediatric severe sepsis: current trends and outcomes from the Pediatric Health Information Systems database.

OBJECTIVE: To 1) describe the characteristics and outcomes over time of PICU patients with severe sepsis within the dedicated U.S. children's hospitals, 2) identify patient subgroups at risk for mortality from pediatric severe sepsis, and 3) describe overall pediatric severe sepsis resource utilization. DESIGN: Retrospective review of a prospectively collected multi-institutional children's hospital database. SETTING: PICUs in 43 U.S. children's hospitals. PATIENTS: PICU patients from birth to younger than 19 years were identified with severe sepsis by modified Angus criteria and International Classification of Diseases, 9th Revision, codes for severe sepsis and septic shock. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data from the Pediatric Health Information System database collected by the Children's Hospital Association from 2004 to 2012. Pediatric severe sepsis was defined by 1) International Classification of Diseases, 9th Revision, codes reflecting severe sepsis and septic shock and 2) International Classification of Diseases, 9th Revision, codes of infection and organ dysfunction as defined by modified Angus criteria. From 2004 to 2012, 636,842 patients were identified from 43 hospitals. Pediatric severe sepsis prevalence was 7.7% (49,153) with an associated mortality rate of 14.4%. Age less than 1 year (vs age 10 to < 19) (odds ratio, 1.4), underlying cardiovascular condition (odds ratio, 1.4) and multiple organ dysfunction, conferred higher odds of mortality. Resource burden was significant with median hospital length of stay of 17 days (interquartile range, 8-36 d) and PICU length of stay of 7 days (interquartile range, 2-17 d), with median cost/day of $4,516 and median total hospitalization cost of $77,446. There was a significant increase in the severe sepsis prevalence rate from 6.2% to 7.7% from 2004 to 2012 (p < 0.001) and a significant decrease in mortality from 18.9% to 12.0% (p < 0.001). Center mortality was negatively correlated with prevalence (rs = -0.48) and volume (rs = -0.39) and positively correlated with cost (rs = 0.36). CONCLUSIONS: In this largest reported pediatric severe sepsis cohort to date, prevalence increased from 2004 to 2012 while associated mortality decreased. Age, cardiovascular comorbidity, and organ dysfunction were significant prognostic factors. Pediatric severe sepsis remains an important cause for PICU admission and mortality and leads to a substantial burden in healthcare costs. Individual center's prevalence and volume are associated with improved outcomes.

The Impact of Gender Affirming Medical Care During Adolescence on Adult Health Outcomes Among Transgender and Gender Diverse Individuals in the United States: The Role of State-Level Policy Stigma.

Purpose: Gender affirming medical care (GAMC) aims to alleviate gender dysphoria by helping people align their physical body more closely with their gender identity. Bills seeking to limit or prohibit GAMC for trans children and adolescents have become a controversial topic. This study aimed to examine whether exposures to GAMC during adolescence are associated with adult psychological and general health outcomes, and to demonstrate the mechanism through which state-level legislation may work to moderate the association. Methods: We conducted analyses using data from the 2015 U.S. Transgender Survey, which surveyed 27,715 transgender and gender diverse (TGD) adults between August and September of 2015. The study compared the health outcomes of those who had GAMC exposures during adolescence with those who did not. Moderation analysis with propensity score matching was used to adjust for potential confounding factors. The general and psychological health outcomes measured were past-month severe psychological distress, past-year suicidal ideation, participant's general health, and past-year health care avoidance due to possible mistreatment. Results: GAMC during adolescence was negatively associated with severe psychological distress in adulthood. When examining past-year health care avoidance due to possible mistreatment, the effect sizes differed significantly between those in a trans-supportive state and those in a trans-unsupportive state. Conclusion: Our work highlights the importance of state-level policy stigma in understanding the association between GAMC and health outcomes. Findings point to the importance of enacting long-term legislative safeguards against TGD discrimination and removing barriers to access the full spectrum of care for adolescents who identify as TGD.