Increased Pediatric Respiratory Syncytial Virus Case Counts Following the Emergence of SARS-CoV-2 Can Be Attributed to Changes in Testing.

BACKGROUND: Respiratory syncytial virus (RSV) circulation dropped markedly early in the COVID-19 pandemic, followed by a resurgence with heightened case counts. The "immunity debt" hypothesis proposes that the RSV-naїve pediatric population increased during the period of low transmission. However, the evidence supporting this hypothesis is limited, and the role of changing testing practices in the perceived surge has not been comprehensively evaluated. METHODS: We conducted a multicenter, retrospective analysis of 342 530 RSV encounters and 980 546 RSV diagnostic tests occurring at 32 US pediatric hospitals in 2013-2023. We used interrupted time series analysis to estimate pandemic-associated changes in RSV patient and test volume and to quantify changes in the proportions of patients requiring hospitalization, intensive care, or mechanical ventilation. We quantified the fraction of the shifts in case counts and in the age of diagnosed patients attributable to changes in testing. RESULTS: RSV patient volume increased 2.4-fold (95% confidence interval [CI]: 1.7, 3.5) in 2021-2023 relative to the pre-pandemic phase and was accompanied by an 18.9-fold increase (95% CI: 15.0, 23.9) in RSV test volume. Shifts in patient volume and in patient age were largely attributable to increased testing. The proportions of patients with RSV that required hospitalization, intensive care, or mechanical ventilation declined significantly across all patient age groups. CONCLUSIONS: A surge in RSV testing, rather than in viral circulation, likely underlies the increased case counts observed in 2021-2023. These findings warrant a critical assessment of the immunity debt hypothesis and highlight the importance of considering the testing denominator when surveillance strategies are dynamic.

Relationship between long-acting reversible contraception and acne in a cohort of adolescents and young adults.

BACKGROUND: The use of progestin-only long-acting reversible contraception (LARC) may be a risk factor for acne. Few studies have focused primarily on the effects of hormonal LARC on the development or exacerbation of acne in adolescents and young adults. We sought to understand the incidence and management of acne following hormonal LARC insertion in this adolescent/young adult population. METHODS: A secondary data analysis was conducted of prospectively collected quality improvement (QI) data from the Adolescent Medicine LARC Collaborative. Subjects were evaluated by clinicians in adolescent medicine clinics at participating study sites, and acne severity was documented using a standardized recording instrument and scale. Descriptive statistics were reported as frequencies and percentages for categorical variables or mean and standard deviation (SD) for continuous variables. We compared demographic and clinical characteristics by those who had worsening acne, accounting for site inter-correlation using Cochran-Mantel-Haenszel chi-square tests for categorical variables and linear generalized estimating equation (GEE) regression for continuous variables. RESULTS: Of 1319 subjects who completed LARC insertion, 28.5% (376/1319) experienced worsening acne following use of progestin-only LARC. Acne was a contributing factor to LARC removal in only 3% (40/1319), and the sole reason for removal in 0.4% (5/1319) of all subjects. As this was a secondary analysis of prospectively collected QI data, limitations of this study include incomplete or inaccurate documentation of acne severity. Moreover, LARC insertions without follow-up/removal visits or with only follow-up/removal within 8 weeks of insertion were excluded from our study, which may also bias results. CONCLUSIONS: Adolescents and young adults seeking progestin-only LARC should be counseled about the potential for developing acne or experiencing a worsening of existing acne during LARC use. However, acne was not a common reason for LARC discontinuation.

Quantifying Procedure-level Prophylaxis Misutilization in Pediatric Surgery: Implications for the Prioritization of Antimicrobial Stewardship Efforts.

OBJECTIVE: To quantify procedure-level inappropriate antimicrobial prophylaxis utilization as a strategy to identify high-priority targets for stewardship efforts in pediatric surgery. BACKGROUND: Little data exist to guide the prioritization of antibiotic stewardship efforts as they relate to prophylaxis utilization in pediatric surgery. METHODS: This was a retrospective cohort analysis of children undergoing elective surgical procedures at 52 children's hospitals from October 2015 to December 2019 using the Pediatric Health Information System database. Procedure-level compliance with consensus guidelines for prophylaxis utilization was assessed for indication, antimicrobial spectrum, and duration. The relative contribution of each procedure to the overall burden of noncompliant cases was calculated to establish a prioritization framework for stewardship efforts. RESULTS: A total of 56,845 cases were included with an overall inappropriate utilization rate of 56%. The most common reason for noncompliance was unindicated utilization (43%), followed by prolonged duration (32%) and use of excessively broad-spectrum agents (25%). Procedures with the greatest relative contribution to noncompliant cases included cholecystectomy and repair of inguinal and umbilical hernias for unindicated utilization (63.2% of all cases); small bowel resections, gastrostomy, and colorectal procedures for use of excessively broad-spectrum agents (70.1%) and pectus excavatum repair and procedures involving the small and large bowel for prolonged duration (57.6%). More than half of all noncompliant cases were associated with 5 procedures (cholecystectomy, small bowel procedures, inguinal hernia repair, gastrostomy, and pectus excavatum). CONCLUSIONS: Cholecystectomy, inguinal hernia repair, and procedures involving the small and large bowel should be considered high-priority targets for antimicrobial stewardship efforts in pediatric surgery.

Assessment of Patients With ARFID Presenting to Multi-Disciplinary Tertiary Care Program.

There are no standard assessment approaches for Avoidant Restrictive Food Intake Disorder (ARFID). We describe our approach to multidisciplinary assessment after assessing more than 550 patients with ARFID. We collected online survey (ARFID-specific instruments, measures of anxiety, depression) measures. Electronic medical record data (mental health and gastrointestinal diagnoses, micronutrient and bone density assessments, and growth parameters) were extracted for the 239 patients with ARFID seen between 2018 and 2021 with both parent and patient responses to online surveys. We identified 5 subtypes/combinations of subtypes: low appetite; sensory sensitivity; fear + sensory sensitivity; fear + low appetite; fear + sensory sensitivity + low appetite. Those with appetite-only subtype had higher mean age (14.0 years, P < 0.01) and the lowest average body mass index z score (-1.74, P < 0.01) compared to other subtypes. Our experience adds to understanding of clinical presentations in patients with ARFID and may aid in assessment formulation.

Adolescent/Young Adult Long-Acting Reversible Contraception: Experience from a Multisite Adolescent Medicine Collaborative.

OBJECTIVE: To report on long-acting reversible contraception (LARC) experience and continuation rates in the Adolescent Medicine LARC Collaborative. STUDY DESIGN: LARC insertion data (682 implants and 681 intrauterine devices [IUDs]) were prospectively collected from January 1, 2017, through December 31, 2019, across 3 Adolescent Medicine practices. Follow-up data through December 31, 2020, were included to ensure at least 1 year of follow-up of this cohort. Continuation rates were calculated at 1, 2, and 3 years, overall and by Adolescent Medicine site, as were descriptive statistics for LARC procedural complications and patient experience. RESULTS: Implant and IUD insertion complications were uncommon and largely self-limited, with no IUD-related uterine perforations. Uterine bleeding was the most frequently reported concern at follow-up (35% implant, 25% IUD), and a common reason for early device removal (45% of implant removals, 32% of IUD removals). IUD malposition or expulsion occurred following 6% of all insertions. The pooled implant continuation rate at 1 year was 87% (range, 86%-91% across sites; P = .63), 66% at 2 years (range, 62%-84%; P = .01), and 42% at 3 years (range, 36%-60%; P = .004). The pooled IUD continuation rate at 1 year was 88% (range, 87%-90% across sites; P = .82), 77% at 2 years (range, 76%-78%; P = .94), and 60% at 3 years (range, 57%-62%; P = .88). CONCLUSIONS: LARC is successfully provided in Adolescent Medicine clinical settings, with continuation rates analogous to those of well-resourced clinical trials. Uterine bleeding after LARC insertion is common, making counselling imperative. Future analyses will assess whether the medical management of LARC-related nuisance bleeding improves continuation rates in our Adolescent Medicine patient population.

Disentangling individual, school, and neighborhood effects on screen time among adolescents and young adults in the United States.

OBJECTIVES: To examine the association between individual, neighborhood, and school-level influences on individual screen time among adolescents and young adults (AYAs) in the National Longitudinal Study of Adolescent to Adult Health. METHODS: We classified screen time continuously as self-reported total hours per week of television, videos, and video/computer games at baseline and categorical as extended screen time (≥14 h per week). We fit cross-classified multilevel models (CCMM) to examine to examine the individual-, school- and neighborhood-level demographic and socioeconomic factors associated with screen time. Models were fit using MLwiN with Bayesian estimation procedures. RESULTS: AYAs reported an average of 22.8 (SD = 19.4) and 21.9 (SD = 20.3) hours of screen time, respectively. At the individual level, younger age, male sex, Black/multiracial race, receipt of public assistance, and lower parental education were associated with higher screen time. At the school level, being out of session (i.e., school and national holidays including summer), having a higher proportion of non-White students, and having a lower proportion of parents with a college education were associated with higher individual screen time. CONCLUSIONS: We found that individual-level factors most influence youth screen time, with smaller contributions from school factors.

Variation in hospital performance measures from the Turkey Ministry of Health.

BACKGROUND: The Turkish healthcare system has seen broad population-based improvements in expanded health insurance coverage and access to healthcare services. Hospital performance in this national system is understudied. We aimed to identify trends in hospital performance over time following implementation of the Health Transformation Program and describe how regional outcomes correlate with regional vital statistics. OBJECTIVE: We examine hospital performance data collected by the PHA from 2013 to 2015. We aim to identify the temporal variation in hospital performance for nearly 30 individual measures and to describe the relationship between hospital-level performance measures and regional vital statistics. METHODS: We conducted a retrospective cohort study of 674 public hospitals in Turkey using baseline data from 2013 and follow-up data from 2014-15 collected by the Turkish Statistical Institution and the Public Hospital Agency. We report demographic and socioeconomic data across 12 geographic regions and analyze 29 hospital-level performance measures across four domains: (i) health services; (ii) administrative services; (iii) financial services and (iv) quality measures. We examine temporal variation, and study correlation between performance measures and regional vital statistics. We fit mixed-effects linear regression models to estimate linear trend over time accounting for within-hospital residual correlation. We prepared our manuscript in accordance with guidelines set by the STROBE statement for cohort studies. RESULTS: During the 3 years of study period, 21 of 29 measures improved and 8 measures worsened. All but three measures demonstrated significant differences across regions of the country. Several measures, including inpatient efficiency, patient satisfaction and audit score, are associated with regional infant mortality and life expectancy. CONCLUSIONS: Evidence of temporal improvement in hospital-level performance may suggest some positive changes within the Turkish national healthcare system. Correlation of some measures with regional level health outcomes suggests a quality measurement strategy to monitor performance changes in the future. Although hospital-level functions have improved performance, the results of our study may help achieve further improvement for the health of the country's citizens.

Leveraging the Incidence, Burden, and Fiscal Implications of Unplanned Hospital Revisits for the Prioritization of Prevention Efforts in Pediatric Surgery.

OBJECTIVE: To characterize procedure-level burden of revisit-associated resource utilization in pediatric surgery with the goal of establishing a prioritization framework for prevention efforts. SUMMARY OF BACKGROUND DATA: Unplanned hospital revisits are costly to the health care system and associated with lost productivity on behalf of patients and their families. Limited objective data exist to guide the prioritization of prevention efforts within pediatric surgery. METHODS: Using the Pediatric Health Information System (PHIS) database, 30-day unplanned revisits for the 30 most commonly performed pediatric surgical procedures were reviewed from 47 children's hospitals between January 1, 2012 and March 31, 2015. The relative contribution of each procedure to the cumulative burden of revisit-associated length of stay and cost from all procedures was calculated as an estimate of public health relevance if prevention efforts were successfully applied (higher relative contribution = greater potential public health relevance). RESULTS: 159,675 index encounters were analyzed with an aggregate 30-day revisit rate of 10.8%. Four procedures contributed more than half of the revisit-associated length of stay burden from all procedures, with the highest relative contributions attributable to complicated appendicitis (18.4%), gastrostomy (13.4%), uncomplicated appendicitis (13.0%), and fundoplication (9.4%). Four procedures contributed more than half of the revisit-associated cost burden from all procedures, with the highest relative contributions attributable to complicated appendicitis (18.8%), gastrostomy (14.6%), fundoplication (10.4%), and uncomplicated appendicitis (10.2%). CONCLUSIONS AND RELEVANCE: A small number of procedures account for a disproportionate burden of revisit-associated resource utilization in pediatric surgery. Gastrostomy, fundoplication, and appendectomy should be considered high-priority targets for prevention efforts within pediatric surgery.

Global Tracheostomy Collaborative: data-driven improvements in patient safety through multidisciplinary teamwork, standardisation, education, and patient partnership.

There is growing recognition of the need for a coordinated, systematic approach to caring for patients with a tracheostomy. Tracheostomy-related adverse events remain a pervasive global problem, accounting for half of all airway-related deaths and hypoxic brain damage in critical care units. The Global Tracheostomy Collaborative (GTC) was formed in 2012 to improve patient safety and quality of care, emphasising knowledge, skills, teamwork, and patient-centred approaches. Inspired by quality improvement leads in Australia, the UK, and the USA, the GTC implements and disseminates best practices across hospitals and healthcare trusts. Its database collects patient-level information on quality, safety, and organisational efficiencies. The GTC provides an organising structure for quality improvement efforts, promoting safety of paediatric and adult patients. Successful implementation requires instituting key drivers for change that include effective training for health professionals; multidisciplinary team collaboration; engagement and involvement of patients, their families, and carers; and data collection that allows tracking of outcomes. We report the history of the collaborative, its database infrastructure and analytics, and patient outcomes from more than 6500 patients globally. We characterise this patient population for the first time at such scale, reporting predictors of adverse events, mortality, and length of stay indexed to patient characteristics, co-morbidities, risk factors, and context. In one example, the database allowed identification of a previously unrecognised association between bleeding and mortality, reflecting ability to uncover latent risks and promote safety. The GTC provides the foundation for future risk-adjusted benchmarking and a learning community that drives ongoing quality improvement efforts worldwide.

Impact of standardized protocols for cytomegalovirus disease prevention in pediatric solid organ transplant recipients.

End-organ disease caused by CMV is a significant cause of morbidity and mortality in pediatric SOT recipients. Pediatric transplant centers have adopted various approaches for CMV disease prevention in this patient population. We observed significant practice variation in CMV testing, prophylaxis, and surveillance across SOT groups in our center. To address this, we implemented evidence-based standardized protocols and measured outcomes pre- and post-implementation of these protocols. We performed retrospective chart review for SOT recipients from 2009 to 2014 at Boston Children's Hospital. Using descriptive statistics, we measured practice improvement in provision of appropriate prophylaxis, occurrence of neutropenia and associated complications, and occurrence of CMV DNAemia and CMV disease pre- and post-intervention. The pre- and post-intervention periods included 141 and 109 patients, respectively. With the exception of kidney transplant recipients, provision of appropriate valganciclovir prophylaxis improved across SOT groups post-intervention (P < .01). Occurrence of >1 episode of neutropenia was greater in the preintervention period (30% vs 10%, P < .001). In both periods, neutropenia was associated with few episodes of invasive infections. The occurrence of CMV disease did not differ and was overall low. However, due to routine surveillance a significantly greater number of asymptomatic CMV DNAemia episodes were identified and treated in the post-intervention period. Implementation of standardized prevention protocols helped to improve the provision of appropriate prophylaxis to patients at risk for CMV acquisition, increased the diagnosis and treatment of asymptomatic CMV DNAemia, and decreased episodes of recurrent neutropenia in patients receiving prophylaxis.

Quality of pediatric abdominal CT scans performed at a dedicated children's hospital and its referring institutions: a multifactorial evaluation.

BACKGROUND: Pediatric patients requiring transfer to a dedicated children's hospital from an outside institution may undergo CT imaging as part of their evaluation. Whether this imaging is performed prior to or after transfer has been shown to impact the radiation dose imparted to the patient. Other quality variables could also be affected by the pediatric experience and expertise of the scanning institution. OBJECTIVE: To identify differences in quality between abdominal CT scans and reports performed at a dedicated children's hospital, and those performed at referring institutions. MATERIALS AND METHODS: Fifty consecutive pediatric abdominal CT scans performed at outside institutions were matched (for age, gender and indication) with 50 CT scans performed at a dedicated freestanding children's hospital. We analyzed the scans for technical parameters, report findings, correlation with final clinical diagnosis, and clinical utility. Technical evaluation included use of intravenous and oral contrast agents, anatomical coverage, number of scan phases and size-specific dose estimate (SSDE) for each scan. Outside institution scans were re-reported when the child was admitted to the children's hospital; they were also re-interpreted for this study by children's hospital radiologists who were provided with only the referral information given in the outside institution's report. Anonymized original outside institutional reports and children's hospital admission re-reports were analyzed by two emergency medicine physicians for ease of understanding, degree to which the clinical question was answered, and level of confidence in the report. RESULTS: Mean SSDE was lower (8.68) for children's hospital scans, as compared to outside institution scans (13.29, P = 0.03). Concordance with final clinical diagnosis was significantly lower for original outside institution reports (38/48, 79%) than for both the admission and study children's hospital reports (48/50, 96%; P = 0.005). Children's hospital admission reports were rated higher than outside institution reports for completeness, ease of understanding, answering of clinical question, and level of confidence of the report (P < 0.001). CONCLUSION: Pediatric abdominal CT scans performed and interpreted at a dedicated children's hospital are associated with higher technical quality, lower radiation dose and a more clinically useful report than those performed at referring institutions.

Cross-sectional and Prospective Examination of Weight Misperception and Depressive Symptoms Among Youth with Overweight and Obesity.

This study aims to determine the association between weight misperception (considering oneself average or underweight) and depressive symptoms among youth with overweight/obesity. Linear regression models (adjusted for age, BMI, parental education, percent poverty) were used to examine cross-sectional (wave II, 1996, n = 3898, M age = 15.9, SD = 0.13) and longitudinal (from wave II to IV, 1996-2008/2009, n = 2738, M age = 28.5, SD = 0.06) associations between weight misperception and depressive symptoms (Center for Epidemiologic Studies-Depression Scale) in a subsample of White, Black, Asian, Hispanic, and Multi-racial male and female youth with overweight/obesity participating in the National Longitudinal Study of Adolescent Health. Average BMI was 29.0 (0.16) at wave II and 35.7 (0.23) at wave IV. Thirty-two percent misperceived their weight status as average weight (n = 1151, 30 %) or underweight (n = 99, 3 %). In fully adjusted cross-sectional models, White (ß = -1.92, 95 % CI = -2.79, -1.06) and Multi-racial (ß = -4.43, 95 % CI = -6.90, -1.95) youth who perceived themselves as average weight had significantly lower depressive symptoms compared to accurate weight-perceivers. In fully adjusted longitudinal models, White youth (ß = -0.41, 95 % CI = -0.81, -0.004) who perceived themselves as average weight had significantly lower depressive symptoms 12 years later. Findings suggest that weight misperception may be protective against depression among White adolescents and young adults with overweight/obesity. Clinical and population interventions should consider potential harmful effects of correcting weight misperceptions on the mental health of youth with overweight/obesity.

Child Abuse, Resting Blood Pressure, and Blood Pressure Reactivity to Psychosocial Stress.

OBJECTIVE: Childhood trauma is associated with hypertension in adults. It is unknown whether childhood trauma predicts elevated blood pressure earlier in development. We investigated whether the trauma of child abuse was associated with blood pressure in adolescents. METHODS: The sample included 145 adolescents aged 13-17 years, 40% with exposure to child abuse. The mean age of participants was 14.93 years (SD = 1.33); 58% were female. The majority self-identified as non-Hispanic White (43%), with the remainder identifying as non-Hispanic Black (17%), Hispanic (17%), or other/mixed race (23%). We used established age/sex/height-specific cutoffs to determine the prevalence of prehypertension and hypertension in the sample. We used two-sample t tests to examine associations of abuse with resting systolic blood pressure (SBP) and diastolic blood pressure (DBP) and blood pressure reactivity to the Trier Social Stress Test and a frustration task. We used linear regression to adjust for potential confounders including sociodemographic variables, body mass index, smoking, and psychopathology. RESULTS: Mean resting SBP and DBP were 114.07 mmHg and 61.35 mmHg in those with a history of abuse and 111.39 mmHg and 56.89 mmHg in those without a history of abuse. This difference was significant for DBP only. Twelve percent of participants met criteria for prehypertension or hypertension based on resting blood pressure values; this did not differ between those with and without an abuse history. Child abuse was associated with lower DBP and SBP reactivity to laboratory stress tasks and reduced DBP reactivity to frustration. These associations were robust to adjustment for potential confounders. CONCLUSIONS: Child abuse is associated with higher resting DBP and blunted DBP and SBP reactivity to laboratory stress in adolescence. These findings suggest a potential pathway by which child abuse leads to hypertension.

Weight misperception among young adults with overweight/obesity associated with disordered eating behaviors.

OBJECTIVE: The purpose of this study was to examine the cross-sectional association between weight misperception among young adults with overweight/obesity and disordered eating behaviors. METHOD: In a subsample of young adults with overweight or obesity participating in Wave III (2001-2002) of The National Longitudinal Study of Adolescent to Adult Health (n = 5,184), we examined the cross-sectional association between weight under-perception (i.e., perceiving oneself to be at a healthy body weight or underweight) and disordered eating (fasting/meal skipping for weight control, purging/pills for weight control, overeating/loss of control eating, and use of performance-enhancing products/substances). RESULTS: About 20% of young adult females under-perceived their weight compared to 48% of males. Individuals who misperceived their weight as healthy were significantly less likely to report fasting/meal skipping (Females: OR: 0.25, 95% CI: 0.14-0.43; Males: OR: 0.31, 95% CI: 0.20-0.48) and vomiting or taking diet pills/laxatives/diuretics (Females: OR: 0.10, 95% CI: 0.04-0.25; Males: OR: 0.10, 95% CI: 0.04-0.25) for weight control. Among females, those who misperceived their weight status as healthy were also less likely to report overeating or loss of control eating (OR: 0.41, 95% CI: 0.24-0.71). Greater use of performance-enhancing products/substances was seen among males who under-perceived their weight as healthy (OR: 2.06, 95% CI: 1.57-2.72) and among both females (OR: 2.29, 95% CI: 1.40-20.0) and males (OR: 2.27, 95% CI: 1.13-4.55) who perceived themselves to be underweight. DISCUSSION: Weight under-perception among young adults with overweight/obesity may convey some benefit related to disordered eating behaviors, but could be a risk factor for the use of performance-enhancing products/substances. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord ; 49:937-946).

Ultrasound Guidance and Other Determinants of Successful Peripheral Artery Catheterization in Critically Ill Children.

OBJECTIVE: Peripheral arterial catheterization is a common invasive procedure performed in critically ill children. However, the benefits of using ultrasound guidance for this procedure in critically ill children, especially when used by inexperienced trainees, are unclear. Our aims were to evaluate whether the use of ultrasound guidance for the placement of radial arterial catheters reduced time and improved success when compared with the palpation method and also to determine patient and trainee variables that influence procedure outcomes. Finally, we evaluated whether adoption of ultrasound guidance among trainees comes at the expense of learning landmark-based methods. DESIGN: Prospective observational cohort. SETTING: University affiliated PICU. PATIENTS: A total of 208 procedures performed by 45 trainees in 192 unique patients (1 mo to 20 yr old) were observed. INTERVENTION: Implementation of ultrasound curriculum. MEASUREMENTS AND MAIN RESULTS: The main outcome measures were time and number of attempts required for the procedure. Compared with palpation method, ultrasound guidance was associated with reduced procedure time (8.1 ± 5.2 min compared with 16.5 ± 8.8 min; p < 0.001), reduced number of attempts (3.1 ± 2.6 attempts compared with 6.9 ± 4.2 attempts; p < 0.001), and improved first attempt success rate (28% compared with 11%; p = 0.001) even after adjusting for key confounders in multivariate random effects models. The factors most likely to interfere with peripheral arterial catheterization are patient age, patient systolic blood pressure, patient body mass index, degree of fluid overload, and trainee months in fellowship. The use of ultrasound guidance mitigates the influence of each of these factors. We found no evidence that the adoption of ultrasound guidance by trainees is associated with reduced proficiency in landmark-based methods. CONCLUSIONS: The use of ultrasound guidance by trainees for radial artery catheterization in critically ill children is associated with improved outcomes compared with the palpation method.

Disentangling the relative influence of schools and neighborhoods on adolescents' risk for depressive symptoms.

OBJECTIVES: Although schools and neighborhoods influence health, little is known about their relative importance, or the influence of one context after the influence of the other has been taken into account. We simultaneously examined the influence of each setting on depression among adolescents. METHODS: Analyzing data from wave 1 (1994-1995) of the National Longitudinal Study of Adolescent Health, we used cross-classified multilevel modeling to examine between-level variation and individual-, school-, and neighborhood-level predictors of adolescent depressive symptoms. Also, we compared the results of our cross-classified multilevel models (CCMMs) with those of a multilevel model wherein either school or neighborhood was excluded. RESULTS: In CCMMs, the school-level random effect was significant and more than 3 times the neighborhood-level random effect, even after individual-level characteristics had been taken into account. Individual-level indicators (e.g., race/ethnicity, socioeconomic status) were associated with depressive symptoms, but there was no association with either school- or neighborhood-level fixed effects. The between-level variance in depressive symptoms was driven largely by schools as opposed to neighborhoods. CONCLUSIONS: Schools appear to be more salient than neighborhoods in explaining variation in depressive symptoms. Future work incorporating cross-classified multilevel modeling is needed to understand the relative effects of schools and neighborhoods.

Neonatal Opioid Withdrawal Syndrome Treatment Guidelines and Birth Hospital Utilization.

BACKGROUND AND OBJECTIVES: In November 2020, the American Academy of Pediatrics published guidelines for management of neonatal opioid withdrawal syndrome (NOWS), recommending nonpharmacologic treatment as the first-line approach, unless pharmacologic treatment is needed for severe NOWS. Using data from tertiary care pediatric hospitals, we examined the impact of the guidelines on use of pharmacotherapy, length of stay, and NICU admission for infants with NOWS. METHODS: We extracted birth hospitalization data for newborns diagnosed with NOWS discharged from 2019 to 2022 from the Pediatric Health Information System. We compared hospital utilization and pharmacologic treatment pre- and postguidelines and used interrupted time series regression to examine trends over time. RESULTS: We included N = 824 newborns (n = 434 pre, n = 390 post) with NOWS from 11 hospitals. The use of pharmacologic treatment was significantly lower in the postguidelines period (59.0% pre versus 50.3% post; P = .01). Median length of stay was similar pre and post (P = .55). NICU admission was significantly lower in the postguidelines period (78.6% pre versus 46.7% post; P < .001), with an immediate decrease (ß = -23.0%; P < .001) and a decrease over time in the postguidelines period (ß = -0.7% per month; P = .03). Most hospitals reduced pharmacologic treatment (8 of 11; 73%) and NICU use (10 of 11; 91%) postguidelines. CONCLUSIONS: There was a reduction in the use of pharmacologic treatment and NICU utilization for infants with NOWS after the release of American Academy of Pediatrics guidelines for NOWS management.

Increased pediatric RSV case counts following the emergence of SARS-CoV-2 are attributable to increased testing.

Background: The incidence of respiratory syncytial virus (RSV) dropped markedly early in the COVID-19 pandemic, followed by a resurgence with heightened case counts. The "immunity debt" hypothesis proposes that the RSV-naive pediatric population increased during the period of low transmission, resulting in a subsequent increased risk of infection. However, the evidence supporting this hypothesis is limited, and no studies have comprehensively evaluated the role of changing respiratory viral testing practices in the perceived surge. Methods: We conducted a multicenter, retrospective analysis of 342,530 RSV encounters and 980,546 RSV diagnostic tests occurring at 32 United States pediatric hospitals between 2013 and 2023. We used interrupted time series analysis to estimate pandemic-associated changes in RSV patient and testing volume, and to quantify changes in the proportions of patients admitted from the emergency department (ED), admitted to the intensive care unit (ICU), and receiving mechanical ventilation. We quantified the fraction of the observed shifts in case counts and in the age of diagnosed patients attributable to changes in RSV testing practices. Finally, we analyzed 524,404 influenza virus encounters and 1,768,526 influenza diagnostic tests to address the specificity of the findings to RSV. Findings: RSV patient volume increased 2.4-fold (95% CI: 1.7, 3.5) in 2021-2023 relative to the pre-pandemic phase, and was accompanied by an 18.9-fold increase (95% CI: 15.0, 23.9) in RSV test volume. Over two-thirds of the apparent shifts in patient volume and in patient age were attributable to increased testing, which was concentrated among older pediatric patients. The proportions of patients with RSV requiring hospitalization, intensive care, or mechanical ventilation declined significantly across all patient age groups. These declines were not observed for patients with influenza virus. Interpretation: A surge in RSV testing, rather than in viral circulation, likely underlies the increased case counts observed in 2021-2023. We identify expected consequences of increased testing, including the diagnosis of less severe cases and a shift in the patient age distribution. These findings warrant a critical assessment of the immunity debt hypothesis, while highlighting the importance of considering the testing denominator when surveillance strategies are dynamic. Funding: National Institutes of Health & Howard Hughes Medical Institute.

Enhancing Pressure Injury Surveillance Using Natural Language Processing.

OBJECTIVE: This study assessed the feasibility of nursing handoff notes to identify underreported hospital-acquired pressure injury (HAPI) events. METHODS: We have established a natural language processing-assisted manual review process and workflow for data extraction from a corpus of nursing notes across all medical inpatient and intensive care units in a tertiary care pediatric center. This system is trained by 2 domain experts. Our workflow started with keywords around HAPI and treatments, then regular expressions, distributive semantics, and finally a document classifier. We generated 3 models: a tri-gram classifier, binary logistic regression model using the regular expressions as predictors, and a random forest model using both models together. Our final output presented to the event screener was generated using a random forest model validated using derivation and validation sets. RESULTS: Our initial corpus involved 70,981 notes during a 1-year period from 5484 unique admissions for 4220 patients. Our interrater human reviewer agreement on identifying HAPI was high ( κ = 0.67; 95% confidence interval [CI], 0.58-0.75). Our random forest model had 95% sensitivity (95% CI, 90.6%-99.3%), 71.2% specificity (95% CI, 65.1%-77.2%), and 78.7% accuracy (95% CI, 74.1%-83.2%). A total of 264 notes from 148 unique admissions (2.7% of all admissions) were identified describing likely HAPI. Sixty-one described new injuries, and 64 describe known yet possibly evolving injuries. Relative to the total patient population during our study period, HAPI incidence was 11.9 per 1000 discharges, and incidence rate was 1.2 per 1000 bed-days. CONCLUSIONS: Natural language processing-based surveillance is proven to be feasible and high yield using nursing handoff notes.

Pediatric hospital utilization for patients with avoidant restrictive food intake disorder.

BACKGROUND: Avoidant restrictive food intake disorder (ARFID) is a relatively new feeding and eating disorder added to the DSM-5 in 2013 and ICD-10 in 2018. Few studies have examined hospital utilization for patients with ARFID specifically, and none to date have used large administrative cohorts. We examined inpatient admission volume over time and hospital utilization and 30-day readmissions for patients with ARFID at pediatric hospitals in the United States. METHODS: Using data from the Pediatric Health Information System (PHIS), we identified inpatient admissions for patients with ARFID (by principal International Classification of Diseases, 10th Revision, ICD-10 diagnosis code) discharged October 2017-June 2022. We examined the change over time in ARFID volume and associations between patient-level factors (e.g., sociodemographic characteristics, co-morbid conditions including anxiety and depressive disorders and malnutrition), hospital ARFID volume, and hospital utilization including length of stay (LOS), costs, use of enteral tube feeding or GI imaging during admission, and 30-day readmissions. Adjusted regression models were used to examine associations between sociodemographic and clinical factors on LOS, costs, and 30-day readmissions. RESULTS: Inpatient ARFID volume across n = 44 pediatric hospitals has increased over time (ß = 0.36 per month; 95% CI 0.26-0.46; p < 0.001). Among N = 1288 inpatient admissions for patients with ARFID, median LOS was 7 days (IQR = 8) with median costs of $16,583 (IQR = $18,115). LOS and costs were highest in hospitals with higher volumes of ARFID patients. Younger age, co-morbid conditions, enteral feeding, and GI imaging were also associated with LOS. 8.5% of patients were readmitted within 30 days. In adjusted models, there were differences in the likelihood of readmission by age, insurance, malnutrition diagnosis at index visit, and GI imaging procedures during index visit. CONCLUSIONS: Our results indicate that the volume of inpatient admissions for patients with ARFID has increased at pediatric hospitals in the U.S. since ARFID was added to ICD-10. Inpatient stays for ARFID are long and costly and associated with readmissions. It is important to identify effective and efficient treatment strategies for ARFID in the future.

Recent studies indicate that Avoidant Restrictive Food Intake Disorder (ARFID) is a complex feeding and eating disorder often diagnosed in younger children. To date, there are no large studies using administrative data to examine hospital utilization or costs among patients with ARFID. In a geographically diverse cohort of pediatric hospitals in the United States, we found inpatient admissions for ARFID have increased over time and that ARFID is associated with long, costly stays and readmissions which has important implications for identifying efficient treatment strategies. Future studies are needed to explore effective and efficient treatment strategies and prevent readmissions in this patient population.