Mapping Systemic Inflammation and Antibody Responses in Multisystem Inflammatory Syndrome in Children (MIS-C).

Initially, children were thought to be spared from disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, a month into the epidemic, a novel multisystem inflammatory syndrome in children (MIS-C) emerged. Herein, we report on the immune profiles of nine MIS-C cases. All MIS-C patients had evidence of prior SARS-CoV-2 exposure, mounting an antibody response with intact neutralization capability. Cytokine profiling identified elevated signatures of inflammation (IL-18 and IL-6), lymphocytic and myeloid chemotaxis and activation (CCL3, CCL4, and CDCP1), and mucosal immune dysregulation (IL-17A, CCL20, and CCL28). Immunophenotyping of peripheral blood revealed reductions of non-classical monocytes, and subsets of NK and T lymphocytes, suggesting extravasation to affected tissues. Finally, profiling the autoantigen reactivity of MIS-C plasma revealed both known disease-associated autoantibodies (anti-La) and novel candidates that recognize endothelial, gastrointestinal, and immune-cell antigens. All patients were treated with anti-IL-6R antibody and/or IVIG, which led to rapid disease resolution.

Longitudinal Assessment of Association Between Tobacco Use and Tobacco Dependence Among Adults: Latent Class Analysis of the Population Assessment of Tobacco and Health Study Waves 1-4.

INTRODUCTION: With increasing tobacco product varieties, understanding tobacco use (TU) profiles and their associations with tobacco dependence (TD) has also become increasingly challenging. AIMS AND METHODS: We aimed to identify TU profiles and their associations with TD over time, and to identify subgroups with high risk of TD. We included 3463 adult recent tobacco users who had complete TU and TD data across waves 1-4 of the Population Assessment of Tobacco and Health (PATH) study. We used a composite index of TD and a summed TD score from an established 16-item TD measure. We applied a latent class analysis to identify TU profiles based on participants' usage of eight common tobacco product groups at each survey wave and to check the stability of the TU profiles over time. We then used generalized estimating equations regressions to evaluate the longitudinal TU-TD association, adjusting for potential confounders. RESULTS: We identified three distinct TU profiles that remained consistent across four survey waves: Dominant cigarette users (62%-68%), poly users with high propensity of using traditional cigarettes, e-cigarettes, and cigars (24%-31%), and dominant smokeless product users (7%-9%). Covariate-adjusted models showed that TD was significantly lower among the poly users and the dominant smokeless users, compared to that among the dominant cigarette users. CONCLUSIONS: Both TU profiles and their associations with TD were stable over time at the population level. Poly users and smokeless product users were consistently associated with lower TD than cigarette-dominant users, suggesting the need for tailored tobacco cessation interventions for users with different TU profiles. IMPLICATIONS: The finding of consistent TU profiles across four survey waves extends the current literature in capturing TU patterns in an evolving tobacco product landscape. The finding of the overall higher level of TD among the cigarette-dominant users compared to the other TU latent profiles (the Cig+eCig+Cigar dominant poly users and the dominant smokeless product users) can help identify high-risk groups for potential interventions. Our application of innovative statistical methods to high-quality longitudinal data from the PATH study helps improve the understanding of the dynamic TU-TD relationship over time.

Smoking Status, Nicotine Medication, Vaccination, and COVID-19 Hospital Outcomes: Findings from the COVID EHR Cohort at the University of Wisconsin (CEC-UW) Study.

INTRODUCTION: Available evidence is mixed concerning associations between smoking status and COVID-19 clinical outcomes. Effects of nicotine replacement therapy (NRT) and vaccination status on COVID-19 outcomes in smokers are unknown. METHODS: Electronic health record data from 104 590 COVID-19 patients hospitalized February 1, 2020 to September 30, 2021 in 21 U.S. health systems were analyzed to assess associations of smoking status, in-hospital NRT prescription, and vaccination status with in-hospital death and ICU admission. RESULTS: Current (n = 7764) and never smokers (n = 57 454) did not differ on outcomes after adjustment for age, sex, race, ethnicity, insurance, body mass index, and comorbidities. Former (vs never) smokers (n = 33 101) had higher adjusted odds of death (aOR, 1.11; 95% CI, 1.06-1.17) and ICU admission (aOR, 1.07; 95% CI, 1.04-1.11). Among current smokers, NRT prescription was associated with reduced mortality (aOR, 0.64; 95% CI, 0.50-0.82). Vaccination effects were significantly moderated by smoking status; vaccination was more strongly associated with reduced mortality among current (aOR, 0.29; 95% CI, 0.16-0.66) and former smokers (aOR, 0.47; 95% CI, 0.39-0.57) than for never smokers (aOR, 0.67; 95% CI, 0.57, 0.79). Vaccination was associated with reduced ICU admission more strongly among former (aOR, 0.74; 95% CI, 0.66-0.83) than never smokers (aOR, 0.87; 95% CI, 0.79-0.97). CONCLUSIONS: Former but not current smokers hospitalized with COVID-19 are at higher risk for severe outcomes. SARS-CoV-2 vaccination is associated with better hospital outcomes in COVID-19 patients, especially current and former smokers. NRT during COVID-19 hospitalization may reduce mortality for current smokers. IMPLICATIONS: Prior findings regarding associations between smoking and severe COVID-19 disease outcomes have been inconsistent. This large cohort study suggests potential beneficial effects of nicotine replacement therapy on COVID-19 outcomes in current smokers and outsized benefits of SARS-CoV-2 vaccination in current and former smokers. Such findings may influence clinical practice and prevention efforts and motivate additional research that explores mechanisms for these effects.

Secondhand marijuana exposure in a convenience sample of young children in New York City.

BACKGROUND: Biomarkers of exposure to marijuana smoke can be detected in the urine of children with exposure to secondhand marijuana smoke, but the prevalence is unclear. METHODS: We studied children between the ages of 0 to 3 years who were coming in for well-child visits or hospitalized on the inpatient general pediatric unit between 2017 and 2018 at Kravis Children's Hospital at Mount Sinai. Parents completed an anonymous survey, and urine samples were analyzed for cotinine and 11-nor-9-carboxy-Δ9-tetrahydrocannabinol (COOH-THC), a metabolite of Δ9-tetrahydrocannabinol. RESULTS: Fifty-three children had urine samples available for analysis. COOH-THC was detectable in 20.8% of the samples analyzed and urinary cotinine was detectable in 90.2%. High levels of tobacco exposure (defined as cotinine ≥2.0 ng/ml) were significantly associated with COOH-THC detection (p < 0.01). We found that 34.8% of children who lived in attached housing where smoking was allowed within the property had detectable COOH-THC compared to 13.0% of children who lived in housing where smoking was not allowed at all. CONCLUSIONS: This study adds to the growing evidence that children are being exposed to marijuana smoke, even in places where recreational marijuana use is illegal. It is critical that more research be done on the impact of marijuana smoke exposure on children's health and development. IMPACT: We found that 20.8% of the 53 children recruited from Mount Sinai Hospital had detectable marijuana metabolites in their urine. Children with household tobacco smoke exposure and children who lived in attached housing where smoking was allowed on the premises were more likely to have detectable marijuana smoke metabolites. This study adds to the growing evidence that children are being exposed to marijuana smoke, even in places where marijuana remains illegal by state law. As states consider marijuana legalization, it is critical that the potential adverse health effects from marijuana exposure in children be taken into account.

Elective caesarean section and bronchiolitis hospitalization: A retrospective cohort study.

BACKGROUND: We sought to evaluate whether elective caesarean section is associated with subsequent hospitalization for bronchiolitis. METHODS: This is a retrospective cohort study that used the electronic medical record database of Clalit Health Services, the largest healthcare fund in Israel, serving over 4.5 million members and over half of the total population. The primary outcome was bronchiolitis admission in the first 2 years of life. We performed logistic regression analyses to identify independent associations. We repeated the analysis using boosted decision tree machine learning techniques to confirm our findings. RESULTS: There were 124 553 infants enrolled between 2008 and 2010, and 5168 (4.1%) were hospitalized for bronchiolitis in the first 2 years of life. In logistic regression models stratified by seasons, elective caesarean section birth was associated with 15% increased odds (95% CI: 1.02-1.30) for infants born in the fall season, 28% increased odds (95% CI: 1.11, 1.47) for those born in the winter, 35% increased odds (95% CI: 1.12-1.62) for those born in the spring and 37% increased odds (95% CI: 1.18-1.60) for those born in the summer. In the boosted gradient decision tree analysis, the area under the curve for risk of bronchiolitis admission was 0.663 (95% CI: 0.652, 0.674) with timing of birth as the most important feature. CONCLUSION: Elective caesarean section, a potentially modifiable risk factor, is associated with increased odds of hospitalization for bronchiolitis in the first 2 years of life. These data should be considered when scheduling elective caesarean sections especially for infants born in spring and summer months.

Examining the role of healthcare access in racial/ethnic disparities in receipt of provider-patient discussions about smoking: A latent class analysis.

Using insurance as a single indicator of healthcare access in examining the association between race/ethnicity and healthcare encounter-based interventions for smoking may not be adequate. In this study, we assessed the role of healthcare access using multifactorial measures in accounting for racial/ethnic disparities in the receipt of provider-patient discussions, defined as either being asked about smoking or advised to quit smoking by providers. We identified adult current smokers from the 2015 National Health Interview Survey. We first conducted a latent class analysis (LCA) to identify the underlying patterns of healthcare access measured by 13 indicators of healthcare access and utilization. We then used a propensity score - based weighting approach to examine racial/ethnic disparities in receiving provider-patient discussions about smoking or quitting in stratified groups by the distinct healthcare access clusters. Out of the 4134 adult current smokers who visited a doctor or a healthcare provider during the past 12 months, 3265 (79.90%) participants were classified as having high healthcare access and 869 (20.10%) participants as having low healthcare access. Compared to non-Hispanic whites, Hispanics had significantly lower odds of being asked about smoking (OR 0.46, 95% CI (0.27-0.77)) and being advised to quit (OR 0.57, 95% CI (0.34-0.97)) in the low access group, but neither association was significant in the high access group. In addition to increasing health insurance coverage, reducing other healthcare access barriers for Hispanics will likely facilitate provider-patient discussion and promote tobacco cessation among Hispanic smokers.

Changes in pediatric hospital care during the COVID-19 pandemic: a national qualitative study.

BACKGROUND: The COVID-19 pandemic has necessitated rapid changes in healthcare delivery in the United States, including changes in the care of hospitalized children. The objectives of this study were to identify major changes in healthcare delivery for hospitalized children during the COVID-19 pandemic, identify lessons learned from these changes, and compare and contrast the experiences of children's and community hospitals. METHODS: We purposefully sampled participants from both community and children's hospitals serving pediatric patients in the six U.S. states with the highest COVID-19 hospitalization rates at the onset of the pandemic. We recruited 2-3 participants from each hospital (mix of administrators, front-line physicians, nurses, and parents/caregivers) for semi-structured interviews. We analyzed interview data using constant comparative methods to identify major themes. RESULTS: We interviewed 30 participants from 12 hospitals. Participants described how leaders rapidly developed new hospital policies (e.g., directing use of personal protective equipment) and how this was facilitated by reviewing internal and external data frequently and engaging all relevant stakeholders. Hospital leaders optimized communication through regular, transparent, multi-modal, and bi-directional communication. Clinicians increased use of videoconference and telehealth to facilitate physical distancing, but these technologies may have disadvantaged non-English speakers. Due to declining volumes of hospitalized children and surges of adult patients, clinicians newly provided care for hospitalized adults. This was facilitated by developing care teams supported by adult hospitalists, multidisciplinary support via videoconference, and educational resources. Participants described how the pandemic negatively impacted clinicians' mental health, and they stressed the importance of mental health resources and wellness activities/spaces. CONCLUSIONS: We identified several major changes in inpatient pediatric care delivery during the COVID-19 pandemic, including the adoption of new hospital policies, video communication, staffing models, education strategies, and staff mental health supports. We outline important lessons learned, including strategies for successfully developing new policies, effectively communicating with staff, and supporting clinicians' expanding scope of practice. Potentially important focus areas in pandemic recovery include assessing and supporting clinicians' mental health and well-being, re-evaluating trainees' skills/competencies, and adapting educational strategies as needed. These findings can help guide hospital leaders in supporting pandemic recovery and addressing future crises.

Secondhand smoke exposure and higher blood pressure in children and adolescents participating in NHANES.

We assessed the relationship between acute and intermittent secondhand tobacco smoke (SHS) exposure with child and adolescent blood pressure (BP). We analyzed cross-sectional data from 3579 children and adolescents aged 8-17 years participating in the National Health and Nutrition Examination Survey (NHANES) collected between 2007 and 2012, with SHS exposure assessed via serum cotinine (a biomarker for acute exposures) and urine NNAL (4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol, a biomarker for intermittent exposures). BP percentiles and z-scores were calculated according to the 2017 guidelines established by the American Academy of Pediatrics. We used weighted linear regression accounting for the complex sampling weights from NHANES and adjusting for socio-demographic and clinical characteristics. Overall, 56% of the children were non-Hispanic white with a mean age of 12.6 years. There was approximately equal representation of boys and girls. Approximately 15.9% of participants lived in homes where smoking was present. In adjusted models, an interquartile range (IQR) increase in urinary NNAL was associated with 0.099 (95% CI: 0.033, 0.16) higher diastolic blood pressure (DBP) z-score, and with a 0.094 (95% CI: 0.011, 0.18) higher systolic blood pressure (SBP) z-score. The odds of being in the hypertensive range was 1.966 (95% CI: 1.31, 2.951) times greater among children with high NNAL exposures compared to those with undetectable NNAL. For serum cotinine, an IQR increase was associated with 0.097 (95% CI: 0.020, 0.17) higher DBP z-scores, but was not significantly associated with SBP z-scores. The associations of cotinine and NNAL with BP also differed by sex. Our findings provide the first characterization of the relationship between a major tobacco-specific metabolite, NNAL, and BP z-scores in a nationally representative population of US children.

Secondhand Smoke Exposure and Depressive Symptoms in Children: A Longitudinal Study.

INTRODUCTION: We investigated whether secondhand smoke (SHS) exposure is associated with depressive symptoms in a population-based sample of children. METHODS: Never-smoking students from 29 French-language elementary schools in Greater Montréal, Canada, were followed from 5th to 11th grade (2005-2011) in five waves: 1 (5th grade), 2 (spring 6th grade), 3 (7th grade), 4 (9th grade), and 5 (11th grade). Associations between depressive symptoms and SHS exposure at home and in cars were examined in cross-sectional and longitudinal gamma generalized regression models adjusted for sex, maternal education, and neighborhood socioeconomic status. RESULTS: The sample comprised 1553 baseline never-smokers (mean [SD] age = 10.7 [0.5] years; 44% male; 89% French-speaking). SHS exposure at home and in cars was associated with higher depressive symptom scores in cross-sectional analyses pooled across grades and adjusted for demographics (B [95% confidence interval (CI)] = 0.041 [0.017 to 0.068] for home exposure; 0.057 [0.030 to 0.084] for car exposure). In longitudinal analyses from fifth to sixth grade, B (95% CI), adjusted for demographics and baseline depressive symptoms, was 0.042 (0.003 to 0.080) for home exposure and 0.061 (0.019 to 0.103) for car exposure. From sixth to seventh grade, B (95% CI) was 0.057 (0.003 to 0.110) for home exposure and 0.074 (0.015 to 0.133) for car exposure. SHS exposure at any age did not predict depressive symptoms 2 years later. CONCLUSIONS: SHS exposure is associated with depressive symptoms in young persons, both concurrently and 1 year later. This finding adds to the evidence base supporting that children should be protected from SHS exposure. IMPLICATIONS: SHS exposure has deleterious effects on physical health and results of this study raise concerns that such exposure might also affect the mental health of young persons. Clearly, protecting children from SHS in all locations is a critical public health priority. Although research is needed to determine if the association between SHS exposure and depressive symptoms is causal, continued implementation of smoking bans and educational efforts to discourage smoking in vehicles when children are present are warranted.

What is new in electronic-cigarettes research?

PURPOSE OF REVIEW: Electronic cigarettes (e-cigarettes) and other vaping devices have seen extraordinary growth in use in the past 10 years, and companies are accelerating their development of new products and marketing efforts. In turn, researchers have increased their efforts to determine how e-cigarettes affect health, how marketing these products impacts adolescents and how the use of e-cigarettes may affect adolescents' use of other tobacco products. Products like Juul were not on the market 2 years ago; thus, frequent updates on the topic are essential. RECENT FINDINGS: Studies have begun to demonstrate that users of the newer pod systems are exposed to high levels of nicotine, as well as other chemicals. These products are highly marketed, with a strong emphasis on how adolescents can use them surreptitiously. This is concerning to researchers, and other studies have continued to demonstrate that teens who use e-cigarettes are more likely to go on to use combusted tobacco. Further research has also failed to demonstrate that e-cigarettes are useful for people wishing to quit smoking combusted tobacco. SUMMARY: E-cigarettes and vaping systems are not safe products and should not be used by adolescents.

Impact of Discharge Components on Readmission Rates for Children Hospitalized with Asthma.

OBJECTIVES: To describe hospital-based asthma-specific discharge components at children's hospitals and determine the association of these discharge components with pediatric asthma readmission rates. STUDY DESIGN: This is a multicenter retrospective cohort study of pediatric asthma hospitalizations in 2015 at children's hospitals participating in the Pediatric Health Information System. Children ages 5 to 17 years were included. An electronic survey assessing 13 asthma-specific discharge components was sent to quality leaders at all 49 hospitals. Correlations of combinations of asthma-specific discharge components and adjusted readmission rates were calculated. RESULTS: The survey response rate was 92% (45 of 49 hospitals). Thirty-day and 3-month adjusted readmission rates varied across hospitals, ranging from 1.9% to 3.9% for 30-day readmissions and 5.7% to 9.1% for 3-month readmissions. No individual or combination discharge components were associated with lower 30-day adjusted readmission rates. The only single-component significantly associated with a lower rate of readmission at 3 months was having comprehensive content of education (P < .029). Increasing intensity of discharge components in bundles was associated with reduced adjusted 3-month readmission rates, but this did not reach statistical significance. This was seen in a 2-discharge component bundle including content of education and communication with the primary medical doctor, as well as a 3-discharge component bundle, which included content of education, medications in-hand, and home-based environmental mitigation. CONCLUSIONS: Children's hospitals demonstrate a range of asthma-specific discharge components. Although we found no significant associations for specific hospital-level discharge components and asthma readmission rates at 30 days, certain combinations of discharge components may support hospitals to reduce healthcare utilization at 3 months.

Impact of a behaviorally-based weight loss intervention on parameters of insulin resistance in breast cancer survivors.

BACKGROUND: Breast cancer survivors with excess weight are more likely to have negative breast cancer outcomes. Biomarkers related to insulin resistance may help explain this negative association. Weight loss is associated with improvements in insulin sensitivity. Our goal was to identify the impact of a behaviorally based weight loss intervention on indices of insulin resistance. METHODS: Overweight, early stage breast cancer survivors who completed initial cancer therapy were enrolled in a 6 month behaviorally based weight loss intervention that included calorie reduction, exercise and behavior modification. Biomarkers related to insulin resistance were obtained at baseline and after the intervention. Results from participants who achieved ≥5% weight loss were compared to those who lost less weight. RESULTS: Despite not having diabetes as a preexisting diagnosis prior to the study, 69% of all participants were considered to have pre-diabetes or diabetes at baseline based on American Diabetes Association definitions. Participants who achieved ≥5% weight loss had significantly lower fasting insulin, AUC insulin, and insulin resistance as measured by HOMA-IR. Beta cell function decreased as anticipated when insulin resistance improved. Additionally, leptin levels declined. CONCLUSIONS: Breast cancer survivors who achieved ≥5% weight loss demonstrated significant improvements in indices of insulin resistance. Despite an exclusion criteria of diabetes at the time of enrolment, a high proportion met criteria for pre-diabetes or diabetes at baseline. Pre-diabetes appears to be under recognized in overweight breast cancer survivors. Behaviorally based weight loss interventions can result in weight loss and improvements in biomarkers related to breast cancer outcomes and additionally may decrease the chance of developing diabetes. TRIAL REGISTRATION: NCT01482702 4/12/2010 (retrospectively registered).  https://clinicaltrials.gov/ct2/show/NCT01482702?term=Dittus&rank=4.

Changes in medical errors after implementation of a handoff program.

BACKGROUND: Miscommunications are a leading cause of serious medical errors. Data from multicenter studies assessing programs designed to improve handoff of information about patient care are lacking. METHODS: We conducted a prospective intervention study of a resident handoff-improvement program in nine hospitals, measuring rates of medical errors, preventable adverse events, and miscommunications, as well as resident workflow. The intervention included a mnemonic to standardize oral and written handoffs, handoff and communication training, a faculty development and observation program, and a sustainability campaign. Error rates were measured through active surveillance. Handoffs were assessed by means of evaluation of printed handoff documents and audio recordings. Workflow was assessed through time-motion observations. The primary outcome had two components: medical errors and preventable adverse events. RESULTS: In 10,740 patient admissions, the medical-error rate decreased by 23% from the preintervention period to the postintervention period (24.5 vs. 18.8 per 100 admissions, P<0.001), and the rate of preventable adverse events decreased by 30% (4.7 vs. 3.3 events per 100 admissions, P<0.001). The rate of nonpreventable adverse events did not change significantly (3.0 and 2.8 events per 100 admissions, P=0.79). Site-level analyses showed significant error reductions at six of nine sites. Across sites, significant increases were observed in the inclusion of all prespecified key elements in written documents and oral communication during handoff (nine written and five oral elements; P<0.001 for all 14 comparisons). There were no significant changes from the preintervention period to the postintervention period in the duration of oral handoffs (2.4 and 2.5 minutes per patient, respectively; P=0.55) or in resident workflow, including patient-family contact and computer time. CONCLUSIONS: Implementation of the handoff program was associated with reductions in medical errors and in preventable adverse events and with improvements in communication, without a negative effect on workflow. (Funded by the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, and others.).

Racial and Ethnic Differences in Pediatric Readmissions for Common Chronic Conditions.

OBJECTIVE: To compare the timing and magnitude of variation of pediatric readmission rates across race/ethnicity for selected chronic conditions: asthma, diabetes, seizures, migraines, and depression. STUDY DESIGN: Retrospective analysis of hospitalizations at 48 children's hospitals in the 2013 Pediatric Health Information System database for children (ages 0-18 years) admitted for asthma (n = 36 910), seizure (n = 35 361), diabetes (n = 12 468), migraine (n = 5882), and depression (n = 5132). Generalized linear models with a random effect for hospital were used to compare the likelihood of readmission by patients' race/ethnicity, adjusting for severity of illness, age, payer, and medical complexity. Adjusted readmission rates were calculated by week over 1 year. RESULTS: Significant variation in adjusted readmission rates by race/ethnicity existed for conditions aside from depression. Disparities for diabetes and asthma emerged at 3 and 4 weeks, respectively; they remained divergent up to 1 year with the highest 1-year readmission rates in non-Hispanic blacks vs other race/ethnicities (diabetes: 21.7% vs 13.4%, P < .001; asthma: 21.4% vs 14.6%, P < .001). Disparities for migraines and seizure emerged at 6 and 7 weeks, respectively; they remained up to 1 year, with the highest 1-year readmission rates in non-Hispanic whites vs other race/ethnicities (migraine: 17.3% vs 13.6%, P < .001; seizure: 23.9% vs 21.9%, P < .001). CONCLUSIONS: Readmission disparities behave differently across chronic conditions. They emerge more quickly after discharge for children hospitalized with asthma or diabetes than for seizures or migraines. The highest readmission rates were not consistently observed for 1 particular race/ethnicity. Study findings can impact pediatric chronic disease management to improve care for children with these conditions.

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.

Patient Characteristics Associated with Differences in Admission Frequency for Diabetic Ketoacidosis in United States Children's Hospitals.

OBJECTIVES: To determine across and within hospital differences in the predictors of 365-day admission frequency for diabetic ketoacidosis (DKA) in children at US children's hospitals. STUDY DESIGN: Multicenter retrospective cohort analysis of 12,449 children 2-18 years of age with a diagnosis of DKA in 42 US children's hospitals between 2004 and 2012. The main outcome of interest was the maximum number of DKA admissions experienced by each child within any 365-day interval during a 5-year follow-up period. The association between patient characteristics and the maximum number of DKA admissions within a 365-day interval was examined across and within hospitals. RESULTS: In the sample, 28.3% of patients admitted for DKA experienced at least 1 additional DKA admission within the following 365 days. Across hospitals, patient characteristics associated with increasing DKA admission frequency were public insurance (OR 1.97, 95% CI 1.71-2.26), non-Hispanic black race (OR 2.40, 95% CI 2.02-2.85), age ≥ 12 (OR 1.98, 95% CI 1.7-2.32), female sex (OR 1.41, 95% CI 1.29-1.55), and mental health comorbidity (OR 1.36, 95% CI 1.13-1.62). Within hospitals, non-Hispanic black race was associated with higher odds of 365-day admission in 59% of hospitals, and public insurance was associated with higher odds in 56% of hospitals. Older age, female sex, and mental health comorbidity were associated with higher odds of 365-day admission in 42%, 29%, and 15% of hospitals, respectively. CONCLUSIONS: Across children's hospitals, certain patient characteristics are associated with more frequent DKA admissions. However, these factors are not associated with increased DKA admission frequency for all hospitals.

Comparative Effectiveness of Dexamethasone versus Prednisone in Children Hospitalized with Asthma.

OBJECTIVES: To study the comparative effectiveness of dexamethasone vs prednisone/prednisolone in children hospitalized with asthma exacerbation not requiring intensive care. STUDY DESIGN: This multicenter retrospective cohort study, using the Pediatric Health Information System, included children aged 4-17 years who were hospitalized with a principal diagnosis of asthma between January 1, 2007 and December 31, 2012. Children with chronic complex condition and/or initial intensive care unit (ICU) management were excluded. Propensity score matching was used to detect differences in length of stay (LOS), readmissions, ICU transfer, and cost between groups. RESULTS: 40,257 hospitalizations met inclusion criteria; 1166 (2.9%) received only dexamethasone. In the matched cohort (N = 1284 representing 34 hospitals), the LOS was significantly shorter in the dexamethasone group compared with the prednisone/prednisolone group. The proportion of subjects with a LOS of 3 days or more was 6.7% in the dexamethasone group and 12% in the prednisone/prednisolone group (P = .002). Differences in all-cause readmission at 7- and 30 days were not statistically significant. The dexamethasone group had lower costs of index admission ($2621 vs $2838; P < .001) and total episode of care (including readmissions) ($2624 vs $2856; P < .001) compared with the prednisone/prednisolone group. There were no clinical significant differences in ICU transfer or readmissions between groups. CONCLUSIONS: Dexamethasone may be considered an alternative to prednisone/prednisolone for children hospitalized with asthma exacerbation not requiring admission to intensive care.

Impact of inpatient bronchiolitis clinical practice guideline implementation on testing and treatment.

OBJECTIVE: To determine the association between institutional inpatient clinical practice guidelines (CPGs) for bronchiolitis and the use of diagnostic tests and treatments. STUDY DESIGN: A multicenter retrospective cohort study of infants aged 29 days to 24 months with a discharge diagnosis of bronchiolitis was conducted between July 2011 and June 2012. An electronic survey was sent to quality improvement leaders to determine the presence, duration, and method of CPG implementation at participating hospitals. The Wilcoxon rank-sum test was used to perform bivariate comparisons between hospitals with CPGs and those without CPGs. Multivariable analysis was used to determine associations between CPG characteristics and the use of tests and treatments; analyses were clustered by hospital. RESULTS: The response rate to our electronic survey was 77% (33 of 43 hospitals). The majority (85%) had an institutional bronchiolitis CPG in place. Hospitals with a CPG had universal agreement regarding recommendations against routine tests and treatments. The presence of a CPG was not associated with significant reductions in the use of tests and treatments (eg, complete blood count, chest radiography, bronchodilator use, steroid and antibiotic use). A longer interval duration since CPG implementation and presence of an easily accessible online CPG document were associated with significant reductions in the performance of complete blood count and chest radiography and the use of corticosteroids. Other implementation factors demonstrated mixed results. CONCLUSION: Most children's hospitals have an institutional bronchiolitis CPG in place. The content of these CPGs is largely uniform in practice recommendations against tests and treatments. The presence of institutional CPGs did not significantly reduce the ordering of tests and treatments. Online accessibility of a written CPG and prolonged duration of implementation reduce tests and treatments.

Tobacco smoke incursions in multiunit housing.

OBJECTIVES: We sought to describe the prevalence of secondhand tobacco smoke incursions reported by multiunit housing (MUH) residents, pinpoint factors associated with exposure, and determine whether smoke-free building policy was associated with prevalence of reported tobacco smoke incursions. METHODS: Data are from a 2011 nationally representative dual-frame survey (random-digit-dial and Internet panels) of US adults aged 18 years and older. Individuals who lived in MUH and who reported no smoking in their homes for the past 3 months, whether or not they reported being smokers themselves, were included in this study. Incursions were defined as smelling tobacco smoke in their building or unit. RESULTS: Of 562 respondents, 29.5% reported smoke incursions in their buildings. Of these, 16% reported incursions in their own unit, 36.2% of which occurred at least weekly. Government-subsidized housing and partial smoke-free policies were associated with a higher likelihood of reporting smoke incursions. CONCLUSIONS: Many residents of multiunit housing are exposed to tobacco smoke in their units and buildings. Partial smoke-free policies do not appear to protect residents and might increase the likelihood of incursions in residents' individual units.