Provision of Guideline-Based Pediatric Asthma Care in US Emergency Departments.

OBJECTIVES: National guidelines for routine pediatric acute asthma care recommend providing corticosteroids, and discourage routinely obtaining chest radiographs (CXRs) and using antibiotics. We examined rates of adherence to all 3 of these aspects during emergency department (ED) visits and compared performance between pediatric and general EDs. METHODS: Using the National Hospital Ambulatory Medical Care Survey, we included all nontransfer ED visits for patients younger than 19 years with a diagnosis of asthma and treatment with albuterol from 2005 to 2015. Guideline-based care, defined as (1) corticosteroids, (2) no antibiotics, and (3) no CXR, was assessed for each visit. Hospitals were categorized as pediatric or general and compared according to rates of guideline-based care. Multivariable analyses were used to identify demographic and hospital-level characteristics associated with guideline-based care. RESULTS: More than 7 million ED visits met eligibility criteria. Antibiotic provision and CXR acquisition were significantly higher in general EDs (20% vs 11%, 40% vs 26%, respectively), while steroid provision was similar (63% vs 62%). Overall, 34% of visits involved guideline-based care, with a higher rate for pediatric EDs compared with general EDs (42% to 31%). Visit at a pediatric ED (odds ratio, 1.62 [confidence interval 1.17-2.25]) and black race (odds ratio, 1.48 [confidence interval 1.07-2.02]) were independently associated with guideline-based care in a multivariate analysis. CONCLUSIONS: Guideline-based care was more common in pediatric EDs, although only one-third of all pediatric-age visits met the definition of guideline-based care. Future policy and education efforts to reduce unnecessary antibiotic and CXR use for children with asthma are warranted.

Population dynamics and methodological assessments from a 15-year period of Amphibian monitoring in British Columbia's Southern Gulf Islands.

With amphibian populations facing a multitude of threats, including habitat loss, climate change, invasive species and infectious diseases, it is important to identify valuable amphibian habitat and the imminent pressures these environments face. Between 2004 and 2019, 6 years of amphibian surveys were conducted at Greenburn, Roe and McLean lakes in the Southern Gulf Islands of British Columbia, Canada. We assessed (1) species composition and trends of native amphibians, including at-risk northern red-legged frog (Rana aurora); (2) observations of invasive American bullfrog (Lithobates catesbeianus); and (3) the efficacy of visual encounter and trapping survey methods in determining multi-species amphibian occupancy. The shallow, semi-ephemeral McLean Lake hosted more amphibian species and more breeding activity than the larger, deeper waters of Greenburn and Roe lakes. Despite multiple observations, bullfrogs have thus far not established a detectable population within these lakes, with the presence of native and introduced predators as potential contributing factors. Declining trends in occupancy of native populations of R. aurora, Pacific chorus frog (Pseudacris regilla) and rough-skinned newt (Taricha granulosa) were observed at all three lakes. Results varied within years by species and survey method, highlighting the importance of effective replication and employing complementary survey methods to optimize studies of amphibian occupancy. These observations also emphasize the value of shallow, small- to medium-sized waterbodies to native amphibian populations in the Southern Gulf Islands. As these waterbodies become increasingly threatened by global climate change and habitat degradation, the potential impacts of declining freshwater ecosystem health on amphibian populations should be considered.

Spatial Concentration and Spillover: Eviction Dynamics in Neighborhoods of Los Angeles, California, 2005-2015.

The lack of sufficient affordable housing in Los Angeles, California burdens many renter households with the threat of an eviction. Research has identified individual- and neighborhood-level sociodemographic correlates of eviction, but the uneven distribution of sociodemographic characteristics and housing conditions across neighborhoods likely produces broader patterns of spatial clustering in eviction prevalence across local areas. We use spatial autoregressive models to explain the spatial concentration and spillover effects for two types of formal eviction filings-court-based and no-fault Ellis Act petitions-within and across census tracts in Los Angeles. Court-based filings show greater and more persistent spatial concentration, particularly in neighborhoods with higher percentages of Black residents. We find evidence of spatial correlation for both types of eviction, however, suggesting that identifying the spatial distribution of eviction prevalence across local areas is important to understanding how location shapes eviction risk in metropolitan areas.

Fluid Balance Is Associated with Clinical Outcomes and Extravascular Lung Water in Children with Acute Asthma Exacerbation.

RATIONALE: The effects of fluid administration during acute asthma exacerbation are likely unique in this patient population: highly negative inspiratory intrapleural pressure resulting from increased airway resistance may interact with excess fluid administration to favor the accumulation of extravascular lung water, leading to worse clinical outcomes. OBJECTIVES: Investigate how fluid balance influences clinical outcomes in children hospitalized for asthma exacerbation. METHODS: We analyzed the association between fluid overload and clinical outcomes in a retrospective cohort of children admitted to an urban children's hospital with acute asthma exacerbation. These findings were validated in two cohorts: a matched retrospective and a prospective observational cohort. Finally, ultrasound imaging was used to identify extravascular lung water and investigate the physiological basis for the inferential findings. MEASUREMENTS AND MAIN RESULTS: In the retrospective cohort, peak fluid overload [(fluid input - output)/weight] is associated with longer hospital length of stay, longer treatment duration, and increased risk of supplemental oxygen use (P values < 0.001). Similar results were obtained in the validation cohorts. There was a strong interaction between fluid balance and intrapleural pressure: the combination of positive fluid balance and highly negative inspiratory intrapleural pressures is associated with signs of increased extravascular lung water (P < 0.001), longer length of stay (P = 0.01), longer treatment duration (P = 0.03), and increased risk of supplemental oxygen use (P = 0.02). CONCLUSIONS: Excess volume administration leading to fluid overload in children with acute asthma exacerbation is associated with increased extravascular lung water and worse clinical outcomes.

Pediatric Review and Perioperative Considerations.

Perioperative management of pediatric patients demands knowledge of the relevant ways in which pediatric physiology and physiological regulation differs from the adult. This article will outline some of these most pertinent differences, and also present current recommendations for perioperative management.

Emergency Department Management of Febrile Respiratory Illness in Children.

BACKGROUND: There are limited data regarding testing and treatment patterns for children presenting to the emergency department (ED) with a febrile respiratory illness. OBJECTIVES: The aims of the study were to evaluate the rates of diagnostic testing, antibiotic use, and pneumonia diagnosis among children presenting to an ED with a febrile respiratory illness and to evaluate whether differences exist on the basis of care at a pediatric versus a general ED. METHODS: Cross-sectional study of children presenting to an ED with a febrile respiratory illness from 2001 to 2010 used the National Hospital Ambulatory Medical Care Survey. Using extrapolated estimates from the weighted population sample, rates of laboratory and radiographic testing, antibiotic use, and pneumonia diagnosis were ascertained. Comparisons were made between children treated at a general versus pediatric ED. A subpopulation of children undergoing chest radiograph was identified to target those with concern for radiographic pneumonia. RESULTS: Fifteen percent of the 12 million visits for febrile respiratory illness occurred in a pediatric ED. Thirteen percent (95% confidence interval [CI], 11-15) of patients had a complete blood count, 4% (95% CI, 3-5) had a blood culture, and 33% (95% CI, 30-35) had a chest radiograph obtained; no differences were observed on the basis of ED type. Despite similar rates of pneumonia diagnosis, antibiotics were prescribed less often for children cared for in a pediatric (35% [95% CI, 30-41]) versus general ED (50% [95% CI, 47-53]). Similar findings were observed among the subgroup of children with febrile respiratory illness undergoing chest radiograph. CONCLUSIONS: High rates of diagnostic testing were observed among children with febrile respiratory illnesses, despite low rates of pneumonia diagnosis. Antibiotic use was higher among children cared for at a general ED compared with pediatric ED.

Abdominal Lymphatic Malformation Presenting as Acute Abdominal Pain: A Common Pediatric Complaint, but an Unusual Diagnosis.

We present the clinical and radiological findings involving a mesenteric lymphatic malformation causing volvulus in a toddler presenting with acute abdominal pain, as well as its treatment options.

Impact of Chest Radiography on Antibiotic Treatment for Children With Suspected Pneumonia.

OBJECTIVE: National guidelines discourage routine chest radiographs (CXRs) to confirm suspected pneumonia in children managed as outpatients. However, limiting CXRs may lead to antibiotic overuse. We examined the impact of CXRs and clinical suspicion on antibiotic treatment for children with suspected pneumonia. METHODS: Children aged 3 months to 18 years undergoing CXR for suspected pneumonia in a pediatric emergency department were prospectively enrolled. Before CXR, physicians indicated their initial plan for antibiotics (yes or no) and clinical suspicion for radiographic pneumonia (<5%, 5-10%, 11-20%, 21-50%, 51-75%, >75%). Subjects had radiographic pneumonia if their CXRs demonstrated definite or possible findings of pneumonia. We compared antibiotic treatment according to pre-CXR antibiotic plan and suspicion for pneumonia and CXR results. RESULTS: Among the 107 children with a plan for antibiotics before CXR, 72% ultimately received antibiotics compared with 19% of the 1503 children without a pre-CXR plan for antibiotics (P < 0.001). Among those patients with a pre-CXR plan for antibiotics, 96% of children with radiographic pneumonia were ultimately treated compared with 54% without radiographic pneumonia (P < 0.001). If antibiotics were not initially planned, 37% with radiographic pneumonia were treated compared with 8% without radiographic pneumonia (P < 0.001). The use of CXR was more likely to influence antibiotic prescribing patterns when the clinical suspicion of pneumonia was low (<20%). CONCLUSIONS: Among children with high suspicion for pneumonia, CXRs infrequently altered the initial plan for antibiotics. However, when clinical suspicion for pneumonia was low, the use of CXR may reduce unnecessary antibiotic use.

Systems modeling of anti-apoptotic pathways in prostate cancer: psychological stress triggers a synergism pattern switch in drug combination therapy.

Prostate cancer patients often have increased levels of psychological stress or anxiety, but the molecular mechanisms underlying the interaction between psychological stress and prostate cancer as well as therapy resistance have been rarely studied and remain poorly understood. Recent reports show that stress inhibits apoptosis in prostate cancer cells via epinephrine/beta2 adrenergic receptor/PKA/BAD pathway. In this study, we used experimental data on the signaling pathways that control BAD phosphorylation to build a dynamic network model of apoptosis regulation in prostate cancer cells. We then compared the predictive power of two different models with or without the role of Mcl-1, which justified the role of Mcl-1 stabilization in anti-apoptotic effects of emotional stress. Based on the selected model, we examined and quantitatively evaluated the induction of apoptosis by drug combination therapies. We predicted that the combination of PI3K inhibitor LY294002 and inhibition of BAD phosphorylation at S112 would produce the best synergistic effect among 8 interventions examined. Experimental validation confirmed the effectiveness of our predictive model. Moreover, we found that epinephrine signaling changes the synergism pattern and decreases efficacy of combination therapy. The molecular mechanisms responsible for therapeutic resistance and the switch in synergism were explored by analyzing a network model of signaling pathways affected by psychological stress. These results provide insights into the mechanisms of psychological stress signaling in therapy-resistant cancer, and indicate the potential benefit of reducing psychological stress in designing more effective therapies for prostate cancer patients.

Primary care visits for asthma monitoring over time and association with acute asthma visits for urban Medicaid-insured children.

OBJECTIVES: To examine the association between numbers of primary care provider (PCP) visits for asthma monitoring (AM) over time and acute asthma visits in the emergency department (ED) and at the PCP for Medicaid-insured children. METHODS: We prospectively enrolled 2-10 years old children during ED asthma visits. We audited hospital and PCP records for each subject for three consecutive years. We excluded subjects also receiving care from asthma subspecialists. PCP AM visits were those with documentation that suggested discussion of asthma management but no acute asthma symptoms or findings. PCP "Acute Asthma" visits were those with documentation of acute asthma symptoms or findings, regardless of treatment. ED asthma visits were those with documented asthma treatment. Generalized liner models were used to analyze the association between numbers of AM visits and acute asthma visits to the ED and PCP. RESULTS: One hundred three subjects were analyzed. Over the 3 years, the mean number of AM visits/child was 2.5 ± 2.3 (standard deviation), range 0-10. Only 50% of subjects had at least 1 PCP visit with an asthma controller medication documented. The mean number of ED asthma visits/child was 3.2 ± 2.8; range 1-18. The mean number of PCP Acute Asthma visits/child was 0.7 ± 1.6; range 0-11. Increasing AM visits was associated with more ED visits (estimate 0.088; 95% CI 0.001, 0.174), and more PCP Acute Asthma visits (estimate 0.297; 95% CI 0.166, 0.429). Increasing PCP visits for any diagnosis was not associated with ED visits (estimate 0.021; 95% CI -0.018, 0.06). CONCLUSIONS: Asthma monitoring visits and documented controller medication for these urban Medicaid-insured children occurred infrequently over 3 years, and having more asthma monitoring visits was not associated with fewer ED or PCP acute asthma visits.

The chicken or the egg? Mycoplasma pneumoniae complicated by left ventricle thrombus and anterior myocardial infarction: a case report.

Background: Mycoplasma pneumoniae can be associated with extrapulmonary manifestations, including vasculitis, myocarditis, and thrombosis. In rare cases, it has also been implicated in intracardiac thrombus formation. Case Summary: A previously healthy 25-year-old male presented with worsening abdominal pain, an episode of acute chest pain, new lightheadedness, and gait instability in the setting of M. pneumoniae. Initial blood tests were notable for mild coagulopathy, thrombocytosis, transaminitis, and elevated high-sensitivity troponin. Further, workup revealed systematic emboli to the cerebellum, kidneys, spleen, anterior myocardial infarction, and a left ventricular multilobular mural mass. Due to the unknown composition of the mass with concern for further embolic events, the patient underwent successful surgical excision with the mass ultimately defined as a thrombus. Hypercoagulable workup was notably inconclusive and intraoperative myocardial biopsies revealed organizing infarction without inflammation or healed myocarditis. Post-operative course was complicated by left ventricular dysfunction and acute kidney injury, both with eventual improvement. Patient has remained on guideline-directed medical therapy and prophylactic anticoagulation. Discussion: We presume that the formation of the ventricular thrombus in this case was a result of transient thrombophilia in the setting of M. pneumonia resulting in coronary obstruction and subsequent myocardial injury. This case underscores the challenge of determining the pathophysiological sequence of events in patients with mycoplasma who develop systemic embolism and the management of a large residual thrombus, particularly in regard to surgical consideration.

Use of PKA-mediated phenotypes for genetic and small-molecule screens in Schizosaccharomyces pombe.

PKA (protein kinase A) in the fission yeast Schizosaccharomyces pombe controls transcription of genes involved in metabolism, cell growth and sexual development. In the present review, we discuss phenotypes associated with either high or low PKA activity in the context of how they can be used to carry out genetic or small-molecule screens that affect components of the PKA pathway. Although our recent research has focused on the study of heterologously expressed cyclic nucleotide PDEs (phosphodiesterases), these same methods can be used to target other S. pombe proteins or their functionally equivalent orthologues that act in the PKA pathway.

Emergency department epidemiology of pneumococcal bacteremia in children since the institution of widespread PCV7 vaccination.

BACKGROUND: The heptavalent pneumococcal conjugate vaccine (PCV7) has produced a shift in the epidemiology of invasive infections from Streptoccoccus pneumoniae. OBJECTIVE: Our aim was to determine the temporal changes in pneumococcal bacteremia (Streptococcus pneumoniae bacteremia [SPB]) in the emergency department (ED) since the introduction of PCV7. METHODS: This was a retrospective cohort study of children 0-18 years with SPB evaluated from 1998-2009 in a tertiary-care pediatric ED. The primary outcome was annual proportion of children with SPB from PCV7 serotypes (ie, 4, 6B, 9V, 14, 18C, 19F, and 23F) and nonvaccine serotypes (NVT). Rates of SPB (per 10,000 ED visits) were calculated. SPB was analyzed by time period: before October 2000 was considered "pre-PCV7," November 2000 to October 2003 was considered "peri-PCV7," and after November 2003 was "post-PCV7." Febrile young children (FYC) were defined as children age <36 months and fever without source. RESULTS: A total of 201 episodes of SPB occurred during the study, with a median age of 20.3 months (interquartile range 10.7-49.5 months; range 1.6-215.4 months); 56.7% were male and 69.7% were African American. SPB from PCV7 serotypes decreased more than fourfold, from 82.2% pre-PCV7 to 19.5% peri- and post-PCV7. Most SPB was from NVT serotype 19A (31.3%) peri- and post-PCV7. Annual rates of SPB were 4.01/10,000 ED visits pre-PCV7, decreasing to 2.10 peri-PCV7, and 1.75 post-PCV7. Among the 56 (27.8%) FYC with SPB, NVT were responsible for 11.5% of SPB pre-PCV7, and increased to 80.0% peri- and post-PCV7 (p < 0.001). CONCLUSIONS: Rates of SPB have decreased since the introduction of PCV7, yet SPB still occurs among children in the ED. NVT are increasing in prevalence, and SPB from PCV7-serotypes have decreased.

Low-Dose Colchicine for Secondary Prevention of Coronary Artery Disease: JACC Review Topic of the Week.

Among statin-treated patients, inflammation assessed by means of high-sensitivity C-reactive protein (hsCRP) is a more powerful determinant of cardiovascular death and all-cause mortality than low-density-lipoprotein cholesterol (LDL-C). Several therapies that target residual inflammatory risk significantly reduce vascular event rates. For coronary artery disease patients already taking guideline-directed medical care, including statins, low-dose colchicine (0.5 mg/d orally) has been shown to safely lower major adverse cardiovascular events by 31% among those with stable atherosclerosis and by 23% after recent myocardial infarction. These magnitudes of benefit are larger than those seen in contemporary secondary prevention trials of adjunctive lipid-lowering agents. Low-dose colchicine is contraindicated in patients with significant renal or liver dysfunction and should be temporarily discontinued when taking concomitant agents such as clarithromycin, ketoconazole, and cyclosporine that share metabolism pathways. Lipid lowering and inflammation inhibition are not in conflict but are synergistic. In the future, combined use of aggressive LDL-C-lowering and inflammation-inhibiting therapies may become standard of care for most atherosclerosis patients. In June 2023, the U.S. Food and Drug Administration approved the use of low-dose colchicine to reduce the risk of myocardial infarction, stroke, coronary revascularization, and cardiovascular death in adult patients with established atherosclerotic disease or with multiple risk factors for cardiovascular disease.

Trends in the Use of Procalcitonin at US Children's Hospital Emergency Departments.

OBJECTIVES: Procalcitonin (PCT) was approved by the Food and Drug Administration in 2016. We assessed changes in PCT utilization over time in emergency departments (EDs) at US Children's Hospitals and identified the most common conditions associated with PCT testing. METHODS: We performed a cross-sectional study of children <18 years of age presenting to 1 of 33 EDs contributing data to the Pediatric Health Information System between 2016 and 2020. We examined trends in PCT utilization during an ED encounter between institutions and over the study period. Using All Patients Refined Diagnosis Related Groups, we identified the most common conditions for which PCT was obtained (overall, and relative to the performance of a complete blood count). RESULTS: The overall rate of PCT testing increased from 0.2% of all ED visits in 2016 to 1.8% in 2020. Across hospitals, the proportion of ED encounters with PCT obtained ranged from 0.0005% to 4.3% with marked variability in overall use. Among children who had PCT testing performed, the most common diagnoses were fever (10.7%), infections of the upper respiratory tract (9.2%), and pneumonia (5.9%). Relative to the performance of a complete blood count, rates of PCT testing were highest among children with sepsis (28.7%), fever (21.4%), pulmonary edema/respiratory failure (17.3%), and bronchiolitis/respiratory syncytial virus pneumonia (15.6%). CONCLUSIONS: PCT utilization in the ED has increased over the past 5 years with variation between hospitals. PCT is most frequently obtained for children with respiratory infections and febrile illnesses.

Neisseria sicca endocarditis requiring mitral valve replacement in a previously healthy adolescent.

Infective endocarditis due to Neisseria sicca, a normal inhabitant of the upper respiratory tract, is rarely reported but associated with embolic phenomena and large vegetations often requiring surgical intervention. We report a previously healthy 12-year-old girl who presented with prolonged fever and altered mental status. The patient developed rapidly progressive respiratory insufficiency and cardiovascular instability, and echocardiography demonstrated a large vegetation on the mitral valve. She developed worsening mitral regurgitation with resultant pulmonary hemorrhage and underwent mitral valve replacement. Her blood culture was positive for N. sicca. This infection should be considered in patients with prolonged high fever and multiorgan dysfunction. Despite a typically severe course, reported mortality is low.

Exhaled nitric oxide levels during treatment of pediatric acute asthma exacerbations and association with the need for hospitalization.

OBJECTIVES: To examine how exhaled nitric oxide (eNO) levels measured before and after treatment of asthma exacerbations relate to emergency department (ED) disposition. METHODS: We enrolled children 6 to 17 years old treated for asthma exacerbations in a pediatric ED. Using an offline single-breath eNO sampling technique, we collected replicate initial samples before treatment and replicate final samples when disposition was decided. We determined correlations and coefficients of variability of eNO values (parts per billion, ppb) of samples and compared by disposition (hospitalization or discharge) mean initial and final eNO levels and initial-to-final change. RESULTS: Eighty-one subjects had initial and final eNO values; 24 subjects with more severe presentations had final values only. Replicate eNO samples were correlated (initial r = 0.98, final r = 0.99) and had low coefficients of variability (initial, 0.059 ± 0.057; final, 0.061 ± 0.070). For subjects with initial and final values, initial eNO levels were similar by disposition (mean difference, -8.0 ppb; 95% confidence interval [CI], -24.8 to 8.9 ppb), as were final levels (mean difference, -2.8 ppb; 95% CI, -23.8 to 18.2 ppb). Overall, final eNO was higher than initial (36.3 ± 29.7 vs 31.5 ± 23.9 ppb), but only 63% of subjects had any increase. Change in eNO was similar by disposition (mean difference, 4.6 ppb; 95% CI, -3.4 to 12.6). For more severe subjects with final eNO only, eNO was similar by disposition (P = 0.47). CONCLUSIONS: For children aged 6 to 17 years with asthma exacerbations, eNO levels can be reliably measured. However, eNO levels measured before treatment or when disposition was determined did not distinguish children needing hospitalization.

Evaluation of a substance abuse, HIV and hepatitis prevention initiative for urban Native Americans: the Native Voices program.

Although many community-based prevention interventions are conducted in American Indian and Alaska Native (AI/AN) communities, few studies report the outcomes. This article is a mixed methods outcome evaluation of an HIV/AIDS, hepatitis, and substance abuse prevention intervention for an urban AI/AN community, Native Voices. The study group wascomposed of 100youth (ages 13 to 18) who lived in the San Francisco Bay Area. The outcome measures of interest were knowledge, perception of risk, sexual self-efficacy, ethnic identity, and sexual risk behavior. The findings indicate that knowledge, perception of risk, and sexual self-efficacy increased, while no change was shown in measures of ethnic identity and behavior. Findings extended prior research by evaluating the Gathering of Native Americans (GONA) curriculum, a promising intervention designed for AI/AN people.