Using behavioral theory to understand partisan differences in COVID-19 vaccination and booster intentions.

In 2020, the Food and Drug Administration granted emergency use authorization for two COVID-19 vaccines. Two years later, the Centers for Disease Control and Prevention estimated that more than 250 million individuals had received at least one dose of the vaccine. Despite the large numbers of individuals vaccinated against COVID-19, partisan differences surrounding the COVID-19 vaccine emerged, creating a potential challenge for health communications aimed at increasing vaccine uptake. A better understanding of partisan differences in attitudes and intentions towards vaccination may help guide public health strategies aimed at increasing vaccine uptake. To determine whether a commonly used theory of behavioral intentions used to craft public health messages explains partisan differences in intentions. Data were drawn from a national panel of US adults and collected between February 21, 2022, and March 3, 2022, using an online survey (n = 1845). Among respondents identifying as either Democrat or Republican (n = 1466), path analysis models were estimated to test whether partisan differences in vaccination or booster intentions were explained by the theoretical constructs of protection motivation theory (PMT). PMT accounted for approximately half of the covariate-adjusted mean difference in COVID-19 vaccination intentions between Democrats and Republicans, and nearly all the mean difference in booster intentions. Party affiliation indirectly affected intentions via its association with perceived susceptibility to COVID-19, vaccine/booster efficacy, and perceived costs of getting a COVID-19 vaccine or booster dose. Compared with Democrats, Republicans may be less likely to get vaccinated or receive a booster dose because of beliefs that they are less susceptible to COVID-19, that the vaccine is less effective, and that vaccination comes with disadvantages. Theories of behavioral intentions can help to identify the underlying theoretical determinants driving behavioral differences between political groups.

Breast cancer statistics, 2013.

In this article, the American Cancer Society provides an overview of female breast cancer statistics in the United States, including data on incidence, mortality, survival, and screening. Approximately 232,340 new cases of invasive breast cancer and 39,620 breast cancer deaths are expected to occur among US women in 2013. One in 8 women in the United States will develop breast cancer in her lifetime. Breast cancer incidence rates increased slightly among African American women; decreased among Hispanic women; and were stable among whites, Asian Americans/Pacific Islanders, and American Indians/Alaska Natives from 2006 to 2010. Historically, white women have had the highest breast cancer incidence rates among women aged 40 years and older; however, incidence rates are converging among white and African American women, particularly among women aged 50 years to 59 years. Incidence rates increased for estrogen receptor-positive breast cancers in the youngest white women, Hispanic women aged 60 years to 69 years, and all but the oldest African American women. In contrast, estrogen receptor-negative breast cancers declined among most age and racial/ethnic groups. These divergent trends may reflect etiologic heterogeneity and the differing effects of some factors, such as obesity and parity, on risk by tumor subtype. Since 1990, breast cancer death rates have dropped by 34% and this decrease was evident in all racial/ethnic groups except American Indians/Alaska Natives. Nevertheless, survival disparities persist by race/ethnicity, with African American women having the poorest breast cancer survival of any racial/ethnic group. Continued progress in the control of breast cancer will require sustained and increased efforts to provide high-quality screening, diagnosis, and treatment to all segments of the population.

Prevalence of Planned Abdominal Binder Use after Vaginal Delivery.

OBJECTIVES: Pregnancy and vaginal delivery are risk factors for pelvic floor dysfunction. Abdominal binder use may increase intraabdominal pressure, affecting pelvic floor healing or function in recently traumatized postpartum pelvic floor muscle. This study assesses the prevalence of postpartum abdominal binder use, timing, and reasons for use. METHODS: In this cross-sectional observational survey study, women who underwent a vaginal delivery at our institution were enrolled. Participants were excluded if they did not speak Spanish or English. Participants were recruited on the postpartum unit. Data were deidentified and analyzed as appropriate for each variable. RESULTS: In total, 673 surveys were completed. Seven were excluded because they had cesarean deliveries. The average age was 26 years. Median gravidity and parity were 2 and 2. In total, 549 women (82%) planned to wear an abdominal binder postpartum. In all, 335 women provided a specific time when they would start use: 240 women (71%) would start at ≤2 days postpartum, 60 women (18%) would start at 3 to 7 days postpartum, and 35 women (11%) would start after 1 week postpartum. Common reasons reported for use included appearance, support, pain, swelling, weight loss, and recommendation. CONCLUSIONS: Among women delivering at our institution, planned abdominal binder use postvaginal delivery is common. The reasons cited include health and desire to return to prior body shape. The effects of using an abdominal binder in the postpartum period are unknown. More research is needed to better elucidate how increased postpartum intraabdominal pressure affects healing in traumatized pelvic floor muscles.

Procedural sedation in children with autism spectrum disorders: A survey of current practice patterns of the society for pediatric sedation members.

BACKGROUND: Children with autism spectrum disorder are challenging to sedate because of communication, sensory, and behavioral challenges. AIMS: The aim of this survey was to determine how procedural sedation is provided to children with autism spectrum disorders and whether sedation programs have specialized protocols for procedural sedation of these children. METHODS: We surveyed physician Medical Directors of sedation programs who are members of the Society for Pediatric Sedation, asking about practice characteristics and resource utilization during procedural sedation of children with autism spectrum disorders. RESULTS: Of 58 directors, 47 (81%) responded. Of the programs surveyed, 53% were either a large university medical center and 40% were a freestanding children's hospital. Only (12/47, 25.5%) of the programs used an individualized autism coping plan. To accomplish procedural sedation in this study cohort, 36% of the programs used additional nurses, whereas a child life specialist was used in 55% of the programs surveyed. Only 28% of the centers allotted additional time to accommodate children with autism spectrum disorders. Distraction methods were used in 80% whereas restrains were used in 45% programs for were used most commonly for i.v. catheter placement. Propofol was the preferred agent for 70% of programs for imaging, while propofol + fentanyl was used by 66% of programs for painful procedures. Although 57% of directors reported that their program staff was extremely comfortable providing procedural sedation for children with autism spectrum disorder, 79% of the directors wanted more education about behavioral management strategies for procedural sedation of these children. CONCLUSION: Among the Society for Pediatric Sedation programs, significant institutional variation exists on the delivery of procedural sedation to children with autism spectrum disorders. A better understanding of resources required, standardization of behavioral management strategies and pharmacologic approaches, and protocol development may help optimize care to this vulnerable population.

Factors affecting same-day cancelation of outpatient pediatric oncologic procedural sedation.

BACKGROUND: Children with cancer undergo serial invasive, painful procedures as a part of their diagnosis, treatment, and surveillance regimens that require procedural sedation (PS). Some may have a delay in their treatment plan due to same-day cancelation (SDC) of the procedure due to issues related to sedation or other factors. The objective of this report was to evaluate the factors resulting in the SDC of hematology and oncology patients in an outpatient pediatric sedation service. METHODS: Retrospective review of children with cancer or other hematologic disorders undergoing outpatient procedures using a dedicated pediatric sedation team from January 2012 to December 2017. The children with SDC were compared to controls (ie, patients not canceled) during the above study period. RESULTS: A total of 100 patients had SDC during the study. The median age was 10 years (25th percentile to 75th percentile: 7-10 years). The overall SDC rate was 3% and 78/100 (78%) had acute lymphoblastic leukemia. Most common procedure was lumbar puncture with intrathecal chemotherapy in 82/100 (82%) patients. Inadequate blood counts, acute illness, and not nil per os (NPO) accounted for 83% of the reasons for SDC. Type of health insurance, estimated household income, or distance traveled to the clinic did not impact SDC. CONCLUSIONS: The most common factors for SDC included inadequate blood counts, acute illness, and not meeting NPO guidelines. Understanding factors affecting SDC may help improve the efficiency of time-sensitive care delivered to children with cancer and other hematologic concerns by a pediatric sedation service.

Indicators for chronic disease surveillance - United States, 2013.

Chronic diseases are an important public health problem, which can result in morbidity, mortality, disability, and decreased quality of life. Chronic diseases represented seven of the top 10 causes of death in the United States in 2010 (Murphy SL, Xu J, Kochanek KD. Deaths: final data for 2010. Natl Vital Stat Rep 2013;6. Available at http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_04.pdf Adobe PDF file). Chronic diseases and risk factors vary by geographic area such as state and county, where essential public health interventions are implemented. The chronic disease indicators (CDIs) were established in the late 1990s through collaboration among CDC, the Council of State and Territorial Epidemiologists, and the Association of State and Territorial Chronic Disease Program Directors (now the National Association of Chronic Disease Directors) to enable public health professionals and policymakers to retrieve data for chronic diseases and risk factors that have a substantial impact on public health. This report describes the latest revisions to the CDIs, which were developed on the basis of a comprehensive review during 2011-2013. The number of indicators is increasing from 97 to 124, with major additions in systems and environmental indicators and additional emphasis on high-impact diseases and conditions as well as emerging topics.

Cigarette smoking and cancer screening underutilization by state: BRFSS 2010.

INTRODUCTION: To quantify the impact of current smokers' underutilization of colorectal cancer (CRC) and breast cancer screenings on overall cancer screening prevalence at the state level. METHODS: Behavioral Risk Factor Surveillance System 2010 data were used to calculate states' prevalence of screening for breast cancer and CRC overall and by current smoking status. To quantify the effect of underutilization of screening by current smokers on the overall breast cancer and CRC screening prevalence in each state, we derived a cancer screening underutilization (CSU) measure. RESULTS: CRC screening rates among adults aged 50 years and older ranged from 38.3% in Oklahoma to 59.5% in Rhode Island for current smokers and from 58.0% in Idaho to 75.9% in New Hampshire for nonsmokers. Mammography rates among women aged 40 years and older ranged from 26.8% in Utah to 63.6% in the District of Columbia for current smokers and from 50.8% in Utah to 73.0% in Massachusetts for nonsmokers. As a result, CSU values ranged from 2.1% to 6.7% for CRC screening and from 0.3% to 7.9% for mammography. Most states with the largest CSU values were located in the South or Midwest, whereas those with the smallest CSU values were located in the Northeast or West. CONCLUSIONS: Lower levels of CRC and mammography screening among current smokers substantially contribute to many states' lower overall screening prevalence, particularly in Southern and Midwestern states where smoking prevalence is highest. These findings underscore the potential for more concentrated efforts to promote cessation and screening among smokers as a means to achieving cancer screening goals.

Combining estimates from two surveys: an example from monitoring 2009 influenza A (H1N1) pandemic vaccination.

During the 2009 influenza A (H1N1) pandemic, there was an ongoing need to monitor 2009 H1N1 vaccination coverage at the national and state level to evaluate the vaccination campaign; thus, precise vaccination coverage estimates were needed in a timely fashion. The current objective is to describe and evaluate the methodology used to combine 2009 H1N1 vaccination coverage estimates from the Behavioral Risk Factor Surveillance System (BRFSS) and the National 2009 H1N1 Flu Survey (NHFS). H1N1 state level vaccination coverage estimates were combined by taking weighted averages of the BRFSS and NHFS estimates, with more weight given to the estimate with the larger effective sample size (sample size/design effect). The impact of the choice of weights was evaluated by comparing estimates when the design effect was removed from the weights. Combined vaccination coverage estimates for children generally fell midway between NHFS and BRFSS estimates because of larger NHFS sample sizes but smaller BRFSS design effects. Adult estimates were more closely weighted to BRFSS estimates because of larger BRFSS sample sizes. Combined standard errors were smaller than the survey-specific standard errors. When removing the design effect from the weights, the child combined estimates were more closely weighted to those from NHFS, resulting in larger standard errors. Adult combined estimates were similar regardless of choice of weight because of similar design effects across the two surveys. Combining estimates by weighting by the effective sample size allowed timely release of more precise estimates in all states during the 2009 H1N1 pandemic.

Electronic Versus Paper and Pencil Survey Administration Mode Comparison: 2019 Youth Risk Behavior Survey.

BACKGROUND: Since the inception of the Youth Risk Behavior Surveillance System in 1991, all surveys have been conducted in schools, using paper and pencil instruments (PAPI). For the 2019 YRBSS, sites were offered the opportunity to conduct their surveys using electronic data collection. This study aimed to determine whether differences in select metrics existed between students who completed the survey electronically versus using PAPI. METHODS: Thirty risk behaviors were examined in this study. Data completeness, response rates and bivariate comparisons of risk behavior prevalence between administration modes were examined. RESULTS: Twenty-nine of 30 questions examined had more complete responses among students using electronic surveys. Small differences were found for student and school response rates between modes. Twenty-five of 30 adolescent risk behaviors showed no mode effect. CONCLUSIONS: Seven of 44 states and DC participated electronically. Because survey data were more complete; school and student response rates were consistent; and minor differences existed in risk behaviors between modes, the acceptability of collecting data electronically was demonstrated.

Overview and Methodology of the Adolescent Behaviors and Experiences Survey - United States, January-June 2021.

Many U.S. schools closed nationwide in March 2020 to prevent the spread of COVID-19. School closures and online-only instruction have negatively affected certain students, with studies showing adverse effects of the pandemic on mental health. However, little is known about other experiences such as economic and food insecurity and abuse by a parent, as well as risk behaviors such as alcohol and drug use among youths across the United States during the pandemic. To address this gap, CDC developed the one-time, online Adolescent Behaviors and Experiences Survey (ABES), which was conducted during January-June 2021 to assess student behaviors and experiences during the COVID-19 pandemic among high school students, including unintentional injury, violence, tobacco product use, sexual behaviors, and dietary behaviors. This overview report of the ABES MMWR Supplement describes the ABES methodology, including the student questionnaire and administration, sampling, data collection, weighting, and analysis. ABES used a stratified, three-stage cluster probability-based sampling approach to obtain a nationally representative sample of students in grades 9-12 attending public and private schools. Teachers of selected classes provided students with access to the anonymous online survey while following local consent procedures. Data were collected using a 110-item questionnaire during January-June 2021 in 128 schools. A total of 7,998 students submitted surveys, and 7,705 of these surveys had valid data (i.e., ≥20 questions answered). The school response rate was 38%, the student response rate was 48%, and the overall response rate was 18%. Information on mode of instruction and school-provided equipment was also collected from all sampled schools. This overview report provides student- and school-level characteristics obtained from descriptive analyses, and the other reports in the ABES MMWR Supplement include information on substance use, mental health and suicidality, perceived racism, and disruptions to student life among high school students. Findings from ABES during the COVID-19 pandemic can help guide parents, teachers, school administrators, community leaders, clinicians, and public health officials in decision-making for student support and school health programs.

Health Risk Behaviors, Experiences, and Conditions Among Students Attending Private and Public High Schools.

BACKGROUND: Approximately 8.8% of US high school students attended private schools in 2015. Few studies have characterized health risk behaviors among these students or compared prevalence of behaviors between students in private and public schools using a contemporary, nationally representative sample. METHODS: Pooled 2007-2017 national Youth Risk Behavior Survey data were used to estimate the prevalence of 35 health risk behaviors for 89,848 public and private high school students. Unadjusted prevalence ratios were used to compare prevalence by school type. Differences in behaviors by school type were explored by sex and grade. RESULTS: Among private school students, the prevalence ranged from 5.0% to 31.9% for sexual risk behaviors; from 0.8% to 30.1% for substance use behaviors; from 0.7% to 21.8% for behaviors related mental health and suicide; from 3.2% to 6.8% for violence victimization experiences; and from 3.1% to 52.9% for behaviors related to unhealthy diet and physical inactivity. Private school students were less likely than public school students to report most behaviors; differences by school type were generally consistent across sex and grade. CONCLUSIONS: Students in both public and private schools reported health risk behaviors. Findings might inform prevention activities by identifying behaviors to prioritize in each school setting.

School-Level Poverty and Rurality Associated With Differences in Sexual Risk Behaviors Among U.S. Public High School Students.

PURPOSE: This study examined associations between student sexual behaviors and both school-level socioeconomic status and metropolitan status. METHODS: National Youth Risk Behavior Survey data from 2017 (N = 14,765, response rate = 60%) and 2019 (N = 13,677, 60%) were combined. School-level socioeconomic status (low-, mid-, and high-poverty based on the percentage of students eligible for free or reduced-price meals) and metropolitan status (urban, suburban/town, or rural) were identified for students attending public high schools. Sexual behaviors included currently sexually active, four or more lifetime sexual partners, condom use during the last sexual intercourse, hormonal birth control use during the last sexual intercourse, condom and hormonal birth control use during the last sexual intercourse, and drank alcohol or used drugs before the last sexual intercourse. Adjusted prevalence ratios were calculated using logistic regression models, controlling for sex, race/ethnicity, and grade. RESULTS: Compared to students attending low-poverty schools, high-poverty school students were significantly more likely to be currently sexually active (adjusted prevalence ratio = 1.4 [95% confidence interval = 1.1-1.8]) and have four or more lifetime sexual partners (1.6 [1.0-2.5]), but were significantly less likely to have drank alcohol or used drugs before the last sexual intercourse (.7 [.5-.9]) and have used hormonal birth control during the last sexual intercourse (.7 [.6-1.0]). Compared to students attending rural schools, urban school students were significantly less likely to be currently sexually active (.8 [.7-.9]) and have four or more lifetime sexual partners (.7 [.5-.9]). CONCLUSIONS: School-level socioeconomic status and metropolitan status were associated with differential risk in sexual behaviors.

Transportation Risk Behaviors Among High School Students - Youth Risk Behavior Survey, United States, 2019.

Motor-vehicle crashes are a leading cause of death and nonfatal injury among U.S. adolescents, resulting in approximately 2,500 deaths and 300,000 nonfatal injuries each year. Risk for motor-vehicle crashes and resulting injuries and deaths varies, depending on such behaviors as seat belt use or impaired or distracted driving. Improved understanding of adolescents' transportation risk behaviors can guide prevention efforts. Therefore, data from the 2019 Youth Risk Behavior Survey were analyzed to determine prevalence of transportation risk behaviors, including not always wearing a seat belt, riding with a driver who had been drinking alcohol (riding with a drinking driver), driving after drinking alcohol, and texting or e-mailing while driving. Differences by student characteristics (age, sex, race/ethnicity, academic grades in school, and sexual identity) were calculated. Multivariable analyses controlling for student characteristics examined associations between risk behaviors. Approximately 43.1% of U.S. high school students did not always wear a seat belt and 16.7% rode with a drinking driver during the 30 days before the survey. Approximately 59.9% of students had driven a car during the 30 days before the survey. Among students who drove, 5.4% had driven after drinking alcohol and 39.0% had texted or e-mailed while driving. Prevalence of not always wearing a seat belt was higher among students who were younger, black, or had lower grades. Riding with a drinking driver was higher among Hispanic students or students with lower grades. Driving after drinking alcohol was higher among students who were older, male, Hispanic, or had lower grades. Texting while driving was higher among older students or white students. Few differences existed by sexual identity. Multivariable analyses revealed that students engaging in one transportation risk behavior were more likely to engage in other transportation risk behaviors. Traffic safety and public health professionals can use these findings to reduce transportation risk behaviors by selecting, implementing, and contextualizing the most appropriate and effective strategies for specific populations and for the environment.

Does hypertension at initial presentation adversely affect outcomes in pediatric traumatic brain injury?

BACKGROUND: Adults with traumatic brain injury (TBI) who present hypertensive suffer worse outcomes and increased mortality compared to normotensive patients. The purpose of this study is to determine if age-adjusted hypertension on presentation is associated with worsened outcomes in pediatric TBI. METHODS: A retrospective chart review was conducted on pediatric patients with severe TBI admitted to a single system pediatric tertiary care center. The primary outcome was mortality. Secondary outcomes included length of stay, need for neurosurgical intervention, duration of mechanical ventilation, and the need for inpatient rehabilitation. RESULTS: Of 150 patients, 70% were hypertensive and 30% were normotensive on presentation. Comparing both groups, no statistically significant differences were noted in mortality (13.3% for both groups), need for neurosurgical intervention (51.4% vs 48.8%, p = 0.776), length of stay (6 vs 8 days, p = 0.732), duration of mechanical ventilation (2 vs 3 days, p = 0.912), or inpatient rehabilitation rates (48.6% vs 48.9%, p = 0.972). In comparing just the hypertensive patients, there was a trend toward increased mortality in the 95th and 99th percentile groups at 15.8% and 14.1%, versus the 90th percentile group at 6.7% but the difference was not statistically significant (p = 0.701). CONCLUSIONS: Contrary to the adult literature, pediatric patients with severe TBI and hypertension on presentation do not appear to have worsened outcomes compared to those who are normotensive. However, a trend toward increased mortality did exist at extremes of age adjusted hypertension. Larger scale studies are needed to validate these findings. STUDY TYPE: Retrospective cohort study LEVEL OF EVIDENCE: III.

Overview and Methods for the Youth Risk Behavior Surveillance System - United States, 2019.

Health risk behaviors practiced during adolescence often persist into adulthood and contribute to the leading causes of morbidity and mortality in the United States. Youth health behavior data at the national, state, territorial, tribal, and local levels help monitor the effectiveness of public health interventions designed to promote adolescent health. The Youth Risk Behavior Surveillance System (YRBSS) is the largest public health surveillance system in the United States, monitoring a broad range of health-related behaviors among high school students. YRBSS includes a nationally representative Youth Risk Behavior Survey (YRBS) and separate state, local school district, territorial, and tribal school-based YRBSs. This overview report describes the surveillance system and the 2019 survey methodology, including sampling, data collection procedures, response rates, data processing, weighting, and analyses presented in this MMWR Supplement. A 2019 YRBS participation map, survey response rates, and student demographic characteristics are included. In 2019, a total of 78 YRBSs were administered to high school student populations across the United States (national and 44 states, 28 local school districts, three territories, and two tribal governments), the greatest number of participating sites with representative data since the surveillance system was established in 1991. The nine reports in this MMWR Supplement are based on national YRBS data collected during August 2018-June 2019. A full description of 2019 YRBS results and downloadable data are available (https://www.cdc.gov/healthyyouth/data/yrbs/index.htm).Efforts to improve YRBSS and related data are ongoing and include updating reliability testing for the national questionnaire, transitioning to electronic survey administration (e.g., pilot testing for a tablet platform), and exploring innovative analytic methods to stratify data by school-level socioeconomic status and geographic location. Stakeholders and public health practitioners can use YRBS data (comparable across national, state, tribal, territorial, and local jurisdictions) to estimate the prevalence of health-related behaviors among different student groups, identify student risk behaviors, monitor health behavior trends, guide public health interventions, and track progress toward national health objectives.

Modified-Bolus Placement as a Therapeutic Tool in the Treatment of Pediatric Feeding Disorders: Analysis From a Retrospective Chart Review.

Purpose Recognizing the need to advance the treatment of pediatric feeding disorders, an emerging area of inquiry focuses on therapeutic techniques that address expulsion and packing possibly associated with oral-motor dysfunction. In the current study, we documented the use of modified-bolus placement in the treatment of pediatric feeding disorders at an intensive, multidisciplinary day-treatment center over a 26-month period. Method The retrospective observational cohort study involved patients admitted for the assessment and treatment of chronic food refusal from August 2013 to October 2015. Results Patients (n = 23) who received modified bolus placement displayed moderate-to-severe oral-motor deficits. Use of modified-bolus placement was associated with reduced expulsion and packing of bites during meals, and treatment gains coincided with a threefold increase in grams consumed per meal. Conclusion Results provide additional support for the potential therapeutic benefits of enhancing bolus placement onto the tongue as a means to improve mealtime performance in children with pediatric feeding disorders when included as an adjunct to more traditional behavioral approaches.

Comparison of a Smartphone Otoscope and Conventional Otoscope in the Diagnosis and Management of Acute Otitis Media.

Acute otitis media (AOM) is a leading cause of health encounters and antimicrobial prescriptions in children worldwide. We assessed (1) the rates of antimicrobial prescribing by pediatric emergency department clinicians using a smartphone otoscope device as compared with a conventional otoscope and (2) clinician acceptability of the smartphone device. We conducted a randomized control study in children's hospital emergency departments over 6 months. More than 1500 encounters were analyzed. The odds of prescribing antibiotics after being given a diagnosis of AOM by clinicians assigned to the smartphone group was 11% higher than the conventional group (18.8% vs 18.0%, odds ratio = 1.106, P = .600). Eight (73%) of the 11 physicians in the smartphone group preferred the smartphone device over the conventional otoscope. Use of a smartphone otoscope for detection of AOM in a pediatric emergency department setting did not lead to an increased likelihood of AOM diagnosis.

Long-Term Clinical Outcomes and Parental Satisfaction After Dextranomer/Hyaluronic Acid (Dx/HA) Injection for Primary Vesicoureteral Reflux.

Purpose: Endoscopic dextranomer/hyaluronic acid (Dx/HA) injection is a common treatment for vesicoureteral reflux (VUR) with excellent reported short-term clinical success rates. Long-term outcomes are less well-defined. We assessed long-term outcomes and parental satisfaction after Dx/HA injection for primary VUR with >5-year follow-up. Materials and Methods: Families of all patients who underwent Dx/HA injection for primary VUR at our institution between 2008 and 2012 were contacted for telephone interview. Data collected by phone included parental satisfaction and presence and severity of UTIs pre-operatively and post-operatively. Patient demographics, radiographic VUR data, need for secondary surgery, and surgical indications were obtained through chart review. Results: Five hundred and seventy-five patients underwent Dx/HA injection for primary VUR between 2008 and 2012. Ninety-nine (17.2%) of these patients' parents were successfully contacted and interviewed. Median follow-up time from surgery to survey was 8.4 (IQR 6.8-9.6) years. Secondary surgery was performed in 13/99 (13.1%), most commonly repeat Dx/HA injection. Seven patients (7.1%) underwent secondary Dx/HA injection for persistent VUR without UTIs at a median of 0.35 (IQR 0.33-0.77) years post-operatively. Five patients (5.1%) underwent Dx/HA injection (n = 3) or ureteral reimplantation (n = 2) for VUR with febrile UTIs (fUTIs) at a median of 2.2 (IQR 1.3-5.1) years. One patient had ureteral reimplantation for symptomatic obstruction 2.8 years after initial surgery. Only 3/99 (3.0%) required open or laparoscopic surgery after Dx/HA injection. Eighty-three families (84.7%) reported ≥1 fUTIs pre-operatively. Of these, only 9/83 (10.8%) reported fUTIs post-operatively, for an overall clinical success rate of 89.2%. Clinical success was 93.1% in patients whose pre-operative fUTIs were treated outpatient and 80.0% in those hospitalized at least once for fUTI treatment pre-operatively. Ninety-four percent of parents were highly satisfied, 2.4% partially satisfied, and 3.5% dissatisfied. Conclusions: Endoscopic injection with Dx/HA for primary VUR appears to have good long-term clinical success rates and high parental satisfaction, mirroring our previously reported short-term results. Post-operative ureteral obstruction is rare but may occur years post-operatively, justifying initial sonographic surveillance, and repeat imaging in symptomatic patients.

Primary versus secondary anastomosis in intestinal atresia.

PURPOSE: Neonates with intestinal atresia (IA) undergo either primary anastomosis (PA) or ostomy creation with secondary anastomosis (SA). Our purpose was to compare outcomes for PA and SA and to assess factors influencing procedure selection. METHODS: We conducted a retrospective cohort study of neonates with IA between 2009 and 2015. Patient characteristics, operative details, and outcomes were collected. Surgeon-level preferences (defined as performing >50% PA or SA) were assessed using logistic regression. RESULTS: Of 92 IA patients, 70 (76.1%) underwent PA and 22 (23.9%) underwent SA. Neonates with PA had shorter hospitalizations (27 days vs. 95 days, p < 0.001), shorter total parenteral nutrition duration (19 days vs. 74.5 days, p < 0.001), and fewer readmissions (33.3% vs. 63.2%, p = 0.024). On multivariable regression analysis, higher Apgar scores (Odds Ratio (OR) 4.16, 95% Confidence Interval (CI) 1.20-14.29) and uncomplicated atresia (OR 3.97, 95% CI 1.37-11.48) were associated with PA. At the surgeon-level, utilization of PA varied from 43.5% to 100%. Surgeon preference is not influenced by the demographic, presentation, or surgical findings of this patient population. CONCLUSIONS: PA has better outcomes than SA. Though procedural selection is influenced by the clinical status of the neonate, however surgeon preference plays a significant role in this clinical decision. LEVEL OF EVIDENCE: Level III Treatment Study.

The Impact of Disruption of the Care Delivery System by Commercial Laboratory Testing in a Children's Health Care System.

CONTEXT.­: Disruption of outpatient laboratory services by routing the samples to commercial reference laboratories may seem like a cost-saving measure by the payers, but results in hidden costs in quality and resources to support this paradigm. OBJECTIVE.­: To identify differences when outpatient tests are performed at the Children's Healthcare of Atlanta (Children's) Hospital lab compared to a commercial reference lab, and the financial costs to support the reference laboratory testing. DESIGN.­: Outpatient testing was sent to 3 different laboratories specified by the payer. Orders were placed in the Children's electronic health record, blood samples were drawn by the Children's phlebotomists, samples were sent to the testing laboratory, and results appeared in the electronic health record. Data comparing the time to result, cancelled samples, and cost to sustain the system of ordering and reporting were drawn from multiple sources, both electronic and manual. RESULTS.­: The median time from phlebotomy to result was 0.7 hours for testing at the Children's lab and 20.72 hours for the commercial lab. The median time from result posting to caregiver acknowledgment was 5.4 hours for the Children's lab and 18 hours for the commercial lab. The commercial lab cancelled 2.7% of the tests; the Children's lab cancelled 0.8%. The financial cost to support online ordering and reporting for testing performed at commercial labs was approximately $640,000 per year. CONCLUSIONS.­: Tangible monetary costs, plus intangible costs related to delayed results, occur when the laboratory testing system is disrupted.