Effect of an Evaluation Algorithm on CT Utilization in Identifying Appendicitis in Children.

OBJECTIVE: Our objective was to determine if there was a significant change in computed tomography (CT) utilization or length of stay (LOS) among patients evaluated for acute appendicitis after implementation of an appendicitis evaluation algorithm. METHODS: We conducted a retrospective chart review of patients aged 3-18 years in an urban, tertiary pediatric emergency department with acute abdominal pain, evaluated for appendicitis. Data were collected for 6 months preimplementation and postimplementation of the evaluation algorithm with a 3-month washout period between September 2018 and November 2019. Main outcomes were rate of CT utilization and LOS preimplementation and postimplementation and were analyzed using χ 2 test and Mann-Whitney U test, respectively. Descriptive analysis of demographics was performed, in addition to logistic regression to assess differences between the 2 study periods. RESULTS: A total of 2872 charts were identified with a chief complaint inclusive of "abdominal pain." Of these, 1510 met age requirements but did not meet at least 1 inclusion criteria; 229 more were excluded upon chart review for a final study sample of 1133 patients. Of these, 648 (57.2%) were female, 747 (65.9%) were White, and 988 (87.2%) were non-Hispanic. The majority of patients (770, 68%) were discharged home from the emergency department without a diagnosis of acute appendicitis. Neither CT (25.7% to 24.8%; P = 0.794) nor ultrasound (59.5% to 59.7%; P = 1.000) utilization significantly changed postimplementation. Total ED median LOS increased significantly (333.50 to 362.00 minutes; P = 0.011). Significant factors associated with CT utilization included fever, migration of pain, and right lower quadrant tenderness. Significant factors associated with appendicitis diagnosis included right lower quadrant pain, nausea/vomiting, migration of pain, and peritoneal signs. CONCLUSIONS: Overall, the appendicitis evaluation algorithm did not significantly decrease CT utilization or LOS. Equivocal grade 2 or 3 ultrasound finding rates were high, likely leading to higher rates of CT utilization and increasing LOS.

Use of the Child Opportunity Index to Examine Racial Variations in Outpatient Antibiotic Prescribing to Children.

To examine further racial and ethnic variations in antibiotic prescribing to children, we used the Child Opportunity Index. Black children were less likely to be prescribed an antibiotic. Low- and moderate-opportunity areas were associated with greater rates of antibiotic prescribing, after adjusting for race and other factors.

Polysomnographic outcomes of revision adenoidectomy in children with obstructive sleep apnea and recurrent/residual adenoidal hypertrophy.

INTRODUCTION: Recurrent/residual adenoidal hypertrophy after adenotonsillectomy in children can result in obstructive sleep apnea (OSA). We aimed to assess the polysomnographic (PSG) outcomes of revision adenoidectomy in children with recurrent/residual adenoidal hypertrophy and OSA. METHODS: This was a single-center retrospective study that included children with sleep studies that confirmed OSA and known history of adenotonsillectomy who were diagnosed with adenoidal hypertrophy and subsequently underwent revision adenoidectomy. Pre- and postoperative PSG variables of revision adenoidectomy were included in the analysis. RESULTS: A total of 20 children were included in the study. The cohort included 13 males and 7 females with a mean age of 7.8 years (± 3.6 years). The mean BMI z score was 1.96 [1.31, 2.43]. The median duration from adenotonsillectomy performance was 2.3 years [1.4, 4.0]. Overall, revision adenoidectomy resulted in significant improvements in multiple respiratory parameters, including AHI 6.6 [1.4, 13. 7] vs 14.8 [7.4, 20.7], p = 0.02; oxygen desaturations nadir 88.0 [84.0, 93.0] vs 80.0 [72.2, 88.9], p = 0.01; supine AHI 8.6 [1.5, 14.3] vs 17.6 [8.3, 30.2], p = 0.02; and arousal index 12.2 [9.6, 15.7] vs 18.9 [13.4, 24.9], p = 0.04. CONCLUSIONS: Children with recurrent/residual adenoidal hypertrophy after adenotonsillectomy who undergo revision adenoidectomy experience improvements in respiratory event, gas exchange, and arousal index.

Significance of electrocardiogram abnormalities in children presenting to the emergency department with acute COVID-19 infection.

OBJECTIVES: Acute COVID-19 infection may be associated with electrocardiogram (EKG) abnormalities in pediatric patients. We have anecdotally observed EKG abnormalities in patients without MIS-C or significant cardiac disease requiring intervention or further follow-up. Our aim was to determine the incidence of abnormal EKG findings and correlate with evidence of significant cardiac pathology in pediatric patients who present to the emergency department during an acute COVID-19 infection. METHODS: We conducted a retrospective chart review of 209 pediatric patients diagnosed in the emergency department with acute COVID-19 infection and had an EKG during the same encounter; patients with MIS-C were excluded. Primary objectives included determination of the incidence of EKG abnormalities in patients presenting to the emergency department (ED) with acute COVID-19 infection who did not require hospitalization. Secondary objectives included correlation of these findings with other concomitant testing of possible cardiac pathology (echocardiograms, biomarkers), and clinical outcomes. RESULTS: EKG abnormalities were identified in 84 (40%) patients. Echo was performed in 28 (13.4%) patients; only 1 was abnormal, and considered an incidental finding. The most common EKG abnormality involved nonspecific ST-T wave patterns, suggestive of but not diagnostic for underlying pericardial or myocardial disease. Serum troponin and BNP values were normal in all patients tested, either with a normal or abnormal EKG. A normal EKG had a 100% sensitivity and negative predictive value in predicting a normal echocardiogram. No patients were hospitalized and there was normalization of EKG abnormalities during short-term follow up. CONCLUSIONS: Despite a high incidence of abnormal EKG repolarization patterns in pediatric patients presenting with acute (non-MIS-C) COVID-19 infections, these patients generally do not have abnormal cardiac biomarkers or echocardiograms, and the risk for adverse cardiac events is low.

Impact of COVID-19 pandemic healthcare restrictions on utilisation and diagnostic yield of outpatient transthoracic echocardiograms.

BACKGROUND: During the COVID-19 pandemic, Kentucky prohibited elective medical procedures from 3/18/2020-4/27/2020. We sought to determine if cessation of elective procedures in Kentucky during the COVID-19 pandemic resulted in a decrease in the proportion of rarely appropriate outpatient transthoracic echocardiograms interpreted at the open echocardiography lab at Norton Children's Hospital. METHODS: A retrospective chart review was conducted comparing proportions of rarely appropriate outpatient paediatric transthoracic echocardiograms performed pre-COVID (3/21/2019-4/28/2019) and during COVID (3/19/2020-4/27/2020). Transthoracic echocardiogram indication was determined by chart review and echocardiogram reports. Indication appropriateness was evaluated using paediatric appropriate use criteria for initial outpatient transthoracic echocardiogram or CHD follow-up as applicable. RESULTS: Of transthoracic echocardiograms pre-COVID, 100 (37.7%) were rarely appropriate versus 18 (20.2%) during COVID. Pre-COVID, paediatric cardiologists tended to order fewer rarely appropriate transthoracic echocardiograms than paediatricians (35.9% versus 46.4%), although this difference was not statistically significant. Cardiologists ordered the majority of outpatient transthoracic echocardiograms during COVID (77/89, 86.5%), limiting the ability to compare transthoracic echocardiogram indications by provider type. There was no significant difference in diagnostic yield of initial outpatient transthoracic echocardiograms with (13.0%) abnormal studies pre-COVID versus 7 (15.5%) during COVID. CONCLUSION: While elective procedures were prohibited in Kentucky during the COVID-19 pandemic, a decrease in the proportion of rarely appropriate outpatient paediatric transthoracic echocardiograms was observed. There was no significant difference in diagnostic yield of initial outpatient transthoracic echocardiograms between time periods, suggesting that clinically significant echocardiogram findings were still detected despite more prudent utilisation of echocardiography during this time.

The impact of converting a power plant from coal to natural gas on pediatric acute asthma.

BACKGROUND AND OBJECTIVES: Air pollutants play a pivotal role in the frequency and severity of asthma symptoms. As cleaner air initiatives are increasingly being implemented, it is important to appraise how these changes relate to acute pediatric asthma. The objective of this study is to evaluate the effect of a Gas and Electric Company's transition from using coal to natural gas as their fuel source on pediatric asthma-related illnesses in Louisville, KY. METHODS: Data were collected for children 2-17 years old from a large regional healthcare system, for which an asthma-related primary diagnosis was present between April 1, 2013 and April 1, 2018. Using an interrupted time series design, we analyzed monthly rates of asthma-related visits to urgent care (UC) and emergency departments (ED). Segmented Poisson regression models were used to assess whether the power company's transition was associated with changes in trends of asthma-related visits. RESULTS: There were a total of 7,735 subjects who met inclusion criteria. Prior to the complete factory transition from coal to natural gas, the mean monthly rate for asthma-related visits was 163.9. After the transition, we observed a significant decrease to a mean monthly rate of 100.3 asthma-related visits (p < 0.001). In addition, the proportion of inpatient (23.7% vs. 30.5%, p < 0.001) visits significantly increased, while ED & UC (76.3 vs. 69.5%, p < 0.001) were significantly decreased. CONCLUSION: Converting an electrical power plant from coal to natural gas lead to a profound and sustained decrease in pediatric acute asthma exacerbation in Louisville, KY.

High-level psychotropic polypharmacy: a retrospective comparison of children in foster care to their peers on Medicaid.

BACKGROUND: The use of antipsychotic medication and psychotropic polypharmacy has increased in the United States over the last two decades especially for children from low-income families and those in foster care. Although attention has been paid to providing greater insight, prescribing patterns remain concerning since there is a lack of evidence related to safety and efficacy. High-level psychotropic polypharmacy has not been described. We aim to compare the use of HLPP for children receiving Medicaid services and those in foster care and identify factors associated with the duration of use of high-level psychotropic polypharmacy. Additionally, we will examine the frequency of laboratory metabolic screening and emergency department, inpatient, and outpatient visits. METHODS: A cross-sectional, secondary analysis of statewide data describes trends in high-level psychotropic polypharmacy from 2012 to 2017 and the prevalence and predictors of high-level psychotropic polypharmacy duration and resource use in 2017 for all children on Medicaid and those in foster care. High-level psychotropic polypharmacy included concurrent use, at least four classes of medications including an antipsychotic, and at least 30 days duration. RESULTS: High-level psychotropic polypharmacy increased from 2012 to 2014 for both groups but stabilized in 2015-2016. Children in foster care showed a slight increase compared to their peers in 2017. There was no association between duration and demographic characteristics or foster care status. Diagnoses predicted duration. Neither group received metabolic monitoring at an acceptable rate. CONCLUSIONS: Concerning patterns of high-level psychotropic polypharmacy and metabolic monitoring were identified. Cautious use of high-level psychotropic polypharmacy and greater oversight to ensure that these children are receiving comprehensive services like behavioral health, primary care, and primary prevention.

Longitudinal Trends in the Diagnosis of Attention-Deficit/Hyperactivity Disorder and Stimulant Use in Preschool Children on Medicaid.

OBJECTIVES: To describe trends in the diagnosis of attention-deficit/hyperactivity disorder (ADHD) and prescribing of stimulants in preschool-age children receiving Medicaid and to identify factors associated with the receipt of psychosocial care. STUDY DESIGN: Data were extracted from 2012-2016 Kentucky Medicaid claims for children aged <6 years. ADHD was identified using International Classification of Diseases, Tenth Revision codes F90.0, F90.1, F90.2, F90.8, and F90.9. Psychosocial therapy was defined as having at least 1 relevant Current Procedural Terminology code in a claim within the year. A generalized linear model with a logit link and binomial distribution was used to assess factors associated with receipt of psychosocial treatment in 2016. RESULTS: More than 2500 (1.24%) preschool-aged children receiving Medicaid had a diagnosis of ADHD in 2016, with 988 (38.2%) of those receiving a stimulant medication. Children in foster care were diagnosed with and/or treated for ADHD 4 times more often than other Medicaid recipients. Of the 1091 preschoolers receiving stimulants, 99 (9%) did not have a diagnosis of ADHD. There were no significant differences in diagnoses by race/ethnicity, but children reported to be black, Hispanic, or other race/ethnicity received stimulants at a lower rate than white children. Positive predictors for receiving psychosocial therapy in 2016 included having the diagnosis but not receiving a stimulant, having at least 1 prescription written by a psychiatrist, having comorbidities, and age. The use of stimulants in children aged <6 years declined from 0.9% in 2012 to 0.5% in 2016. CONCLUSIONS: Promising trends demonstrate a decreasing use of stimulants in preschoolers; however, continued vigilance is needed to promote the optimal use of psychosocial interventions.

Providers' Behaviors and Beliefs on Prescribing Antipsychotic Medication to Children: A Qualitative Study.

Fragmentation in behavioral and mental health care to children has resulted in suboptimal care and high rates of psychotropic medication use, especially antipsychotic medications (APM). A qualitative study, based on the Theory of Planned Behavior (TPB), aimed to better understand prescribing practices, barriers to optimal treatment, and potential interventions to safeguard the use of APM for children in Kentucky. The most common barrier to optimal care was access to mental health specialists. Social norms and pressure from families contribute to increased medication use. We identify promising interventions to safeguard the use of APM through the lens of the TPB.

Association of Circulating Markers of Microbial Translocation and Hepatic Inflammation with Liver Injury in Patients with Type 2 Diabetes.

BACKGROUND: Virtually the entire spectrum of liver disease is observed in association with type 2 diabetes mellitus (T2DM); indeed, T2DM is now the most common cause of liver disease in the U.S. We conducted a pilot study to investigate the relevance of increased microbial translocation and systemic inflammation in the development of liver injury in patients with T2DM. METHODS: Patients with T2DM (n = 17) and non-diabetic controls (NDC; n = 11) aged 25-80 yrs. participated in this study. Serum levels of endotoxin, calprotectin, soluble CD14 and CD163, and several inflammatory cytokines were measured. In addition to standard liver injury markers, ALT and AST, novel serum markers of liver injury, keratin 18 (K-18) M30 (apoptosis-associated caspase-cleaved keratin 18), and M65 (soluble keratin 18) were evaluated. Statistical analyses were performed using the Mann-Whitney test to assess differences between study groups. Pearson's correlation analysis was performed to determine the strength of association between two variables using GraphPad Prism 9.5.0 software. RESULTS: Patients with T2DM had significantly higher levels of sCD14 in comparison to NDC, suggesting an increase in gut permeability, microbial translocation, and monocyte/macrophage activation. Importantly, relevant to the ensuing inflammatory responses, the increase in sCD14 in patients with T2DM was accompanied by a significant increase in sCD163, a marker of hepatic Kupffer cell activation and inflammation. Further, a positive correlation was observed between sCD163 and endotoxin and sCD14 in T2DM patients but not in NDC. In association with these changes, keratin 18 (K-18)-based serum markers (M65 and M30) that reflect hepatocyte death were significantly higher in the T2DM group indicating ongoing liver injury. Notably, both M65 and M30 levels correlated with sCD14 and sCD163, suggesting that immune cell activation and hepatic inflammation may be linked to the development of liver injury in T2DM. CONCLUSIONS: These findings suggest that the pathogenic changes in the gut-liver axis, marked by increased microbial translocation, may be a major component in the etiology of hepatocyte inflammation and injury in patients with T2DM. However, larger longitudinal studies, including histological evidence, are needed to confirm these observations.

Changes in Psychiatric Medication Use During the COVID-19 Pandemic in a Pediatric Long-Term Care Facility.

Background: Coronavirus disease 2019 (COVID-19) caused a global pandemic that dramatically altered infection control procedures in long-term care facilities. Mental health decline among residents of geriatric facilities during the pandemic has been described (Ferro Uriguen et al., 2022). Our study aims to evaluate psychological effects of the pandemic on residents of a pediatric long-term care facility, a population comprised of medically complex children. To characterize this, we compared patterns of psychotropic medication use during the COVID-19 pandemic to those of the prepandemic period among residents of a 76-bed pediatric long-term care facility. Methods: We conducted a retrospective study of psychotropic medication use from January 2019 to August 2022 using de-identified monthly facility medication refill data. Linear multivariable regression models were used to estimate the level and trends in the monthly rates of medication refills per 10,000 bed days among resident children before and after the pandemic onset. Six classes of psychotropic medications were analyzed including antipsychotics, antidepressants and anxiety medications, trazodone, clonidine, mood stabilizers, and gabapentin. Results: The pandemic onset was associated with a significant increase in the monthly prescribing rates of antidepressant and anxiety medications (20.83; 95% CI, 3.96-37.71; p = 0.017), mood stabilizers (10.44; 95% CI, 5.79-15.09; p < 0.001), and trazodone (-27.66; 95% CI, -40.44 to 14.88; p < 0.001) above those expected by prepandemic trends. The trend in trazodone use changed significantly during the pandemic from decreasing prepandemic to increasing (2.21; 95% CI, 1.28-3.14; p < 0.001). Antidepressant, anxiety medication, and gabapentin use increased throughout the study. Antidepressant and anxiety medication use surged early in the pandemic, but then continued growth at their prior rates of use. Discussion: Increased use of antidepressant and anxiety medications and trazodone suggests a possible impact of the COVID-19 pandemic on rates of anxiety, depression, sleep disturbance, and agitation among children with severe intellectual and developmental disabilities living in long-term care.

A case study on variations in network structure and cross-sector alignment in two local systems serving pregnant and parenting women in recovery.

OBJECTIVE: To describe network structure and alignment across organizations in healthcare, public health, and social services sectors that serve pregnant and parenting women with substance use disorder (SUD) in an urban and a rural community. DATA SOURCES AND STUDY SETTINGS: Two community networks, one urban and one rural with each including a residential substance use treatment program, in Kentucky during 2021. STUDY DESIGN: Social network analysis measured system collaboration and cross-sector alignment between healthcare, public health, and social services organizations, applying the Framework for Aligning Sectors. To understand the alignment and structure of each network, we measured network density overall and between sectors, network centralization, and each organization's degree centrality and effective size. DATA COLLECTION/EXTRACTION METHODS: Computer-assisted telephone interviews were conducted to document alignment around shared purpose, data, financing, and governance. PRINCIPAL FINDINGS: On average, overall and cross-sector network densities in both communities were similar. However, alignment was highest for data sharing and financing in the urban community and for shared purpose and governance in the rural community. Cross-sector partnerships involving healthcare organizations were more prevalent in the rural county (44% vs. 38% for healthcare/public health, 44% vs. 29% for healthcare/social services), but more prevalent for those involving public health/social services organizations in the urban county (42% vs. 24%). A single healthcare organization had the highest degree centrality (Mdn [IQR] = 26 [26-9.5]) and effective size (Mdn [IQR] = 15.9 [20.6-8.7]) within the rural county. Social services organizations held more central positions in the urban county (degree centrality Mdn [IQR] = 13 [14.8-9.5]; effective size Mdn [IQR] = 10.4 [11.4-7.9]). CONCLUSIONS: Cross-sector alignment may strengthen local capacity for comprehensive SUD care for pregnant and parenting women. Healthcare organizations are key players in cross-sector partnerships in the rural community, where one healthcare facility holds the central brokerage role. In contrast, public health agencies are key to cross-sector collaboration with social services in the urban community.

Variation in Lymph Node Assessment for Colon Cancer at the Tumor, Surgeon, and Hospital Level.

BACKGROUND: We hypothesized that tumor- and hospital-level factors, compared with surgeon characteristics, are associated with the majority of variation in the 12 or more lymph nodes (LNs) examined quality standard for resected colon cancer. STUDY DESIGN: A dataset containing an anonymized surgeon identifier was obtained from the National Cancer Database for stage I to III colon cancers from 2010 to 2017. Multilevel logistic regression models were built to assign a proportion of variance in achievement of the 12 LNs standard among the following: (1) tumor factors (demographic and pathologic characteristics), (2) surgeon factors (volume, approach, and margin status), and (3) facility factors (volume and facility type). RESULTS: There were 283,192 unique patient records with 15,358 unique surgeons across 1,258 facilities in our cohort. Achievement of the 12 LNs standard was high (90.3%). Achievement of the 12 LNs standard by surgeon volume was 88.1% and 90.7% in the lowest and highest quartiles, and 86.8% and 91.6% at the facility level for high and low annual volume quartiles, respectively. In multivariate analysis, the following tumor factors were associated with meeting the 12 LNs standard: age, sex, primary tumor site, tumor grade, T stage, and comorbidities (all p < 0.001). Tumor factors were responsible for 71% of the variation in 12 LNs yield, whereas surgeon and facility characteristics contributed 17% and 12%, respectively. CONCLUSIONS: Twenty-nine percent of the variation in the 12 LNs standard is linked to modifiable factors. The majority of variation in this quality metric is associated with non-modifiable tumor-level factors.

Diagnosis of Pancreatic Cancer after Cholecystectomy in the Elderly.

BACKGROUND: Previous studies evaluating whether recent cholecystectomy is associated with a pancreas cancer diagnosis are limited. We aimed to examine if cholecystectomy was performed more frequently in the year prior to cancer diagnosis than would be expected in a similar non-cancer population. METHODS: SEER-Medicare linked files were used to identify patients with pancreatic adenocarcinoma. Cancer diagnoses were considered to be "timely" if within 2 months of cholecystectomy or "delayed" if 2-12 months after cholecystectomy. Clinical factors and survival outcomes were compared using chi-square and Kaplan-Meier analyses. RESULTS: Rate of cholecystectomy in the year prior to diagnosis of cancer was 1.9% for the cancer group, compared to .4% in the non-cancer group (OR = 4.7, 95% CI 4.4-5.1). Differences in the cancer vs non-cancer cohorts at the time of cholecystectomy included a higher age (74 vs 70, P < .0001), more males (49.9% vs 41.7%, P < .0001), and more frequent open technique (21.0% vs 9.4%, P < .0001). Acute pancreatitis was nearly twice as common in the cancer cohort (19.1%) vs the non-cancer cohort (10.7%), P < .0001. There were no differences between patients who had a timely diagnosis after cholecystectomy compared to a delayed diagnosis with regard to age, gender, comorbidity index, race, or rural/urban designation. The rates of localized disease and subsequent resection were also similar between the delayed and timely groups. Overall unadjusted survival was no different between timely and delayed diagnoses, P = .96. DISCUSSION: Elderly patients diagnosed with pancreatic adenocarcinoma are more likely to have had a recent cholecystectomy compared to those without.

Role of neck radiography in assessing recurrent/residual adenoid hypertrophy in children with OSA and history of adenotonsillectomy: a sleep physician perspective.

STUDY OBJECTIVES: Recurrent/residual adenoid hypertrophy after adenotonsillectomy in children can result in obstructive sleep apnea (OSA). We aimed to assess the role of soft tissue neck X-ray (STN-XR) in evaluating recurrent/residual adenoid tissue hypertrophy. METHODS: This was a single-center retrospective study that included children with sleep study-confirmed OSA and a known history of adenotonsillectomy who underwent STN-XR to evaluate for recurrent/residual adenoid tissue hypertrophy. STN-XR nasopharyngeal obliteration and baseline polysomnographic data were analyzed. Multiple linear regression was used to assess the independent relationship between the results of STN-XR and the total apnea-hypopnea index, while controlling for relevant characteristics. RESULTS: The study included 160 participants with a median age of 10 years (quartile [Q] 1 = 7, Q3 = 12.25). More than half of the children were male (59.4%) and the median body mass index z-score was 2.11 (Q1 = 1.23, Q3 = 2.54). STN-XR was normal in 39.4%, and it showed mild, moderate, and complete nasopharyngeal obliteration in 20.6%, 32.5%, and 7.5% of the participants, respectively. Multiple regression analysis showed that moderate and complete nasopharyngeal obliteration was associated with an increase in the mean total apnea-hypopnea index by 109% (P = .0002) and 185% (P = .001), respectively, when compared with children without nasopharyngeal obliteration. However, mild nasopharyngeal obliteration, body mass index z-score, age, sex, and race were not significantly associated with an increase in the total apnea-hypopnea index. CONCLUSIONS: STN-XR was useful in assessing recurrent/residual adenoid tissue hypertrophy in children with OSA and a history of adenotonsillectomy. Moderate and complete nasopharyngeal obliteration were associated with significantly increased apnea-hypopnea index. Pediatric sleep physicians may consider STN-XR in the evaluation of children with OSA and previous history of adenotonsillectomy. CITATION: Senthilvel E, Nguyen QL, Gunaratnam B, Feygin YB, Palani R, El-Kersh K. Role of neck radiography in assessing recurrent/residual adenoid hypertrophy in children with OSA and history of adenotonsillectomy: a sleep physician perspective. J Clin Sleep Med. 2023;19(6):1027-1033.

Emergency departments: An underutilized resource to address pediatric influenza vaccine coverage.

BACKGROUND: Emergency department (ED) based influenza vaccine (IV) programs have been successful in adults; however, little is known about pediatric ED IV programs in terms of prevalence, feasibility, or successful implementation. AIMS: To describe the reach and effectiveness of IV practices in pediatric EDs, and identify IV facilitators and barriers. METHODS: We assessed, via cross-sectional survey of pediatric ED physicians, number of EDs offering IV to children, vaccines administered annually, and perceived facilitators/barriers to vaccination. The proportion of EDs offering IV is reported. Chi-square tests compared facilitators and barriers among high performers (≥50 IV/year), low performers (<50 IV/yr), and non-vaccinators. We calculated an area of missed effect for the number of children who could be vaccinated if non-vaccinating EDs offered IV. RESULTS: Among 492 physicians from 166 EDs, 142 responded (representing 61 (37.3 %) EDs). Most EDs were in large, urban, academic, freestanding children's hospitals (Table 1). Only twenty-six EDs (44.3 %) offer ≥ 1 IV/yr. Seventeen (65.4 %) were low performers, five (19.2 %) high performers, and four (15.4 %) were model programs. High/model performers used establish workflows more commonly than lower performers (78 % vs. 33 %), although this was not statistically significant (p = 0.077). Common facilitators included: strong provider and administration buy-in, electronic health record facilitation, storage/accessibility, and having a leadership team/champion (Fig. 1). Non-vaccinators commonly perceived lack of these factors as barriers. Many (24/61, 39.3 %) EDs expressed interested in establishing or growing IV programs. Up to 18,250 unvaccinated children could receive IV annually if non-vaccinating EDs offered IV during influenza season. CONCLUSIONS: Over half of EDs participating in the Pediatric Emergency Medicine Collaborative Research Committee do not currently offer pediatric IV. Addressing identified barriers/facilitators to develop IV programs in EDs has potential to improve vaccination rates, especially among minority and underserved children.

Emergency Departments: An Underutilized Resource for Expanding COVID-19 Vaccine Coverage in Children.

COVID-19 vaccine (CV) acceptance rates remain suboptimal in children. Emergency departments (EDs) represent a unique opportunity to improve vaccination rates, particularly in underserved children. Little is known about the presence or reach of CV programs in US EDs. We assessed, via a cross-sectional survey of pediatric ED physicians, the number of EDs offering CVs to children, the approximate numbers of vaccines administered annually, and the perceived facilitators/barriers to vaccination. The proportion of EDs offering CVs is reported. Chi-square tests compared facilitators and barriers among frequent vaccinators (≥50 CVs/year), infrequent vaccinators (<50 CVs/year), and non-vaccinators. Among 492 physicians from 166 EDs, 142 responded (representing 61 (37.3%) EDs). Most EDs were in large, urban, academic, freestanding children's hospitals. Only 11 EDs (18.0%) offer ≥1 CV/year, and only two (18.2%) of these gave ≥50 CVs. Common facilitators of vaccination included the electronic health record facilitation of vaccination, a strong provider/staff buy-in, storage/accessibility, and having a leadership team or champion. Barriers included patient/caregiver refusal, forgetting to offer vaccines, and, less commonly, a lack of buy-in/support and the inaccessibility of vaccines. Many (28/47, 59.6%) EDs expressed interest in establishing a CV program.

Associations With Severe Desaturation Events Among Children Receiving Noninvasive Respiratory Support at Time of Intubation.

BACKGROUND: Endotracheal intubation is a common procedure associated with adverse events, including severe desaturation. Many patients receive noninvasive respiratory support to reduce the need for intubation. There are minimal data about the association between noninvasive respiratory support and the risk of a severe desaturation event during intubation. We aim to differentiate patients based on the level of noninvasive respiratory support, analyze the severe desaturation event by groups, and identify modifiable risk factors. METHODS: Oral intubations, excluding tube exchanges or re-intubation after unplanned extubation, from October 2018 through July 2020, at the study site were reviewed. A severe desaturation event was defined as [Formula: see text] < 70% or a >15% decrease from baseline in cyanotic heart disease. We analyzed outcomes by 4 groups: room air/nasal cannula (≤0.5 L/kg/min), high-flow nasal cannula (HFNC) (0.5-2 L/kg/min), high HFNC (≥2 L/kg/min), and noninvasive ventilation (NIV). RESULTS: Of 243 subjects who were intubated, 31% were receiving room air/nasal cannula, 25% were receiving HFNC, 18% were receiving high HFNC, and 26% were receiving NIV. Twelve percent of all the subjects had a severe desaturation event. In a univariate analysis, the incidence of a severe desaturation event was similar among all levels of respiratory support (P = .14). A severe desaturation event was more likely in those subjects who were receiving [Formula: see text] ≥ 0.6 at the time of the decision to intubate (19.6%) versus [Formula: see text] < 0.6 (8.1%) (P = .02). The duration of noninvasive respiratory support was longer (5 vs 1 h; P = .02) among those with a severe desaturation event. In a regression analysis, when adjusting for ≥2 intubation attempts pre-intubation, NIV use was independently associated with increased odds of severe desaturation events (odds ratio 3.14, CI 1.08-10.5). CONCLUSIONS: Results of our study suggest that [Formula: see text] > 0.60, the duration of noninvasive respiratory support, and exposure to NIV before an intubation are risk factors of severe desaturation events during intubation.

First-line Behavioral Health Treatment Prior to Stimulant or Alpha-2 Agonist Use for Preschoolers on Kentucky Medicaid in 2017.

OBJECTIVE: We aimed to assess the degree to which the American Academy of Pediatrics' (AAP) clinical guidelines were followed when treating attention deficit/hyperactivity disorder (ADHD) in preschoolers. METHOD: Using Medicaid claims for children 4 to 5 years of age receiving their first dose of stimulants/alpha-2 agonists in 2017 (n = 836), we determined if BH was received prior to initiation of medication. We examined predictors after controlling for confounders. RESULTS: More than half the sample did not receive first-line BH, which did not differ by demographics. Those receiving BH prior to medication had a higher rate of receiving an ADHD diagnosis. Only three diagnoses were significant in multivariate (OR 13.8, 95% CI [1.7-115.1]) analyses. CONCLUSION: More than half the sample did not, conservatively, meet the AAP clinical recommendations. Further research is needed to identify targets for intervention. Limitations are noted.

Inappropriate Prescribing of Antibiotics to Pediatric Patients Receiving Medicaid: Comparison of High-Volume and Non-High-Volume Antibiotic Prescribers-Kentucky, 2019.

Inappropriate antibiotic prescribing to pediatric Medicaid patients was compared among high-volume and non-high-volume prescribers. High-volume prescribers had a higher percentage of inappropriate prescriptions than non-high-volume prescribers (17.2% versus 15.8%, p = 0.005). Targeting high-volume prescribers for stewardship efforts is a practical approach to reducing outpatient antibiotic prescribing that also captures inappropriate use.