Racial and Ethnic Differences in Length of Stay for US Children Hospitalized for Acute Osteomyelitis.

OBJECTIVE: To examine the associations between race and ethnicity and length of stay (LOS) for US children with acute osteomyelitis. STUDY DESIGN: Using the Kids' Inpatient Database, we conducted a cross-sectional study of children <21 years old hospitalized in 2016 or 2019 with acute osteomyelitis. Using survey-weighted negative binomial regression, we modeled LOS by race and ethnicity, adjusting for clinical and hospital characteristics and socioeconomic status. Secondary outcomes included prolonged LOS, defined as LOS of >7 days (equivalent to LOS in the highest quartile). RESULTS: We identified 2388 children discharged with acute osteomyelitis. The median LOS was 5 days (IQR, 3-7). Compared with White children, children of Black race (adjusted incidence rate ratio [aIRR] 1.15; 95% CI, 1.05-1.27), Hispanic ethnicity (aIRR 1.11; 95% CI, 1.02-1.21), and other race and ethnicity (aIRR 1.12; 95% CI, 1.01-1.23) had a significantly longer LOS. The odds of Black children experiencing prolonged LOS was 46% higher compared with White children (aOR, 1.46; 95% CI, 1.01-2.11). CONCLUSIONS: Children of Black race, Hispanic ethnicity, and other race and ethnicity with acute osteomyelitis experienced longer LOS than White children. Elucidating the mechanisms underlying these race- and ethnicity-based differences, including social drivers such as access to care, structural racism, and bias in provision of inpatient care, may improve management and outcomes for children with acute osteomyelitis.

Multicenter Analysis of Attrition from the Pediatric Tuberculosis Infection Care Cascade in Boston.

OBJECTIVE: To characterize losses from the pediatric tuberculosis (TB) infection care cascade to identify ways to improve TB infection care delivery. STUDY DESIGN: We conducted a retrospective cohort study of children (age <18 years) screened for TB within 2 Boston-area health systems between January 2017 and May 2019. Patients who received a tuberculin skin test (TST) and/or an interferon gamma release assay (IGRA) were included. RESULTS: We included 13 353 tests among 11 622 patients; 93.9% of the tests were completed. Of 199 patients with positive tests for whom TB infection evaluation was clinically appropriate, 59.3% completed treatment or were recommended to not start treatment. Age 12-17 years (vs < 5 years; aOR 1.59; 95% CI, 1.32-1.92), non-English/non-Spanish language preference (vs English; aOR, 1.34; 95% CI, 1.02-1.76), and receipt of an IGRA (vs TST, aOR, 30.82; 95% CI, 21.92-43.34) were associated with increased odds of testing completion. Odds of testing completion decreased as census tract social vulnerability index quartile increased (ie, social vulnerability worsened; most vulnerable quartile vs least vulnerable quartile, aOR, 0.77; 95% CI, 0.60-0.99). Odds of completing treatment after starting treatment were higher in females (vs males; aOR, 2.35; 95% CI, 1.14-4.85) and were lower in patients starting treatment in a primary care clinic (vs TB/infectious diseases clinic; aOR, 0.44; 95% CI, 0.27-0.71). CONCLUSIONS: Among children with a high proportion of negative TB infection tests, completion of testing was high, but completion of evaluation and treatment was moderate. Transitions toward IGRA testing will improve testing completion; interventions addressing social determinants of health are important to improve treatment completion.

Comorbidities Associated with Hospitalization and Progression Among Adolescents with Symptomatic Coronavirus Disease 2019.

OBJECTIVE: To identify subgroups likely to benefit from monoclonal antibody and antiviral therapy by evaluating the relationship between comorbidities and hospitalization among US adolescents with symptomatic coronavirus disease 2019 (COVID-19). STUDY DESIGN: We analyzed the relationship between presence of comorbidities and need for hospitalization within 28 days of COVID-19 diagnosis for adolescents aged 12-17 years listed in the Pediatric COVID-19 US registry, a multicenter retrospective cohort of US pediatric patients with COVID-19. Comorbidities assessed included obesity, chronic kidney disease (CKD), diabetes, immunosuppressive disease or treatment, sickle cell disease (SCD), heart disease, neurologic disease/neurodevelopmental disorders, and pulmonary disease (excluding patients with mild asthma). We used multivariable logistic regression to determine race/ethnicity-adjusted associations between comorbidities and hospitalization. RESULTS: A total of 1877 patients met our inclusion criteria, of whom 284 (15%) were hospitalized within 28 days of their COVID-19 diagnosis. In a race/ethnicity-adjusted model, the following comorbidities were independently associated with increased odds of hospitalization: SCD (aOR, 6.9; 95% CI, 3.0-15.9), immunocompromising condition (aOR, 6.4; 95% CI, 3.8-10.8), obesity (aOR, 3.2; 95% CI, 2.1-4.9), diabetes (aOR, 3.0; 95% CI, 1.4-6.2), neurologic disease (aOR, 2.8; 95% CI, 1.8-4.3), and pulmonary disease (excluding mild asthma) (aOR, 1.9; 95% CI, 1.2-3.1). Heart disease and CKD were not independently associated with hospitalization. CONCLUSIONS: SCD, immunocompromising conditions, obesity, diabetes, neurologic disease, and pulmonary disease (excluding mild asthma) were associated with hospitalization for symptomatic COVID-19. Adolescents with acute COVID-19 and these comorbidities should be prioritized for consideration of therapy to avert hospitalization.

A Contemporary Analysis of Pediatric Urology Surgical Volume at a Tertiary Care Center.

OBJECTIVE: To describe the annual volume of pediatric urology cases in an academic, tertiary care setting. METHODS: A retrospective review was performed of all patients operated on by 4 pediatric urologists (total of 2.5 full-time equivalents) at an academic, tertiary care center with a free-standing children's hospital from 2016 to 2017 (24 months). Basic case information was collected from operative reports. Descriptive statistics are reported using nonparametric methods. "Uncommon" was defined a priori as occurring <10% of the time. RESULTS: During the entire study period, 2718 patients underwent 4580 procedures. This equated to 1088 patients and 1832 procedures per full-time equivalent. Median age at surgery was 3.2 years (IQR 0.8-10) and 757 (16.5%) of patients were female. Most procedures were elective (4406, 96.2%) and did not require postoperative admission (3842, 83.9%). Urgent and emergent cases were uncommon (174, 3.8%). Most cases were classified as general pediatric urology (3894, 85%) with 319 (7%) classified as major reconstruction, 275 (6%) as laparoscopy/endourology and 92 (2%) as oncology. The most common cases involved the groin/scrotum (1415, 30.9%), prepuce (809, 17.7%), phallus (802, 17.5%), and endoscopy (652, 14.2%). All other case types were uncommon. CONCLUSION: This description of an academic pediatric urology practice at a tertiary care center with a free-standing children's hospital noted a high volume of elective, outpatient procedures that are largely general pediatric urology. Uncommon cases include urgent/emergent interventions, major reconstruction, laparoscopy/endourology, and oncology procedures.

Discovery of hypospadias during newborn circumcision should not preclude completion of the procedure.

OBJECTIVE: To test the hypothesis that completion of newborn circumcision does not complicate hypospadias repair, and that circumcision will minimize future operations. STUDY DESIGN: Children referred for distal hypospadias over a 5-year period were grouped by presentation. Children with an aborted circumcision owing to concerns for hypospadias were subdivided into patients who underwent hypospadias repair (group 1a) and those who underwent circumcision (group 1b). Group 2 consisted of patients with a completed circumcision who underwent hypospadias repair. Children with traditionally recognized distal hypospadias served as controls. RESULTS: A total of 93 newborns had an aborted newborn circumcision. Of these, 28 underwent hypospadias repair (group 1a), and 47 underwent circumcision completion under general anesthesia (group 1b). The remaining 18 either deferred surgery or underwent in-office circumcision. Ten patients with hypospadias and an intact prepuce had a completed circumcision and subsequently underwent repair (group 2). The control group comprised 151 patients. No patients with a completed circumcision experienced complications after hypospadias repair, whereas the control group had a 5.3% rate of complications. CONCLUSION: Performing circumcision in newborns with hypospadias and an intact prepuce did not affect repair or the risk of complications. These findings, along with previous results, demonstrate that newborn circumcision can be safely completed in children with an intact prepuce. Furthermore, aborting a newborn circumcision after dorsal slit will expose a substantial number of children to additional procedures under general anesthesia.

Adherence to antiretroviral therapy in an urban, free-care HIV clinic in Guatemala City, Guatemala.

BACKGROUND: Numerous studies have demonstrated that, in addition to inherent qualities of antiretroviral (ARV) medications, adherence is affected by demographic, socioeconomic, and psychological factors. There are limited data about factors affecting adherence to antiretroviral therapy (ART) among HIV-infected persons in urban Guatemalan HIV care centers. METHODS: Participants were patients at an urban, free-care public clinic in Guatemala City and obtained medications from a closed-pharmacy system. Nonpregnant patients ≥18 years who received medications from the Global Fund to Fight AIDS, Tuberculosis & Malaria, who had taken ARV medications for ≥12 weeks, who arrived for an appointment at the clinic, and who provided informed consent were interviewed. Adherence was measured using pharmacy pill counts and patient self-reports. Recent biological markers for each patient were collected from the clinic's database, and χ( 2) and descriptive statistics were used to analyze results. RESULTS: Among 122 patients interviewed, mean adherence by pill count was 97%. A total of 110 patients (90%) had adherence ≥95% using pharmacy pill counts, and 108 (89%) had adherence ≥95% using self-reports. Virologic failure (viral load [VL] ≥500 copies/mL) was significantly less common among patients with ≥95% adherence (P = .02). Family and spousal support for treatment were significantly associated with ≥95% adherence (P = .01 and .003, respectively). The presence of stavudine (d4T) in a patient's regimen was significantly associated with <95% adherence according to self-reports (P < .01). The most common self-reported cause for missing medications was forgetfulness, followed by leaving medications at home. Inability to travel to the clinic was a major cause of missing medications, and only 51 patients (41.8%) reported always having sufficient economic resources to reach the clinic for appointments and to refill prescriptions. CONCLUSIONS: In this urban Central American population, high levels of adherence were measured by both self-report and pharmacy pill count. Socioeconomic and demographic conditions associated with adherence and specific reasons for missing medications were identified.