One Score to Rule Them All? Comparing the Predictive and Concurrent Validity of 30 Hearts and Flowers Scoring Approaches.

The Hearts and Flowers (H&F) task is a computerized executive functioning (EF) assessment that has been used to measure EF from early childhood to adulthood. It provides data on accuracy and reaction time (RT) across three different task blocks (hearts, flowers, and mixed). However, there is a lack of consensus in the field on how to score the task that makes it difficult to interpret findings across studies. The current study, which includes a demographically diverse population of kindergarteners from Boston Public Schools (N = 946), compares the predictive and concurrent validity of 30 ways of scoring H&F, each with a different combination of accuracy, RT, and task block(s). Our exploratory results provide evidence supporting the use of a two-vector average score based on Zelazo et al.'s approach of adding accuracy and RT scores together only after individuals pass a certain accuracy threshold. Findings have implications for scoring future tablet-based developmental assessments.

Prospective External Validation of the Esbenshade Vanderbilt Models Accurately Predicts Bloodstream Infection Risk in Febrile Non-Neutropenic Children With Cancer.

PURPOSE: The optimal management of fever without severe neutropenia (absolute neutrophil count [ANC] ≥500/µL) in pediatric patients with cancer is undefined. The previously proposed Esbenshade Vanderbilt (EsVan) models accurately predict bacterial bloodstream infections (BSIs) in this population and provide risk stratification to aid management, but have lacked prospective external validation. MATERIALS AND METHODS: Episodes of fever with a central venous catheter and ANC ≥500/µL occurring in pediatric patients with cancer were prospectively collected from 18 academic medical centers. Variables included in the EsVan models and 7-day clinical outcomes were collected. Five versions of the EsVan models were applied to the data with calculation of C-statistics for both overall BSI rate and high-risk organism BSI (gram-negative and Staphylococcus aureus BSI), as well as model calibration. RESULTS: In 2,565 evaluable episodes, the BSI rate was 4.7% (N = 120). Complications for the whole cohort were rare, with 1.1% (N = 27) needing intensive care unit (ICU) care by 7 days, and the all-cause mortality rate was 0.2% (N = 5), with only one potential infection-related death. C-statistics ranged from 0.775 to 0.789 for predicting overall BSI, with improved accuracy in predicting high-risk organism BSI (C-statistic 0.800-0.819). Initial empiric antibiotics were withheld in 14.9% of episodes, with no deaths or ICU admissions attributable to not receiving empiric antibiotics. CONCLUSION: The EsVan models, especially EsVan2b, perform very well prospectively across multiple academic medical centers and accurately stratify risk of BSI in episodes of non-neutropenic fever in pediatric patients with cancer. Implementation of routine screening with risk-stratified management for non-neutropenic fever in pediatric patients with cancer could safely reduce unnecessary antibiotic use.

Home visiting impacts during the pandemic: Evidence from a randomized controlled trial of child first.

Existing research has found that home visiting programs for families with young children can improve children's development and strengthen caregiver and family well-being. However, the pandemic created numerous challenges for home visiting programs, forcing them to deliver services online or in a hybrid format to respond to pandemic-related challenges. Questions remain about the impacts of these programs when delivered at-scale via a hybrid model, especially during this uniquely challenging time. The present study reports 12-month impacts from a randomized controlled trial of Child First-an evidence-based home visiting program that provides psychotherapeutic, parent-child intervention (children ages 0-5) embedded in a coordinated system of care-when implemented as a hybrid service. This study estimates impacts within four domains: families' receipt of services, caregiver psychological well-being and parenting, child behavior, and family economic well-being. After randomly assigning families (N = 226) to receive Child First or typical community services, the research team surveyed caregivers (N = 183) about a year after study enrollment. Results from regression models with site fixed effects revealed suggestive evidence that Child First reduced caregivers' job loss, residential mobility, and self-reported substance abuse, and increased receipt of virtual services during the pandemic. There were null impacts on caregivers' psychological well-being, families' involvement with the child welfare system, children's behaviors, and other indicators of economic well-being. Implications for future research and policy are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Risk Factors for Readmission Following Febrile Neutropenia in Pediatric Oncology Patients.

Febrile neutropenia is the most common reason for admission from the emergency department for pediatric oncology patients. We identified pediatric inpatients age 1 to 21 years with an International Classification of Diseases, Ninth Revision (ICD-9) diagnosis code of malignancy and either fever with neutropenia or fever alone over a 6-year period (2007-2012) using the PHIS+ database. We evaluated factors associated with readmission within 7 days after index hospitalization. There were 4029 index hospitalizations among 2349 patients in 6 hospitals, 294 encounters (7.3%) were followed by readmission within 7 days. Factors associated with increased odds of readmission included being in the lowest quartile for median household income (odds ratio [OR]=1.64, P =0.009), diagnosis of acute lymphoblastic leukemia (OR=1.37, P =0.016), lack of anerobic coverage during index hospitalization (OR=1.48, P =0.026), and absolute neutrophil count <200 cells/µL at discharge from index hospitalizations (OR=1.55, P =0.008). Patients who required readmission had a longer median length of stay and greater hospitalization costs during the index hospitalization. There was a trend towards increasing hospitalization rates for febrile neutropenia over time. While absolute neutrophil count is incorporated into many risk stratification strategies for fever management, further work should focus on addressing socioeconomic factors which may impact readmission rates.

Does kindergarten instruction matter for sustaining the prekindergarten (PreK) boost? Evidence from individual- and classroom-level survey and observational data.

The sustaining environments hypothesis theorizes that the lasting effects of PreK programs are contingent on the quality of the subsequent learning environment in early elementary school. The current study tests this theory by leveraging data from students (N = 462) who did and did not enroll in the Boston Public Schools (BPS) prekindergarten (PreK) program as well as features of their kindergarten instruction measured at the child- and classroom-levels using surveys and observations. Taken together, findings revealed limited evidence for the sustaining environments hypothesis. The bulk of the results were null, indicating that in general, associations between enrollment in BPS PreK and language, literacy, and math skills through the spring of kindergarten did not vary by kindergarten instructional experiences. When examining distinct types of instructional experiences, there were some inklings that child-level observational measures of kindergarten learning experiences-particularly those capturing constrained versus unconstrained instruction-were more predictive of PreK persistence than observed global classroom quality measures or survey-based measures of advanced instruction. However, these associations were not always specific to outcomes matching the content delivered during this instruction (math vs. literacy), consistent with the possibility of either cross-domain effects or that instructional variables are proxies for more general instructional practices. Findings for future research and theory are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Trends in Pediatric Primary Immunodeficiency: Incidence, Utilization, Transplantation, and Mortality.

BACKGROUND: Primary immunodeficiency disorders (PIDDs) describe a myriad of diseases caused by inherited defects within the immune system. As the number of identified genetic defects associated with PIDDs increases, understanding the incidence and outcomes of PIDD patients becomes imperative. OBJECTIVE: To characterize the frequency of new diagnoses, patterns of health care utilization, rates of hematopoietic stem cell transplantation (HSCT), and mortality in pediatric patients with PIDDs. METHODS: A retrospective cohort analysis of the Pediatric Health Information System database from 2004 to 2018 for pediatric inpatients with an International Classification of Diseases, Ninth and 10th Revisions (ICD-9/ICD-10). code associated with PIDD. RESULTS: A total of 17,234 patients with a PIDD were hospitalized from 2004 to 2018. There were 2.8 new PIDD diagnoses and 6.3 PIDD hospitalizations per 1,000 discharges; these metrics were unchanged during the study period. The number of new diagnoses for B-cell and antibody defects significantly increased over time. The number of new PIDD diagnoses significantly increased in adolescents or adults and decreased in infants. T-cell disorders had the highest number of intensive care unit admissions. There were 747 PIDD patients who underwent HSCT; complications of HSCT significantly decreased over time. Mortality rates significantly decreased in all PIDD patients and in patients receiving HSCT. CONCLUSIONS: The total hospitalizations and incidence of PIDDs within the hospitalized pediatric population were unchanged. There were significant changes in the class of PIDD diagnosed, the age at diagnosis, and health care utilization metrics. Mortality significantly decreased over time within the PIDD cohort.

Premedication prior to PEG-asparaginase is cost-effective in pediatric patients with acute lymphoblastic leukemia.

BACKGROUND: PEG-asparaginase is critical in pediatric acute lymphoblastic leukemia (ALL) therapy but is highly immunogenic. Severe allergic reactions lead to substitution of further PEG-asparaginase with Erwinia. Erwinia is associated with more frequent dosing, increased expense, and limited availability. Premedication may reduce rates of allergic reactions. PROCEDURES: This Markov model evaluated the cost-effectiveness of three strategies: premedication plus therapeutic drug monitoring (TDM), TDM alone, and no premedication or TDM. We modeled two scenarios: a standard-risk (SR) B-ALL patient receiving two asparaginase doses and a high-risk (HR) patient receiving seven asparaginase doses. The model incorporated costs of asparaginase, premedication, TDM and clinic visits, and lost parental wages associated with each additional Erwinia dose. We incorporated a five-year time horizon with a societal perspective. Outcomes were Erwinia substitutions avoided and differences in quality-adjusted life years (QALYs). Probabilistic and one-way sensitivity analyses evaluated model uncertainty. RESULTS: In both scenarios, premedication was the least costly strategy. In SR and HR scenarios, premedication with monitoring resulted in 8% and 7% fewer changes to Erwinia compared with monitoring alone and 3% and 2% fewer changes compared with no premedication/monitoring, respectively. Premedication resulted in the most QALYs gained in the SR patients. Individual variation of model inputs did not change premedication/monitoring favorability for either scenario. In probabilistic sensitivity analyses, premedication/monitoring was favored in >87% of iterations in both scenarios. CONCLUSION: Compared with other strategies, premedication use and asparaginase level monitoring in children with B-ALL is potentially cost-saving.

Rhode Island's Opioid Overdose Hospital Standards and Emergency Department Naloxone Distribution, Behavioral Counseling, and Referral to Treatment.

STUDY OBJECTIVE: We sought to determine the influence of the Levels of Care for Rhode Island Emergency Departments and Hospitals for Treating Overdose and Opioid Use Disorder (Levels of Care) on emergency department (ED) provision of take-home naloxone, behavioral counseling, and referral to treatment. METHODS: A retrospective analysis of Rhode Island ED visits for opioid overdose from 2017 to 2018 was performed using data from a statewide opioid overdose surveillance system. Changes in provision of take-home naloxone, behavioral counseling, and referral to treatment before and after Levels of Care implementation were assessed using interrupted time series analysis. We compared outcomes by hospital type using multivariable modified Poisson regression models with generalized estimating equation estimation to account for hospital-level variation. RESULTS: We analyzed 245 overdose visits prior to Levels of Care implementation (January to March 2017) and 1340 overdose visits after implementation (hospital certification to December 2018). After implementation, the proportion of patients offered naloxone increased on average by 13% (95% confidence interval [CI] 5.6% to 20.4%). Prior to implementation, the proportion of patients receiving behavioral counseling and treatment referral was declining. After implementation, this decline slowed and stabilized, and on average 18.6% more patients received behavioral counseling (95% CI 1.3% to 35.9%) and 23.1% more patients received referral to treatment (95% CI 2.7% to 43.5%). Multivariable analysis showed that after implementation, there was a significant increase in the likelihood of being offered naloxone at Level 1 (adjusted relative risk [aRR] 1.31 [95% CI 1.06 to 1.61]) and Level 3 (aRR 3.13 [95% CI 1.08 to 9.06]) hospitals and an increase in referrals for medication for opioid use disorder (from 2.5% to 17.8%) at Level 1 hospitals (RR 7.73 [95% CI 3.22 to 18.55]). Despite these increases, less than half of the patients treated for an opioid overdose received behavioral counseling or referral to treatment CONCLUSION: The establishment of ED policies for treatment and services after opioid overdose improved naloxone distribution, behavioral counseling, and referral to treatment at hospitals without previously established opioid overdose services. Future investigations are needed to better characterize implementation barriers and evaluate policy influence on patient outcomes.

Alterations of Circulating Biomarkers During Late Term Pregnancy Complications in the Horse Part II: Steroid Hormones and Alpha-Fetoprotein.

Preterm labor and/or abortion causes considerable economic impact on the equine industry. Unfortunately, few experimental models exist for the induction of various pregnancy-related complications, and therefore extrapolations are made from the experimental model for ascending placentits, although inferences may be minimal. Certain steroid hormones (progestogens, estrogens) and fetal proteins (alpha-fetoprotein; AFP) might improve the diagnostics for abnormal pregnancy, but the utility of these markers in the field is unknown. To assess this, thoroughbred mares (n = 702) were bled weekly beginning in December 2013 until parturition/abortion. Following parturition, fetal membranes were assessed histopathologically and classified as either ascending placentitis (n = 6), focal mucoid placentitis (n = 6), idiopathic abortion (n = 6) or no disease (n = 20). Weekly serum samples were analyzed for concentrations of progesterone, estradiol-17ß, and AFP. Samples were analyzed retrospectively from the week of parturition/abortion in addition to the preceding four weeks. For both ascending and focal mucoid placentitis, a significant increase in progesterone and AFP was noted, alongside a significant decrease in estradiol-17ß and the ratio of estradiol-17ß to progesterone in comparison to controls. In contrast, idiopathic abortions experienced a decrease in progesterone concentrations alongside an increase in AFP, and this was only noted in the week preceding parturition/abortion. In conclusion, spontaneous placental infection in the horse altered both endocrine and feto-secretory markers in maternal circulation, while minimal changes were noted preceding noninfectious idiopathic abortion. Additionally, this is the first study to report an alteration in steroid hormones and AFP during the disease process of focal mucoid placentitis, the etiology of which includes Nocardioform placentitis.

Is Skill Type the Key to the PreK Fadeout Puzzle? Differential Associations Between Enrollment in PreK and Constrained and Unconstrained Skills Across Kindergarten.

This study examines whether associations between enrollment in public and non-public PreK and children's (N = 508; Mage  = 5.60 years in fall of kindergarten) math and language and literacy outcomes were more likely to be sustained through the spring of kindergarten for unconstrained versus constrained skills. Associations between public PreK and language, literacy, and math outcomes were more strongly sustained through the spring of kindergarten for unconstrained skills, relative to constrained skills. Only associations between non-public PreK and unconstrained language skills were sustained through the spring of kindergarten. Associations in the fall of kindergarten differed by family income and dual language learner (DLL) status but there was no subgroup variation by the spring of kindergarten. Implications for policy and practice are discussed.

The mediating role of child-teacher dependency in the association between early mother-child attachment and behavior problems in middle childhood.

This study examines child-teacher dependency in preschool as a pathway through which mother-child attachment is associated with children's behavior problems across middle childhood. Data include direct assessments of attachment security and styles, teacher reports of child-teacher dependency, and maternal reports of behavior problems from the NICHD SECCYD (N = 769 children). Children with more secure attachments at 24 months were less likely to exhibit child-teacher dependency at 54 months. Children with ambivalent, controlling, or insecure/other attachments at 36 months had higher levels of child-teacher dependency at 54 months. Results from multi-level models showed that child-teacher dependency at 54 months was associated with higher levels of internalizing, but not externalizing, behavior problems across middle childhood. Child-teacher dependency partially mediated the association between insecure/other mother-child attachment and internalizing behaviors in middle childhood. Supporting preschool teachers to reduce child-teacher dependency may help ameliorate risk for internalizing behaviors posed by insecure/other attachment.

Impact of PCV-13 vaccine on invasive pneumococcal disease in hospitalised children: A multi-institutional analysis.

AIM: We aimed to describe changes in invasive pneumococcal disease (IPD) hospitalisations after introduction of the pneumococcal conjugate vaccine (PCV13). METHODS: This was a retrospective analysis of the Pediatric Health Information System (PHIS) database, including children with IPD pre-PCV13 (2004-2009) and post-PCV13 (2012-2017). Healthy children and those with chronic conditions were analysed separately. The primary outcome was IPD incidence. Secondary outcomes included length of stay, intensive care unit (ICU) admission, mechanical ventilation and mortality. RESULTS: 9160 hospitalisations for IPD were included. The IPD rate per 100 000 discharges was 180 pre-PVC13 and 150 post-PCV13 [17% decrease (P = 0.085)]. The observed IPD rate in 2017 was 45.5% lower than the rate predicted by the pre-PCV13 trend (95% CI: 44%-46%). While a significant decrease in IPD (32%, P = 0.026) was observed among healthy children, there was no change in those with chronic conditions (9%, P = 0.24). In the post-PCV13 period, more IPD patients had chronic conditions, ICU admissions and longer ICU stays. CONCLUSION: Although there was no overall reduction in IPD after PCV13, we observed a significant decrease in IPD among healthy patients. Further research is needed to elucidate microbiology or other factors contributing to persistent IPD hospitalisations.

Initial Opioid Prescription and Number Needed to Harm.

Prescription opioids are an important step in the development of persistent opioid use. Our study estimates the change in long-term opioid use before and after a 2017 regulatory update on acute pain prescribing. Prescribing information was abstracted from the Rhode Island Prescription Drug Monitoring Program (PDMP). Using the changed rates of initial opioid prescriptions of 8 or more days, and a calculated Number Needed to Harm for prescriptions of that duration, the rates of long-term opioid use were estimated decrease by 111 long-term opioid users per month.

Transfusion support: Considerations in pediatric populations.

Over 400,000 units of blood and blood products are transfused to pediatric patients annually, yet only sparse high-quality data exist to guide the preparation and administration of blood products in this population. The direct application of data from studies in adult patients should be undertaken with caution, as there are dissimilarities in the pathology and physiology between adult and pediatric patients. We provide an overview of available evidence in the field of pediatric transfusion medicine, summarizing indications for blood product transfusion, thresholds for transfusion and indications for blood product modifications.

Cost-effectiveness of levofloxacin prophylaxis against bacterial infection in pediatric patients with acute myeloid leukemia.

BACKGROUND: Infections are the leading cause of therapy-related mortality in pediatric patients with acute myeloid leukemia (AML). Although effectiveness of levofloxacin antibacterial prophylaxis in oncology patients is recognized, its cost-effectiveness is unknown. This study evaluated epidemiologic data regarding levofloxacin use and the cost-effectiveness of this strategy as the cost per bacteremia episode, intensive care unit (ICU) admission, and death avoided in children with AML. PROCEDURE: A retrospective cohort study using the Pediatric Health Information System (PHIS) database compared demographic and clinical characteristics and receipt of levofloxacin prophylaxis in children with AML admitted for chemotherapy from January 1, 2014, through December 31, 2018. We then developed a decision analysis model in this population that compared costs associated with bacteremia, ICU admission, or death secondary to bacteremia to levofloxacin prophylaxis cost from a healthcare perspective. Time horizon is one chemotherapy cycle. Probabilistic and one-way sensitivity analyses evaluated model uncertainty. RESULTS: Prophylaxis cost $8491 per bacteremia episode prevented compared with an average added hospital cost of $119 478. Prophylaxis cost $81 609 per ICU admission avoided, compared with an average added hospital cost of $94 181. Prophylaxis cost $220 457 per death avoided. In sensitivity analysis, at a willingness-to-pay threshold of $100 000 per bacteremia episode avoided, prophylaxis remained cost-effective in 94.6% of simulations. Prophylaxis use was more common in recent years in patients with relapsed disease and with chemotherapy regimens considered more intensive. CONCLUSION: Prophylaxis is cost-effective in preventing bacterial infections in patients with AML. Findings support increased use in patients considered at high risk of bacterial infection secondary to myelosuppression.