Sleep from Infancy Through Adolescence.

This article describes the changes in normal sleep regulation, structure, and organization and sleep-related changes in respiration from infancy to adolescence. The first 2 years of age are striking, with more time asleep than awake. With development, the electroencephalogram architecture has a marked reduction in rapid eye movement sleep and the acquisition of K-complexes, sleep spindles, and slow-wave sleep. During adolescence there is a reduction in slow-wave sleep and a delay in the circadian phase. Infants have a more collapsible upper airway and lower lung volumes than older children, which predisposes them to obstructive sleep apnea and sleep-related hypoxemia.

Keep it simple: A novel technique for measuring airflow using a wireless patch.

OBJECTIVES: Despite the growing use of home sleep testing for obstructive sleep apnea (OSA), there are significant barriers that make it difficult for patients. This study aimed to evaluate a new set of wireless patches for the detection of OSA as compared to polysomnography (PSG) respiratory signals. Safety was also evaluated. METHODS: Patients (n = 25; mean age = 51.3; SD = 15.6) undergoing standard PSG evaluation for OSA wore 2 device patches applied on the chest and abdomen to provide surrogates of respiratory effort and derived airflow. Two sets of respiratory data (with common SpO2 and heart rate as a reference from PSG) were created, one from PSG and one from the device patches. Data were scored by a Registered Polysomnographic Technologist. Linear regression analyses and Bland-Altman plots were used to compare the two derived apnea-hypopnea indices (AHI). Bench testing was performed to determine whether the device patch respiratory signal accuracy remained consistent for different body characteristics. RESULTS: There was a significant correlation for AHI between the device patch and PSG (r = 0.979; P < .001; 95% CI 0.952, 1.00). There were also significant correlations between PSG and the device patch for supine AHI (r = 0.866, P < .001, 95% CI 0.610, 0.965) and nonsupine AHI (r = 0.983; <0.001, 95% CI 0.954, 1.00). No differences in respiratory signal accuracy were found with bench testing comparison groups. CONCLUSIONS: These preliminary results suggest that the device patch may be an effective way to measure respiratory dynamics, including derived airflow, to evaluate OSA. Results show promise as a new innovative method for home sleep testing.

Obstructive Sleep Apnea as the First Presentation of Juvenile Nasal Angiofibroma.

CITATION: Lobl M, Zandieh SO. Obstructive sleep apnea as the first presentation of juvenile nasal angiofibroma. J Clin Sleep Med. 2019;15(9):1373-1375.

Asthma and subjective sleep disordered breathing in a large cohort of urban adolescents.

OBJECTIVE: Sleep disordered breathing (SDB) has not been well studied in urban adolescents with asthma in community settings. Nor has the association of SDB symptoms and asthma severity been studied. We characterized self-reported symptoms suggesting SDB and investigated the association of SDB symptoms, probable asthma, and asthma severity. METHODS: 9,565 adolescents from 21 inner-city high schools were screened for an asthma intervention study. Students reported on symptoms suggesting SDB using questions from the 2007 NHANES, if they were ever diagnosed with asthma, and on asthma symptoms. Using generalized linear mixed models with logit link with school as a random intercept and adjusting for age, gender, and race/ethnicity, we examined associations of SDB symptoms, and demographic characteristics, probable asthma, and asthma severity. RESULTS: 12% reported SDB symptoms. Older and bi-racial participants (compared to Caucasian) had higher odds of symptoms suggesting SDB (p <.001). Compared to those without probable asthma, adolescents with probable asthma had 2.63 greater odds of reporting SDB symptoms (p <.001). Among those with probable asthma, the odds of reporting SDB symptoms increased with asthma severity. When exploring daytime severity and severity due to night wakening separately, results were similar. All results remained significant when controlling for age, gender, and ethnicity. CONCLUSIONS: In a large urban community cohort of predominately ethnic minority adolescents, self-reported SDB symptoms were associated with probable asthma and increased asthma severity. This study highlights the importance of SDB as a modifiable co-morbidity of asthma.

Association of Youth and Caregiver Anxiety and Asthma Care Among Urban Young Adolescents.

OBJECTIVE: To examine the association of adolescent asthma-related anxiety, social anxiety, separation anxiety, and caregiver asthma-related anxiety with asthma care by urban adolescents. METHODS: Participants were 386 ethnic minority adolescents (mean age 12.8 years) with persistent asthma and their caregivers. Adolescents reported what they do to prevent asthma symptoms and to manage acute symptoms, and if they or their caregiver is responsible for their asthma care. Adolescents completed the Youth Asthma-Related Anxiety Scale, and the social and separation anxiety subscales of the Screen for Child Anxiety and Emotional Disorders (SCARED); caregivers completed the Parent Asthma-Related Anxiety Scale. Linearity of the associations was assessed by generalized additive models. When there was no evidence for nonlinearity, linear mixed effects models were used to evaluate the effects of the predictors. RESULTS: Adolescent asthma-related anxiety had a strong curvilinear relationship with symptom prevention (P < .001). Adolescents took more prevention steps as their anxiety increased, with a plateau at moderate anxiety. There was a linear relationship of adolescent asthma-related anxiety to symptom management (ß = 0.03, P = .021) and to asthma responsibility (ß = 0.11, P = .015), and of caregiver asthma-related anxiety to adolescent symptom prevention (ß = 0.04, P = .001). Adolescent social and separation anxiety had weak to no relationship with asthma care. Results remained consistent when controlling for each of the other anxieties. CONCLUSIONS: Asthma-related anxiety plays an important, independent role in asthma care. When low, adolescents may benefit from increased support from caregivers and awareness of the consequences of uncontrolled asthma. When elevated, health providers should ensure the adolescents are not assuming responsibility for asthma care prematurely.

Impact of cilia ultrastructural examination on the diagnosis of primary ciliary dyskinesia.

Ultrastructural examination of cilia is the "gold standard" for diagnosing primary ciliary dyskinesia. There is little evidence suggesting the most effective method of procuring a ciliary biopsy and scant benchmark data on rates of conclusive biopsies or on the diagnostic impact of such biopsies. To critically assess rates of inconclusive, positive, and negative ciliary biopsies and to identify clinical factors associated with conclusive results, we reviewed ciliary biopsies submitted for electron microscopy from 2006 to 2011, noting whether specimens were adequate for analysis and whether the ciliary structure was normal. The biopsy site, method used, procedurist's specialty, and clinical diagnoses were determined. Biopsy findings were categorized by diagnostic impact. Over 5 years, 187 patients had 211 biopsies. Conclusive results were obtained on 133/211 biopsies (63%); the remainder were insufficient. The rate of inconclusive biopsies did not vary significantly (P > 0.05; Fisher's exact) among sampling methods. Abnormal results were identified in 8/133 (6.0%) of the adequate specimens. Forceps compared to brush biopsies (abnormal in 4/12 versus 4/121 of the adequate specimens, P  =  0.002), along with multiple biopsy samples (taken on same or different days) compared with a single biopsy sample (abnormal in 3/12 versus 1/110 of the adequate specimens, P  =  0.01), were more likely to yield an abnormal result. Only 63% of pediatric ciliary biopsies provide adequate morphology for analysis, the large majority of these samples showing normal ciliary anatomy. The method of obtaining biopsies did not significantly affect result conclusiveness. Understanding the diagnostic impact of ultrastructural analysis is important as new diagnostic algorithms are developed for primary ciliary dyskinesia.

The maintenance of wakefulness test in pediatric narcolepsy.

Objective tools are needed to assess the response to treatment in pediatric narcolepsy. This article presents a single-center experience documenting the use of the maintenance of wakefulness test (MWT) in a pediatric series. This study reviewed the charts of children with narcolepsy who had an MWT performed between January 2008 and June 2012. A cutoff was used for mean sleep latency: <8 minutes for inadequate control of hypersomnia, and >20 minutes to indicate adequate control on medications. Thirteen tests were performed on 10 children (median age 15.8 years, range 8.7-20.3 years) with narcolepsy, of which six had cataplexy and three were boys. Comorbid conditions included Prader-Willi syndrome, bipolar affective disorder, and epilepsy (n = 1 each). The median mean sleep latency for all studies was 16 minutes (range 5.8-40 minutes). Sleep-onset rapid eye movement sleep events were seen in three of 13 studies. In seven patients, findings from the MWT resulted in changes in management. These data suggest that the MWT may be a useful and feasible test for assessing response to treatment in children with narcolepsy. Future research is needed to obtain normative MWT data on children with and without narcolepsy.

Adenotonsillectomy for obstructive sleep apnea in children with syndromic craniosynostosis.

BACKGROUND: The role of adenotonsillectomy in the treatment of obstructive sleep apnea in patients with craniosynostosis is not well established. METHODS: A retrospective review was conducted of all children with syndromic craniosynostosis (Apert, Crouzon, and Pfeiffer syndromes) seen at Boston Children's Hospital from January 2001 through April 2011. The primary outcome measure was the apnea/hypopnea index before and after adenotonsillectomy. RESULTS: There were 47 patients (66 percent Apert syndrome, 19 percent Pfeiffer syndrome, and 15 percent Crouzon syndrome) less than 21 years of age (mean, 1.2 ± 3.3 years at first visit) who were followed for a mean of 14.6 ± 8.6 years. Of children with at least one polysomnogram, 83 percent had obstructive sleep apnea (42 percent severe, 19 percent moderate, 22 percent mild). Adenotonsillectomy was performed in 62 percent of patients. Preoperative and postoperative polysomnography was performed in 45 percent of children undergoing adenotonsillectomy. Following adenotonsillectomy, the mean apnea/hypopnea index was not significantly different, and obstructive sleep apnea persisted in 11 of 13 children. CONCLUSIONS: Obstructive sleep apnea is commonly present in children with syndromic craniosynostosis and is a complex disease with airway obstruction at several different levels. Adenotonsillectomy often does not improve the severity of obstructive sleep apnea in this population.

A ballroom dance classroom program promotes moderate to vigorous physical activity in elementary school children.

PURPOSE: To determine if an existing ballroom dance classroom program meets national recommendations to engage children in moderate to vigorous physical activity (MVPA) for ≥50% of class time and to determine class effects on body mass index (BMI). DESIGN: Prospective descriptive study. Setting . Two New York City public schools. PARTICIPANTS: Seventy-nine fourth and fifth grade students. MEASUREMENTS: The System for Observing Fitness Instruction Time (SOFIT) and direct heart rate monitoring were used to determine participants' MVPA levels during class time. Weight and height were measured to calculate BMI. ANALYSIS: Means were calculated for continuous variables; frequency counts and percentages were calculated for categorical variables. Change in BMI percentiles was assessed by using Bhapkar's χ(2) test of overall marginal homogeneity. RESULTS: Data from SOFIT observations showed that a mean of 50.0% and 67.0% of class time in the first and second halves of the program, respectively, were spent in MVPA. Data from the heart rate monitoring revealed that 71.1% of students were at ≥25% heart rate reserve, which indicated MVPA for ≥50% of class time. Improvement was seen in BMI percentile (p= .051). CONCLUSION: Ballroom dance provides MVPA in elementary school children for ≥50% of class time and has a positive impact on BMI percentiles.

Transitioning between ambulatory EHRs: a study of practitioners' perspectives.

OBJECTIVE: To evaluate practitioners' expectations of, and satisfaction with, older and newer electronic health records (EHRs) after a transition. MATERIAL AND METHODS: Pre- and post-transition survey administered at six academic-affiliated ambulatory care practices from 2006 to 2008. Four practices transitioned to one commercial EHR and two practices to another. We compared respondents' expectations of, and satisfaction with, the newer EHR. RESULTS: 523 subjects were eligible: 217 were available before transition and 306 after transition. 162 pre-transition and 197 post-transition responses were received, yielding 75% and 64% response rates, respectively. Practitioners were more satisfied with the newer EHRs (64%) compared with the older (56%) (p=0.15) and a small majority (58%) were satisfied with the transition. Practitioners' satisfaction with the older EHRs for completing clinical tasks was high. The newer EHRs exceeded practitioner expectations regarding remote access (61% vs 74%; p=0.03). However, the newer EHRs did not meet practitioners' expectations regarding their ability to perform clinical tasks, or more globally, improve medication safety (81% vs 61%; p<0.001), efficiency (70% vs 44%; p<0.001), and quality of care (77% vs 67%; p=0.04). DISCUSSION: Most practitioners had favorable opinions about EHRs and reported overall improved satisfaction with the newer EHRs. However, practitioners' high expectations of the newer EHRs were often unmet regarding facilitation of specific clinical tasks or for improving quality, safety, and efficiency. CONCLUSION: To ensure practitioners' expectations, for instance regarding improvements in medication safety, are met, vendors should develop and implement refinements in their software as practices upgrade to newer, certified EHRs.

Satisfaction after the transition between electronic health record systems at six ambulatory practices.

RATIONALE, AIMS AND OBJECTIVES: Early adopters of electronic health records (EHRs) are transitioning from older to newer EHRs to satisfy meaningful use requirements. Facilitators and barriers to satisfaction after transitioning are important to understand as provider satisfaction is linked with improvement in health care. METHOD: We conducted a cross-sectional survey of providers who transitioned from an older to a newer EHR at six academic, urban ambulatory medical practices. A novel survey was developed to assess: (1) satisfaction with the EHR implementation; (2) patterns of information technology use; (3) work perceptions; (4) methods for completing clinical tasks; and (5) demographic characteristics. We analysed the results using bivariate and multivariate analyses. RESULTS: The response rate was 64% (n = 197). A small majority were satisfied with the new EHR (64%, n = 120). Providers who reported satisfaction with overall quality of work life, their workload and the transition were more likely to be satisfied with the new EHR (P < 0.01). Providers who reported using the Internet at least daily were also more likely to be satisfied with the new EHR (P < 0.05). In a multivariate model, satisfaction with the transition was a strong predictor of satisfaction with the new EHR (P < 0.01). Barriers to satisfaction include dissatisfaction with: maintaining problem and medication lists, tracking health maintenance information, referring to clinical practice guidelines and ordering laboratory and radiology tests (P < 0.01). CONCLUSION: This study provides groundwork for understanding the facilitators and barriers to provider satisfaction after the transition between EHRs and provides insight into areas requiring attention by entities undergoing similar transitions.

Retrograde lacrimal duct airflow during nasal positive pressure ventilation.

Noninvasive ventilation is widely used for chronic respiratory failure in children with neuromuscular disorders, thus avoiding the need for tracheostomy. However, the pressures required to support ventilation in these children may be considerably higher than those necessary to treat obstructive sleep apnea. The complications of nasal positive airway pressure are numerous, including skin breakdown, conjunctivitis, nasal congestion, airway dryness, pneumothorax, and bowel obstruction. Ophthalmologic complaints are particularly common, largely attributed to an air leak in the mask. In the present case, we demonstrate, through two modalities-video and CT scan-retrograde airflow through the nasolacrimal duct causing sleep disruption and eye irritation in a profoundly hypotonic 14-month-old boy with chronic respiratory failure on bilevel ventilation during sleep.

Revisiting predictors of parental health care-seeking behaviors for nonurgent conditions at one inner-city hospital.

INTRODUCTION: To determine important predictors of why parents seek care for their children at a pediatric emergency department (ED) compared to their child's primary care provider's (PCP's) walk-in clinic. DESIGN: Cross-sectional study. SETTING: An inner-city hospital located in New York City, from April 2003 to January 2004. PARTICIPANTS: A convenience sample of 170 parents with children younger than 18 years, Medicaid beneficiaries, had a PCP, and presented with a nonurgent medical problem either at the pediatric ED or walk-in clinic. MAIN OUTCOME MEASURE: The main outcome measure was the setting in which parents sought care for their child; odds ratios (ORs) were calculated for parents seeking care in the pediatric ED compared to those seeking care at the walk-in clinic, adjusting for predisposing, enabling, and need-related factors. RESULTS: Of the 170 parent-child visits, 87 (51%) were seeking care at the ED and 83 (49%) at their child's walk-in clinic. In logistic regression, single parenting was the strongest predictor for seeking care in the ED (OR, 5.54; 95% confidence interval [CI], 1.4-26.9), followed by Hispanic ethnicity (OR, 4.96; 95% CI, 1.43-17.2), low parental perceptions of their child's physical health (OR, 0.90; 95% CI, 0.82-0.99), controlling for number of chronic conditions, parental working status, and satisfaction with their PCP. CONCLUSIONS: Single parenting, Hispanic ethnicity, and perceptions of health are associated with health care-seeking behaviors in high cost settings among Medicaid beneficiaries. Targeted education programs could be used to influence future site of care.

Correlates of expected satisfaction with electronic health records in office practices by practitioners.

Practitioners' resistance towards electronic health records (EHRs) is a known barrier to implementation and use. This is a cross-sectional study 467 practitioners working at 12 ambulatory care outpatient practices. We analyzed how mean expected satisfaction for future use of EHRs differed at both the level of the provider and the practice. We found that practitioners generally have positive expectations of EHR systems. However, these expectations depend on comfort with IT and typing skills.

Providers' expectations of ambulatory electronic health records (EHRs).

Little is known about how providers expect the implementation of a new electronic health record (EHR) will affect their clinical workflow. We found that providers currently completing clinical tasks electronically are more satisfied with task completion than those completing similar tasks on paper. Yet, these already electronic providers expect less future satisfaction with the new EHR compared with paper-based providers. Further understanding of provider expectations can assist in optimally tailoring implementation plans.

Challenges to EHR implementation in electronic- versus paper-based office practices.

BACKGROUND: Challenges in implementing electronic health records (EHRs) have received some attention, but less is known about the process of transitioning from legacy EHRs to newer systems. OBJECTIVE: To determine how ambulatory leaders differentiate implementation approaches between practices that are currently paper-based and those with a legacy EHR system (EHR-based). DESIGN: Qualitative study. PARTICIPANTS: Eleven practice managers and 12 medical directors all part of an academic ambulatory care network of a large teaching hospital in New York City in January to May of 2006. APPROACH: Qualitative approach comparing and contrasting perceived benefits and challenges in implementing an ambulatory EHR between practice leaders from paper- and EHR-based practices. Content analysis was performed using grounded theory and ATLAS.ti 5.0. RESULTS: We found that paper-based leaders prioritized the following: sufficient workstations and printers, a physician information technology (IT) champion at the practice, workflow education to ensure a successful transition to a paperless medical practice, and a high existing comfort level of practitioners and support staff with IT. In contrast, EHR-based leaders prioritized: improved technical training and ongoing technical support, sufficient protection of patient privacy, and open recognition of physician resistance, especially for those who were loyal to a legacy EHR. Unlike paper-based practices, EHR-based leadership believed that comfort level with IT and adjustments to workflow changes would not be difficult challenges to overcome. CONCLUSIONS: Leadership at paper- and EHR-based practices in 1 academic network has different priorities for implementing a new EHR. Ambulatory practices upgrading their legacy EHR have unique challenges.

Risk factors in preventable adverse drug events in pediatric outpatients.

OBJECTIVE: To determine whether there are racial/ethnic, socioeconomic, parental linguistic, or parental educational disparities in children who experienced an adverse drug event (ADE) in the ambulatory setting. STUDY DESIGN: We conducted a prospective cohort study of pediatric patients <21 years seen during 2-month study periods from July 2002 to April 2003 at 6 office practices in Boston. The primary outcome measure was ADEs. Descriptive analysis of patient characteristics and types of ADEs experienced was followed by multivariate analysis to determine risk factors associated with presence of a preventable ADE. RESULTS: A total of 1689 patients receiving 2155 prescriptions were analyzed via a survey and chart review. Overall, 242 children (14%) experienced an ADE, of which 55 (23%) had a preventable ADE and 186 (77%) had a non-preventable ADE. In multivariate analysis, children with multiple prescriptions (odds ratio, 1.46; 95% CI, 1.01-2.11) were at increased risk of having a preventable ADE, controlling for parental education, racial/ethnic, English proficiency, practice type, and duration of care. CONCLUSIONS: Children with multiple prescriptions are at increased risk of having a preventable ADE. Further attention should be directed toward improved communication among healthcare providers and patients.

A qualitative analysis of an electronic health record (EHR) implementation in an academic ambulatory setting.

OBJECTIVES: To determine pre-implementation perspectives of institutional, practice and vendor leadership regarding best practice for implementation of two ambulatory electronic health records (EHRs) at an academic institution. DESIGN: Semi-structured interviews with ambulatory care network and information systems leadership, medical directors, practice managers and vendors before EHR implementation. Results were analysed using grounded theory with ATLAS.ti version 5.0. MEASUREMENTS: Qualitative data on perceived benefits of EHRs as well as facilitators and barriers to successful implementation. RESULTS: Interviewees perceived data accessibility, quality and safety measurement, improvement and reporting as benefits of EHR use. Six themes emerged for EHR implementation best practice: effective communication; successful system migration; sufficient hardware, technical equipment, support and training; safeguards for patient privacy; improved efficiency; and a sustainable business plan. CONCLUSIONS: Achieving the benefits of EHRs identified by our interviewees depends on successful implementation and use. Further identification of best implementation practices for EHRs is required, given the financial and clinical consequences of poor implementation.

Hazing of suburban middle school and high school athletes.

Little is known about the prevalence of hazing behaviors among adolescent athletes. Our survey of 1105 6th-12th grade athletes found that 17.4% had been subjected to practices that qualify as hazing. Many of these teenagers do not comprehend the abusive and potentially dangerous nature of hazing.