Development and Validation of an Automated Classifier to Diagnose Acute Otitis Media in Children.

Importance: Acute otitis media (AOM) is a frequently diagnosed illness in children, yet the accuracy of diagnosis has been consistently low. Multiple neural networks have been developed to recognize the presence of AOM with limited clinical application. Objective: To develop and internally validate an artificial intelligence decision-support tool to interpret videos of the tympanic membrane and enhance accuracy in the diagnosis of AOM. Design, Setting, and Participants: This diagnostic study analyzed otoscopic videos of the tympanic membrane captured using a smartphone during outpatient clinic visits at 2 sites in Pennsylvania between 2018 and 2023. Eligible participants included children who presented for sick visits or wellness visits. Exposure: Otoscopic examination. Main Outcomes and Measures: Using the otoscopic videos that were annotated by validated otoscopists, a deep residual-recurrent neural network was trained to predict both features of the tympanic membrane and the diagnosis of AOM vs no AOM. The accuracy of this network was compared with a second network trained using a decision tree approach. A noise quality filter was also trained to prompt users that the video segment acquired may not be adequate for diagnostic purposes. Results: Using 1151 videos from 635 children (majority younger than 3 years of age), the deep residual-recurrent neural network had almost identical diagnostic accuracy as the decision tree network. The finalized deep residual-recurrent neural network algorithm classified tympanic membrane videos into AOM vs no AOM categories with a sensitivity of 93.8% (95% CI, 92.6%-95.0%) and specificity of 93.5% (95% CI, 92.8%-94.3%) and the decision tree model had a sensitivity of 93.7% (95% CI, 92.4%-94.9%) and specificity of 93.3% (92.5%-94.1%). Of the tympanic membrane features outputted, bulging of the TM most closely aligned with the predicted diagnosis; bulging was present in 230 of 230 cases (100%) in which the diagnosis was predicted to be AOM in the test set. Conclusions and Relevance: These findings suggest that given its high accuracy, the algorithm and medical-grade application that facilitates image acquisition and quality filtering could reasonably be used in primary care or acute care settings to aid with automated diagnosis of AOM and decisions regarding treatment.

Incidence and Transmission of SARS-CoV-2 in US Child Care Centers After COVID-19 Vaccines.

Importance: SARS-CoV-2 surveillance studies in US child care centers (CCCs) in the post-COVID-19 vaccine era are needed to provide information on incidence and transmission in this setting. Objective: To characterize SARS-CoV-2 incidence and transmission in children attending CCCs (students) and their child care providers (CCPs) and household contacts. Design, Setting, and Participants: This prospective surveillance cohort study was conducted from April 22, 2021, through March 31, 2022, and included 11 CCCs in 2 cities. A subset (surveillance group) of CCPs and students participated in active surveillance (weekly reverse transcription-polymerase chain reaction [RT-PCR] swabs, symptom diaries, and optional baseline and end-of-study SARS-CoV-2 serologic testing), as well as all household contacts of surveillance students. Child care center directors reported weekly deidentified self-reported COVID-19 cases from all CCPs and students (self-report group). Exposure: SARS-CoV-2 infection in CCC students. Main Outcomes and Measures: SARS-CoV-2 incidence, secondary attack rates, and transmission patterns were determined from diary entries, self-reports to CCC directors, and case logs. Incidence rate ratios were measured using Poisson regression clustering on centers with a random intercept and unstructured matrix. Results: From a total population of 1154 students and 402 CCPs who self-reported cases to center directors, 83 students (7.2%; mean [SD] age, 3.86 [1.64] years; 55 male [66%]), their 134 household contacts (118 adults [mean (SD) age, 38.39 (5.07) years; 62 female (53%)], 16 children [mean (SD) age, 4.73 (3.37) years; 8 female (50%)]), and 21 CCPs (5.2%; mean [SD] age, 38.5 [12.9] years; 18 female [86%]) participated in weekly active surveillance. There were 154 student cases (13%) and 87 CCP cases (22%), as defined by positive SARS-CoV-2 RT-PCR or home antigen results. Surveillance students had a higher incidence rate than self-report students (incidence rate ratio, 1.9; 95% CI, 1.1-3.3; P = .01). Students were more likely than CCPs to have asymptomatic infection (34% vs 8%, P < .001). The CCC secondary attack rate was 2.7% to 3.0%, with the upper range representing possible but not definite secondary cases. Whether the index case was a student or CCP, transmission within the CCC was not significantly different. Household cumulative incidence was 20.5%, with no significant difference in incidence rate ratio between adults and children. Household secondary attack rates were 50% for children and 67% for adults. Of 30 household cases, only 5 (17%) represented secondary infections caused by 3 students who acquired SARS-CoV-2 from their CCC. Pre- and poststudy seroprevalence rates were 3% and 22%, respectively, with 90% concordance with antigen or RT-PCR results. Conclusions and Relevance: In this study of SARS-CoV-2 incidence and transmission in CCCs and students' households, transmission within CCCs and from children infected at CCCs into households was low. These findings suggest that current testing and exclusion recommendations for SARS-CoV-2 in CCCs should be aligned with those for other respiratory viruses with similar morbidity and greater transmission to households.

External Validation of the UTICalc with and Without Race for Pediatric Urinary Tract Infection.

OBJECTIVE: To validate externally the UTICalc, a popular clinical decision support tool used to determine the risk of urinary tract infections (UTIs) in febrile children, and compare its performance with and without the inclusion of race and at differing risk thresholds. METHODS: We performed a retrospective, singlecenter case-control study of febrile children (2-24 months) in an emergency department. Cases with culture-confirmed UTI were matched 1:1 to controls. We compared the performance of the original model which included race (version 1.0) to a revised model which did not consider race (version 3.0). We evaluated model performance at risk thresholds between 2% and 5%. RESULTS: We included 185 cases and 197 controls (median age 8.4 months; IQR, 4.4-13.0 months; 60.5% girls). When using UTICalc version 1.0, the model area under the receiver operator characteristic curve (AUROC) was 73.4% (95% CI 68.4%-78.5%), which was similar to the version 3.0 model (73.8%; 95% CI 68.7%-78.8%). When using a 2% risk threshold, the version 3.0 model demonstrated a sensitivity of 96.7% and a specificity of 25.0%, with declines in sensitivity and gains in specificity at higher risk thresholds. Version 1.0 of the UTICalc had 12 false negatives, of whom 10 were Black (83%); whereas version 3.0 had 6 false negatives, of whom 2 were Black (33%). CONCLUSIONS: Versions of the UTICalc with and without race had similar performance to each other with a slight decline from the original derivation sample. The removal of race did not adversely affect the accuracy of the UTICalc.

Identifying Children Likely to Benefit From Antibiotics for Acute Sinusitis: A Randomized Clinical Trial.

Importance: The large overlap between symptoms of acute sinusitis and viral upper respiratory tract infection suggests that certain subgroups of children being diagnosed with acute sinusitis, and subsequently treated with antibiotics, derive little benefit from antibiotic use. Objective: To assess if antibiotic therapy could be appropriately withheld in prespecified subgroups. Design, Setting, and Participants: Randomized clinical trial including 515 children aged 2 to 11 years diagnosed with acute sinusitis based on clinical criteria. The trial was conducted between February 2016 and April 2022 at primary care offices affiliated with 6 US institutions and was designed to evaluate whether symptom burden differed in subgroups defined by nasopharyngeal Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis on bacterial culture and by the presence of colored nasal discharge. Interventions: Oral amoxicillin (90 mg/kg/d) and clavulanate (6.4 mg/kg/d) (n = 254) or placebo (n = 256) for 10 days. Main Outcomes and Measures: The primary outcome was symptom burden based on daily symptom scores on a validated scale (range, 0-40) during the 10 days after diagnosis. Secondary outcomes included treatment failure, adverse events including clinically significant diarrhea, and resource use by families. Results: Most of the 510 included children were aged 2 to 5 years (64%), male (54%), White (52%), and not Hispanic (89%). The mean symptom scores were significantly lower in children in the amoxicillin and clavulanate group (9.04 [95% CI, 8.71 to 9.37]) compared with those in the placebo group (10.60 [95% CI, 10.27 to 10.93]) (between-group difference, -1.69 [95% CI, -2.07 to -1.31]). The length of time to symptom resolution was significantly lower for children in the antibiotic group (7.0 days) than in the placebo group (9.0 days) (P = .003). Children without nasopharyngeal pathogens detected did not benefit from antibiotic treatment as much as those with pathogens detected; the between-group difference in mean symptom scores was -0.88 (95% CI, -1.63 to -0.12) in those without pathogens detected compared with -1.95 (95% CI, -2.40 to -1.51) in those with pathogens detected. Efficacy did not differ significantly according to whether colored nasal discharge was present (the between-group difference was -1.62 [95% CI, -2.09 to -1.16] for colored nasal discharge vs -1.70 [95% CI, -2.38 to -1.03] for clear nasal discharge; P = .52 for the interaction between treatment group and the presence of colored nasal discharge). Conclusions: In children with acute sinusitis, antibiotic treatment had minimal benefit for those without nasopharyngeal bacterial pathogens on presentation, and its effects did not depend on the color of nasal discharge. Testing for specific bacteria on presentation may represent a strategy to reduce antibiotic use in this condition. Trial Registration: ClinicalTrials.gov Identifier: NCT02554383.

Short-Course Therapy for Urinary Tract Infections in Children: The SCOUT Randomized Clinical Trial.

Importance: There is a paucity of pediatric-specific comparative data to guide duration of therapy recommendations in children with urinary tract infection (UTI). Objective: To compare the efficacy of standard-course and short-course therapy for children with UTI. Design, Setting, Participants: The Short Course Therapy for Urinary Tract Infections (SCOUT) randomized clinical noninferiority trial took place at outpatient clinics and emergency departments at 2 children's hospitals from May 2012, through, August 2019. Data were analyzed from January 2020, through, February 2023. Participants included children aged 2 months to 10 years with UTI exhibiting clinical improvement after 5 days of antimicrobials. Intervention: Another 5 days of antimicrobials (standard-course therapy) or 5 days of placebo (short-course therapy). Main Outcome Measures: The primary outcome, treatment failure, was defined as symptomatic UTI at or before the first follow-up visit (day 11 to 14). Secondary outcomes included UTI after the first follow-up visit, asymptomatic bacteriuria, positive urine culture, and gastrointestinal colonization with resistant organisms. Results: Analysis for the primary outcome included 664 randomized children (639 female [96%]; median age, 4 years). Among children evaluable for the primary outcome, 2 of 328 assigned to standard-course (0.6%) and 14 of 336 assigned to short-course (4.2%) had a treatment failure (absolute difference of 3.6% with upper bound 95% CI of 5.5.%). Children receiving short-course therapy were more likely to have asymptomatic bacteriuria or a positive urine culture at or by the first follow-up visit. There were no differences between groups in rates of UTI after the first follow-up visit, incidence of adverse events, or incidence of gastrointestinal colonization with resistant organisms. Conclusions and Relevance: In this randomized clinical trial, children assigned to standard-course therapy had lower rates of treatment failure than children assigned to short-course therapy. However, the low failure rate of short-course therapy suggests that it could be considered as a reasonable option for children exhibiting clinical improvement after 5 days of antimicrobial treatment. Trial Registration: ClinicalTrials.gov Identifier: NCT01595529.

Reassessment of the Role of Race in Calculating the Risk for Urinary Tract Infection: A Systematic Review and Meta-analysis.

Importance: A previously reported prediction model included a child's race to estimate risk of urinary tract infection (UTI), but race-conscious medicine encourages investigating how race is likely to be a proxy for other factors that should instead be used for risk prediction. Objectives: To systematically review the available literature to evaluate the robustness of the association between race and UTI and to assess whether other variables could replace race as a variable in a previously developed prediction tool without adversely affecting its accuracy. Data Source: MEDLINE was searched through May 28, 2021. Study Selection: English-language studies that reported data on the prevalence of UTI according to race for children younger than 18 years were included. Data Extraction and Synthesis: Two independent reviewers assessed studies for risk of bias and abstracted data. Random-effects models were used to pool odds ratios, and meta-regression was used to explore heterogeneity. Main Outcomes and Measures: Odds of UTI among non-Black children vs Black children. Results: Sixteen studies (17 845 children) were included. In the primary analysis, which included 11 studies, the pooled odds ratio of UTI among non-Black children was 2.44-fold higher (95% CI, 1.87-3.20) than among Black children. The corresponding odds ratio in studies with low or very low risk of bias was 4.84-fold higher (95% CI, 3.16-7.41; I2 = 0%) among non-Black children than among Black children. Replacing race with history of UTI and duration of fever resulted in a model with similar accuracy (training cohort: overall sensitivity, 96% [95% CI, 94%-98%]; overall specificity, 35% [95%, 32%-38%]; overall area under the receiver operating characteristic curve, 0.80 [95% CI, 0.77-0.82]; validation cohort: overall sensitivity, 97% [95% CI, 90%-100%]; overall specificity, 32% [95% CI, 26%-37%]; overall area under the receiver operating characteristic curve, 0.84 [95% CI, 0.77-0.92]). Conclusions and Relevance: Although previous studies suggested that an association between race and UTI exists, because of the issues associated with the inclusion of race in decision models, we replaced the variable of race with history of UTI and duration of fever in a previously developed risk prediction model and found similar accuracy.

Sixth-Hour Trancutaneous Bilirubin and Need for Phototherapy in DAT Positive Newborns.

OBJECTIVES: To characterize the outcomes of ABO incompatible direct antiglobulin test (DAT) positive newborns and determine the predictive ability of a sixth-hour transcutaneous bilirubin (TcB for needing phototherapy ≤24 hours of age. METHODS: Retrospective, cross-sectional study from May 2013 to March 2017. Of 10 942 consecutive newborns ≥35 weeks estimated gestational age, 829 were ABO incompatible and DAT positive. After excluding for antibodies other than ABO (51), missing data (4), miscategorization of blood type O (1), and duplicate record (1), 772 newborns remained. Of 772, a subsample of 346 newborns with both TcB and total serum bilirubin (TSB) tests within 1 hour of the sixth hour was analyzed to determine the predictive ability. RESULTS: Phototherapy was required in 281 of 772 (36.4%); 156 (20.2%) in the first 24 hours. There were 10 (1.3%) admissions for hyperbilirubinemia to the NICU for intravenous immunoglobin. Birth weight, infant blood type B, TSB, reticulocyte count, and TcB were all significantly associated with phototherapy ≤24 hours. On multivariate analysis, significant predictors of phototherapy ≤24 hours were TSB and reticulocyte count if no TcB was done and TcB alone if no blood tests were done. TcB was highly predictive (odds ratio 3.1, 95% confidence interval: 2.4-4.0) and nearly as accurate as the TSB and reticulocyte count (area under the curve, 0.90 and 0.96, respectively). Low (<3.0 mg/dL) and high (≥5.3 mg/dL) risk TcB cutoffs demonstrated a negative predictive value of 98% and positive predictive value of 85%, respectively. CONCLUSIONS: Among high-risk ABO incompatible DAT positive newborns, the sixth-hour TcB is highly predictive of the need for phototherapy ≤24 hours.

A Survey of Healthcare Providers About Reproductive Healthcare for Adolescent Women With Epilepsy.

STUDY OBJECTIVE: To evaluate knowledge, attitudes, and practices about sexual and reproductive health (SRH) for adolescent and young adult (AYA) women with epilepsy among general pediatricians, adolescent medicine specialists, and pediatric gynecologists. DESIGN: Survey comprising previously validated and novel items that underwent content validity testing and was distributed through specialty listservs. Categorical variables analyzed with χ2 or Fisher exact tests, and continuous variables with Kruskal-Wallis tests. SETTING: Online. PARTICIPANTS: Physicians and Advanced practice providers. INTERVENTIONS: Online survey. MAIN OUTCOME MEASURE(S): Questions testing SRH knowledge, assessing confidence in SRH counseling practices and frequency of intended SRH counseling, and identifying barriers and facilitators to SRH provision for AYA women with epilepsy. RESULTS: Of 329 participants, 57% were general pediatricians, 27% were adolescent medicine specialists, and 16% were pediatric gynecologists. On 15 items assessing knowledge, general pediatricians scored significantly lower than respondents in the other specialties (P < .01). Among 11 items about confidence in SRH skills, general pediatricians were significantly less confident than respondents in the other specialties (P < .01). General pediatricians reported that they would perform annual counseling less often on 7 SRH counseling topics compared with respondents in the other specialties (P < .01). In all, 54% of the respondents reported that barriers to SRH provision include limited time during visits and lack of epilepsy knowledge. Respondents identified facilitators including guidelines/algorithms for managing SRH (83%), provider education (61%), and electronic health record alerts (60%). CONCLUSION: Responses suggest suboptimal knowledge, confidence, and care provision regarding SRH for AYA women with epilepsy, particularly among general pediatricians. Identified barriers and facilitators may serve as targets for interventions to improve SRH provision.

Racial Differences in Urine Testing of Febrile Young Children Presenting to Pediatric Hospitals.

INTRODUCTION: Dating back to 2011, practice guidelines considered Black race a factor associated with lower risk of urinary tract infection (UTI). Race-based clinical decisions raise concerns about potential treatment disparities. We investigate urine testing (urinalysis and/or urine culture) among young febrile children in the emergency department (ED), revisits, and potential missed diagnoses by race/ethnicity. METHODS: We performed a multicenter retrospective cohort study of children 2-24 months evaluated in 26 US EDs from 2009 to 2019 with a fever diagnosis. We evaluated longitudinal testing trends, constructed a generalized linear mixed-effects model to identify the association of race/ethnicity with testing, and characterized UTI diagnoses and ≤ 7-day revisits. RESULTS: Of 734,730 included patients, 24.1% were Black. Variation in urine testing was observed by patient race/ethnicity (23.4% Black, 31.7% White, 33.9% Hispanic, 30.0% other race). Relative differences in testing persisted over time. Black patients had lower adjusted odds of testing (0.70, 95% confidence interval [CI] 0.69-0.71). Among patients with urine testing, 2.4% (95% CI 2.3-2.6%) of Black and 3.3% (95% CI 3.1-3.4%) of White patients were diagnosed with UTI. Among Black patients with urine testing on the index visit, 8.5% (95% CI 8.2-8.8%) had return visits compared to 7.6% (95% CI 7.5-7.8%) among those without urine testing on index visit. Among patients with urine testing on revisit, UTI diagnosis was similar by race/ethnicity. CONCLUSION: Black patients had lower rates of urine testing and UTI diagnoses relative to other racial/ethnic groups. This was not associated with higher rates of missed diagnoses or unscheduled return visits.

Intranasal Surfactant for Acute Otitis Media: A Randomized Trial.

BACKGROUND: Acute otitis media (AOM) is the most frequent reason for children to be prescribed antimicrobial treatment. Surfactants are naturally occurring substances that may restore the eustachian tube's function and potentially enhance resolution of AOM. METHODS: This was a phase 2a, single-center, double-blind, randomized, placebo-controlled, parallel group clinical trial to assess safety, tolerability, and efficacy of 20 mg per day intranasal OP0201 as an adjunct therapy to oral antimicrobial agents for treating AOM in young children. We randomly assigned 103 children aged 6 to 24 months with AOM to receive either OP0201 or placebo twice daily for 10 days. All children received amoxicillin-clavulanate 90/6.4 mg/kg per day in 2 divided doses for 10 days. Participants were managed for up to 1 month. Postrandomization visits occurred between days 4 and 6 (visit 2), days 12 and 14 (visit 3), and days 26 and 30 (visit 4). Primary efficacy endpoints were resolution of a bulging tympanic membrane at visit 2 and resolution of middle-ear effusion at visit 3. RESULTS: No clinically meaningful differences between treatment groups were apparent for primary or secondary endpoints. There were no safety concerns identified. CONCLUSIONS: In young children with AOM, intranasally administered surfactant (OP0201) did not improve clinical outcomes. Further research may be warranted among children with persistent middle-ear effusion.

Tympanostomy Tubes or Medical Management for Recurrent Acute Otitis Media.

BACKGROUND: Official recommendations differ regarding tympanostomy-tube placement for children with recurrent acute otitis media. METHODS: We randomly assigned children 6 to 35 months of age who had had at least three episodes of acute otitis media within 6 months, or at least four episodes within 12 months with at least one episode within the preceding 6 months, to either undergo tympanostomy-tube placement or receive medical management involving episodic antimicrobial treatment. The primary outcome was the mean number of episodes of acute otitis media per child-year (rate) during a 2-year period. RESULTS: In our main, intention-to-treat analysis, the rate (±SE) of episodes of acute otitis media per child-year during a 2-year period was 1.48±0.08 in the tympanostomy-tube group and 1.56±0.08 in the medical-management group (P = 0.66). Because 10% of the children in the tympanostomy-tube group did not undergo tympanostomy-tube placement and 16% of the children in the medical-management group underwent tympanostomy-tube placement at parental request, we conducted a per-protocol analysis, which gave corresponding episode rates of 1.47±0.08 and 1.72±0.11, respectively. Among secondary outcomes in the main analysis, results were mixed. Favoring tympanostomy-tube placement were the time to a first episode of acute otitis media, various episode-related clinical findings, and the percentage of children meeting specified criteria for treatment failure. Favoring medical management was children's cumulative number of days with otorrhea. Outcomes that did not show substantial differences included the frequency distribution of episodes of acute otitis media, the percentage of episodes considered to be severe, and antimicrobial resistance among respiratory isolates. Trial-related adverse events were limited to those included among the secondary outcomes of the trial. CONCLUSIONS: Among children 6 to 35 months of age with recurrent acute otitis media, the rate of episodes of acute otitis media during a 2-year period was not significantly lower with tympanostomy-tube placement than with medical management. (Funded by the National Institute on Deafness and Other Communication Disorders and others; ClinicalTrials.gov number, NCT02567825.).

Laparoscopic Vertical Sleeve Gastrectomy as a Treatment Option for Adults with Diabetes Mellitus.

Obesity is a major factor in the worldwide rise in the prevalence of type 2 diabetes mellitus. The obesity "epidemic" will require novel, effective interventions to permit both the prevention and treatment of diabetes caused by obesity. Laparoscopic vertical sleeve gastrectomy is a newer bariatric surgical procedure with a lower risk of complications (compared to Roux-en-Y gastric bypass surgery). Based in part on restriction of daily caloric intake, sleeve gastrectomy has a major role in inducing significant weight loss and weight loss is maintained for at least 10 years. Prior studies have supported the utility of the vertical sleeve gastrectomy for the treatment and management of subgroups of individuals with diabetes mellitus. There are reports of 11% to 76.9% of obese individuals discontinuing use of diabetic medications in studies lasting up to 8 years after vertical sleeve gastrectomy. Major ongoing issues include the preoperative determination of the suitability of diabetic patients to undergo this bariatric surgical procedure. Understanding how this surgical procedure is performed and the resulting anatomy is important when vertical sleeve gastrectomy is being considered as a treatment option for diabetes. In the postoperative periods, specific macronutrient goals and micronutrient supplements are important for successful and safer clinical results. An understanding of immediate- and long term- potential complications is important for reducing the potential risks of vertical sleeve gastrectomy. This includes the recognition and treatment of postoperative nutritional deficiencies and disorders. Vertical sleeve gastrectomy is a component of a long term, organized program directed at treating diabetes related to obesity. This approach may result in improved patient outcomes when vertical sleeve gastrectomy is performed to treat type 2 diabetes in obese individuals.

Corticosteroids to prevent kidney scarring in children with a febrile urinary tract infection: a randomized trial.

BACKGROUND: To evaluate the efficacy of adjuvant systemic corticosteroids in reducing kidney scarring. A previous study suggested that use of adjuvant systemic corticosteroids reduces kidney scarring in children radiologically confirmed to have extensive pyelonephritis. Efficacy of corticosteroids for children with febrile urinary tract infection (UTI) has not been studied. METHODS: Children aged 2 months to 6 years with their first febrile UTI were randomized to corticosteroids or placebo for 3 days (both arms received antimicrobial therapy); kidney scarring was assessed using 99mTc-dimercaptosuccinic acid kidney scan 5-24 months after the initial UTI. RESULTS: We randomized 546 children of which 385 had a UTI and 254 had outcome kidney scans (instead of the 320 planned). Rates of kidney scarring were 9.8% (12/123) and 16.8% (22/131) in the corticosteroid and placebo groups, respectively (p = 0.16), corresponding to an absolute risk reduction of 5.9% (95% confidence interval: - 2.2, 14.1). CONCLUSION: While children randomized to adjuvant corticosteroids tended to develop fewer kidney scars than children who were randomized to receive placebo, a statistically significant difference was not achieved. However, the study was limited by not reaching its intended sample size. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov , NCT01391793, Registered 7/12/2011 Graphical abstract.

Influenza Vaccine Requirements in United States Child Care Centers.

BACKGROUND: Influenza vaccine is the most effective means to prevent influenza for the high-risk population of child care attendees. This national survey assessed child care center directors' reports of seasonal influenza vaccine requirements for children and adult caregivers. METHODS: This was a 2016 telephone-based survey of child care center directors randomly selected from a national database of licensed United States child care centers and queried about influenza vaccine requirements. Conceptually related items were grouped into 4 indexes: general infection control, use of health consultants, quality of child care, and pandemic influenza preparedness. These indexes, along with other center and director characteristics, were used to predict director-reported influenza vaccine requirements. RESULTS: Of 518 child care center directors, only 24.5% and 13.1% reported an influenza vaccine requirement for children and adult caregivers, respectively. Center and director characteristics and the indexes were not associated with a director-reported influenza vaccine requirement. After adjusting for covariates, only having a state influenza vaccine law for children and an adult influenza vaccine requirement predicted having a child influenza vaccine requirement. Only having a child influenza vaccine requirement predicted having an adult vaccine requirement. CONCLUSIONS: Director-reported influenza vaccine requirements for children and adult caregivers were influenced primarily by state influenza vaccine laws. Given the high risk of children in child care and low director-reported influenza vaccine requirements, more states should pass laws requiring influenza vaccine for children and adult caregivers at child care programs.

Biomarkers that differentiate false positive urinalyses from true urinary tract infection.

BACKGROUND: The specificity of the leukocyte esterase test (87%) is suboptimal. The objective of this study was to identify more specific screening tests that could reduce the number of children who unnecessarily receive antimicrobials to treat a presumed urinary tract infection (UTI). METHODS: Prospective cross-sectional study to compare inflammatory proteins in blood and urine samples collected at the time of a presumptive diagnosis of UTI. We also evaluated serum RNA expression in a subset. RESULTS: We enrolled 200 children; of these, 89 were later demonstrated not to have a UTI based on the results of the urine culture obtained. Urinary proteins that best discriminated between children with UTI and no UTI were involved in T cell response proliferation (IL-9, IL-2), chemoattractants (CXCL12, CXCL1, CXCL8), the cytokine/interferon pathway (IL-13, IL-2, INFγ), or involved in innate immunity (NGAL). The predictive power (as measured by the area under the curve) of a combination of four urinary markers (IL-2, IL-9, IL-8, and NGAL) was 0.94. Genes in the pathways related to inflammation were also upregulated in serum of children with UTI. CONCLUSIONS: Urinary proteins involved in the inflammatory response may be useful in identifying children with false positive results with current screening tests for UTI; this may reduce unnecessary treatment.

Bariatric surgery among vulnerable populations: The effect of the Affordable Care Act's Medicaid expansion.

BACKGROUND: Obesity disproportionately affects vulnerable populations. Bariatric surgery is an effective long-term treatment for obesity-related complications; however, bariatric surgical rates are lower among racial minorities and low-income and publicly insured patients. The Affordable Care Act's Medicaid expansion improved access to health insurance, but its impact on bariatric surgical disparities has not been evaluated. We sought to determine the impact of the Affordable Care Act's Medicaid expansion on disparate utilization rates of bariatric surgery. METHODS: A total of 47,974 nonelderly adult bariatric surgical patients (ages 18-64 years) were identified in 2 Medicaid-expansion states (Kentucky and Maryland) versus 2 nonexpansion control states (Florida and North Carolina) between 2012 and 2015 using the Healthcare Cost and Utilization Project's State Inpatient Database. Poisson interrupted time series were conducted to determine the adjusted incidence rates of bariatric surgery by insurance (Medicaid/uninsured versus privately insured), income (high income versus low income), and race (African American versus white). The difference in the counts of bariatric surgery were then calculated to measure the gap in bariatric surgery rates. RESULTS: The adjusted incidence rate of bariatric surgery among Medicaid or uninsured and low-income patients increased by 15.8% and 5.1% per quarter, respectively, after the Affordable Care Act in expansion states (P < .001). No marginal change was seen in privately insured and high-income patients in expansion states. The adjusted incidence rates increased among African American and white patients, but these rates did not change significantly before and after the Affordable Care Act in expansion states. CONCLUSION: The gap in bariatric surgery rates by insurance and income was reduced after the Affordable Care Act's Medicaid expansion, but racial disparities persisted. Future research should track these trends and identify factors to reduce racial disparity in bariatric surgery.

Randomized Trial of Irrigation and Curetting for Cerumen Removal in Young Children.

Objectives: To gather preliminary data on the effectiveness and feasibility of cerumen removal using three irrigation methods and a metal curette in young children. Study design: Pilot study conducted as a randomized clinical trial of well and ill children age 6 months to 6 years with ≥25% cerumen occlusion in at least one ear. Children were stratified by age and randomized to one of four methods of cerumen removal: syringe with attached angiocath tubing, Elephant Ear Washer Bottle System®, OtoClear® Spray Wash Kit, or metal curette. Clinicians, blinded from treatment assignment, assessed the degree of cerumen occlusion before and after the procedure. Outcomes included reduction in cerumen occlusion, successful removal, time until completion and parental satisfaction. Rules for stopping procedures were established a priori. Results: Thirty-eight children underwent procedures (59 ears). There were no significant differences in reduction in cerumen and successful removal among the methods. Overall, 36 (61%) of 59 of procedures were successful. The syringe with angiocath tubing took the most time (P = 0.04) and resulted in the most stopped procedures (P < 0.01). Parental satisfaction scores were not significantly different. Conclusions: Irrigation methods performed comparably to cerumen removal with curette; the SA method had drawbacks. Irrigation can be performed by non-clinicians, which is potentially a significant advantage. (Clinical trial registration: http://www.isrctn.com/ISRCTN74402562).