Differences in testing for drugs of abuse amongst racial and ethnic groups at children's hospitals.

OBJECTIVES: Racial and ethnic differences in drug testing have been described among adults and newborns. Less is known regarding testing patterns among children and adolescents. We sought to describe the association between race and ethnicity and drug testing at US children's hospitals. We hypothesized that non-Hispanic White children undergo drug testing less often than children from other groups. METHODS: We conducted a retrospective cohort study of emergency department (ED)-only encounters and hospitalizations for children diagnosed with a condition for which drug testing may be indicated (abuse or neglect, burns, malnutrition, head injury, vomiting, altered mental status or syncope, psychiatric, self-harm, and seizure) at 41 children's hospitals participating in the Pediatric Health Information System during 2018 and 2021. We compared drug testing rates among (non-Hispanic) Asian, (non-Hispanic) Black, Hispanic, and (non-Hispanic) White children overall, by condition and patient cohort (ED-only vs. hospitalized) and across hospitals. RESULTS: Among 920,755 encounters, 13.6% underwent drug testing. Black children were tested at significantly higher rates overall (adjusted odds ratio [aOR]: 1.18; 1.05-1.33) than White children. Black-White testing differences were observed in the hospitalized cohort (aOR: 1.42; 1.18-1.69) but not among ED-only encounters (aOR: 1.07; 0.92-1.26). Asian, Hispanic, and White children underwent testing at similar rates. Testing varied by diagnosis and across hospitals. CONCLUSIONS: Hospitalized Black children were more likely than White children to undergo drug testing at US children's hospitals, though this varied by diagnosis and hospital. Our results support efforts to better understand and address healthcare disparities, including the contributions of implicit bias and structural racism.

Accuracy of Patient-Specific Implants in Virtually Planned Segmental Le Fort I Osteotomies.

(1) Background: In orthognathic surgery, segmental Le Fort I osteotomies are a valuable method to correct maxillary deformities or transversal discrepancies. However, these procedures are technically challenging, and osteosynthesis can be prone to error. (2) Methods: In this retrospective, monocentric cohort study, patients were enrolled who underwent a virtually planned segmental maxillary osteotomy during their combined treatment. Positioning and osteosynthesis were achieved by either a 3D-printed splint and conventional miniplates or patient-specific implants (PSI). The preoperative CT data, virtual planning data, and postoperative CBCT data were segmented. The deviation of all the segments from the desired virtually planned position was measured using the analysis function of IPS CaseDesigner. (3) Results: 28 Patients in the PSI Group and 22 in the conventional groups were included. The PSI group showed significantly lower deviation from the planned position anteroposteriorly (-0.63 ± 1.62 mm vs. -1.3 ± 2.54 mm) and craniocaudally (-1.39 ± 1.59 mm vs. -2.7 ± 3.1 mm). For rotational deviations, the pitch (0.64 ± 2.59° vs. 2.91 ± 4.08°), as well as the inward rotation of the lateral segments, was positively influenced by PSI. (4). Conclusions: The presented data show that patient-specific osteosynthesis significantly reduces deviations from the preoperative plan in virtually planned cases. Transversal expansions and vertical positioning can be addressed better.

Making Trauma Less Traumatic: Implementing Inpatient Pediatric Screening of Acute Stress Symptoms.

OBJECTIVES: Pediatric patients hospitalized for physical injury and trauma are at increased risk of developing acute stress disorder. Routine identification and referral for treatment of patients with psychological sequelae of traumatic injury were added to the accreditation requirements of the American College of Surgeons for pediatric trauma centers in 2022. We aimed to use quality improvement methodology with iterative interventions to increase psychological screening consults for admitted pediatric trauma patients to 80% in 6 months. METHODS: We planned a quality improvement intervention to increase identification of posttraumatic psychological symptoms in pediatric trauma patients. We created a Making Trauma Less Traumatic consultation service with a dedicated therapist to provide screening, treatment, and referral. Key interventions included education of key stakeholders and iterative improvements in consultation workflow. Our primary measure was frequency of eligible pediatric trauma patients who had consultation requests for posttrauma therapy during admission. We additionally monitored percent of patients with positive symptom screens and lost to follow-up. RESULTS: From September 2020 through November 2021, consults for eligible pediatric trauma patients improved from a baseline of 4.1% to a weekly mean of 100%. Of those screened, 32.7% had at least 1 symptom of acute stress. No families declined screening or therapy, though 29.5% were lost to intended follow-up. CONCLUSIONS: We present a successful model of implementing routine psychological screening of pediatric trauma patients utilizing a dedicated consultation service. A high number of admitted patients screened positive for symptoms during hospitalization. Families were accepting of the intervention though follow-up was challenging.

The value of prebent reconstruction plates and in-house 3D printing.

INTRODUCTION: Reconstruction plates, prebent on 3D printed models, are a cheap, quick, and safe solution to improve mandibular reconstruction procedures. The European Medical Device Regulation has changed recently and severely affects 3D printing in hospitals. Therefore, its legitimation must be discussed. This retrospective observational Case-Control Study aimed to evaluate the impact of prebent reconstruction plates on the condylar position in the temporomandibular joint after continuity resection of the mandible in oncological cases. MATERIALS AND METHODS: We included patients who underwent segmental mandibular resection without exarticulation of the condyle or history of prior surgery. The patients were divided into groups with prebent plates on a stereolithographic model and intraoperatively bent reconstruction plates. The segmental defects were categorized using the Jewer Classification. Computed Tomography (CT) scans before and after surgery were analyzed using a standardized method to measure the metric movement of the condyles, as well as their angulation to reference planes to quantify positional changes (primary outcome measures). The influence of the defect location, according to the Jewer classification, was evaluated as a secondary outcome measure. RESULTS: 73 patients, including 33 with preformed reconstruction plates, were included. We could show significantly fewer rotational deviations in cases of prefabricated osteosynthesis in the coronal plane (p<0,001) and in the sagittal plane (p<0,027). DISCUSSION: Using preformed reconstruction plates on 3D printed models improves the correct anatomical position of the condyle after mandibular resection. Especially Jewer-class-L defects seem to benefit from individualized reconstruction plates.

Flavonoid-Phenolic Acid Hybrids Are Potent Inhibitors of Ferroptosis via Attenuation of Mitochondrial Impairment.

Cinnamic acid, ferulic acid, and the flavonoids quercetin and taxifolin (dihydroquercetin) are naturally occurring compounds found in plants. They are often referred to as polyphenols and are known, among others, for their pharmacological effects supporting health through the inhibition of aging processes and oxidative stress. To improve their bioavailability, pharmacological activities, and safety, the creation of novel flavonoid-phenolic acid hybrids is an area of active research. Previous work showed that such hybridization products of phenolic acids and flavonoids enhanced the resilience of neuronal cells against oxidative stress in vitro, and attenuated cognitive impairment in a mouse model of Alzheimer's disease (AD) in vivo. Notably, the therapeutic effects of the hybrid compounds we obtained were more pronounced than the protective activities of the respective individual components. The underlying mechanisms mediated by the flavonoid-phenolic acid hybrids, however, remained unclear and may differ from the signaling pathways activated by the originating structures of the respective individual phenolic acids or flavonoids. In this study, we characterized the effects of four previously described potent flavonoid-phenolic acid hybrids in models of oxidative cell death through ferroptosis. Ferroptosis is a type of iron-dependent regulated cell death characterized by lipid peroxidation and mitochondrial ROS generation and has been linked to neurodegenerative conditions. In models of ferroptosis induced by erastin or RSL3, we analyzed mitochondrial (lipid) peroxidation, mitochondrial membrane integrity, and Ca2+ regulation. Our results demonstrate the strong protective effects of the hybrid compounds against ROS formation in the cytosol and mitochondria. Importantly, these protective effects against ferroptosis were not mediated by radical scavenging activities of the phenolic hybrid compounds but through inhibition of mitochondrial complex I activity and reduced mitochondrial respiration. Our data highlight the effects of flavonoid-phenolic acid hybrids on mitochondrial metabolism and further important mitochondrial parameters that collectively determine the health and functionality of mitochondria with a high impact on the integrity and survival of the neuronal cells.

Characteristics and Outcomes of Children Discharged With Nasoenteral Feeding Tubes.

OBJECTIVES: To describe the characteristics and outcomes of children discharged from the hospital with new nasoenteral tube (NET) use after acute hospitalization. METHODS: Retrospective cohort study using multistate Medicaid data of children <18 years old with a claim for tube feeding supplies within 30 days after discharge from a nonbirth hospitalization between 2016 and 2019. Children with a gastrostomy tube (GT) or requiring home NET use in the 90 days before admission were excluded. Outcomes included patient characteristics and associated diagnoses, 30-day emergency department (ED-only) return visits and readmissions, and subsequent GT placement. RESULTS: We identified 1815 index hospitalizations; 77.8% were patients ≤5 years of age and 81.7% had a complex chronic condition. The most common primary diagnoses associated with index hospitalization were failure to thrive (11%), malnutrition (6.8%), and acute bronchiolitis (5.9%). Thirty-day revisits were common (49%), with 26.4% experiencing an ED-only return and 30.9% hospital readmission. Revisits with a primary diagnosis code for tube displacement/dysfunction (10.7%) or pneumonia/pneumonitis (0.3%) occurred less frequently. A minority (16.9%) of patients progressed to GT placement within 6 months, 22.3% by 1 year. CONCLUSIONS: Children with a variety of acute and chronic conditions are discharged from the hospital with NET feeding. All-cause 30-day revisits are common, though revisits coded for specific tube-related complications occurred less frequently. A majority of patients do not progress to GT within a year. Home NET feeding may be useful for facilitating discharge among patients unable to meet their oral nutrition goals but should be weighed against the high revisit rate.

Transfusion-Transmitted Malaria: Two Pediatric Cases From the United States and Their Relevance in an Increasingly Globalized World.

In non-endemic settings, transfusion-transmitted malaria (TTM) is rare but potentially fatal and becoming more common with globalization. We present two pediatric cases that demonstrate donor screening using questionnaires is subject to error and that TTM should be considered with fever following numerous transfusions in children, particularly sickle cell patients.

Mitigating "Educational Groundhog Day" - The Role of Learner Handoffs Within Clinical Rotations: A Survey of Pediatric Educational Leaders.

BACKGROUND: Medical students decry frequent changes in faculty supervision, leading to the experience of "educational groundhog day." The discontinuity in supervision, cursory relationships, and uncoordinated feedback impede students' skill acquisition and delay entrustment decisions. Whereas patient handoff bundles are common, little is known about similarly structured approaches to learner handoffs (LHs). OBJECTIVE: To describe current LH procedures and practices within pediatric clerkships and subinternships and to gauge interest in a future LH bundle. METHODS: Nine items included in the 2016 Council on Medical Student Education in Pediatrics annual member survey were analyzed using mixed-methods. RESULTS: The response rates were 66% (101 of 152) and 40% (165 of 411) for institutions and individuals, respectively. After limiting data to complete responses to programs with traditional block rotations, 54% of individual respondents (76 of 141) identified as inpatient faculty and about a quarter endorsed providing LHs. Inpatient faculty most commonly supervise medical students for 5 to 7 days. Most endorsed needing 1 to 3 days to determine a student's baseline performance and 5 days or more to make entrustment decisions. Three-quarters of inpatient faculty endorsed interest in LHs, while fewer than 16% of course directors currently provide LH expectations. Four themes emerged: instrument features, stakeholder buy-in, impact, and utility. CONCLUSIONS: Typical inpatient faculty service days approximate the time required for making entrustment decisions about clinical students. While most inpatient faculty desire a LH bundle for use within a clinical rotation, few institutions and faculty currently use LHs. LHs could accelerate entrustment decisions by allowing coordinated feedback that might hasten learner clinical-skill development.

Cortactin expression: Association with disease progression and survival in oral squamous cell carcinoma.

BACKGROUND: Cortactin (CTTN) is located on chromosome 11q13 and is associated with invasiveness in various cancer entities. CTTN protein expression could be a prognosticator of oral squamous cell carcinoma (OSCC) in terms of recurrence and survival. METHODS: CTTN-dependent invasion was performed using migration assay in human papillomavirus-negative head and neck squamous cell carcinoma (HNSCC) cells. Cortactin protein analysis in tissue microarrays was used for correlation with clinical parameters, as well as for survival analysis. Gene expression profiling in HNSCC cells was performed to unreveal CTTN signaling. RESULTS: Knockdown of CTTN in HNSCC cells showed less invasion in vitro. Gene expression profiling showed various deregulated genes known to be involved in progression. We confirmed the link between CTTN overexpression and progression in a large clinical cohort. High expression was associated with worse overall and progression-free survival. CONCLUSIONS: We propose CTTN for managing OSCC in terms of adjuvant therapy and aftercare. Furthermore, our study reveals new potential targets in CTTN signaling for individualized OSCC therapy.

Mapping the distribution of stem/progenitor cells across the mouse middle ear during homeostasis and inflammation.

The middle ear epithelium is derived from neural crest and endoderm, which line distinct regions of the middle ear cavity. Here, we investigate the distribution of putative stem cell markers in the middle ear, combined with an analysis of the location of label-retaining cells (LRCs) to create a map of the middle ear mucosa. We show that proliferating cells and LRCs were associated with specific regions of the ear epithelium, concentrated in the hypotympanum at the base of the auditory bulla and around the ear drum. Sox2 was widely expressed in the endodermally derived ciliated pseudostratified epithelium of the hypotympanum. This part of the middle ear showed high levels of Wnt activity, as indicated by the expression of Axin2, a readout of Wnt signalling. Keratin 5 showed a more restricted expression within the basal cells of this region, with very little overlap between the Sox2- and keratin 5-positive epithelium, indicating that these genes mark distinct populations. Little expression of Sox2 or keratin 5 was observed in the neural crest-derived middle ear epithelium that lined the promontory, except in cases of otitis media when this epithelium underwent hyperplasia. This study lays the foundation for furthering our understanding of homeostasis and repair in the middle ear.

Current Issues in Intravenous Fluid Use in Hospitalized Children.

BACKGROUND: Fluid and electrolyte therapy is an important component in the care of the hospitalized child. Previous pediatric guidelines have followed the Holliday-Segar method of calculating and delivering maintenance IV fluids, using hypotonic fluids in maintenance therapy. However, research demonstrates that hypotonic fluids can lead to iatrogenic hyponatremia and that isotonic fluid is a safer alternative. OBJECTIVE: To provide the ideal approach to intravenous (IV) fluid use in the hospitalized child and determine the safety and effectiveness of isotonic maintenance fluid therapy. METHOD: We searched PubMed, Medline, Cochrane Controlled Clinical Trials Register, and Clinical- Trials.gov for potentially relevant publications from the last five years (2011 to July 2016) with an emphasis on randomized control trials (RCTs) and contemporary evidence-based treatment guidelines. RESULTS: For maintenance IV fluids, isotonic solutions decreased risk of hyponatremia and did not increase risk of hypernatremia. Some studies demonstrate increased ADH production or hyponatremia on admission for hospitalized patients. CONCLUSION: While there is no ideal composition of maintenance IV fluids for all children, isotonic fluids are safer than hypotonic fluids for use as maintenance in hospitalized children due to the decreased risk of iatrogenic hyponatremia. This article also provides recommendations for other types of fluid management in the inpatient pediatric population.

A Quality Improvement Initiative: Improving the Frequency of Inpatient Electronic Prescribing.

OBJECTIVE: To improve the frequency of electronic prescribing (e-prescribing) of discharge prescriptions at a children's hospital via a bundle of quality improvement interventions. METHODS: Surveys and focus groups were conducted with patient families and pediatric residents to identify barriers and propose solutions to e-prescribing. These data were used to generate a series of interventions, including the following: (1) provider education; (2) changes in patient registration workflow; and (3) electronic health record changes to improve the frequency of e-prescribing on the pediatric hospital medicine (PHM) service. The primary outcome measure was the e-prescribing frequency, with a balance measure of e-prescribing errors. RESULTS: From July 2014 through June 2015, e-prescribing frequency on the PHM service improved from a median of 7.4% to 48.9% (P < .001) and was sustained for an additional 6 months (July 2015-December 2015), surpassing meaningful use targets with associated US News and World Report hospital ranking points. The frequency of PHM prescription errors remained unchanged, and in comparison, the resident outpatient clinic revealed no statistically significant change in e-prescribing frequency during this time period. CONCLUSIONS: Engaging front-line providers in hospital-wide initiatives and quality improvement interventions can directly affect hospital metrics in programs such as meaningful use and US News and World Report, as shown through successful improvement in PHM e-prescribing frequency. Future studies are necessary to determine whether increased e-prescribing frequency affects patient outcomes and compliance.

Development and Integration of the Ear.

The perception of our environment via sensory organs plays a crucial role in survival and evolution. Hearing, one of our most developed senses, depends on the proper function of the auditory system and plays a key role in social communication, integration, and learning ability. The ear is a composite structure, comprised of the external, middle, and inner ear. During development, the ear is formed from the integration of a number of tissues of different embryonic origin, which initiate in distinct areas of the embryo at different time points. Functional connections between the components of the hearing apparatus have to be established and maintained during development and adulthood to allow proper sound submission from the outer to the middle and inner ear. This highly organized and intimate connectivity depends on intricate spatiotemporal signaling between the various tissues that give rise to the structures of the ear. Any alterations in this chain of events can lead to the loss of integration, which can subsequently lead to conductive hearing loss, in case of outer and middle ear defects or sensorineural hearing loss, if inner ear structures are defective. This chapter aims to review the current knowledge concerning the development of the three ear compartments as well as mechanisms and signaling pathways that have been implicated in the coordination and integration process of the ear.

A defect in early myogenesis causes Otitis media in two mouse models of 22q11.2 Deletion Syndrome.

Otitis media (OM), the inflammation of the middle ear, is the most common disease and cause for surgery in infants worldwide. Chronic Otitis media with effusion (OME) often leads to conductive hearing loss and is a common feature of a number of craniofacial syndromes, such as 22q11.2 Deletion Syndrome (22q11.2DS). OM is more common in children because the more horizontal position of the Eustachian tube (ET) in infants limits or delays clearance of middle ear effusions. Some mouse models with OM have shown alterations in the morphology and angle of the ET. Here, we present a novel mechanism in which OM is caused not by a defect in the ET itself but in the muscles that control its function. Our results show that in two mouse models of 22q11.2DS (Df1/+ and Tbx1(+/-)) presenting with bi- or unilateral OME, the fourth pharyngeal arch-derived levator veli palatini muscles were hypoplastic, which was associated with an earlier altered pattern of MyoD expression. Importantly, in mice with unilateral OME, the side with the inflammation was associated with significantly smaller muscles than the contralateral unaffected ear. Functional tests examining ET patency confirmed a reduced clearing ability in the heterozygous mice. Our findings are also of clinical relevance as targeting hypoplastic muscles might present a novel preventative measure for reducing the high rates of OM in 22q11.2DS patients.