Higher total ultrafiltration volume during cardiopulmonary bypass-assisted infant cardiac surgery is associated with acute kidney injury and fluid overload.

BACKGROUND: Ultrafiltration (UF) is used for fluid removal during and after infant cardiopulmonary bypass (CPB) surgery to reduce fluid overload. Excessive UF may have the opposite of its intended effect, resulting in acute kidney injury (AKI), oliganuria, and fluid retention. METHODS: This is a single-center, retrospective review of infants treated with conventional and/or modified UF during CPB surgery. UF volume was indexed to weight. AKI was defined using serum creatinine "Kidney Disease Improving Global Outcome (KDIGO)" criteria. Fluid balance was defined according to: [Formula: see text]. Peak fluid overload was determined on postoperative day 3. Multivariable logistic regression adjusted for multiple covariates was used to explore associations with UF, AKI, and fluid overload. RESULTS: Five hundred thirty subjects < 1 year of age underwent CPB-assisted congenital heart surgery with UF. Sixty-four (12%) developed postoperative AKI. On multivariable regression, higher indexed total UF volume was associated with increased AKI risk (OR 1.11, 95% CI=1.04-1.19, p = 0.003). UF volume > 119.9 mL/kg did not reduce peak fluid overload. Subjects with AKI took longer to reach a negative fluid balance (2 vs. 3 days, p = 0.04). Those with more complex surgery were at highest AKI risk (STAT 3 [25-75 percentile: 3-4] in AKI group versus STAT 3 [25-75 percentile: 2-4] in non-AKI group, p = 0.05). AKI was reduced in subjects undergoing more complex surgery and treated with UF volume < 119.9 mL/kg. CONCLUSIONS: Judicious use of UF in more complex congenital cardiac surgery reduces the risk of AKI.

Cold Debriefings after In-hospital Cardiac Arrest in an International Pediatric Resuscitation Quality Improvement Collaborative.

INTRODUCTION: Clinical event debriefing functions to identify optimal and suboptimal performance to improve future performance. "Cold" debriefing (CD), or debriefing performed more than 1 day after an event, was reported to improve patient survival in a single institution. We sought to describe the frequency and content of CD across multiple pediatric centers. METHODS: Mixed-methods, a retrospective review of prospectively collected in-hospital cardiac arrest (IHCA) data, and a supplemental survey of 18 international institutions in the Pediatric Resuscitation Quality (pediRES-Q) collaborative. Data from 283 IHCA events reported between February 2016 and April 2018 were analyzed. We used a Plus/Delta framework to collect debriefing content and performed a qualitative analysis utilizing a modified Team Emergency Assessment Measurement Framework. Univariate and regression models were applied, accounting for clustering by site. RESULTS: CD occurred in 33% (93/283) of IHCA events. Median time to debriefing was 26 days [IQR 11, 41] with a median duration of 60 minutes [20, 60]. Attendance was variable across sites (profession, number per debriefing): physicians 12 [IQR 4, 20], nurses 1 [1, 6], respiratory therapists 0 [0, 1], and administrators 1 [0, 1]. "Plus" comments reported per event were most commonly clinical standards 47% (44/93), cooperation 29% (27/93), and communication 17% (16/93). "Delta" comments were in similar categories: clinical standards 44% (41/93), cooperation 26% (24/93), and communication 14% (13/93). CONCLUSIONS: CDs were performed after 33% of cardiac arrests in this multicenter pediatric IHCA collaborative. The majority of plus and delta comments could be categorized as clinical standards, cooperation and communication.

Families With TRICARE Report Lower Health Care Quality And Access Compared To Other Insured And Uninsured Families.

Children in military families, who receive health insurance through the TRICARE program, face barriers to care such as frequent relocations, unique behavioral health needs, increased complex health care needs, and lack of accessible specialty care. How TRICARE-insured families perceive health care access and quality for their children compared to their civilian peers' perceptions remains unknown. Using data from the Medical Expenditure Panel Survey, we found that TRICARE-insured families were less likely to report accessible or responsive care compared to civilian peers, whether commercially or publicly insured or uninsured. Military families whose children had complex health or behavioral health care needs reported worse health care access and quality than similar nonmilitary families. Addressing these gaps may require military leaders to examine barriers to achieving acceptable health care access across military treatment facilities and off-base nonmilitary specialty providers, particularly for children with complex health or behavioral health needs.

Routine Cholesterol Tests and Subsequent Change in BMI Among Overweight and Obese Children.

INTRODUCTION: In 2011, the National Heart, Lung and Blood Institute and American Academy of Pediatrics concluded that both familial and obesity-associated dyslipidemias increase cardiovascular risk and recommended universal cholesterol testing at ages 9 to 11. It remains unknown whether testing influences body mass index (BMI) trajectory, a key modifiable cardiovascular outcome. METHODS: This quasi-experimental-matched cohort includes children aged 9 to 11 years completing well visits in a diverse primary care network from 2012 to 2014. Participants had baseline BMI ≥85th% and no prior cholesterol testing. Propensity score matching identified untested children similar to tested children on weight measures, practice site, sex, age, race, ethnicity, insurance, and well visit frequency. Change in BMI z-score was assessed over 18 months. Regression adjusted for residual confounding following matching. Data were analyzed in 2018. RESULTS: Matching improved balance between tested and untested children for all characteristics. The matched cohort of 1808 children was predominantly non-Latino black (48%) or non-Latino white (33%), and Medicaid insured (39%). Baseline BMI z-score was 1.88 for tested and 1.84 for untested children. Of tested children, 25% had cholesterol levels above the 2011 guideline's "acceptable" range. Two children received cholesterol lowering medications. Adjusted analysis found no difference in change in BMI z-score between tested and untested children (0.02, 95% confidence interval -0.01, 0.04). CONCLUSIONS: Individual risk assessment in the form of cholesterol testing is not associated with change in BMI trajectory among overweight and obese children. Though testing may identify familial hypercholesterolemia, results suggest testing does not change BMI trajectory, a key strategy to reduce cardiovascular risk.

Interhospital Variation in the Costs of Pediatric/Congenital Cardiac Catheterization Laboratory Procedures: Analysis of Data From the Pediatric Health Information Systems Database.

Background Cardiac catheterization is an important but costly component of health care for young patients with cardiac disease. Measurement of variation in their cost between hospitals and identification of the reasons for this variation may help reduce cost without compromising quality. Methods and Results Using data from Pediatric Health Information Systems Database from January 2007 to December 2015, the costs of 9 procedures were measured. Mixed-effects multivariable models were used to generate case-mix-adjusted estimates of each hospital's cost for each procedure and measure interhospital variation. Procedures (n=35 637) from 43 hospitals were studied. Median costs varied from $8249 (diagnostic catheterization after orthotopic heart transplantation) to $38 909 (transcatheter pulmonary valve replacement). There was marked variation in the cost of procedures between hospitals with 3.5- to 8.9-fold differences in the case-mix-adjusted cost between the most and least expensive hospitals. No significant correlation was found between hospitals' procedure-specific mortality rates and costs. Higher procedure volume was not associated with lower cost except for diagnostic procedures in heart transplant patients and pulmonary artery angioplasty. At the hospital level, the proportion of cases that were outliers (>95th percentile) was significantly associated with rank in terms of cost (Spearman's ρ ranging from 0.37 to 0.89, P<0.01). Conclusions Large-magnitude hospital variation in cost was not explained by case-mix or volume. Further research is necessary to determine the degree to which variation in cost is the result of differences in the efficiency of the delivery of healthcare services and the rate of catastrophic adverse outcomes and resultant protracted and expensive hospitalizations.

Description of hot debriefings after in-hospital cardiac arrests in an international pediatric quality improvement collaborative.

BACKGROUND: The American Heart Association recommends debriefing after attempted resuscitation from in-hospital cardiac arrest (IHCA) to improve resuscitation quality and outcomes. This is the first published study detailing the utilization, process and content of hot debriefings after pediatric IHCA. METHODS: Using prospective data from the Pediatric Resuscitation Quality Collaborative (pediRES-Q), we analyzed data from 227 arrests occurring between February 1, 2016, and August 31, 2017. Hot debriefings, defined as occurring within minutes to hours of IHCA, were evaluated using a modified Team Emergency Assessment Measure framework for qualitative content analysis of debriefing comments. RESULTS: Hot debriefings were performed following 108 of 227 IHCAs (47%). The median interval to debriefing was 130 min (Interquartile range [IQR] 45, 270). Median debriefing duration was 15 min (IQR 10, 20). Physicians facilitated 95% of debriefings, with a median of 9 participants (IQR 7, 11). After multivariate analysis, accounting for hospital site, debriefing frequency was not associated with patient age, gender, race, illness category or unit type. The most frequent positive (plus) comments involved cooperation/coordination (60%), communication (47%) and clinical standards (41%). The most frequent negative (delta) comments involved equipment (46%), cooperation/coordination (45%), and clinical standards (36%). CONCLUSION: Approximately half of pediatric IHCAs were followed by hot debriefings. Hot debriefings were multi-disciplinary, timely, and often addressed issues of team cooperation/coordination, communication, clinical standards, and equipment. Additional studies are warranted to identify barriers to hot debriefings and to evaluate the impact of these debriefings on patient outcomes.

Scalability of an Evidence-Based Adolescent Pregnancy Prevention Program: New Evidence From 5 Cluster-Randomized Evaluations of the Teen Outreach Program.

OBJECTIVES: To determine if the Teen Outreach Program (TOP), a youth development and service learning program, can reduce sexual risk-taking behaviors compared with a business as usual or benign counterfactual. METHODS: We synthesized results of 5 independent studies conducted in 5 geographically and ethnically diverse locations between 2011 and 2015 with 17 194 middle and high school students. Each study cluster-randomized classes, teachers, or schools to treatment or control groups and included the students enrolled in those clusters at baseline in an intent-to-treat analysis. Multilevel models tested impacts on recent sexual activity, recent unprotected sexual activity, and sexual initiation among the sexually inexperienced at baseline at approximately 1 and 2 years after baseline. RESULTS: Precision-weighted average effect sizes showed nonsignificant reductions of 1 percentage point or less in recent sexual activity (5 studies: -0.6; P = .32), recent unprotected sex (5 studies: -0.2; P = .76), and sexual initiation (4 studies: -1.1; P = .10) after 1 year. CONCLUSIONS: There was little evidence of the effectiveness of TOP in reducing sexual risk-taking behaviors. Results underscored the importance of continually evaluating evidence-based programs that have previously been shown to be effective.

Progressive limbic encephalopathy: Problems and prospects.

BACKGROUND: It was observed that a good number of patients presenting with psychiatric manifestations when investigated later because of unresponsiveness to treatment or late development of organic features turned out to be treatable limbic syndromes. INTRODUCTION: The aim of this study is to assess the patients presenting with new onset neuropsychiatric symptoms satisfying the criteria for probable limbic encephalitis. PATIENTS AND METHODS: Patients referred to neurology department following a period of treatment for neuropsychiatric symptoms, which did not respond to conventional treatment were analyzed using Electroencephalography (EEG), magnetic resonance imaging, cerebrospinal fluid, screening for malignancy Vasculitic work-up, histopathology and autoantibody done when feasible. RESULTS: There were 22 patients satisfying criteria for probable limbic encephalitis. Their mean age was 34.5 years. Symptoms varied from unexplained anxiety, panic and depression, lack of inhibition, wandering, incontinence, myoclonus, seizures and stroke like episodes. Three had systemic malignancy, 10 had chronic infection, one each with vasculitis, acute disseminated encephalomyelitis, Hashimoto encephalitis and two each with non-convulsive status, cryptogenic and Idiopathic inflammation. CONCLUSION: All patients who present with new onset neuropsychiatric symptoms need to be evaluated for sub-acute infections, inflammation, autoimmune limbic encephalitis and paraneoplastic syndrome. A repeated 20 minute EEG is a very effective screening tool to detect organicity.

Clinical status and cardiovascular risk profile of adults with a history of juvenile dermatomyositis.

OBJECTIVE: A pilot study of adults who had onset of juvenile dermatomyositis (JDM) in childhood, before current therapeutic approaches, to characterize JDM symptoms and subclinical cardiovascular disease. STUDY DESIGN: Eight adults who had JDM assessed for disease activity and 8 healthy adults (cardiovascular disease controls) were tested for carotid intima media thickness and brachial arterial reactivity. Adults who had JDM and 16 age-, sex-, and body mass index-matched healthy metabolic controls were evaluated for body composition, blood pressure, fasting glucose, lipids, insulin resistance, leptin, adiponectin, proinflammatory oxidized high-density lipoprotein (HDL), and nail-fold capillary end row loops. RESULTS: Adults with a history of JDM, median age 38 years (24-44 years) enrolled a median 29 years (9-38 years) after disease onset, had elevated disease activity scores, skin (7/8), muscle (4/8), and creatine phosphokinase (2/8). Compared with cardiovascular disease controls, adults who had JDM were younger, had lower body mass index and HDL cholesterol (P = .002), and increased intima media thickness (P = .015) and their brachial arterial reactivity suggested impairment of endothelial cell function. Compared with metabolic controls, adults who had JDM had higher systolic and diastolic blood pressure, P = .048, P = .002, respectively; lower adiponectin (P = .03); less upper arm fat (P = .008); HDL associated with end row loops loss (r = -0.838, P = .009); and increased proinflammatory oxidized HDL (P = .0037). CONCLUSION: Adults who had JDM, 29 years after disease onset, had progressive disease and increased cardiovascular risk factors.

Clinician-assigned and parent-report questionnaire-derived child psychiatric diagnoses: correlates and consequences of disagreement.

The objectives of this study were to determine (a) if child characteristics relate to disagreement between clinician-assigned diagnoses and diagnoses derived from parent-report questionnaire, which were available to clinicians, and (b) if disagreement predicts subsequent number of clinic visits attended. This study evaluated the odds of agreement versus disagreement for internalizing and externalizing problems as a function of child age, gender, race, public-aid status, symptom severity, and impairment among 900 children (3-19 years) in a large, urban, child psychiatry clinic. A mixed-effects regression approach was used to evaluate the relationship between disagreement and visit attendance. Internalizing problem disagreement was more likely for children who were males, older, less symptomatic, and receiving Medicaid. Externalizing problem disagreement was more likely for children who were female, older, less impaired, and less symptomatic. Internalizing disagreement predicted significantly fewer visits; externalizing disagreement did not. Clinician-parent disagreement about the nature of child problems may have clinical consequences, especially for internalizing disorders. Attention to child characteristics that predict agreement may diminish discrepancies and reduce attrition from treatment.

Association of normal nailfold end row loop numbers with a shorter duration of untreated disease in children with juvenile dermatomyositis.

OBJECTIVE: To determine the association of normal numbers of end row loops (ERLs) in nailfold capillaries at the time of diagnosis of juvenile dermatomyositis (DM) with clinical findings in untreated children with the disease and to identify predictors of the development of decreased numbers of ERLs. METHODS: Clinical and laboratory data from 80 untreated children with juvenile DM were collected. ERL numbers were recorded at the time of diagnosis and at 24 months and 36 months thereafter. The 12 children who had normal ERLs at diagnosis were compared with the remaining 68 children. Outcomes included the duration of untreated disease, the duration of treatment with immunosuppressive medications, family medical history, Disease Activity Score (DAS) for juvenile DM, creatinine phosphokinase level, aldolase level, absolute number of CD3-CD56+/16+ natural killer cells, and von Willebrand factor antigen level. Cross-sectional and longitudinal analyses were performed. RESULTS: At diagnosis, children with normal ERLs had a shorter duration of untreated disease (P = 0.03) and a lower skin DAS (P = 0.045). Over time, an increased likelihood of having decreased numbers of ERLs was associated with a longer duration of untreated disease and with a higher skin DAS. CONCLUSION: The presence of a normal number of ERLs in juvenile DM appears to be associated with a shorter duration of symptoms and may be a useful indicator of disease chronicity in the newly diagnosed child. Normal ERLs is also associated with a lower skin DAS. The lack of association between normal ERLs and other variables indicates that normal findings on nailfold capillaroscopy should not be used as justification to delay immunosuppressive therapy in children with typical symptoms of juvenile DM.

Tobacco-related documentation in pediatric practice.

OBJECTIVE: The goal of this study was to evaluate tobacco-related documentation in children's medical records. METHOD: A cross-sectional, consecutive sample of 4216 parents at 13 primary care practices was surveyed on demographics, health habits, and smoking status of household members. The medical records of 2085 children from a subsample of 1149 families (all households with smokers and a sample of nonsmoking households) were reviewed for tobacco-related documentation at the first visit to the practice and visits in the 14 months preceding recruitment. Relationships of documentations with visit type, household smoking status, and use of charting prompts were examined. RESULTS: Most children (93%) had > or =1 visit during the reviewed period (77% had a health supervision visit), 23% were aged > or =11 years, 52% were Medicaid/uninsured, and 70% lived with smokers; 30.6% of children had family tobacco use status documented at a first visit to the practice and 15.4% had prenatal tobacco use status documented. Among children with a visit in the reviewed period, 39.3% with a health supervision visit and 9.6% without had a tobacco-related notation at a visit (P < .001). Overall, 15.2% of children living with a smoker had a visit notation indicating that someone in the household smoked. In households with smokers, documentation of household tobacco use status often disagreed with parent survey. Charting prompts significantly increased rates of identification of family tobacco use history and prenatal tobacco use history. CONCLUSIONS: Correct identification of household smoking status was absent for most children living with smokers. Improved documentation systems may facilitate tobacco-related surveillance and counseling.

Increased prevalence of risk factors for morbidity and mortality in the US Hispanic CF population.

Hispanic ethnicity is an independent risk factor for increased morbidity and mortality in cystic fibrosis (CF) patients. In order to compare the prevalence of risk factors for morbidity and mortality between the Hispanic CF population and the non-Hispanic CF population, we performed a cross-sectional study of patients in the 2004 Cystic Fibrosis Foundation Patient Registry. Among 22,714 CF patients, 1,511 were identified as ethnic Hispanic. Hispanic patients were diagnosed earlier (2.8 vs. 3.3 years, P = 0.005) and acquired Pseudomonas aeruginosa at a younger age (6.6 years vs. 10 years, P < 0.001). FEV(1) was lower for Hispanic patients (81.5% vs. 87% predicted for those under 18 years old [P < 0.001] and 2.1 L vs. 2.3 L for those 18 years and older [P = 0.01]). Hispanic patients had similar or better nutritional status. Hispanic patients were more likely to be diagnosed with liver disease (OR 1.31 [1.1, 1.56]) but less likely to be diagnosed with depression (OR 0.53 [0.39, 0.68]), bone and joint disease (OR 0.55 [0.41, 0.71]), or CF-related diabetes (OR 0.53 [0.43, 0.62]). Hispanic patients had lower median income by zip code ($41,930 vs. $47,341; P < 0.001), a higher rate of government insurance (55.2% vs. 32.0%; P < 0.001), and greater percentage of mothers with less than a high school education (26.7% vs. 6.5%; P < 0.001). We conclude that there is an increased prevalence of important risk factors for morbidity and mortality in the Hispanic CF population.

Performance of a rapid antigen-detection test and throat culture in community pediatric offices: implications for management of pharyngitis.

OBJECTIVES: The goals were to establish performance characteristics of a rapid antigen-detection test and blood agar plate culture performed and interpreted in community pediatric offices and to assess the effect of the pretest likelihood of group A streptococcus pharyngitis on test performance (spectrum bias). METHODS: Two throat swabs were collected from 1848 children 3 to 18 years of age who were evaluated for acute pharyngitis between November 15, 2004, and May 15, 2005, in 6 community pediatric offices. One swab was used to perform the rapid antigen-detection test and a blood agar plate culture in the office and the other was sent to our laboratory for blood agar plate culture. Clinical findings were used to calculate the McIsaac score for each patient. The sensitivities of the office tests were calculated, with the hospital laboratory culture results as the criterion standard. RESULTS: Thirty percent of laboratory blood agar plate cultures yielded group A streptococcus (range among sites: 21%-36%). Rapid antigen-detection test sensitivity was 70% (range: 61%-80%). Office culture sensitivity was significantly greater, 81% (range: 71%-91%). Rapid antigen-detection test specificity was 98% (range: 98%-99.5%), and office culture specificity was 97% (range: 94%-99%), a difference that was not statistically significant. The sensitivity of a combined approach using the rapid antigen-detection test and back-up office culture was 85%. Among patients with McIsaac scores of >2, rapid antigen-detection test sensitivity was 78%, office culture sensitivity was 87%, and combined approach sensitivity was 91%. Positive diagnostic test results were significantly associated with McIsaac scores of >2. CONCLUSIONS: The sensitivity of the office culture was significantly greater than the sensitivity of the rapid antigen-detection test, but neither test was highly sensitive. The sensitivities of each diagnostic modality and the recommended combined approach were best among patients with greater pretest likelihood of group A streptococcus pharyngitis.

Promoting growth interpretation and lifestyle counseling in primary care.

OBJECTIVE: To pilot a practice-directed intervention to promote growth interpretation and lifestyle counseling during child health supervision visits. STUDY DESIGN: The intervention at 4 diverse primary care practices included education, facilitation by a practice-change leadership team, tools, and guidance from the study team. Preintervention and postintervention evaluations used were clinician interviews, in-office surveys of parents, 1-month post-visit telephone survey, visit observations, and medical record reviews. Outcomes evaluated growth interpretation documentation, clinician recognition of overweight, topic discussed at health supervision visit, and parental visit content recall and health behavior changes. RESULTS: The intervention was well accepted, and tools provided were deemed helpful. Documentation of growth interpretation was higher after intervention (pre versus post: 32% vs 87%; P< .001). Parent reports of topics discussed were similar between evaluation periods (pre versus post: growth 96% vs 99%; diet 90% vs 93%; physical activity 81% vs 85%). Observed topics at health supervision visits were similarly high and were unchanged between periods. Parental recall of topics at 1 month was also high and similar between periods. Parental report of adoption of a healthier behavior for themselves or their child at 1 month did not significantly change. CONCLUSIONS: The Systematic Nutritional Assessment in Pediatric Practice intervention provides a promising model to increase interpretation and documentation of growth.