A retrospective cohort study analyzing the changes in early childhood development during the COVID-19 pandemic.

OBJECTIVE: To investigate early childhood development (ECD) outcomes in different subgroups before and during the COVID-19 pandemic. STUDY DESIGN: A retrospective cohort study of children 3-58 months of age whose caregivers completed a Survey of Well-being of Young Children (SWYC) as part of a well child visit (WCC). The data were divided into two phases: pre-pandemic (September 2018 - February 2020), and during pandemic (September 2020 - February 2022). The difference in the proportion of forms with Meets Expectations interpreted scores on the SWYC Developmental Milestones pre-pandemic versus during the pandemic timeframe overall and among subgroups were reported. Hypotheses were tested using logistic regression with repeated measures. RESULTS: 14,550 patients were included in the sample for analysis with 52,558 SWYC form observations. There was no difference in the odds of a Meets Expectations interpreted score before and after the pandemic for the entire sample, OR 0.99 (95 % CI: 0.94-1.04). There was evidence of decreased odds of an interpreted score of Meets Expectations for the following subgroups: male, Hispanic/Latino ethnicity, ages of 24, 30 or 36 months at WCC, Medicaid insurance, 2nd HOUSES Quartile, requiring interpreter, single parent household, young maternal age, maternal substance abuse, and race identified as Native Hawaiian/Pacific Islander, American Indian/Native Alaskan or Other. CONCLUSION: Decreased odds of meeting developmental milestones during the pandemic were evident in certain high risk sub-groups revealing unequal distribution of suboptimal developmental outcomes within our population during the pandemic that may be exacerbating existing inequities impacting development in children.

Neonatal hemophagocytic lymphohistiocytosis: A meta-analysis of 205 cases.

BACKGROUND: Neonatal hemophagocytic lymphohistiocytosis (nHLH), defined as HLH that presents in the first month of life, is clinically devastating. There have been few large descriptive studies of nHLH. OBJECTIVES: The objective of this study was to perform a meta-analysis of published cases of nHLH. METHODS: A comprehensive literature database search was performed. Cases of HLH were eligible for inclusion if clinical analysis was performed at age ≤30 days. Up to 70 variables were extracted from each case. RESULTS: A total of 544 studies were assessed for eligibility, and 205 cases of nHLH from 142 articles were included. The median age of symptom onset was day of life 3 (interquartile range [IQR]: 0-11, n = 141). Median age at diagnosis was day of life 15 (IQR: 6-27, n = 87). Causes of HLH included familial HLH (48%, n = 99/205), infection (26%, n = 53/205), unknown (17%, n = 35/205), macrophage activation syndrome/rheumatologic (2.9%, n = 4/205), primary immune deficiency (2.0%, n = 5/205), inborn errors of metabolism (2.4%, n = 5/205), and malignancy (2.0%, n = 4/205). Fever was absent in 19% (n = 28/147) of all neonates and 39% (n = 15/38) of preterm neonates. Bicytopenia was absent in 26% (n = 47/183) of patients. Central nervous system (CNS) manifestations were reported in 63% of cases (n = 64/102). Liver injury (68%, n = 91/134) and/or liver failure (24%, n = 32/134) were common. Flow cytometry was performed in 22% (n = 45/205) of cases. Many patients (63%, n = 121/193) died within the period of reporting. Discernable values for HLH diagnostic criteria were reported between 30% and 83% of the time. CONCLUSIONS: Evaluation of nHLH requires rapid testing for a wide range of differential diagnoses. HLH diagnostic criteria such as fever and bicytopenia may not occur as frequently in the neonatal population as in older pediatric populations. Neurologic and hepatic manifestations frequently occur in the neonatal population. Current reports of nHLH suggest a high mortality rate. Future publications containing data on nHLH should improve reporting quality by reporting all clinically relevant data.

Site-specific effects of dobutamine on cardiac conduction and refractoriness.

BACKGROUND: Isoproterenol, a non-specific beta agonist, is commonly used during electrophysiology studies (EPS). However, with the significant increase in the price of isoproterenol in 2015 and the increasing number of catheter ablations performed, the cost implications cannot be ignored. Dobutamine is a less expensive synthetic compound developed from isoproterenol with a similar mechanism to enhance cardiac conduction and shorten refractoriness, thus making it a feasible substitute with a lower cost. However, the use of dobutamine for EPS has not been well-reported in the literature. OBJECTIVE: To determine the site-specific effects of various doses of dobutamine on cardiac conduction and refractoriness and assess its safety during EPS. METHODS: From February 2020 to October 2020, 40 non-consecutive patients scheduled for elective EPS, supraventricular tachycardia, atrial fibrillation, and premature ventricular contraction ablations at a single center were consented and prospectively enrolled to assess the effect of dobutamine on the cardiac conduction system. At the end of each ablation procedure, measures of cardiac conduction and refractoriness were recorded at baseline and with incremental doses of dobutamine at 5, 10, 15, and 20 mcg/kg/min. For the primary analysis, the change per dose of dobutamine from baseline to each dosing level of dobutamine received by the patients, comparing atrioventricular node block cycle length (AVNBCL), ventricular atrial block cycle length (VABCL) and sinus cycle length (SCL), was tested using mixed-effect regression. For the secondary analysis, dobutamine dose level was tested for association with relative changes from baseline of each electrophysiologic parameter (SCL, AVNBCL, VABCL, atrioventricular node effective refractory period (AVNERP), AH, QRS, QT, QTc, atrial effective refractory period (AERP), ventricular effective refractory period (VERP), using mixed-effect regression. Changes in systolic and diastolic blood pressures were also assessed. The Holm-Bonferroni method was used to adjust for multiple testing. RESULTS: For the primary analysis there was no statistically significant change of AVNBCL and VABCL relative to SCL from baseline to each dose level of dobutamine. The SCL, AVNBCL, VABCL, AVNERP, AERP, VERP and the AH, and QT intervals all demonstrated a statistically significant decrease from baseline to at least one dose level with incremental dobutamine dosing. Two patients (5%) developed hypotension during the study and one patient (2.5%) received a vasopressor. Two patients (5%) had induced arrhythmias but otherwise no major adverse events were noted. CONCLUSION: In this study, there was no statistically significant change of AVNBCL and VABCL relative to SCL from baseline to any dose level of dobutamine. As expected, the AH and QT intervals, and the VABCL, VERP, AERP and AVNERP all significantly decreased from baseline to at least one dose level with an escalation in dobutamine dose. Dobutamine was well-tolerated and safe to use during EPS.

Clinical, Sociodemographic, and Neighborhood Characteristics Associated with Adverse Pregnancy Outcomes.

Background: Cardiovascular risk is increased by a history of adverse pregnancy outcomes (APOs). Efforts to understand and prevent these adverse outcomes may improve both fetal and birthing persons' outcomes in the peripartum period, and over the patient's lifetime. This study aims to assess the association of clinical, sociodemographic, and economic neighbor-hood factors with preterm birth (PTB) and APOs (the composite of stillbirth, small for gestation age, and low birthweight). Materials and Methods: This is a cross-sectional study using the electronic medical records of deliveries from seven Northwell Health hospitals between January 1, 2018 and July 31, 2020. There were 62,787 deliveries reviewed in this study. Deliveries that were not the first for the patient during the study period and multiple gestational pregnancies were excluded. Patients with incomplete data on outcome were also excluded. Main outcomes were PTB and composite APOs. Measures included history of PTB, hypertension, diabetes, body mass index, race/ethnicity, age, preferred language, marital status, parity, health insurance, and median income, percent unemployment, and mean household size by zip code. Results: Of the 62,787 deliveries, 43.3% were from white, Non-Hispanic, and Non-Latino patients. There were 4,552 (7.2%) PTBs and 8,634 (13.8%) APOs. Patients enrolled in public insurance had higher odds of PTB (odds ratio [OR] 1.15, 95% CI 1.06-1.24) and APOs (OR 1.19, 95% CI 1.12-1.25). There was a statistically significant association of both PTB (p = 0.037) and APOs (p = 0.005) when comparing patients that live in a zip code with a median income over 100k to those with an income <100k. In addition, living in a zip code within the second quintile of unemployment was associated with lower odds of APOs (OR 0.92, 95% CI 0.84-0.99). Conclusions: Numerous sociodemographic and clinical factors are associated with both PTB and APOs. Tailored programs addressing these disparities may improve outcomes in pregnant persons.

First-Generation Cephalosporins for Treatment of Acute Hematogenous Osteomyelitis in Children: A Study of Efficacy and Adverse Effects.

Background: Acute hematogenous osteomyelitis (AHO) is a relatively infrequent but significant infection in pediatric patients. As Staphylococcus aureus is the most common cause of AHO, intravenous and oral first-generation cephalosporins are common therapies. Cephalexin is a commonly prescribed oral therapy for pediatric AHO, although it requires frequent dosing that may affect adherence. Cefadroxil is a comparable oral first-generation cephalosporin with a more desirable dosing schedule. Methods: We reviewed pediatric patients admitted to Mayo Clinic between March 2002 and September 2020 for management of AHO who received treatment with a first-generation cephalosporin. We reviewed timing of oral therapy transition, therapy-associated adverse effects, and recurrence of disease after completion of therapy. Results: There were 59 patients included in the study. There was similar occurrence of adverse effects in patients receiving cefadroxil and cephalexin, although use of cefadroxil coincided with more gastrointestinal adverse effects and leukopenia and use of cephalexin with more rash and neutropenia. One secondary treatment failure occurred in our study, in a patient receiving cephalexin for treatment of septic arthritis. Conclusions: Cefadroxil may be a reasonable alternative oral therapy for methicillin-susceptible S aureus or culture-negative AHO in pediatric patients, particularly when a less frequent dosing schedule is desired. Future study with a larger sample size is warranted.

Effect of Electronic Health Record Prompts on the Frequency of Blood Lead Tests.

INTRODUCTION/OBJECTIVES: Elevated blood lead levels can cause impaired cognition and behavioral problems in children. Screening is important for identifying children with elevated blood lead levels, but many children who qualify for screening do not get tested. We aimed to see if the addition of prompts in the electronic health record (EHR) would lead to differences in blood lead tests ordered for children with government insurance. METHODS: In May 2018, a prompt was added to our institutional EHR that reminded primary care practitioners to recommend lead testing for patients with government insurance. For this retrospective observational pre-post comparative study, we reviewed the rate of blood lead test orders and completed collection before and after the prompt was introduced. RESULTS: The number of blood lead tests ordered did not increase after prompts were introduced in the EHR; rather, the lead screening rates at 12-month well-child visits decreased from 63.6% to 53.8% (P = .008). The 24-month visit data did not change significantly for the number of lead tests ordered before and after the prompt was introduced in the EHR. The number of lead tests completed showed a significant decrease after the prompt was introduced for the 12-month visit (P < .001) but no significant change for the 24-month visit (P = .70). CONCLUSIONS: This study showed that the addition of prompts in the EHR was not associated with an increase in the number of blood lead level tests ordered. Further research is needed to determine factors that could affect lead screening rates.

The impact of teleneonatology on the Transport Risk Index of Physiologic Stability score for outborn neonates: A prospective, observational study.

INTRODUCTION: Teleneonatology (TN) allows neonatologists to use real-time, audio-video telemedicine to manage critically ill neonates located in community hospitals (CHs). The California Transport Risk Index of Physiologic Stability (Ca-TRIPS) score is a validated metric that predicts the risk of 7-day mortality for neonates undergoing medical transport. We hypothesized that neonates born in CHs who received TN consults would have lower (better) Ca-TRIPS scores upon arrival of the transport team than those who did not. METHODS: Neonates born in CHs between 8 December 2018 and 31 July 2022 who were transported to the neonatal intensive care unit were screened for eligibility. TN was available at 50% (12/24) of CHs, where care teams decided when to activate the service. Study data were abstracted from the electronic health record and used to calculate Ca-TRIPS scores. Scores were evaluated using zero-inflated negative binomial regression. RESULTS: Forty-two percent (161/385) of neonates received a TN consult. Neonates that received TN had lower birth weight, gestational age, and Apgar scores and were more often admitted with respiratory distress syndrome and respiratory failure. Neonates who received TN were less likely to have a Ca-TRIPS score of zero (odds ratio 0.51; 95% confidence interval 0.33, 0.78). When adjusted for baseline characteristics, this difference was no longer significant. Non-zero Ca-TRIPS scores were not different between groups. DISCUSSION: In this observational study, neonates that received TN did not have lower (better) Ca-TRIPS scores. Findings may be limited by confounding bias given between-group differences in baseline patient characteristics. Randomized studies are needed to determine whether TN impacts the physiologic stability of neonates requiring medical transport.

Characteristics of Suspected COVID-19 Discharged Emergency Department Patients Who Returned During the First Wave.

INTRODUCTION: Limited information exists on patients with suspected coronavirus disease 2019 (COVID-19) who return to the emergency department (ED) during the first wave. In this study we aimed to identify predictors of ED return within 72 hours for patients with suspected COVID-19. METHODS: Incorporating data from 14 EDs within an integrated healthcare network in the New York metropolitan region from March 2-April 27, 2020, we analyzed this data on predictors for a return ED visit-including demographics, comorbidities, vital signs, and laboratory results. RESULTS: In total, 18,599 patients were included in the study. The median age was 46 years old [interquartile range 34-58]), 50.74% were female, and 49.26% were male. Overall, 532 (2.86%) returned to the ED within 72 hours, and 95.49% were admitted at the return visit. Of those tested for COVID-19, 59.24% (4704/7941) tested positive. Patients with chief complaints of "fever" or "flu" or a history of diabetes or renal disease were more likely to return at 72 hours. Risk of return increased with persistently abnormal temperature (odds ratio [OR] 2.43, 95% CI 1.8-3.2), respiratory rate (2.17, 95% CI 1.6-3.0), and chest radiograph (OR 2.54, 95% CI 2.0-3.2). Abnormally high neutrophil counts, low platelet counts, high bicarbonate values, and high aspartate aminotransferase levels were associated with a higher rate of return. Risk of return decreased when discharged on antibiotics (OR 0.12, 95% CI 0.0-0.3) or corticosteroids (OR 0.12, 95% CI 0.0-0.9). CONCLUSION: The low overall return rate of patients during the first COVID-19 wave indicates that physicians' clinical decision-making successfully identified those acceptable for discharge.

The optimal gestational age to deliver patients with chronic hypertension on antihypertensive therapy.

OBJECTIVE: To identify the optimal gestational age of planned delivery in pregnancies complicated by chronic hypertension requiring antihypertensive medications that minimizes the risk of adverse perinatal events and maternal morbidity. METHODS: Retrospective cohort study of singleton pregnancies after 37 weeks of gestation complicated by chronic hypertension on antihypertensive medication, delivered at 7 hospitals within an academic health system in New York from 12/1/2015 to 9/3/2020. Two comparisons were made (1) planned deliveries at 37-376/7 weeks versus expectant management, (2) planned deliveries at 38-386/7 weeks versus expectant management. Patients with other maternal or fetal conditions were excluded. The primary outcome was a composite of adverse perinatal outcomes including stillbirth, neonatal death, assisted ventilation, cord pH < 7.0, 5-minute Apgar ≤5, diagnosis of respiratory disorder, and neonatal seizures. The secondary outcomes included preeclampsia, eclampsia, primary cesarean delivery, postpartum readmission, and infant stay greater than 5 days. Odds ratios were estimated with multiple logistic regression and adjusted for confounding effects. RESULTS: A total of 555 patients met inclusion criteria. Patients who underwent planned delivery at 37 weeks compared to expectant management did not appear to be at higher risk of adverse perinatal outcomes (14.9% vs 10.4%, aOR 1.49, 95% CI: 0.77-2.88). Similarly, we did not find a difference in the primary outcome in patients who underwent planned delivery at 38 weeks versus those expectantly managed (9.7% vs 10.1%, (aOR 0.84, 95% CI: 0.39-1.76). There were no differences in the rates of primary cesarean or preeclampsia at 37 and 38 weeks. CONCLUSION: Our findings suggest that there is no difference in neonatal or maternal outcomes for chronic hypertensive patients on medication if delivery is planned or expectantly managed at 37 or 38 weeks' gestation.

Use of TIMP-2 and IGFBP-7 for prediction of postoperative acute kidney injury after cardiac surgery.

BACKGROUND: The following cell cycle arrest urinary biomarkers, tissue inhibitor of metalloproteinases-2 (TIMP-2) and insulin-like growth factor-binding protein 7 (IGFBP-7), have been used for early detection of acute kidney injury (AKI) in critically ill patients. The purpose of this study is to validate the use of these urinary biomarkers in patients undergoing open heart surgery. MATERIALS AND METHODS: In a single-center prospective observational study, urine samples were collected in 108 consecutive patients who underwent open heart surgery immediately after separation from cardiopulmonary bypass and on postoperative day 1, and were sent for the biomarker [TIMP-2]*[IGFBP7] analysis. Acute kidney injury was defined based on KDIGO criteria, and levels of [TIMP-2]*[IGFBP7] were analyzed for the ability to predict AKI. RESULTS: Of the 108 patients, 19 (17.6%) patients developed postoperative AKI within 48 hours of surgery. At the threshold of > 0.3 (ng/mL)2/1,000, post-cardiopulmonary bypass [TIMP-2]*[IGFBP-7] had a sensitivity of 13% and specificity of 82% for predicting postoperative AKI. Postoperative day-1 [TIMP-2]*[IGFBP-7] had a sensitivity of 47% and a specificity of 59% for predicting postoperative AKI. There were no differences in [TIMP-2]*[IGFBP-7] values at either timepoint between patients who developed postoperative AKI as compared to those who did not. CONCLUSION: Urinary [TIMP-2]*[IGFBP7] was not predictive of the risk of AKI after cardiac surgery in this single-center study population.

Prevalence and clinical significance of arrhythmias during labour in women with structurally normal hearts.

OBJECTIVES: Examine the association between arrhythmias and adverse maternal outcomes in women with structurally normal hearts. METHODS: This was a case-control study of women admitted in labour to one of eight hospitals of Northwell Health from January 2015 to June 2021. After excluding women with structurally abnormal hearts, we identified women with an arrhythmic event and randomly subsampled the rest of the cohort to create a control group of 1025 patients. Multivariate analysis was performed to examine the association between arrhythmias and the incidence of caesarean section (CS), preterm labour (PTL), admission to the neonatal intensive care unit and longer length of stay (LOS). RESULTS: Of 1 41 769 women admitted in labour with a structurally normal heart, 137 had at least one arrhythmic event (0.097%). Supraventricular tachycardia (SVT), atrial fibrillation/flutter (AF) and frequent premature ventricular complexes or non-sustained ventricular tachycardia (VA) were present in 65 (0.046%), 22 (0.016%) and 46 (0.032%) women, respectively. Arrhythmia was previously diagnosed in 58.0% SVT cases but only in 9.7% AF and 8.1% VA cases. After adjusting for age, parity and comorbidities, the presence of any arrhythmia was an independent predictor of CS (OR 1.7 95% CI 1.2 to 2.5), PTL (OR 1.8, CI 1.1 to 3.0) and LOS (mean ratio 1.6, CI 1.4 to 1.8). This association was driven by presence of SVT and AF, whereas VAs were not associated with adverse outcomes. CONCLUSIONS: Arrhythmias, specifically SVT and AF, during labour in women with structurally normal heart are independently associated with adverse obstetrical outcomes.

Clinical significance of unexplained persistent sinus tachycardia in women with structurally normal heart during the peripartum period.

BACKGROUND: Persistent sinus tachycardia (ST) is frequently encountered during pregnancy and peripartum period and its etiology often remains elusive. We sought to examine the possible association between unexplained persistent ST and obstetric outcomes. METHODS: A case control study was conducted using chart review of women admitted in labor to one of 7 hospitals of Northwell Health between January 2015 to June 2021. After excluding women with structurally abnormal hearts, we identified patients with persistent ST during the peripartum period, defined as a heart rate of more than 100 bpm for more than 48 h. A control group was created by randomly subsampling those who did not meet the inclusion criteria for sinus tachycardia. Obstetric outcomes were measured as mother's length of stay (LOS), pre-term labor (PTL), admission to the neonatal ICU (NICU), and whether she received cesarean-section (CS). RESULTS: Seventy-eight patients with persistent ST were identified, out of 141,769 women admitted for labor throughout the Northwell Health system. 23 patients with ST attributable to infection or hypovolemia from anemia requiring transfusion and 55 with unclear etiology were identified. After adjusting for age and parity, pregnant mothers with ST were 2.35 times more likely to have a CS than those without (95% CI: 1.46-3.81, p = 0.0005) and had 1.38 times the LOS (1.21- 1.56, p < 0.0001). Among mothers with ST, those with unexplained ST were 2.14 times more likely to have a CS (1.22-3.75, p = 0.008). CONCLUSION: Among pregnant patients, patients with ST have higher rates of CS.This association is unclear, however potential mechanisms include catecholamine surge, indolent infection, hormonal fluctuations, and medications. More studies are needed to explore the mechanism of ST in pregnant woman to determine the clinical significance and appropriate management.

Outcomes of COVID-19 infection in multiple sclerosis and related conditions: One-year pandemic experience of the multicenter New York COVID-19 Neuroimmunology Consortium (NYCNIC).

OBJECTIVE: To determine outcomes of COVID-19 in patients with Multiple Sclerosis (MS) and related conditions, and to determine predictors of these outcomes. METHODS: This was a multicenter, observational cohort study of patients with MS or related CNS autoimmune disorders who developed confirmed or highly suspected COVID-19 infection from 2/1/2020 to 12/31/2020. MAIN OUTCOME AND MEASURE: The primary outcome measure was hospitalization status due to COVID-19. Severity of infection was measured using a 4-point ordinal scale: 1. home care; 2. hospitalization without mechanical ventilation; 3. hospitalization and mechanical ventilation, and 4. death. RESULTS: Of 474 patients in the study, 63.3% had confirmed COVID-19 infection and 93.9% were diagnosed with an MS phenotype. Mean age was 45 ± 13 (mean±SD) years, 72% were female, and 86% were treated with a DMT at the time of infection. 58 patients (12.2%) were hospitalized. 24 patients (5.1%) were critically ill (requiring ICU care or outcome of death), of which 15 patients (3.2%) died. Higher neurological disability and older age independently predicted hospitalization. 85% (102/120) of patients with known antibody results not treated with anti-CD20 therapies were seropositive while only 39.5% (17/43) of patients treated with anti-CD20 demonstrated seropositivity (p < 0.0001). Only 25% (2/8) of patients with PCR-confirmed COVID-19 being treated with anti-CD20 therapies demonstrated seropositivity. CONCLUSIONS: Neurological disability and older age independently predicted hospitalization due to COVID-19. Additionally, the results demonstrate that anti-CD20 therapies significantly blunt humoral responses post-infection, a finding that carries implications with regards to natural or vaccine-mediated immunity.

Sociodemographic predictors and transportation patterns of COVID-19 infection and mortality.

BACKGROUND: The United States Centers for Disease Control and Prevention (CDC)-sanctioned prevention strategies have included frequent handwashing with soap and water, covering the mouth and nose with a mask when around others, cleaning and disinfecting maintaining a distance of at least 6 feet from others, etc. Although many of these recommendations are based upon observation and past infection control practices, it is important to combine and explore public data sets to identify predictors of infection, morbidity and mortality to develop more finely honed interventions, based on sociodemographic factors. METHOD: Cross-sectional study of both states in the US and counties in NY state. RESULTS: Population density was found to be significantly associated with state-level coronavirus infection and mortality rate (b = 0.49, 95% confidence interval (CI): 0.34, 0.64, P < .0001). States that have lower socioeconomic status, lower mean age and denser populations are associated with higher incidence rates. In regard to NY state, counties with a higher percentage of minority residents had higher COVID-19 mortality rates (b = 2.61, 95% CI: 0.36, 4.87, P = 0.023). Larger population cohorts were associated with lower COVID-19 mortality rates after adjusting for other variables in the model (b = -1.39, 95% CI: -2.07, -0.71, P < 0.001). Population density was not significantly associated with COVID-19 mortality rates after adjustment across counties in the NY state. Public ridership was not indicative of cases or mortality across states in the USA; however, it is a significant factor associated with incidence (but not mortality) in NY counties. CONCLUSION: Population density was the only significant predictor of mortality across states in the USA. Lower mean age, lower median household incomes and more densely populated states were at higher risk of COVID-19 infection. Population density was not found to be a significant independent variable compared to minority status and socioeconomic factors in the New York epicenter. Meanwhile, public ridership was found to be a significant factor associated with incidence in New York counties.