Urine biomarkers of acute kidney injury and association with brain MRI abnormalities in neonatal hypoxic-ischemic encephalopathy.

OBJECTIVE: Determine whether urine biomarkers NGAL (neutrophil gelatinase-associated lipocalin), KIM-1 (kidney injury molecule 1) and IL-18 (interleukin-18) are associated with abnormal MRI findings in neonates with hypoxic-ischemic encephalopathy (HIE) who underwent therapeutic hypothermia (TH). STUDY DESIGN: Secondary analysis of a multicenter, prospective study of neonates with HIE requiring TH. Urine biomarkers were obtained at 12 and 24 h of life (HOL). Brain MRI was scored per NICHD criteria. Association between biomarkers and MRI stage was determined. RESULTS: In 57 neonates with HIE, only IL-18 at 24 HOL was significantly increased in neonates with MRI Stage 2B or greater, compared to Stage 2A or less (mean 398.7 vs. 182.9 pg/mL, p = 0.024.) A multivariate model including IL-18 at 24 HOL and 5-min Apgar performed best, with an AUC of 0.84 (SE = 0.07, p = 0.02). CONCLUSIONS: Elevated urine IL-18 at 24 HOL was associated with more severe brain MRI abnormalities among neonates with HIE.

Implementation of Guidelines Limiting Postoperative Opioid Prescribing at a Children's Hospital.

OBJECTIVES: Variability in opioid-prescribing practices after common pediatric surgical procedures at our institution prompted the development of opioid-prescribing guidelines that provided suggested dose limitations for narcotics. The aims of this study were to improve opioid prescription practices through implementation of the developed guidelines and to assess compliance and identify barriers preventing guideline utilization. METHODS: We conducted a single-center cohort study of all children who underwent the most common outpatient general surgery procedures at our institution from August 1, 2018, to February 1, 2020. We created guidelines designed to limit opioid prescription doses based on data obtained from standardized postoperative telephone interviews. Three 6-month periods were evaluated: before guideline implementation, after guideline initiation, and after addressing barriers to guideline compliance. Targeted interventions to increase compliance included modification of electronic medical record defaults and provider educations. Differences in opioid weight-based doses prescribed, filled, and taken, as well as protocol adherence between the 3 timeframes were evaluated. RESULTS: A total of 1033 children underwent an outpatient procedure during the 1.5-year time frame. Phone call response rate was 72.22%. There was a significant sustained decrease in opioid doses prescribed (P < 0.0001), prescriptions filled (P = 0.009), and opioid doses taken (P = 0.001) after implementation, without subsequent increase in reported pain on postoperative phone call (P = 0.96). Protocol compliance significantly improved (62.39% versus 83.98%, P < 0.0001) after obstacles were addressed. CONCLUSIONS: Implementation of a protocol limiting opioid prescribing after frequently performed pediatric general surgery procedures reduced opioids prescribed and taken postoperatively. Interventions that addressed barriers to application led to increased protocol compliance and sustained decreases in opioids prescribed and taken without a deleterious effect on pain control.

Comparing novel virtual reality and nursing standard care on burn wound care pain in adolescents: A randomized controlled trial.

PURPOSE: This study compared the effectiveness of age-appropriate, high technology, interactive virtual reality (VR) distraction with standard care (SC) provided by the nurse on adolescents' acute procedural pain intensity perception during burn wound care treatment in the ambulatory clinic setting. DESIGN: This randomized controlled trial included 43 adolescents ages 10-21 from the ambulatory burn clinic of a large children's hospital. METHODS: Blinded study participants were randomly assigned to either VR or SC (non-significantly different, current mean burn surface area, 1.3 and 1.7, respectively) during the first burn wound care procedure in the burn clinic. Blinded research staff collected pre-procedure data including Spielberger's State-Trait Anxiety Inventory and postprocedure wound care pain intensity using the Adolescent Pediatric Pain Tool. A total of 41 participants completed all study procedures. RESULTS: No statistically significant difference in burn wound care procedural pain was noted between the VR and SC groups after adjusting for several factors. Pre-procedure state and trait anxiety correlated with reported pre-procedure pain. Wound care pain was found to be significantly associated with pre-wound care pain score, time from original burn to clinic burn care treatment, and length of wound care treatment. These factors accounted for approximately 45% of the variation in pain scores during wound care treatment. PRACTICE IMPLICATIONS: VR distraction can be a useful pain management strategy but may not take the place of the unique nurse-patient relationship that occurs during clinical encounters. Tailoring pain management during burn wound care requires consideration of anxiety, time from the burn injury to the wound care procedure, length of time of the wound care procedure, and pretreatment pain level. Knowing patients' needs, desires, and temperaments along with the specifics about the healthcare procedures are critical to formulating individualized care plans that may or may not include VR. Newer technology, such as easier-to-use, less expensive VR, may assist with translation into practice making its clinical use more routine.

Utilization of Training Dolls to Enhance Caregiver Education for Pediatric Tracheostomy Care.

BACKGROUND: Caregivers of tracheostomized children must learn and demonstrate multiple tracheostomy care skills. At our hospital, caregiver education is provided through a combination of written instructions, classroom sessions, hands-on practice with a manikin, and bedside demonstration. As part of a quality improvement initiative, caregivers were provided a training doll to practice skills. METHODS: A training doll was provided to caregivers of children within the first week of tracheostomy placement to practice skills. Two questionnaires were utilized during the education process to evaluate utility of the training dolls, skills practiced, and confidence in performing skills. The first questionnaire was completed at the time of the classroom session and the second questionnaire after training was completed. A chart review was conducted to compare outcomes for children whose caregivers did and did not receive a training doll. RESULTS: Caregivers of 33 children with a tracheostomy received training dolls, and 28 were not provided dolls. The majority of caregivers felt the training doll was helpful for practicing skills (initial 93%, second questionnaire 85%). Some caregivers reported a lack of confidence in changing the tracheostomy tube (47%) and using a self-inflating bag (21%) in the initial questionnaire. Confidence increased for all skills in the second questionnaire. Few caregivers reported not using the training doll (initial 21%, second 11%). There were no significant differences in hospital length of stay (LOS) (P = .21) or time to complete training (P = .21) for children whose caregivers were and were not provided a doll. CONCLUSIONS: The majority of caregivers utilized the training doll to practice tracheostomy skills and found it helpful for training. The training doll did not significantly impact hospital LOS or time to complete training. Use of a training doll to practice tracheostomy skills is an additional tool to assist caregivers with learning required skills prior to discharge home.

Impact of Post-Visit Outreach on Inhaled Corticosteroid Refill Persistence in Children and Young Adults With Asthma.

BACKGROUND: Inhaled corticosteroids (ICSs) are a fundamental pillar of most regimens for long-term control of persistent asthma. Poor adherence to ICS medication is a common problem in the asthma population that can lead to poor asthma control. We hypothesized that conducting a follow-up telephone call after general pediatric clinic visits for asthma would improve refill persistence. METHODS: We conducted a prospective cohort analysis of pediatric and young adult subjects followed in our pediatric primary care clinic for asthma on ICS medication found to have poor ICS refill persistence. This cohort received a follow-up telephone outreach call 5-8 weeks after the clinic visit. The primary outcome measure was refill persistence with regard to ICS therapy. RESULTS: There were 289 subjects who met the inclusion criteria and did not meet any exclusion criteria for the study (n = 131 in the primary cohort, n = 158 in the post-COVID cohort). The mean ICS refill persistence increased significantly for subjects in the primary cohort (39.4 ± 30.8% post intervention vs 32.4 ± 19.7% pre intervention) (P = .02) but not in the post-COVID cohort (36.4 ± 25.6% post intervention vs 38.9 ± 21.0% pre intervention) (P = .26). There was not a statistically significant change in hospitalizations after the intervention in either the primary or the post-COVID cohorts (P = .08 and .07, respectively). Systemic corticosteroid courses and emergency department visits decreased significantly post intervention (P = .01 and P = .004, respectively) in the primary group but not in the post-COVID group (P = .75 and P = .16, respectively). CONCLUSIONS: These results suggest that telephone outreach after out-patient clinic visits for asthma may have short-term benefit in ICS refill persistence; however, the effect size was small.

Curriculum and Competency Evaluation in Respiratory Therapy Entry-to-Practice Programs.

BACKGROUND: Essential skills for respiratory therapists extend beyond the traditional scope of therapy. Respiratory therapists are expected to communicate effectively, deliver bedside education, and practice within interprofessional teams. Respiratory therapy entry-to-practice program accreditation standards require evaluation of student competence in communication and interprofessional practice. This study aimed to determine if entry into practice programs include curriculum and competency evaluation for oral communication, patient education, telehealth, and interprofessional activities. METHODS: The primary objective was to identify the curriculum and method of competency evaluation. The secondary objective was to compare degree programs. Directors of accredited respiratory therapy programs were invited to complete an anonymous survey with regard to degree program type, oral communication, patient education, learning strategies, telehealth, and interprofessional activities. Degree programs were classified as associate's of science 2 year, associate's of science < 2 year, or bachelor's of science. RESULTS: Of 370 invited programs, respondents in 136 programs (37%) completed the survey. Oral communication competence was evaluated by 82%. Patient education curriculum and competency evaluation were reported by 86% and 73%, respectively. Telehealth was rarely included or evaluated. Interprofessional activities were included by 74%, of whom 67% evaluated competency. Bachelor's of science programs were more likely to include a specific patient education course (P = .004), evaluate oral communication competency with unpaid preceptors (P = .036), and evaluate interprofessional competence through formal interprofessional programs (P = .005). Associate's degree 2-year programs used laboratory proficiency for patient education competency evaluation more often than other programs (P = .01). associate's of science < 2-year programs were more likely to include simulation experiences that involved motivational interviewing (P = .01). CONCLUSIONS: Differences exist among program types for curriculum and competency evaluation. Telehealth was rarely included or evaluated at any degree level. Programs should evaluate the need for enhanced patient education and telehealth instruction.

Renal oximetry for early acute kidney injury detection in neonates with hypoxic ischemic encephalopathy receiving therapeutic hypothermia.

BACKGROUND: Neonates with hypoxic ischemic encephalopathy (HIE) receiving therapeutic hypothermia are at high risk of acute kidney injury (AKI). METHODS: We performed a two-site prospective observational study from 2018 to 2019 to evaluate the utility of renal near-infrared spectroscopy (NIRS) in detecting AKI in 38 neonates with HIE receiving therapeutic hypothermia. AKI was defined by a delayed rate of serum creatinine decline (< 33% on day 3 of life, < 40% on day 5, and < 46% on day 7). Renal saturation (Rsat) and systemic oxygen saturation (SpO2) were continuously measured for the first 96 h of life (HOL). Renal fractional tissue oxygen extraction (RFTOE) was calculated as (SpO2 - Rsat)/(SpO2). Using renal NIRS, urine biomarkers, and perinatal factors, logistic regression was performed to develop a model that predicted AKI. RESULTS: AKI occurred in 20 of 38 neonates (53%). During the first 96 HOL, Rsat was higher, and RFTOE was lower in the AKI group vs. the no AKI group (P < 0.001). Rsat > 70% had a fair predictive performance for AKI at 48-84 HOL (AUC 0.71-0.79). RFTOE ≤ 25 had a good predictive performance for AKI at 42-66 HOL (AUC 0.8-0.83). The final statistical model with the best fit to predict AKI (AUC = 0.88) included RFTOE at 48 HOL (P = 0.012) and pH of the infants' first postnatal blood gas (P = 0.025). CONCLUSIONS: Lower RFTOE on renal NIRS and pH on infant first blood gas may be early predictors for AKI in neonates with HIE receiving therapeutic hypothermia. A higher resolution version of the Graphical abstract is available as Supplementary information.

The Sepsis Bundle Effect: An Evaluation of Culture Results and Utilization in Pediatric Appendicitis.

INTRODUCTION: Sepsis prevention pathways, which often include blood and urine cultures, are common in children's hospitals. Fever and tachycardia, signs often seen in patients with appendicitis, frequently trigger these pathways. We hypothesized that cultures were frequently obtained in children with appendicitis. MATERIALS AND METHODS: We conducted a single-center retrospective cohort study evaluating children with image-confirmed appendicitis from 4/1/2019 to 10/1/2020, coinciding with the initiation of sepsis prevention pathways. Factors associated with culture acquisition, as well as culture results, treatment, and outcomes were evaluated. RESULTS: Six hundred and fifty eight children presented with acute appendicitis during the 1.5-year period, with a median age of 10.67 years (interquartile range (IQR) 8.17-14.08). Cultures were obtained in 22.9%, including blood culture (BCx) in 8.1% and urine culture (UCx) in 17.9%. Culture acquisition decreased by 17.6% after sepsis protocol initiation. Blood culture acquisition correlated with fever (P = .003) and younger age (P = .03), whereas the attainment of BCx and UCx was associated with female sex (P = .04, P < .0001), complicated appendicitis (P = .0001, P = .03), and unknown diagnosis (P < .0001, P < .0001). There were five positive UCx (4.24%); however, all remained asymptomatic despite a short antibiotic duration dictated by institutional appendicitis protocol. The one positive BCx (1.89%) was suspected contamination and not treated. DISCUSSION: The findings of this cohort suggest a low incidence of positive culture as well as lack of impact on clinical management in image-proven appendicitis and the initiation of a sepsis bundle without automatic culture acquisition may result in decreased culture attainment.

Positive Airway Pressure Device Care and Cleaning Practices in the Pediatric Home.

BACKGROUND: Regular care and cleaning of positive airway pressure (PAP) devices are important for maintaining equipment in the home. Illness and hospitalization have occurred from inadequate cleaning and use of tap water in the humidifier. In recent years, ozone and ultraviolent-light disinfection devices have been advertised for cleaning home PAP equipment. Our clinic provides instructions; however, cleaning practices performed in the home are unknown. METHODS: A survey of home cleaning practices for PAP equipment was conducted in a pediatric sleep clinic during 2019-2020. Survey domains were method, cleaning and replacement frequency for each component, type of water used, instruction preferences, and demographics. The primary aim was to identify home PAP cleaning practices and compare with provided instructions. The secondary aim was to determine if respiratory-related symptoms (eg, congestion, runny nose, sneezing, coughing) occurred or increased with PAP use or inadequate cleaning. RESULTS: The survey was completed by 96 respondents. Most reported weekly cleaning of mask (36, 38%), tubing (41, 43%), and humidifier (31, 33%) with soap and water as the primary method for each. The majority used distilled water in the humidifier (74, 77%) and reported respiratory symptoms did not occur with PAP use (64, 67%). Very few indicated a device was used to clean equipment. No associations were found between length of time for PAP use and cleaning practices. There was a moderately low correlation between age and cleaning. Increased age was associated with decreased cleaning frequency (r = 0.20, P = .048). CONCLUSIONS: Care and cleaning practices of home PAP equipment varied from instructions provided in clinic. Most reported at least weekly cleaning of items for which daily cleaning is recommended. Few reported using a device for cleaning or having respiratory symptoms from PAP treatment.

Mortality among infants of diabetic mothers with hypertrophic cardiomyopathy.

OBJECTIVE: To assess the association between hypertrophic cardiomyopathy (HCM) and mortality among infants of diabetic mothers (IDMs). METHODS: We performed a retrospective cohort study of hospitalized IDMs admitted at ≤14-days-old in the Pediatric Health Information System (years 2004 - 2019). Multivariable logistic regression was used to evaluate the association between HCM and mortality; covariates in the model were prematurity, sex, and congenital malformations of the cardiovascular, nervous, urinary and musculoskeletal systems. RESULTS: Among 32,993 IDMs, there were 203 (0.6%) with HCM. Black and Hispanic children were disproportionately represented among children with HCM compared to those without HCM (23.2 vs. 14.9%, p = .001 for Black, and 30.0 vs. 22.1%, p = .007 for Hispanic). IDMs with HCM were also larger at birth (median birth weight 4120 g [interquartile range 3600-4703] vs. 3270 g [interquartile range 2535-3910]; p < .001). In-hospital mortality in patients with HCM was greater than in those without HCM (4.9 vs. 1.3%, p < 0.001), and odds of mortality were greater among those with HCM (adjusted odds ratio 2.10, 95% confidence interval: 1.04-4.25; p = .038). CONCLUSION: We identify HCM as a contributor to in-hospital mortality. These data reinforce the need for more specific diagnostic criteria, better prevention of maternal diabetes, and effective therapies for HCM in IDMs.

Circulating long-chain acylcarnitine concentrations are not affected by exercise training in pregnant women with obesity.

The purpose of this study was to determine the effect of exercise during pregnancy in sedentary women with obesity on longitudinal changes in long-chain acylcarnitine (LC-AC) concentrations. We hypothesized that exercise training would significantly decrease circulating LC-ACs throughout gestation compared with a nonexercise control group. Pregnant women with obesity considered otherwise healthy [n = 80, means ± SD; body mass index (BMI): 36.9 ± 5.7 kg/m2] were randomized into an exercise (n = 40, aerobic/resistance 3 times/wk, ∼13th gestation week until birth) or a nonexercise control (n = 40) group. At gestation week 12.2 ± 0.5 and 36.0 ± 0.4, a submaximal exercise test was conducted, and indirect calorimetry was used to measure relative resting energy expenditure (REE), as well as respiratory exchange ratio (RER) at rest. Fasting blood samples were collected and analyzed for LC-AC concentrations. Fitness improved with prenatal exercise training; however, exercise training did not affect circulating LC-AC. When groups were collapsed, LC-ACs decreased during gestation (combined groups, P < 0.001), whereas REE (kcal/kg/day, P = 0.008) increased. However, average REE relative to fat-free mass (FFM) (kcal/kg FFM/day) and RER did not change. There was an inverse relationship between the change in RER and all LC-ACs (except C18:2) throughout gestation (C14: r = -0.26, P = 0.04; C16: r = -0.27, P = 0.03; C18:1: r = -0.28, P = 0.02). In summary, a moderate-intensity exercise intervention during pregnancy in women with obesity did not alter LC-ACs concentrations versus control, indicating that the balance between long-chain fatty acid availability and oxidation neither improved nor worsened with an exercise intervention.NEW & NOTEWORTHY This research showed that a moderate-intensity prenatal exercise program, consisting of aerobic and resistance training, did not negatively impact normal alterations in substrate supply and demand for the mother and the offspring throughout gestation. Findings provide support for metabolic safety of exercise during pregnancy.

Outcomes of Pediatric Titration Sleep Studies Following Empirical Use of Positive Airway Pressure and the Effect on Adherence to Therapy.

BACKGROUND: Obstructive sleep apnea (OSA) is diagnosed through polysomnography (PSG) testing and commonly treated with positive airway pressure (PAP). The initial recommended treatment for pediatric OSA is adenotonsillectomy, but when this is contraindicated or ineffective, PAP is the next option. Children followed in our pediatric sleep disorders center who are diagnosed with OSA and meet criteria for therapy are empirically prescribed a PAP device, usually auto-titrating PAP (APAP), to avoid delays in therapy. Titration PSG is performed later to assess adequacy of settings. The aims of this study were to determine how often PSG titration results in changes to empirically prescribed PAP and to assess adherence to therapy before and after PSG titration. METHODS: A retrospective medical records review was completed for children diagnosed with OSA, prescribed PAP, and had a titration PSG within a 5-y consecutive period of 2008-2012. Demographic data, type of device, pressure settings, and adherence downloads were reviewed. Adherence was assessed before and after titration overall and compared for those who did and did not have therapy changes following titration. RESULTS: The study included 121 participants. Median age at the time of the diagnostic PSG was 11 (interquartile range [IQR] 8-14) y. Most (106, 88%) were initially prescribed APAP. Median length of time between initial and follow-up PSG was 6.4 (IQR 4.4-10.1) months. The majority (94, 78%) had therapy changes following titration. Overall, adherence percentage > 4 h per night was not significantly increased post titration (P = .47). There were no statistically significant differences in adherence between those who had therapy changes and those who did not (P = .26). CONCLUSIONS: Titration studies resulted in therapy modifications for most children. Adherence was not increased following the titration PSG. Changes in therapy did not result in increased adherence. Titration PSGs may optimize empirically prescribed settings.

Urine Biomarkers for the Assessment of Acute Kidney Injury in Neonates with Hypoxic Ischemic Encephalopathy Receiving Therapeutic Hypothermia.

OBJECTIVE: To evaluate the predictive performance of urine biomarkers for acute kidney injury (AKI) in neonates with hypoxic ischemic encephalopathy (HIE) receiving therapeutic hypothermia. STUDY DESIGN: We performed a multicenter prospective observational study of 64 neonates. Urine specimens were obtained at 12, 24, 48, and 72 hours of life and evaluated for neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), cystatin C, interleukin-18 (IL-18), tissue inhibitor of metalloproteinases 2 (TIMP2), and insulin-like growth factor-binding protein 7 (IGFBP7). Logistic regression models with receiver operating characteristics for area under the curve (AUC) were used to assess associations with neonatal modified KDIGO (Kidney Disease: Improving Global Outcomes) AKI criteria. RESULTS: AKI occurred in 16 of 64 infants (25%). Neonates with AKI had more days of vasopressor drug use compared with those without AKI (median [IQR], 2 [0-5] days vs 0 [0-2] days; P = .026). Mortality was greater in neonates with AKI (25% vs 2%; P = .012). Although NGAL, KIM-1, and IL-18 were significantly associated with AKI, the AUCs yielded only a fair prediction. KIM-1 had the best predictive performance across time points, with an AUC (SE) of 0.79 (0.11) at 48 hours of life. NGAL and IL-18 had AUCs (SE) of 0.78 (0.09) and 0.73 (0.10), respectively, at 48 hours of life. CONCLUSIONS: Urine NGAL, KIM-1, and IL-18 levels were elevated in neonates with HIE receiving therapeutic hypothermia who developed AKI. However, wide variability and unclear cutoff levels make their clinical utility unclear.

Practices and Perceptions of Face Mask Use in a Pediatric Health System During the COVID-19 Pandemic.

BACKGROUND: Face coverings are recommended to help mitigate the spread of COVID-19. Guidelines regarding face mask use have evolved from the time when COVID-19 first emerged. Practices for face mask use in the United States vary widely. METHODS: Clinical and nonclinical staff from a pediatric health care system were invited to complete a survey regarding perceptions and practices of face mask use during the COVID-19 pandemic. Overall results were analyzed, and subgroup analyses were conducted to compare clinical and nonclinical staff, and clinical staff who do and do not provide direct patient care. RESULTS: The response rate was approximately 24% (1,128 of 4,698). Most respondents were clinical staff who provide patient care. A surgical/procedure mask was most often worn for patient care by 72% (P < .001). Most respondents (70%) reported wearing a cloth mask when not in the hospital (P < .001). Cloth masks were worn for a mean of 3.4 ± 3.9 d before washing. Frequent hand hygiene before putting on the mask, before removing, and after removing was reported as 56%, 44%, and 62%, respectively. The most common challenges reported were glasses fogging (69%), skin irritations (45%), and headaches (31%). Qualitative data revealed themes of feeling unsafe, beliefs and practices about COVID-19 and masks, mandates and enforcement of wearing masks, availability of personal protective equipment, and care delivery challenges. CONCLUSIONS: Practices and perceptions of face masks varied among staff in a pediatric health care system. Some staff did not feel that masks are effective in preventing virus spread, and others did not feel safe in performing job duties. Hand hygiene for mask handling was not practiced consistently. A large number of staff reported having experienced challenges or health issues when wearing a mask. Clinical staff who provide direct patient care reported more issues than both nonclinical and clinical staff who do not provide care.

Exercise training and diet-induced weight loss increase markers of hepatic bile acid (BA) synthesis and reduce serum total BA concentrations in obese women.

Regular exercise has profound metabolic influence on the liver, but effects on bile acid (BA) metabolism are less well known. BAs are synthesized exclusively in the liver from cholesterol via the rate-limiting enzyme cholesterol 7 alpha-hydroxylase (CYP7A1). BAs contribute to the solubilization and absorption of lipids and serve as important signaling molecules, capable of systemic endocrine function. Circulating BAs increase with obesity and insulin resistance, but effects following exercise and diet-induced weight loss are unknown. To test if improvements in fitness and weight loss as a result of exercise training enhance BA metabolism, we measured serum concentrations of total BAs (conjugated and unconjugated primary and secondary BAs) in sedentary, obese, insulin-resistant women (N = 11) before (PRE) and after (POST) a ∼14-wk exercise and diet-induced weight loss intervention. BAs were measured in serum collected after an overnight fast and during an oral glucose tolerance test (OGTT). Serum fibroblast growth factor 19 (FGF19; a regulator of BA synthesis) and 7-alpha-hydroxy-cholesten-3-one (C4, a marker of CYP7A1 enzymatic activity) also were measured. Using linear mixed-model analyses and the change in V̇O2peak (mL/min/kg) as a covariate, we observed that exercise and weight loss intervention decreased total fasting serum BA by ∼30% (P = 0.001) and increased fasting serum C4 concentrations by 55% (P = 0.004). C4 was significantly correlated with serum total BAs only in the POST condition, whereas serum FGF19 was unchanged. These data indicate that a fitness and weight loss intervention modifies BA metabolism in obese women and suggest that improved metabolic health associates with higher postabsorptive (fasting) BA synthesis. Furthermore, pre- vs. postintervention patterns of serum C4 following an OGTT support the hypothesis that responsiveness of BA synthesis to postprandial inhibition is improved after exercise and weight loss.NEW & NOTEWORTHY Exercise and weight loss in previously sedentary, insulin-resistant women facilitates a significant improvement in insulin sensitivity and fitness that may be linked to changes in bile acid metabolism. Diet-induced weight loss plus exercise-induced increases in fitness promote greater postabsorptive bile acid synthesis while also sensitizing the bile acid metabolic system to feedback inhibition during a glucose challenge when glucose and insulin are elevated.

Impact of Perioperative Tachydysrhythmias on Mortality and Length of Stay in Complete Repair of Tetralogy of Fallot: A Multicenter Retrospective Cohort Study from the Pediatric Health Information System.

INTRODUCTION: Tachydysrhythmias (TDS) frequently occur after complete repair of tetralogy of Fallot (TOF). However, not much is known about the effect of TDS on morbidity and mortality after TOF repair. We sought to assess the associations between TDS and mortality and morbidity after repair of TOF using a multicentre database. MATERIALS AND METHODS: We identified all children aged 0-5 years in the Pediatric Health Information System who underwent TOF repair between 2004 and 2015. Codes for TDS were used to identify cases. Outcome variables were inpatient mortality and total length of stay (LOS). Univariate and multiple logistic and linear regression analyses were used to identify the effects of multiple risk factors, including TDS, on mortality and LOS. RESULTS: A total of 7,749 patients met inclusion criteria, of which 1,493 (19%) had codes for TDS. There was no association between TDS and inpatient mortality. However, TDS were associated with 1.1 days longer LOS and accounted for 2% of the variation observed in LOS. CONCLUSION: After complete repair of TOF, TDS were not associated with mortality and appeared to have only a modest effect on LOS.

Markers of branched-chain amino acid catabolism are not affected by exercise training in pregnant women with obesity.

Despite the role of branched-chain amino acids (BCAAs) in physiological processes such as nutrient signaling and protein synthesis, there is ongoing debate about the link between circulating BCAAs and insulin resistance (IR) in various populations. In healthy women, IR mildly increases during pregnancy, whereas both BCAAs and markers of BCAA catabolism decrease, indicating that fetal growth is being prioritized. Exercise reduces IR in nonpregnant adults, but less is known about the effect of exercise during pregnancy in women with obesity on IR and BCAA breakdown. The aim of this study was to determine the effect of a moderate-intensity exercise intervention during pregnancy on maternal circulating BCAAs and markers of BCAA catabolism [short-chain acylcarnitines (ACs)], and their associations with IR. Healthy obese [n = 80, means ± SD; body mass index (BMI): 36.9 ± 5.7 kg/m2] pregnant women were randomized into an exercise (n = 40, aerobic/resistance 3×/wk, ∼13th gestation week until birth) or a nonexercise control (n = 40) group. Blood was collected at 12.2 ± 0.5 and 36.0 ± 0.4 gestation weeks and analyzed for BCAA-derived acylcarnitine concentrations as markers of BCAA breakdown toward oxidative pathways, and glucose and insulin concentrations [updated homeostatic model assessment of IR (HOMA2-IR)]. After adjusting for HOMA2-IR, there were no interaction effects of group by time. In addition, there was a main positive effect of time on HOMA2-IR (12 wk: 2.3 ± 0.2, 36 wk: 3.0 ± 0.2, P = 0.003). A moderate-intensity exercise intervention during pregnancy in women with obesity was not associated with changes in BCAA-derived ACs versus standard of care. The decrease in BCAA-derived ACs throughout gestation could not be explained by IR.NEW & NOTEWORTHY This research showed an increase in insulin resistance (IR) and decrease in branched-chain amino acid catabolism throughout gestation in women with obesity, and addition of a moderate exercise intervention (known to attenuate IR in nonpregnant populations) did not alter these shifts. Findings provide support for metabolic safety of exercise during pregnancy.

Analyzing coagulation dynamics during treatment of vascular malformations with thromboelastography.

BACKGROUND/OBJECTIVES: Slow-flow vascular malformations are abnormal vessels that can lead to activation and consumption of coagulation factors and thrombosis, known as localized intravascular coagulopathy (LIC). Most clinical and research evidence of vascular malformation hemostasis relies on conventional coagulation studies, which may not provide a complete picture. Thromboelastograpy (TEG) is a tool that can provide real-time assessment of a patient's coagulation dynamics, and may allow for a more individualized treatment approach. We hypothesized that patients with slow-flow vascular malformations will have changes in TEG parameters peri-procedure that will help predict blood product or medication administration. DESIGN/METHODS: Institutional Review Board approved prospective study of patients with slow-flow vascular malformations undergoing a sedated, minor procedure. TEG and conventional coagulation studies were obtained preprocedure, 15 min, and when possible, at 30 min after the start of the procedure. RESULTS: Twenty-five patients were enrolled. Median age was 15 years (range 3-47 years). Procedures included laser and/or sclerotherapy. There were no changes in TEG parameters from baseline to 15 min or 30 min. The following decreased from baseline to 15 min: fibrinogen 313 to 287 mg/dL (P = .001), D-dimer 1.3 to 1.1 mg/L (P = .02), hemoglobin 12.8 to 11.8 g/dL (P = .001), and platelet count 272 000 to 256 000 (P = .006). No patient had a bleeding/thrombotic complication during or within 1 week postprocedure. CONCLUSION: We saw no change in TEG parameters or bleeding or clotting complications despite significant numerical changes in conventional coagulation profiles, suggesting that conventional studies may not be as useful in determining risks of bleeding or thrombotic complications peri-procedure for minor procedures.

Transition From an ICU Ventilator to a Portable Home Ventilator in Children.

BACKGROUND: The transition from an ICU ventilator to a portable home ventilator (PHV) for children requiring long-term mechanical ventilation is a crucial step in preparing for discharge home and may not be successful on the first attempt. A review of this process at our institution revealed that some children required multiple trials before they were able to tolerate a PHV. A protocol was developed to standardize the transition process and reduce the number of failed attempts. Key features of the protocol included a transition readiness assessment and criteria for changing to the PHV. METHODS: A retrospective chart review was completed to evaluate the process of changing to a PHV before and after the protocol was in place during the time period of 2011-2018. Primary outcome measures included the number of transition attempts and the length of time to achieve successful transition. A successful transition attempt was defined as the ability to tolerate a PHV for 14 d. RESULTS: The study included 56 children ≤ 3 y old with a tracheostomy who required long-term ventilator support. The majority of subjects were from the neonatal ICU and had a diagnosis of bronchopulmonary dysplasia. There was a significant decrease in the number of attempts (P = .005) and in the length of time (P = .01) to successfully transition to a PHV for those who underwent the protocol. CONCLUSIONS: The process of changing from an ICU ventilator to a PHV in children requiring long-term mechanical ventilation was improved through the use of a standardized protocol. Both the number of failed attempts and the length of time to achieve successful transition were reduced when the protocol was applied. Further study is needed to evaluate other medical and nonmedical factors that may affect successful transition to a PHV.

Gastrostomy and Tracheostomy After Complete Repair of Tetralogy of Fallot in Children With 22q11.2 Deletion Syndrome.

OBJECTIVES: Caring for a child with gastrostomy and/or tracheostomy can cause measurable parental stress. It is generally known that children with 22q11.2 deletion syndrome are at greater risk of requiring gastrostomy or tracheostomy after heart surgery, although the magnitude of that risk after complete repair of tetralogy of Fallot has not been described. We sought to determine the degree to which 22q11.2 deletion is associated with postoperative gastrostomy and/or tracheostomy after repair of tetralogy of Fallot. DESIGN: Retrospective cohort study. SETTING: Pediatric Health Information System. PATIENTS: Children undergoing complete repair of tetralogy of Fallot (ventricular septal defect closure and relief of right ventricular outflow tract obstruction) from 2003 to 2016. Patients were excluded if they had pulmonary atresia, other congenital heart defects, and/or genetic diagnoses other than 22q11.2 deletion. MEASUREMENTS AND MAIN RESULTS: Two groups were formed on the basis of 22q11.2 deletion status. Outcomes were postoperative tracheostomy and postoperative gastrostomy. Bivariate analysis and Kaplan-Meier analysis at 150 days postoperatively were performed. There were 4,800 patients, of which 317 (7%) had a code for 22q11.2 deletion. There were no significant differences between groups for age at surgery or sex. Patients with 22q11.2 deletion had significantly higher rates of gastrostomy (18% vs 5%; p < 0.001) and higher rates of tracheostomy (7% vs 1%; p < 0.001); there was no difference for mortality. Kaplan-Meier analyses also showed higher rates of gastrostomy (p = 0.024) and tracheostomy (p = 0.037). CONCLUSIONS: The present study establishes rates of postoperative gastrostomy and tracheostomy in children with 22q11.2 deletion after complete repair of tetralogy of Fallot. These data are useful to clinicians for providing families with preoperative counseling.