A Provider-Focused Intervention to Increase Universal HIV Testing among Adolescents in School-Based Health Centers.

We describe a provider-focused intervention to increase universal HIV testing among adolescent users in a network of School-Based Health Centers (SBHC) and compare the rate of HIV test offer and acceptance for SBHCs with and without the HIV testing intervention. The intervention was implemented at the six largest SBHCs in the 12-site network and included system- and staff-level initiatives, including an implementation coach to support SBHC associates. Rates of HIV test offer and acceptance at six sites in the Intervention Cohort were compared to that at the six sites in a Non-Intervention Cohort which was not randomly selected but had comparable distributions by age, gender and race/ethnicity. The model showed an intervention effect for universal HIV test offer, but no overall effect for test acceptance. Analyzing the intervention effect by whether a patient had a history of sexual activity, the intervention was very effective early in its implementation at increasing test offer to those with no history of sexual activity, and late in its implementation at increasing test acceptance for those with no or unknown sexual activity. Increasing and sustaining universal HIV testing in SBHCs may benefit from using Implementation Science frameworks to guide adaptation of the intervention.

Relationships of race and area deprivation indices to outcomes in pediatric patients with inflammatory bowel disease.

OBJECTIVES: Social determinants of health (SDOH) are nonmedical factors that influence health outcomes. Children with chronic illnesses living with socioeconomic risk factors have higher rates of unfavorable health outcomes. Our study aimed to assess the association between area deprivation indices (ADI), as a proxy for SDOH, and outcomes in pediatric patients with inflammatory bowel disease (IBD). METHODS: A retrospective chart review was conducted on 134 pediatric patients with IBD, ages 0-21 years. Explanatory variables were the patient's ADI and demographics. Outcomes were assessed from time of diagnosis over a 1-year follow-up period. The primary outcome was the ratio of missed to completed appointments; secondary outcomes were the numbers of IBD-related emergency department (ED) visits and IBD-related hospitalizations. RESULTS: Race/ethnicity was significantly associated with ADI (p < 0.001). In a multivariable regression model, no variables were associated with ratio of missed to completed appointments. Notably, ADI was not significantly associated with the ratio of missed to completed appointments. In a Poisson regression, Black (non-Hispanic) and Hispanic race/ethnicity, Medicaid insurance, female gender, and lower age were significantly associated with more IBD-related ED visits; ADI was not. In a similar model, Black (non-Hispanic) race, Medicaid insurance status, and lower age were significantly associated with more IBD-related hospitalizations; ADI was not. CONCLUSIONS: In our cohort, ADI was not significantly associated with the ratio of missed to completed appointments, IBD-related ED visits, and IBD-related hospitalizations; however, race/ethnicity, age at diagnosis, insurance, and gender were associated with these outcomes.

Prevalence and Factors Associated With Mycoplasma genitalium Infection in At-Risk Female Adolescents in Bronx County, New York.

BACKGROUND: Mycoplasma genitalium infection can adversely affect female reproductive health, but data are limited about prevalence and characteristics of the infection in female adolescents. We employed a sensitive assay to detect M. genitalium infection, and we describe its characteristics in a clinical sample of women younger than 21 years. METHODS: We recruited females aged 13 to 20 years in children's hospital clinics whose clinicians were testing for chlamydia/gonorrhea. Participants completed a questionnaire providing demographics, sexual history, and current symptoms. Urine/endocervical samples were tested for chlamydia/gonorrhea and partitioned for M. genitalium testing using Aptima M. genitalium assay. We reviewed records for the clinic visit to document examination, diagnosis, and results of sexually transmitted infection (STI) testing. We compared prevalence of M. genitalium infection by demographics, sexual history, symptoms, and signs. RESULTS: Of 153 participants mean age 18.07 ± 1.68 years, 58% self-identified as Hispanic, 27% Black, 64% straight/heterosexual, 27% bisexual, 1% gay/lesbian, 29% reported a prior STI diagnosis. Prevalence of M. genitalium was 11.1% (17/153), 13 of 17 were asymptomatic, 2 of 17 had pelvic inflammatory disease (PID), 3 of 17 coinfected with chlamydia or gonorrhea. Prevalence of chlamydia was 6.6% and of gonorrhea 2.6%. A logistic regression model indicated independent associations of bisexual orientation versus all other orientations (adjusted odds ratio [aOR], 4.80; 95% confidence interval [CI], 1.38-16.67), self-reported prior STI (aOR, 3.83; 95% CI, 1.10-13.37), and self-reported prior PID (aOR, 9.12; 95% CI, 1.02-81.72) with higher odds of M. genitalium infection. CONCLUSIONS: Findings suggest that in at-risk female populations younger than 21 years, M. genitalium is a prevalent STI and symptomatic adolescents may warrant testing and treatment. Further study of harms and benefits of testing asymptomatic bisexual female adolescents or those with prior STI/PID is needed.

Childhood asthma in the Bronx, NY; the impact of pollutants on length of hospital stay.

OBJECTIVE: The length of hospital stay (LOS) is a proxy of asthma exacerbation severity and healthcare cost. The study aims to estimate the effect of ambient air pollution on pediatric asthma LOS in the Bronx, NY. METHODS: A total of 1,920 children admitted to the hospital in Bronx, NY due to asthma during 2017-2019 period were included in the study. Demographic and clinical parameters were obtained from medical records. Daily ozone (O3) and fine particulate matter (PM2.5) measurements were obtained from local air quality networks. Poisson regression adjusting for gender, age, weight status, respiratory infections including influenza, and ambient temperature was applied to determine whether there was an association of air pollution with length of hospital stay. RESULTS: The mean LOS varied by age, sex, weight status, influenza vaccination status, respiratory viral panel (RVP) results, asthma controller use, and asthma classification. After controlling for these factors in Poisson regression, the mean LOS increased up to 10.62% (95%CI: 0.78-21.41; p = 0.03) for an increase of 10 µg/m3 of PM2.5 exposure on admission day, and 3.90% (95%CI = 0.06-7.88; p = 0.05) for an increase of 10 ppbv of O3 concentration during the previous day. CONCLUSION: Ambient particulate and ozone pollution is associated with lengthier hospital stays for pediatric asthma, potentially indicating more severe asthma exacerbations.

Decreasing the Newborn Birth Hospitalization Length of Stay.

OBJECTIVES: This study aimed to determine our ability to shorten birth hospitalization length of stay (LOS) in which patient characteristics were associated with early discharge and had effects on early newborn readmission rate. STUDY DESIGN: Retrospective chart review of births from April 1, 2020 to December 31, 2020, was considered for this study. Delivery mode and maternal and newborn characteristics were evaluated for effect on discharge timing. Hospital readmissions within 7 days of discharge were reviewed. RESULTS: In total, 845 out of 1,077 total live births were included in the study population. Five hundred and eighty-nine (69.7%) newborns were discharged early (<48 hours after vaginal delivery [VD] and <72 hours after cesarean delivery [CS]). Factors associated with early discharge included 79.8% CS (p < 0.001), 84% birth after 2 p.m. (p < 0.001), 71.2% no diagnosis of maternal diabetes (p = 0.02), and 70.6% negative maternal coronavirus disease 2019 (p = 0.01). The overall 7-day readmission rate was 1.2 and 0.5% for newborns discharged early after VD. CONCLUSION: Most newborns can be discharged early without increasing newborn readmission. KEY POINTS: · Most patients were discharged <72 hours after CS.. · Most patients were discharged <48 hours after VD.. · Early discharge does not affect newborn readmissions..

Impact of Z score system on the management of coronary artery lesions in Kawasaki disease.

BACKGROUND: Coronary artery aneurysms are well-described in Kawasaki disease and the Multisystem Inflammatory Syndrome in Children and are graded using Z scores. Three Z score systems (Boston, Montreal, and DC) are widely used in North America. The recent Pediatric Heart Network Z score system is derived from the largest diverse sample to-date. The impact of Z score system on the rate of coronary dilation and management was assessed in a large real-world dataset. METHODS: Using a combined dataset of patients with acute Kawasaki disease from the Children's Hospital at Montefiore and the National Heart, Lung, and Blood Institute Kawasaki Disease Study, coronary Z scores and the rate of coronary lesions (Z ≥ 2.0) and aneurysms (Z ≥ 2.5) were determined using four Z score systems. Agreement among Z scores and the effect on Kawasaki management were assessed. RESULTS: Of 333 patients analysed, 136 were from Montefiore and 197 from the Kawasaki Disease Study. Age, sex, body surface area, and rate of coronary lesions did not differ between the samples. Among the four Z score systems, the rate of acute coronary lesions varied from 24 to 55%. The mean left anterior descending Z scores from Pediatric Heart Network and Boston had a large uniform discrepancy of 1.3. Differences in Z scores among the four systems may change anticoagulation management in up to 22% of a Kawasaki population. CONCLUSIONS: Choice of Z score system alone may impact Kawasaki disease diagnosis and management. Further research is necessary to determine the ideal coronary Z score system.

Modified DIVA Score: An Improved Clinical Predictive Tool for Detecting Difficult Access in Children.

OBJECTIVE: This study aims to validate the DIVA (Difficult Intravenous Access) score in our population and to identify any additional patient characteristics that may be associated with difficult access in children. METHODS: This was a cross-sectional study in an urban quaternary pediatric emergency department with patients younger than 21 years and Emergency Severity Index ≥2 who require intravenous (IV) access for their management. In addition to patient characteristics comprising the DIVA score, data were collected on patient "history of difficult access," hydration status, skin shade, history of sickle cell disease or diabetes, technology dependence, and body mass index. The number of IV cannulation attempts and total time taken were recorded for each patient. "Difficult access" was defined as ≥2 or more attempts or time >30 minutes to achieve successful IV cannulation. RESULTS: A convenience sample of 300 pediatric patients was enrolled. The DIVA score had a sensitivity of 51% (95% confidence interval [CI], 40.8%-61.14%) and a specificity of 82.99% (95% CI, 76.95%-87.99%) for predicting "difficult access" in our population. Among all patient characteristics examined in this study, only "history of difficult access" improved the identification of "difficult access" patients. The "history of difficult access" variable had a sensitivity of 61% (95% CI, 50.7%-70.6%) and a specificity of 75.7% (95% 95% CI, 69.12%-81.62%) in predicting "difficult access." With the addition of "history of difficult access" to the original DIVA score, we developed a "modified DIVA score (m-DIVA)." The m-DIVA score had a sensitivity of 78% (95% CI, 68.6%-85.6%) and specificity of 67% (95% CI, 59.9%-73.58%), representing a 52.9% improvement in correctly identifying "difficult access" patients over the original DIVA score. CONCLUSIONS: The m-DIVA score, which incorporates prior history, increases the screening test's sensitivity in identifying "difficult access" patients and should be further investigated as clinical tool.

Children and young adults hospitalized for severe COVID-19 exhibit thrombotic coagulopathy.

We report the clinical and laboratory coagulation characteristics of 27 pediatric and young adult patients (2 months to 21 years) treated for symptomatic COVID-19 at a children's hospital in the Bronx, New York, between March 1 and May 31, 2020. D-Dimer was > 0.5 µg/mL (upper limit of normal) in 25 (93%) patients at admission; 11 (41%) developed peak D-dimer > 5 µg/mL during admission. Seven (26%) patients developed venous thromboembolism: three with deep vein thrombosis and four with pulmonary embolism. Requirement of increased ventilatory support was a risk factor for thrombosis (P = 0.006). Three of eight (38%) patients on prophylactic anticoagulation developed thrombosis; however, no patients developed VTE on low-molecular-weight heparin prophylaxis titrated to anti-Xa level. Manifestation of COVID-19 disease was severe or critical in 16 (59%) patients. Four (15%) patients died of COVID-19 complications: all had comorbidities. Elevated D-dimer and increased VTE rate were observed in this young cohort, particularly in those with severe respiratory complications, suggesting thrombotic coagulopathy. More data are needed to guide thromboprophylaxis in this age group.

Children and Adolescents with Disabilities and Exposure to Disasters, Terrorism, and the COVID-19 Pandemic: a Scoping Review.

PURPOSE OF REVIEW: This paper reviews the empirical literature on exposures to disaster or terrorism and their impacts on the health and well-being of children with disabilities and their families since the last published update in 2017. We also review the literature on studies examining the mental health and functioning of children with disabilities during the COVID-19 pandemic. RECENT FINDINGS: Few studies have examined the effects of disaster or terrorism on children with disabilities. Research shows that children with disabilities and their families have higher levels of disaster exposure, lower levels of disaster preparedness, and less recovery support due to longstanding discriminatory practices. Similarly, many reports of the COVID-19 pandemic have documented its negative and disproportionate impacts on children with disabilities and their families. In the setting of climate change, environmental disasters are expected to increase in frequency and severity. Future studies identifying mitigating factors to disasters, including COVID-19; increasing preparedness on an individual, community, and global level; and evaluating post-disaster trauma-informed treatment practices are imperative to support the health and well-being of children with disabilities and their families.

Fitz-Hugh-Curtis syndrome in adolescent and young adult females: Utility of a decision rule.

BACKGROUND: The diagnosis of Fitz-Hugh-Curtis syndrome (FHC) is often missed or delayed in patients with right upper quadrant pain (RUQ). OBJECTIVE: To develop a decision rule that predicts FHC in females with RUQ pain based on a constellation of historical features, physical examination findings and laboratory results. METHODS: We conducted a prospective study to test the utility of our FHC decision rule in sexually active females, aged 13-20 years, with RUQ pain who were seen in an urban ED over 57 months. The decision rule was based on 4 features: 1. Presence of pleuritic chest pain, 2. Tenderness over the anterior border of liver, 3. History of worsening pain on R lateral position and 4. An erythrocyte sedimentation rate > 30 mm/h. The rule was considered positive if all 4 features were present. FHC was diagnosed in patients with RUQ pain and a positive GEN-PROBE Aptima Combo Assay for either gonorrhea or chlamydia on urine or endocervical specimens. RESULTS: 130 patients were enrolled. 24 were excluded, leaving 106 (81.5%) for analysis. 34/106 (32%) had STI/FHC. There were no differences in mean age or sexual characteristics between those with and without STI/FHC. A positive FHC decision rule had a positive predictive value of 75% (95%CI: 46.8%-91.1%) based on 96 cases for whom all features were available for analysis. CONCLUSION: Our decision rule shows promise in allowing for the early identification of FHC in adolescent and young adult females. Additional study is needed to corroborate these findings and test its generalizability.

The ongoing impact of COVID-19 on asthma and pediatric emergency health-seeking behavior in the Bronx, an epicenter.

BACKGROUND: The Bronx has the highest prevalence of asthma in the United States (US), and was also an early COVID-19 epicenter, making it a unique study location. Worldwide reports describe significant declines in pediatric emergency department (PED) visits during COVID-19. The ongoing impact of COVID-19 on all PED presentations, including asthma, at an early epicenter has not been studied beyond the pandemic peak and into the early phases of state re-opening. OBJECTIVES: To compare PED health-seeking behaviors and clinical characteristics during the 2020 pandemic and subsequent initial New York State (NYS) phased re-opening to the same period in 2019. METHODS: Retrospective chart review of children <21 years utilizing the PED at a high-volume quaternary children's hospital in The Bronx, NY from March 15th 2020 - July 6th 2020 (pandemic cohort) and the same interval in 2019 (comparison cohort). Visits were assigned to pre-determined diagnostic categories. Demographic and clinical data were compared. RESULTS: 19,981 visits were included. Visits declined by 66% during 2020. Proportions of asthma visits (2% vs. 7%, p < 0.0001) and minor medical problems (61% vs. 67%, p < 0.0001) had significant declines in the pandemic cohort, while major medical problems (13% vs. 8%, p < 0.0001), appendicitis (1% vs. 0.4%, p < 0.0001) and other surgical complaints (1% vs. 0.5%, p < 0.0001) had proportional increases in the pandemic cohort. No significant proportional changes were noted among psychosocial and trauma groups between the two cohorts. CONCLUSION: The pandemic cohort experienced a substantial decrease in PED volume, but an increase in acuity and admission rates, which was sustained through the NYS phase-II re-opening. Despite being located in an asthma hub, the incidence of asthma-related PED visits declined appreciably in the pandemic cohort. Future studies examining the effects of indoor allergens in isolation on pediatric asthma are warranted.

Acute chest syndrome in the setting of SARS-COV-2 infections-A case series at an urban medical center in the Bronx.

New York City has emerged as one of the epicenters of the SARS-COV-2 pandemic, with the Bronx being disproportionately affected. This novel coronavirus has caused significant respiratory manifestations raising the concern for development of acute chest syndrome (ACS) in patients with sickle cell disease (SCD). We report a series of pediatric SCD SARS-COV-2-positive patients admitted with ACS. SARS-COV-2-positive SCD patients, who did not develop ACS, were the comparison group. Hydroxyurea use (P-value = .02) and lower absolute monocyte counts (P-value = .04) were noted in patients who did not develop ACS. These preliminary findings need to be further evaluated in larger cohorts.

Liver Stiffness Measurement by Vibration Controlled Transient Elastography Does Not Correlate to Hepatic Iron Overload in Children With Sickle Cell Disease.

BACKGROUND: Children with sickle cell disease (SCD) are at risk of liver injury because of sickle cell hepatopathy and iron overload from chronic transfusions (CT). The authors examine the association between iron overload and liver stiffness measurement (LSM) by vibration controlled transient elastography (VCTE), which has been shown to correlate with fibrosis. METHODS: Patients 21 years of age and less with SCD had VCTE performed; those who received CT underwent magnetic resonance imaging T2* for iron quantification. RESULTS: The authors enrolled 42 patients, 17 (40%) of whom received CT. There was no difference in LSM between patients who underwent CT (5.5±1.5 kPa) and those who did not (5.2±2.3 kPa) (P=0.923). There was no correlation between iron quantification and LSM (r=-0.077, P=0.769). However, children 12 years of age and older had abnormal LSM when compared with a reference range (P=0.013). CONCLUSION: VCTE is a noninvasive technology that is feasible in children with SCD. LSM values were elevated in older children but did not correlate with iron overload, suggesting that fibrosis may not be affected by iron overload alone. Though additional data are needed, LSM may be a useful test for the progression of liver disease in SCD regardless of iron burden.

Are inner-city children with asthma receiving specialty care as recommended in national asthma guidelines?

OBJECTIVE: To examine whether children with asthma in an urban health care network are receiving asthma specialty care, and which factors, if any, are associated with the receipt of this care, including child's racial/ethnic group, age, socio-economic status (SES), insurance, and/or acute care utilization. METHODS: This study is a retrospective cohort study of children aged 7-17 years who received primary care at an urban medical center in 2012 and had a primary or secondary ICD9 code for asthma. Data on asthma-related health care utilization from 1997 to 2012 were accessed using a software application linked to the electronic medical record. Analyses included descriptive statistics (means and percentages) as well as bivariate and multivariable logistic regressions. RESULTS: The participants were 4959 children (59% Hispanic and 37% Black, Non-Hispanic) with a mean age = 11.1 years ± 3.05, with 56.8% males. Only 19% of the children had outpatient asthma specialist care: pulmonary (16%) and/or allergy (7%). Only 42% with an asthma-related hospitalization had an outpatient asthma specialist visit. The receipt of specialty care did not vary by race/ethnicity, SES or private vs. public insurance, but was more likely with hospitalization for asthma (OR 3.4) or ≥2 lifetime ED visits (OR 2.6) and less likely for those who were uninsured (OR 0.7). CONCLUSIONS: In contrast to guideline recommendations, few inner-city children with high asthma morbidity in this sample had seen asthma specialists. Efforts are needed to ensure that inner-city children with asthma are receiving guideline-recommended asthma specialty care.

The Prevalence of Left Ventricular Hypertrophy in Obese Children Varies Depending on the Method Utilized to Determine Left Ventricular Mass.

Obesity and left ventricular hypertrophy (LVH) have been identified as independent risk factors for cardiovascular events. The definition of LVH depends on the geometric algorithm used to calculate LV mass (LVM) by echocardiography and the method used to normalize LVM for body size. This study evaluates the effect of these methods on the prevalence of LVH in obese children. LVM for 109 obese and 109 age-matched non-obese children was calculated using M-mode or two-dimensional echocardiography (2DE). LVM was then normalized to height 2.7 as indexed LVM (LVMI), to body surface area (BSA), height, and lean body mass (LBM) as LVM Z-scores. LVH was defined as LVMI >95th ‰ using age-specific normal reference values or LVM Z-scores ≥2. The prevalence of LVH by LVMI and LVM Z-scores was compared. There was a correlation between LVM determined by M-mode and by 2DE (R (2) = 0.91), although M-mode LVM was greater than 2DE LVM. However, the difference between these values was greater in obese children than in non-obese children. Based on the method of normalization, the prevalence of LVH among obese children was 64 % using LVMI, 15 % using LVM Z-scores for height, 8 % using LVM Z-scores for BSA and 1 % using LVM Z-scores for LBM. Height-based normalization correlates with obesity and hypertension. The methods used to measure and normalize LVM have a profound influence on the diagnosis of LVH in obese children. Further study is needed to determine which method identifies children at risk for cardiovascular morbidity and mortality.

Multidisciplinary Support for Healthcare Transitioning Across an Urban Healthcare Network.

BACKGROUND: A successful transition from pediatric to adult oriented health care is a vital process in maintaining a patient-centered medical home for youth with special health care needs (YSHCNs). We assessed practices of pediatric providers who transition YSCHNs to adult-oriented medical care in a large urban academic healthcare network. METHODS: A cross-sectional Web-based survey was distributed to 376 generalist and subspecialist pediatric providers. Survey assessed provider-reported utilization of 11 Essential Steps adapted from the 2002 Consensus Statement on Health Care Transitions for YSHCNs, and recent transitioning literature. Compliance score (CS11) was calculated as a sum of steps completed. Additional items assessed knowledge of transitioning literature and respondent demographics. RESULTS: Survey achieved a 28% response rate (n=105), of whom 84 reported assisting transitioning YSHCNs. Only 16.7% of these respondents were compliant with 7 or more of the 11 Essential Steps. Respondents who identified social work or nursing were more likely to have CS11 scores ≥7 compared to those without and were more likely to be compliant with specific steps. CONCLUSION: We found limited and incomplete utilization of recommended transitioning steps for YSHCNs by pediatric providers within a large urban healthcare network. Access to support from social work and nursing was associated with greater utilization of specific recommended steps, and with more optimal compliance. Further research needs to assess the transitioning practices of all members of the multidisciplinary team and whether operationalizing healthcare transition for YSHCNs as a multidisciplinary activity impacts the transitioning process and patient outcomes.

Where Do We Go from here? Post-pandemic Planning and the Future of Graduate Medical Education.

Background: As the pandemic wanes, there is an opportunity to reevaluate resultant changes in graduate medical education (GME), particularly from the viewpoints of those affected most. We aimed to assess both trainee and faculty perceptions on the educational changes and innovations resulting from the pandemic to inform future educational planning. Methods: We surveyed trainees and core education faculty at three New York City children's hospitals. Surveys assessed perceived changes to educational activities, skills, scholarship, effectiveness of virtual teaching, future desirability, and qualitative themes. Results: The survey was completed by 194 participants, including 88 (45.4%) faculty and 106 (54.6%) trainees. Trainees were more likely to report a negative impact of the pandemic compared with faculty (75.5% vs. 50%, p < 0.01). Most respondents reported a decrease in formal educational activities (69.8%), inpatient (77.7%) and outpatient (77.8%) clinical teaching. Despite this, most perceived clinical and teaching skills to have stayed the same. Most (93.4%) participated in virtual education; however, only 36.5% of faculty taught virtually. Only 4.2% of faculty had extensive training in virtual teaching and 28.9% felt very comfortable teaching virtually. In the future, most (87.5%) prefer a hybrid approach, particularly virtual didactic conferences and virtual grand rounds. Faculty themes included challenges to workflows and increased empathy for trainees, while trainee themes included increased work/life balance and support, but increased burnout. Conclusion: Many changes and innovations resulted from the pandemic. Hospital systems and GME programs should consider this data and incorporate viewpoints from trainees and faculty when adapting educational strategies in the future. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-023-01737-8.

Risk factors for Recurrent Clostridioides Difficile Infection in Children.

OBJECTIVE: The aims of this study were to determine the epidemiologic and treatment factors associated with recurrent C. difficile infection in children. METHODS: We conducted a 13-year retrospective review of pediatric C. difficile infections at our institution focusing on the epidemiologic, clinical, and treatment factors associated with recurrent disease. Repeat episodes occurring between 4 weeks and 2 months after initial infection were defined as early recurrences, whereas repeat episodes between 2 and 12 months after initial infection were defined as late recurrences. RESULTS: We identified 303 children with C. difficile infection. Recurrent infections were limited to children with chronic conditions, affecting 27.4% (68 of 248) of this cohort. Early and late recurrences occurred in 36.8 and 63.2% of children, respectively. Among children with a chronic condition, female sex and initial use of metronidazole (as opposed to vancomycin) were associated with recurrent disease in bivariate and multivariate analyses. Overall, there was a high treatment failure rate (34 of 102, 33.3%) once children had developed recurrent disease. CONCLUSIONS: Findings from this study demonstrate the importance of underlying chronic conditions in the development of recurrent C. difficile disease and the shortcomings of current treatment options for recurrent cases. Additionally, our findings indicate that initial treatment selection may impact the likelihood of future disease, with metronidazole usage being associated with higher recurrence rates than vancomycin. These findings highlight the need for additional studies to better understand the implications of C. difficile treatment strategies.

Treatment of Attention-Deficit/Hyperactivity Disorder with Medication in Children with Autism Spectrum Disorder With and Without Intellectual Disability: A DBPNet Study.

Children with autism spectrum disorder (ASD) and intellectual disability (ID)/global delay (GD) frequently have symptoms of attention-deficit/hyperactivity disorder (ADHD). We describe the practice patterns of developmental behavioral pediatricians (DBPs) in the treatment of children with ASD and coexisting ADHD and compare medication classes for children with and without intellectual disability. In bivariate analyses, we compared demographic characteristics, co-occurring conditions, and medication classes for children with and without intellectual disability. Significantly more patients with ID/GD were prescribed α-agonists than patients without ID/GD, but the difference was no longer significant when controlling for age in logistic regression children with ID/GD had more comorbidities and were more likely to be prescribed more than on psychotropic medication. In conclusion, age rather than ID/GD was associated with medication choice.

Associating a standardized reporting tool for chest radiographs with clinical complications in pediatric acute chest syndrome.

BACKGROUND: Acute chest syndrome (ACS) is an important cause of morbidity in sickle cell disease (SCD). A standardized tool for reporting chest radiographs in pediatric SCD patients did not previously exist. OBJECTIVE: To analyze the interobserver agreement among pediatric radiologists' interpretations for pediatric ACS chest radiographs utilizing a standardized reporting tool. We also explored the association of radiographic findings with ACS complications. METHODS: This was a retrospective cohort study of pediatric ACS admissions from a single institution in 2019. ICD-10 codes identified 127 ACS admissions. Two radiologists independently interpreted the chest radiographs utilizing a standardized reporting tool, a third radiologist adjudicated discrepancies, and κ analysis assessed interobserver agreement. Clinical outcomes were correlated with chest radiograph findings utilizing Pearsons' χ2 , t tests, and Mann-Whitney U tests. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. RESULTS: Interobserver agreement was moderate to near-perfect across variables, with κ analysis showing near-perfect agreement for opacity reported in the right upper lobe (0.84), substantial agreement for right lower lobe (0.63), and vertebral bony changes (0.72), with moderate agreement for all other reported variables. On the initial chest radiograph, an opacity located in the left lower lobe (LLL) correlated with pediatric intensive care unit transfer (p = .03). Pleural effusion on the initial chest radiograph had a 3.98 OR (95% CI: 1.35-11.74) of requiring blood products and a 10.67 OR (95% CI: 3.62-31.39) for noninvasive ventilation. CONCLUSION: The standardized reporting tool showed moderate to near-perfect agreement between radiologists. LLL opacity, and pleural effusion were associated with increased risk of ACS complications.