Showing papers by "Michael D. Cabana published in 2022"

Collaboration and Shared Decision-Making Between Patients and Clinicians in Preventive Health Care Decisions and US Preventive Services Task Force Recommendations.

Abstract: The US Preventive Services Task Force (USPSTF) works to improve the health of people nationwide by making evidence-based recommendations for preventive services. Patient-centered care is a core value in US health care. Shared decision-making (SDM), in which patients and clinicians make health decisions together, ensures patients' rights to be informed and involved in preventive care decisions and that these decisions are patient-centered. SDM has a role across the spectrum of USPSTF recommendations. For A or B recommendations (judged by the USPSTF to have high or moderate certainty of a moderate or substantial net benefit at the population level), SDM allows individual patients to decide whether to accept such services based on their personal values and preferences. For C recommendations (indicating at least moderate certainty of a small net benefit at the population level), SDM is critical for individual patients to decide whether the net benefit for them is worthwhile. For D recommendations (reflecting at least moderate certainty of a zero or negative net benefit) or I statements (low certainty of net benefit), clinicians should be prepared to discuss these services if patients ask. More evidence is needed to determine if, in addition to promoting patient-centeredness, SDM reduces inequities in preventive care, as well as to define new strategies to find time for discussion of preventive services in primary care.

“It’s impossible to do it all”: a cross-sectional observational study of pediatric faculty parents during the COVID-19 pandemic

Abstract: Background: The coronavirus disease 2019 (COVID-19) pandemic has caused systemic changes to schooling, childcare, and the workplace, uniquely impacting the lives of physicians and parents, especially women. Experiences of those filling multiple roles as pediatric faculty parents remain largely undocumented.

Effect of Early Infant Probiotic Supplementation on Eczema, Asthma, and Rhinitis at 7 Years of Age.

Abstract: We previously reported the initial results of the Trial of Infant Probiotic Supplementation (TIPS) study to determine if daily administration of a probiotic, Lactobacillus rhamnosus GG (LGG), during the first 6 months of life to children at high risk for allergic disease because of asthma in a parent can decrease their cumulative incidence of eczema.1 To date, the TIPS study is the only of its type performed in the United States.urour initial report, when all children were at least 2 years of age, we noted no effect on the incidence of eczema. We now present additional results, with the participants at least 7 years of age, on the cumulative incidence of eczema, asthma, and rhinitis.The TIPS study is a randomized, double-masked, parallel-arm, controlled trial designed to evaluate the effectiveness of daily LGG supplementation for the first 6 months of life to decrease the incidence of eczema, a potential early marker of asthma.1 For this analysis, we used physician-diagnosed asthma and physician-diagnosed rhinitis as secondary outcomes.To determine the effects of LGG on cumulative incidence of study outcomes, we performed modified intention-to-treat analyses with all participants who received treatment in the study arm to which they had been randomly assigned. We used survival analysis approaches to estimate Kaplan-Meier curves for each treatment group. We used nonparametric log-rank tests to determine differences between treatment groups and failure plots to visualize the cumulative probability of experiencing each outcome during follow-up.We used separate Cox proportional hazards regression models to compare the incidence of each outcome between the intervention and control groups, adjusting for mode of delivery and breastfeeding duration. Breastfeeding duration (in months up to 12) was treated as a time-dependent covariate.All analyses were performed using SAS version 9.4 software (SAS Institute Inc, Cary, NC). P < .05 was set for statistical significance. The protocol was approved by the Albert Einstein College of Medicine Institutional Review Board.Over the 7-year follow-up, 49 (53%) of 92 intervention and 54 (59%) of 92 control participants remained in the study for an overall 56% retention rate. Eczema was diagnosed in 78 participants, asthma in 32, and rhinitis in 15. The mean follow-up time was 5.7 years (median, 7 years). Incidence of eczema was high during infancy but low thereafter. In contrast, incidence rates for asthma and rhinitis were constant during childhood. Although the initial cumulative incidence seemed to favor the intervention in the early years of life for eczema and asthma, this trajectory was not sustained. The results showed no difference in the primary or secondary outcomes (Fig 1). Main findings from the Cox proportional hazards regression model are presented in Table 1. Cesarean delivery was associated with a greater incidence of rhinitis, with a hazard ratio (HR) of 3.33 (95% confidence interval [CI], 1.21–9.21).This follow-up report reveals that early infant LGG supplementation does not affect the cumulative incidence of eczema, asthma, and rhinitis at 7 years of age. Kalliomäki et al2 reported that early LGG supplementation decreases the likelihood of eczema and wheezing; however, their LGG supplementation occurred through both postnatal infant and prenatal maternal supplementation. The effect of LGG supplementation may only be discernable in infants born into high-risk scenarios because of altered gastrointestinal microbiota development3,4 (eg, cesarean delivery, lack of breast milk exposure); however, few TIPS study infants were exclusively fed formula or were cesarean delivered. Although LGG supplementation in infants is associated with significant increases in the similarity of the infant gut microbiota and metabolome to that of an infant at low risk for allergic disease, it does so only for the 6-month period in which LGG is administered.5 It is possible that probiotic supplementation to the mother during pregnancy and/or the infant for a longer period may be more effective.The results presented in Table 1 reveal that breastfeeding may increase the risk of eczema (HR, 11.97); however, the CIs are extremely wide (95% CI, 6.81–21.02), suggesting an unstable estimate. In addition, the effect of breastfeeding is not consistent, as there is no association with asthma or rhinitis incidence; therefore, we cannot clearly interpret this result. There is the potential of a type II error, as the TIPS study was designed to have 80% power to detect an HR <0.66, corresponding with a 10% absolute reduction in the 2-year cumulative incidence of eczema.Despite these limitations of the results, we can build on our earlier report regarding eczema. For this population of infants at higher risk for allergic disease, we cannot support the use of early infant LGG probiotic supplementation for the prevention of eczema, asthma, or rhinitis.

SARS-CoV-2 Gastrointestinal Shedding in Hospitalized Children.

Abstract: BACKGROUND Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a respiratory virus that can cause gastrointestinal (GI) symptoms, with studies demonstrating detection of stool viral RNA weeks after respiratory tract clearance. It is unknown if children who test negative for SARS-CoV-2 on a nasopharyngeal (NP) swab may be shedding the virus in their stool. OBJECTIVE To measure the prevalence of SARS-CoV-2 stool shedding in children with positive and negative SARS-CoV-2 NP polymerase chain reactions (PCR) tests, and to determine clinical factors associated with GI shedding. METHODS In this cross-sectional study, we enrolled hospitalized patients 0 to 21 years old with a positive or a negative SARS-CoV-2 NP PCR test who had respiratory and/or GI symptoms. Participants were surveyed, and stool samples were sent for viral PCR testing. Fisher's exact test was used to evaluate bivariate associations of stool PCR test positivity with categorical variables. RESULTS Sixty-seven patients were consented; 34 patients did not provide stool samples so 33 patients were included: 17 NP-positive and 16 NP-negative for SARS-CoV-2. Eight of the 17 NP-positive patients had a positive stool PCR test for SARS-CoV-2, while none of the 16 SARS-CoV-2 NP-negative patients had a positive result (P < .01). For the 17 SARS-CoV-2 NP-positive patients, GI symptoms were associated with a positive stool PCR test (P = .05) for SARS-CoV-2, but this association was not found for all 33 patients (P = .11). No associations were found with patients in an immunocompromised state or those with a comorbid condition, fever and/or chills, respiratory symptoms, headache and/or myalgias, or anosmia and/or ageusia. CONCLUSIONS SARS-CoV-2 GI shedding is common and associated with GI symptoms in NP-positive children, with 47% having positive stool PCRs for SARS-CoV-2. GI shedding was not demonstrated in SARS-CoV-2 NP-negative children.

Effect of Early Infant Lactobacillus rhamnosus GG Supplementation in Preventing Viral Respiratory Illness

Abstract: The role of early probiotic supplementation in infants for the prevention of respiratory viral illnesses is unclear. We examined the association of Lactobacillus rhamnosus GG (LGG) supplementation during the first 6 months of life with the frequency and severity of viral illnesses during the first 24 months of life. We conducted a secondary analysis of data from the randomized controlled Trial of Infant Probiotic Supplementation (n = 184). Parents reported the number of respiratory viral illnesses, and a composite severity score was created based on symptoms. A negative binomial regression model and a mixed-effects linear regression model assessed for differences in the number of episodes and severity of episodes between treatment groups, respectively. There was no significant difference in the incidence rate of viral illness episodes or symptom severity between treatment groups. Daily supplementation with LGG in early infancy does not decrease the number or severity of viral illnesses during the first 2 years of life.

Sleep-Disordered Breathing and Sleep Quality in a Longitudinal Pediatric Cohort

Abstract: Sleep-disordered breathing (SDB) is characterized by the disruption of normal respiratory patterns and ventilation during sleep, and ranges in severity from milder symptoms, like snoring and mouth breathing, to more severe conditions like obstructive sleep apnea (OSA). SDB is associated with poor behavioral and neurodevelopmental outcomes, including impaired cognition, attention, and school performance.1-3 Even milder and more common symptoms such as snoring are associated with neurobehavioral deficits comparable to those found in children with OSA, and may be important determinants of poor outcomes.1-5 Previous studies have not found a direct correlation between conventional polysomnographic parameters of SDB severity, such as obstructive apnea-hypopnea episodes and oxygen desaturations, and these outcomes, suggesting other mechanisms may mediate these adverse effects.1-6 One of the proposed mechanisms by which SDB is thought to exert negative influences on neurocognitive function and behavior is through sleep fragmentation, impaired sleep quality, and resulting daytime sleepiness.1,5,6 Yet little is known about SDB-related sleep quality disturbances in the general pediatric population, particularly among those with symptoms on the milder end of the SDB spectrum. Limited data are available from small, cross-sectional studies evaluating polysomnographic parameters of sleep architecture among children with SDB.7-10 However, longitudinal population-based studies examining the impact of SDB symptoms on sleep quality over time are lacking. We aimed to determine whether mild SDB symptoms are associated with impaired sleep quality throughout early childhood in a population-based cohort. Methods