Showing papers by "Monroe Carell Jr. Children's Hospital at Vanderbilt published in 2017"
Vanderbilt University Medical Center1, Vanderbilt University2, University of Manitoba3, Ohio State University4, Indiana University5, Trinity College, Dublin6, Northeastern University7, Tufts Medical Center8, University of British Columbia9, University of Edinburgh10, Stanford University11, Johns Hopkins University12, Watford General Hospital13, University of Toronto14, Sunnybrook Health Sciences Centre15, Federal University of Rio de Janeiro16, Pasteur Institute17, Monash University18, McGill University19, Utrecht University20, Monroe Carell Jr. Children's Hospital at Vanderbilt21
TL;DR: The epidemiology of delirium is reviewed, the current best practices for management of critically ill patients at risk forDelirium or experiencingdelirium are reviewed, recent advances in the understanding of delIRium are identified, as well as gaps in knowledge are identified.
Abstract: Delirium, a prevalent organ dysfunction in critically ill patients, is independently associated with increased morbidity. This last decade has witnessed an exponential growth in delirium research in hospitalized patients, including those critically ill, and this research has highlighted that delirium needs to be better understood mechanistically to help foster research that will ultimately lead to its prevention and treatment. In this invited, evidence-based paper, a multinational and interprofessional group of clinicians and researchers from within the fields of critical care medicine, psychiatry, pediatrics, anesthesiology, geriatrics, surgery, neurology, nursing, pharmacy, and the neurosciences sought to address five questions: (1) What is the current standard of care in managing ICU delirium? (2) What have been the major recent advances in delirium research and care? (3) What are the common delirium beliefs that have been challenged by recent trials? (4) What are the remaining areas of uncertainty in delirium research? (5) What are some of the top study areas/trials to be done in the next 10 years? Herein, we briefly review the epidemiology of delirium, the current best practices for management of critically ill patients at risk for delirium or experiencing delirium, identify recent advances in our understanding of delirium as well as gaps in knowledge, and discuss research opportunities and barriers to implementation, with the goal of promoting an integrated research agenda.
142 citations
Monroe Carell Jr. Children's Hospital at Vanderbilt1, University of California, Los Angeles2, New York University3, Nationwide Children's Hospital4, Children's Hospital of Orange County5, Case Western Reserve University6, East Carolina University7, Boston Children's Hospital8, Primary Children's Hospital9, Duke University10, Vanderbilt University Medical Center11
TL;DR: In this randomized clinical trial of patients with CPVT, flecainide plus & bgr;-blocker significantly reduced ventricular ectopy during exercise compared with placebo plus &bgr; -blocker and &b Gr;- blocker alone.
Abstract: Importance Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a potentially lethal genetic arrhythmia syndrome characterized by polymorphic ventricular tachycardia with physical or emotional stress, for which current therapy with β-blockers is incompletely effective. Flecainide acetate directly suppresses sarcoplasmic reticulum calcium release—the cellular mechanism responsible for triggering ventricular arrhythmias in CPVT—but has never been assessed prospectively. Objective To determine whether flecainide dosed to therapeutic levels and added to β-blocker therapy is superior to β-blocker therapy alone for the prevention of exercise-induced arrhythmias in CPVT. Design, Setting, and Participants This investigator-initiated, multicenter, single-blind, placebo-controlled crossover clinical trial was conducted from December 19, 2011, through December 29, 2015, with a midtrial protocol change at 10 US sites. Patients with a clinical diagnosis of CPVT and an implantable cardioverter-defibrillator underwent a baseline exercise test while receiving maximally tolerated β-blocker therapy that was continued throughout the trial. Patients were then randomized to treatment A (flecainide or placebo) for 3 months, followed by exercise testing. After a 1-week washout period, patients crossed over to treatment B (placebo or flecainide) for 3 months, followed by exercise testing. Interventions Patients received oral flecainide or placebo twice daily, with the dosage guided by trough serum levels. Main Outcomes and Measures The primary end point of ventricular arrhythmias during exercise was compared between the flecainide and placebo arms. Exercise tests were scored on an ordinal scale of worst ventricular arrhythmia observed (0 indicates no ectopy; 1, isolated premature ventricular beats; 2, bigeminy; 3, couplets; and 4, nonsustained ventricular tachycardia). Results Of 14 patients (7 males and 7 females; median age, 16 years [interquartile range, 15.0-22.5 years]) randomized, 13 completed the study. The median baseline exercise test score was 3.0 (range, 0-4), with no difference noted between the baseline and placebo (median, 2.5; range, 0-4) exercise scores. The median ventricular arrhythmia score during exercise was significantly reduced by flecainide (0 [range, 0-2] vs 2.5 [range, 0-4] for placebo; P Conclusions and Relevance In this randomized clinical trial of patients with CPVT, flecainide plus β-blocker significantly reduced ventricular ectopy during exercise compared with placebo plus β-blocker and β-blocker alone. Trial Registration clinicaltrials.gov Identifier:NCT01117454
109 citations
Johns Hopkins University1, Emory University2, University of Tennessee Health Science Center3, National Institutes of Health4, Cedars-Sinai Medical Center5, Children's Hospital of Philadelphia6, Johns Hopkins University School of Medicine7, Kaiser Permanente8, University of Pennsylvania9, Medical University of South Carolina10, LSU Health Sciences Center Shreveport11, University of Maryland, Baltimore12, Washington University in St. Louis13, Cincinnati Children's Hospital Medical Center14, University of Louisville15, Baylor College of Medicine16, University of North Carolina at Chapel Hill17, Case Western Reserve University18, University of Chicago19, VCU Medical Center20, University of Texas Southwestern Medical Center21, Stony Brook University22, Children's Hospital of Eastern Ontario23, University of Alabama at Birmingham24, Monroe Carell Jr. Children's Hospital at Vanderbilt25, University of Utah26, Mayo Clinic27, Henry Ford Health System28, Montreal Heart Institute29, University of Pittsburgh30, University of Toronto31, Icahn School of Medicine at Mount Sinai32
TL;DR: The detection of variants associated with IBD risk in only people of African descent demonstrates the importance of studying the genetics of IBD and other complex diseases in populations beyond those of European ancestry.
109 citations
TL;DR: CBT produced the greatest improvements to daily functioning, and this effect was significantly larger than that produced by relaxation therapy, which has important clinical implications for treatment of adults with IBS.
108 citations
TL;DR: This study provides the first example of HMOs functioning as antibiofilm agents against GBS, and shows that H MOs from mothers of specific milk groups can modulate the growth and biofilm formation of GBS.
Abstract: Streptococcus agalactiae (Group B Streptococcus, GBS) is a Gram-positive bacterial pathogen that causes invasive infections in both children and adults During pregnancy, GBS is a significant cause of infection of the fetal membranes (chorioamnionitis), which can lead to intra-amniotic infection, preterm birth, stillbirth, and neonatal sepsis Recently, breastfeeding has been thought to represent a potential mode of GBS transmission from mother to newborn, which might increase the risk for late-onset sepsis Little is known, however, about the molecular components of breast milk that may support or prevent GBS colonization In this study, we examine how human milk oligosaccharides (HMOs) affect the pathogenesis of GBS HMOs from discrete donor samples were isolated and profiled by matrix-assisted laser desorption/ionization (MALDI) mass spectrometry (MS) Growth and biofilm assays show that HMOs from mothers of specific milk groups can modulate the growth and biofilm formation of GBS High-resolution fiel
94 citations
Boston Children's Hospital1, Harvard University2, University of Utah3, Monroe Carell Jr. Children's Hospital at Vanderbilt4, Children's Hospital of Philadelphia5, University of Pennsylvania6, Seattle Children's7, University of Washington8, Vanderbilt University Medical Center9, George Washington University10, Children's National Medical Center11, University of Cincinnati12, Cincinnati Children's Hospital Medical Center13
TL;DR: Among children without comorbidities hospitalized with CAP in a non-ICU setting, the rate of bacteremia was low, and isolated pathogens were usually susceptible to penicillin.
Abstract: BACKGROUND AND OBJECTIVES: National guidelines recommend blood cultures for children hospitalized with presumed bacterial community-acquired pneumonia (CAP) that is moderate or severe. We sought to determine the prevalence of bacteremia and characterize the microbiology and penicillin-susceptibility patterns of positive blood culture results among children hospitalized with CAP. METHODS: We conducted a cross-sectional study of children hospitalized with CAP in 6 children’s hospitals from 2007 to 2011. We included children 3 months to 18 years of age with discharge diagnosis codes for CAP using a previously validated algorithm. We excluded children with complex chronic conditions. We reviewed microbiologic data and classified positive blood culture detections as pathogens or contaminants. Antibiotic-susceptibility patterns were assessed for all pathogens. RESULTS: A total of 7509 children hospitalized with CAP were included over the 5-year study period. Overall, 34% of the children hospitalized with CAP had a blood culture performed; 65 (2.5% of patients with blood cultures; 95% confidence interval [CI]: 2.0%–3.2%) grew a pathogen. Streptococcus pneumoniae accounted for 78% of all detected pathogens. Among detected pathogens, 50 (82%) were susceptible to penicillin. Eleven children demonstrated growth of an organism nonsusceptible to penicillin, representing 0.43% (95% CI: 0.23%–0.77%) of children with blood cultures obtained and 0.15% (95% CI: 0.08%–0.26%) of all children hospitalized with CAP. CONCLUSIONS: Among children without comorbidities hospitalized with CAP in a non-ICU setting, the rate of bacteremia was low, and isolated pathogens were usually susceptible to penicillin. Blood cultures may not be needed for most children hospitalized with CAP.
60 citations
TL;DR: There was a significant relationship between canine cortisol and behavior, thus strengthening the argument for the use of cortisol in canine well-being research and enhancing therapy dog involvement in hospital settings.
59 citations
TL;DR: A prediction rule using history and physical examination, chest x-ray, and laboratory evaluation at the time of presentation after BAT identifies children at very low risk for IAI for whom CT can be avoided.
Abstract: Background Computed tomography is commonly used to rule out intra-abdominal injury (IAI) in children, despite associated cost and radiation exposure. Our purpose was to derive a prediction rule to identify children at very low risk for IAI after blunt abdominal trauma (BAT) for whom a CT scan of the abdomen would be unnecessary. Study Design We prospectively enrolled children younger than 16 years of age who presented after BAT at 14 Level I pediatric trauma centers during 1 year. We excluded patients who presented more than 6 hours after injury or underwent abdominal CT before transfer. We used binary recursive partitioning to derive a prediction rule identifying children at very low risk of IAI and IAI requiring acute intervention (IAI-I) using clinical information available in the trauma bay. Results We included 2,188 children with a median age of 8 years. There were 261 patients with IAI (11.9%) and 62 patients with IAI-I (2.8%). The prediction rule consisted of (in descending order of significance): aspartate aminotransferase >200 U/L, abnormal abdominal examination, abnormal chest x-ray, report of abdominal pain, and abnormal pancreatic enzymes. The rule had a negative predictive value of 99.4% for IAI and 100.0% for IAI-I in patients with none of the prediction rule variables present. The very-low-risk population consisted of 34% of the patients and 23% received a CT scan. Computed tomography frequency ranged from 4% to 96% by center. Conclusions A prediction rule using history and physical examination, chest x-ray, and laboratory evaluation at the time of presentation after BAT identifies children at very low risk for IAI for whom CT can be avoided.
58 citations
TL;DR: This review focuses on pediatric CAP in the United States and other industrialized nations, specifically highlighting the changing epidemiology of CAP, diagnostic and therapeutic challenges, and areas for further research.
56 citations
Newcastle University1, University of Rochester2, University of Freiburg3, Robert Jones and Agnes Hunt Orthopaedic Hospital4, National Institutes of Health5, University of California, Los Angeles6, Leeds Teaching Hospitals NHS Trust7, University of Utah8, Boston Children's Hospital9, Children's Memorial Hospital10, National Autonomous University of Mexico11, University of Calgary12, University College London13, University of California, Davis14, University of Duisburg-Essen15, Dresden University of Technology16, University of Kansas17, University of Western Ontario18, Harvard University19, Nemours Foundation20, University of Messina21, University of Turin22, University of Padua23, Pennsylvania State University24, University of Göttingen25, Monroe Carell Jr. Children's Hospital at Vanderbilt26, University of North Carolina at Chapel Hill27, Children's Hospital of Eastern Ontario28, Children's National Medical Center29
TL;DR: A clinical trial that compares the 3 most frequently prescribed corticosteroid regimes for Duchenne muscular dystrophy, standardizes treatment of DMD complications, and standardizes prevention of cortiosteroid side effects and seeks to establish a standard corticosterone regimen for DMD.
49 citations
Monroe Carell Jr. Children's Hospital at Vanderbilt1, St. Jude Children's Research Hospital2, University of California, Davis3, University of Southern California4, Cincinnati Children's Hospital Medical Center5, Baylor College of Medicine6, University of Pittsburgh7, Alfred I. duPont Hospital for Children8, University of Virginia9, Primary Children's Hospital10
TL;DR: The response rate to the combination of vincristine and irinotecan and the outcome of patients with high‐risk hepatoblastoma is reported.
Abstract: BACKGROUND
The identification of new therapies for high-risk (HR) hepatoblastoma is challenging. Children's Oncology Group study AHEP0731 included a HR stratum to explore the efficacy of novel agents. Herein, the authors report the response rate to the combination of vincristine (V) and irinotecan (I) and the outcome of patients with high-risk hepatoblastoma.
METHODS
Patients with newly diagnosed metastatic hepatoblastoma or those with a serum α-fetoprotein (AFP) level 1 log10) decline in their AFP level. Responders were to receive 2 additional cycles of VI intermixed with 6 cycles of the combination of cisplatin, doxorubicin, 5-fluorouracil, and vincristine (C5VD). Nonresponders were to receive 6 cycles of C5VD alone.
RESULTS
A total of 32 patients with a median age at diagnosis of 26 months (range, 11-159 months) were enrolled between September 2009 and February 2012. Fourteen of 30 evaluable patients were responders (RECIST and AFP in 6 patients, RECIST only in 3 patients, and AFP only in 5 patients). The median AFP decline after 2 cycles of VI for the entire group was 345,565 ng/mL (85% of the initial AFP). The 3-year event-free and overall survival rates were 49% (95% confidence interval, 30%-65%) and 62% (95% confidence interval, 42%-77%), respectively.
CONCLUSIONS
The VI combination appears to have substantial activity against HR hepatoblastoma. The ultimate impact of this regimen in improving the outcomes of children with HR hepatoblastoma remains to be determined. Cancer 2017;123:2360–2367. © 2017 American Cancer Society.
TL;DR: In this paper, the effects of early diagnosis, dermatologic presentation, and antifungal treatment on outcomes are lacking, and the authors defined CCC as a diffuse rash involving the body, extremities, face or scalp, and/or funisitis, presenting in the first week (≤7 days).
Abstract: Background Congenital cutaneous candidiasis (CCC) is a challenging diagnosis due to various rash presentations. Inadequate early treatment is associated with high rates of dissemination and death. The effects of early diagnosis, dermatologic presentation, and antifungal treatment on outcomes are lacking. Methods CCC cases were reviewed from 2 academic neonatal intensive care units (NICUs) from 2004 to 2015. We defined CCC as a diffuse rash involving the body, extremities, face or scalp, and/or funisitis, presenting in the first week (≤7 days), with identification of Candida species from skin or mucous membrane cultures, and/or by culture or staining of the placenta or umbilical cord. Results CCC occurred in 0.1% of all NICU admissions (21 of 19 303) and 0.6% of infants <1000 grams birth weight. Median gestational age of CCC infants was 26 3/7 (range, 23 0/7-40 4/7) weeks. Skin findings were commonly present on the day of birth [median (range): 0 (0-6) days], appearing most frequently as a desquamating, maculopapular, papulopustular, and/or erythematous diffuse rash. When systemic antifungal therapy was started empirically at the time of rash presentation and continued for a median (interquartile range) of 14 (14-15) days, all patients survived and none developed dissemination. Delaying systemic treatment, exclusive use of nystatin, and treating for <10 days was associated with Candida bloodstream dissemination. Conclusions CCC is an invasive infection that presents as a diffuse rash in preterm and term infants. Prompt systemic antifungal treatment at the time of skin presentation for ≥14 days prevents dissemination and Candida-related mortality.
TL;DR: The findings demonstrate that E3 ubiquitin ligase TRIP12 plays an important role in nervous system development and function, and further document that TRIP 12 haploinsufficiency causes a childhood-onset neurodevelopmental disorder.
Abstract: Impairment of ubiquitin-proteasome system activity involving ubiquitin ligase genes UBE3A, UBE3B, and HUWE1 and deubiquitinating enzyme genes USP7 and USP9X has been reported in patients with neurodevelopmental delays. To date, only a handful of single-nucleotide variants (SNVs) and copy-number variants (CNVs) involving TRIP12, encoding a member of the HECT domain E3 ubiquitin ligases family on chromosome 2q36.3 have been reported. Using chromosomal microarray analysis and whole-exome sequencing (WES), we have identified, respectively, five deletion CNVs and four inactivating SNVs (two frameshifts, one missense, and one splicing) in TRIP12. Seven of these variants were found to be de novo; parental studies could not be completed in two families. Quantitative PCR analyses of the splicing mutation showed a dramatically decreased level of TRIP12 mRNA in the proband compared to the family controls, indicating a loss-of-function mechanism. The shared clinical features include intellectual disability with or without autistic spectrum disorders, speech delay, and facial dysmorphism. Our findings demonstrate that E3 ubiquitin ligase TRIP12 plays an important role in nervous system development and function. The nine presented pathogenic variants further document that TRIP12 haploinsufficiency causes a childhood-onset neurodevelopmental disorder. Finally, our data enable expansion of the phenotypic spectrum of ubiquitin-proteasome dependent disorders.
Baylor College of Medicine1, Children's Mercy Hospital2, University of Texas Health Science Center at Houston3, Children's Hospital of Wisconsin4, University of Texas Southwestern Medical Center5, Primary Children's Hospital6, Children's Hospital Los Angeles7, Boston Children's Hospital8, University of California, San Francisco9, University of Wisconsin-Madison10, Emory University11, Monroe Carell Jr. Children's Hospital at Vanderbilt12
TL;DR: There is a high rate of recurrent laryngeal nerve injury after H-type TEF repair, which underscores the need for meticulous surgical technique at the initial repair and suggests that early vocal cord evaluation should be performed for any post-operative respiratory difficulty.
TL;DR: It is indicated that UPEC is deprived of purine nucleotides within the intracellular niche and relies on de novo purine synthesis to meet this metabolic requirement.
Abstract: The ability to de novo synthesize purines has been associated with the intracellular survival of multiple bacterial pathogens. Uropathogenic Escherichia coli (UPEC), the predominant cause of urinary tract infections, undergoes a transient intracellular lifestyle during which bacteria clonally expand into multicellular bacterial communities within the cytoplasm of bladder epithelial cells. Here, we characterized the contribution of the conserved de novo purine biosynthesis-associated locus cvpA-purF to UPEC pathogenesis. Deletion of cvpA-purF, or of purF alone, abolished de novo purine biosynthesis but did not impact bacterial adherence properties in vitro or in the bladder lumen. However, upon internalization by bladder epithelial cells, UPEC deficient in de novo purine biosynthesis was unable to expand into intracytoplasmic bacterial communities over time, unless it was extrachromosomally complemented. These findings indicate that UPEC is deprived of purine nucleotides within the intracellular niche and relies on de novo purine synthesis to meet this metabolic requirement.
TL;DR: Low-cost strategies, including collaborative sharing, peer benchmarking, and coaching, increased judicious use of antibiotics in a diverse range of hospitals for pediatric CAP.
Abstract: BACKGROUND AND OBJECTIVES: The Value in Inpatient Pediatrics Network sponsored the Improving Care in Community Acquired Pneumonia collaborative with the goal of increasing evidence-based management of children hospitalized with community acquired pneumonia (CAP). Project aims included: increasing use of narrow-spectrum antibiotics, decreasing use of macrolides, and decreasing concurrent treatment of pneumonia and asthma. METHODS: Data were collected through chart review across emergency department (ED), inpatient, and discharge settings. Sites reviewed up to 20 charts in each of 6 3-month cycles. Analysis of means with 3-σ control limits was the primary method of assessment for change. The expert panel developed project measures, goals, and interventions. A change package of evidence-based tools to promote judicious use of antibiotics and raise awareness of asthma and pneumonia codiagnosis was disseminated through webinars. Peer coaching and periodic benchmarking were used to motivate change. RESULTS: Fifty-three hospitals enrolled and 48 (91%) completed the 1-year project (July 2014–June 2015). A total of 3802 charts were reviewed for the project; 1842 during baseline cycles and 1960 during postintervention cycles. The median before and after use of narrow-spectrum antibiotics in the collaborative increased by 67% in the ED, 43% in the inpatient setting, and 25% at discharge. Median before and after use of macrolides decreased by 22% in the ED and 27% in the inpatient setting. A decrease in asthma and CAP codiagnosis was noted, but the change was not sustained. CONCLUSIONS: Low-cost strategies, including collaborative sharing, peer benchmarking, and coaching, increased judicious use of antibiotics in a diverse range of hospitals for pediatric CAP.
Boston Children's Hospital1, University of Tennessee Health Science Center2, University of Texas MD Anderson Cancer Center3, University of Michigan4, Children's Hospital of Orange County5, Monroe Carell Jr. Children's Hospital at Vanderbilt6, University of Louisville7, Seattle Children's8, Children's Memorial Hospital9, Medical College of Wisconsin10, Cincinnati Children's Hospital Medical Center11, Montreal Children's Hospital12, Greenville Health System13, Harvard University14, University of Texas Health Science Center at Houston15
TL;DR: There is a paucity of high-quality evidence in the literature regarding timing of appendectomy for patients with acute appendicitis and its association with adverse events or resource utilization.
TL;DR: Preoperative factors, including a missense polymorphism in GJA5, are independently associated with increased risk for CHB and may prove useful in predicting recovery of AV conduction among patients with CHB after congenital heart surgery.
Oregon Health & Science University1, Children's Hospital of Philadelphia2, Boston Children's Hospital3, Duke University4, Children's Mercy Hospital5, University of Illinois at Chicago6, University of California, Los Angeles7, Monroe Carell Jr. Children's Hospital at Vanderbilt8, Seattle Children's9, Nationwide Children's Hospital10, Vanderbilt University11, Yale University12, University of Virginia Health System13, Women & Children's Hospital of Buffalo14, University of Texas at Austin15, Stanford University16, Mount Sinai Hospital17
TL;DR: These guidelines for the conduct of STMs in LMICs may be a useful tool to ensure safe, responsible, and ethical STMs given increasing engagement of HIC providers in this work.
TL;DR: This study is the first to clinically demonstrate an association between elevated serum leptin levels and SCFE, regardless of BMI, and adds to existing literature suggesting that SCFE is a multifactorial process and that leptin levels may have profound physiological effects on the development of various disease states.
Abstract: BACKGROUND Slipped capital femoral epiphysis (SCFE) is strongly associated with childhood obesity, yet the prevalence of obesity is orders of magnitude greater than the prevalence of SCFE Therefore, it is hypothesized that obesity is not, by itself, a sufficient condition for SCFE, but rather one component of a multifactorial process requiring preexisting physeal pathology Leptin elevation is seen to varying degrees in patients with obesity, and as leptin has been shown to cause physeal pathology similar to the changes seen in SCFE, we propose that leptin may be a factor distinguishing between patients with SCFE and equally obese children without hip abnormalities METHODS Serum leptin levels were obtained from 40 patients with SCFE and 30 control patients with approximate body mass index (BMI) matching BMI percentiles were calculated according to Centers for Disease Control and Prevention population data by patient age and sex Patients were compared by demographic characteristics, leptin levels, odds of leptin elevation, and odds of SCFE RESULTS The odds of developing SCFE was increased by an odds ratio of 49 (95% confidence interval [CI], 131 to 1848; p < 002) in patients with elevated leptin levels, regardless of obesity status, sex, and race When grouping patients by their obesity status, non-obese patients with SCFE showed elevated median leptin levels at 58 ng/mL compared with non-obese controls at 17 ng/mL (p = 0006) Similarly, obese patients with SCFE showed elevated median leptin levels at 179 ng/mL compared with equally obese controls at 105 ng/mL (p = 0039) Serum leptin levels increased in association with obesity (p < 0001), with an increase in leptin of 017 ng/mL (95% CI, 007 to 027 ng/mL) per BMI percentile point CONCLUSIONS To our knowledge, this study is the first to clinically demonstrate an association between elevated serum leptin levels and SCFE, regardless of BMI This adds to existing literature suggesting that SCFE is a multifactorial process and that leptin levels may have profound physiological effects on the development of various disease states Despite a strong association with adiposity, leptin levels vary between patients of equal BMI and may be a vital resource in prognostication of future obesity-related comorbidities LEVEL OF EVIDENCE Prognostic Level III See Instructions for Authors for a complete description of levels of evidence
TL;DR: Initial immobilization of a toddler's fracture in a boot may allow faster return to weight-bearing, and that radiographic follow-up may be unnecessary for treatment planning, suggests that immobilization type can be at the physician and family's discretion.
Abstract: Background:The toddler’s fracture is a common pediatric nondisplaced spiral tibia fracture that is considered stable with a course of immobilization. However, there is no widely accepted type of immobilization, expected time to weight-bear, nor guidelines for radiographic monitoring. We aimed to com
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TL;DR: The authors discuss the etiology and manifestations of sleep disorders in children with ASD, as well as their clinical evaluation and treatment options.
Abstract: Autism spectrum disorder (ASD) is a neurodevelopmental disorder that has increased in prevalence over the last several decades. A significant proportion of children with ASD have comorbid sleep disorders. The interplay between ASD and sleep is multifactorial and bidirectional. There is evidence for physiological differences in ASD that contribute to sleep problems, including sensory overresponsiveness (SOR) and abnormal melatonin production. Comorbidities associated with ASD (attention deficit hyperactivity disorder [ADHD], mood disorders) as well as medications used to treat these comorbidities often have effects on sleep architecture. In this article the authors discuss the etiology and manifestations of sleep disorders in children with ASD, as well as their clinical evaluation and treatment options.
TL;DR: The data suggest that use of synthetic Hct for the calculation of ECV results in miscategorization of individual patients, and formal measurement of Hct in children and young adults for clinical CMRs is recommended.
Abstract: Extracellular volume fraction (ECV) is altered in pathological cardiac remodeling and predicts death and arrhythmia. ECV can be quantified using cardiovascular magnetic resonance (CMR) T1 mapping but calculation requires a measured hematocrit (Hct). The longitudinal relaxation of blood has been used in adults to generate a synthetic Hct (estimate of true Hct) but has not been validated in pediatric populations. One hundred fourteen children and young adults underwent a total of 163 CMRs with T1 mapping. The majority of subjects had a measured Hct the same day (N = 146). Native and post-contrast T1 were determined in blood pool, septum, and free wall of mid-LV, avoiding areas of late gadolinium enhancement. Synthetic Hct and ECV were calculated and intraclass correlation coefficient (ICC) and linear regression were used to compare measured and synthetic values. The mean age was 16.4 ± 6.4 years and mean left ventricular ejection fraction was 59% ± 9%. The mean measured Hct was 41.8 ± 3.0% compared to the mean synthetic Hct of 43.2% ± 2.9% (p < 0.001, ICC 0.46 [0.27, 0.52]) with the previously published model and 41.8% ± 1.4% (p < 0.001, ICC 0.28 [0.13, 0. 42]) with the locally-derived model. Mean measured mid-free wall ECV was 30.5% ± 4.8% and mean synthetic mid-free wall ECV of local model was 29.7% ± 4.6% (p < 0.001, ICC 0.93 [0.91, 0.95]). Correlations were not affected by heart rate and did not significantly differ in subpopulation analysis. While the ICC was strong, differences between measured and synthetic ECV ranged from −8.4% to 4.3% in the septum and −12.6% to 15.8% in the free wall. Using our laboratory’s normal cut-off of 28.5%, 59 patients (37%) were miscategorized (53 false negatives, 6 false positives) with published model ECV. The local model had 37 miscategorizations (20 false negatives, 17 false positives), significantly fewer but still a substantial number (23%). Our data suggest that use of synthetic Hct for the calculation of ECV results in miscategorization of individual patients. This difference may be less significant once synthetic ECV is calculated and averaged over a large research cohort, making it potentially useful as a research tool. However, we recommend formal measurement of Hct in children and young adults for clinical CMRs.
Monroe Carell Jr. Children's Hospital at Vanderbilt1, Boston Children's Hospital2, University of Pennsylvania3, Children's Hospital of Philadelphia4, Harvard University5, University of Utah6, University of Washington7, Seattle Children's8, Children's National Medical Center9, George Washington University10, University of Toronto11, University of Cincinnati Academic Health Center12, Cincinnati Children's Hospital Medical Center13, Vanderbilt University Medical Center14
TL;DR: The publication of a national pneumonia guideline was associated with sustained increases in the use of penicillins for children hospitalized with pneumonia and local implementation efforts may have enhanced guideline adoption and appeared more relevant than hospitals’ organizational readiness to change.
Abstract: BACKGROUND: We evaluated the impact of the 2011 Pediatric Infectious Diseases Society/Infectious Diseases Society of America pneumonia guideline and hospital-level implementation efforts on antibiotic prescribing for children hospitalized with pneumonia. METHODS: We assessed inpatient antibiotic prescribing for pneumonia at 28 children’s hospitals between August 2009 and March 2015. Each hospital was also surveyed regarding local implementation efforts targeting antibiotic prescribing and organizational readiness to adopt guideline recommendations. To estimate guideline impact, we used segmented linear regression to compare the proportion of children receiving penicillins in March 2015 with the expected proportion at this same time point had the guideline not been published based on a projection of a preguideline trend. A similar approach was used to estimate the short-term (6-month) impact of local implementation efforts. The correlations between organizational readiness and the impact of the guideline were estimated by using Pearson’s correlation coefficient. RESULTS: Before guideline publication, penicillin prescribing was rare ( n = 20, 71%), the median increase was 29.5% (interquartile range: 19.6%–39.1%) compared with 20.1% (interquartile rage: 9.5%–44.5%) among hospitals without such activities ( P = .51). The independent, short-term impact of local implementation efforts was similar in magnitude to that of the national guideline. Organizational readiness was not correlated with prescribing changes. CONCLUSIONS: The publication of the Pediatric Infectious Diseases Society/Infectious Diseases Society of America guideline was associated with sustained increases in the use of penicillins for children hospitalized with pneumonia. Local implementation efforts may have enhanced guideline adoption and appeared more relevant than hospitals’ organizational readiness to change.
TL;DR: Urodynamic studies are crucial to neuropathic bladder management and they often determine surgical intervention, but current evidence indicates that interpretations show poor agreement across physicians, so further work is needed to standardize the reporting and interpretation of urod dynamic studies to optimize patient care.
TL;DR: A comprehensive review of ETV/CPC is offered beginning with the history and theory behind the operation, then the data supporting its use across heterogeneous pediatric populations, and finally the clinical outcomes and future directions are discussed.
Abstract: In the quest to identify the optimal means of cerebrospinal fluid diversion free of shunt dependency, endoscopic third ventriculostomy (ETV) with choroid plexus cauterization (CPC) has been proposed as a promising procedure in select children. Supplementing traditional ETV with obliteration of the choroid plexus has been shown to decrease the likelihood of ultimate shunt dependency by roughly 20%. Originally devised to treat hydrocephalus in infants in sub-Saharan Africa, ETV/CPC has gained eager attention and cautious support in the developed world. Herein, we offer a comprehensive review of ETV/CPC beginning with the history and theory behind the operation. Next, we delve into the data supporting its use across heterogeneous pediatric populations, and finally we discuss clinical outcomes and future directions.
TL;DR: In this paper, nonsteroidal anti-inflammatory drugs were used to induce PDA closure in infants born preterm, and were shown to be effective for a select population of fragile preterm infants.
Boston Children's Hospital1, Harvard University2, Brigham and Women's Hospital3, Partners HealthCare4, University of Colorado Denver5, University of Alberta6, Monroe Carell Jr. Children's Hospital at Vanderbilt7, Stanford University8, University of California, San Francisco9, Children's Hospital of Philadelphia10, Morgan Stanley Children's Hospital11, University of Illinois at Chicago12
TL;DR: Mining of EHRs using computable phenotypes identified a large cohort of patients not recruited using a classic registry, suggesting fusion of E HR and registry data can improve cohort ascertainment for the study of rare diseases.
TL;DR: The HVP was designed to reduce emergency department visits and asthma related hospitalizations in PASC patients and provide clinical experiences for nursing students and increased PASC knowledge of asthma triggers in the home and increased student knowledge and skills related to asthma management.