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Background: Inpatient procedures are common and important health events for older Americans. To facilitate surgical outcomes research, we sought to create and evaluate lists of International Classification of Disease, Tenth Revision (ICD‐10) codes for high‐risk inpatient procedures, defined as having at least a 1% inpatient mortality. Methods: This retrospective national cohort study analyzes Medicare claims from 2018 for patients 65 years and older undergoing inpatient procedures. Surgical Diagnosis Related Group (DRG) codes in the inpatient claims were used to identify procedures. We identified the primary ICD‐10 procedure code for each patient and then compiled all codes with at least a 1% inpatient mortality yielding three separate lists: one list that was blind to elective versus urgent/emergent status, and one each for urgent/emergent and elective procedures. Clinical review by three surgeons was used to remove procedures unlikely to be the proximate cause of mortality. For evaluation, we examined the mortality of each code among fee‐for‐service Medicare beneficiaries in 2017, 2019, and 2020 to determine how many of these satisfied the 1% mortality criterion. Results: This study included 2,241,419 patients from 2018 undergoing inpatient procedures. The final result included 231 (blind to elective vs urgent/emergent status), 167 (urgent/emergent status), and 119 (elective status) ICD‐10 procedure codes for the three lists. Our evaluation from 2017, 2019, and 2020 demonstrated that in our master list, which was blind to elective versus urgent/emergent status, 97.8% of procedures had an inpatient mortality of at least 1%. In our high‐risk procedures lists for urgent/emergent and elective procedures, 100% and 94.1% of codes met this requirement. Conclusions: We developed and evaluated lists of ICD‐10 codes representing high‐risk procedures in patients 65 years and older. These lists will be powerful tools for researchers studying surgical outcomes. [ABSTRACT FROM AUTHOR]

Objective: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) is an important data source for observational studies. While there are guides to ensure appropriate study reporting, there has been no evaluation of NSQIP studies in vascular surgery. We sought to evaluate the adherence of vascular-surgery related NSQIP studies to best reporting practices. Methods: In January 2022, we queried PubMed for all vascular surgery NSQIP studies. We used the REporting of studies Conducted using Observational Routinely-collected Health Data (RECORD) statement and the JAMA Surgery (JAMA-Surgery) checklist to assess reporting methodology. We also extracted the Journal Impact Factor (IF) of each article. Results: One hundred and fifty-nine studies published between 2002 and 2022 were identified and analyzed. The median score on the RECORD statement was 6 out of 8. The most commonly missed RECORD statement items were describing any validation of codes and providing data cleaning information. The median score on the JAMA-Surgery checklist was 2 out of 7. The most commonly missed JAMA-Surgery checklist items were identifying competing risks, using flow charts to help visualize study populations, having a solid research question and hypothesis, identifying confounders, and discussing the implications of missing data. We found no difference in the reporting methodology of studies published in high vs low IF journals. Conclusion: Vascular surgery studies using NSQIP data demonstrate poor adherence to research reporting standards. Critical areas for improvement include identifying competing risks, including a solid research question and hypothesis, and describing any validation of codes. Journals should consider requiring authors use reporting guides to ensure their articles have stringent reporting methodology. [ABSTRACT FROM AUTHOR]

Background: Chronic limb-threatening ischemia (CLTI) can be associated with dismal outcomes but there are limited real-world data to further define the impact of end-stage kidney disease (ESKD) on outcomes nationally in this subset of patients. We sought to characterize national patterns of inpatient treatment of CLTI and compare outcomes in patients without ESKD. Methods: The National Inpatient Sample was queried from 2015-2018 for all hospital admissions including treatment for CLTI. Mixed-effects linear and logistic regression models were used to estimate the effect of ESKD on outcomes and treatment choice. Results: We identified 11 652 hospital admissions with CLTI alone and 2705 with CLTI + ESKD. Hospital admissions with CLTI + ESKD patients included patients who were younger (66 vs 69 years, P <.0001), less likely to be white (39% vs 63%, P <.0001), and more likely to reside in lower income large metropolitan areas. Admissions for CLTI + ESKD patients had a lower likelihood of open arterial reconstruction (OR.40, P <.0001) and a higher likelihood of endovascular revascularization or major limb amputation (OR 1.70, P <.0001). Admissions for CLTI + ESKD also had a 4.5- and 1.5-fold higher odds of in-hospital death and complications. These findings were associated with a longer LOS (P <.0001), increased probability of discharge to rehabilitation facility (50% vs 41%, P <.0001), and greater hospital charges (median, $107 K vs $85 K, P <.0001). Conclusions: Compared to hospital admissions for patients without ESKD, admissions for patients with CLTI + ESKD demonstrated distinctive demographic characteristics, a lower likelihood of open revascularization and a higher likelihood of endovascular revascularization and major limb amputation. Chronic limb-threatening ischemia + ESKD hospital admissions showed worse overall outcomes and greater resource utilization compared to CLTI admissions without ESKD. [ABSTRACT FROM AUTHOR]

Background The absence of consensus for outcomes in pediatric antibiotic trials is a major barrier to research harmonization and clinical translation. We sought to develop expert consensus on study outcomes for clinical trials of children with mild community-acquired pneumonia (CAP). Methods Applying the Delphi method, a multispecialty expert panel ranked the importance of various components of clinical response and treatment failure outcomes in children with mild CAP for use in research. During Round 1, panelists suggested additional outcomes in open-ended responses that were added to subsequent rounds of consensus building. For Rounds 2 and 3, panelists were provided their own prior responses and summary statistics for each item in the previous round. The consensus was defined by >70% agreement. Results The expert panel determined that response to and failure of treatment should be addressed at a median of 3 days after initiation. Complete or substantial improvement in fever, work of breathing, dyspnea, tachypnea when afebrile, oral intake, and activity should be included as components of adequate clinical response outcomes. Clinical signs and symptoms including persistent or worsening fever, work of breathing, and reduced oral intake should be included in treatment failure outcomes. Interventions including receipt of parenteral fluids, supplemental oxygen, need for high-flow nasal cannula oxygen therapy, and change in prescription of antibiotics should also be considered in treatment failure outcomes. Conclusions Clinical response and treatment failure outcomes determined by the consensus of this multidisciplinary expert panel can be used for pediatric CAP studies to provide objective data translatable to clinical practice. [ABSTRACT FROM AUTHOR]

The article discusses research which examined the frequency, timing and association of advance care planning (ACP) billing codes in fee-for-service Medicare patients undergoing transcatheter aortic valve replacement (TAVR) with adverse TAVR outcomes. The study analyzed the correlation of billed ACP with complication or death after surgery. It attributes the low uptake of ACP billing codes to ethical concerns, lack of resources, and health system incentives not aligned with ACP conversations.

We conducted a cross-sectional analysis to determine the rate of retention in HIV care and the factors associated with loss to follow-up (LTFU) among Omani adults living with HIV who were linked to care as of 31 December 2019. Patients (n = 1610) were identified from a central national HIV surveillance dataset. The majority (68.3%) of patients were male, and the median age was 39 years (IQR, 31–48 years). A total of 1480 patient (91.9%) were retained in care. On multivariate analysis, compared to those who received antiretroviral therapy (ART), patients who had never been on ART were 6.8 (95% CI: 3.05–15.16) times more likely to be lost to follow-up. Patients who had a latest HIV viral load (VL) of 200–999 copies/ml (adjusted odds ratio [aOR]: 4.92, 95% CI: 2.27–10.69) and ≥ 1000 copies/ml (aOR: 15.03, 95% CI: 8.31–27.19) compared to those who had a latest HIV VL of <200 copies/ml had higher odds of loss to follow-up. Moreover, patients who were divorced or widowed were 2.64 (95% CI: 1.14–6.07) times more likely to disengage from HIV services, compared to those who were married. These findings will be invaluable in developing targeted interventions that further improve patients' retention in HIV care in Oman. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Reutilization following discharge is costly to families and the health care system. Singular measures of the social determinants of health (SDOH) have been shown to impact utilization; however, the SDOH are multifactorial. The Childhood Opportunity Index (COI) is a validated approach for comprehensive estimation of the SDOH. Using the COI, we aimed to describe the association between SDOH and 30-day revisit rates. METHODS: This retrospective study included children 0 to 17 years within 48 children's hospitals using the Pediatric Health Information System from 1/1/2019 to 12/31/2019. The main exposure was a child's ZIP code level COI. The primary outcome was unplanned readmissions and emergency department (ED) revisits within 30 days of discharge. Primary outcomes were summarized by COI category and compared using chi-square or Kruskal-Wallis tests. Adjusted analysis used generalized linear mixed effects models with adjustments for demographics, clinical characteristics, and hospital clustering. RESULTS: Of 728,997 hospitalizations meeting inclusion criteria, 30-day unplanned returns occurred for 96,007 children (13.2%). After adjustment, the patterns of returns were significantly associated with COI. For example, 30-day returns occurred for 19.1% (95% confidence interval [CI]: 18.2, 20.0) of children living within very low opportunity areas, with a gradient-like decrease as opportunity increased (15.5%, 95% CI: 14.5, 16.5 for very high). The relative decrease in utilization as COI increased was more pronounced for ED revisits. CONCLUSIONS: Children living in low opportunity areas had greater 30-day readmissions and ED revisits. Our results suggest that a broader approach, including policy and system-level change, is needed to effectively reduce readmissions and ED revisits. [ABSTRACT FROM AUTHOR]

Background Although community-acquired pneumonia (CAP) is one of the most common infections in children, no tools exist to risk stratify children with suspected CAP. We developed and validated a prediction model to risk stratify and inform hospitalization decisions in children with suspected CAP. Methods We performed a prospective cohort study of children aged 3 months to 18 years with suspected CAP in a pediatric emergency department. Primary outcome was disease severity, defined as mild (discharge home or hospitalization for <24 hours with no oxygen or intravenous [IV] fluids), moderate (hospitalization <24 hours with oxygen or IV fluids, or hospitalization >24 hours), or severe (intensive care unit stay for >24 hours, septic shock, vasoactive agents, positive-pressure ventilation, chest drainage, extracorporeal membrane oxygenation, or death). Ordinal logistic regression and bootstrapped backwards selection were used to derive and internally validate our model. Results Of 1128 children, 371 (32.9%) developed moderate disease and 48 (4.3%) severe disease. Severity models demonstrated excellent discrimination (optimism-corrected c-indices of 0.81) and outstanding calibration. Severity predictors in the final model included respiratory rate, systolic blood pressure, oxygenation, retractions, capillary refill, atelectasis or pneumonia on chest radiograph, and pleural effusion. Conclusions We derived and internally validated a score that accurately predicts disease severity in children with suspected CAP. Once externally validated, this score has potential to facilitate management decisions by providing individualized risk estimates that can be used in conjunction with clinical judgment to improve the care of children with suspected CAP. [ABSTRACT FROM AUTHOR]

Background Proadrenomedullin (proADM), a vasodilatory peptide with antimicrobial and anti-inflammatory properties, predicts severe outcomes in adults with community-acquired pneumonia (CAP) to a greater degree than C-reactive protein and procalcitonin. We evaluated the ability of proADM to predict disease severity across a range of clinical outcomes in children with suspected CAP. Methods We performed a prospective cohort study of children 3 months to 18 years with CAP in the emergency department. Disease severity was defined as mild (discharged home), mild–moderate (hospitalized but not moderate–severe or severe), moderate–severe (eg, hospitalized with supplemental oxygen, broadening of antibiotics, complicated pneumonia), and severe (eg, vasoactive infusions, chest drainage, severe sepsis). Outcomes were examined using proportional odds logistic regression within the cohort with suspected CAP and in a subset with radiographic CAP. Results Among 369 children, median proADM increased with disease severity (mild: median [IQR], 0.53 [0.43–0.73]; mild–moderate: 0.56 [0.45–0.71]; moderate–severe: 0.61 [0.47–0.77]; severe: 0.70 [0.55–1.04] nmol/L) (P  = .002). ProADM was significantly associated with increased odds of developing severe outcomes (suspected CAP: OR, 1.68; 95% CI, 1.2–2.36; radiographic CAP: OR, 2.11; 95% CI, 1.36–3.38) adjusted for age, fever duration, antibiotic use, and pathogen. ProADM had an AUC of 0.64 (95% CI,.56–.72) in those with suspected CAP and an AUC of 0.77 (95% CI,.68–.87) in radiographic CAP. Conclusions ProADM was associated with severe disease and discriminated moderately well children who developed severe disease from those who did not, particularly in radiographic CAP. [ABSTRACT FROM AUTHOR]

Background Globally, pneumonia is the leading cause of death among children. Few data exist regarding the effect of Haemophilus influenzae type b (Hib) vaccine and 13-valent pneumococcal conjugate vaccine (PCV-13) on the burden of childhood pneumonia in African settings. Methods We collected data on children aged 1 to 59 months at 3 hospitals in Botswana. Hib vaccine and PCV-13 were introduced in Botswana in November 2010 and July 2012, respectively. We compared pneumonia hospitalizations and deaths prevaccine (January 2009 to October 2010) with postvaccine (January 2013 to December 2017) using seasonally adjusted, interrupted time-series analyses. Results We identified 6943 pneumonia hospitalizations and 201 pneumonia deaths. In the prevaccine period, pneumonia hospitalizations and deaths increased by 24% (rate, 1.24; 95% CI,.94–1.64) and 59% (rate, 1.59; 95% CI,.87–2.90) per year, respectively. Vaccine introduction was associated with a 48% (95% CI, 29–62%) decrease in the number of pneumonia hospitalizations and a 50% (95% CI, 1–75%) decrease in the number of pneumonia deaths between the end of the prevaccine period (October 2010) and the beginning of the postvaccine period (January 2013). During the postvaccine period, pneumonia hospitalizations and deaths declined by 6% (rate,.94; 95% CI,.89–.99) and 22% (rate,.78; 95% CI,.67–.92) per year, respectively. Conclusions Pneumonia hospitalizations and deaths among children declined sharply following introduction of Hib vaccine and PCV-13 in Botswana. This effect was sustained for more than 5 years after vaccine introduction, supporting the long-term effectiveness of these vaccines in preventing childhood pneumonia in Botswana. [ABSTRACT FROM AUTHOR]

Hypoxia plays a major role in cell survival, angiogenesis, glycolytic metabolism and metastasis in breast cancer. Hyperbaric oxygen therapy (HBOT) has a well-established effect for attenuating the effects of hypoxia by enhancing the effects of chemotherapy drugs and increasing oxygen delivery to the tissues. The hypoxic environment encourages cancer cells to acquire stemness and become resistant to chemotherapeutic drugs. We have used HBOT as an adjunct to neoadjuvant chemotherapy in breast cancer patients with the objective of reducing tumour hypoxia and improving the response to chemotherapy. A randomised controlled trial was conducted in patients with breast cancer. The patients were randomly allocated into the study group receiving neoadjuvant chemotherapy (NAC) with HBOT and the control group who received NAC only. The NAC consisted of 3 cycles of intravenous injection of cyclophosphamide, 5-fluorouracil and epirubicin. The HBOT was administered along with the chemotherapy in 3 sessions in each cycle at graded pressures in each sessions. Ultrasound evaluation of patients was carried out and breast tumour size was measured after every cycle of HBOT. All the patients were operated after 3 cycles of chemotherapy and modified radical mastectomy was carried out. The response of therapy was recorded in both the groups. Patients receiving HBOT achieved significantly higher percentage reduction of tumour volume (43.1%) and the largest dimension (80.21%) (p < 0.0001) compared with those receiving chemotherapy alone. Trial registry: CTRI/2019/03/018258 [ABSTRACT FROM AUTHOR]

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Background Human immunodeficiency virus–exposed but uninfected (HIV-EU) children have a higher mortality rate than the children of HIV-negative mothers (HIV-unexposed). Causal mediators of the poor health outcomes of HIV-EU children remain poorly defined. Methods We conducted a hospital-based prospective cohort study of children aged 1 to 23 months with clinically defined pneumonia. The children were recruited at a referral hospital in Gaborone, Botswana, between April 2012 and June 2016. The primary outcome, treatment failure at 48 hours, was assessed by an investigator blinded to the children's HIV-exposure status. We examined associations between HIV exposure and pneumonia outcomes in HIV-uninfected children. We next determined whether the effect of HIV exposure on outcomes was mediated by low-birth-weight status, nonbreastfeeding, malnutrition, in utero exposure to combination antiretroviral therapy, or pneumonia severity. Results A total of 352 HIV-uninfected children were included in these analyses, including 245 (70%) HIV-unexposed and 107 (30%) HIV-EU children. Their median age was 7.4 months, and 57% were male. Treatment failure occurred in 111 (32%) children, and 19 (5.4%) children died. HIV-EU children were more likely to fail treatment (risk ratio [RR], 1.57 [95% confidence interval (CI), 1.19–2.07]; P =.002) and had a higher in-hospital mortality rate (RR, 4.50 [95% CI, 1.86–10.85]; P =.001) than HIV-unexposed children. Nonbreastfeeding mediated 47% of the effect of HIV exposure on the risk of in-hospital death. Conclusions HIV-EU children have worse pneumonia outcomes than HIV-unexposed children. Nonbreastfeeding mediates nearly half of the effect of HIV exposure on pneumonia mortality. Our findings provide additional evidence for a mortality benefit of breastfeeding by HIV-EU children. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVES: Adults with a history of adverse childhood experiences (ACEs) (eg, abuse) have suboptimal health outcomes. Resilience may blunt this effect. The effect of parental ACEs (and resilience) on coping with challenges involving their children (eg, hospitalization) is unclear. We sought to quantify ACE and resilience scores for parents of hospitalized children and evaluate their associations to parental coping after discharge. METHODS: We conducted a prospective cohort study at a children's hospital (August 2015-May 2016). Eligible participants were English-speaking parents of children hospitalized on the Hospital Medicine or Complex Services team. The ACE questionnaire measured the responding parent's past adversity (ACE range: 0-10; ≥4 ACEs = high adversity). The Brief Resilience Scale (BRS) was used to measure their resilience (range: 1-5; higher is better). The primary outcome was measured by using the Post-Discharge Coping Difficulty Scale via a phone call 14 days post-discharge (range: 0-100; higher is worse). Associations were assessed by using multivariable linear regression, adjusting for parent- and patient-level covariates. RESULTS: A total of 671 (81% of eligible parents) responded. Respondents were primarily women (90%), employed (66%), and had at least a high school degree (65%); 60% of children were white, 54% were publicly insured. Sixty-four percent of parents reported >1 ACE; 19% had >4 ACEs. The mean Brief Resilience Scale score for parents was 3.95. In adjusted analyses, higher ACEs and lower resilience were significantly associated with more difficulty coping after discharge. CONCLUSIONS: More parental adversity and less resilience are associated with parental coping difficulties after discharge, representing potentially important levers for transition-focused interventions. [ABSTRACT FROM AUTHOR]

The impact of dietary behaviors on health outcomes in youth with inflammatory bowel disease (IBD) is unclear. The present study examined dietary behaviors and their association with biomedical factors in youth with IBD. Eighty-six newly diagnosed youth (mean age = 12.6) were included in analyses. Biomedical factors included disease activity and inflammatory markers. Despite adequate total caloric intake, estimated nutrient and fruit and vegetable intakes were below recommended levels. There was a significant negative association between vegetable intake and C-Reactive Protein (p = 0.04). Results suggest that dietary behaviors play an important role in IBD health outcomes. [ABSTRACT FROM AUTHOR]

Aims The aims of this study were: (1) to explore the family perspective on pediatric hospital-to-home transitions; (2) to modify an existing nurse-delivered transitional home visit to better meet family needs; (3) to study the effectiveness of the modified visit for reducing healthcare re-use and improving patient- and family-centered outcomes in a randomized controlled trial. Background The transition from impatient hospitalization to outpatient care is a vulnerable time for children and their families; children are at risk for poor outcomes that may be mitigated by interventions to address transition difficulties. It is unknown if an effective adult transition intervention, a nurse home visit, improves postdischarge outcomes for children hospitalized with common conditions. Design (1) Descriptive qualitative; (2) Quality improvement; (3) Randomized controlled trial. Methods Aim 1 will use qualitative methods, through focus groups, to understand the family perspective of hospital-to-home transitions. Aim 2 will use quality improvement methods to modify the content and processes associated with nurse home visits. Modifications to visits will be made based on parent and stakeholder input obtained during Aims 1 & 2. The effectiveness of the modified visit will be evaluated in Aim 3 through a randomized controlled trial. Discussion We are undertaking the study to modify and evaluate a nurse home visit as an effective acute care pediatric transition intervention. We expect the results will be of interest to administrators, policy makers and clinicians interested in improving pediatric care transitions and associated postdischarge outcomes, in the light of impending bundled payment initiatives in pediatric care. [ABSTRACT FROM AUTHOR]

Background: Tissue loss or gangrene in the setting of lower extremity peripheral artery disease (PAD) may result in amputation. Previous studies have demonstrated elevated mortality rates after major transtibial and transfemoral amputation. Also, amputation of 1 leg may be associated with subsequent major amputation of the contralateral leg. The aim of our study was to identify patient variables associated with mortality and contralateral amputation. Methods: We reviewed the medical records of patients who underwent transfemoral or transtibial amputation secondary to PAD from 2004 to 2009. A total of 454 consecutive major amputations were performed on 391 patients, with 63 of these having a subsequent contralateral amputation. Standard demographic information, comorbidities, prior vascular interventions, and relevant procedural information were extracted from patient records. Kaplan-Meier estimates of survival were calculated. Cox proportional hazard models were used to estimate the risk of death and contralateral amputation. Multivariate Cox proportional hazards models were fit for all variables shown to be marginally associated in the univariate model. Results: In 391 amputees, the mean age was 67.3 years, 63% were male and 62% were caucasian. Patients had high rates of diabetes (63%), hypertension (83%), renal insufficiency (35%), hyperlipidemia (51%), and prior ipsilateral vascular intervention (75%). Seventy percent of patients had below-knee amputations. Perioperative mortality was 9.2% (n ¼ 36). Survival at 12 and 24 months was 70% (95% confidence interval [CI], 65%-74%) and 60% (95% CI, 55%-65%), respectively. Multivariate analysis demonstrated that several independent factors were detrimental to survival including chronic obstructive pulmonary disease (hazard ratio [HR] 1.82, P ¼ .002), dialysis dependence (HR 2.50, P < .001), high cardiac risk (HR 2.20, P < .001), and guillotine amputation (HR 2.49, P ¼ .004). Dialysis (HR 2.42, P ¼ .002) and revision of the index ipsilateral amputation to a higher level (HR 2.02, P ¼ .014) were associated with a subsequent contralateral amputation. Conclusions: Patients with advanced PAD that require lower extremity amputation have diminished survival and significant contralateral amputation rates. Elderly patients on dialysis are particularly prone to dying or losing the other leg after a major amputation. These data support strategies to enhance limb preservation and optimize medical comorbidities in these patients. [ABSTRACT FROM AUTHOR]

The article discusses research which determined differences in clinical outcomes, hospital costs and related hospital readmissions among children with acute hematogenous osteomyelitis on the basis of timing of surgical procedures. The study identified interventional radiology and bedside aspiration procedures. It evaluated outcomes across patient groups by age, race, ethnicity, payer status, admission season, critical illness and emergency department visit without admission.

BACKGROUND AND OBJECTIVES: Treatment of retropharyngeal abscesses (RPAs) and parapharyngeal abscesses (PPAs) includes antibiotics, with possible surgical drainage. Although corticosteroids may decrease inflammation, their role in the management of RPAs and PPAs is unclear. We evaluated the association of corticosteroid administration as part of initial medical management on drainage rates and length of stay for children admitted with RPAs and PPAs. METHODS: We conducted a retrospective study using administrative data of children aged 2 months to 8 years discharged with RPAs and PPAs from 2016 to 2019. Exposure was defined as systemic corticosteroids administered as part of initial management. Primary outcome was surgical drainage. Bivariate comparisons were made between patients in the corticosteroid and noncorticosteroid groups by using Wilcoxon rank or x2 tests. Outcomes were modeled by using generalized linear mixed-effects models. RESULTS: Of the 2259 patients with RPAs and PPAs, 1677 (74.2%) were in the noncorticosteroid group and 582 (25.8%) were in the corticosteroid group. There were no significant differences in age, sex, or insurance status. There was a lower rate of drainage in the corticosteroid cohort (odds ratio: 0.28; confidence interval: 0.22--0.36). Patients in this group were more likely to have repeat computed tomography imaging performed, had lower hospital costs, and were less likely to have opioid medications administered. The corticosteroid cohort had a higher 7-day emergency department revisit rate, but there was no difference in length of stay (rate ratio 0.97; confidence interval: 0.92--1.02). CONCLUSIONS: Corticosteroids were associated with lower odds of surgical drainage among children with RPAs and PPAs. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVES: Time to clinical stability (TCS) is a commonly used outcome in adults with community-acquired pneumonia (CAP), yet few studies have evaluated TCS in children. Our objective was to determine the association between TCS and disease severity in children with suspected CAP, as well as factors associated with reaching early stability. METHODS: This is a prospective cohort study of children (aged 3 months to 18 years) hospitalized with suspected CAP. TCS parameters included temperature, heart rate, respiratory rate, and hypoxemia with the use of supplemental oxygen. TCS was defined as time from admission to parameter normalization. The association of TCS with severity and clinical factors associated with earlier TCS were evaluated. RESULTS: Of 571 children, 187 (32.7%) had at least 1 abnormal parameter at discharge, and none had $3 abnormal discharge parameters. A greater proportion of infants (90 [93%]) had all 4 parameters stable at discharge compared with 12- to 18-year-old youths (21 [49%]). The median TCS for each parameter was <24 hours. Younger age, absence of vomiting, diffusely decreased breath sounds, and normal capillary refill were associated with earlier TCS. Children who did not reach stability were not more likely to revisit after discharge. CONCLUSIONS: A TCS outcome consisting of physiologic variables may be useful for objectively assessing disease recovery and clinical readiness for discharge among children hospitalized with CAP. TCS may decrease length of stay if implemented to guide discharge decisions. Clinicians can consider factors associated with earlier TCS for management decisions. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Validated prognostic tools for pediatric community-acquired pneumonia (CAP) do not exist. Thus, clinicians rely on "gestalt" in management decisions for children with CAP. We sought to determine the ability of clinician gestalt to predict severe outcomes. METHODS: We performed a prospective cohort study of children 3 months to 18 years old presenting to a pediatric emergency department (ED) with lower respiratory infection and receiving a chest radiograph for suspected CAP from 2013 to 2017. Clinicians reported the probability that the patient would develop severe complications of CAP (defined as respiratory failure, empyema or effusion, lung abscess or necrosis, metastatic infection, sepsis or septic shock, or death). The primary outcome was development of severe complications. RESULTS: Of 634 children, 37 (5.8%) developed severe complications. Of children developing severe complications after the ED visit, 62.1% were predicted as having <10% risk by the ED clinician. Sensitivity was >90% at the <1% predicted risk threshold, whereas specificity was >90% at the 10% risk threshold. Gestalt performance was poor in the low-intermediate predicted risk category (1%--10%). Clinicians had only fair ability to discriminate children developing complications from those who did not (area under the receiver operator characteristic curve 0.747), with worse performance from less experienced clinicians (area under the receiver operator characteristic curve 0.693). CONCLUSIONS: Clinicians have only fair ability to discriminate children with CAP who develop severe complications from those who do not. Clinician gestalt performs best at very low or higher predicted risk thresholds, yet many children fall in the low-moderate predicted risk range in which clinician gestalt is limited. Evidence-based prognostic tools likely can improve on clinician gestalt, particularly when risk is low-moderate. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVES: Drug--drug interactions (DDIs) can cause adverse drug events, but little is known about DDI exposure in children in the outpatient setting. This study aimed to determine the prevalence of major DDI exposure and factors associated with higher DDI exposure rates among children in an outpatient setting. METHODS: We performed a cross-sectional study of children aged 0 to 18 years with $1 ambulatory encounter, and $2 dispensed outpatient prescriptions study using the 2019 Marketscan Medicaid database. DDIs (exposure to a major DDI for $1 day) and the adverse physiologic effects of each DDI were identified using DrugBank's interaction database. Primary outcomes included the prevalence and rate of major DDI exposure. We used logistic regression to assess patient characteristics associated with DDI exposure. We examined the rate of DDI exposures per 100 children by adverse physiologic effects category, and organ-level effects (eg, heart rate-corrected QT interval prolongation). RESULTS: Of 781 019 children with $2 medication exposures, 21.4% experienced $1 major DDI exposure. The odds of DDI exposure increased with age and with medical and mental health complexity. Frequently implicated drugs included: Clonidine, psychiatric medications, and asthma medications. The highest adverse physiologic effect exposure rate per 100 children included: Increased drug concentrations (14.6), central nervous system depression (13.6), and heart rate-corrected QT interval prolongation (9.9). CONCLUSIONS: One in 5 Medicaid-insured children with $2 prescription medications were exposed to major DDIs annually, with higher exposures in those with medical or mental health complexity. DDI exposure places children at risk for negative health outcomes and adverse drug events, especially in the harder-to-monitor outpatient setting. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVES: Multisystem inflammatory syndrome in children (MIS-C) is a novel, severe condition following severe acute respiratory syndrome coronavirus 2 infection. Large epidemiologic studies comparing MIS-C to Kawasaki disease (KD) and evaluating the evolving epidemiology of MIS-C over time are lacking. We sought to understand the illness severity of MIS-C compared with KD and evaluate changes in MIS-C illness severity over time during the coronavirus disease 2019 pandemic compared with KD. METHODS: We included hospitalizations of children with MIS-C and KD from April 2020 to May 2022 from the Pediatric Health Information System administrative database. Our primary outcome measure was the presence of shock, defined as the use of vasoactive/inotropic cardiac support or extracorporeal membrane oxygenation. We examined the volume of MIS-C and KD hospitalizations and the proportion of hospitalizations with shock over time using 2-week intervals. We compared the proportion of hospitalizations with shock in MIS-C and KD patients over time using generalized estimating equations adjusting for hospital clustering and age, with time as a fixed effect. RESULTS: We identified 4868 hospitalizations for MIS-C and 2387 hospitalizations for KD. There was a higher proportion of hospitalizations with shock in MIS-C compared with KD (38.7% vs 5.1%). In our models with time as a fixed effect, we observed a significant decrease in the odds of shock over time in MIS-C patients (odds ratio 0.98, P < .001) but not in KD patients (odds ratio 1.00, P 5 .062). CONCLUSIONS: We provide further evidence that MIS-C is a distinct condition from KD. MIS-C was a source of lower morbidity as the pandemic progressed. [ABSTRACT FROM AUTHOR]

BACKGROUND: Antibiotics are frequently used for community-acquired pneumonia (CAP), although viral etiologies predominate.We sought to determine factors associated with antibiotic use among children hospitalized with suspected CAP. METHODS: We conducted a prospective cohort study of children who presented to the emergency department (ED) and were hospitalized for suspected CAP. We estimated risk factors associated with receipt of ≥1 dose of inpatient antibiotics and a full treatment course using multivariable Poisson regression with an interaction term between chest radiograph (CXR) findings and ED antibiotic use. We performed a subgroup analysis of children with nonradiographic CAP. RESULTS: Among 477 children, 60% received inpatient antibiotics and 53% received a full course. Factors associated with inpatient antibiotics included antibiotic receipt in the ED (relative risk 4.33 [95% confidence interval, 2.63-7.13]), fever (1.66 [1.22-2.27]), and use of supplemental oxygen (1.29 [1.11-1.50]). Children with radiographic CAP and equivocal CXRs had an increased risk of inpatient antibiotics compared with those with normal CXRs, but the increased risk was modest when antibiotics were given in the ED. Factors associated with a full course were similar. Among patients with nonradiographic CAP, 29% received inpatient antibiotics, 21% received a full course, and ED antibiotics increased the risk of inpatient antibiotics. CONCLUSIONS: Inpatient antibiotic utilization was associated with ED antibiotic decisions, CXR findings, and clinical factors. Nearly one-third of children with nonradiographic CAP received antibiotics, highlighting the need to reduce likely overuse. Antibiotic decisions in the ED were strongly associated with decisions in the inpatient setting, representing a modifiable target for future interventions. [ABSTRACT FROM AUTHOR]

BACKGROUND: Observation status (OBS) stays incur similar costs to low-acuity, short-stay inpatient (IP) hospitalizations. Despite this, payment for OBS is likely less and may represent a financial liability for children's hospitals. Thus, we described the financial outcomes associated with OBS stays compared to similar IP stays by hospital and payer. METHODS: We conducted a retrospective cohort study of clinically similar pediatric OBS and IP encounters at 15 hospitals contributing to the revenue management program in 2017. Clinical and demographic characteristics were described. For each hospitalization, the cost coverage ratio (CCR) was calculated by dividing revenue by estimated cost of hospitalization. Differences in CCR were evaluated using Wilcoxon rank sum tests and results were stratified by billing designation and payer. CCR for OBS and IP stays were compared by institution, and the estimated increase in revenue by billing OBS stays as IP was calculated. RESULTS: OBS was assigned to 70 981 (56.9%) of 124 789 hospitalizations. Use of OBS varied across hospitals (8%-86%). For included hospitalizations, OBS stays were more likely than IP stays to result in financial loss (57.0% vs 35.7%). OBS stays paid by public payer had the lowest median CCR (0.6; interquartile range [IQR], 0.2-0.9). Paying OBS stays at the median IP rates would have increased revenue by $167 million across the 15 hospitals. CONCLUSIONS: OBS stays were significantly more likely to result in poor financial outcomes than similar IP stays. Costs of hospitalization and billing designations are poorly aligned and represent an opportunity for children's hospitals and payers to restructure payment models. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic has led to changes in health care use, including decreased emergency department visits for children. In this study, we sought to describe the impact of the COVID-19 pandemic on inpatient use within children's hospitals. METHODS: We performed a retrospective study using the Pediatric Health Information System. We compared inpatient use and clinical outcomes for children 0 to 18 years of age during the COVID-19 period (March 15 to August 29, 2020) to the same time frame in the previous 3 years (pre-COVID-19 period). Adjusted generalized linear mixed models were used to examine the association of the pandemic period with inpatient use. We assessed trends overall and for a subgroup of 15 medical All Patient Refined Diagnosis Related Groups (APR-DRGs). RESULTS: We identified 424 856 hospitalizations (mean: 141 619 hospitalizations per year) in the pre-COVID-19 period and 91 532 in the COVID-19 period. Compared with the median number of hospitalizations in the pre-COVID-19 period, we observed declines in hospitalizations overall (35.1%), and by APR-DRG (range: 8.5%--81.3%) with asthma (81.3%), bronchiolitis (80.1%), and pneumonia (71.4%) experiencing the greatest declines. Overall readmission rates were lower during the COVID-19 period; however, other outcomes, including length of stay, cost, ICU use, and mortality remained similar to the pre-COVID-19 period with some variability by APR-DRGs. CONCLUSIONS: US children's hospitals observed substantial reductions in inpatient admissions with largely unchanged hospital-level outcomes during the COVID-19 pandemic. Although the impact on use varied by condition, the most notable declines were related to inpatient admissions for respiratory conditions, including asthma, bronchiolitis, and pneumonia. [ABSTRACT FROM AUTHOR]

BACKGROUND: In several states, payers penalize hospitals when an inpatient readmission follows an inpatient stay. Observation stays are typically excluded from readmission calculations. Previous studies suggest inconsistent use of observation designations across hospitals. We sought to describe variation in observation stays and examine the impact of inclusion of observation stays on readmission metrics. METHODS: We conducted a retrospective cohort study of hospitalizations at 50 hospitals contributing to the Pediatric Health Information System database from January 1, 2018, to December 31, 2018. We examined prevalence of observation use across hospitals and described changes to inpatient readmission rates with higher observation use. We described 30-day inpatient-only readmission rates and ranked hospitals against peer institutions. Finally, we included observation encounters into the calculation of readmission rates and evaluated hospitals' change in readmission ranking. RESULTS: Most hospitals (n = 44; 88%) used observation status, with high variation in use across hospitals (0%-53%). Readmission rate after index inpatient stay (6.8%) was higher than readmission after an index observation stay (4.4%), and higher observation use by hospital was associated with higher inpatient-only readmission rates. When compared with peers, hospital readmission rank changed with observation inclusion (60% moving at least 1 quintile). CONCLUSIONS: The use of observation status is variable among children's hospitals. Hospitals that more liberally apply observation status perform worse on the current inpatient-to-inpatient readmission metric, and inclusion of observation stays in the calculation of readmission rates significantly affected hospital performance compared with peer institutions. Consideration should be given to include all admission types for readmission rate calculation. [ABSTRACT FROM AUTHOR]

BACKGROUND: Host biomarkers predict disease severity in adults with community-acquired pneumonia (CAP). We evaluated the association of the white blood cell (WBC) count, absolute neutrophil count (ANC), C-reactive protein (CRP), and procalcitonin with the development of severe outcomes in children with CAP. METHODS:We performed a prospective cohort study of children 3 months to 18 years of age with CAP in the emergency department. The primary outcome was disease severity: mild (discharged from the hospital), mild-moderate (hospitalized but not moderate-severe or severe), moderate-severe (eg, hospitalized with receipt of intravenous fluids, supplemental oxygen, complicated pneumonia), and severe (eg, intensive care, vasoactive infusions, chest drainage, severe sepsis). Outcomes were examined within the cohort with suspected CAP and in a subset with radiographic CAP. RESULTS: Of 477 children, there were no statistical differences in the median WBC count, ANC, CRP, or procalcitonin across severity categories. No biomarker had adequate discriminatory ability between severe and nonsevere disease (area under the curve [AUC]: 0.53-0.6 for suspected CAP and 0.59-0.64 for radiographic CAP). In analyses adjusted for age, antibiotic use, fever duration, and viral pathogen detection, CRP was associated with moderate-severe disease (odds ratio 1.12; 95% confidence interval, 1.0-1.25). CRP and procalcitonin revealed good discrimination of children with empyema requiring chest drainage (AUC: 0.83) and sepsis with vasoactive infusions (CRP AUC: 0.74; procalcitonin AUC: 0.78), although prevalence of these outcomes was low. CONCLUSIONS: WBC count, ANC, CRP, and procalcitonin are generally not useful to discriminate nonsevere from severe disease in children with CAP, although CRP and procalcitonin may have some utility in predicting the most severe outcomes. [ABSTRACT FROM AUTHOR]

background and objectives: Antibiotic therapy is often prescribed for suspected community-acquired pneumonia (CAP) in children despite a lack of knowledge of causative pathogen. Our objective in this study was to investigate the association between antibiotic prescription and treatment failure in children with suspected CAP who are discharged from the hospital emergency department (ED). methods: We performed a prospective cohort study of children (ages 3 months-18 years) who were discharged from the ED with suspected CAP. The primary exposure was antibiotic receipt or prescription. The primary outcome was treatment failure (ie, hospitalization after being discharged from the ED, return visit with antibiotic initiation or change, or antibiotic change within 7-15 days from the ED visit). The secondary outcomes included parent-reported quality-of-life measures. Propensity score matching was used to limit potential bias attributable to treatment selection between children who did and did not receive an antibiotic prescription. results: Of 337 eligible children, 294 were matched on the basis of propensity score. There was no statistical difference in treatment failure between children who received antibiotics and those who did not (odds ratio 1.0; 95% confidence interval 0.45-2.2). There was no difference in the proportion of children with return visits with hospitalization (3.4% with antibiotics versus 3.4% without), initiation and/or change of antibiotics (4.8% vs 6.1%), or parent-reported quality-of-life measures. conclusions: Among children with suspected CAP, the outcomes were not statistically different between those who did and did not receive an antibiotic prescription. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To derive and internally validate a prediction model for the identification of febrile infants ≤60 days old at low probability of invasive bacterial infection (IBI). METHODS: We conducted a case-control study of febrile infants ≤60 days old who presented to the emergency departments of 11 hospitals between July 1, 2011 and June 30, 2016. Infants with IBI, defined by growth of a pathogen in blood (bacteremia) and/or cerebrospinal fluid (bacterial meningitis), were matched by hospital and date of visit to 2 control patients without IBI. Ill-appearing infants and those with complex chronic conditions were excluded. Predictors of IBI were identified with multiple logistic regression and internally validated with 10-fold cross-validation, and an IBI score was calculated. RESULTS: We included 181 infants with IBI (155 [85.6%] with bacteremia without meningitis and 26 [14.4%] with bacterial meningitis) and 362 control patients. Twenty-three infants with IBI (12.7%) and 138 control patients (38.1%) had fever by history only. Four predictors of IBI were identified (area under the curve 0.83 [95% confidence interval (CI): 0.79-0.86]) and incorporated into an IBI score: age <21 days (1 point), highest temperature recorded in the emergency department 38.0-38.4°C (2 points) or ≥38.5°C (4 points), absolute neutrophil count ≥5185 cells per µL (2 points), and abnormal urinalysis results (3 points). The sensitivity and specificity of a score ≥2 were 98.8% (95% CI: 95.7%-99.9%) and 31.3% (95% CI: 26.3%-36.6%), respectively. All 26 infants with meningitis had scores ≥2. CONCLUSIONS: Infants ≤60 days old with fever by history only, a normal urinalysis result, and an absolute neutrophil count <5185 cells per µL have a low probability of IBI. [ABSTRACT FROM AUTHOR]

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 (<10%). After publication, an absolute increase in penicillin use was observed (27.6% [95% confidence interval: 23.7%-31.5%]) by March 2015. Among hospitals with local implementation efforts (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. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To examine recent national trends in psychotropic use for very young children at US outpatient medical visits. METHODS: Data for 2- to 5-year-old children (N = 43?598) from the 1994-2009 National Ambulatory and National Hospital Ambulatory Medical Care Surveys were used to estimate the weighted percentage of visits with psychotropic prescriptions. Multivariable logistic regression was used to identify factors associated with psychotropic use. Time effects were examined in 4-year blocks (1994-1997, 1998-2001, 2002-2005, and 2006-2009). RESULTS: Psychotropic prescription rates were 0.98% from 1994-1997, 0.83% from 1998-2001, 1.45% from 2002-2005, and 1.00% from 2006-2009. The likelihood of preschool psychotropic use was highest in 2002-2005 (1994-1997 adjusted odds ratio [AOR] versus 2002-2005: 0.67; 1998-2001 AOR versus 2002-2005: 0.63; 2006-2009 AOR versus 2002-2005: 0.64), then diminished such that the 2006-2009 probability of use did not differ from 1994-1997 or from 1998-2001. Boys (AOR versus girls: 1.64), white children (AOR versus other race: 1.42), older children (AOR for 4 to 5 vs 2 to 3 year olds: 3.87), and those lacking private insurance (AOR versus privately insured: 2.38) were more likely than children from other groups to receive psychotropic prescriptions. CONCLUSIONS: Psychotropic prescription was notable for peak usage in 2002-2005 and sociodemographic disparities in use. Further study is needed to discern why psychotropic use in very young children stabilized in 2006-2009, as well as reasons for increased use in boys, white children, and those lacking private health insurance. [ABSTRACT FROM AUTHOR]