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The global rise in non-communicable disease (NCD) suggests that US-based refugees are increasingly affected by chronic conditions. However, health services have focused on the detection of infectious disease, with relatively limited data on chronic NCDs. Using data from a retrospective medical record review of a refugee health program in the urban Northeast (n = 180), we examined the prevalence of chronic NCDs and NCD risk factors among adult refugees who had recently arrived in the US, with attention to region of origin and family composition. Family composition was included because low-income adults without dependent children are at high risk of becoming uninsured. We found that half of the adult refugees in this sample had at least one chronic NCD (51.1%), and 9.5% had three or more NCDs. Behavioral health diagnoses were most common (15.0%), followed by hypertension (13.3%). Half of adults were overweight or obese (54.6%). Chronic NCDs were somewhat more common among adults from Iraq, but this difference was not significant (56.8 vs. 44.6%). Chronic NCDs were common among adults with and without dependent children (61.4 vs. 44.6%, respectively), and these two groups did not significantly differ in their likelihood of having a chronic NCD after adjustment for age and gender (AOR = 0.78, 95% CI = 0.39, 1.55). This study suggests that chronic NCDs are common among adult refugees in the US, including refugees at high risk for uninsurance. We propose that refugee health services accommodate screening and treatment for chronic NCDs and NCD risk factors, and that insurance outreach and enrollment programs target recently arrived refugees.

BACKGROUND The start of transpyloric feedings is often delayed because of challenges in reliably placing tubes blindly at the bedside. OBJECTIVE To determine whether tube placement with the guidance of a noninvasive computerized electromagnetic device shortens the time needed to achieve accurate placement of transpyloric feeding tubes in critically ill children. METHODS In a prospective, randomized trial in a tertiary-care, university-affiliated pediatric intensive care unit, 49 children requiring transpyloric feeding tube placement were randomized to have their tube placed by using conventional blind technique or with the assistance of a noninvasive electromagnetic device. RESULTS Twenty-seven patients were randomized to blind placement, and 22 were randomized to the electromagnetic device group. The time required to place the tubes successfully was significantly longer (P < .03) in the electromagnetic device group (median, 9.5 minutes; 95% confidence interval, 7-13 minutes) compared with the conventional placement group (median, 5 minutes; 95% confidence interval, 4.0-7.0 minutes). CONCLUSIONS Placement of transpyloric feeding tubes with the guidance of a noninvasive electromagnetic device significantly increases the time required for accurate placement. Because placement of transpyloric feeding tubes in critically ill children is common practice in many pediatric intensive care units, technology that delays satisfactory placement may be counterproductive in experienced hands.

The objective of this study was to retrospectively evaluate the utility of serum neopterin as a diagnostic marker of hemophagocytic lymphohistiocytosis (HLH). The medical records of patients diagnosed with HLH (familial and secondary) between January 2000 and May 2009 were reviewed retrospectively, and clinical and laboratory information related to HLH criteria, in addition to neopterin levels, was recorded. A group of 50 patients with active juvenile dermatomyositis (JDM) (who routinely have neopterin levels assessed) served as controls for the assessment of the accuracy, sensitivity, and specificity of neopterin as a diagnostic test for HLH. The Pearson correlation was used to measure the association between serum neopterin levels and established HLH-related laboratory data. Serum neopterin levels were measured using a competitive enzyme immunoassay. During the time frame of the study, 3 patients with familial HLH and 18 patients with secondary HLH were identified as having had serum neopterin measured (all HLH patients were grouped together). The mean neopterin levels were 84.9 nmol/liter (standard deviation [SD], 83.4 nmol/liter) for patients with HLH and 21.5 nmol/liter (SD, 10.13 nmol/liter) for patients with JDM. A cutoff value of 38.9 nmol/liter was 70% sensitive and 95% specific for HLH. For HLH patients, neopterin levels correlated significantly with ferritin levels (r= 0.76,P= 0.0007). In comparison to the level in a control group of JDM patients, elevated serum neopterin was a sensitive and specific marker for HLH. Serum neopterin has value as a diagnostic marker of HLH, and prospective studies are under way to further evaluate its role as a marker for early diagnosis and management of patients.

Our objective was to examine clinical/electrocardiogram (ECG) predictors and outcomes of arrhythmias beyond 1 year after pediatric heart transplantation (HTx). We performed a retrospective chart review of 94 1-year HTx survivors, 1988–2006. Clinical records identified patients with arrhythmias occurring >1 year after HTx requiring pharmacotherapy, excluding acute rejection. We reviewed preoperative diagnosis, gender, age at HTx, operative details, transplant coronary artery disease (TCAD), and mortality. We analyzed serial ECGs after HTx for HR, PR, QRS, QT, and QTc intervals. Our results found complete data in 58 patients, 14 (24%) with arrhythmia and 44 controls. Arrhythmias occurred 1.1–17.9 years after HTx (mean = 6.8): 11 focal atrial tachycardia, 1 atrial fibrillation/flutter, 1 atrioventricular node reentry tachycardia; only 1 patient had ventricular tachycardia (VT). Serial ECG intervals were similar between groups, as well as surgical technique, ischemic time, and rejection history. Seven patients (50%) with arrhythmias had death or graft death versus 11% of the controls (P = 0.006). Patients with arrhythmias were more likely to be diagnosed with TCAD (P = 0.007). The patient with VT had no TCAD. In conclusion, supraventricular arrhythmias were frequent (22%) in 1-year survivors of pediatric HTx. These patients were more likely to develop TCAD and/or graft loss/mortality.

ADV has emerged as an important pathogen in children undergoing allogeneic HPCT. A prospective study of the epidemiology of ADV infection and preemptive therapy of high risk ADV infections in children undergoing HPCT was undertaken. Cultures of throat, urine, and stool for viral pathogens and plasma for ADV PCR were obtained prior to transplantation, weekly for the first 100 days, and then monthly for one yr. Children developing high-risk ADV infections were treated preemptively with cidofovir 1 mg/kg/day given three times weekly for three wk. A case-controlled study was performed to identify risk factors for high-risk ADV infections. Seven (18%) of the 38 subjects developed high-risk ADV infections usually within 100 days of HPCT and were preemptively treated with i.v. cidofovir at a dose of 1 mg/kg/dose three times weekly for nine doses. High-risk ADV infections resolved in all seven patients without renal toxicity. CMV viremia occurred in two of seven patients during or shortly after therapy with cidofovir. A case-control study did not identify any risk factors that achieved statistical significance. Treatment with a modified dosing regimen of cidofovir was well-tolerated and high-risk ADV infections resolved in all patients.

We hypothesized that transillumination would increase peripheral intravenous (IV) insertion success rates in pediatric emergency department patients. Primary outcome was success in first attempt, and secondary outcome was success within 2 attempts.We evaluated IV insertion by pediatric emergency department physicians and nurses using the Veinlite (TransLite, Sugar Land, Tex). Patients who required nonemergent IV insertion were enrolled if younger than 3 years or aged 3 to 21 years with a history of difficult access. Participants were randomly assigned to transillumination or nontransillumination. Analyses were performed using a mixed-effects logistic regression model adjusting for provider effect.We evaluated 240 patients. After adjusting for significant covariates (safety catheter [P = 0.008], visibility [P = 0.01], and palpability [P = 0.03]) and controlling for provider effect, IV placement was more likely successful in first attempt in transilluminated patients (P = 0.03; odds ratio, 2.1 [95% confidence interval, 1.1-3.9]). After adjusting for significant covariates (safety catheter [P0.001], location [P = 0.005], and palpability [P = 0.05]) and controlling for provider effect, IV placement was more likely successful within 2 attempts in transilluminated patients (P = 0.01; odds ratio, 3.5 [95% confidence interval, 1.4-8.9]). Intracluster correlation for random effect of provider was 10% in first attempt and 16% within 2 attempts.After adjusting for multiple significant covariates and controlling for random effect of provider, our results indicated a benefit in the use of Veinlite transillumination for IV insertion in first attempt and within 2 attempts. This technique seemed to facilitate nonemergent IV placement in pediatric patients compared with standard practice.

We compared the remission of pediatric primary nocturnal enuresis in groups of children who used a physician advised practice plan vs a parent chosen alternative.Between January 2004 and January 2006 there were 119 patients with primary nocturnal enuresis enrolled in this prospective, nonrandomized study. For this study primary nocturnal enuresis was defined as wetting at night during sleep during any 6-month interval without any known causative problem. A total of 76 children received the physician advised treatment plan and used an alarm, oxybutynin, desmopressin, an elimination diet and a bowel program, as indicated. A total of 43 children received a parent chosen alternative treatment plan, which consisted of any single or combination of treatments involving an alarm, oxybutynin, desmopressin and an elimination diet or bowel program. Parents from each group completed an intake survey that measured functional bladder capacity using a 3-day home diary and they identified demographic variables. Followup occurred at 2 weeks and then monthly for 12 weeks to study end.We found that the probability of remission by the end of the study for the physician advised treatment group was significantly higher than that of the parent choice group (88% vs 29%, Kaplan-Meier curve p0.0001).The group of children who followed physician advised treatment for primary nocturnal enuresis showed significantly earlier remission of primary nocturnal enuresis than children who followed the parent choice treatment (25th percentile 2 vs 10 weeks).

Although in-depth interviewing is well suited to studying the sensitive topic of end-of-life decision making, no reports have been published assessing the effects on parents of participating in interviews regarding end-of-life decision making for critically ill children.To examine the reactions of pediatric intensive care unit (PICU) patients' parents to interviews on end-of-life decision making for their child.We conducted semistructured interviews on end-of-life decision making with PICU patients' parents from two tertiary care PICUs. We approached 117 parents of 102 patients. Seventy-four parents (63%) of 69 patients participated.Forty-three parents (61%) described the interview as "a good experience," 20 (29%) as "a neutral experience," and 1 (1%) as "a bad experience." The parent who judged the interview negatively stated that, "It bothers me a little bit because my son is [out] there having difficulties and I'm in here and not out there." Fifty-four of 59 parents (92%) said they would participate in another similar interview. Most parents (92%) felt the medical community should continue research on end-of-life decision making. Themes identified from the responses included: emotional reaction to the interviews; exposure to end-of-life decision-making issues; impact on parents' views; and impact on future end-of-life decision making. Parents' comments suggested that many perceived the interviews as beneficial.This study demonstrates the willingness of many parents of critically ill children to participate in study interviews regarding end-of-life decision making, a topic that most parents felt was important and warranted more research.

Objectives.To characterize handwashing behaviors of children and assess the efficacy of a waiting room-based hand hygiene intervention at improving handwashing ability.Design.Prospective randomized pilot study.Setting.Emergency department waiting room at a freestanding urban pediatric hospital.Participants.Children (8–18 years) and their parent.Intervention.Participants were randomized to glow gel hand washing without hand hygiene education or glow gel hand washing with hand hygiene education. After participants washed with glow gel, “dirty areas” were illuminated using a black light, and hands were scored. A questionnaire about handwashing behavior was administered. All subjects returned 2–4 weeks after intervention to repeat glow gel hand washing and the questionnaire.Results.Sixty pediatric patients and 57 parents were recruited, with 77% of patients returning for follow up. Patients were 50% male, 58% Latino, 28% African American, and 8% Caucasian. At the initial visit, 91% of children reported hand washing after using the bathroom and 78% reported hand washing before dinner. On the basis of objective scoring, all children improved handwashing ability when compared with the initial visit (P = .02) and were more likely to use warm water at follow up (P = .01). Parents did not significantly improve in handwashing ability (P = .73).Conclusion.Glow gel hand washing is an effective method to improve children's handwashing ability. This short-term intervention was effective even in the absence of specific hand hygiene education. This intervention could serve as a valuable public health measure to teach hand washing in healthcare settings.

It has recently been demonstrated that variability in blood phenylalanine levels is inversely correlated with IQ and is a better predictor of IQ in early and continuously treated patients with phenylketonuria (PKU) than mean blood phenylalanine levels. This suggests that stability of blood phenylalanine should be a therapeutic goal in patients with PKU. The purpose of this study was to determine if treatment with sapropterin in patients with BH4-responsive PKU would increase the stability of blood phenylalanine levels. The records of all patients treated with sapropterin in the PKU Clinic at Children's Memorial Hospital in Chicago were examined retrospectively. Patients were included in the study if they were responsive to sapropterin during a 2- to 4-week challenge (reduction of blood phenylalanine level of at least 25% after 2weeks of therapy or, in the case of patients with well-controlled blood phenylalanine at the time of testing, increased dietary phenylalanine tolerance by 4weeks of treatment). A total of 37 subjects were eligible for inclusion (16male; 21 female); the mean age was 12.6years (range, 1.5–32.0). The total number of observations (phenylalanine levels) for all subjects was 1391 with a mean of 39 per subject (range, 13–96). Linear mixed modeling was utilized to estimate variances of the blood phenylalanine before (pre) and after (post) starting sapropterin. Likelihood ratio test was performed using SAS 9.1. Means and standard deviations for phenylalanine as estimated by the model were 6.67mg/dl (4.20) and post 5.16 (3.78). The mean level post-sapropterin was significantly lower ( p =.0002). The within-subject variances (mean and SD) of phenylalanine were: pre 6.897 (2.62) and post 4.799 (2.19). These two variances are significantly different with a p =.0017. We conclude that sapropterin therapy results in increased stability of blood phenylalanine levels. This effect is likely to improve cognitive outcome in BH4-responsive patients with PKU.

Objective To broaden existing knowledge of pediatric end-of-life decision making by exploring factors described by parents of patients in the pediatric intensive care unit (PICU) as important/influential if they were to consider withdrawing life-sustaining therapies. Design Quantitative and qualitative analysis of semi-structured one-on-one interviews. Setting The PICUs at 2 tertiary care hospitals. Participants English- or Spanish-speaking parents who were older than 17 years and whose child was admitted to the PICU for more than 24 hours to up to 1 week. Intervention Semi-structured one-on-one interviews. Results Forty of 70 parents (57%) interviewed said they could imagine a situation in which they would consider withdrawing life-sustaining therapies. When asked if specific factors might influence their decision making, 64% of parents said they would consider withdrawing life-sustaining therapies if their child were suffering; 51% would make such a decision based on quality-of-life considerations; 43% acknowledged the influence of physician-estimated prognosis in their decision; and 7% said financial burden would affect their consideration. Qualitative analysis of their subsequent comments identified 9 factors influential to parents when considering withdrawing life-sustaining therapies: quality of life, suffering, ineffective treatments, faith, time, financial considerations, general rejection of withdrawing life-sustaining therapies, mistrust/doubt toward physicians, and reliance on self/intuition. Conclusion Parents describe a broad range of views regarding possible consideration of withdrawing life-sustaining therapies for their children and what factors might influence such a decision.

To examine risk factors for lack of immunization, we tested the impact of maternal, paternal, and household variables on child immunization status in childrenor =1 year in a rural area of Ethiopia. Data collected by face-to-face interview on maternal, paternal, household and child variables from cross-sectional random sample community-based study on health and well-being in rural Ethiopia was used to test hypotheses on immunization status of children (n = 924). Bivariate and multivariate logistic regression models were used for two immunization outcomes: record of at least one vaccination, and record of DPT3, indicating completion of the DPT series. Complete data were available for 924 childrenor =1 year of which 79% had at least one vaccination. Of those, 64% had DPT3/Polio3; below recommended coverage level. Children were more likely to be vaccinated if the mother reported antenatal care (ANC), and less likely to be vaccinated if the mother had a history of stillbirth, and no opinion of health center. Children were more likely to have DPT3 if: mother hador =1 year of education, mother reported ANC, or older paternal age. Children were less likely to have DPT3 in households with food insecurity and no maternal opinion of health center. The study had three findings with implications for immunization programming: (1) Mothers completing the recommended ANC visits is strongly associated with receiving at least one vaccination and with completing a vaccination series; (2) Maternal education is associated with a completed vaccination series; (3) Paternal characteristics may affect vaccination series completion.

Hispanic ethnicity is an independent risk factor for increased morbidity and mortality in cystic fibrosis (CF) patients. In order to compare the prevalence of risk factors for morbidity and mortality between the Hispanic CF population and the non-Hispanic CF population, we performed a cross-sectional study of patients in the 2004 Cystic Fibrosis Foundation Patient Registry. Among 22,714 CF patients, 1,511 were identified as ethnic Hispanic. Hispanic patients were diagnosed earlier (2.8 vs. 3.3 years, P = 0.005) and acquired Pseudomonas aeruginosa at a younger age (6.6 years vs. 10 years, P0.001). FEV(1) was lower for Hispanic patients (81.5% vs. 87% predicted for those under 18 years old [P0.001] and 2.1 L vs. 2.3 L for those 18 years and older [P = 0.01]). Hispanic patients had similar or better nutritional status. Hispanic patients were more likely to be diagnosed with liver disease (OR 1.31 [1.1, 1.56]) but less likely to be diagnosed with depression (OR 0.53 [0.39, 0.68]), bone and joint disease (OR 0.55 [0.41, 0.71]), or CF-related diabetes (OR 0.53 [0.43, 0.62]). Hispanic patients had lower median income by zip code ($41,930 vs. $47,341; P0.001), a higher rate of government insurance (55.2% vs. 32.0%; P0.001), and greater percentage of mothers with less than a high school education (26.7% vs. 6.5%; P0.001). We conclude that there is an increased prevalence of important risk factors for morbidity and mortality in the Hispanic CF population.

The aim of this study was to compare functional gait differences between patients with myelomeningocele (MM) who have a ventriculoperitoneal shunt (VPS) with those who do not. Our analyses were adjusted for confounding by age, lesion level, orthotic use, and assistive device use. The Functional Mobility Scale (FMS) was used to compare the shunted group (n=98; 60 males, 38 females; mean age 10y 2mo [SD 3y 11mo]; 73 sacral/19 low lumber/six high lumbar lesion level) with the non-shunted group (n=63; 32 males, 31 females; mean age 9y 11mo [SD 3y 11mo]; 45 sacral/12 low lumber/six high lumbar lesion level). Participants with a shunt had lower FMS 500 and FMS 50 scores compared with participants without a shunt; hence the participants without a shunt were more independent in their ambulation at medium and longer distances. For a subset of participants who underwent a three-dimensional gait analysis, we also collected temporal-spatial gait parameters (velocity, cadence, and stride length). Our results show that participants with MM and no shunt who underwent gait analysis(11 males, 10 females; mean age 9y 6mo [SD 4y]; 15 sacral/6 low lumber/0 high lumbar lesion level) tend to walk at a significantly greater velocity and stride length as compared with those with a shunt (33 males, 18 females; mean age 10y [SD 4y]; 38 sacral/13 low lumber/zero high lumbar lesion level). These data allow the treatment team to present more specific information regarding functional ambulatory expectations to patients with MM and their families.

The purpose of this study was to evaluate the safety and efficacy of pressure-limited power injection of contrast medium through central lines for pediatric body CT examinations.All patients with a central line who were referred for body CT examinations requiring an i.v. contrast agent were prospectively evaluated. The power injector was pressure limited to 25 psi (172 kPa). A standard dose of 2 mL/kg of iodinated contrast medium was power-injected through the central line. Two pediatric radiologists scored all examinations on a scale of 1 (poor) to 5 (superior) for adequacy of contrast enhancement. Regression and receiver operating characteristic analyses were performed.The subjects were 63 patients 0.3-22 years old. Nineteen of these patients had tunneled lines, 18 had ports, and 26 had peripherally inserted central catheters. There were no complications related to power injection. Regression analysis showed a significant association between patient weight and contrast enhancement adequacy score (p0.001), higher patient weights yielding lower contrast enhancement adequacy scores. Receiver operating characteristic analysis showed a weight cutoff of 30 kg as a reasonable predictor of adequacy of contrast enhancement. For patients weighing 30 kg or more, the average contrast enhancement score was 2.4 (suboptimal to adequate). For patients weighing less than 30 kg, the average contrast enhancement score was 3.4 (adequate to good).Pressure-limited power injection through central lines in children is safe. The contrast enhancement obtained with 25 psi (172 kPa) pressure-limited injection is acceptable only for patients who weigh less than 30 kg.

Objective: Length of time elapsed between recurrent laryngeal nerve (RLN) injury and surgery may affect voice result. The purpose of this study was to compare voice outcome after thyroplasty in patients with short- and long-term vocal fold immobility. Methods: Thirty-five patients with longstanding vocal fold immobility (8.3 years) and 35 patients more acutely denervated (10 months) underwent type I thyroplasty. Trained listeners before and after surgery rated perceptual judgments of voice. Acoustic and aerodynamic data were analyzed. Results: Voice outcome did not differentiate the two groups with respect to objective measures. Perceptual ratings of post-operative voice quality favored the short-term patients, with the long-term group having a mildly ‘constricted’ quality. Conclusion: Thyroplasty yields a functional voice result even when substantial time has elapsed. Patients with chronic immobility may be unable to release longstanding hyperfunctional voicing behaviors even after surgery has afforded them an improved mechanism. In five of 35 long-term patients, therapy enhanced voice quality.

Nager's syndrome, which has the facial features of Treacher Collins syndrome, preaxial upper limb defects, short stature, and frequently subnormal intelligence, is very rare. Five new cases have been collected. In four, there was virtually total absence of the soft palate. This has been described in two patients in the past. Differing methods of correcting this are presented.