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Background: The tibial tubercle to trochlear groove (TT-TG) distance is often utilized for determining the surgical treatment for patients with patellar instability (PI). It is thought to directly represent the position of the TT on the tibia. Recent work has shown that the measurement of the TT-TG distance is multifactorial. Purpose: To investigate the relationship between relative tibial external rotation (rTER) and trochlear dysplasia (TD), as well as the location of the TG and TT in patients with and without PI, and to correlate these and other anatomic measurements with the TT-TG distance. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 89 patients with PI who underwent magnetic resonance imaging were identified with 92 matched control patients. A standardized measurement protocol on axial magnetic resonance imaging determined rTER, the proximal and distal TG lateralization (pTGL and dTGL, respectively) ratios, and the TT lateralization (TTL) ratio. Other measures of interest included the lateral trochlear inclination angle, sulcus angle, and lateral patellar inclination angle. Univariate regression was used to determine the associations of TD (lateral trochlear inclination angle, sulcus angle) with rTER and the TG position, and multivariate regression was used to model associations among all the variables with the proximal and distal TT-TG distances. Results: rTER was significantly higher in the study group ( P < .001), and univariate regression showed a significant association between dysplasia measures and rTER ( P < .001). The pTGL ratio was lower in the study group ( P = .025), but there was no difference in the dTGL ratio ( P = .090) or the TTL ratio ( P = .098) between the groups. There were no associations between dysplasia measures and the pTGL and dTGL ratios ( P > .05). Multivariate regression showed that the proximal TT-TG distance is predicted by the sulcus angle, pTGL ratio, rTER, and TTL ratio ( P < .05) and that the distal TT-TG distance is predicted by the lateral patellar inclination angle, dTGL ratio, sulcus angle, rTER, and TTL ratio ( P < .05). Conclusion: rTER had a significant association with TD. The position of the proximal TG was more medial in patients with PI. There was no significant difference in the TTL ratio between patients with and without PI. The TT-TG distance was associated with multiple anatomic measures and was not solely predicated on the position of the TT.

Background Increased knee flexion at initial contact and in stance is a common problem for children with cerebral palsy. Surgical correction with percutaneous hamstring lengthening is an alternative to open hamstring lengthening; however, outcomes are less well documented, and there is concern about increasing anterior pelvic tilt. The purpose of this study was to evaluate the short-term outcomes of percutaneous hamstring lengthenings in children with cerebral palsy using comprehensive gait analysis techniques. Research Question Does percutaneous hamstring lengthening improve knee function, and do knee and anterior pelvic tilt outcomes vary by GMFCS level? Methods A convenience sample of 52 patients with both pre and post-surgical gait analyses was evaluated retrospectively for changes in gait function in terms of temporal-spatial parameters, kinematics and kinetics. Patients were divided into two GMFCS subgroups: GMFCS level I/II and III. Results The percutaneous hamstring lengthening results in statistically significant improvements in knee function during gait with increased knee extension at initial contact (mean 32° SD 13° to mean 21° SD 11°, p = 0.000) and improved mean knee flexion in stance (mean 23° SD 12° to mean 16° SD 11°, p = 0.000) for the total study cohort. Beneficial changes were found for knee function in both GMFCS level subgroups; however, there was an increase in pelvic tilt pre to post-surgery in the GMFCS level III subgroup (mean 21° SD 8° to mean 26° SD 6°, p = 0.012) but not the GMFCS level I/II subgroup (mean 18° SD 7° to mean 20° SD 8°, p = 0.427). Significance Percutaneous hamstring lengthening can improve knee function for all patients; however, the impact on anterior pelvic tilt varies by GMFCS level, with increasing anterior tilt for GMFCS level III only. This study highlights the importance of understanding differences in surgical outcomes by GMFCS level to better predict post-surgical function.

BACKGROUND: Kawasaki disease (KD) is an acute vasculitis of young children. A comparison of US hospitalization rates and epidemiologic features of KD in 2020 to those of precoronavirus disease years has yet to be reported. METHODS: Using a large, inpatient database, we conducted a retrospective cohort study and analyzed data for patients with (1) diagnosis coding for KD, (2) IV immunoglobulin treatment administered during hospitalization and (3) discharge date between January 1, 2016, and December 30, 2020. Severe cases were defined as those requiring adjunctive therapy or IV immunoglobulin-resistant therapy. RESULTS: The annual number of KD hospitalizations were stable from 2016 to 2019 (n = 1652, 1796, 1748, 1692, respectively) but decreased in 2020 (n = 1383). KD hospitalizations demonstrated seasonal variation with an annual peak between December and April. A second peak of KD admissions was observed in May 2020. The proportion of KD cases classified as severe increased to 40% in 2020 from 33% during the years 2016-2019 (P < 0.01). Median age in years increased from 2.9 in subjects hospitalized from 2016 to 2019 to 3.2 in 2020 (P = 0.002). CONCLUSIONS: Compared with the previous 4 years, the annual number of pediatric KD admissions decreased, and children discharged with diagnostic codes for KD in 2020 were generally older and more likely to have severe morbidity possibly reflective of misdiagnosed multisystem inflammatory syndrome in children. Clinicians should be wary of a possible rise in KD rates in the postcoronavirus disease 2019 era as social distancing policies are lifted and other viruses associated with KD return.

Background Develop a clinical and biological predictive model for colectomy risk in children newly diagnosed with ulcerative colitis (UC). Methods This was a multicenter inception cohort study of children (ages 4-17 years) newly diagnosed with UC treated with standardized initial regimens of mesalamine or corticosteroids (CS) depending upon initial disease severity. Therapy escalation to immunomodulators or infliximab was based on predetermined criteria. Patients were phenotyped by clinical activity per the Pediatric Ulcerative Colitis Activity Index (PUCAI), disease extent, endoscopic/histologic severity, and laboratory markers. In addition, RNA sequencing defined pretreatment rectal gene expression and high density DNA genotyping by the Affymetrix UK Biobank Axiom Array. Coprimary outcomes were colectomy over 3 years and time to colectomy. Generalized linear models, Cox proportional hazards multivariate regression modeling, and Kaplan-Meier plots were used. Results Four hundred twenty-eight patients (mean age 13 years) started initial theapy with mesalamine (n = 136), oral CS (n = 144), or intravenous CS (n = 148). Twenty-five (6%) underwent colectomy at ≤1 year, 33 (9%) at ≤2 years, and 35 (13%) at ≤3 years. Further, 32/35 patients who had colectomy failed infliximab. An initial PUCAI ≥ 65 was highly associated with colectomy (P = 0.0001). A logistic regression model predicting colectomy using the PUCAI, hemoglobin, and erythrocyte sedimentation rate had a receiver operating characteristic area under the curve of 0.78 (95% confidence interval [0.73, 0.84]). Addition of a pretreatment rectal gene expression panel reflecting activation of the innate immune system and response to external stimuli and bacteria to the clinical model improved the receiver operating characteristic area under the curve to 0.87 (95% confidence interval [0.82, 0.91]). Conclusions A small group of children newly diagnosed with severe UC still require colectomy despite current therapies. Our gene signature observations suggest additional targets for management of those patients not responding to current medical therapies.

Despite limited data, methotrexate (MTX) is often used as primary maintenance therapy in pediatric Crohn disease (CD). We sought to assess the effectiveness of MTX as "initial" primary maintenance therapy in newly diagnosed mild/moderate pediatric CD and ascertain baseline predictive factors.Single-center 10-year retrospective review of newly diagnosed CD patients treated with MTX as primary maintenance therapy. We compared baseline characteristics of those patients with sustained response/clinical remission to those patients who escalated to anti-TNF therapy within 1 year. Pediatric Crohn Disease Activity Index (PCDAI) ≤ 10 defined remission.We identified 65 patients (mean age, 11.8 years; 72 % male; mean ± SD PCDAI, 17.8 ± 10.5) who started MTX ≤4 months of diagnosis as their primary maintenance therapy. Initial therapy prior to MTX was corticosteroids (CS) (54/65), defined diet (4/65), and combination CS/diet (6/65). Oral dosing was used in 55%; mean dose was 11.4 mg/m 2 orally and 12.5 mg/m 2 subcutaneously. At 1 year, 36 of 65 (55%) were on MTX monotherapy, and of those, 32 of 36 were in clinical remission; 81% were in steroid-free remission for the year following induction. For the 36 patients on MTX at 1 year, 14 (39%) had gross mucosal healing (22% of the original cohort). Ten additional patients had mucosal improvement (37% of total healed/improved). Fifteen patients (23%) were early failures, transitioning to anti-TNF ≤4 months. Baseline PCDAI, hemoglobin, ESR, albumin, and route of administration were not predictive of outcome. MTX was well tolerated in our cohort, with only 1 patient stopping due to elevated aminotransferases. No patient required CD surgery in the 1-year follow-up.MTX may have a primary maintenance role in mild/moderate CD.

BACKGROUND The COVID-19 pandemic exposed significant vulnerabilities of traditional in-person recruitment methodology in the context of limited access to clinical facilities. Remote recruitment is a potential solution, but its yield and efficiency are unknown. OBJECTIVE This study aimed to determine remote recruitment and enrollment rates for a pilot feasibility trial of an electronic monitoring device (EMD) for asthma in the pediatric population. METHODS Children aged 4-18 years with persistent asthma receiving inhaler medications compatible with an EMD were screened for enrollment in a feasibility and acceptability trial. The emergency department (ED) and inpatient wards were identified as initial in-person recruitment locations prior to the pandemic. Owing to the COVID-19 pandemic, recruitment sites transitioned from exclusive ED or inpatient enrollment to outpatient primary care or pulmonary clinics in an attempt to increase enrollment rates. Study staff called families to determine their interest in the study. Patient age, race and ethnicity, insurance, contact attempts, and reasons for enrollment or refusal were recorded. e-Consent was obtained through the REDCap database, and baseline surveys were administered by telephone. RESULTS Since November 2019, the study staff reached 147 out of 278 (52.3%) eligible families by telephone. In total, 37 (13%) families contacted were enrolled in the study. It took the study staff a mean of 2 attempts to reach individuals for initial enrollment but a mean of 4 additional attempts to complete consent forms. Of the families approached, 47% were Hispanic or Latino, 26.5% were Black or African American, 24.5% were White, and 2% were Asian. Among patients approached, 20% Asian, 16% White, 14.5% Hispanic or Latino, and 12% Black patients were enrolled in the study. CONCLUSIONS Telephone recruitment had a low yield across all racial and ethnic groups, averaging approximately 1 successful enrollment per 8 candidates approached. A substantial number of contacts was required to obtain e-consent forms and complete survey questionnaires after participants agreement to enroll. The study findings suggest that when there are barriers to in-person recruitment, remote recruitment is a feasible alternative, but the yield is relatively low, and enrollment requires persistent, repeated follow-up contact.

There are limited data regarding the impact of gender within congenital heart surgery. Our aim was to assess gender-related experiences by surgeons in this field.A cross-sectional survey was emailed to practicing congenital heart surgeons to ascertain the perception of gender in 5 domains: training, professional career, clinical practice, personal life, and career outlook.The survey response rate was 94% (17/18) for women and 44% (112/257) for men. More than half of women (53%) were discouraged from pursuing congenital heart surgery (P .001) and reported a negative impact of gender in attaining their first congenital heart surgery job (P .001) compared with men. Despite similar demographics, women reported lower starting annual salaries ($150K-$250K vs $250K-$400K), lower current annual salaries ($500K-$750K vs $750K-$1M), lower academic ranks (clinical instructor 6% vs 4% [P = .045], assistant professor 35% vs 19% [P = .19], associate professor 41% vs 25% [P = .24], and professor 6% vs 41% [P = .005]) along with lower annual salaries at the associate professor ($500K-$750K vs $1M-$1.25M) and professor levels ($1M-$1.25M vs$1.5M) compared with men. Sexual harassment was experienced more frequently by women both in training (65% vs 6%, P .001) and in practice (65% and 4%, P .001).This survey highlights many areas of gender-related differences: discouragement due to gender to pursue congenital heart surgery, sexual harassment in training and practice, salary and academic rank differentials, negative gender perception at work, and lower career satisfaction for women. Despite various differences between both genders, the majority in each group would choose to enter this profession again as well as encourage others to do so.

To study patterns of use of Fresh Frozen Plasma (FFP) and Cryoprecipitate (CRYO) in a level 4 NICU and assess what proportions were not supported by literature.single centered retrospective observational. Charts of neonates admitted between 1/1/2010 to 12/31/2017 to CT Children's level 4 NICU were reviewed. Transfusions were assigned as "supported" or "non-supported" based on available evidence. Groups were compared using T-tests and chi-squared analyses.of 4110 total admissions, 197 (4.8%) received a total of 461 transfusions (374 FFP, 87 CRYO). Only 59% of FFP and 60% CRYO were supported by literature. Within the "non-supported" group the largest category was neonates transfused prophylactically.A large proportion of transfusions administered to neonates was not evidence-based, suggesting there are opportunities for improvement in use of these products.

BackgroundCharacterization of neutralization antibodies to SARS-CoV-2 infection or vaccination in children and young adults with inflammatory bowel disease (IBD) receiving biologic therapies is crucial.MethodsWe performed a prospective longitudinal cohort study evaluating SARS-CoV-2 Spike protein receptor binding domain (S-RBD) IgG positivity along with consistent clinical symptoms in patients with IBD receiving infliximab or vedolizumab. Serum was also obtained following immunization with approved vaccines. IgG antibody to the spike protein binding domain of SARS-CoV-2 was assayed with a fluorescent bead-based immunoassay that takes advantage of the high dynamic range of fluorescent molecules using flow cytometry. A sensitive and high-throughput neutralization assay that incorporates SARS-CoV-2 Spike protein onto a lentivirus and measures pseudoviral entry into ACE2 expressing HEK-293 cells was used.Results436 patients were enrolled (mean age 17 years, range 2-26 years, 58% male, 71% Crohn’s disease, 29% ulcerative colitis, IBD-unspecified). 44 (10%) of enrolled subjects had SARS-CoV-2 S-RBD IgG antibodies. Compared to non-IBD adults (ambulatory) and hospitalized pediatric patients with PCR documented SARS-CoV-2 infection, S-RBD IgG antibody levels were significantly lower in the IBD cohort and by 6 months post infection most patients lacked neutralizing antibody. Following vaccination (n=33) patients had a 15-fold higher S-RBD antibody response in comparison to natural infection, and all developed neutralizing antibodies to both wild type and variant SARS-CoV-2.Conclusions and RelevanceThe lower and less durable SARS-CoV-2 S-RBD IgG response to natural infection in IBD patients receiving biologics puts them at risk of reinfection. The robust response to immunization is likely protective.SummaryOur study showed a low and poorly durable SARS-CoV-2 S-RBD neutralizing IgG response to natural infection in IBD patients receiving biologics potentially putting them at risk of reinfection. However, they also had a robust response to immunization that is likely protective

Background The COVID-19 pandemic exposed significant vulnerabilities of traditional in-person recruitment methodology in the context of limited access to clinical facilities. Remote recruitment is a potential solution, but its yield and efficiency are unknown. Objective This study aimed to determine remote recruitment and enrollment rates for a pilot feasibility trial of an electronic monitoring device (EMD) for asthma in the pediatric population. Methods Children aged 4-18 years with persistent asthma receiving inhaler medications compatible with an EMD were screened for enrollment in a feasibility and acceptability trial. The emergency department (ED) and inpatient wards were identified as initial in-person recruitment locations prior to the pandemic. Owing to the COVID-19 pandemic, recruitment sites transitioned from exclusive ED or inpatient enrollment to outpatient primary care or pulmonary clinics in an attempt to increase enrollment rates. Study staff called families to determine their interest in the study. Patient age, race and ethnicity, insurance, contact attempts, and reasons for enrollment or refusal were recorded. e-Consent was obtained through the REDCap database, and baseline surveys were administered by telephone. Results Since November 2019, the study staff reached 147 out of 278 (52.3%) eligible families by telephone. In total, 37 (13%) families contacted were enrolled in the study. It took the study staff a mean of 2 attempts to reach individuals for initial enrollment but a mean of 4 additional attempts to complete consent forms. Of the families approached, 47% were Hispanic or Latino, 26.5% were Black or African American, 24.5% were White, and 2% were Asian. Among patients approached, 20% Asian, 16% White, 14.5% Hispanic or Latino, and 12% Black patients were enrolled in the study. Conclusions Telephone recruitment had a low yield across all racial and ethnic groups, averaging approximately 1 successful enrollment per 8 candidates approached. A substantial number of contacts was required to obtain e-consent forms and complete survey questionnaires after participants agreement to enroll. The study findings suggest that when there are barriers to in-person recruitment, remote recruitment is a feasible alternative, but the yield is relatively low, and enrollment requires persistent, repeated follow-up contact. Conflicts of Interest None declared.

Objective To identify and contrast risk factors for six-month pediatric asthma readmissions using traditional models (Cox proportional-hazards and logistic regression) and artificial neural-network modeling. Methods This retrospective cohort study of the 2013 Nationwide Readmissions Database included children 5 to 18 years old with a primary diagnosis of asthma. The primary outcome was time to asthma readmission in the Cox model, and readmission within 180 days in logistic regression. A basic neural network construction with 2 hidden layers and multiple replications considered all dataset variables and potential variable interactions to predict 180-day readmissions. Logistic regression and neural-network models were compared on area-under-the receiver-operating curve. Results Of 18,489 pediatric asthma hospitalizations, 1858 were readmitted within 180 days. In Cox and logistic models, longer index length of stay, public insurance, and nonwinter index admission seasons were associated with readmission risk, whereas micropolitan county was protective. In neural-network modeling, 9 factors were significantly associated with readmissions. Four overlapped with the Cox model (nonwinter-month admission, long length of stay, public insurance, and micropolitan hospitals), whereas 5 were unique (age, hospital bed number, teaching-hospital status, weekend index admission, and complex chronic conditions). The area under the curve was 0.592 for logistic regression and 0.637 for the neural network. Conclusions Different methods can produce different readmission models. Relying on traditional modeling alone overlooks key readmission risk factors and complex factor interactions identified by neural networks.

Background Charcot-Marie-Tooth disease (CMT) results in distal muscle weakness that leads to gait difficulties in both the stance and swing phases, thus limiting function in the community. A primary purpose of ankle foot orthoses (AFOs) is to improve gait function; however, little is known about what AFOs are prescribed and how they benefit children with CMT. Research question To determine the impact of previously prescribed AFOs on gait in children with CMT using comprehensive gait analysis techniques. Methods We examined strength, passive range of motion and gait (kinematics, kinetics and temporal-spatial) for barefoot and AFO walking on 15 children with a diagnosis of CMT. Participants used their prescribed AFOs, the design of which varied depending on the patient. Comparisons between barefoot and AFO walking were completed for selected ankle, knee and hip kinematics and kinetics and temporal-spatial parameters. Subgroups were also evaluated based upon specific ankle kinematics relevant to AFO prescription. Results AFOs resulted in increased walking velocity (0.91, SD 0.31 to 1.13, SD 0.23 m/sec, p = 0.001) and improved ankle kinematics (dorsiflexion in mid-swing: -11, SD 10 to 0, SD 5 degrees, p = 0.0001) and kinetics (peak plantar flexor moment in stance: 0.71, SD 0.30 to 0.85, SD 0.29 Nm/kg, p = 0.001). In patients with increased equinus in swing, AFOs resulted in improved ankle kinematics. In patients with increased dorsiflexion in terminal stance, AFOs did not provide the support that was needed to improve gait function. Significance AFOs enhance gait function in children with CMT by improving walking velocity and selected ankle kinematics and kinetics. It is important that the AFO design be aligned with the patient’s specific joint level impairment and associated gait dysfunction. Comprehensive gait analysis techniques can measure differences between barefoot and AFO function and help to clarify the most appropriate AFO prescription for an individual child.

The purpose of this pilot study was to evaluate the acceptability and feasibility of a 10-week community-based, culturally tailored mental health intervention, called Healthy Sudanese Families, with 12 South Sudanese refugee women living in a metropolitan area of the Midwestern United States. This mixed-methods study used the Dinka and Arabic versions of the Hopkins Symptoms Checklist-25 to measure indicators of anxiety and depression and a final focus group to evaluate the women's responses to the intervention. The women found the mental health intervention acceptable and relevant. Methodological challenges encountered in cross-cultural research with refugees are discussed.

Objectives and Study: SARS-CoV-2, a novel coronavirus causing the pandemic clinical disease COVID-19, is generally associated with mild disease in most young patients with inflammatory bowel disease (IBD) despite their receiving immunosuppressive therapy. The aim of this study was to longitudinally evaluate characteristics of clinical and serologic response to SARS-CoV-2 infection in a cohort of young patients with IBD receiving biologics. Methods: Starting May 2020 we obtained serum on patients with IBD at the time of infusion with either infliximab or vedolizumab, along with baseline demographic and clinical data, as well possible SARSCoV2 exposure history (patient, family member). To measure antibodies to SARS-CoV-2, we used a fluorescent bead-based immunoassay that takes advantage of the high dynamic range of fluorescent molecules using flow cytometry. We immobilized biotinylated SARS-CoV-2 Spike protein receptor binding domain (S-RBD) or Nucleocapsid protein of SARS-CoV-2 (N) to detect specific IgG antibodies to the virus in patient serum. Spike protein-RBD-specific antibodies were detectable in serial dilutions up to 100,000-fold of serum samples. Titration curves from COVID-19 convalescent and healthy controls were used to normalize the area under the curve (AUC) values to quantitate the antibody levels. Antibody isotypes were measured using anti-Ig (IgG, IgA, IgM, IgG1-4) specific secondary antibodies conjugated to a fluorescent tag. We used a sensitive and high throughput SARS-CoV-2 neutralization assay using a lentivirus that expresses Spike protein to assess specific inhibition of viral entry. The results shown reflect the first serum sample obtained from unique patients. Results: 410 subjects were studied (mean age 17 years, 59% male, 305 (74%) Crohn's disease, 105 (25%) ulcerative colitis/IBD-U, 341 (83%) on infliximab, 69 (17%) vedolizumab, 13% concomitant methotrexate. 27/410 (6.6%) were positive for S-RBD and Nucleocapsid specific IgG. AUC values varied from 3150 to 285724 (Fig 1). S-RBD specific IgA+ 4/27 (15%) and IgG1+ 20/27 (74%) were found. Other isotypes undetectable. Patients' serum efficiently neutralized the virus at up to 10,000-fold serial dilution in only 10/27 (37%). (Fig 2). No differences in age, gender, diagnosis, or specific therapies were noted for (+) vs (-) anti-SARS-CoV-2 antibody status. 13/27 (48%) patients were asymptomatic. Non-exclusive symptoms were rhinorrhea 9 (33%), headache 8 (30%), sore throat 4 (15%). cough 4 (15%), diarrhea 4 (15%), chills 3 (11%), loss of smell/taste 2 (7%), fever 1 (4%). No patient was hospitalized. 4 (15%) had a family member with PCR+ COVID-19. Conclusions: We found a significant prevalence of anti SARS-CoV-2 antibody in our IBD population with the majority of + patients having non-neutralizing antibody. The role of biologics in mitigating clinical and serologic response to SARS-CoV-2 requires exploration.

A general diagnostic approach to the evaluation of asymptotic approximation in likelihood based models is developed and applied to logistic regression. The expected asymptotic and observed log-likelihood functions are compared using a chi distribution in a directional Bayesian setting. This provides a general approach to assessing and visualizing non-convergence in higher dimensional models. Several well-known examples from the logistic regression literature are discussed.

Human leukocyte antigens (HLA) class II donor-specific antibodies (DSAs) are associated with microcirculation inflammation, transplant glomerulopathy and ultimately graft loss. There is however no data on allograft outcomes in deceased donor kidney transplant recipients who have not received any desensitization prior to transplantation.We prospectively evaluated the association of HLA DR and DQ DSAs on rejection and short-term graft survival in patients who did not receive desensitization prior to transplantation. On the basis of their cumulative strength of HLA DR and/or DQ DSA, the patients were dichotomized into: 1) median fluorescence intensity (MFI)1000 and 2) MFI≥1000.In the two year study period, 50 consecutive patients with HLA DR and/or DQ sensitization were transplanted in our two centers. Post-transplantation, the incidence of acute rejection was significantly greater in the MFI≥1000 group (35%; 8/22) compared to the MFI1000 group (7%; 2/28) (p0.001). There were two graft losses, both in the MFI≥1000 group.The strength of DR and/or DQ DSA at the time of renal transplantation influences the risk of rejection in non-desensitized recipients with HLA class II DSA.

The likelihood function plays a central role in statistical analysis in relation to information, from both frequentist and Bayesian perspectives. In large samples several new properties of the likelihood in relation to information are developed here. The Arrow-Pratt absolute risk aversion measure is shown to be related to the Cramer-Rao Information bound. The derivative of the log-likelihood function is seen to provide a measure of information related stability for the Bayesian posterior density. As well, information similar prior densities can be defined reflecting the central role of likelihood in the Bayes learning paradigm.

The effects of centering response and explanatory variables as a way of simplifying fitted linear models in the presence of correlation are reviewed and extended to include nonlinear models, common in many biological and economic applications. In a nonlinear model, the use of a local approximation can modify the effect of centering. Even in the presence of uncorrelated explanatory variables, centering may affect linear approximations and related test statistics. An approach to assessing this effect in relation to intrinsic curvature is developed and applied. Mis-specification bias of linear versus nonlinear models also reflects this centering effect.

Background: The association between vancomycin trough (VT) and acute kidney injury (AKI) at the recommended doses remains controversial. Methods: The authors conducted a retrospective, observational cohort study of 500 adult patients who received vancomycin for ≥72 h. Data collected included 2 main predictors: average VT (including only VTs before the occurrence of AKI), first VT and other possible risk factors for AKI. The baseline characteristics/variables between patients with AKI and patients with no AKI were compared. Logistic regression models were used to develop multivariate models. The authors divided the patients into 4 subgroups: (1) VT Results: AKI occurred in 12.85% of patients while on vancomycin. The incidence of AKI in subgroups 1-4 was 8.02, 13.61, 13.70 and 31.82%, respectively, using the first VT, that is significantly higher in subgroup 4. Using average VT, AKI incidence was 5, 10.38, 19.01 and 25.58%, respectively, that is significantly higher in subgroups 3 and 4. On multivariate logistic regression, average VT, first VT, average VT >15, first VT >15, methicillin-resistant Staphylococcus aureus infection and morbid obesity were significantly associated with increased incidence of AKI. Conclusion: Clinicians should be careful when aiming for a VT >15 μg/ml as this is associated with increased incidence of AKI.

Background: Optimal communication between all members of the healthcare team is important to ensure safe and efficient patient care.Objective: To improve communication between nurses and resident physicians by developing and implementing a paging protocol.Methods: A resident-led workgroup was assembled to identify opportunities for improving communication. A survey was designed to assess current practices and perceptions related to resident and nurse communication. A facilitated focus group of residents and nurses met on two separate occasions to review the survey results and develop a set of mutually agreeable paging guidelines. The group chose to adopt the ISBARR communication tool and planned educational interventions accordingly. Residents and nurses were resurveyed roughly three months’ post-intervention.Results: The results indicated a 12.8% reduction (p=0.017) in the percentage of nurse respondents that “never” inquire whether or not another nurse on the unit needs to speak with the same physician prior to paging. A 10.3% increase (p=0.033) in resident respondents that “usually” receive grouped pages, and an 11% reduction (p=0.042) in the percentage of resident respondents that “never: receive grouped pages. However, only 53.3% (n=60) of nurse respondents and 44.1% (n=68) of resident respondents felt their ISBARR training was adequate. Moreover, only 38.4% and 30.9% of nurse and resident respondents, respectively felt the paging guidelines and ISBARR had improved overall communications between the two groups.Conclusions: While the follow-up survey results revealed some improvements in paging practices, the need for continued education was clear.

The overall design quality of studies conducted on psychotropic substances prescribed to autism spectrum disorder and attention deficit hyperactivity disorder children is reviewed. Searches were conducted on Medline and Cochrane Controlled Trials Register. Peer-reviewed, published studies, written in English were included. Only studies that focused on children, had a minimal sample size of ten participants, and were conducted between 1994 and 2004 were included in the review. Two hundred and eighty one studies were identified and reviewed with 184 (65.5%) focused primarily on methylphenidate, with the remaining 97 studies examined stimulants, antipsychotics, antidepressants, alpha agonists, anxiolytics, and mood stabilizers. Of these, 152 (54.1%) did not employ optimal double blind placebo controlled design and 106 (37.7%) were conducted with less than 30 participants. The upper quartile for median study duration across all medications examined was 9.75 weeks for double-blinded studies and 16 weeks for all studies. Many pharmacotherapy studies conducted on children with autism spectrum disorder and attention deficit hyperactivity disorder are of limited duration, weak quality design and may be seriously underpowered. The issue of follow-up is rarely adequately addressed. These findings raise both safety and efficacy questions that have yet to be adequately studied.

Background: Since the emergency department (ED) waiting room hosts a large, captive audience of patients and visitors, it may be an ideal location for conduct-ing focused stroke education. The aim of this study was to assess the effective-ness of various stroke education methods.Methods: Patients and visitors of an urban ED waiting room were randomized into one of the following groups: video, brochure, one-to-one teaching, combi-nation of these three methods, or control group. We administered a 13-question multiple-choice test to assess stroke knowledge prior to, immediately after, and at 1 month post-education to patients and visitors in the ED waiting room.Results: Of 4 groups receiving education, all significantly improved their test scores immediately post intervention (test scores 9.4±2.5-10.3±2.0, P

Background. There are many surveys to assess teaching excellence, but few validated tools to assess improvements in teaching confidence among faculty over time. We hypothesized that previously validated surveys for learner evaluation of faculty teaching excellence also can be used as a self-evaluation tool to assess changes in faculty teaching skills confidence over time. Methods. A cohort study was designed using a composite survey from two previously validated surveys (SETQ and CanMEDS) on teaching excellence. The composite survey was administered before and after a faculty development course on teaching excellence at the University of Kansas Medical Center in the Spring of 2012. Course “completers” attended more than 50% of the course and “non-completers” attended 50% or less of the course. Results. The overall mean change in survey result scores on a five-point Likert scale was nearly one point for “completers” (mean difference = 0.92, SD = 0.41) as opposed to 0.34 for “noncompleters” (SD = 0.34, p = 0.001). The Cronbach’s alpha coefficients for the pre-course surveys were 0.83 and 0.85 versus 0.88 and 0.83 for the post-course surveys, indicating a high internal consistency for both survey instruments. Conclusions. Measurable improvements in teaching skills confidence occur following faculty professional development courses. These improvements can be assessed more efficiently by using previously validated and reliable assessment tools in new and innovative ways. KS J Med 2015; 8(1):8-17.

The use of high dimensional linear models is common in large database settings. The linearity of such models is often assumed. In sparse settings with the number of subjects (n) less than the number of variables (p) standard algorithms include the lars-LASSO approach which often provides stable convergence. In some cases the underlying data may be more appropriately modeled with a nonlinear model. The use of a linear model in such cases creates model mis-specification and instability for lars-LASSO based approaches. This is studied by using simulations with various relative sample sizes, correlation structures and error distributions.