Search

Context Chronic stress is a risk factor for preterm birth; however, objective measures of stress in pregnancy are limited. Maternal stress biomarkers may fill this gap. Steroid hormones and neurosteroids such as allopregnanolone (ALLO) play important roles in stress physiology and pregnancy maintenance and therefore may be promising for preterm birth prediction. Objective We evaluated maternal serum ALLO, progesterone, cortisol, cortisone, pregnanolone, and epipregnanolone twice in gestation to evaluate associations with preterm birth. Methods We performed a nested case-control study using biobanked fasting serum samples from the Healthy Start prebirth cohort. We included healthy women with a singleton pregnancy and matched preterm cases with term controls (1:1; N = 27 per group). We used a new HPLC-tandem mass spectrometry assay to quantify ALLO and five related steroids. We used ANOVA, Fisher exact, χ2, t test, and linear and logistic regression as statistical tests. Results Maternal serum ALLO did not associate with preterm birth nor differ between groups. Mean cortisol levels were significantly higher in the preterm group early in pregnancy (13w0d-18w0d; P < 0.05) and higher early pregnancy cortisol associated with increased odds of preterm birth (at 13w0d; odds ratio, 1.007; 95% CI, 1.0002-1.014). Progesterone, cortisone, pregnanolone, and epipregnanolone did not associate with preterm birth. Conclusion The findings from our pilot study suggest potential utility of cortisol as a maternal serum biomarker for preterm birth risk assessment in early pregnancy. Further evaluation using larger cohorts and additional gestational timepoints for ALLO and the other analytes may be informative.

This diagnostic study assesses the ability of a pediatric blood pressure percentile tool to accelerate identification of children with hypertension and hypotension by clinicians and researchers.

BACKGROUND AND OBJECTIVES Serious bacterial infection (SBI) is common in the PICU. Antibiotics can mitigate associated morbidity and mortality but have associated adverse effects. Our objective is to develop machine learning models able to identify SBI-negative children and reduce unnecessary antibiotics. METHODS We developed models to predict SBI-negative status at PICU admission using vital sign, laboratory, and demographic variables. Children 3-months to 18-years-old admitted to our PICU, between 2011 and 2020, were included if evaluated for infection within 24-hours, stratified by documented antibiotic exposure in the 48-hours prior. Area under the receiver operating characteristic curve (AUROC) was the primary model accuracy measure; secondarily, we calculated the number of SBI-negative children subsequently provided antibiotics in the PICU identified as low-risk by each model. RESULTS A total of 15 074 children met inclusion criteria; 4788 (32%) received antibiotics before PICU admission. Of these antibiotic-exposed patients, 2325 of 4788 (49%) had an SBI. Of the 10 286 antibiotic-unexposed patients, 2356 of 10 286 (23%) had an SBI. In antibiotic-exposed children, a radial support vector machine model had the highest AUROC (0.80) for evaluating SBI, identifying 48 of 442 (11%) SBI-negative children provided antibiotics in the PICU who could have been spared a median 3.7 (interquartile range 0.9–9.0) antibiotic-days per patient. In antibiotic-unexposed children, a random forest model performed best, but was less accurate overall (AUROC 0.76), identifying 33 of 469 (7%) SBI-negative children provided antibiotics in the PICU who could have been spared 1.1 (interquartile range 0.9–3.7) antibiotic-days per patient. CONCLUSIONS Among children who received antibiotics before PICU admission, machine learning models can identify children at low risk of SBI and potentially reduce antibiotic exposure.

This cohort study uses data from the US National COVID Cohort Collaborative to evaluate upper airway infections in children during the surge of the Omicron (B.1.1.529) variant of SARS-CoV-2 in the US.

Importance: Understanding of SARS-CoV-2 infection in US children has been limited by the lack of large, multicenter studies with granular data. Objective: To examine the characteristics, changes over time, outcomes, and severity risk factors of children with SARS-CoV-2 within the National COVID Cohort Collaborative (N3C). Design, Setting, and Participants: A prospective cohort study of encounters with end dates before September 24, 2021, was conducted at 56 N3C facilities throughout the US. Participants included children younger than 19 years at initial SARS-CoV-2 testing. Main Outcomes and Measures: Case incidence and severity over time, demographic and comorbidity severity risk factors, vital sign and laboratory trajectories, clinical outcomes, and acute COVID-19 vs multisystem inflammatory syndrome in children (MIS-C), and Delta vs pre-Delta variant differences for children with SARS-CoV-2. Results: A total of 1068410 children were tested for SARS-CoV-2 and 167262 test results (15.6%) were positive (82882 [49.6%] girls; median age, 11.9 [IQR, 6.0-16.1] years). Among the 10245 children (6.1%) who were hospitalized, 1423 (13.9%) met the criteria for severe disease: mechanical ventilation (796 [7.8%]), vasopressor-inotropic support (868 [8.5%]), extracorporeal membrane oxygenation (42 [0.4%]), or death (131 [1.3%]). Male sex (odds ratio [OR], 1.37; 95% CI, 1.21-1.56), Black/African American race (OR, 1.25; 95% CI, 1.06-1.47), obesity (OR, 1.19; 95% CI, 1.01-1.41), and several pediatric complex chronic condition (PCCC) subcategories were associated with higher severity disease. Vital signs and many laboratory test values from the day of admission were predictive of peak disease severity. Variables associated with increased odds for MIS-C vs acute COVID-19 included male sex (OR, 1.59; 95% CI, 1.33-1.90), Black/African American race (OR, 1.44; 95% CI, 1.17-1.77), younger than 12 years (OR, 1.81; 95% CI, 1.51-2.18), obesity (OR, 1.76; 95% CI, 1.40-2.22), and not having a pediatric complex chronic condition (OR, 0.72; 95% CI, 0.65-0.80). The children with MIS-C had a more inflammatory laboratory profile and severe clinical phenotype, with higher rates of invasive ventilation (117 of 707 [16.5%] vs 514 of 8241 [6.2%]; P

BackgroundReports of SARS-CoV-2 causing laryngotracheobronchitis (commonly known as croup) have been limited to small case series. Early reports suggest the Omicron (B.1.1.529) strain of SARS-CoV-2 (the dominant circulating US strain since the week of 12/25/2021) replicates more efficiently in the conducting airways. This may increase the risk of a croup phenotype in children as they have smaller airway calibers.MethodsDescription of the incidence, change over time, and characteristics of children with SARS-CoV-2 and upper airway infection (UAI) diagnoses within the National COVID Cohort Collaborative (N3C) before and during the rise of the Omicron variant. We compare the demographics, comorbidities, and clinical outcomes of hospitalized SARS-CoV-2 positive children with and without UAI.ResultsSARS-CoV-2 positive UAI cases increased to the highest number per month (N = 170) in December 2021 as the Omicron variant became dominant. Of 15,806 hospitalized children with SARS-CoV-2, 1.5% (234/15,806) had an UAI diagnosis. Those with UAI were more likely to be male, younger, white, have asthma and develop severe disease as compared to those without UAI.ConclusionsPediatric acute UAI cases have increased during the Omicron variant surge with many developing severe disease. Improved understanding of this emerging clinical phenotype could aid in therapeutic decision-making and healthcare resource planning.

Patient safety data including rates of obstetric anal sphincter injury (OASI) are often derived from hospital discharge codes. With the transition to electronic medical records (EMRs), we hypothesized that electronic provider-entered delivery data would more accurately document obstetric perineal injury than traditional billing/diagnostic codes. We evaluated the accuracy of perineal laceration diagnoses after singleton vaginal deliveries during one calendar year at an American tertiary academic medical center. We reviewed the entire hospital chart to determine the most likely laceration diagnosis and compared that expert review diagnosis (ExpRD) with documentation in the EMR delivery summary (EDS) and ICD-9 diagnostic codes (IDCs). We retrospectively selected 354 total delivery records. OASI complicated 56 of those. 303 records (86%) were coded identically by the EDS and IDCs. Diagnoses from the IDCs and the EDS were mostly correct compared with ExpRD (sensitivity = 96%, specificity = 100%). There was no systematic over- or under-diagnosis of OASI for either the EDS (p = 0.070) or the IDCs (p = 0.447). When considering all laceration types the EDS was correct for 21 (5.9%) lacerations that were incorrect according to the IDCs. Overall, the EDS was more accurate (p

The gold standard for imaging of meningiomas is MRI with gadolinium-based contrast agent. Due to increased costs, time, and uncertain chronic effects of gadolinium exposure, use of noncontrast T2-weighted imaging (T2WI) in lieu of contrast-enhanced MRI has been an increasing focus of research across various diagnostic scenarios. The purpose of this study was to evaluate the diagnostic accuracy of T2WI in detecting changes in meningioma tumor volume.Imaging and clinical data were reviewed for 82 consecutive patients undergoing MR-surveillance of intracranial meningioma. Using volumetric-T2WI, two neuroradiologists independently calculated tumor volumes. Measurements were compared to a baseline study contrast-enhanced T1 tumor volume. Using contrast-enhanced sequences as the reference standard, statistical analysis was performed to determine the accuracy of T2WI in detecting changes of meningioma volume.Using only T2WI, readers detected meningioma volume change ≥ 20% in 19/82 patients and volume change20% in 63/82 patients. Reader accuracy for detecting change in tumor volume on T2WI ≥ 20% was 0.85, sensitivity 0.65, specificity 0.93, positive predictive value (PPV) 0.79, and negative predictive value (NPV) 0.87. For meningiomas1 ml, reader accuracy for detecting change in tumor volume on T2WI ≥20% was 0.90, sensitivity 0.78, specificity 0.95, PPV 0.88, and NPV 0.91. Change in tumor volume on T2WI ≥20% was detected with 100% accuracy for posterior fossa meningiomas. Inter-reader agreement for all meningiomas was moderate (κ = 0.45) improving to substantial agreement (κ = 0.77) with tumor volumes1 ml.Volumetric-T2WI detects changes in meningioma volume with comparable accuracy to gold standard T1 postcontrast imaging, particularly with higher tumor volumes and posterior fossa locations.

ImportanceSARS-CoV-2ObjectiveTo determine the characteristics, changes over time, outcomes, and severity risk factors of SARS-CoV-2 affected children within the National COVID Cohort Collaborative (N3C)DesignProspective cohort study of patient encounters with end dates before May 27th, 2021.Setting45 N3C institutionsParticipantsChildren Main Outcomes and MeasuresCase incidence and severity over time, demographic and comorbidity severity risk factors, vital sign and laboratory trajectories, clinical outcomes, and acute COVID-19 vs MIS-C contrasts for children infected with SARS-CoV-2.Results728,047 children in the N3C were tested for SARS-CoV-2; of these, 91,865 (12.6%) were positive. Among the 5,213 (6%) hospitalized children, 685 (13%) met criteria for severe disease: mechanical ventilation (7%), vasopressor/inotropic support (7%), ECMO (0.6%), or death/discharge to hospice (1.1%). Male gender, African American race, older age, and several pediatric complex chronic condition (PCCC) subcategories were associated with higher clinical severity (p≤0.05). Vital signs (all p≤0.002) and many laboratory tests from the first day of hospitalization were predictive of peak disease severity. Children with severe (vs moderate) disease were more likely to receive antimicrobials (71% vs 32%, pCompared to those with acute COVID-19, children with MIS-C were more likely to be male, Black/African American, 1-to-12-years-old, and less likely to have asthma, diabetes, or a PCCC (p<0.04). MIS-C cases demonstrated a more inflammatory laboratory profile and more severe clinical phenotype with higher rates of invasive ventilation (12% vs 6%) and need for vasoactive-inotropic support (31% vs 6%) compared to acute COVID-19 cases, respectively (pConclusionsIn the largest U.S. SARS-CoV-2-positive pediatric cohort to date, we observed differences in demographics, pre-existing comorbidities, and initial vital sign and laboratory test values between severity subgroups. Taken together, these results suggest that early identification of children likely to progress to severe disease could be achieved using readily available data elements from the day of admission. Further work is needed to translate this knowledge into improved outcomes.

BackgroundThe majority of U.S. reports of COVID-19 clinical characteristics, disease course, and treatments are from single health systems or focused on one domain. Here we report the creation of the National COVID Cohort Collaborative (N3C), a centralized, harmonized, high-granularity electronic health record repository that is the largest, most representative U.S. cohort of COVID-19 cases and controls to date. This multi-center dataset supports robust evidence-based development of predictive and diagnostic tools and informs critical care and policy.Methods and FindingsIn a retrospective cohort study of 1,926,526 patients from 34 medical centers nationwide, we stratified patients using a World Health Organization COVID-19 severity scale and demographics; we then evaluated differences between groups over time using multivariable logistic regression. We established vital signs and laboratory values among COVID-19 patients with different severities, providing the foundation for predictive analytics. The cohort included 174,568 adults with severe acute respiratory syndrome associated with SARS-CoV-2 (PCR >99% or antigen ConclusionsThis is the first description of an ongoing longitudinal observational study of patients seen in diverse clinical settings and geographical regions and is the largest COVID-19 cohort in the United States. Such data are the foundation for ML models that can be the basis for generalizable clinical decision support tools. The N3C Data Enclave is unique in providing transparent, reproducible, easily shared, versioned, and fully auditable data and analytic provenance for national-scale patient-level EHR data. The N3C is built for intensive ML analyses by academic, industry, and citizen scientists internationally. Many observational correlations can inform trial designs and care guidelines for this new disease.

Patient safety data including rates of obstetric anal sphincter injury (OASI) are often derived from hospital discharge codes. With the transition to electronic medical records (EMRs), we hypothesized that electronic provider-entered delivery data would more accurately document obstetric perineal injury than traditional billing/diagnostic codes.We evaluated the accuracy of perineal laceration diagnoses after singleton vaginal deliveries during one calendar year at an American tertiary academic medical center. We reviewed the entire hospital chart to determine the most likely laceration diagnosis and compared that expert review diagnosis (ExpRD) with documentation in the EMR delivery summary (EDS) and ICD-9 diagnostic codes (IDCs).We retrospectively selected 354 total delivery records. OASI complicated 56 of those. 303 records (86%) were coded identically by the EDS and IDCs. Diagnoses from the IDCs and the EDS were mostly correct compared with ExpRD (sensitivity = 96%, specificity = 100%). There was no systematic over- or under-diagnosis of OASI for either the EDS (p = 0.070) or the IDCs (p = 0.447). When considering all laceration types the EDS was correct for 21 (5.9%) lacerations that were incorrect according to the IDCs. Overall, the EDS was more accurate (p 0.05) owing to errors in IDC minor laceration diagnoses.Electronic medical record delivery summary data and EMR-derived diagnostic codes similarly characterize OASI. The EDS does not improve OASI reporting, but may be more accurate when considering all perineal lacerations. This assumes that providers have correctly identified and categorized the lacerations that they record in the EMR.

To develop and validate case definitions (computable phenotypes) to accurately identify neurosurgical and critical care events in children with traumatic brain injury.Prospective observational cohort study, May 2013 to September 2015.Two large U.S. children's hospitals with level 1 Pediatric Trauma Centers.One hundred seventy-four children less than 18 years old admitted to an ICU after traumatic brain injury.Prospective data were linked to database codes for each patient. The outcomes were prospectively identified acute traumatic brain injury, intracranial pressure monitor placement, craniotomy or craniectomy, vascular catheter placement, invasive mechanical ventilation, and new gastrostomy tube or tracheostomy placement. Candidate predictors were database codes present in administrative, billing, or trauma registry data. For each clinical event, we developed and validated penalized regression and Boolean classifiers (models to identify clinical events that take database codes as predictors). We externally validated the best model for each clinical event. The primary model performance measure was accuracy, the percent of test patients correctly classified. The cohort included 174 children who required ICU admission after traumatic brain injury. Simple Boolean classifiers were greater than or equal to 94% accurate for seven of nine clinical diagnoses and events. For central venous catheter placement, no classifier achieved 90% accuracy. Classifier accuracy was dependent on available data fields. Five of nine classifiers were acceptably accurate using only administrative data but three required trauma registry fields and two required billing data.In children with traumatic brain injury, computable phenotypes based on simple Boolean classifiers were highly accurate for most neurosurgical and critical care diagnoses and events. The computable phenotypes we developed and validated can be used in any observational study of children with traumatic brain injury and can reasonably be applied in studies of these interventions in other patient populations.

Objectives:In children with traumatic brain injury, 1) to describe the hospital discharge functional outcome and change from baseline function using the Functional Status Scale and 2) to determine any associations between discharge Functional Status Scale and age, injury mechanism, neurologic examin

Although Music Therapy, an allied health discipline, is often included in standard care for the treatment of children with mental health disorders, there is a lack of empirical evidence to support its contribution for the care of children and adolescents in mental health services. The goal of this retrospective research is to examine whether group music therapy affects mood states of adolescent inpatients in a psychiatric hospital service based within a large children’s hospital. A secondary aim was to understand if specific patient demographic predictors influenced the mood outcome. Participants included 352 predominately white, non-Hispanic patients (12–21 years old, with a mean age of 15.13 ± 1.88 years) who completed 596 mood measures between August 2010 and March 2013. Participants completed the Fast Assessment of Children’s Emotions (FACE) before and after a group music therapy session. Based on a binary outcome model of change or no change, the probability of a change in total mood score was high (probability of change 0.82 [95%CI 0.79, 0.85]). There were no significant associations between age, gender, or other specific demographics that were tested, nor changes in individual or total mood scores within this sample. This preliminary research documents the immediate impact of group music therapy sessions on mood of adolescent patients in this setting diagnosed with a range of psychiatric disorders.

Aim A single-institution review assessing patient characteristics contributing to daily organ motion in postoperative endometrial and cervical cancer patients treated with intensity-modulated radiotherapy (IMRT). Background The Radiation Therapy Oncology Group has established consensus guidelines for postoperative pelvic IMRT, recommending a 7 mm margin on all three axes of the target volume. Materials and methods Daily shifts on 457 radiation setups for 18 patients were recorded in the x axis (lateral), y axis (superior–inferior) and z axis (anterior–posterior); daily positions of the planning tumor volume were referenced with the initial planning scan to quantify variations. Results Of the 457 sessions, 85 (18.6%) had plan shifts of at least 7 mm in one of the three dimensions. For obese patients (body mass index [BMI] ≥ 30), 75/306 (24.5%) sessions had plan shifts ≥7 mm. Odds of having a shift ≥7 mm in any direction was greater for obese patients under both univariate (OR 4.227, 95% CI 1.235–14.466, p = 0.021) and multivariate (OR 5.000, 95% CI 1.341–18.646, p = 0.016) analyses (MVA). Under MVA, having a BMI ≥ 30 was associated with increased odds of shifts in the anterior–posterior (1.173 mm, 95% CI 0.281–2.065, p = 0.001) and lateral (2.074 mm, 95% CI 1.284–2.864, p 0.000) directions but not in the superior–inferior axis (0.298 mm, 95% CI −0.880 to 1.475, p = 0.619) exceeding 7 mm. Conclusions Based on these findings, the standard planned tumor volume expansion of 7 mm is less likely to account for daily treatment changes in obese patients.

Purpose To describe national trends in peripheral endovascular interventions by physician specialty, anatomic segment of disease, and clinical location of service. Materials and Methods Current Procedural Terminology codes were used to identify claims for peripheral vascular interventions (PVIs) in 2011–2017 Physician Supplier Procedure Summary master files, which contain 100% Part B Medicare billing. Market share was defined as enrollment-adjusted proportion of billed PVI services for each specialty. Annual volume of billed services was additionally evaluated by clinical location (inpatient, outpatient, office-based laboratories) and anatomic segment of disease (iliac, femoral/popliteal, infrapopliteal). Results Aggregate PVI claims increased 31.3%, from 227,091 in 2011 to 298,127 in 2017. Annual market share remained relatively stable for all specialties: surgery, 48.3%–49.6%; cardiology, 37.2%–35.1%; radiology, 12.8%–13.3%. Accounting for Medicare enrollment, the volume of iliac interventions decreased by 18% over the study period, while femoral/popliteal interventions increased modestly (+7.5%) and infrapopliteal interventions increased (+46%). The greatest proportional increase in infrapopliteal claims occurred among radiologists (surgeons +40.4%, cardiologists +32.1%, radiologists +106.6%). Adjusting for enrollment, claims from office-based laboratories increased substantially (+305.7%), while hospital-based billing decreased (inpatient −25.7%, outpatient −12.9%). Office-based laboratory utilization increased dramatically with all specialties (surgery +331.8%, cardiology +256.0%, radiology +475.7%). Conclusions Utilization of PVIs continues to increase, while specialty market shares have stabilized since 2011, leaving surgeons and cardiologists as the major providers of endovascular peripheral artery disease care. The greatest relative increases are occurring in infrapopliteal interventions and office-based laboratory procedures, where radiologist involvement has increased dramatically.

OBJECTIVES To determine the rate, etiology, and timing of unplanned and planned hospital readmissions and to identify risk factors for unplanned readmission in children who survive a hospitalization for trauma. DESIGN Multicenter retrospective cohort study of a probabilistically linked dataset from the National Trauma Data Bank and the Pediatric Health Information System database, 2007-2012. SETTING Twenty-nine U.S. children's hospitals. PATIENTS 51,591 children (< 18 yr at admission) who survived more than or equal to a 2-day hospitalization for trauma. MEASUREMENTS AND MAIN RESULTS The primary outcome was unplanned readmission within 1 year of discharge from the injury hospitalization. Secondary outcomes included any readmission, reason for readmission, time to readmission, and number of readmissions within 1 year of discharge. The primary exposure groups were isolated traumatic brain injury, both traumatic brain injury and other injury, or nontraumatic brain injury only. We hypothesized a priori that any traumatic brain injury would be associated with both planned and unplanned hospital readmission. We used All Patient Refined Diagnosis Related Groups codes to categorize readmissions by etiology and planned or unplanned. Overall, 4,301/49,982 of the patients (8.6%) with more than or equal to 1 year of observation time were readmitted to the same hospital within 1 year. Many readmissions were unplanned: 2,704/49,982 (5.4%) experienced an unplanned readmission in the first year. The most common reason for unplanned readmission was infection (22%), primarily postoperative or posttraumatic infection (38% of readmissions for infection). Traumatic brain injury was associated with lower odds of unplanned readmission in multivariable analyses. Seizure or RBC transfusion during the index hospitalization were the strongest predictors of unplanned, earlier, and multiple readmissions. CONCLUSIONS Many survivors of pediatric trauma experience unplanned, and potentially preventable, hospital readmissions in the year after discharge. Identification of those at highest risk of readmission can guide targeted in-hospital or postdischarge interventions.

The TG/HDL-C ratio is used as a marker of insulin resistance (IR) in Caucasians. However, there are conflicting data on TG/HDL-C ratio as a predictor of IR in African Americans. Compared to Caucasians, African Americans have lower TG levels and increased insulin levels despite a greater risk for diabetes. We hypothesized that the TG/HDL-C ratio is predictive of IR and/or β-cell function in African American (AA) women.Non-diabetic AA women (n = 41) with a BMI25 kg/m(2) underwent frequently sampled intravenous glucose tolerance test (FSIGTT). Insulin sensitivity (SI) and the acute insulin response to glucose (AIRg) were measured using minimal model and β-cell function was determined by disposition index (DI = S I*AIRg). IR was defined as the lowest tertile of SI (1.8 × 10(-4)min(-1)/μU/ml) and inadequate β cell compensation was defined as the lowest tertile of DI (900). Data were analyzed using logistic regression models and area under the receiver operating characteristic curve (AUC-ROC). An AUC-ROC0.70 was defined as significant discrimination.The mean (± SD) age was 38.5 ± 11.3 years, with BMI of 33.5 ± 6.7 kg/m(2) and fasting glucose of 86.5 ± 10.5 mg/dL. The AUC-ROC for the prediction of DI900 was 0.74 indicating that a higher TG/HDL-C ratio was associated with decreased DI. However, the AUC-ROC for prediction of IR or low AIRg (335 μU/ml) was not significant.This study confirmed that the TG/HDL-C ratio is a poor predictor of IR in AA women. However, we did show an inverse association between the TG/HDL-C ratio and β-cell function, suggesting that this simple tool may effectively identify AA women at risk for DM2.

Introduction Excessive crystalloid resuscitation of blunt injured adults is deleterious. We hypothesize that children, unlike adults, are resistant to the adverse effects of high volume resuscitation. Methods We reviewed the trauma databases at two level-one trauma centers, including all children age 4–16years admitted following blunt trauma with an injury severity score (ISS) ≥15 to determine the relationship between crystalloid volume received and clinical outcomes. Results A total of 384 children were included. After controlling for age, sex, AIS head, ISS, GCS on presentation, hemoglobin, blood transfusion, and surgical procedures in the first 24hours, crystalloid volume greater than 60ml/kg in the first 24hours was associated with increased length of stay (LOS) and need for mechanical ventilation. On univariate analysis, initial crystalloid volume of >60ml/kg was associated with anemia and thrombocytopenia. Volume of resuscitation was not associated with ARDS, ACS, MOF, urinary tract infection, or blood stream infection. However, these complications were exceedingly rare, with no children developing MOF. Conclusions Excessive crystalloid resuscitation was associated with increased hospital LOS and need for mechanical ventilation. Increased rates of other complications including ARDS, ACS, and MOF were not observed. Injured children appear relatively resistant to some of the adverse effects of early high volume fluid resuscitation.

ObjectivesTrauma and, in particular, traumatic brain injury (TBI) cause enormous morbidity and mortality worldwide. Children who survive trauma have many health burdens, but how often those burdens lead to emergency care or hospital readmission is unknown. Readmissions occur frequently in adult TBI survivors: approximately 21-28% within one year. No single existing U.S. database contains the necessary variables to study readmissions of children hospitalized after trauma. We previously demonstrated that probabilistic linkage with Markov chain Monte Carlo parameter refinement could accurately link records of children with severe TBI without using protected health information. That work was presented at the IHDLN Conference in 2014. The objectives of this study are to 1) expand the previous linkage to include children with any type of trauma and 2) to determine the 1-year rates of Emergency Department (ED) visit and hospital readmission in children with TBI versus other trauma. ApproachUsing the algorithm we reported previously, we linked the records of children hospitalized after trauma during 2007-2012 in the U.S. National Trauma Data Bank (NTDB) with the Pediatric Health Information System (PHIS) database. The NTDB contains the Glasgow Coma Scale (GCS), necessary to categorize TBI. The PHIS database contains a unique identifier for each patient at each hospital, making longitudinal studies possible. Probabilistic linkage was performed using LinkSolv (Strategic Matching, Inc., Morrisonville, NY). We identified ED visits and hospital readmissions of the index cohort in the PHIS database through March 31, 2015. ResultsAmong children hospitalized after acute trauma for >= 2 days, we found that 83% of NTDB records linked accurately. Of the children hospitalized at 28 U.S. hospitals in 19 states, 49,477 were discharged alive; 15,438 had TBI. This represents approximately 10% of U.S. pediatric TBI hospitalizations during that period. The median age was 8 years and 64% were male. The 1-year hospital readmission rate was higher (12.2%, 283/2,306) in those with both TBI and other injuries than those with isolated TBI (8.5%, 1,120/13,132) or non-TBI injuries (8.1%, 2,790/34,039, p < 0.01 across groups). The 1-year ED visit rate differed only modestly between those three groups (14.1% versus 15.4% versus 14.2%, p < 0.01). ConclusionsThis study leverages two linked national datasets to investigate emergency care and hospital readmission in children who survive trauma. Multivariable analyses are ongoing and will be completed by August 2016. We will generate hypotheses about potentially modifiable causes of emergency care and readmission.

Traumatic brain injury (TBI) causes substantial morbidity and mortality in US children. Post-traumatic seizures (PTS) occur in 11-42% of children with severe TBI and are associated with unfavorable outcome. Electroencephalographic (EEG) monitoring may be used to detect PTS and antiepileptic drugs (AEDs) may be used to treat PTS, but national rates of EEG and AED use are not known. The purpose of this study was to describe the frequency and timing of EEG and AED use in children hospitalized after severe TBI.Retrospective cohort study of 2165 children at 30 hospitals in a probabilistically linked dataset from the National Trauma Data Bank (NTDB) and the Pediatric Health Information Systems (PHIS) database, 2007-2010. We included children (age18 years old at admission) with linked NTDB and PHIS records, severe (Emergency Department [ED] Glasgow Coma Scale [GCS]8) TBI, hospital length of stay24 h, and non-missing disposition. The primary outcomes were EEG and AED use.Overall, 31.8% of the cohort had EEG monitoring. Of those, 21.8% were monitored on the first hospital day. The median duration of EEG monitoring was 2.0 (IQR 1.0, 4.0) days. AEDs were prescribed to 52.0% of the cohort, of whom 61.8% received an AED on the first hospital day. The median duration of AED use was 8.0 (IQR 4.0, 17.0) days. EEG monitoring and AED use were more frequent in children with known risk factors for PTS. EEG monitoring and AED use were not related to hospital TBI volume.EEG use is relatively uncommon in children with severe TBI, but AEDs are frequently prescribed. EEG monitoring and AED use are more common in children with known risk factors for PTS.

To determine the 24-h effects of brinzolamide/brimonidine tartrate 1%/0.2% fixed combination (BBFC) on intraocular pressure (IOP), ocular perfusion pressure (OPP), blood pressure (BP), and heart rate (HR).Sixty subjects with open angle glaucoma (OAG) or ocular hypertension (OHTN) were admitted overnight for 24-h monitoring of IOP, BP, and HR. All subjects underwent the first, baseline 24-h study after washout of all medications, if necessary. Subjects were then randomized to receive either (1) timolol maleate 0.5% twice daily or (2) BBFC 3 times daily. After 4 weeks of treatment, all subjects completed a follow-up 24-h study visit. At each study visit, IOP, BP, and HR were measured every 2 h in the habitual position. OPP was calculated as 2/3[diastolic BP +1/3(systolic BP-diastolic BP)]-IOP.Treatment with BBFC significantly lowered IOP during the diurnal period (-2.7 ± 0.4 mmHg; P 0.01) and nocturnal period (-0.8 ± 0.3 mmHg; P 0.01). Timolol similarly reduced IOP during the diurnal period, but did not lower IOP overnight. Over a 24-h period, BBFC achieved a significantly greater IOP reduction than timolol (-0.7 ± 0.4 mmHg; P = 0.04). BBFC failed to achieve an increase in OPP during any time period, while timolol increased OPP during the diurnal period only. A significantly greater reduction in HR occurred in the timolol group.BBFC significantly lowers IOP during both the diurnal and nocturnal periods, but has no effect on OPP. Timolol only lowers IOP during the diurnal period.

Traumatic brain injury causes substantial morbidity and mortality in children. Posttraumatic seizures may worsen outcomes after traumatic brain injury. Posttraumatic seizures risk factors are not completely understood. Our objective was to clarify posttraumatic seizures risk factors in a large cohort of children with severe traumatic brain injury.Retrospective cohort study of a probabilistically linked dataset from the National Trauma Data Bank and the Pediatric Health Information Systems database, 2007-2010.Twenty-nine U.S. children's hospitals.A total of 2,122 children (age,18 yr old at admission) with linked National Trauma Data Bank and Pediatric Health Information Systems records, severe (emergency department Glasgow Coma Scale,8) traumatic brain injury, hospital length of stay more than 24 hours, and nonmissing disposition.None.The outcome was posttraumatic seizures, identified using validated International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes. Prespecified candidate predictors of posttraumatic seizures included age, injury mechanism, emergency department Glasgow Coma Scale, intracranial hemorrhage type, hypoxia, hypotension, and cardiac arrest. Posttraumatic seizures were diagnosed in 25.2% of children with severe traumatic brain injury. In those without abuse/assault or subdural hemorrhage, the posttraumatic seizures rate varied between 36.6% in those less than 2 years old and 16.4% in those 14-17 years old. Age, abusive mechanism, and subdural hemorrhage are each significant predictors of posttraumatic seizures. The risk of posttraumatic seizures has a complex relationship with these predictors. The estimated odds of posttraumatic seizures decrease with advancing age, odds ratio equal to 0.929 (0.905-0.954) per additional year of age with no abuse/assault and no subdural hemorrhage; odds ratio equal to 0.820 (0.730-0.922) per additional year of age when abuse and subdural hemorrhage are present. An infant with accidental traumatic brain injury and subdural hemorrhage has approximately the same estimated probability of posttraumatic seizures as an abused infant without subdural hemorrhage (47% [95% CI, 39-55%] vs 50% [95% CI, 41-58%]; p = 0.69). The triad of young age, injury by abuse/assault, and subdural hemorrhage confers the greatest estimated probability for posttraumatic seizures (60% [95% CI, 53-66%]).Posttraumatic seizures risk in children with severe traumatic brain injury is greatest with a triad of younger age, injury by abuse/assault, and subdural hemorrhage. However, posttraumatic seizures are common even in the absence of these factors.

Although dance/movement therapy (DMT) is often used in conjunction with traditional therapies for treating children with psychiatric disorders, the evidence base for this therapy is currently small. The goal of this retrospective research is to examine whether DMT, embedded within larger psychiatric therapeutic programs, affects changes in mood states of adolescents suffering from a variety of psychiatric illnesses. Participants include 402 predominately white, non-Hispanic patients (14–21 years old, with a mean age of 14.56 ± 1.70 years) who completed 671 mood measures between August 2010 and December 2011. Participants completed the Fast Assessment of Children's Emotions before and after a group DMT session. When controlling for pre-mood scores, there was a significant change in all mood states and a significant odds of a change in total mood score, per unit increase in pre-total mood score, after one DMT session (odds ratio = 1.84; p ≤ .01). There was no significant association between patient characteristics and changes in individual or total mood scores, indicating that DMT may be useful for a wide range of patients. The results from this formative study will help researchers develop prospective studies focusing on therapeutic effects of DMT for a wide range of patients.

OBJECTIVE: To compare 3 methods of weight determination for medication dose calculations in obese children and to discuss feasibility for use in routine care. METHODS: This was a patient safety and quality improvement study evaluating patients (2–19 years old) admitted to the pediatric intensive care unit during a 13-month period (July 2010–July 2011). Patients identified as obese (≥95th percentile body mass index [BMI] for age), including severely obese (≥99th percentile BMI for age), were included in the weight method comparison portion of this study. Lean body mass estimations, using equations derived by the Peters and Foster methods, were compared to ideal body weight estimates by using the BMI method. Absolute differences between values generated by the 3 methods, intraclass correlation (ICC), and Bland-Altman plots were calculated. RESULTS: A total of 1369 patients met initial criteria; 176 met criteria for the dosing weight comparison (age ± SD = 9.28 ± 5 years; actual weight ± SD = 55.5 ± 33.9 kg; 46% female). Sixty were severely obese and 116 were obese. Mean ICC between methods was 0.968 (95% Confidence interval (CI): 0.959, 0.975). The Peters method estimated higher weights than the Foster or BMI method. Bland-Altman plots illustrated good agreement between methods in children with weight below 50 kg, but decreased agreement above 50 kg, which was influenced by sex. CONCLUSIONS: All methods demonstrated strong correlation and acceptable agreement in children below 50 kg. Systematic biases were identified in children above 50 kg where variance was higher. The BMI method was least complex to calculate and the most feasible method for daily use.

Objective To characterize the psychometric properties of a novel Obstetric Communication Assessment Tool (OCAT) in a pilot study of standardized difficult OB communication scenarios appropriate for undergraduate medical evaluation. Methods We developed and piloted four challenging OB Standardized Patient (SP) scenarios in a sample of twenty-one third year OB/GYN clerkship students: Religious Beliefs (RB), Angry Father (AF), Maternal Smoking (MS), and Intimate Partner Violence (IPV). Five trained Standardized Patient Reviewers (SPRs) independently scored twenty-four randomized video-recorded encounters using the OCAT. Cronbach's alpha and Intraclass Correlation Coefficient-2 (ICC-2) were used to estimate internal consistency (IC) and inter-rater reliability (IRR), respectively. Systematic variation in reviewer scoring was assessed using the Stuart-Maxwell test. Results IC was acceptable to excellent with Cronbach's alpha values (and 95% Confidence Intervals [CI]): RB 0.91 (0.86, 0.95), AF 0.76 (0.62, 0.87), MS 0.91 (0.86, 0.95), and IPV 0.94 (0.91, 0.97). IRR was unacceptable to poor with ICC-2 values: RB 0.46 (0.40, 0.53), AF 0.48 (0.41, 0.54), MS 0.52 (0.45, 0.58), and IPV 0.67 (0.61, 0.72). Stuart-Maxwell analysis indicated systematic differences in reviewer stringency. Conclusions Our initial characterization of the OCAT demonstrates important issues in communications assessment. We identify scoring inconsistencies due to differences in SPR rigor that require enhanced training to improve assessment reliability. We outline a rational process for initial communication tool validation that may be useful in undergraduate curriculum development, and acknowledge that rigorous validation of OCAT training and implementation is needed to create a valuable OB communication assessment tool.

Objectives/Hypothesis: To evaluate the effect of larynx and esophageal inlet sparing on dysphagia recovery after intensity-modulated radiotherapy (IMRT) for stage III-IV oropharyngeal squamous cell carcinoma. Study Design: Retrospective study. Methods: Of 88 patients treated with IMRT, 38 were planned with a larynx + esophageal inlet mean dose 60 Gy. Mean pharyngeal constrictor doses in patients receiving a mean dose to the larynx + esophageal inlet of ≤50 Gy versus >50 Gy were: 60 Gy and 69 Gy, 55 Gy and 67 Gy, and 47 Gy and 57 Gy, for the superior, middle, and inferior constrictors, respectively (P < .0001). Conclusions: A dose constraint on the larynx and esophageal inlet during IMRT planning reduces dose to pharyngeal constrictors and expedites PEG tube removal.

Background Global climate change is expected to increase the risk of diarrhoeal diseases, a leading cause of childhood mortality. However, there is considerable uncertainty about the magnitude of these effects and which populations bear the greatest risks. Methods We conducted a systematic review using defined search terms across four major databases and, additionally, examined the references of 54 review articles captured by the search. We evaluated sources of heterogeneity by pathogen taxon, exposure measure, study quality, country income level and regional climate, and estimated pooled effect estimates for the subgroups identified in the heterogeneity analysis, using meta-analysis methods. Results We identified 26 studies with 49 estimates. Pathogen taxa were a source of heterogeneity. There was a positive association between ambient temperature and all-cause diarrhoea (incidence rate ratio (IRR) 1.07; 95% confidence interval (CI) 1.03, 1.10) and bacterial diarrhoea (IRR 1.07; 95% CI 1.04, 1.10), but not viral diarrhoea (IRR 0.96; 95% CI 0.82, 1.11). These associations were observed in low-, middle- and high-income countries. Only one study of protozoan diarrhoea was identified. Conclusions Changes in temperature due to global climate change can and may already be affecting diarrhoeal disease incidence. The vulnerability of populations may depend, in part, on local pathogen distribution. However, evidence of publication bias and the uneven geographical distribution of studies limit the precision and generalizability of the pooled estimates.

This project develops computationally efficient software to generate classification of pediatric complex chronic conditions using a free, open-source statistical environment.

Importance Intracranial pressure (ICP) monitoring is a mainstay of therapy for children with traumatic brain injury (TBI), but its overall association with patient outcome is unclear. Objective To test the hypothesis that ICP monitoring is associated with improved functional survival of children with severe TBI. Design, Setting, and Participants A propensity-weighted effectiveness analysis was conducted using 2 linked national databases with data from 30 US children’s hospitals from January 1, 2007, to December 31, 2012, on 3084 children with severe TBI. Clinical events including neurosurgical procedures were identified using validated computable phenotypes. Data analysis was conducted from September 1, 2016, to March 1, 2017. Exposure Placement of an ICP monitor. Main Outcomes and Measures A composite of hospital mortality, discharge to hospice, or survival with placement of new tracheostomy and gastrostomy tubes. Results Of the 3084 children in the study (1128 girls and 1956 boys; mean [SD] age, 7.03 [5.44] years), 1002 (32.4%) underwent ICP monitoring, with substantial hospital variation (6% to 50% by hospital). Overall, 484 children (15.7%) experienced the primary composite outcome. A propensity approach using matching weights generated good covariate balance between those who did and those who did not undergo ICP monitoring. Using a propensity-weighted logistic regression model clustered by hospital, no statistically significant difference was found in functional survival between monitored and unmonitored patients (odds ratio of poor outcome among those who underwent ICP monitoring, 1.31; 95% CI, 0.99-1.74). In a prespecified secondary analysis, no difference in mortality was found (odds ratio, 1.16; 95% CI, 0.89-1.50). Prespecified subgroup analyses of children younger and older than 2 years of age and among those with unintentional and inflicted (intentional) injuries also showed no difference in outcome with ICP monitoring. Conclusions and Relevance With the use of linked national data and validated computable phenotypes, no evidence was found of a benefit from ICP monitoring on functional survival of children with severe TBI. Intracranial pressure monitoring is a widely but inconsistently used technology with incompletely demonstrated effectiveness. A large prospective cohort study or randomized trial is needed.

Maternal obesity is associated with increased systemic inflammation and an increased risk of preterm premature rupture of membranes. There is an established association between an inflammatory intrauterine environment and adverse neonatal outcomes that is independent of gestational age and mediated by the fetal inflammatory response. It is unknown whether the maternal systemic inflammation that is present in obese women influences the intrauterine environment and predisposes the fetus to adverse neonatal outcomes after preterm premature rupture of membranes.The purpose of this study was to determine whether maternal obesity is associated with adverse neonatal outcomes in pregnancies that are complicated by preterm premature rupture of membranes.This was a secondary analysis of the Maternal-Fetal Medicine Units Network Randomized Clinical Trial on the Beneficial Effects of Antenatal Magnesium Sulfate. Women with singleton pregnancies that were affected by preterm premature rupture of membranes who delivered live-born infants between 24 + 0 and 33 + 6 weeks of gestation were included. An adverse neonatal outcome was defined as a composite outcome of neonatal death, severe necrotizing enterocolitis, respiratory distress syndrome, sepsis, or severe intraventricular hemorrhage. The rates of the composite outcome were compared between obese (body mass index, ≥30 kg/m(2)) and nonobese women. Multivariable logistic regression was used to evaluate the independent effect of obesity on neonatal outcomes. Magnesium sulfate administration, steroid administration, maternal diabetes mellitus, gestational age at delivery, indomethacin exposure, birthweight, and chorioamnionitis were all considered as possible covariates in the multivariable regression models.Three hundred twenty-five of the 1288 women (25.2%) who were included were obese, and 202 of these women (62.2%) had neonates with adverse outcomes. In univariable analysis, maternal prepregnancy obesity was associated with increased odds of an adverse neonatal outcome (odds ratio, 0.30, 95% confidence interval, 1.00-1.68). However, in our multivariable logistic regression model, gestational age at delivery (odds ratio, 0.93, 95% confidence interval, 0.92-0.94 per day), but not maternal obesity (odds ratio, 1.02, 95% confidence interval, 0.75-1.38), was associated with adverse neonatal outcomes. Obese African American women experienced preterm premature rupture of membranes (189 vs 196 days; p.001) and delivery (199 vs 205 days; p.001) earlier than nonobese African American women. This difference was not seen in non-African American women.Maternal obesity was not associated independently with adverse neonatal outcomes in pregnancies that were affected by preterm premature rupture of membranes after adjustment for gestational age at birth. However, obese African American women rupture and deliver earlier than other women, which causes increased neonatal morbidity.

Histologic grade analyses for prostate cancer (PCa) have traditionally included Gleason scores (GS) of ≤6, 7, and 8-10. Stratified biochemical progression-free survival has increasingly been reported within these groups on analyses of primary-secondary patterns (PSPs) (e.g., 3+4 vs. 4+3) and overall GS (e.g., 8 vs. 9 vs. 10) but with limited data regarding stratified survival outcomes. In this analysis, outcomes for biopsy-assigned GS 6 to 10 were comprehensively evaluated to identify stratifications prognostic for survival in patients undergoing external beam radiation therapy (EBRT).The Surveillance, Epidemiology, and End Results database was examined for T1-4 N0 M0, GS 6 to 10 PCa managed with EBRT alone from 2004 to 2006. GS and PSP variations were analyzed for PCa-specific survival (PCSS) and overall survival (OS).Overall, 26,885 patients were evaluated. Preliminary PSP analyses identified stratifications for 3+4 vs. 4+3 = 7 and 4+4 = 8 vs. GS 8 with pattern 5 (P5) (i.e., 3+5 and 5+3) as significant; however, no differences were observed for 4+5 vs. 5+4 = 9. The primary analysis included stratifications for GS 6, 3+4, 4+3, 4+4, 8 w/P5, 9, and 10, where the 7.5-year PCSS rates were 99%, 97%, 95%, 91%, 86%, 81%, and 78% and 7.5-year OS rates were 83%, 76%, 72%, 67%, 66%, 58%, and 54%, respectively. PCSS differences for sequential score increases were all significant on univariate analyses (all P0.05). In sequential multivariate analyses of PCSS accounting for age, prostate-specific antigen, T stage, year, marital status, race, and tumor registry, the identified GS stratifications remained significant (all P0.05), with the exception of GS 8 w/P5 vs. 9 (P = 0.11). In overall multivariate analyses, the identified GS stratifications represented the strongest prognostic factor for survival. Subgroup analyses demonstrated that presence of any P5 was an independent prognostic factor for survival.In the largest reported survival analysis of Gleason stratifications, biopsy-assigned GS 6, 3+4, 4+3, 4+4, 8 w/P5, 9, and 10 represented sequential prognostic factors for survival in patients managed with definitive EBRT.

Purpose We performed a patterns-of-care analysis evaluating the effects of newer technology and recent research findings on treatment decisions over 26 years to determine whether patients with cervical cancer are being appropriately selected for treatment to optimize the therapeutic ratio. Methods and Materials A retrospective analysis was conducted using the Surveillance, Epidemiology and End Results (SEER) program from 1983 to 2009. We identified 10,933 women with stage IB-IIB cervical carcinoma. Results Of the 10,933 subjects identified, 40.1% received surgery, 26.8% received radiation (RT), and 33.1% received surgery plus RT. RT use increased after 2000 compared to prior to 2000, with a corresponding decrease in surgery and surgery plus RT. Among patients with risk factors including tumor size >4 cm, positive parametria, and positive lymph nodes, declining use of surgery plus RT was observed. However, 23% of patients with tumors >4 cm, 20% of patients with positive parametria, and 55% of node-positive patients continued to receive surgery plus RT as of 2009. Factors associated with increased use of surgery plus RT included patient age Conclusions In this largest patterns-of-care analysis to date for patients with locally advanced cervical cancer, we found a substantial proportion of patients continue to undergo surgery followed by radiation, despite randomized data supporting the use of definitive radiation therapy, with lower morbidity than surgery and radiation.

To evaluate the survival outcomes for patients with lymph node-positive, nonmetastatic prostate cancer undergoing definitive local therapy (radical prostatectomy [RP], external beam radiation therapy [EBRT], or both) versus no local therapy (NLT) in the US population in the modern prostate specific antigen (PSA) era.The Surveillance, Epidemiology, and End Results database was queried for patients with T1-4N1M0 prostate cancer diagnosed from 1995 through 2005. To allow comparisons of equivalent datasets, patients were analyzed in separate clinical (cN+) and pathologically confirmed (pN+) lymph node-positive cohorts. Kaplan-Meier overall survival (OS) and prostate cancer-specific survival (PCSS) estimates were generated, with accompanying univariate log-rank and multivariate Cox proportional hazards comparisons.A total of 796 cN+ and 2991 pN+ patients were evaluable. Among cN+ patients, 43% underwent EBRT and 57% had NLT. Outcomes for cN+ patients favored EBRT, with 10-year OS rates of 45% versus 29% (P.001) and PCSS rates of 67% versus 53% (P.001). Among pN+ patients, 78% underwent local therapy (RP 57%, EBRT 10%, or both 11%) and 22% had NLT. Outcomes for pN+ also favored local therapy, with 10-year OS rates of 65% versus 42% (P.001) and PCSS rates of 78% versus 56% (P.001). On multivariate analysis, local therapy in both the cN+ and pN+ cohorts remained independently associated with improved OS and PCSS (all P.001). Local therapy was associated with favorable hazard ratios across subgroups, including patients aged ≥70 years and those with multiple positive lymph nodes. Among pN+ patients, no significant differences in survival were observed between RP versus EBRT and RP with or without adjuvant EBRT.In this large, population-based cohort, definitive local therapy was associated with significantly improved survival in patients with lymph node-positive prostate cancer.

To analyze the stage-specific management of male breast cancer (MBC) with surgery and radiation therapy (RT) and relate them to outcomes and to female breast cancer (FBC).The Surveillance, Epidemiology, and End Results database was queried for all primary invasive MBC and FBC diagnosed from 1973 to 2008. Analyzable data included age, race, registry, grade, stage, estrogen and progesterone receptor status, type of surgery, and use of RT. Stage was defined as localized (LocD): confined to the breast; regional (RegD): involving skin, chest wall, and/or regional lymph nodes; and distant: M1. The primary endpoint was cause-specific survival (CSS).A total of 4276 cases of MBC and 718,587 cases of FBC were identified. Male breast cancer constituted 0.6% of all breast cancer. Comparing MBC with FBC, mastectomy (M) was used in 87.4% versus 38.3%, and breast-conserving surgery in 12.6% versus 52.6% (P10(-4)). For males with LocD, CSS was not significantly different for the 4.6% treated with lumpectomy/RT versus the 70% treated with M alone (hazard ratio [HR] 1.33; 95% confidence interval [CI] 0.49-3.61; P=.57). Postmastectomy RT was delivered in 33% of males with RegD and was not associated with an improvement in CSS (HR 1.11; 95% CI 0.88-1.41; P=.37). There was a significant increase in the use of postmastectomy RT in MBC over time: 24.3%, 27.2%, and 36.8% for 1973-1987, 1988-1997, and 1998-2008, respectively (P.0001). Cause-specific survival for MBC has improved: the largest significant change was identified for men diagnosed in 1998-2008 compared with 1973-1987 (HR 0.73; 95% CI 0.60-0.88; P=.0004).Surgical management of MBC is dramatically different than for FBC. The majority of males with LocD receive M despite equivalent CSS with lumpectomy/RT. Postmastectomy RT is greatly underutilized in MBC with RegD, although a CSS benefit was not demonstrated. Outcomes for MBC are improving, attributable to improved therapy and its use in this unscreened population.

Background Hypocalcemia is a frequent complication of thyroidectomy. Although typically mild and temporary, it can lead to an increased length of stay, readmission, and in some cases be permanent. Controversy exists as to whether vitamin D deficiency (VDD) contributes to post-thyroidectomy hypocalcemia. Methods This is a retrospective study of 152 patients who underwent thyroidectomy. Patients with or without VDD were compared. Data were analyzed for demographics, operative procedure, calcium levels, and complications of hypocalcemia. Results There was no difference in the rates of biochemical or symptomatic hypocalcemia or in the need for readmission between the VDD and non-VDD groups. A multivariate analysis controlling for central neck dissection, parathyroid autotransplant, and preoperative diagnosis confirmed no association between VDD and post-thyroidectomy hypocalcemia. Conclusions Despite VDD being common in patients undergoing thyroidectomy, our results do not suggest that this increases the rate of hypocalcemia. Thus, preoperative evaluation/repletion of VDD is unlikely to reduce post-thyroidectomy hypocalcemia rates.

Purpose To investigate the predictive value of the complete ophthalmic examination at first presentation in foreseeing the need for surgery in patients with pediatric orbital cellulitis. Design Retrospective observational case series. Methods We reviewed 136 cases of radiographically confirmed orbital cellulitis between 2004 and 2012 at Children's Hospital Colorado. The presenting ophthalmic examinations, imaging results, medical and surgical interventions, and clinical complications were recorded. The main outcome measures were ophthalmic examinations on presentation, medical or surgical interventions, and complications. Results The median age was 6.5 years. Of the patients, 56 (41%) underwent surgical intervention, and 80 patients (59%) were managed medically. Patients requiring surgery had higher rates of extraocular motility (EOM) restriction (78.6% vs 38.8% P P P P Conclusions In pediatric orbital cellulitis, the likelihood of surgical intervention can be estimated accurately based on the ophthalmic examination on initial presentation to the hospital. Risk factors for surgery include age older than 9 years, proptosis, EOM restriction, and elevated IOP. These factors may be used to identify patients at high risk for failure of medical management early in the clinical course.