Retrospective observational study of chloral hydrate use in mechanically-ventilated pediatric intensive care unit (PICU) patients 2012–2017

Introduction: Chloral hydrate (CH) has long been utilized as a pediatric procedural sedation agent. However, very little is published describing CH use in a pediatric intensive care unit (PICU) setting. The aim of this retrospective observational cohort study was to investigate and describe the use of CH in mechanically-ventilated, critically ill children at a large pediatric tertiary referral hospital.Methods: Data were extracted from the hospital electronic medical record and a locally maintained registry of all children admitted to the PICU between 2012 and 2017. Patients admitted to the cardiovascular ICU were not included in this review. The clinical and pharmacy data for 3806 consecutive PICU admissions of mechanically-ventilated, critically ill children were examined.Results: 283 admissions received CH during their first ICU stay. CH-exposed children were younger (16 months vs. 35 months, p < 0.001), the median total dose of CH (indexed to duration of ventilation) was 11 mg/kg/day, the median time to first CH dose was 3 days and more CH doses were administered at night (1112 vs. 958, p < 0.001). We constructed a propensity score to adjust for the differences in patients with and without CH exposure using logistic regression including variables of age, sex, diagnosis, and PRISM3 score. After adjustment, the median length of mechanical ventilation was 5 days longer in the CH-exposed group (95% Confidence Interval [CI] 4–6) compared to unexposed CH patients. Similarly, the median length of ICU duration was 9.4 days longer (95% CI 7.1–11.6) and median length of hospital admission duration was 13.2 days longer (95% CI 7.8–18.6) in CH-exposed patients compared to CH-non-exposed. After adjustment, CH-exposed patients had a 9% higher median exposure to HFOV (95% CI 3.9–14.6), but did not have higher median exposures to new tracheostomy (95% CI −0.4–2.2) or ECMO (95% CI −0.2–5.0).Discussion: As part of an extended sedation regimen in mechanically-ventilated and critically ill children, CH is associated with somewhat higher complexity of illness and longer ICU durations

Multicenter prevalence of anaphylaxis in clinic-based oral food challenges

Background Although previous single-center studies report the rate of anaphylaxis for oral food challenges (OFCs) as 9% to 11%, little is known regarding the epidemiology of clinical OFCs across multiple centers in the United States. Objective To examine the epidemiology, symptoms, and treatment of clinical low-risk OFCs in the nonresearch setting. Methods Data were obtained from 2008 to 2013 through a physician survey in 5 food allergy centers geographically distributed across the United States. Allergic reaction rates and the association of reaction rates with year, hospital, and demographics were determined using a linear mixed model. Meta-analysis was used to pool the proportion of reactions and anaphylaxis with inverse-variance weights using a random-effects model with exact confidence intervals (CIs). Results A total of 6,377 OFCs were performed, and the pooled estimate of anaphylaxis was 2% (95% CI, 1%-3%). The rate of allergic reactions was 14% (95% CI, 13%-16%) and was consistent during the study period (P = .40). Reaction rates ranged from 13% to 33%. Males reacted 16% more frequently than females (95% CI, 4%-37.5%; P = .04). Foods challenged in 2013 varied geographically, with peanut as the most challenged food in the Northeast, Midwest, and West and egg as the most challenged in the South. Conclusion As the largest national survey of allergic reactions of clinical open OFCs in a nonresearch setting in the United States, this study found that performing clinical nonresearch open low-risk OFCs results in few allergic reactions, with 86% of challenges resulting in no reactions and 98% without anaphylaxis

Hosmer-Lemeshow goodness-of-fit test: Translations to the Cox Proportional Hazards Model

Thesis (Master's)--University of Washington, 2012Background: The goodness of fit of a statistical model is commonly assessed by describing how well the model fits the observed data. For logistic regression the Hosmer-Lemeshow goodness-of-fit test compares the number of expected events from the logistic regression model to the number of observed events within deciles of predicted probabilities. This research evaluates two translations of the Hosmer-Lemeshow goodness-of-fit test for logistic regression to the Cox proportional hazards model, the Cook-Ridker (CR) and the D'Agostino-Nam (DAN) tests. These translations are compared to a test which was designed specifically for survival data, the Grønnesby and Borgan (GB) test. The GB test uses martingale residuals to compare the count of events to the semi-parametric estimates from the Cox proportional hazards model on a cumulative hazards scale. In contrast, the CR and DAN translations compare the non-parametric Kaplan-Meier estimate and the semi-parametric Cox proportional hazards estimate of survival at a fixed time. Methods: The sizes of these tests are investigated by simulating survival data and varying the baseline hazard function (exponential, Weibull and log-logistic), effect size, percentage of censoring, sample size, number of groups, and the choice of fixed time point (for the CR and DAN tests). Results: The sizes of the CR and DAN tests are near the nominal level in very few of the simulated scenarios. For most scenarios the CR and DAN tests have a size that is either much larger or much lower than the nominal level. However, when using half the maximum simulated time as the fixed time point the sizes of the CR and DAN test are near or closer to the nominal level in more scenarios compared to when the maximum time point is used. In addition, numerical issues can occur when the estimated survival probability is zero and when the estimated expected number of events is either close to zero or close to one. These results also expand on previous simulation studies showing that the size of the Grønnesby and Borgan test is notably above 0.05 in larger sample sizes (1000 or more). Conclusions: Although the CR and DAN translations of the Hosmer-Lemeshow goodness-of-fit test to the Cox proportional hazards regression are conceptually intuitive they appear to have an incorrect size and numerical issues can occur. The Grønnesby and Borgan test should be used instead since it has a more appropriate size when used with the correct number of groups

Causes for Withdrawal in an Urban Peritoneal Dialysis Program

Background. Peritoneal dialysis (PD) is an underutilized dialysis modality in the United States, especially in urban areas with diverse patient populations. Technique retention is a major concern of dialysis providers and might influence their approach to patients ready to begin dialysis therapy. Methods. Records from January 2009 to March 2014 were abstracted for demographic information, technique duration, and the reasons for withdrawal. Results. The median technique survival of the 128 incident patients during the study window was 781 days (2.1 years). The principle reasons for PD withdrawal were repeated peritonitis (30%); catheter dysfunction (18%); ultrafiltration failure (16%); patient choice or lack of support (16%); or hernia, leak, or other surgical complications (6%); and a total of 6 patients died during this period. Of the patients who did not expire and were not transplanted, most transferred to in-center hemodialysis and 8% transitioned to home-hemodialysis. Conclusions. Our findings suggest measures to ensure proper catheter placement and limiting infectious complications should be primary areas of focus in order to promote technique retention. Lastly, more focused education about home-hemodialysis as an option may allow those on PD who are beginning to demonstrate signs of technique failure to stay on home therapy

Single phase computed tomography is equivalent to dual phase method for localizing hyperfunctioning parathyroid glands in patients with primary hyperparathyroidism: a retrospective review

Objective This study aims to compare the sensitivity of dual phase (non-contrast and arterial) versus single phase (arterial) CT for detection of hyper-functioning parathyroid glands in patients with primary hyperparathyroidism. Methods The CT scans of thirty-two patients who have biochemical evidence of primary hyperparathyroidism, pathologically proven parathyroid adenomas, and pre-operative multiphase parathyroid imaging were evaluated retrospectively in order to compare the adequacy of single phase vs. dual phase CT scans for the detection of parathyroid adenomas. Results The parathyroid adenomas were localized in 83% of cases on single arterial phase CT and 80% of cases on dual phase CT. The specificity for localization of parathyroid tumor was 96% for single phase CT and 97% for dual phase CT. The results were not significantly different (p = 0.695). These results are similar to those found in the literature for multiphase CT of 55–94%. Conclusions Our study supports the use of a single arterial phase CT for the detection of hyperfunctioning parathyroid adenomas. Advances in knowledge: a single arterial phase CT has similar sensitivity for localizing parathyroid adenomas as dual phase CT and significantly reduces radiation dose to the patient

Does a Minority of Children With Functional Gastrointestinal Disorders Receive Formal Diet Advice?

Background: Diet therapies may be recommended for pediatric functional gastrointestinal disorders (FGIDs). However, little is known about the frequency with which diet therapy is recommended in FGIDs. Our aims were to determine and contrast the frequency and types of diet recommendations provided to children with FGIDs by pediatric gastroenterologists (PGIs) versus primary care pediatricians (PCPs). Methods: A retrospective chart review was performed using data from a large, metropolitan children\u27s academic healthcare system to identify subjects meeting Rome IV criteria for functional abdominal pain, functional dyspepsia, irritable-bowel syndrome (IBS), and/or abdominal migraine over a period of 23 months. Results: Of 1929 patient charts reviewed, 268 were included for further analyses. Of these, 186 patients (69%) were seen by a PGI and 82 (31%) by a PCP. The most common diagnosis was IBS (49% for PGIs and 71% for PCPs). Diet recommendations were provided to 115 (43%) patients (PGI group: 86 [75%] vs PCP group: 29 [25%]; P \u3c.1). The most frequent recommendations were high fiber (PGI: 15%; PCP: 14%) and low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) diet (PGI: 12%; PCP: 4%). Of those provided with diet recommendations, only 20% (n = 23) received an educational consult by a dietitian. Provision of diet recommendations was not affected by years in practice. Conclusion: Despite increasing awareness of the role of diet in the treatment of childhood FGIDs, a minority of patients receive diet recommendations in tertiary care or primary care settings. When diet recommendations were given, there was great variability in the guidance provided

The effect of screening for vaccine hesitancy on the subsequent development of hesitancy: a randomized controlled trial, Houston, TX

Vaccine hesitancy remains a global health threat. Addressing parental vaccine hesitancy is essential to maintaining high vaccine coverage levels and preventing disease outbreaks; however, it is unknown if administering a vaccine hesitancy screening tool negatively impacts parental vaccine beliefs. We conducted a stratified randomized controlled trial in pediatric primary care practices. English-speaking parents ≥18 years of age seeking routine care for infants <3 months of age were eligible. Participants were randomized to receive 1 of 2 surveys – the Parent Attitudes about Childhood Vaccines (PACV) survey or a placebo survey. Six months after initial enrollment, all participants were asked to complete the PACV, regardless of initial randomization group. Our primary outcome was the proportion of hesitant to non-hesitant parents at 6-months between randomization groups. We examined associations between vaccine hesitancy and participant characteristics. We also evaluated the change in the proportion of vaccine-hesitant parents in the PACV group between baseline and 6-month follow up. We enrolled 1705 parents at baseline. At 6-month follow up, 819 parents completed the PACV (50.2% from PACV group vs. 54.1% from placebo group). The proportion of hesitant parents at 6 months did not differ between PACV and placebo groups (6.6% vs. 6.1%; p = .78) and the odds of hesitancy among PACV group participants was not higher than those in the placebo group (OR = 1.10; 95% CI: 0.63–1.93; p = .743). Race was the only characteristic significantly associated with vaccine hesitancy at 6-month follow up (p = .003). Overall, administration of the PACV did not trigger vaccine hesitancy in this study population

Pediatric continuous renal replacement therapy: have practice changes changed outcomes? A large single-center ten-year retrospective evaluation

Abstract Background To evaluate changes in population characteristics and outcomes in a large single-center pediatric patient cohort treated with continuous renal replacement therapy (CRRT) over a 10 year course, coincident with multiple institutional practice changes in CRRT delivery. Methods A retrospective cohort study with comparative analysis of all patients treated from 2004 to 2013 with CRRT in the neonatal, pediatric, and cardiovascular intensive care units within a free-standing pediatric tertiary care hospital. Results Three hundred eleven total patients were identified, 38 of whom received concurrent treatment with extracorporeal membrane oxygenation. 273 patients received CRRT only and were compared in two study eras (2004–2008 n = 129; 2009–2013 n = 144). Across eras, mean patient age decreased (9.2 vs 7.7 years, p = 0.08), and the most common principal diagnosis changed from cardiac to liver disease. There was an increase in patients treated with continuous renal replacement therapy between cohorts for acute kidney injury of multi factorial etiology (44% vs 56%) and a decrease in treated patients with sepsis (21% vs 11%, p = 0.04). There was no significant difference in survival to hospital discharge between eras (47% vs 49%). Improvement in outpatient follow-up after discharge amongst survivors was seen between study eras (33% vs 54%). Conclusions Despite multiple institutional practice changes in provision of CRRT, few changes were seen regarding patient demographics, diseases treated, indications for therapy, and survival over 10 years at a single tertiary care. Recognition of need for follow-up nephrology care following CRRT is improving. Ongoing assessment of the patient population in a changing landscape of care for critically ill pediatric patients remains important