Heidi V. Connolly

Sleep-Disordered Breathing and Behaviors of Inner-City Children With Asthma

OBJECTIVE: To explore the relationship between sleep-disordered breathing (SDB) and behavioral problems among inner-city children with asthma. METHODS: We examined data for 194 children (aged 4–10 years) who were enrolled in a school-based asthma intervention program (response rate: 72%). SDB was assessed by using the Sleep-Related Breathing Disorder Questionnaire that contains 3 subscales: snoring, sleepiness, and attention/hyperactivity. For the current study, we modified the Sleep-Related Breathing Disorder Questionnaire by removing the 6 attention/hyperactivity items. A sleep score of >0.33 was considered indicative of SDB. To assess behavior, caregivers completed the Behavior Problem Index (BPI), which includes 8 behavioral subdomains. We conducted bivariate analyses and multiple linear regression to determine the association of SDB with BPI scores. RESULTS: The majority of children (mean age: 8.2 years) were male (56%), black (66%), and insured by Medicaid (73%). Overall, 33% of the children experienced SDB. In bivariate analyses, children with SDB had significantly higher (worse) behavior scores compared with children without SDB on total BPI (13.7 vs 8.8) and the subdomains externalizing (9.4 vs 6.3), internalizing (4.4 vs 2.5), anxious/depressed (2.4 vs 1.3), headstrong (3.2 vs 2.1), antisocial (2.3 vs 1.7), hyperactive (3.0 vs 1.8), peer conflict (0.74 vs 0.43), and immature (2.0 vs 1.5). In multiple regression models adjusting for several important covariates, SDB remained significantly associated with total BPI scores and externalizing, internalizing, anxious/depressed, headstrong, and hyperactive behaviors. Results were consistent across SDB subscales (snoring, sleepiness). CONCLUSIONS: We found that poor sleep was independently associated with behavior problems in a large proportion of urban children with asthma. Systematic screening for SDB in this high-risk population might help to identify children who would benefit from additional intervention.

Transit time heterogeneity in canine small intestine: significance for oxygen transport.

We previously found that local O2 extraction efficacy in isolated pump-perfused intestine was enhanced when systemic reflex vasoconstriction was stimulated by hypovolemia (Samsel, R.W., and P.T. Schumacker. 1994. J. Appl. Physiol. 77: 2291-2298). The microvascular mechanism underlying this beneficial effect could involve a redistribution of flow between mucosa and serosa, or an adjustment in the heterogeneity of perfusion within those regions. We measured regional blood flows and distributions of flow and capillary erythrocyte transit times in two segments of small intestine in anesthetized dogs (n = 10). Each vascularly isolated segment of intestine was pump-perfused under high flow (O2 supply-independent VO2) and low flow (O2 supply-dependent) conditions. During the first gut segment, the animal was kept normovolemic using i.v. fluids to minimize reflex vasoconstriction. During the second, the animal was hemorrhaged to augment vasoconstriction (n = 7), or kept normovolemic to control for the effects of time (n = 3). Blood flow distributions were measured using 15 microm radiolabeled microspheres. Tissue blood volume was measured using 99mTc-labeled red blood cells. Capillary volume was determined as the product of tissue blood volume and the histologically derived fraction of vascular volume in the capillaries. Transit times were calculated as the ratio of capillary volume to flow. Each gut segment was fixed and sectioned into 350 approximately 100 mg tissue pieces for analysis. Data revealed significant spatial heterogeneity of blood flow and capillary transit times in both mucosa and muscularis, with relative dispersions (SD/Mean) ranging from 23 to 97%. Hypovolemia caused an increase in flow heterogeneity in muscularis at both high and low flow states, and in mucosa under high flow conditions. However, hypovolemia also elicited changes in capillary volume, such that transit time heterogeneity remained unchanged. Augmentation of vasoconstrictor tone caused a redistribution of flow toward mucosa (P < 0.003) under high and low flow conditions. This redistribution correlated with the improvements in O2 extraction ratio (P = 0.022). Thus, the improvement in gut O2 extraction efficacy seen with increased vasoconstriction may be explained mostly by an intramural redistribution of flow between mucosa and muscularis. Capillary transit time heterogeneity remained unchanged, suggesting that this variable is tightly regulated.

Duration of mechanical ventilation in life-threatening pediatric asthma: description of an acute asphyxial subgroup.

Objective. Acute asphyxial asthma (AAA) is well described in adult patients and is characterized by a sudden onset that may rapidly progress to a near-arrest state. Despite the initial severity of AAA, mechanical ventilation often restores gas exchange promptly, resulting in shorter durations of ventilation. We believe that AAA can occur in children and can lead to respiratory failure that requires mechanical ventilation. Furthermore, children with rapid-onset respiratory failure that requires intubation in the emergency department (ED) are more likely to have AAA and a shorter duration of mechanical ventilation than those intubated in the pediatric intensive care unit (PICU). Methods. An 11-year retrospective chart review (1991-2002) was conducted of all children who were aged 2 through 18 years and had the primary diagnosis of status asthmaticus and required mechanical ventilation. Results. During the study period, 33 (11.4%) of 290 PICU admissions for status asthmaticus required mechanical ventilation. Thirteen children presented with rapid respiratory failure en route, on arrival, or within 30 minutes of arrival to the ED versus 20 children who progressed to respiratory failure later in their ED course or in the PICU. Mean duration of mechanical ventilation was significantly shorter in the children who presented with rapid respiratory failure versus those with progressive respiratory failure (29 ± 43 hours vs 88 ± 72 hours). Children with rapid respiratory failure had greater improvements in ventilation and oxygenation than those with progressive respiratory failure as measured by pre- and postintubation changes in arterial carbon dioxide pressure, arterial oxygen pressure/fraction of inspired oxygen ratio, and alveolar-arterial gradient. According to site of intubation, 23 children required intubation in the ED, whereas 10 were intubated later in the PICU. Mean duration of mechanical ventilation was significantly shorter in the ED group versus the PICU group (42 ± 63 hours vs 118 ± 46 hours). There were significantly greater improvements in ventilation and oxygenation in the ED group versus the PICU group as measured by pre- and postintubation changes in arterial carbon dioxide pressure and arterial oxygen pressure/fraction of inspired oxygen ratio. Conclusions. AAA occurs in children and shares characteristics seen in adult counterparts. Need for early intubation is a marker for AAA and may not represent a failure to maximize preintubation therapies. AAA represents a distinct form of life-threatening asthma and requires additional study in children.

Sleep Difficulties and Medications in Children With Autism Spectrum Disorders: A Registry Study

OBJECTIVES: Sleep difficulties are common in children with autism spectrum disorders, with wide-ranging effects on the child’s daytime behavior. We reviewed data within our Autism Speaks Autism Treatment Network Registry to determine the prevalence of sleep difficulties and patterns of medication use. METHODS: Data from 1518 children ages 4 to 10 years were analyzed to determine the number of children documented to have sleep difficulties by parent-completed questionnaires and clinician-completed forms and how these findings related to the use of sleep medications. RESULTS: The Children’s Sleep Habits Questionnaire total score was ≥41 (associated with clinically significant sleep problems in past research) in 71% of children. The prevalence of sleep diagnoses was less frequent (30% of children aged 4–10 years; P < .0001). Medications for sleep were prescribed in 46% of 4- to 10-year-olds given a sleep diagnosis. The most common medication used for sleep was melatonin followed by α-agonists, with a variety of other medications taken for sleep (anticonvulsants, antidepressants, atypical antipsychotics, and benzodiazepines). Children taking medications for sleep had worse daytime behavior and pediatric quality of life than children not taking sleep medications. CONCLUSIONS: Parent concerns about sleep may not be reflected in the information gathered during a clinic visit, supporting the need to develop screening practice pathways for sleep in autism spectrum disorders. Furthermore, many medications taken for sleep have adverse effects, supporting the need for evidence-based interventions in this population.

Sleep associated gas exchange abnormalities in children and adolescents with habitual snoring.

The purpose of this study was to describe the prevalence of polysomnographically diagnosed OSAS and to describe the severity of sleep associated gas exchange abnormalities (SAGEA) in habitually snoring children. We hypothesized that there would be a high prevalence of OSAS in obese children with habitual snoring and that the most overweight children would have the most significant SAGEA.

The pediatric sleep clinical global impressions scale - A new tool to measure pediatric insomnia in autism spectrum disorders

Objective: To pilot a clinician-based outcome measure that provides complementary information to objective measures and parent-based questionnaires for insomnia in children with autism spectrum disorders (ASD). Method: The authors developed a Pediatric Sleep Clinical Global Impressions Scale (CGI). Questions included (1) the childs ability to fall asleep and remain sleeping independently (i.e., apart from parents); (2) bedtime resistance; (3) sleep onset delay; (4) night awakening; (5) parental satisfaction with their childs current sleep patterns; (6) family functioning as affected by their childs current sleep patterns; and (7) clinicians overall concern with the childs sleep. After refining the instrument through the evaluation of vignettes by ASD and sleep experts, the authors piloted the Pediatric Sleep CGI in a 12-week randomized trial of iron supplementation in children with ASD. Clinicians completed Pediatric Sleep CGIs and structured sleep histories, parents completed the Childrens Sleep Habits Questionnaire (CSHQ), and children wore actigraphy watches. Results: In repeated measures models, the Pediatric Sleep CGI and CSHQ were correlated for sleep onset delay (r = .66, p < .001), night wakings (r = .40, p < .001), and total score (r = .29, p < .001). The CGI-S sleep onset delay and actigraphy sleep onset delay scores (r = .75, p = .0095) were also correlated. The overall CGI-S showed improvement with therapy (p = .047). Conclusion: The Pediatric Sleep CGI shows promise in measuring clinician-rated outcomes in pediatric insomnia in children with ASD. Larger samples will be necessary to examine reliability, validity, and measure to change, as well as applicability to other populations with pediatric insomnia.

Clinical Features of Young Women with Hypergonadotropic Amenorrhea

One hundred fifteen women under age 40 presenting with hypergonadotropic amenorrhea (follicle-stimulating hormone greater than 40 mIU/mL) were evaluated. Incomplete pubertal maturation and chromosomal abnormalities were more likely in the 18 women (15.7%) with primary amenorrhea than in those with secondary amenorrhea. The 97 women with secondary hypergonadotropic amenorrhea were significantly more apt to complain of symptoms of estrogen deficiency, have been pregnant before diagnosis, and have evidence of ovulation after diagnosis. Withdrawal bleeding occurred commonly (greater than 48%) in those women administered exogenous progestin. Immune abnormalities occurred with approximately equal frequency (17.4%), and spinal bone density was decreased in both groups.

MANAGEMENT OF ATRIAL ARRHYTHMIAS IN ADULT FONTAN PATIENTS

Atrial arrhythmias are very common and associated with significant morbidity in the adult Fontan population. The optimal management strategy is unknown. Retrospective review of adult Fontan patients followed at Mayo Clinic between 1994-2014. We excluded patients that underwent Fontan operation

An unexpected finding on a pediatric chest radiograph

A 2-month-old male infant without significant perinatal history presented to the Emergency Department (ED) for evaluation of recurrent emesis. A barium swallow, obtained at 2 weeks of age after an apneic event, demonstrated gastroesophageal reflux. The child was started on ranitidine and cisapride, and he was changed to elemental formula. Despite these measures, the infant continued to have frequent post-prandial effortless emesis. A 1-day history of worsening emesis, rapid breathing, irritability, and post-tussive perioral cyanosis prompted the visit. His mother denied bilious or bloody emesis, fever, or diarrhea. Physical examination revealed a non-toxic, small, but vigorous infant. Initial vital signs included a temperature of 37.2°C, pulse 162 beats/min, respiratory rate 62 breaths/min, and blood pressure 80/58 mm Hg. His weight was 4 kg (tenth percentile for age). The respiratory examination revealed quiet tachypnea. The lung fields were clear to auscultation. Grunting, flaring, and retractions were absent. Oxyhemoglobin saturation obtained on room air was 99%. The remainder of the physical examination was normal. A chest X-ray study, obtained to look for evidence of pneumonia, revealed localized narrowing of the intrathoracic trachea best viewed on the lateral projection (Figure 1). The infant was admitted to the pediatric floor for further evaluation of the tracheal abnormality. Rigid bronchoscopy demonstrated significant compression of the right antero-lateral trachea by a pulsatile mass, consistent with an aberrant innominate artery. Rigid esophagoscopy showed hyperemia of the distal esophagus, and biopsy demonstrated grade II esophagitis, confirming the prior diagnosis of gastroesophageal reflux disease. Echocardiogram revealed no intracardiac lesion. Respiratory symptoms abated after surgical arteriopexy. He completed a course of antibiotics for presumed aspiration