Lindsey Asti

Risk factors and outcomes associated with severe Clostridium difficile infection in children

Background: The incidence and severity of Clostridium difficile infection (CDI) is increasing among adults; however, little is known about the epidemiology of CDI among children. Methods: We conducted a nested case-control study to identify the risk factors for and a prospective cohort study to determine the outcomes associated with severe CDI at 2 childrens hospitals. Severe CDI was defined as CDI and at least 1 complication or ≥2 laboratory or clinical indicators consistent with severe disease. Studied outcomes included relapse, treatment failure, and CDI-related complications. Isolates were tested to determine North American pulsed-field gel electrophoresis type 1 lineage. Results: We analyzed 82 patients with CDI, of whom 48 had severe disease. Median age in years was 5.93 (1.78–12.16) and 1.83 (0.67–8.1) in subjects with severe and nonsevere CDI, respectively (P = 0.012). All patients with malignancy and CDI had severe disease. Nine subjects (11%) had North American pulsed-field gel electrophoresis type 1 isolates. Risk factors for severe disease included age (adjusted odds ratio [95% confidence interval]: 1.12 [1.02, 1.24]) and receipt of 3 antibiotic classes in the 30 days before infection (3.95 [1.19, 13.11]). If infants less than 1 year of age were excluded, only receipt of 3 antibiotic classes remained significantly associated with severe disease. Neither the rate of relapse nor treatment failure differed significantly between patients with severe and nonsevere CDI. There was 1 death. Conclusions: Increasing age and exposure to multiple antibiotic classes were risk factors for severe CDI. Although most patients studied had severe disease, complications were infrequent. Relapse rates were similar to those reported in adults.

Suicide trends among elementary school-aged children in the United States From 1993 to 2012

IMPORTANCE Suicide is a leading cause of death among school-aged children younger than 12 years but little is known about the epidemiology of suicide in this age group. OBJECTIVE To describe trends in suicide among US children younger than 12 years by sociodemographic group and method of death. DESIGN, SETTING, AND PARTICIPANTS Period trend analysis of national mortality data on suicide in children aged 5 to 11 years in the United States from January 1, 1993, to December 31, 2012. Data were analyzed per 5-year periods, between 1993 to 1997 and 2008 to 2012. MAIN OUTCOMES AND MEASURES Number of suicide deaths and crude suicide rates. Period trends in rates of suicide were estimated using negative binomial regression incidence rate ratios (IRRs). RESULTS The overall suicide rate among children aged 5 to 11 years remained stable between 1993 to 1997 and 2008 to 2012 (from 1.18 to 1.09 per 1 million; IRR = 0.96; 95% CI, 0.90-1.03). However, the suicide rate increased significantly in black children (from 1.36 to 2.54 per 1 million; IRR = 1.27; 95% CI, 1.11-1.45) and decreased in white children (from 1.14 to 0.77 per 1 million; IRR = 0.86; 95% CI, 0.79-0.94). The overall firearm suicide rate (IRR = 0.69; 95% CI, 0.57-0.85) and firearm suicide rate among white boys (IRR = 0.72; 95% CI, 0.59-0.88) decreased significantly during the study. The rate of suicide by hanging/suffocation increased significantly in black boys (IRR = 1.35; 95% CI, 1.14-1.61), although the overall change in suicide rates by hanging/suffocation or other suicide methods did not change during the study. CONCLUSIONS AND RELEVANCE The stable overall suicide rate in school-aged children in the United States during 20 years of study obscured a significant increase in suicide incidence in black children and a significant decrease in suicide incidence among white children. Findings highlight a potential racial disparity that warrants attention. Further studies are needed to monitor these emerging trends and identify risk, protective, and precipitating factors relevant to suicide prevention efforts in children younger than 12 years.

Improving surveillance for pediatric Clostridium difficile infection: derivation and validation of an accurate case-finding tool.

Background: The incidence of Clostridium difficile infection (CDI) is increasing. Multicenter studies of CDI have been limited by the lack of valid case-finding tools. To facilitate pediatric studies of CDI, we constructed a case-finding tool using administrative data. Methods: A cross-sectional study was performed using the Pediatric Health Information System database and microbiologic data from 4 member hospitals. Using patients with laboratory-confirmed CDI as the standard, we determined the sensitivity, specificity, positive (PPV), and negative (NPV) predictive value of an ICD-9-CM code for identifying children with laboratory-confirmed CDI. Results: We identified 109 patients with laboratory-confirmed CDI and 119 patients with CDI ICD-9-CM code. The sensitivity, specificity, PPV, and NPV were 80.73%, 99.89%, 73.95%, and 99.92%, respectively, for this comparison. The addition of a billing charge for both C. difficile laboratory test and treatment medication to the ICD-9-CM code increased the specificity and PPV, but resulted in a slight decrease in the sensitivity and NPV. The use of administrative data for identifying pediatric cases of CDI was also compared with that of chart review, and was found to be a stronger surrogate for identifying cases of CDI when compared with microbiology data alone. Conclusions: These results demonstrate that the use of administrative data for CDI is a reliable and accurate method for identifying pediatric patients with CDI. The use of administrative data could facilitate the completion of larger studies due to its greater accessibility and reduced costs.

Sacral nerve stimulation allows for decreased antegrade continence enema use in children with severe constipation

BACKGROUND Sacral nerve stimulation (SNS) can be beneficial for children with constipation, but no studies have focused on children with constipation severe enough to require antegrade continence enemas (ACEs). Our objective was to evaluate the efficacy of SNS in children with constipation treated with ACE. METHODS Using a prospective patient registry, we identified patients <21years old who were receiving ACE prior to SNS placement. We compared ACE/laxative usage, PedsQL Gastrointestinal Symptom Scale (GSS), Fecal Incontinence Quality of Life Scale (FIQL), Fecal Incontinence Severity Index (FISI), and Vancouver Dysfunctional Elimination Syndrome Score (DES) at baseline and progressive follow-up time intervals. RESULTS Twenty-two patients (55% male, median 12years) were included. Median ACE frequency decreased from 7 per week at baseline to 1 per week at 12months (p<0.0001). Ten children (45%) had their cecostomy/appendicostomy closed. Laxative use, GSS, FIQL, and DES did not change. FISI improved over the first 12months with statistical significance reached only at 6months (p=0.02). Six (27%) children experienced complications after SNS that required further surgery. CONCLUSIONS In children with severe constipation dependent on ACE, SNS led to a steady decrease in ACE usage with nearly half of patients receiving cecostomy/appendicostomy closure within 2years. LEVEL OF EVIDENCE IV.

Morbidity of peripherally inserted central catheters in pediatric complicated appendicitis

BACKGROUND The purpose of this study was to compare postoperative outcomes of pediatric patients with complicated appendicitis managed with or without a peripherally inserted central catheter (PICC). METHODS Patients aged ≤18 y in the Pediatric Health Information System database with complicated appendicitis that underwent appendectomy during their index admission in 2000-2012 were grouped by whether they had a PICC placed using relevant procedure and billing codes. Rates of subsequent encounters within 30 d of discharge along with associated diagnoses and procedures were determined. A propensity score-matched (PSM) analysis was performed to account for differences in baseline exposures and severity of illness. RESULTS We included 33,482 patients with complicated appendicitis; of whom, 6620 (19.8%) received a PICC and 26,862 (80.2%) did not. The PICC group had a longer postoperative length of stay (median 7 versus 5 d, P<0.001) and were more likely to undergo intra-abdominal abscess drainage during the index admission (14.4% versus 2.1%, P<0.001), and have a reencounter (17.5% versus 11.4%, P<0.001) within 30 d of discharge. However, in the PSM cohort (n=4428 in each group), outcomes did not differ between treatment groups, although the PICC group did have increased odds for the development of other postoperative complications (odds ratio=3.95, 95% confidence interval: 1.45, 10.71). CONCLUSIONS After accounting for differences in severity of illness by PSM, patients managed with PICCs had a similar risk for nearly all postoperative complications, including reencounters. Postoperative management of pediatric complicated appendicitis with a PICC is not clearly associated with improved outcomes.

A comparison of injuries sustained from recreational compared to organized motorized vehicle use in children

PURPOSE To examine the injury severity and patterns of injury for pediatric motorized recreational vehicle (MRV) drivers injured during organized events (OE) compared to recreational use (RU). METHODS All pediatric MRV injuries between 2006 and 2012 in our institutional trauma registry were studied for mechanism of injury, initial evaluation, and treatment. Injuries with an Abbreviated Injury Scale ≥2 were categorized by body region and diagnosis. RESULTS Out of 589 collisions, 92 (16%) occurred during an OE. Compared to RU drivers, OE drivers were more likely to wear helmets (92% vs. 40%, p<0.001) and other protective equipment (79% vs. 6%, p<0.001). There was no difference in rates of hospital admission, rates of surgical intervention, injury severity scores, rates of intensive care unit admission, or lengths of stay. There were no differences in injuries by body region or injury type, except that dislocations were more common in OE drivers (2% vs. 0%, p=0.038). CONCLUSION Despite higher rates of helmet and protective gear use, pediatric MRV drivers participating in OEs sustain similarly severe injuries as drivers using MRVs recreationally. No differences were observed in body regions involved or outcomes. Public perception that OE use of MRV for children is safe should be addressed.

Differences in Health Care Needs, Health Care Utilization, and Health Care Outcomes Among Children With Special Health Care Needs in Ohio: A Comparative Analysis Between Medicaid and Private Insurance.

Objective: This study explores comparative differentials in health care needs, health care utilization, and health status between Medicaid and private/employer-sponsored insurance (ESI) among a statewide population of children with special health care needs (CSHCN) in Ohio. Methods: We used data from the 2012 Ohio Medicaid Assessment Survey to examine CSHCNs health care needs, utilization, status, and health outcomes by insurance type. Adjusted multivariable logistic regression models were used to explore associations between public and private health insurance, as well as the utilization and health outcome variables. Results: Bivariate analyses indicate that the Medicaid population had higher care coordination needs (odds ratio [OR] = 1.6; 95% confidence interval [CI], 1.1-2.2) as well as need for mental/educational health care services (OR = 1.5; 95% CI; 1.1-2.0). They also reported higher unmet dental care needs (OR = 2.2; 95% CI, 1.2-4.0), higher emergency department (ED) utilization (OR = 2.3; 95% CI, 1.7-3.2), and worse overall health (OR = 0.6; 95% CI, 0.4-0.7), oral health (OR = 0.4; 95% CI, 0.3-0.5), and vision health (OR = 0.4; 95% CI, 0.2-0.6). After controlling for demographic variables, CSHCN with Medicaid insurance coverage were more likely to need mental health and education services (adjusted odds ratio [AOR] = 1.8; 95% CI; 1.2-2.6), had significantly more ED visits (AOR = 2.3; 95% CI, 1.5-3.5), and were less likely to have excellent overall health (AOR = 0.64; 95% CI, 0.4-0.9), oral health (AOR = 0.43; 95% CI, 0.3-0.7), and vision health (AOR = 0.38; 95% CI, 0.2-0.6) than those with private insurance/ESI. Conclusion: The CSHCN population is a highly vulnerable population. While Ohios Medicaid provides greater coverage to CSHCN, disparities continue to exist within access and services that Medicaid provides versus the ones provided by private insurance/ESI.

Comparison of 30-day outcomes between thoracoscopic and open lobectomy for congenital pulmonary lesions.

OBJECTIVE To compare postoperative length of stay and 30-day outcomes between thoracoscopic and open lobectomy performed on a nonemergency basis for congenital pulmonary lesions using a validated national database. MATERIALS AND METHODS We identified all nonemergency lobectomies performed on patients with congenital pulmonary lesions in the 2012 National Surgical Quality Improvement Program (NSQIP) Pediatric database and compared demographic, clinical, and 30-day outcome characteristics between patients who underwent an open or thoracoscopic lobectomy. Logistic regression with Firths penalized likelihood bias-reduction method was used to determine predictive risk factors for a postoperative length of stay (LOS) of >3 days. RESULTS Of 101 patients included, 40 (39%) underwent thoracoscopic lobectomy. In comparison with patients undergoing thoracoscopic lobectomy, patients undergoing open lobectomy were significantly more likely to be admitted prior to surgery, be American Society of Anesthesiologists Class ≥ 3, receive oxygen support prior to surgery, and have other congenital anomalies or cardiac risk factors. Both groups had similar total operative times (open versus thoracoscopic, 150 versus 173 minutes; P=.216). Patients undergoing open lobectomy had longer postoperative LOS (4 versus 3 days; P=.001) and more often received an intraoperative or postoperative transfusion (12% versus 0%; P=.003). The procedure type was not an independent risk factor for postoperative LOS >3 days in the multivariable analysis. CONCLUSIONS Patients undergoing thoracoscopic lobectomy have fewer comorbidities at baseline, receive fewer perioperative transfusions, and have a shorter postoperative LOS. Accrual of additional patients within the NSQIP Pediatric database will allow for further risk-adjusted analyses to control for differences in baseline characteristics between patients undergoing open and thoracoscopic resections.

Acetaminophen and Expired Medication Storage in Homes with Young Children

Objective: To describe the storage of acetaminophen and expired medications in homes with young children. Methods: This pilot study used direct observation of medication storage practices of 24 families with children aged 2-6 years. An observer conducted home interviews documenting specific information about where and how each medication was stored and if the medication contained acetaminophen or was expired. Safe storage was defined as medications stored above 5 feet or if stored below 5 feet, medications must be locked. Results: Acetaminophen was found in 23 homes and all homes had at least one expired medication. Of the 799 medications, 99 (12%) contained acetaminophen and 219 (27%) were expired. Approximately 30% of acetaminophen and 15% of expired medications were stored unsafely. Acetaminophen was more likely to be stored unsafely compared to non-acetaminophen products [odds ratio=1.65, 95% confidence interval (CI): 1.07, 2.55], whereas the odds of unsafe storage for expired medicines were 0.36 (95% CI: 0.21, 0.64) compared to non-expired medications. Acetaminophen-containing and expired medications were more likely to be stored in the bathroom. Conclusions: The high proportion of unsafely stored acetaminophen-containing medications and high number of expired medications in the home are of concern for families with young children. It is unclear if parents are aware of the toxicity of acetaminophen or the risk of harm from expired medications being in the home where young children are present. These results can be used to develop an intervention program aimed at improving the safe storage of medications in homes with young children.

A decade of hospital discharges related to eosinophilic esophagitis

ABSTRACT Eosinophilic esophagitis (EoE) is a recently characterized chronic, allergic, gastrointestinal disorder. Using the Pediatric Health Information System, we report trends in diagnostic codes related to EoE in inpatients from 1999 through 2010. Esophagitis not elsewhere classifiable, EoE, and dysphagia have increased over time. Similar to other allergic disorders, EoE appears to be increasing across the United States.