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Objective: This project sought to describe provider- and parent-identified needs and barriers to obtaining home- and community-based services (HCBS) for children with disability (CWD) and to determine ways pediatric health care institutions can improve access to HCBS services., Methods: In this exploratory sequential mixed methods evaluation, semi-structured interviews and focus groups were conducted with multidisciplinary providers and staff from an independent children's hospital, followed by a survey of English and Spanish-speaking parents of CWD. Data from interviews and surveys were then triangulated for overarching common themes regarding how pediatric health care institutions can better support access to HCBS., Results: Among 382 parent respondents, 74.1% reported that their child needed a HCBS, most commonly physical/occupational/speech therapies, school-based support, and case management services. Two-thirds of parents reported at least one barrier to accessing HCBS and one-third experience >3 barriers. While multiple current institutional strengths were noted, internal weaknesses included lack of provider knowledge, staffing difficulties, and lack of protocols for identifying and tracking patients needing or receiving HCBS. External threats included requirements to entry for HCBS and transfer of care, with opportunities for improvement involving dissemination of information, funding support, and connection between providers/support staff and services., Conclusions: Parents of CWD identified HCBS as necessary for the health of this population, but multiple barriers to HCBS were identified by both parents and providers. Multiple internal and external opportunities for improvement relative to pediatric health care institutions were identified, suggesting a need for a comprehensive approach to ensure that CWD receive necessary HCBS., Competing Interests: Declaration of Competing Interest Dr. Foster received compensation for medical record consultation and/or expert witness testimony. The authors otherwise have no conflicts of interest to disclose., (Copyright © 2024 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objective: Research shows that population-level rates of obesity, which rose dramatically from the 1970s through the mid-2000s, have since plateaued or even started to decline. However, overall improvements may mask differences in trends for different subgroups. For instance, obesity rates have continued to climb among low-income adolescents, leading to growing income-related gaps in obesity. By comparison, we know little about whether income-related disparities have also changed among elementary school children. To address this gap, we examined two cohorts of the Early Childhood Longitudinal Study - Kindergarten cohort, which followed children entering school in 1998 and 2010. We hypothesized that income-related disparities in obesity have also grown larger over time among young children., Methods: We used data from nationally representative samples of children who entered kindergarten in 1998 and 2010. We documented rates of overweight and obesity from kindergarten through third grade, examined how rates differed for children from high- and low-income families, and tested whether income-related disparities changed over time., Results: Rates of overweight and obesity were 2 to 5 percentage points higher in the later cohort, and overall increases masked substantial variation by income. Specifically, these increases were driven by children in lower-income households, resulting in substantially larger income-related disparities in overweight and obesity in the later cohort., Conclusions: As we hypothesized, income-related disparities in young children's obesity grew between 1998 and 2014. This suggests that efforts to curb increasing rates of obesity may have been more successful for higher-income families. We discuss potential mechanisms that may account for increasing disparities., (Copyright © 2020 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Background: It is widely accepted that hemodialysis graft surveillance combined with correction of stenosis reduces thrombosis and prolongs graft survival. Nevertheless, few randomized controlled trials have evaluated this approach., Methods: In this randomized controlled trial, 101 patients were assigned to control, flow (Qa), or stenosis groups, and were followed for up to 28 months. All patients had monthly Qa measured by ultrasound dilution and quarterly percent stenosis measured by duplex ultrasound. Referral for angiography was based on the following criteria: (1) control group (N = 34), clinical criteria; (2) flow group (N = 32), Qa <600 mL/min or clinical criteria; and (3) stenosis group (N = 35), stenosis>50% or clinical criteria. Stenosis >or=50% during angiography was corrected by preemptive percutaneous transluminal angioplasty (PTA)., Results: The preemptive PTA rate in the control group (0.22/patient year) was two thirds the rate in the flow group (0.34/patient year), and was highest in the stenosis group (0.65/patient year, P < 0.01). The percentage of grafts that thrombosed was similar in the control (47%) and flow groups (53%), but reduced in the stenosis group (29%, P = 0.10). Two-year graft survival was similar in the control (62%), flow (60%), and stenosis groups (64%) (P = 0.89)., Conclusion: Qa and stenosis surveillance were not associated with improved graft survival, although thrombosis was reduced in the stenosis group. The most important factors in this result may be that monthly Qa and quarterly stenosis measurements were not accurate or timely indicators of risk of thrombosis or progressive stenosis. This study does not support the concept that Qa or stenosis surveillance are superior to aggressive clinical monitoring.

Background: The LifeSite Hemodialysis Access System is a subcutaneous access device designed to maximize blood flow while minimizing access-related complications. The purpose of this study was to compare the efficacy and safety of the LifeSite System to a similar but transcutaneous access device, the Tesio-Cath Hemodialysis Catheter., Methods: The study was conducted in two phases. A multi-center randomized prospective design was utilized for the first phase (Phase 1) where thirty-four patients were enrolled in the Tesio-Cath group and 36 patients into the LifeSite group where 0.2% sodium oxychlorosene was used as an antimicrobial solution for the LifeSite. A nonrandomized, but otherwise identical, second phase of the study followed where a 70% isopropyl alcohol solution was utilized as the antimicrobial solution for 34 additional LifeSite patients (Phase 2)., Results: Device function was evaluated in Phase 1 of the trial. Actual blood flow (determined by ultrasound dilution) was greater in the LifeSite versus the Tesio-Cath group (358.7 vs. 331.8 mL/min, P < 0.001 for machine-indicated blood flow of 400 mL/min). Infection comparisons were performed for all three groups encompassing Phase 1 and 2 of the trial; Tesio-Catheter, LifeSite System with oxychlorosene, and LifeSite System with 70% isopropyl alcohol. Device-related infections were defined as systemic bacteremia without another obvious site of origin and exit site infections requiring systemic antibiotics or device removal. This revealed infection rates per 1000 device use days of 1.3 for the LifeSite alcohol group, 3.3 for the Tesio-Cath group, and 3.4 per for the LifeSite oxychlorosene group. There was no statistically significant difference in device related infection rates between the Tesio-Cath and the LifeSite oxychlorosene groups. There were significant differences in infection rate between LifeSite alcohol group and the other two groups (P < 0.05). Device thrombosis was defined by the need for instillation of thrombolytic agents to maintain blood flow>300 mL/min. There was no difference in the need for thrombolytic infusions between the LifeSite oxychlorosene group and the Tesio-Cath group (P = 0.1496); however, the LifeSite alcohol group required significantly fewer thrombolytic infusions than the Tesio-Cath group (P = 0.0295) to maintain adequate blood flow. Device survival at 6 months after stratification by diabetic status and adjusting for age was significantly better in the LifeSite alcohol group (89.9%) than in the LifeSite oxychlorosene group (64.8%, P = 0.0286) and in the Tesio-Cath (69.1%, P = 0.0292) group., Conclusions: The LifeSite Hemodialysis Access System, when used with 70% isopropyl alcohol as an antimicrobial solution, provides superior performance with a lower infection rate and better device survival than a standard cuffed tunneled hemodialysis catheter.

Nitric oxide (NO) synthesis is inhibited by a variety of L-arginine analogs including NG-nitro-L-arginine methyl ester (L-NAME) and NG NG-dimethylarginine (ADMA). ADMA is present in elevated concentrations in renal failure and potentially could alter microcirculatory hemodynamics during peritoneal dialysis (PD). This investigation utilized the techniques of intravital microscopy to quantitate the mesenteric arteriolar hemodynamic effects of PD solutions during NO synthesis inhibition. L-NAME (100 microns) produced maximum arteriolar vasoconstriction to 74% of baseline diameter (19.9 +/- 2.2 vs. 26.9 +/- 1.4 microns, P < 0.001, N = 10) and ADMA (100 microns) to 68% (20.5 +/- 2.5 vs. 30.1 +/- 2.0 microns, P < 0.01, N = 6). L-NAME decreased red blood cell velocity to 44% of baseline velocity (3.8 +/- 0.8 vs. 8.5 +/- 1.1 mm/second, P < 0.001) and ADMA to 52% (5.1 +/- 1.1 vs. 9.8 +/- 0.9 mm/second, P < 0.01, N = 6). Despite NO synthesis inhibition, standard PD solutions reversed these hemodynamic effects with both 1.5% and 4.25% Dianeal (Baxter) rapidly reversing the vasoconstriction and restoring blood flow back to baseline values. When Dianeal and L-NAME were simultaneously superfused, no L-NAME induced vasoconstriction occurred and Dianeal maintained vasodilatory properties despite L-NAME (P < 0.01, N = 5). This investigation reaffirms that basal levels of NO are important in maintaining normal hemodynamics in the mesenteric microcirculation. Reversal of the L-NAME induced arteriolar hemodynamic effects by Dianeal suggests that the endogenous NO synthesis inhibitor ADMA has no significant effects in the regulation of the mesenteric microvascular arteriolar hemodynamics during PD. Since these PD solutions remain vasoactive despite NO synthesis inhibition, this suggests that these PD solutions possess vasoactive properties primarily through a NO independent mechanism.

High-dose intravenous mannitol infusion in various clinical settings may result in acute renal failure (ARF). This form of ARF is characteristically anuric and follows a distinctive clinical course. Most importantly, it occurs only after high doses of mannitol (> 200 g/day or cumulative dose of > 400 g in 48 hours), but not at lower doses. It appears that a low dose of mannitol acts as a renal vasodilator while high-dose mannitol is renal vasoconstrictor. Mannitol-induced ARF responds promptly to hemodialysis with rapid resolution of anuria and recovery of renal failure. This is a report of a case of anuric ARF after high-dose mannitol infusion for treatment of narrow-angle glaucoma that readily responded to acute hemodialysis. The literature is also reviewed for ARF associated with mannitol infusion in patients who received dialysis and those who did not receive dialysis; and the possible mechanism(s) of mannitol nephrotoxicity are discussed. Hemodialysis should be performed for rapid reversal of mannitol-induced ARF. Patients not treated with hemodialysis have increased morbidity and significant prolongation of their hospital course.