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Rural communities experience a lack of pediatric mental health providers. It is unclear if this leads to greater unmet needs for specialty mental health services among rural children.Data from the 2016-2019 National Survey of Children's Health were used to identify children aged 6-17 years with a mental health condition. Caregiver-reported need and receipt of specialty mental health care for their child (met need, unmet need, or no need) was compared according to residence in a Metropolitan Statistical Area (MSA).The analysis included 13,021 children (14% living outside MSAs). Unmet need for mental health services was reported for 9% of children, with no difference by rural-urban residence (p = 0.940). Multivariable analysis confirmed this finding and identified urban children as less likely to have no need for mental health services, compared to rural children (relative risk ratio of no need vs. met need: 0.79; 95% confidence interval: 0.65, 0.95; p = 0.015).Children with mental health conditions living in rural areas (outside MSAs) did not have higher rates of unmet needs for specialty mental health services, but they had lower rates of any caregiver-reported needs for such services. Further work is needed to examine caregivers' demand for pediatric specialty mental health services.

There have been ongoing efforts to increase the presence of underrepresented minorities in medicine (URMM), including faculty development initiatives, mentoring programs and outreach efforts. However, URMM faculty face unique challenges that are crucial for academic institutions and leaders to recognize in order to improve retention of this group and allow for meaningful advancement in the field. This paper introduces the concept of gate blocking, defined as what happens to minority faculty as a result of the consequences of the minority tax and systems designed to advantage some and disadvantage others. In addition to defining gate blocking, the authors make recommendations to address this concern in academic medicine and promote the advancement and retention of URMM faculty.

Although preoperative anemia has been suggested to predict postsurgical morbidity and mortality among infants1 year of age, the data were drawn from heterogeneous patient cohorts including severely ill infants undergoing complex, high-risk procedures. We aimed to determine whether untreated preoperative anemia was associated with increased risk of postoperative complications in infants1 year of age who underwent pyloromyotomy, a common and relatively simple surgery.Infants1 year of age undergoing pyloromyotomy were identified from the American College of Surgeons (ACS) National Surgical Quality Improvement Program-Pediatric database. Preoperative anemia was defined as a hematocrit ≤40% for infants 0-30 days of age and ≤30% for infants more than 30 days of age. Patients who received pre- or postoperative blood transfusions were excluded.We identified 2948 patients who met our inclusion criteria, of whom 843 were anemic (29%). The overall rate of complications in this cohort was 6%. The most common postoperative complications were readmission (97 cases), surgical site infection (43), reoperation (39), prolonged hospital stay (24), urinary tract infection (3), 30-day mortality (3) and cardiac arrest (2). We found no differences in the incidence of complications in anemic versus nonanemic patients on bivariate analysis or multivariable logistic regression (adjusted odds ratio = 1.2; 95% confidence interval: 0.8-1.7; P = 0.319).In relatively healthy infants undergoing pyloromyotomy, untreated preoperative anemia was not associated with postoperative compilations and should not be considered a significant risk factor. Level of evidence III.

Objective We prospectively evaluated intracuff pressure (IP) during one-lung ventilation (OLV) to characterize potential risk associated with overinflation of the cuff used for OLV. Design Prospective observational study over a 2-year period, in infants and children undergoing thoracic surgery. The IPs of the tracheal and bronchial balloon were measured using a manometer and compared to a previously recommended threshold of 30 cmH2O. Data were compared by the device type used to achieve OLV. Setting Freestanding tertiary-care pediatric hospital. Participants Patients ≤18 years of age undergoing thoracic procedures requiring OLV. Interventions Measurement of IP. Measurements and main results Thirty patients were enrolled (age 5 months-18 years) with a median weight of 28 kg. Median tracheal and bronchial IPs were 32 cmH2O (range: 11, 90) and 44 cmH2O (range: 10, 100), respectively. The tracheal and bronchial IPs exceeded 30 cmH2O in 13 of 20 patients (65%) and 21 of 30 patients (70%), respectively. Conclusions IP was high and in excess of recommended levels in most children undergoing OLV. Continuous monitoring of IP may be indicated during OLV to address the risks involved and ensure the prevention of complications related to high IP. Type of study Prospective comparative study. Level of evidence Level II.

Background The lung allocation score (LAS) prioritizes lung transplant (LTx) candidates with poor transplant-free survival and expected survival benefit from LTx. Although patients with the highest LAS have the shortest waiting time, mortality benefit is unclear in this group, raising criticism that the LAS inappropriately prioritizes critically ill candidates. We aim to identify a threshold above which increasing LAS values do not predict increasing survival benefit. Methods The United Network for Organ Sharing Registry was queried for first-time adult LTx candidates with LAS ≥ 30 between May 2005 and December 2016. Survival was tracked from the time of listing through the posttransplant period and compared with survival while remaining on the waitlist, using proportional hazards regression. The survival benefit of LTx was modeled as a piecewise-constant time-dependent covariate, moderated by candidate LAS. Results Of the overall cohort (N = 21,157), LTx was particularly protective for 365 patients with an initial LAS of 70 to 79 (hazard ratio of death after undergoing LTx relative to remaining on the waitlist, 0.2; 95% CI, 0.1-0.3). However, the survival benefit of LTx did not meaningfully increase for 1,042 patients listed with even higher LAS. Among patients with cystic fibrosis, the survival benefit of LTx was constant above an LAS of approximately 50. Conclusions Consistent survival benefit of LTx was observed among patients with an initial LAS of 70 and greater. This result supports equalizing priority for donor lung allocation for patients with LAS ≥ 70. A lower LAS threshold for maximum priority is indicated in patients with cystic fibrosis.

u ca Background There are limited data to guide the selection of the appropriate sized endobronchial tube for main stem intubation to provide one-lung ventilation in children. The relationship between the cricoid and the main bronchi (right and left) has been previously evaluated using two-dimensional computed tomography (CT) imaging and video-bronchoscopic images. The present study defines the three-dimensional, CT-derived volume-based relationships between the right main-stem bronchus (RMB), left main-stem bronchus (LMB), and the cricoid ring. Methods The three-dimensional CT images of 35 children, less than 8 years of age, undergoing radiological evaluation unrelated to airway or mediastinal symptomatology were examined. The images of the airway column were evaluated at the level of the cricoid and main stem bronchi (right and left). Volumes were calculated and comparisons made between these levels. Results There was no statistically significant difference based on gender for the cricoid and main stem bronchi volumes. A statistically significant difference was observed between the cricoid and left main stem bronchi volumes as well as between the right and left main stem bronchi. Conclusion The relationship (ratio) between the volumes of the cricoid and main stem bronchi remains constant by age. The cricoid dimensions can be used to predict the main stem bronchi dimensions.

Background Pediatric tonsillectomies are increasingly being performed as an outpatient procedure thereby increasing the parental role in post-operative pain management. However, it is unclear if parents receive adequate teaching regarding pain management. We introduced a video teaching tool and compared its efficacy alone and in combination with the standard verbal instruction. Methods A prospective study which randomized parents or caregivers of children undergoing tonsillectomy ± adenoidectomy into three groups: 1) standard verbal post-operative instructions; 2) watching the video teaching tool along with standard verbal instructions or 3) video teaching tool only. Parents completed pre and post-instruction assessments of their knowledge of post-operative pain management with responses scored from 0 to 8. Telephone assessments were conducted within 48 post-operative hours with a subjective rating of the helpfulness of the video teaching tool. Results The study cohort included 99 patients and their families. The median pre-instruction score was 5 of 8 points (Interquartile range [IQR]: 4, 6) and this remained at 5 following instruction. (IQR:4, 6; p = 0.702 difference from baseline). Baseline scores did not vary across the groups (p = 0.156) and there was no increase in the knowledge score from pre to post-test across the three groups. Groups B and C rated the helpfulness of the video teaching tool with a median score of 4 of 5. (IQR: 4, 5). Conclusions A baseline deficit exists in parental understanding of post-operative pain management that did not statistically improve regardless of the form post-operative instruction used (verbal vs. video-based instruction). However, the high helpfulness scores in both video groups support the use of video instruction as an alternative to or to complement to verbal instruction. However, further identification of knowledge deficits is required for optimization of post-operative educational materials.

Data on the safety of endoscopic sinus surgery (ESS) are limited in children with cystic fibrosis (CF). We used a multi-institutional surgical registry to examine ESS outcomes in children with CF.The 2014-2015 American College of Surgeons' National Surgical Quality Improvement Program-Pediatric database was queried for patients age18 years undergoing elective ESS. Prolonged hospital stay (1 day), 30-day readmission, and 30-day unplanned reoperation were compared according to presence of CF diagnosis.The data included 213 children with CF (age 10 ± 5 years, 105/108 male/female) and 821 children without CF (age 10 ± 5 years, 504/317 male/female). CF patients were more likely than non-CF patients to require prolonged hospital stay (30% vs. 9%, p 0.001), yet had similar rates of readmission (6% vs. 4%; p = 0.189) and reoperation (0 vs. 1%; p = 0.133). All readmissions but one among CF patients were unrelated to ESS. In the non-CF cohort, reasons for ESS-related readmissions included recurrence of sinusitis, postoperative pain, and bleeding.We demonstrate the safety of ESS in the largest cohort of children with CF reviewed to date. Multi-institutional review of ESS safety may contribute to monitoring expansion of this intervention in children with CF.

Background The average ages of lung transplant (LTx) recipients and donors are increasing. With older recipients considered to be especially at high risk of posttransplant mortality, we sought to determine whether the use of allografts from older donors affects survival among older patients undergoing LTx. Methods The United Network for Organ Sharing registry was used to identify patients aged 65-80 y receiving a first-time LTx between 1987 and 2013. Survival analysis examined implications of a donor-recipient age difference >10 y using Cox proportional hazards regression. Results The cohort selected for analysis included 3227 elderly LTx recipients, of whom 263 (8.15%) had donors within 10 y of their age at transplantation. Univariate Cox models found no differences with LTx involving donors at least 10 y younger than the recipient with respect to overall survival (hazard ratio = 0.979; 95% confidence interval [CI] = 0.807-1.188; P = 0.831) or conditional survival past 1 y (hazard ratio = 1.067; 95% CI = 0.819-1.391; P = 0.629) relative to LTx involving donors within 10 y of an elderly recipient's age. These findings were substantiated in multivariate analysis adjusting for potential confounders. Conclusions In elderly LTx recipients aged 65-80 y at transplantation, intermediate-term survival was not influenced by donor age. For the viable elderly LTx candidate, a carefully selected older donor should be considered to increase donor availability.

To evaluate the effects of transesophageal echocardiography (TEE) probe insertion on the endotracheal cuff pressure (CP).Prospective observational study.Single standing, not-for-profit pediatric hospital.A total of 80 pediatric patients (aged 6 days to 18.4 years) who underwent cardiac surgery and intraoperative TEE.None.Following anesthesia induction and endotracheal intubation, the CP was recorded at 4 points: before the insertion of the TEE (P1), at TEE insertion (P2), during TEE examination (P3), and after the probe was advanced into the stomach (P4). Twenty patients were enrolled in each of the following age groups:1 year of age; 1-4 years of age; 5-8 years of age; and 9-18 years of age. CP was compared between pairs of time points using paired t-tests, and differences in CP over time were compared among age groups using repeated-measures analysis of variance. CP at P1, P2, P3, and P4 was 18.7±11.6, 26.7±14.4, 22.3±12.4, and 20.6±12.6 cmH2O, respectively. Although CP significantly increased from P1 to P2 (p0.001), there was no significant difference between P1 and P4 (95% CI; -0.3 to 4.1; p = 0.083). There was no significant difference in CP change based on the age of the patient.Following a transient increase in CP with TEE probe insertion, the CP returned to baseline after the tip of the TEE probe was advanced into the stomach. There was no variation among age groups in the magnitude of the CP change during the study.

Objectives The objectives of this study were to evaluate the effect of ventricular morphology on perioperative outcomes during Fontan surgery. Design Retrospective cohort study. Setting Single standing, not-for-profit pediatric hospital. Participants A total of 72 patients who underwent Fontan surgery using cardiopulmonary bypass without aortic cross-clamp between January 1, 2009 and December 31, 2014. Interventions None. Measurements and Main Results The patients were divided into 3 categories depending on their single-ventricle lesions: (1) LV group (n = 20): left dominant and hypoplastic right ventricle; (2) RV group (n = 37): right dominant and hypoplastic left ventricle; and (3) BV group (n = 15): biventricular or indeterminate dominance. Perioperative major adverse events were collected based on the Society of Thoracic Surgeons database. The need for perioperative allogeneic blood transfusions also was determined. The mean age was 3.3±1.7 years and the mean weight was 13.6±4.0 kg. All patients had extracardiac lateral tunnel or conduit Fontan procedures. Sixty-nine of the patients (96%) underwent tracheal extubation in the operating room. Anesthesia, surgery, and CPB times were 326±68, 239±73, and 70±41 minutes, respectively. Eleven patients (15%) required allogeneic blood products intraoperatively, while 30 patients (42%) required allogeneic blood products during the perioperative period. Length of cardiac intensive care unit stay and hospital stay (median [IQR]) were 1 [1,2] and 12 [9,18] days, respectively. There was no mortality and no significant differences between groups in major postoperative complications, anesthetic or surgical variables. Conclusions No difference in the immediate perioperative outcomes was noted based on ventricular morphology.

Background The influence of posttransplant lymphoproliferative disease (PTLD) on long-term survival after heart transplantation (HTx) in adult recipients needs better characterization. Methods The United Network for Organ Sharing database was queried from 2006 to 2015 to compare survival between adult HTx recipients with and without PTLD. Cox proportional hazards models were used to analyze the primary outcome of survival, and competing-risks regression was used to analyze the outcome of PTLD development. Results A total of 14,487 HTx recipients who had data on PTLD were included in univariate Cox analysis and Kaplan–Meier survival function, while 10,422 were included in multivariable Cox analysis and 162 selected for a matched-pairs sample after matching on the propensity of developing PTLD. The cohort included 120 patients who were diagnosed with PTLD. Onset of PTLD, treated as a time-varying covariate, was adversely associated with survival in univariate (HR = 4.953; 95% CI: 3.768, 6.511; p

Background Patients with cystic fibrosis (CF) experience obstacles to employment, regardless of whether they have undergone lung transplantation (LTx). We investigated socioeconomic and clinical factors predicting long-term employment outcomes in CF patients receiving LTx. Methods Data from the United Network for Organ Sharing registry were used to identify CF patients 18–59years-old who received LTx between 2000 and 2010 and survived greater than 5years. Long-term employment status was determined by center-reported follow-up data on patients working for income, collected at the 5th transplant anniversary. After multiple imputation to complete missing data on covariates, multivariable logistic regression was used to identify associations between characteristics at or after LTx and long-term work participation. Results There were 745 patients who met inclusion criteria and contributed employment data within 365days of their 5th LTx anniversary. In this cohort, 48% (358/745) were working for income 5years after LTx. Younger age, male gender, better pulmonary function attained post-transplant, pre-transplant work participation, and private health insurance (compared to government Medicaid or Medicare insurance) at the time of transplant predicted greater odds of post-transplant employment. Conclusions Lack of work experience and reliance on government health insurance at the time of transplant predict lower long-term work participation among LTx recipients with CF. By contrast, long-term employment outcomes were not negatively affected by comorbidities at or after transplantation in this cohort. Despite resolving some physiological obstacles to employment in patients with CF, LTx may introduce new socioeconomic barriers to employment.

A survival advantage has been demonstrated for lung transplantation (LTx) in the cystic fibrosis (CF) population, but children may be at higher risk of post-transplant mortality than adults.The registry of the International Society for Heart and Lung Transplantation (ISHLT) was queried for lung transplants performed during the period 1998 to 2014 in patients with CF. Period differences were assessed by dividing the sample into LTxs performed between 2006 and 2014 and those performed between 1998 and 2005. Age ≥18 years distinguished adult from pediatric recipients. Supplemental analyses of United States of America (USA) LTx recipients with CF utilized 1998 to 2014 data from the United Network for Organ Sharing (UNOS) registry.A total of 7,245 patients from the ISHLT registry were selected for analysis. Kaplan-Meier curves confirmed a survival disadvantage of children as compared to adults with CF in 2006 to 2014 (p0.001), and in the earlier era of 1998 to 2005 (p = 0.002). Univariate Cox proportional hazards regression revealed that age18 years at transplantation [hazard ratio (HR) = 1.367; 95% confidence interval (CI) 1.225 to 1.526; p0.001] and LTxs performed in 1998 to 2005 (HR = 1.131; 95% CI 1.042 to 1.227; p = 0.003) were associated with greater mortality hazard. Multivariable Cox regression adjusting for potential confounders and interacting LTx era with recipient age group confirmed the persistence of age-related survival disparities after LTx in CF in the contemporary era. Analysis of UNOS data demonstrated survival disparities between children and adult CF patients receiving LTx in majority-adult programs.An age-related survival disparity after LTx has persisted in the international CF population. Data from the USA suggest this disparity is not fully explained by differences in center volume between adult and pediatric programs in the contemporary era.

Drug abuse in the family is known to increase the risk of child abuse, but its impact on outcomes of hospitalizations for non-accidental trauma (NAT) has not been characterized.We aimed to identify how frequently drug abuse in the household was documented among children with known or suspected NAT, and to correlate drug abuse in the family with hospitalization outcomes.At our tertiary care hospital, we retrospectively queried hospital admissions of children ages 0-17 who had a Child Abuse and Neglect consultation ordered during an inpatient stay.Case manager documentation and consult notes from the inpatient response team were used to determine suspected or confirmed presence of household substance abuse.We identified 185 children meeting inclusion criteria (59 %1 year; 34 % 1-5 years; 7% 6-14 years of age). Drug abuse in the family was documented in 44 cases (24 %). Among 178 children surviving to discharge, drug abuse was associated with lower likelihood of discharge home (50 % vs. 70 % among children with no documented drug abuse, p = 0.018). After discharge, we found no statistically significant differences in rehospitalizations or emergency department visits according to documentation of drug abuse in the family.Our study addresses the role of family drug abuse in outcomes of hospitalizations for NAT. Significantly, half of cases with suspected or known drug abuse had no prior CPS involvement, and drug abuse was associated with discharge outcomes after controlling for prior CPS involvement.

Introduction Obstructive Sleep Apnea (OSA) and Sleep Disordered Breathing (SDB) in children tend to be a more complex and multifactorial disease than in adults. Although adult screening tools, such as the STOP-BANG questionnaire, their application limited in pediatrics. We used our previously described 6-point questionnaire to identify OSA in children and evaluated its use for predicting post-operative respiratory events. Methods Children from 3 to 18 years of age presenting for surgery were eligible. Exclusion criteria were emergency surgery or refusal to participate. A 6-question survey regarding symptoms of OSA/SDB was administered preoperatively. Neck circumference was measured. Height and weight were recorded from preoperative data and the body mass index (BMI) percentile obtained. Results 749 patients were enrolled in the study. 707 patients were in the final analysis (359 boys and 348 girls, mean age 12 ± 4 years). The median 6-item questionnaire score was 1 (interquartile range: 0, 2) and 186 (26%) scored ≥ 2 of 6 points. Children with predicted OSA (yes on ≥ 2 questions) were more likely than without predicted OSA to require supplemental oxygen in the PACU (24% vs. 17%; 95% confidence interval [CI] of difference: −0.3%, 13%; p = 0.049). Amongst 681 patients with available data on Post Anesthesia Care Unit (PACU) length of stay (LOS), prolonged LOS (>1 h) was not more likely among children with predicted OSA (42%) compared to those without predicted OSA (39%; 95% CI of difference: −5%, 11%; p = 0.479). Outcomes assessed after PACU discharge noted no differences. Specifically, overnight hospital stay was required in 33% of patients with predicted OSA as compared to 29% of those without (95% CI of difference: −4%, 11%; p = 0.399). On POD 0, supplemental oxygen was used on the inpatient ward for 6% of patients with predicted OSA compared to 4% of patients without predicted OSA (95% CI of difference: −2%, 6%; p = 0.272). Conclusion The incidence of OSA/SDB is under-appreciated in children presenting for non-otolaryngological surgical procedures. Although patients judged to have OSA on the 6-item question may need for supplemental oxygen longer in the PACU, no other outcomes differences were noted.

Wealth ownership is highly concentrated in the U.S. and this inequality may be reproduced in subsequent generations through wealth transfers. Yet we do not know how households respond to the receipt of a wealth transfer and whether time amplifies the initial benefit of a wealth transfer. Using the Survey of Consumer Finances, we test whether wealth transfer recipients gain an advantage that cumulates with time. We find that the positive association between transfer amount and present net worth weakens as time elapsed since transfer receipt increases. The larger the wealth transfer, the more its association with net worth is diminished by time since transfer receipt. Though wealth transfers provide recipients with a significant initial advantage, households appear to adapt to wealth transfer receipt by some combination of reduced savings and increased consumption. We demonstrate an association between receiving a larger wealth transfer and one type of increased consumption, gift-giving.

Background The influence of age and gender on survival after lung transplant in patients with idiopathic pulmonary fibrosis (IPF) is not well defined. Methods The United Network for Organ Sharing database was queried to identify IPF patients receiving lung transplant between 2005 and 2015. Results There were 6,677 patients receiving lung transplant between May 2015 and June 2015 who met the inclusion criteria, predominantly males (n = 4,769, 71%). Within 1 year posttransplant, the survival curves of male and female recipients diverged, with male recipients having significantly worse survival (log-rank test p = 0.008). Univariate Cox proportional hazards regressions demonstrated no gender difference in survival below age 65 years (HR = 1.051; 95% CI = 0.945, 1.168; p = 0.362) but a significant increase in mortality hazard associated with male gender among patients age 65 years and older (HR = 1.161; 95% CI = 1.000, 1.347; p = 0.049). Multivariable Cox regression accounting for age modulation of the gender effect further demonstrated the emergence of a male disadvantage in post-transplant survival above age 65 years at transplantation. Conclusions In patients with IPF receiving lung transplant at greater than 65 years of age, male gender is associated with significantly increased risk for death, so referral for lung transplant in IPF should be considered early in the disease course.