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Purpose: To develop reference charts that describe normative quadriceps strength recovery after total knee arthroplasty (TKA) as measured by handheld dynamometry (HHD).Materials and Methods: We con...

Cyclin-dependent kinase-like 5 (CDKL5) deficiency disorder is a rare neurodevelopmental disorder characterized by infantile-onset refractory epilepsy, profound developmental delays, and cerebral visual impairment. Although there is evidence that the presence of cerebral visual impairment in CDKL5 deficiency disorder is common, the potential impact of cerebral visual impairment severity on developmental attainment has not been explored directly. Focusing on a cohort of 46 children with CDKL5 deficiency disorder, examination features indicative of cerebral visual impairment were quantified and compared to developmental achievement. The derived cerebral visual impairment severity score was inversely correlated with developmental attainment, bolstering the supposition that cerebral visual impairment severity may provide a useful early biomarker of disease severity and prognosis. This study demonstrates the utility of a cerebral visual impairment score to better capture the range of cerebral visual impairment severity in the CDKL5 deficiency disorder population and further elucidates the interaction between cerebral visual impairment and developmental outcomes.

PURPOSE: Studies based on administrative databases show that infant pyeloplasty is associated with minority race/ethnicity but lack clinical data that may influence treatment. Our objective was to identify clinical and demographic factors associated with pyeloplasty in infants from three large tertiary centers. METHODS: We reviewed infants with unilateral Society for Fetal Urology (SFU) grade 3-4 hydronephrosis seen at three tertiary centers from 2/1/2018-9/30/2019. Patients were excluded if > 6 months old or treated surgically prior to the initial visit. Outcomes were: pyeloplasty < age 1 year and SFU grade on most recent ultrasound (US) within the first year. Covariables included: age at the initial visit, race/ethnicity, treating site, insurance type, febrile UTI, and initial imaging findings. Univariable and multivariable analyses were performed using log-rank tests and Cox proportional hazards models, respectively. RESULTS: 197 patients met study criteria; 19.3% underwent pyeloplasty. Pyeloplasty was associated with: treating site (p=0.03), SFU 4 on initial US (p =0.001), MAG-3 (p 20 minutes (p < 0.001) in patients undergoing a MAG-3 (n=107). MAG-3 (p

Purpose: Up to 1.8% of youth identify as transgender; many will be treated with a gonadotropin-releasing hormone agonist (GnRHa). The impact of GnRHa on insulin sensitivity and body composition in transgender youth is understudied. We aimed to evaluate differences in insulin sensitivity and body composition in transgender youth on GnRHa therapy compared with cisgender youth. Methods: Transgender participants were matched to cisgender participants on age, body mass index, and sex assigned at birth. Transgender males (n=9, ages 10.1–16.0 years) on GnRHa (mean±standard deviation duration of exposure: 20.9±19.8 months) were compared with cisgender females (n=14, ages 10.6–16.2). Transgender females (n=8, ages 12.6–16.1) on GnRHa (11.3±7 months) were compared with cisgender males (n=17, ages 12.5–15.5). Differences in insulin sensitivity (1/[fasting insulin], homeostatic model of insulin resistance [HOMA-IR]), glycemia (hemoglobin A1C [HbA1c], fasting glucose), and body composition (dual-energy X-ray absorptiometry) were evaluated using a mixed linear regression model. Results: Transgender males had lower 1/fasting insulin and higher HOMA-IR (p=0.031, p=0.01, respectively), fasting glucose (89±4 vs. 79±13 mg/dL, p=0.012), HbA1c (5.4±0.2 vs. 5.2±0.2%, p=0.039), and percent body fat (36±7 vs. 32±5%, p=0.042) than matched cisgender females. Transgender females had lower 1/fasting insulin and higher HOMA-IR (p=0.028, p=0.035), HbA1c (5.4±0.1% vs. 5.1±0.2%, p=0.007), percent body fat (31±9 vs. 24±10%, p=0.002), and lower percent lean mass (66±8 vs. 74±10%, p

Objective:Children with infantile spasms may develop Lennox-Gastaut syndrome. The diagnostic criteria for Lennox-Gastaut syndrome are vague, and many experts use varying combinations of the following criteria for diagnosis: paroxysmal fast activity on electroencephalography (EEG), slow spike and wave on EEG, developmental delay, multiple seizure types, and nocturnal tonic seizures. Our objective was to determine the prevalence of Lennox-Gastaut syndrome in a high-risk cohort of children with a history of infantile spasms and the characteristics of infantile spasms that were associated with the diagnosis of Lennox-Gastaut syndrome.Methods:Children with infantile spasms who were diagnosed and treated at Children’s Hospital Colorado between 2012 and 2018 were included. Lennox-Gastaut syndrome was defined as having 3 of 5 of the following characteristics: paroxysmal fast activity, slow spike and wave, current developmental delay, multiple seizure types, or tonic seizures. Descriptive statistics were performed using median and interquartile range. Univariable analysis was performed with Pearson chi-square, Fisher exact, or the Kruskal-Wallis test.Results:Ninety-seven children met inclusion criteria, and 36% (35/97) met criteria for Lennox-Gastaut syndrome. Developmental delay and history of seizures prior to the onset of infantile spasms were identified as risk factors for the development of Lennox-Gastaut syndrome ( P = .003) as was poor response to first treatment for spasms ( P = .004). Children with an unknown etiology of infantile spasms were less likely to develop Lennox-Gastaut syndrome ( P = .019). Eighty percent (28/35) of the children who met Lennox-Gastaut syndrome criteria lacked a documented diagnosis.Conclusions:Thirty-six percent of children with infantile spasms met criteria for Lennox-Gastaut syndrome. Risk factors for development of Lennox-Gastaut syndrome were developmental delay and seizures prior to the onset of infantile spasms and poor response to first treatment for infantile spasms. Children with an unknown etiology of infantile spasms were less likely to develop Lennox-Gastaut syndrome. Eighty percent of the children who met our criteria were not given a documented diagnosis of Lennox-Gastaut syndrome, which highlights the fact that many children may not be receiving a diagnosis of Lennox-Gastaut syndrome. We recommend establishing clear guidelines for the diagnosis of Lennox-Gastaut syndrome to ensure that the diagnosis is being made accurately.

INTRODUCTION: People with Down syndrome have health risks that require specific lifelong preventive healthcare. With increasing life expectancy, people with Down syndrome also face health conditions typical of their unaffected peers and thus need coordinated healthcare. The purpose of this study is to describe rates of age/gender- and Down syndrome-specific preventive healthcare activities among adolescents and adults with Down Syndrome. METHODS: Using Medicaid claims (2006–2010) in California, Colorado, Michigan, and Pennsylvania, the cohort was defined as people with Down syndrome aged ≥12 years seen by primary care providers and enrolled in Medicaid for ≥45 of 60 months without dual Medicare enrollment (n=3,501). Age focus-consistent primary care providers were defined as having a focus concordant with a patient’s age: 12–17 years, child or mixed focus; ≥26 years, adult or mixed focus; 18–25 years, any focus. Differences in healthcare activities were evaluated using Pearson’s chi-square, Fisher’s exact, and Kruskal-Wallis tests. Analyses were performed in 2015–2017. RESULTS: Seventy-nine percent of the cohort had an age focus-consistent primary care provider. However, 40% of adults aged ≥26 years received care from child-focused primary care provider. Only 43% with an age focus-consistent provider had ≥1 well examination (age focus-inconsistent primary care provider: 35%, p

Background Pulmonary exacerbations (PEx) are important contributors to morbidity and mortality in cystic fibrosis (CF). Understanding risk factors for PEx is critical to improve treatment; pulmonary exacerbations also serve as an important outcome in CF clinical trials. Current risk estimates generally only evaluate time to the first PEx. Methods accounting for multiple exacerbations during the observation period could provide more power to detect significant risk factors. Methods The Early Pseudomonas Infection Control (EPIC) Observational Study enrolled participants between 2004 and 2006 who were ≤ 12 years of age and negative for Pseudomonas aeruginosa. First and multiple event analyses were used to investigate risk factors for pulmonary exacerbations. Results We evaluated a total of 5129 PEx from 1734 CF patients in the EPIC study. Multiple event analysis identified 2 more factors associated with occurrence of PEx compared to first event analysis. After adjusting for multiple factors, the following were associated with higher occurrence of PExs: female gender, older age at enrollment, household cigarette smoke exposure, increased cough at the most recent encounter, having used antibiotics since the previous encounter, a positive culture for any CF organism at the most recent encounter, and having had a PEx in the last 30 days. Conclusions Multiple event analyses use all PEx events and may identify more risk factors for PEx than analysis of time to first PEx. We have provided an example of how to apply this type of analysis and how to interpret estimates in the context of the EPIC study.

Context As many as 1.8% of adolescents identify as transgender and many more seek care, yet the impact of gender-affirming hormone therapy (GAHT) on cardiometabolic health is unknown. Objective To determine insulin sensitivity and body composition among transgender females (TF) and males (TM) on estradiol or testosterone, compared with cisgender females (CF) and males (CM). Design Pilot, cross-sectional study conducted from 2016–2018. Setting Academic regional transgender referral center. Participants Transgender adolescents on either testosterone or estradiol for at least 3 months were recruited. Nineteen TM were matched to 19 CM and 42 CF on pubertal stage and body mass index (BMI). Eleven TF were matched to 23 CF and 13 TF to 24 CM on age and BMI. Main Outcome Measures 1/[fasting insulin] and body composition (dual-energy x-ray absorptiometry). Results Total body fat was lower in TM than CF mean ± SD: (29% ± 7% vs 33% ± 7%; P = 0.002) and higher than in CM (28% ± 7% vs 24% ± 9%; P = 0.047). TM had higher lean mass than CF (68% ± 7% vs 64% ± 7%, P = 0.002) and lower than CM (69% ± 7% vs 73% ± 8%; P = 0.029). Insulin sensitivity was not different between the groups. TF had lower body fat than CF (31% ± 7% vs 35% ± 8%; P = 0.033) and higher than CM (28% ± 6% vs 20% ± 10%; P = 0.001). TF had higher lean mass than CF (66% ± 6% vs 62% ± 7%; P = 0.032) and lower than CM (69% ± 5% vs 77% ± 9%; P = 0.001). TF were more insulin resistant than CM (0.078 ± 0.025 vs 0.142 ± 0.064 mL/μU; P = 0.011). Conclusions Transgender adolescents on GAHT have significant differences in body composition compared with cisgender controls, with a body composition intermediate between BMI-matched CMs and CFs. These changes in body composition may have consequences for the cardiometabolic health of transgender adolescents. ClinicalTrials.gov NCT02550431

BACKGROUND: There is a need for new strategies to improve the success of obesity treatment within the primary care setting. OBJECTIVE: To determine if patients offered low out-of-pocket cost weight management tools achieved more weight loss compared to usual care. DESIGN: Twelve-month pragmatic clinical weight loss trial with a registry-based comparator group performed in primary care clinics of an urban safety-net hospital. PARTICIPANTS: From a large clinical registry, we randomly selected 428 patients to have the opportunity to receive the intervention. INTERVENTIONS: Medical weight management tools—partial meal replacements, recreation center vouchers, pharmacotherapy, commercial weight loss program vouchers, and a group behavioral weight loss program—for $5 or $10 monthly. Patients chose their tools, could switch tools, and could add a second tool at 6 months. MAIN MEASURES: The primary outcome was the proportion of intervention-eligible patients who achieved ≥ 5% weight loss. The main secondary outcome was the proportion of on-treatment patients who achieved ≥ 5% weight loss. KEY RESULTS: Overall, 71.3% (305 of 428) had available weight measurement data/PCP visit data to observe the primary outcome. At 12 months, 23.3% (71 of 305) of intervention-eligible participants and 15.7% (415 of 2640) of registry-based comparators had achieved 5% weight loss (p

OBJECTIVES: To evaluate trends and factors associated with mode of delivery in the rural Southwest Trifinio region of Guatemala. METHODS: We conducted a retrospective analysis of self-reported antepartum factors and postpartum outcomes recorded in a quality improvement database among 430 women enrolled in a home-based maternal healthcare program between June 1, 2015 and August 1, 2017. RESULTS: Over the study period, the rates of cesarean delivery (CD) increased (from 30% to 45%) and rates of vaginal delivery (VD) decreased (70% to 55%) while facility-based delivery attendance remained stable around 70%. Younger age (23.5 years for VD versus 21.6 years for CD, p < 0.001), nulliparity (25.1% for VD versus 45.0% for CD, p < 0.001), prolonged/obstructed labor (2.4% for VD versus 55.6% for CD, p < 0.001), and fetal malpresentation (0% for VD versus 16.3% CD, p < 0.001) significantly influenced mode of delivery in univariate analysis. The leading indications for CD were labor dysfunction (47.5%), malpresentation (14.5%), and prior cesarean delivery (19.8%). The CD rate among the subpopulation of term, nulliparous women with singleton pregnancies in vertex presentation also increased from 20% of all CD in 2015, to 38% in 2017. CONCLUSIONS: Among low-income women from rural Guatemala, the CD rate has increased above the World Health Organization (WHO) recommendations in a period of 3 years. Additional research on the factors affecting this trend are essential to guide interventions that might improve the appropriateness of CD, and to determine if reducing or stabilizing rates is necessary.

BackgroundTacrolimus is given post-kidney transplant to suppress the immune system, and the amount of drug in the body is measured frequently. Higher variability over time may be indicative of poor drug adherence, leading to more adverse events. It is important to account for the variation in Tacrolimus, not just the average change over time.MethodsUsing data from the University of Colorado, we compare methods of assessing how the variability in Tacrolimus influences the hazard of de novo Donor Specific Antibodies (dnDSA), an early warning sign of graft failure. We compare multiple joint models in terms of fit and predictive ability. We explain that the models that account for the individual-specific variability over time have the best predictive performance. These models allowed each patient to have an individual-specific random error term in the longitudinal Tacrolimus model, and linked this to the hazard of dnDSA model.ResultsThe hazard for the variance and coefficient of variation (CV) loading parameter were greater than 1, indicating that higher variability of Tacrolimus had a higher hazard of dnDSA. Introducing the individual-specific variability improved the fit, leading to more accurate predictions about the individual-specific time-to-dnDSA.ConclusionsWe showed that the individual’s variability in Tacrolimus is an important metric in predicting long-term adverse events in kidney transplantation. This is an important step in personalizing the dosage of TAC post-transplant to improve outcomes post-transplant.

Background : Hospitalized children have high rates of tobacco smoke exposure; parents who smoke may be receptive to interventions during their child's hospitalization. Objective : We tested the efficacy of a smoking cessation intervention for parents of hospitalized children. Methods : We conducted a randomized, single-blind clinical trial from 12/14-5/18 at the Children's Hospital Colorado. Hospitalized children who had a parent who smoked tobacco were eligible. Intervention: Intervention participants received motivational interviewing sessions, 2 weeks of nicotine replacement therapy; both groups received referral to the Quitline Consenting parents completed a questionnaire; urine was collected from the child for measurement of cotinine. Our primary outcome was: 1) increase in reporting “no one is allowed to smoke anywhere” in the home (smoke-free home rule). Additional outcomes included: 2) change in child's cotinine from baseline to 1 year, and 3) parental quitting at 1 year. Data were analyzed using Chi-square and t-tests for bivariable data, and multivariable logistic and linear regression. Results : Of 1641 eligible families approached, 252 were randomized (15%); 149 families had follow-up data at 12 months (59%). In the adjusted analysis, there was no difference between the groups in smoke free home rules, or child cotinine level; in an intention-to-treat analysis, 15% in the intervention group vs. 8% of controls reported quit (p=0.07). Conclusions : A smoking cessation intervention can be delivered to parents of hospitalized children. While hospitalization provides an opportunity to help parents quit smoking, more efficient and effective engagement strategies are needed to optimize tobacco control success.

Objective he purpose of this study will be to determine the efficacy of error-manipulation gait training (error-augmentation or error-correction) to improve step length symmetry and secondary health outcomes in veterans with unilateral nontraumatic transtibial amputation (TTA). Methods This will be a 3-arm, parallel, assessor-blinded, randomized controlled trial, with baseline, postintervention, and 3-month follow-up assessments in a VA Geriatric Research Education and Clinical Center. Participants are 54 US military veterans ranging in age from 50 to 85 years with a unilateral transtibial nontraumatic amputation. Participants will be randomized into 1 of 3 groups: error-augmentation training (EAT), error-correction training (ECT), or supervised walking (CTL). Each group will complete 8 split-belt treadmill walking training sessions of 25 minutes each over 4 weeks. The EAT group will walk with belts moving at asymmetrical speeds. The ECT group will walk to the cadence of a metronome and the split belts moving at symmetrical speeds. The CTL group will walk with symmetrical belt speeds and without feedback. Step length symmetry is the primary outcome and will be assessed using an asymmetry index during overground walking. Secondary outcomes include lower extremity joint work during treadmill walking, 6-Minute Walk Test performance, daily step count, participant-perceived disability, and residual-limb integumentary health. Outcomes will be assessed at preintervention, 1-week postintervention (primary endpoint), and 13 weeks postintervention. Impact This study protocol focuses on an understudied area of rehabilitation for patients with nontraumatic unilateral TTA who have high levels of spatiotemporal gait asymmetry and mobility impairment. The results of this study will inform future implementation of clinical gait training interventions to improve spatiotemporal gait symmetry and long-term health and disability outcomes in patients with nontraumatic unilateral TTA.

BACKGROUND Group visits can support health behavior change and self-efficacy. In primary care, an advance care planning (ACP) group visit may leverage group dynamics and peer mentorship to facilitate education and personal goal setting that result in ACP engagement. OBJECTIVE To determine whether the ENgaging in Advance Care Planning Talks (ENACT) group visits intervention improves ACP documentation and readiness in older adults. METHODS This randomized clinical trial was conducted among geriatric primary care patients from the University of Colorado Hospital Seniors Clinic, Aurora, CO, from August 2017 to November 2019. Participants randomized to ENACT group visits (n = 55) participated in two 2-hour sessions with discussions of ACP topics and use of ACP tools (i.e., Conversation Starter Kit, Medical Durable Power of Attorney form, and PREPARE videos). Participants randomized to the control arm (n = 55) received the Conversation Starter Kit and a Medical Durable Power of Attorney form by mail. The primary outcomes included presence of ACP documents or medical decision-maker documentation in the electronic health record (EHR) at 6 months, and a secondary outcome was ACP readiness (validated four-item ACP Engagement Survey) at 6 months. RESULTS Participants were a mean of 77 years old, 60% female, and 79% white. At 6 months, 71% of ENACT participants had an advance directive in the EHR (26% higher) compared with 45% of control arm participants (P

Introduction: Pediatric early warning scores (PEWS) identify hospitalized children at risk for deterioration. Manual calculation is prone to human error. Electronic health records (EHRs) enable automated calculation, removing human error. This study’s objective was to compare the accuracy of automated EHR-based PEWS calculation (AutoPEWS) to manual calculation and evaluate the non-inferiority of AutoPEWS in predicting deterioration. Methods: We performed a retrospective cohort study inclusive of non-intensive care unit inpatients at a freestanding children’s hospital over 4.5 months in Fall 2018. AutoPEWS mapped the historical manual PEWS scoring rubric to frequently used EHR documentation. We determined accuracy by comparing the expected respiratory subset score based on the current respiratory rate to the actual respiratory score of AutoPEWS and the manual PEWS. The agreement was determined using kappa statistics. We used predicted probabilities from a generalized linear mixed model to calculate areas under the curve for each combination of scores (AutoPEWS, manual) and deterioration outcome (rapid response team activation, unplanned intensive care unit transfer, critical deterioration event). We compared the adjusted difference in areas under the curves between the scores. Non-inferiority was defined as a difference of

Background Women have higher utilization of “do not attempt resuscitation” ( DNAR ) orders during treatment for critical illness. Occurrence of sex differences in the establishment of DNAR orders after resuscitation from in‐hospital cardiac arrest is unknown. Whether differences in DNAR use by sex lead to disparities in survival remains unclear. Methods and Results We identified 71 820 patients with return of spontaneous circulation ( ROSC ) after in‐hospital cardiac arrest from the Get With The Guidelines–Resuscitation registry. Multivariable models evaluated the association between de novo DNAR (anytime after ROSC , within 12 hours of ROSC , or within 72 hours of ROSC ) by sex and the association between sex and survival to discharge accounting for DNAR . All models accounted for clustering of patients within hospital and adjusted for demographic and cardiac arrest characteristics. The cohort included 30 454 (42.4%) women, who were slightly more likely than male participants to establish DNAR orders anytime after ROSC (45.0% versus 43.5%; adjusted relative risk: 1.15 [95% CI , 1.10–1.20]; P DNAR status within the first 12 hours (51.8% versus 46.5%; adjusted relative risk: 1.40 [95% CI, 1.30–1.52]; P ROSC (75.9% versus 70.9%; adjusted relative risk: 1.35 [95% CI, 1.26–1.45]; P CI , 0.99–1.02]; P =0.74) was appreciated. Conclusions In patients successfully resuscitated from in‐hospital cardiac arrest, there was no survival difference between men and women while accounting for DNAR . However, women had a higher rate of DNAR status early after resuscitation (

Introduction There is overlap in the electroclinical features of many childhood epilepsy syndromes, especially those presenting with multiple seizure types, such as epilepsy with myoclonic-atonic seizures (EMAS) and Lennox-Gastaut syndrome (LGS). This study aimed to determine the frequency of diagnosis switching and the factors influencing epilepsy syndrome diagnosis in a cohort of children with possible EMAS, as well as to explore the relationship between epilepsy syndrome diagnoses, key electroclinical features, and clinically relevant outcomes. Methods This is a cross-sectional retrospective chart review of children treated at the Children’s Hospital of Colorado with a potential diagnosis of EMAS. Results There were 77 patients that met eligibility criteria, including 39% (n = 30) with an initial diagnosis of EMAS and 74% (n = 57) with a final diagnosis of EMAS. On average, for the 65% of patients who received more than one epilepsy diagnosis, the first, second, and third diagnoses were received within one year, three years, and ten years after epilepsy onset, respectively. Final diagnosis was significantly related to obtaining at least a six-month period of seizure freedom, p = 0.03. Classic LGS traits, including paroxysmal fast activity, slow spike-and-wave, and tonic seizures were present in 50% of the overall cohort, although a minority of these patients had a final diagnosis of LGS. However, the presence of more LGS traits was associated with a higher likelihood of ongoing seizures. Adjusted for age of epilepsy onset, seizure freedom was half as likely for every additional LGS trait observed (0.49[0.31, 0.77], p = 0.002). Conclusion Current epilepsy syndrome classification has reduced applicability due to overlapping features. This results in diagnosis switching and limited prognostic value for patients with an overlapping clinical phenotype. Future studies should attempt to stratify patients based not only on epilepsy syndrome diagnosis, but also on the presence of various electroclinical traits to more accurately predict outcome.

OBJECTIVE To examine the impact of a 1-year pragmatic obesity trial on primary care providers' (PCPs) perspectives of treatment. METHODS PCPs from four intervention clinics (PCP-I) and five control clinics (PCP-C) completed pre- and postintervention surveys on weight-loss counseling, comfort discussing obesity treatments, and perceived effectiveness of interventions; questions were rated on 0 to 10 Likert scales. Only PCP-I received patient updates and education about obesity management. RESULTS Eighty PCPs completed preintervention surveys (pre: 71% female, 71% physicians); 82 PCPs completed postintervention surveys (post: 66% female, 70% physicians). PCPs were most comfortable discussing exercise before and after the trial (pre PCP-C: 8.22 [1.44], mean [standard deviation (SD)]; post PCP-C: 8.37 [1.24]; P = 0.8; pre/post PCP-I: 7.88 [1.51] vs. 7.80 [1.71]; P = 0.3). PCPs were initially least comfortable discussing phentermine/topiramate extended release (ER) but developed significantly more comfort after the trial, to a greater degree among PCP-I (pre/post PCP-C: 2.86 [2.66] vs. 3.73 [2.72], P < 0.001; pre/post PCP-I: 4.00 [2.57] vs. 6.17 [2.27], P < 0.001). After the trial, both PCPs rated exercise significantly less effective for weight loss, with a greater decrease in effectiveness rations among PCP-I (pre/post PCP-C: 7.73 [1.94] vs. 6.93 [2.35], P = 0.017; pre/post PCP-I: 6.27 [2.69] vs. 5.15 [2.31], P = 0.001). Both PCPs rated phentermine (pre/post PCP-C: 5.03 [2.05] vs. 5.50 [2.12], P = 0.002; pre/post PCP-I: 5.70 [1.64] vs. 6.83 [1.18], P = 0.001) and phentermine/topiramate ER (pre/post PCP-C: 3.91 [2.33] vs. 5.47 [2.54], P < 0.001; pre/post PCP-I: 5.58 [2.21] vs. 7.02 [1.47], P < 0.001) significantly more effective after the trial, though ratings were higher among PCP-I. CONCLUSIONS PCPs initially overvalued exercise and undervalued weight-loss medications. PCPs exposed to education and experience gave higher comfort and effectiveness ratings to weight-loss medications.

Context Little is known about the health of transgender adults in the United States, a growing population. There have been no large reports examining differences in health status and cardiometabolic disease in subgroups of transgender adults [female-to-male (FTM), male-to-female (MTF), and gender nonconforming (GNC)] in the United States. Objective Compare the health status and prevalence of cardiometabolic disease among specific subgroups of transgender adults (FTM, MTF, GNC) with those of cisgender adults in the United States. Design Secondary data analysis based on the 2015 Behavioral Risk Factor Surveillance System survey. Setting The 22 states in the United States that asked about transgender identity. Participants Noninstitutionalized adults age ≥18 years who reside in the United States, identified through telephone-based methods. Main Outcome Measures Data were extracted for respondents who answered the transgender identity question. Weighted percentages are given for all measures. Adjusted odds ratios (ORs) are reported for health status and cardiometabolic disease measures. Results FTM adults have a higher odds of being uninsured than both cisgender women [OR 3.8; 95% confidence interval (CI), 2.1 to 7.1] and cisgender men (OR 2.5; 95% CI, 1.4 to 4.7). MTF adults have a higher odds of reporting myocardial infarction than cisgender women (OR 2.9; 95% CI, 1.6 to 5.3) but not cisgender men. Conclusions There are significant differences in health status measures and cardiometabolic health between subgroups of transgender adults and cisgender adults. There is a need for additional research to understand the societal and medical (e.g., hormone therapy) effects on these outcomes., There are differences in health status and cardiometabolic health among subgroups of transgender adults compared with cisgender adults on the 2015 Behavioral Risk Factor Surveillance System survey.

OBJECTIVES: To prospectively validate and refine the 5-item "CRASH" screening tool for identifying older drivers needing a behind-the-wheel (BTW) test. DESIGN: Prospective observational study. SETTING: Geriatric and internal medicine primary care clinics affiliated with a tertiary care hospital and a local BTW program. PARTICIPANTS: Cognitively intact drivers aged 65 and older (N = 315). MEASUREMENTS: Participants completed baseline questionnaire (including CRASH tool) and assessments and BTW test (evaluator blinded to questionnaire results) and participated in 1-month telephone follow-up. Analysis included descriptive statistics and examination of predictive ability of the CRASH tool to discriminate normal (pass) from abnormal (conditional pass or fail) on the BTW test, with logistic regression and CART techniques for tool refinement. RESULTS: Two hundred sixty-six participants (84%) had a BTW test; of these, 17% had a normal rating and 83% an abnormal rating. Forty-five percent of those with an abnormal score were advised to limit driving under particular conditions. Neither the CRASH tool nor its individual component variables were significantly associated with the summary BTW score; in refined models with other variables, the best-performing tool had approximately 67% sensitivity and specificity for an abnormal BTW score. Most participants found the BTW test useful and were willing to pay a median of $50. At 1-month follow-up, no participants had stopped driving. CONCLUSION: The CRASH screening tool cannot be recommended for use in clinical practice. FINDINGS on older adults' perceived utility of the BTW test and the stability of driving patterns at 1-month follow-up could be useful for future research studies and for design of older driver programs.© 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society. Language: en

Hospital readmissions are viewed as a mark of inferior health care quality and are penalized. Unplanned postoperative readmission reason and timing after lung resection are not well understood. We examine related, unplanned readmissions after thoracoscopic versus open anatomic lung resections to identify opportunities to improve patient care.We analyzed the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data set, 2012 to 2015, characterizing 30-day related, unplanned postoperative readmissions after anatomic lung resections for primary lung cancer. Risk-adjusted comparison of readmission after thoracoscopic and open resection was performed using propensity matching.Patients (n = 9,510) underwent anatomic lung resections; 4,935 (51.9%) were thoracoscopic resections and 4,575 (48.1%) were open resections. Of the thoracoscopic patients, 10.9% experienced one or more complications, versus 19.4% of patients with open resection (p0.0001). Of the thoracoscopic patients 5.5% experienced related, unplanned readmissions versus 7.2% of the patients with open resection (p0.001). 24.8% of complications after thoracoscopic approach occurred after discharge, versus 15.5% after open approach (p0.0001). Timing of unplanned readmission was similar for both groups. The propensity-matched odds ratio of risk of readmission after thoracoscopic versus open resection was 1.16 (95% confidence interval, 0.949 to 1.411, p = 0.15).Open anatomic lung resections for primary lung cancer had nearly twice the complication rate but only a slightly higher readmission rate than thoracoscopic resection. More complications occurred after discharge after thoracoscopic than open resections. Most readmissions occurred within 2 weeks after both thoracoscopic and open resections. Risk-adjusted comparison identified no statistically significant difference in risk of related, unplanned readmission after thoracoscopic versus open resections. Future studies should focus on identification of processes of care to decrease complications and unplanned readmissions after lung cancer resection.

Background: Studies of transgender adults on gender affirming hormone therapy have shown increased rates of cardiovascular events (myocardial infarction and stroke) and features of metabolic syndrome including increased body mass index (BMI, transgender males) and dyslipidemia (transgender males and females). Studies in youth are limited by mostly small, single-center studies. With 1.8% of adolescents identifying as transgender, and increasing referral rates to gender clinics for care, more information is needed to better inform clinicians, patients and families about potential health risks in this cohort. PEDSnet, a pediatric Learning Health System, captures data from some of the largest pediatric care institutions in the U.S. We aimed to evaluate differences in diagnoses related to metabolic syndrome or cardiometabolic risk among youth with a diagnosis of gender dysphoria compared to matched cisgender controls. Methods: All youth with a diagnosis of gender dysphoria (n=4,177) and at least one outpatient encounter were extracted from the PEDSnet database (6 sites, years 2009-2019) and propensity-score matched on 7 variables (year of birth, age at last visit, site, race, ethnicity, insurance status, duration in database) to 4 controls without gender dysphoria (n=16,664). The odds of having a diagnosis of overweight/obesity, hypertension, dyslipidemia, dysglycemia, liver dysfunction, polycystic ovary syndrome (PCOS) or metabolic syndrome, was examined using generalized estimating equations with an interaction term for sex (as listed in the chart). Results: Of the transgender youth, 66% were female sex, 73% were white race, 9% were of Hispanic ethnicity, and 61% had private insurance. The control group was similar: 67% female sex, 72% white, 9% Hispanic, and 61% had private insurance. Transgender youth and controls both had on average 7 years duration in the database and were 16.2 years old at last visit. Transgender youth had higher odds of dyslipidemia (OR: 1.6 [95% CI: 1.3, 1.8], p

Dravet syndrome is an intractable childhood epilepsy syndrome most often associated with an SCN1A mutation. In our clinical practice, several patients with Dravet syndrome were noted to have short stature and endocrine dysfunction. This has not been reported in the literature. Our study aim was to describe growth measurements and endocrine abnormalities in children with Dravet syndrome.A retrospective chart review was performed at a single institution. Eligibility criteria included clinical and genetic (SCN1A) diagnosis of Dravet syndrome. Records were reviewed for height and weight measurements and serologic evidence of endocrine abnormality, as well as patient demographics, anti-seizure medication, and family history. Age and gender specific trend of height and weight measurements, using z-scores, were compared to CDC growth curves (Centers for Disease Control and Prevention [1]).Sixty-eight children were identified, 46% male, age 1-21 years, taking an average of 2.9 anti-seizure medications per patient. Mean growth parameter measurements were significant for decrease in height z-score of 0.10 (p=0.001) and decrease in weight z-score of 0.09 (p=0.01) for every year increase in age, such that with increasing age the cohort moved farther away from the mean. The average group height and weight z-score, at age 8, was -0.45 and -0.09, respectively. After adjusting for age, neither gender, family history, or anti-seizure medication was associated with height or weight z-score. Serologic endocrine results were available for 26 children (38%). This identified low insulin-like growth factor 1 (IGF-1) in 7/15 and low testosterone in 2/10. Two children received growth hormone supplementation. TSH testing was abnormal10% of the time.Comorbidities in children with Dravet syndrome may involve more systems than previously reported. We report a cohort of children with Dravet syndrome with reduced height and weight growth trend, as well as a subset with endocrine dysfunction evidenced by low IGF-1 and testosterone levels. Additional prospective research is needed to further define the significance of this relationship.

Obstructive sleep apnea (OSA) affects up to 26% of US adults, is often undiagnosed, and increases perioperative morbidity. We hypothesized that patients screened on the day of surgery as moderate/high risk for OSA (S-OSA) present similar perioperative respiratory complications, hospital use, and mortality than patients with previously diagnosed OSA (D-OSA). Second, we hypothesized that both OSA groups have more respiratory complications than No-OSA patients.The electronic medical database from 1 academic and 2 community hospitals was retrospectively queried to identify adults undergoing nonemergent inpatient surgery (January 1, 2012, to December 31, 2014). Based on the day-of-surgery preoperative assessment and STOP-BANG (Snoring, Tiredness, Observed apnea during sleep, high blood Pressure, Body mass index35, Age50 years, thick Neck, Gender male) score, they were classified as D-OSA, S-OSA, or No-OSA. Perioperative respiratory events and interventions, hospital use, and mortality were measured. The primary outcome composite (adverse respiratory events [AREs]) included perioperative hypoxemic events and difficult airway management. Hypoxemic event was defined as peripheral saturation of oxygen (SpO2)90% by continuous pulse oximetry for ≥3 minutes, or if validated and/or manually entered into the medical chart. Hypoxemia was classified as mild (lowest SpO2 86%-89%) or moderate/severe (lowest SpO2 ≤85%). Secondary outcomes included postoperative respiratory interventions, intensive care unit admission, hospital length of stay, and 30-day and 1-year all-cause mortality. Outcomes were compared using linear and logistic regression analyses.A total of 28,912 patients were assessed: 3432 (11.9%) D-OSA; 1546 (5.3%) S-OSA; and 23,934 (82.8%) No-OSA patients. At least 1 ARE was present in 68.0% of S-OSA; 71.0% of D-OSA; and 52.1% of No-OSA patients (unadjusted P.001), primarily ≥1 moderate/severe hypoxemic event after discharge from the postanesthesia care unit (PACU; 39.9% in S-OSA; 39.5% in D-OSA; and 27.1% in No-OSA patients). S-OSA patients compared to D-OSA patients presented lower rates of moderate/severe hypoxemia in the PACU but similar intraoperatively and postoperatively, higher difficult mask ventilation rates, and similar difficult intubation reports. After adjusting for demographic, health, and surgical differences and hospital type, the likelihood of ≥1 ARE was not different in S-OSA and D-OSA patients (adjusted odds ratio 0.90 [99% confidence interval, 0.75-1.09]; P = .15). S-OSA patients compared to D-OSA patients had significantly increased postoperative reintubation, mechanical ventilation, direct intensive care unit admission after surgery, hospital length of stay, and 30-day all-cause mortality.Patients classified as S-OSA have similar rates of AREs to D-OSA patients, but increased postoperative respiratory interventions, hospital use, and 30-day all-cause mortality. These worse postoperative outcomes in S-OSA patients than D-OSA patients could reflect the lack of awareness and appropriate management of this bedside S-OSA diagnosis after PACU discharge. Multidisciplinary interventions are needed for these high-risk patients.

Background Postpartum contraception is important to prevent unintended and closely spaced pregnancies following childbirth. Methods This study is a cluster-randomized trial of communities in rural Guatemala where women receive ante- and postnatal care through a community-based nursing program. When nurses visit women for their postpartum visit in the intervention clusters, instead of providing only routine care that includes postpartum contraceptive education and counseling, the nurses will also bring a range of barrier, short-acting, and long-acting contraceptives that will be offered and administered in the home setting, after routine clinical care is provided. Discussion A barrier to postpartum contraception is access to medications and devices. Our study removes some access barriers (distance, time, cost) by providing contraception in the home. We also trained community nurses to place implants, which are a type of long-acting reversible contraceptive method that was previously only available in the closest town which is about an hour away by vehicular travel. Therefore, our study examines how home-based delivery of routinely available contraceptives and the less routinely available implant may be associated with increased uptake of postpartum contraception within 3 months of childbirth. The potential implications of this study include that nurses may be able to be trained to safely provide contraceptives, including placing implants, in the home setting, and provision of home-based contraception may be an effective way of delivering an evidence-based intervention for preventing unintended and closely spaced pregnancies in the postpartum period. Trial registration Clinicaltrials.gov, NCT04005391. Retrospectively registered on 1 July 2019.

Background Few cluster-randomized trials have been performed in rural Guatemala. Our objective was to describe the feasibility, recruitment and retention in our cluster-randomized trial. Methods In our cluster-randomized trial, a range of contraceptives were brought to mothers’ homes in rural Guatemala. Results Of 173 women approached, 33 were excluded. Of the 140 eligible women, 127 (91%) consented to participate. Of the 87 women who should have been assessed for the primary outcome, three were lost to follow-up, which represents a retention rate of 97%. Conclusions Nurses who are both clinical providers and study staff can feasibly conduct research, which leads to high enrollment and retention rates.

ContextUp to 1.8% of adolescents identify as transgender and many more seek care, yet the impact of gender affirming hormone therapy (GAHT) on cardiometabolic health is unknown.ObjectiveTo determine insulin sensitivity and body composition among transgender females (TF) and males (TM) on estradiol or testosterone, compared to cisgender females (CF) and males (CM).DesignPilot, cross-sectional study conducted from 2016-2018.Setting. Academic regional transgender referral center.ParticipantsTransgender adolescents on either testosterone or estradiol for at least 3 months were recruited. Nineteen TM were matched to 19 CM and 42 CF on pubertal stage and body mass index (BMI). Eleven TF were matched to 23 CF and 13 TF to 24 CM on age and BMI.Main Outcome Measure(s)1/[fasting insulin] and body composition (dual-energy absorptiometry, DXA).ResultsTotal body fat was lower in TM than CF (29±7 vs. 33±7%, p=0.002) and higher than CM (28±7 vs. 24±9%, p=0.047). TM had higher lean mass than CF (68±7 vs. 64±7%, p=0.002) and lower than CM (69± vs. 73±8%, p=0.029). Insulin sensitivity was not different between the groups.TF had lower body fat than CF (31±7 vs. 35±8%, p=0.033) and higher than CM (28±6 vs. 20±10, p=0.001). TF had higher lean mass than CF (66±6 vs. 62±7%, p=0.032) and lower than CM (69±5 vs. 77±9%, p=0.001). TF were more insulin resistant than CM (0.078±0.025 vs. 0.142±0.064, p=0.011).ConclusionsTransgender adolescents on GAHT have significant differences in body composition compared to cisgender controls, with a body composition intermediate between BMI-matched cisgender males and females. These changes in body composition may have consequences for the cardiometabolic health of transgender adolescents.PrecisTransgender youth on gender affirming hormone therapy have differences in their percent fat and lean mass compared to cisgender (non-transgender) youth.

Background and Objectives: Among youth, 0.7% identify as transgender. Markers of cardiometabolic health and body composition in transgender youth undergoing gender-affirming hormone therapy have not been rigorously studied. Our objectives were to evaluate differences in body composition, insulin sensitivity, lipid profile, and aspartate and alanine aminotransferases (AST, ALT) in male-to-female (MTF) youth treated with estradiol (E2) compared to non-transgender female (FC) and male controls (MC). Methods: Fourteen MTF E2-treated (mean + SD E2 dose 1.5 + 1.0 mg/day, duration 1 + 0.8 years) participants (aged 14.5-19.4 years) were compared to BMI percentile-category-matched and age-matched (within 1 year) FC (n=23, aged 14.2-18.3) and MC (n=24, aged 14.5-19.8). Three MTF participants were also on a gonadotropin releasing-hormone analogue (GnRHa) for suppression of endogenous testicular function. Participants had fasted morning laboratory testing and body composition measured by dual-energy X-ray absorptiometry (DXA). Differences (mean + SD) in body composition, insulin sensitivity (estimated from 1/[fasting insulin]), lipids, leptin, AST, ALT and blood pressure (BP) were evaluated using a mixed linear regression model with a random effect for the matched set. A spearman correlation was performed to evaluate for a correlation between 1/[fasting insulin] and % lean mass. Results: MTF vs. FC: Total testosterone was higher in MTF vs. FC (224 + 182 vs. 43 + 10 ng/dL, respectively, p

Human papillomavirus (HPV) causes a number of cancers that disproportionally affect Latinos yet there is a paucity of research on interventions to increase HPV vaccination among this population. We sought to evaluate the efficacy of a web-based, individually customizable intervention, called CHICOs (Combatting HPV Infection and Cancers, tailored intervention) for its impact on HPV vaccine utilization. We conducted a three-armed, randomized, controlled trial in the waiting rooms of five family medicine practices from June 2014-February 2016 where CHICOS was compared to an iPad-based version of the Vaccine Information Sheet from the Centers for Disease Control and Prevention (untailored intervention), and usual care. Pair-wise comparisons between study arms of 6 different measures of HPV vaccine uptake were assessed, with analyses stratified by adolescents versus young adults. Of the 1,294 participants enrolled in the study, 1,013 individuals could be assessed for vaccination. Across study arms, 265 adolescents, but only 18 young adults, received an HPV vaccine dose during the study period. In both intention-to-treat and per-protocol analyses there were essentially no differences between the CHICOS and untailored arms in any vaccination measure, or between the untailored or CHICOS arms and usual care. Our study suggests that a tailored educational intervention may not be effective for increasing HPV vaccine uptake among Latino adolescents or young adults. However, the higher than expected baseline levels of positive vaccination attitudes of study participants could have diminished the statistical power of the study. Trial Registration Number: ClinicalTrials.gov (NCT02145156).

Importance Pediatric transplant recipients are at risk for vaccine-preventable infections owing to immunosuppression, suboptimal response to vaccines before and after transplant, and potential underimmunization if transplant occurred early in life. However, the incidence and burden of illness from vaccine-preventable infections in this population is unknown. Objectives To evaluate in pediatric solid organ transplant recipients the number of hospitalizations for vaccine-preventable infections in the first 5 years after transplant and to determine the associated morbidity, mortality, and costs. Design, Setting, and Participants A retrospective cohort study from January 1, 2004, to December 31, 2011, with 5 years of follow-up per participant (unless they died during the study period). The participants of this multicenter study through the Pediatric Health Information System were solid organ transplant recipients who were younger than 18 years at the time of transplant. Analysis began in July 2017. Exposures Transplant. Main Outcomes and Measures Hospitalizations for a vaccine-preventable infection during the first 5 years after transplant were ascertained usingInternational Classification of Diseases, Ninth Revision, andInternational Statistical Classification of Diseases and Related Health Problems, Tenth Revision, clinical modification diagnosis codes. Data were collected on clinical care, outcomes, and costs during these hospitalizations. Results Of 6980 transplant recipients identified, there were 3819 boys (54.7%), and the mean (SD) age at transplant was 8 (6.2) years. Overall, 1092 patients (15.6%) had a total of 1471 cases of vaccine-preventable infections. There were 187 of 1471 cases (12.7%) that occurred during transplant hospitalization. The case fatality rate was 1.7% for all infections. Excluding infections that occurred during transplant hospitalization (when all patients go to the intensive care unit), 213 of 1257 patients (17.0%) were hospitalized with a vaccine-preventable infection requiring intensive care. In multivariable analysis, age younger than 2 years at time of transplant and receipt of a lung, heart, intestine, or multivisceral organ were positively associated with increased risk of a hospitalization from a vaccine-preventable infection.Transplant hospitalizations complicated by vaccine-preventable infections were $120 498 more expensive (median cost) than transplant hospitalizations not complicated by vaccine-preventable infections. Conclusions and Relevance Hospitalization for vaccine-preventable infections occurred in more than 15% of solid organ transplant recipients in the first 5 years after transplant at a rate of up to 87 times higher than in the general population. There was significant morbidity, mortality, and costs from these infections, demonstrating the importance of immunizing all transplant candidates and recipients. Further research on improving immunization delivery, preventing nosocomial infections, and monitoring response to vaccines in the transplant population is needed.

CDKL5 Deficiency Disorder: Relationship Between Genotype, Epilepsy, Cortical Visual Impairment, and Development Demarest ST, Olson HE, Moss A, et al. Epilepsia. 2019;60(8):1733-1742. doi:10.1111/epi.16285. Epub 2019 Jul 16. PMID: 31313283Objective:The cyclin-dependent kinase-like 5 (CDKL5) gene is a known cause of early-onset developmental and epileptic encephalopathy, also known as CDKL5 deficiency disorder (CDD). We sought to (1) provide a description of seizure types in patients with CDD, (2) provide an assessment of the frequency of seizure-free periods and cortical visual impairment, (3) correlate these features with genotype and gender, and (4) correlate these features with developmental milestones.Methods:This is a cohort study of patients with CDD. Phenotypic features were explored and correlated with gene variant grouping and gender. A developmental score was created based on achieving 7 primary milestones. Phenotypic variables were correlated with the developmental score to explore markers of better developmental outcomes. Multivariate linear regression was used to account for age at last visit.Results:Ninety-two patients with CDD were seen during the enrollment period. Eighteen (19%) were male; median age at the last visit was 5 years (interquartile range: 2.0-11.0). Eighty-one percent of patients developed epileptic spasms, but only 47% of those also had hypsarrhythmia. Previously described hypermotor-tonic-spasms sequence was seen in only 24% of patients, but 56% of patients had seizures with multiple phases (often tonic and spasms). Forty-three percent of patients experienced a seizure-free period ranging from 1 to >12 months, but only 6% were still seizure-free at the last visit. Cortical visual impairment was present in 75% of all CDD patients. None of these features was associated with genotype group or gender. Cortical visual impairment was correlated with reduced milestone achievement after adjusting for age at the last visit and a history of hypsarrhythmia.Significance:The most common seizure types in CDD are epileptic spasms (often without hypsarrhythmia) and tonic seizures that may cluster together. Cortical visual impairment is a common feature in CDD and is correlated with achieving fewer milestones.

OBJECTIVE To develop parsimonious prediction models for postoperative mortality, overall morbidity, and 6 complication clusters applicable to a broad range of surgical operations in adult patients. SUMMARY BACKGROUND DATA Quantitative risk assessment tools are not routinely used for preoperative patient assessment, shared decision making, informed consent, and preoperative patient optimization, likely due in part to the burden of data collection and the complexity of incorporation into routine surgical practice. METHODS Multivariable forward selection stepwise logistic regression analyses were used to develop predictive models for 30-day mortality, overall morbidity, and 6 postoperative complication clusters, using 40 preoperative variables from 2,275,240 surgical cases in the American College of Surgeons National Surgical Quality Improvement Program data set, 2005 to 2012. For the mortality and overall morbidity outcomes, prediction models were compared with and without preoperative laboratory variables, and generic models (based on all of the data from 9 surgical specialties) were compared with specialty-specific models. In each model, the cumulative c-index was used to examine the contribution of each added predictor variable. C-indexes, Hosmer-Lemeshow analyses, and Brier scores were used to compare discrimination and calibration between models. RESULTS For the mortality and overall morbidity outcomes, the prediction models without the preoperative laboratory variables performed as well as the models with the laboratory variables, and the generic models performed as well as the specialty-specific models. The c-indexes were 0.938 for mortality, 0.810 for overall morbidity, and for the 6 complication clusters ranged from 0.757 for infectious to 0.897 for pulmonary complications. Across the 8 prediction models, the first 7 to 11 variables entered accounted for at least 99% of the c-index of the full model (using up to 28 nonlaboratory predictor variables). CONCLUSIONS Our results suggest that it will be possible to develop parsimonious models to predict 8 important postoperative outcomes for a broad surgical population, without the need for surgeon specialty-specific models or inclusion of laboratory variables.

Introduction Adult Medicaid enrollees are more likely to have mental health disorders (MHDs) than privately insured patients and also have high rates of emergency department (ED) visits for ambulatory care–sensitive conditions (ACSCs). We aimed to evaluate the association of MHD and insurance type with ED admissions for ACSC in the United States. Methods We conducted a cross-sectional study of ED visits made by adults aged 18 to 64years using the corrected 2011 National Emergency Department Survey. Using multivariable logistic regression analysis, we controlled for sociodemographics and clinical variables to determine the association between insurance type, MHD, Medicaid, and MHD (as an interaction variable) and ED admissions for ACSC. Results There were 131 million ED visits in 2011; after exclusions, 1.4 million admissions were included in our study. Of all ED visits, 44.7% had an MHD, of which 49.9% were covered by Medicaid and 38.1% were covered by private insurance. A total of 32.6% (95% confidence interval, 32.5%-32.7%) of ED admissions were for an ACSC. Medicaid-covered ED visits were more likely to result in ACSC hospital admission (odds ratio, 1.32; 95% confidence interval, 1.30-1.35) compared with visits covered by private insurance. Among patients with MHD, those with Medicaid insurance had 1.6 times the odds of ACSC admission compared with those privately insured. Conclusion Among all ED admissions, patients covered by Medicaid are more likely to be admitted for an ACSC when compared with those covered by private insurance, with a larger association being present among patients with MHD comorbidities.

Cystic fibrosis (CF) is a hereditary lung disease characterized by loss of lung function over time. Lung function in CF is believed to decline at a higher rate during the adolescence period. It has been also hypothesized that there is a subgroup of individuals for whom lung disease remains relatively stable with only a slight decline over their lifetime. Using data from the University of Colorado CF Children's Registry, we investigate four change point models to model the decline of lung function in children and adolescents: (i) a two-component mixture random change point model, (ii) a two-component mixture-fixed change point model, (iii) a random change point model, and (iv) a fixed change point model. The models are investigated through posterior predictive simulation at the individual and population levels, and a simulation study examining the effects of model misspecification. The data support the mixed random change point model as the preferred model, with roughly 30% of adolescents experiencing a steady decline of 0.5 %FEV1 per year and 70% experiencing an increase in decline of 4.4 %FEV1 per year beginning on average at 14.6 years of age. Copyright © 2016 John Wiley & Sons, Ltd.

Background Counseling to reduce access to lethal means such as firearms and medications is recommended for suicidal adults but does not routinely occur. We developed the Web-based Lock to Live (L2L) decision aid to help suicidal adults and their families choose options for safer home storage. Objective This study aimed to test the feasibility and acceptability of L2L among suicidal adults in emergency departments (EDs). Methods At 4 EDs, we enrolled participants (English-speaking, community-dwelling, suicidal adults) in a pilot randomized controlled trial. Participants were randomized in a 13:7 ratio to L2L or control (website with general suicide prevention information) groups and received a 1-week follow-up telephone call. Results Baseline characteristics were similar between the intervention (n=33) and control (n=16) groups. At baseline, many participants reported having access to firearms (33/49, 67%), medications (46/49, 94%), or both (29/49, 59%). Participants viewed L2L for a median of 6 min (IQR 4-10 min). L2L also had very high acceptability; almost all participants reported that they would recommend it to someone in the same situation, that the options felt realistic, and that L2L was respectful of values about firearms. In an exploratory analysis of this pilot trial, more participants in the L2L group reported reduced firearm access at follow-up, although the differences were not statistically significant. Conclusions The L2L decision aid appears feasible and acceptable for use among adults with suicide risk and may be a useful adjunct to lethal means counseling and other suicide prevention interventions. Future large-scale studies are needed to determine the effect on home access to lethal means. Trial Registration ClinicalTrials.gov NCT03478501; https://clinicaltrials.gov/ct2/show/NCT03478501

BACKGROUND All 50 United States implemented newborn screening (NBS) for cystic fibrosis (CF) by 2010. The purpose of this study was to evaluate trends over the decade when NBS became universal to determine current rates of malnutrition, stunting, and infection rates in U.S. infants with CF. METHODS Annual data were obtained on infants with CF up to 24 months of age diagnosed between 2001 and 2010 in the CF Foundation Patient Registry (CFFPR), in both the years of and after diagnosis, including method of diagnosis, demographics, and growth parameters and microbiology. RESULTS Data were obtained on 8178 infants diagnosed with CF. The percentage of infants diagnosed by NBS increased from 15% in 2001-83% in 2012 (P

Background Persons with Down syndrome (DS) require preventive care that addresses their age-/gender- and syndrome-specific needs. Yet, adolescents and adults with DS do not receive these preventive care services as recommended. Objective/hypothesis To identify factors that predict receipt of age-/gender- and syndrome-specific preventive healthcare among adolescents and adults with DS. We hypothesized that more healthcare encounters and greater medical complexity would increase receipt of preventive care due to more opportunities to complete these activities. Methods Using Medicaid claims (2006–2010) for California, Colorado, Michigan, and Pennsylvania, we conducted a retrospective cohort study of adolescents and adults with DS (≥12 years old). We modeled receipt of both ≥1 wellness examination and ≥1 thyroid function test (TFT) in 2009–2010 as a function of receipt of those same healthcare activities in 2006–08, adjusting for demographics, key comorbidities, and medical complexity using multivariable logistic regression. Results In this cohort of 3487 adolescents and adults with DS accessing Medicaid, 17% received both ≥1 wellness examination and ≥1 TFT in 2006–2008, 15% in 2009–2010, and only 7% during both time periods. Despite medical complexity and frequent healthcare interactions, the best predictor of future receipt of these activities was past receipt. State of residence variably impacted receipt of these preventive activities. Conclusions Although past receipt of wellness examination and TFT was the best predictor of future receipt of these activities, overall rates were quite low in this cohort of adolescents and adults with DS. Further work is needed to improve preventive healthcare delivery to this vulnerable population.

OBJECTIVE:Child physical abuse is commonly missed, putting abused children at risk for repeated injury and death. Several so-called sentinel injuries have been suggested to be associated with high rates of abuse, and to imply the need for routine testing for other, occult traumatic injuries. Our objective was to determine rates of abuse evaluation and diagnosis among children evaluated at leading children’s hospitals with these putative sentinel injuries.METHODS:This is a retrospective secondary analysis of the Pediatric Health Information System database. We identified 30 355 children with putative sentinel injuries. We measured rates of abuse diagnosis and rates of testing commonly used to identify occult injuries.RESULTS:Among all visits for children CONCLUSIONS:Several putative sentinel injuries are associated with high rates of physical abuse. Among eligible children with rib fracture(s), abdominal trauma, or intracranial hemorrhage, rates of abuse were more than 20%. Future work is warranted to test whether routine testing for abuse in these children can improve early recognition of abuse.

Introduction: Group visits for advance care planning (ACP) may help patients document preferences for decision makers and future care. We assessed the impact of a primary care-based ACP group visit (ACP-GV) intervention on older adults9 ACP documentation and why patients participated. Methods: Older adults (>65 years) in primary care participated in a 2-session ACP-GV intervention that promotes group dynamics, peer-based learning, and goal setting. Charts were reviewed at baseline, 3 months, and 12 months for documentation of decision makers and ACP forms. We described patients9 reasons for participating through analysis of transcripts. Results: 118 patients (mean age 76 years; 62% female and 82% white) participated in 16 ACP-GV cohorts. From baseline to 3-month follow-up, documentation of decision maker preferences increased from 39% to 81%, and was 89% at 12-month follow-up. Patients with completed ACP forms increased from 20% to 57% at 3 months, and was 67% at 12 months. Reasons for participating included recognizing the importance of ACP, curiosity, participation recommended by primary care provider, desire to talk with family/friends, and desire to complete advance directives. Conclusions: This ACP-GV intervention increased ACP documentation among patients with diverse reasons for participating. This is a patient-centered approach to ACP in primary care.

ObjectivesTrauma and, in particular, traumatic brain injury (TBI) cause enormous morbidity and mortality worldwide. Children who survive trauma have many health burdens, but how often those burdens lead to emergency care or hospital readmission is unknown. Readmissions occur frequently in adult TBI survivors: approximately 21-28% within one year. No single existing U.S. database contains the necessary variables to study readmissions of children hospitalized after trauma. We previously demonstrated that probabilistic linkage with Markov chain Monte Carlo parameter refinement could accurately link records of children with severe TBI without using protected health information. That work was presented at the IHDLN Conference in 2014. The objectives of this study are to 1) expand the previous linkage to include children with any type of trauma and 2) to determine the 1-year rates of Emergency Department (ED) visit and hospital readmission in children with TBI versus other trauma. ApproachUsing the algorithm we reported previously, we linked the records of children hospitalized after trauma during 2007-2012 in the U.S. National Trauma Data Bank (NTDB) with the Pediatric Health Information System (PHIS) database. The NTDB contains the Glasgow Coma Scale (GCS), necessary to categorize TBI. The PHIS database contains a unique identifier for each patient at each hospital, making longitudinal studies possible. Probabilistic linkage was performed using LinkSolv (Strategic Matching, Inc., Morrisonville, NY). We identified ED visits and hospital readmissions of the index cohort in the PHIS database through March 31, 2015. ResultsAmong children hospitalized after acute trauma for >= 2 days, we found that 83% of NTDB records linked accurately. Of the children hospitalized at 28 U.S. hospitals in 19 states, 49,477 were discharged alive; 15,438 had TBI. This represents approximately 10% of U.S. pediatric TBI hospitalizations during that period. The median age was 8 years and 64% were male. The 1-year hospital readmission rate was higher (12.2%, 283/2,306) in those with both TBI and other injuries than those with isolated TBI (8.5%, 1,120/13,132) or non-TBI injuries (8.1%, 2,790/34,039, p < 0.01 across groups). The 1-year ED visit rate differed only modestly between those three groups (14.1% versus 15.4% versus 14.2%, p < 0.01). ConclusionsThis study leverages two linked national datasets to investigate emergency care and hospital readmission in children who survive trauma. Multivariable analyses are ongoing and will be completed by August 2016. We will generate hypotheses about potentially modifiable causes of emergency care and readmission.

BACKGROUND AND OBJECTIVES: Croup is a clinical diagnosis, and the available evidence suggests that, except in rare cases, ancillary testing, such as radiologic imaging, is not helpful. Given the paucity of inpatient-specific evidence for croup care, we hypothesized that there would be marked variability in the use of not routinely indicated resources (NRIRs). Our primary study objective was to describe the variation and predictors of variation in the use of NRIRs. METHODS: This was a retrospective cohort study that used the Pediatric Health Information System database of generally healthy inpatients with croup aged 6 months to 15 years who were admitted between January 1, 2012 and September 30, 2014. We measured variability in the use of NRIRs: chest and lateral neck radiographs, viral testing, parenteral steroids, and antibiotics. Risk-adjusted analysis was used to compare resource utilization adjusted for hospital-specific effects and average case mix. RESULTS: The cohort included 26 hospitals and 6236 patients with a median age of 18 months. Nine percent of patients required intensive care services, and 3% had a 30-day readmission for croup. We found marked variability in adjusted and unadjusted utilization across hospitals for all resources. In the risk-adjusted analysis, hospital-specific effects rather than patient characteristics were the main predictor of variability in the use of NRIRs. CONCLUSIONS: We observed an up to fivefold difference in NRIR utilization attributable to hospital-level practice variability in inpatient croup care. This study highlights a need for inpatient-specific evidence and quality-improvement interventions to reduce unnecessary utilization and to improve patient outcomes.

Background We hypothesized that children with Dravet syndrome may have additional common features beyond seizures and cognitive impairment. To address this gap in knowledge, we conducted a survey of caregivers of children with Dravet syndrome to identify and quantify their perception of associated symptoms in this population. Methods An electronic survey was developed in REDcap (Research Electronic Data Capture) and sent via e-mail to the participants on the Dravet Syndrome Foundation e-mail list. Questions focused on eating, sleep, behavior, and other symptoms that might be related to Dravet syndrome. The questions were assessed using a four-point Likert scale (e.g., strongly agree to strongly disagree). Results were later dichotomized for analysis. Logistic regression was used to calculate odds ratios of various demographic factors potentially associated with symptoms. Multivariable models were constructed using backward elimination to assess the relationship among a variety of symptoms. Results There were 202 respondents, 96% were parents of a child with Dravet syndrome (the remainder were grandparents or guardians); 90.5% were female. The median age of the affected child was eight years (interquartile range five to 14), 50% were male, and 90.5% were reported to have a known SCN1A mutation. At least one symptom associated with appetite was reported in 99% of respondents, 82% reported a disturbance of sleep, one third reported autonomic symptoms, and 75% reported problems with gait. Inattention and perseveration were reported more commonly than other behavioral disturbances. Significance Caregivers have the perception of many symptoms in children with Dravet syndrome in addition to those that have been previously reported, including appetite, sleep, gait, and behavior. Many of these can significantly affect quality of life for both the child and the caregiver.

Background Hospital readmissions are increasingly viewed as a marker of inferior health care quality and penalized with decreased reimbursement. The timing of, and reasons for, readmissions after esophagectomy for cancer are not well understood. We examined the association of complications to 30-day postoperative-related, unplanned readmission to identify opportunities for improvement in patient care. Methods We analyzed the American College of Surgeons National Surgical Quality Improvement Program database (2012 to 2015) to characterize 30-day postoperative unplanned readmissions after esophagectomy for cancer using descriptive statistics. Type and timing of readmission after discharge was assessed. A Cox proportional hazards model was developed to identify predictors of readmission. Results Of 3,723 patients who underwent esophagectomy for cancer, 1,419 (38.1%) experienced ≥1 complication within 30 days. A total of 400 patients (10.7%) experienced related, unplanned readmissions within 30 days of the operation, and postoperative complications were documented in 263 (65.8%). Leading causes of readmission were infectious, pulmonary, and gastrointestinal complications. Of these patients, 155 (59%) were readmitted within 7 days and 236 (90%) within 14 days of discharge. The Cox proportional hazards model identified readmission being associated with occurrence of postdischarge infectious, pulmonary, venous thromboembolic, and urinary tract infection complications, in-hospital urinary tract infection complications, and log-transformation of length of stay (representing increasing length of stay) (all p Conclusions Postoperative occurrence of common complications and prolonged length of stay are associated with unplanned readmission after esophagectomy. Most patients are readmitted within 1 week of discharge. Earlier follow-up after discharge may identify patients with complications and facilitate outpatient intervention to prevent readmission.

Key Points Question How does the accuracy of lung ultrasound compare with chest radiography for diagnosing cardiogenic pulmonary edema in patients presenting to any clinical setting with dyspnea? Findings In this systematic review with meta-analysis of 6 prospective cohort studies representing 1827 patients, lung ultrasonography was found to be more sensitive than chest radiography for the detection of cardiogenic pulmonary edema and had comparable specificity. Meaning Lung ultrasonography appeared to be useful as an adjunct imaging study in patients presenting with dyspnea at risk for heart failure., Importance Standard tools used to diagnose pulmonary edema in acute decompensated heart failure (ADHF), including chest radiography (CXR), lack adequate sensitivity, which may delay appropriate diagnosis and treatment. Point-of-care lung ultrasonography (LUS) may be more accurate than CXR, but no meta-analysis of studies directly comparing the 2 tools was previously available. Objective To compare the accuracy of LUS with the accuracy of CXR in the diagnosis of cardiogenic pulmonary edema in adult patients presenting with dyspnea. Data Sources A comprehensive search of MEDLINE, Embase, and Cochrane Library databases and the gray literature was performed in May 2018. No language or year limits were applied. Study Selection Study inclusion criteria were a prospective adult cohort of patients presenting to any clinical setting with dyspnea who underwent both LUS and CXR on initial assessment with imaging results compared with a reference standard ADHF diagnosis by a clinical expert after either a medical record review or a combination of echocardiography findings and brain-type natriuretic peptide criteria. Two reviewers independently assessed the studies for inclusion criteria, and disagreements were resolved with discussion. Data Extraction and Synthesis Reporting adhered to the Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy and the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Two authors independently extracted data and assessed the risk of bias using a customized QUADAS-2 tool. The pooled sensitivity and specificity of LUS and CXR were determined using a hierarchical summary receiver operating characteristic approach. Main Outcomes and Measures The comparative accuracy of LUS and CXR in diagnosing ADHF as measured by the differences between the 2 modalities in pooled sensitivity and specificity. Results The literature search yielded 1377 nonduplicate titles that were screened, of which 43 articles (3.1%) underwent full-text review. Six studies met the inclusion criteria, representing a total of 1827 patients. Pooled estimates for LUS were 0.88 (95% Cl, 0.75-0.95) for sensitivity and 0.90 (95% Cl, 0.88-0.92) for specificity. Pooled estimates for CXR were 0.73 (95% CI, 0.70-0.76) for sensitivity and 0.90 (95% CI, 0.75-0.97) for specificity. The relative sensitivity ratio of LUS, compared with CXR, was 1.2 (95% CI, 1.08-1.34; P, This systematic review and meta-analysis compares the accuracy of lung ultrasonography vs chest radiography in the diagnosis of pulmonary edema in acute decompensated heart failure in adults.

Background Roofers are at increased risk for various malignancies and their occupational exposures to polycyclic aromatic hydrocarbons (PAHs) have been considered as important risk factors. The overall goal of this project was to investigate the usefulness of phosphorylated histone H2AX (γH2AX) as a short-term biomarker of DNA damage among roofers. Methods Blood, urine, and dermal wipe samples were collected from 20 roofers who work with hot asphalt before and after 6 h of work on Monday and Thursday of the same week (4 sampling periods). Particle-bound and gas-phase PAHs were collected using personal monitors during work hours. γH2AX was quantified in peripheral lymphocytes using flow cytometry and 8-hydroxy-2-deoxyguanosine (8-OHdG) was assessed in urine using ELISA. General linear mixed models were used to evaluate associations between DNA damage and possible predictors (such as sampling period, exposure levels, work- and life-style factors). Differences in mean biomarker and DNA damage levels were tested via ANOVA contrasts. Results Exposure measurements did not show an association with any of the urinary biomarkers or the measures of DNA damage. Naphthalene was the most abundant PAH in gas-phase, while benzo(e)pyrene was the most abundant particle-bound PAH. Post-shift levels of γH2AX and 8-OHdG were higher on both study days, when compared to pre-shift levels. Cigarette smoking was a predictor of γH2AX and urinary creatinine was a predictor of urinary 8-OHdG. Between-subject variance to total variance ratio was 35.3 % for γH2ax and 4.8 % for 8-OHdG. Conclusion γH2AX is a promising biomarker of DNA damage in occupational epidemiology studies. It has a lower within-subject variation than urinary 8-OHdG and can easily be detected in large scale groups. Future studies that explore the kinetics of H2AX phosphorylation in relation to chemical exposures may reveal the transient and persistent nature of this sensitive biomarker of early DNA damage. Electronic supplementary material The online version of this article (doi:10.1186/s12940-016-0182-4) contains supplementary material, which is available to authorized users.

SummaryObjective Infantile spasms (IS) represent a severe epileptic encephalopathy presenting in the first 2 years of life. Recommended first-line therapies (hormonal therapy or vigabatrin) often fail. We evaluated response to second treatment for IS in children in whom the initial therapy failed to produce both clinical remission and electrographic resolution of hypsarhythmia and whether time to treatment was related to outcome. Methods The National Infantile Spasms Consortium established a multicenter, prospective database enrolling infants with new diagnosis of IS. Children were considered nonresponders to first treatment if there was no clinical remission or persistence of hypsarhythmia. Treatment was evaluated as hormonal therapy (adrenocorticotropic hormone [ACTH] or oral corticosteroids), vigabatrin, or “other.” Standard treatments (hormonal and vigabatrin) were compared to all other nonstandard treatments. We compared response rates using chi-square tests and multivariable logistic regression models. Results One hundred eighteen infants were included from 19 centers. Overall response rate to a second treatment was 37% (n = 44). Children who received standard medications with differing mechanisms for first and second treatment had higher response rates than other sequences (27/49 [55%] vs. 17/69 [25%], p < 0.001). Children receiving first treatment within 4 weeks of IS onset had a higher response rate to second treatment than those initially treated later (36/82 [44%] vs. 8/34 [24%], p = 0.040). Significance Greater than one third of children with IS will respond to a second medication. Choosing a standard medication (ACTH, oral corticosteroids, or vigabatrin) that has a different mechanism of action appears to be more effective. Rapid initial treatment increases the likelihood of response to the second treatment.

To use factor analysis to cluster the 18 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) perioperative complications into a reproducible, smaller number of clinically meaningful groups of postoperative complications, facilitating and streamlining future study and application in live clinical settings.The ACS NSQIP collects and reports on eighteen 30-day postoperative complications (excluding mortality), which are variably grouped in published analyses using ACS NSQIP data. This hinders comparison between studies of this widely used quality improvement dataset.Factor analysis was used to develop a series of complication clusters, which were then analyzed to identify a parsimonious, clinically meaningful grouping, using 2,275,240 surgical cases in the ACS NSQIP Participant Use File (PUF), 2005 to 2012. The main outcome measures are reproducible, data-driven, clinically meaningful clusters of complications derived from factor solutions.Factor analysis solutions for 5 to 9 latent factors were examined for their percent of total variance, parsimony, and clinical interpretability. Applying the first 2 of these criteria, we identified the 7-factor solution, which included clusters of pulmonary, infectious, wound disruption, cardiac/transfusion, venous thromboembolic, renal, and neurological complications, as the best solution for parsimony and clinical meaningfulness. Applying the last (clinical interpretability), we combined the wound disruption with the infectious clusters resulting in 6 clusters for future clinical applications.Factor analysis of ACS NSQIP postoperative complication data provides 6 clinically meaningful complication clusters in lieu of 18 postoperative morbidities, which will facilitate comparisons and clinical implementation of studies of postoperative morbidities.