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To evaluate the association of race and ethnicity with wait times for children in US emergency departments (ED).We performed a cross-sectional study of ED encounters of children (18 years) from 2014 to 2019 using a multistage survey of nonfederal US ED encounters. Our primary variable of interest was composite race and ethnicity: non-Hispanic White (NHW), non-Hispanic Black, Hispanic, and all others. Our outcome was ED wait time in minutes. We evaluated the association between race and ethnicity and wait time in Weibull regression models that sequentially added variables of acuity, demographics, hospital factors, and region/urbanicity.We included 163,768,956 survey-weighted encounters. In univariable analysis, Hispanic children had a lower hazard ratio (HR) of progressing to evaluation (HR 0.84, 95% confidence interval [CI] 0.76-0.93) relative to NHW children, indicating longer ED wait times. This association persisted in serial multivariable models incorporating acuity, demographics, and hospital factors. This association was not observed when incorporating variables of hospital region and urbanicity (HR 0.91, 95% CI 0.83-1.00). In subgroup analysis, Hispanic ethnicity was associated with longer wait times in pediatric EDs (HR 0.76, 95% CI 0.63-0.92), non-metropolitan EDs (HR 0.75, 95% CI 0.64-0.89), and the Midwest region (HR 0.77, 95% CI 0.69-0.87). No differences in wait times were observed for children of Black race or other races.Hispanic children experienced longer ED wait times across serial multivariable models, with significant differences limited to pediatric, metropolitan, and Midwest EDs. These results highlight the presence of disparities in access to prompt emergency care for children.

Although effective for curtailing alloimmune responses, calcineurin inhibitors (CNIs) have an adverse-effect profile that includes nephrotoxicity. In lung transplant (LTx) recipients, the optimal serum levels of the CNI tacrolimus necessary to control alloimmune responses and minimize nephrotoxicity are unknown.This retrospective, single-center study reviewed tacrolimus whole blood trough levels (BTLs), grades of acute cellular rejection (ACR), acute rejection scores, and creatinine clearance (CrCl) obtained in LTx recipients within the first year after their transplant procedure. Comparisons were made between the first 90 days post LTx (when tacrolimus BTLs were maintained10 µg/L) and the remainder of the post-LTX year (when BTLs were10 µg/L).Despite tacrolimus mean BTLs being higher during the first 90 days post LTx compared with the remainder of the first post-LTx year (10.4 ± 0.3 µg/L vs 9.5 ± 0.3 µg/L, P.0001) there was no association with lower grades of ACR (P = .24). The intensity of ACR (as determined by acute rejection scores) did not correlate with tacrolimus mean BTLs at any time during the first posttransplant year (P = .79). During the first 90 days post LTx there was a significant decline in CrCl and a correlation between increasing tacrolimus mean BTLs and declining CrCl (r = -0.26, P = .03); a correlation that was not observed during the remainder of the year (r = -0.09, P = .52).In LTx recipients, maintaining BTLs of the CNI tacrolimus10µg/L did not result in superior control of acute rejection responses but was associated with declining renal function.

Background Although community-acquired pneumonia (CAP) is one of the most common infections in children, no tools exist to risk stratify children with suspected CAP. We developed and validated a prediction model to risk stratify and inform hospitalization decisions in children with suspected CAP. Methods We performed a prospective cohort study of children aged 3 months to 18 years with suspected CAP in a pediatric emergency department. Primary outcome was disease severity, defined as mild (discharge home or hospitalization for 24 hours), or severe (intensive care unit stay for >24 hours, septic shock, vasoactive agents, positive-pressure ventilation, chest drainage, extracorporeal membrane oxygenation, or death). Ordinal logistic regression and bootstrapped backwards selection were used to derive and internally validate our model. Results Of 1128 children, 371 (32.9%) developed moderate disease and 48 (4.3%) severe disease. Severity models demonstrated excellent discrimination (optimism-corrected c-indices of 0.81) and outstanding calibration. Severity predictors in the final model included respiratory rate, systolic blood pressure, oxygenation, retractions, capillary refill, atelectasis or pneumonia on chest radiograph, and pleural effusion. Conclusions We derived and internally validated a score that accurately predicts disease severity in children with suspected CAP. Once externally validated, this score has potential to facilitate management decisions by providing individualized risk estimates that can be used in conjunction with clinical judgment to improve the care of children with suspected CAP.

BACKGROUND Chest radiographs (CXRs) are frequently used in the diagnosis of community-acquired pneumonia (CAP). We sought to construct a predictive model for radiographic CAP based on clinical features to decrease CXR use. METHODS We performed a single-center prospective study of patients 3 months to 18 years of age with signs of lower respiratory infection who received a CXR for suspicion of CAP. We used penalized multivariable logistic regression to develop a full model and bootstrapped backward selection models to develop a parsimonious reduced model. We evaluated model performance at different thresholds of predicted risk. RESULTS Radiographic CAP was identified in 253 (22.2%) of 1142 patients. In multivariable analysis, increasing age, prolonged fever duration, tachypnea, and focal decreased breath sounds were positively associated with CAP. Rhinorrhea and wheezing were negatively associated with CAP. The bootstrapped reduced model retained 3 variables: age, fever duration, and decreased breath sounds. The area under the receiver operating characteristic for the reduced model was 0.80 (95% confidence interval: 0.77–0.84). Of 229 children with a predicted risk of 39%, 140 (61.1%) had CAP (specificity of 90% at a 39% risk threshold). CONCLUSIONS A predictive model including age, fever duration, and decreased breath sounds has excellent discrimination for radiographic CAP. After external validation, this model may facilitate decisions around CXR or antibiotic use in CAP.

The aim of this study was to determine the demographic and associated characteristics of abusive burn injuries in children. Understanding the characteristics of burn injuries may help clinicians differentiate and recognize abusive injuries. We conducted a retrospective study of patients less than 5 years old admitted to an urban burn center from March 1999 to July 2013. Per protocol, all patients with burn injuries were evaluated by a multidisciplinary team (child abuse pediatrician, social worker, and nurse clinician). Demographic information, social risk factors, clinical presentation, caregiver at time of injury, radiographic studies and results, multidisciplinary team determination, and the Department of Children and Family Services investigation outcome were abstracted from the American Burn Association Burn Registry and patient's chart. Patient characteristics were evaluated with abuse status through Wilcoxon rank sum tests for continuous variables and chi-square tests or Fisher's exact test for categorical variables. A multiple logistic regression was fit to identify factors associated with abusive burns. One hundred and ten patients under 5 years were categorized as abuse (38) or accident (72). Demographic characteristics were similar between the abuse and accident groups. A determination of abuse was significantly associated with caregiver type (paramour), site of incident (outside of kitchen), time to seeking help (>4 hours), and the presence of nonburn skin injuries. A detailed history of the burn mechanism as well as psychosocial family risk factors are critical when evaluating pediatric patients with burn injuries, as it may assist the physician in distinguishing abusive from accidental burn injuries.

Objective: Prescription opioid misuse represents a social and economic dilemma in the United States. The authors evaluated primary care providers’ (PCPs) prescribing of Schedule II opioids at our institution in Kentucky. Design: Prospective evaluation of PCPs’ prescribing practices over a 3-year period (October 1, 2014 to September 30, 2017) in an outpatient setting. Methods: An analysis of Schedule II opioid prescribing following the implementation of federal and state guidelines and evidence-based standards. Special attention focused on Schedule II opioid prescriptions with a quantity > 90, Opana/ Oxycontin, and morphine equivalent daily dosage. Results: A statistically significant increase in the total number of PCPs and PCPs who prescribed Schedule II opioids was observed, while there was a concurrent significant decrease in the average number of Schedule II opioid pills prescribed per PCP, Schedule II opioid prescriptions per PCP, Schedule II opioid pills prescribed per patient by PCPs, Schedule II opioid prescriptions with a quantity > 90 per PCP, and Opana/Oxycontin prescriptions per PCP. A statistically significant decline in the average morphine equivalent daily dosage of Schedule II opioids per PCP was noted. Conclusions: This study reports the benefit of incorporating federal and state regulations and institutional evidence-based guidelines into primary care practice to decrease the number of Schedule II opioids prescribed. Further preventive measures include selecting alternative treatments to opioids and reducing the rates of opioid nonmedical use and overdose while maintaining access to prescription opioids when indicated.

Key Points Question Can bruising characteristics distinguish abusive from nonabusive injury in young children? Findings In this cross-sectional study of 2161 children younger than 4.0 years, the bruising clinical decision rule (BCDR) was 96% sensitive and 87% specific for distinguishing abusive from nonabusive trauma in young children based on the characteristics of their bruising. Meaning According to these findings, young children with an affirmative finding for any of the 3 components of the BCDR are at increased risk of abuse and warrant further evaluation., Importance Bruising caused by physical abuse is the most common antecedent injury to be overlooked or misdiagnosed as nonabusive before an abuse-related fatality or near-fatality in a young child. Bruising occurs from both nonabuse and abuse, but differences identified by a clinical decision rule may allow improved and earlier recognition of the abused child. Objective To refine and validate a previously derived bruising clinical decision rule (BCDR), the TEN-4 (bruising to torso, ear, or neck or any bruising on an infant, This cross-sectional study assesses a previously derived bruising clinical decision rule for identifying children at risk of having been physically abused.

Background: Sepsis is a leading cause of morbidity and mortality among children, with early recognition and treatment impacting long-term health outcomes. While studies show screening interventions embedded in electronic health records can improve outcomes, evaluating such interventions is challenged by the lack of a universal reference standard of pediatric sepsis. Objective: Evaluate the test characteristics of an electronic sepsis screening algorithm (Figure 1) implemented in a pediatric emergency department (PED) using two reference standards for defining pediatric sepsis Design/Methods: Evaluation of a high-risk pediatric cohort treated in a PED, March-November …

Purpose: Suicide is the second leading cause of death among youth age 10-to-19 years in the U.S., with youth living in rural areas nearly twice as likely to die by suicide. Although emergency department (ED) visits for suicidal ideation and self-harm represent a critical opportunity for initiation of preventive interventions, urban-rural differences in these visits have not been well characterized. Our objective was to study urban-rural differences in ED visit rates for youth suicidal ideation and self-harm. Methods: We conducted a retrospective, cross-sectional analysis of ED visits for suicidal ideation and self-harm by youth age 5-to-19 years in …

Objectives: Sexual trauma poses a significant concern and is associated with heightened stress, negative health repercussions, and adverse economic effects. A history of abuse may increase a woman’s risk of developing cancer, in particular cervical cancer. We analyzed the impact of screening for sexual abuse in a gynecologic oncology population. Methods: Patients were screened for sexual trauma in a gynecologic oncology clinic over 5 and a half years (April 1, 2011, to September 30, 2016) in this cohort study. The screening questions were selected by behavioral oncology physicians and integrated into the gynecologic history component of the new patient assessment. Patients who screened positive for a history of sexual abuse or intimate partner violence were offered a behavioral oncology referral. Providers were also questioned about the effect of screening on their practice. Results: Of the 1,423 consecutive patients screened for sexual trauma, a total of 164 patients (12%) disclosed a history of sexual abuse. Of the 133 patients who specified their age at the sexual trauma, the majority (107 [80%]) responded that they were a young child or early teen. Most patients (92%) declined counseling. Among individuals presenting with cancer, the distribution of cancer type was statistically different between those patients with and without a sexual trauma history (p = 0.0001). Conclusion: Screening for sexual trauma in a gynecologic oncologic population serves as a valuable opportunity to uncover a history of abuse that may increase a woman’s susceptibility to cancer. This study demonstrates that screening for sexual abuse in a gynecologic oncology setting may be integrated into new patient interviews with minimal disruption. Identification of an undisclosed sexual trauma history allows for an opportunity to offer counseling and minimize the emotional distress that may be precipitated by treatment and exams.

Parents' perceptions of child behavior influence their responses to the child and may be important predictors of physical abuse. We examined whether infants 12 months of age or younger who were described with negative or developmentally unrealistic words were more likely than other infants to have been physically abused. As part of a prospective observational multicenter study investigating bruising and familial psychosocial characteristics, parents were asked to (1) describe their child's personality, and (2) list three words to describe their child. Four independent raters coded parent responses using a qualitative content analysis, identifying descriptors of infants and classifying each as positive, neutral, or negative/unrealistic. A medical expert panel, blinded to the psychosocial data, separately categorized each case as abuse or accident. We then analyzed the potential association between negative/unrealistic descriptors and abusive injury. Of 185 children enrolled, 147 cases (79%) were categorized as accident and 38 (21%) as abuse. Parents used at least one negative/unrealistic descriptor in 35/185 cases (19%), while the remaining 150 cases (81%) included only positive or neutral descriptors. Of the infants described with negative/unrealistic words, 60% were abused, compared to 11% of those described with positive or neutral words (p .0001; age group-adjusted OR = 9.95; 95% confidence interval [3.98, 24.90]). Though limited by sample-size, this pilot study informs future work to create a screening tool utilizing negative/unrealistic descriptors in combination with other predictive factors to identify infants at high risk for physical child abuse.

Objective To determine the impact of long-term, body weight–supported locomotor training after chronic, incomplete spinal cord injury (SCI), and to estimate the health care costs related to lost recovery potential and preventable secondary complications that may have occurred because of visit limits imposed by insurers. Design Prospective observational cohort with longitudinal follow-up. Setting Eight outpatient rehabilitation centers that participate in the Christopher & Dana Reeve Foundation NeuroRecovery Network (NRN). Participants Individuals with motor incomplete chronic SCI (American Spinal Injury Association Impairment Scale C or D; N=69; 0.1–45y after SCI) who completed at least 120 NRN physical therapy sessions. Interventions Manually assisted locomotor training (LT) in a body weight–supported treadmill environment, overground standing and stepping activities, and community integration tasks. Main Outcome Measures International Standards for Neurological Classification of Spinal Cord Injury motor and sensory scores, orthostatic hypotension, bowel/bladder/sexual function, Spinal Cord Injury Functional Ambulation Inventory (SCI-FAI), Berg Balance Scale, Modified Functional Reach, 10-m walk test, and 6-minute walk test. Longitudinal outcome measure collection occurred every 20 treatments and at 6- to 12-month follow-up after discharge from therapy. Results Significant improvement occurred for upper and lower motor strength, functional activities, psychological arousal, sensation of bowel movement, and SCI-FAI community ambulation. Extended training enabled minimal detectable changes at 60, 80, 100, and 120 sessions. After detectable change occurred, it was sustained through 120 sessions and continued 6 to 12 months after treatment. Conclusions Delivering at least 120 sessions of LT improves recovery from incomplete chronic SCI. Because walking reduces rehospitalization, LT delivered beyond the average 20-session insurance limit can reduce rehospitalizations and long-term health costs.

Failure to recognize child maltreatment results in chronic exposure to high-risk environments where re-injury or death may occur. We analyzed a series (n=20) of fatal (n=10) and near-fatal (n=10) physical child abuse cases from the Commonwealth of Kentucky to identify commonalities and determine whether indicators of maltreatment were present prior to the child's fatal or near-fatal event. We conducted retrospective state record reviews involving children

Background Wool clothing may be perceived as a poor choice for use by individuals with sensitive skin or atopic dermatitis. Objectives The aims of the study were to evaluate the effect on atopic dermatitis of wearing fine Merino wool clothing versus standard clothing and to assess the effect of Merino wool clothing on quality of life in children and adults with atopic dermatitis 5 years and older. Methods Subjects with mild to moderate atopic dermatitis were assessed in a crossover fashion after wearing Merino wool clothing for 6 weeks and standard clothing for 6 weeks, for Eczema Area and Severity Index, Dermatology Life Quality Index, static Investigator's Global Assessment, and skin hydration. Results While wearing Merino wool clothing, compared with standard clothing, statistically significant improvements were seen in mean Eczema Area and Severity Index scores, Dermatology Life Quality Index scores, and static Investigator's Global Assessment scores. No significant difference was seen with skin hydration. Wearing Merino wool clothing did not produce any negative cutaneous effects compared with wearing standard clothing. Conclusions Merino wool clothing compared with standard clothing provided improvements in severity of atopic dermatitis as well as quality of life in atopic patients.

Objective To compare caregiver features and caregiving arrangements of children with physical abuse vs accidental injuries. Study design Data came from a prospective, observational, multicenter study investigating bruising and psychosocial characteristics of children younger than 4 years of age. Using logistic regression, we examined how abuse vs accidental injury and severity of injury were associated with caregiver sex, relation to the child, whether caregiving arrangements were different than usual at the time of injury, and length of the main caregiver's relationship with his/her partner. Results Of 1615 patients, 24% were determined to have been physically abused. Abuse was more likely when a male caregiver was present (OR 3.31, 95% CI 2.38-4.62). When the male was the boyfriend of the mother (or another female caregiver), the odds of abuse were very high (OR 169.2, 95% CI 61.3-614.0). Severe or fatal injuries also were more likely when a male caregiver was present. In contrast, abuse was substantially less likely when a female caregiver was present (OR 0.25, 95% CI 0.17-0.37) with the exception of a female babysitter (OR 3.87, 95% CI 2.15-7.01). Caregiving arrangements that were different than usual and caregiver relationships Conclusions We identified caregiver features associated with physical abuse. In clinical practice, questions regarding caregiver features may improve recognition of the abused child. This information may also inform future abuse prevention strategies.

Objective: The objective of this study is to assess the perioperative outcomes when prophylactic bilateral salpingo-oophorectomy (BSO) is performed concomitantly with surgery to repair pelvic organ prolapse (POP) or stress urinary incontinence (SUI). Materials and Methods: This is a retrospective case–control study of patients who underwent abdominal surgery for the correction of POP and/or SUI with or without concomitant BSO at a tertiary care center. The primary outcome measures were postsurgery length of hospitalization, estimated blood loss, and 30-day readmission rate. The secondary outcome measure was detection of ovarian cancer precursor lesions. Results: We identified 734 patients who had surgery for POP and/or SUI. The control group contained 385 patients, and the BSO group contained 349 patients. There was no difference between the control and BSO groups in the postsurgery length of stay (LOS) (35.2 h vs. 34.1 h; P = 0.49), and all-cause 30-day readmission rate (14.2% vs. 11.6%; P = 0.3085). However, there was decreased blood loss (40.8 ml vs. 67.2 ml, P < 0.0001) in the BSO group compared to the control group. Sub-analysis of primary outcomes in postmenopausal women (age > 55) showed decreased postsurgery LOS (33.4 h vs. 37.4 h; P = 0.0208) and decreased blood loss (35.9 ml vs. 82.7 ml; P < 0.0001) in the BSO group compared to control. Conclusion: Secondary to the lack of additional complications, we recommend surgeons give more consideration to finding appropriate candidates for a risk reducing BSO at time of abdominal surgery to repair POP or SUI.

The Neuromuscular Recovery Scale (NRS) is a tool for measuring functional recovery in spinal cord injured (SCI) persons based on tasks that test pre-injury functional capability. The NRS has been shown to be a valid, reliable, and responsive instrument for measuring functional recovery. The NRS has been updated to include three items measuring upper extremity function, and a new scoring mechanism has been defined. The purpose of this prospective, observational study was to explore the properties of the expanded NRS, introduce and evaluate the new scoring method, and to examine the score's relationship with other SCI outcome measures. The NRS and seven other SCI outcome measures were assessed at enrollment and after every 20 locomotor training sessions in 64 participants of the NeuroRecovery Network (NRN) of the Christopher and Dana Reeve Foundation (CDRF). The NRS exhibited a dominant first principal component that correlated strongly with the new NRS score, as well as a potential secondary component discriminating upper extremity function. The new NRS score and its empirical subscales were generally well-correlated with International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI) motor scores and other established SCI functional measures, but exhibited substantial variability at their boundary values. The NRS score was more strongly correlated with other SCI functional measures than ISNCSCI motor scores were. The new NRS score was most responsive to change brought on by locomotor training. The expanded NRS appears to be a valuable tool in measuring functional recovery from SCI; further evaluation of its psychometric properties is warranted.

In the marginal analysis of clustered data, where the marginal distribution of interest is that of a typical observation within a typical cluster, analysis by reweighting has been introduced as a useful tool for estimating parameters of these marginal distributions. Such reweighting methods have foundation in within-cluster resampling schemes that marginalize potential informativeness due to cluster size or within-cluster covariate distribution, to which reweighting methods are asymptotically equivalent. In this paper, we introduce a reweighting scheme for the marginal analysis of clustered data that generalizes prior reweighting methods, with a particular application to measuring bivariate correlation in unpaired clustered data, in which observations of two random variables are not naturally paired at the within-cluster level. We develop unpaired clustered data analogs of well-known product moment correlation coefficients (Pearson, Spearman, phi), as well as the polyserial coefficient for measuring correlation between one discrete and one continuous variable. We evaluate the performance of these coefficients via a simulation study and demonstrate their use by finding no statistically significant association between dental caries at an early age and dental fluorosis at age 13 using a large dental dataset.

This article presents the psychosocial risk factors identified in the cases of 20 children less than four years of age who were victims of fatal or near-fatal physical abuse during a 12 month period in the Commonwealth of Kentucky. These data are related to the article "History, injury, and psychosocial risk factor commonalities among cases of fatal and near-fatal physical child abuse" (Pierce et al., 2017) [1].

Knowledge of fracture characteristics among children with medical conditions affecting bone could help to distinguish medical causes from child abuse.Characterize long bone fracture morphology among children diagnosed with medical conditions linked to bone health.Patients18 years at a single pediatric hospital diagnosed with a medical condition linked to bone health and ≥1 long bone fracture were studied.This retrospective medical record review categorized underlying medical diagnoses as: metabolic bone disease, genetic disorder of connective tissue, neurologic disorder and other chronic disease. A pediatric radiologist reviewed plain films to determine fracture type and location. Descriptive statistics, as well as logistic regression were used to compare fracture types by clinical characteristics.Ninety-four patients were included and their diagnoses were genetic connective disorder (19; 20.2 %), metabolic bone disease (16; 17.0 %), neurologic disorder (27; 28.7 %), and other (32; 34.0 %). A total of 216 long bone fractures were sustained; 52.1 % of children had1 long bone fracture. Of the 216 fractures, 55 (25.5 %) were in children1 year, 118 (54.6 %) were associated with known trauma, and 122 (56.5 %) were in non-ambulatory patients. Lower extremity fractures occurred with greatest frequency and most fractures occurred at the mid-diaphysis. Transverse was the most common fracture type in all diagnostic categories. Children with metabolic disorders had highest odds of transverse fracture (COR 3.55, CI 1.45-8.67; neurologic disorders as reference group).Diseases affecting bone health can influence fracture morphology. Transverse fractures were most common in bones impacted by disease.

Objective The importance of subcortical pathways to functional motor recovery after spinal cord injury (SCI) has been demonstrated in multiple animal models. The current study evaluated descending interlimb influence on lumbosacral motor excitability after chronic SCI in humans. Methods Ulnar nerve stimulation and transcutaneous electrical spinal stimulation were used in a condition-test paradigm to evaluate the presence of interlimb connections linking the cervical and lumbosacral spinal segments in non-injured (n=15) and spinal cord injured (SCI) (n=18) participants. Results Potentiation of spinally evoked motor responses (sEMRs) by ulnar nerve conditioning was observed in 7/7 SCI participants with volitional leg muscle activation, and in 6/11 SCI participants with no volitional activation. Of these six, conditioning of sEMRs was present only when the neurological level of injury was rostral to the ulnar innervation entry zones. Conclusions Descending modulation of lumbosacral motor pools via interlimb projections may exist in SCI participants despite the absence of volitional leg muscle activation. Significance Evaluation of sub-clinical, spared pathways within the spinal cord after SCI may provide an improved understanding of both the contributions of different pathways to residual function, and the mechanisms of plasticity and functional motor recovery following rehabilitation..

When lesions in the spinal cord occur, the neural activation of respiratory muscles is compromised (De Troyer and Heilporn, 1980; De Troyer et al., 1986, 1990; Estenne et al., 2000a) resulting in significant respiratory dysfunction (De Troyer and Heilporn, 1980; Linn et al., 2000, 2001; Yokoba et al., 2003). However the underlying mechanisms that contribute to this dysfunction remain unclear. The aims of this study were: (1) to investigate whether a correlation exists between pulmonary function and the International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI) examination scores for sensory and motor function; (2) to evaluate whether compensatory muscle activation plays a role in pulmonary function after spinal cord injury (SCI). We recorded Forced Vital Capacity (FVC); Forced Expiratory Volume in 1s (FEV1); and electromyography (EMG) of respiratory muscles during maximum respiratory tasks in 36 with SCI and 15 neurologically intact participants. Results indicate that pulmonary function (FVC, FEV1) was strongly correlated with motor and sensory scores from the ISNCSCI exam and maximal expiratory pressure (MEP) was also significantly related to ISNCSCI sensory scores (ρ=0.73, p

Background. The Neuromuscular Recovery Scale (NRS) was developed by researchers and clinicians to functionally classify people with spinal cord injury (SCI) by measuring functionally relevant motor tasks without compensation. Previous studies established strong interrater and test-retest reliability and validity of the scale. Objective. To determine responsiveness of the NRS, a version including newly added upper-extremity items, in an outpatient rehabilitation setting. Methods. Assessments using the NRS and 6 other instruments were conducted at enrollment and discharge from a locomotor training program for 72 outpatients with SCI classified as American Spinal Injury Association Impairment Scale grades A to D (International Standards for Neurological Classification of Spinal Cord Injury). Mixed-model t statistics for instruments were calculated and adjusted for confounding factors (eg, sample size, demographic variables) for all patients and subgroups stratified by injury level and/or severity. The resulting adjusted response means (ARMs) and 95% confidence intervals (CIs) were used to determine responsiveness, and significant differences between instruments were identified with pairwise comparisons. Results. The NRS was significantly responsive for SCI outpatients (ARM = 1.05; CI = 0.75-1.35). Changes in motor function were detected across heterogeneous groups. Regardless of injury level or severity, the responsiveness of the NRS was equal to, and often significantly exceeded, the responsiveness of other instruments. Conclusions. The NRS is a responsive measure that detects change in motor function during outpatient neurorehabilitation for SCI. There is potential utility for its application in randomized controlled trials and as a measure of clinical recovery across diverse SCI populations.

BACKGROUND Repeated and prolonged use of surfactants can cause irritant as well as allergic contact dermatitis. OBJECTIVE This study reports the frequency of positive patch test results to surfactants tested on the North American Contact Dermatitis Group screening series including cocamidopropyl betaine (CAPB), amidoamine (AA), dimethylaminopropylamine (DMAPA), oleamidopropyl dimethylamine (OPD), and cocamide diethanolamide (CDEA), and correlations of positive reactions between CAPB and the other surfactants. METHODS This was a retrospective analysis of 10 877 patients patch tested between 2009 and 2014 to the surfactants CAPB, AA, DMAPA, OPD, and CDEA. Frequencies of positive reactions to these surfactants were calculated, and trends of reactivity between the surfactants analyzed. CONCLUSIONS The OPD had the highest rate of positive patch reactions (2.3%) followed by DMAPA (1.7%), and CAPB (1.4%). The AA and CDEA had the lowest rate of positive reactions (0.8%). There was a high degree of overlap in positive patch tests between the surfactants. The CDEA was the least likely to coreact with another surfactant.

Children's participation in physical activity is a leading health indicator to combat obesity and sedentary lifestyles. The challenge to battle this problem is placed in the hands of early childhood educators. However, there is little evidence that early childhood educators have the skills and knowledge to design and implement appropriate movement practices for young children. The purpose of this study was to assess the effectiveness of a movement programme implemented by classroom teachers. Participants were 33 preschoolers. The BOT-2 test was used to assess children's motor skills. Results showed that improvement in motor proficiency was observed in both the control (p = .02) and experimental (p = .001) groups. However, the improvement observed in the experimental group was significantly greater than the control group (p = .04). Acceptability of the intervention questionnaire responded to by teachers showed that the intervention was easy to implement and beneficial to the children.

OBJECTIVES:: Abusive head trauma is a leading cause of traumatic death and disability during infancy and early childhood. Evidence-based screening tools for abusive head trauma do not exist. Our research objectives were 1) to measure the predictive relationships between abusive head trauma and isolated, discriminating, and reliable clinical variables and 2) to derive a reliable, sensitive, abusive head trauma clinical prediction rule that-if validated-can inform pediatric intensivists' early decisions to launch (or forego) an evaluation for abuse. DESIGN:: Prospective, multicenter, cross-sectional, observational. SETTING:: Fourteen PICUs. PATIENTS:: Acutely head-injured children less than 3 years old admitted for intensive care. INTERVENTIONS:: None. MEASUREMENTS AND MAIN RESULTS:: Applying a priori definitional criteria for abusive head trauma, we identified clinical variables that were discriminating and reliable, calculated likelihood ratios and post-test probabilities of abuse, and applied recursive partitioning to derive an abusive head trauma clinical prediction rule with maximum sensitivity-to help rule out abusive head trauma, if negative. Pretest probability (prevalence) of abusive head trauma in our study population was 0.45 (95 of 209). Post-test probabilities of abusive head trauma for isolated, discriminating, and reliable clinical variables ranged from 0.1 to 0.86. Some of these variables, when positive, shifted probability of abuse upward greatly but changed it little when negative. Other variables, when negative, largely excluded abusive head trauma but increased probability of abuse only slightly when positive. Some discriminating variables demonstrated poor inter-rater reliability. A cluster of five discriminating and reliable variables available at or near the time of hospital admission identified 97% of study patients meeting a priori definitional criteria for abusive head trauma. Negative predictive value was 91%. CONCLUSIONS:: A more complete understanding of the specific predictive qualities of isolated, discriminating, and reliable variables could improve screening accuracy. If validated, a reliable, sensitive, abusive head trauma clinical prediction rule could be used by pediatric intensivists to calculate an evidence-based, patient-specific estimate of abuse probability that can inform-not dictate-their early decisions to launch (or forego) an evaluation for abuse. Language: en

Patients with hepatocellular carcinoma (HCC) have been advantaged on the liver transplant waiting list within the United States, and a 6-month delay and exception point cap have recently been implemented to address this disparity. An alternative approach to prioritization is an HCC-specific scoring model such as the MELD Equivalent (MELDEQ ) and the mixed new deMELD. Using data on adult patients added to the UNOS waitlist between 30 September 2009 and 30 June 2014, we compared projected dropout and transplant probabilities for patients with HCC under these two models. Both scores matched actual non-HCC dropout in groups with scores

Ketamine is commonly used in the emergency department for short, painful procedures. We describe changes in blood pressure (BP) and heart rate (HR) during procedural sedation with ketamine, as these changes have not been well described in children.We performed a secondary analysis of a prospective, observational study involving children aged 8 to 18 years who received procedural sedation with ketamine in a pediatric emergency department. Serial vital signs and sedation scores were recorded from baseline until recovery from ketamine procedural sedation. Time of orthopedic manipulation was also recorded. Linear mixed-effect models were used to evaluate changes in systolic BP (SBP), diastolic BP (DBP), and HR using 3 sedation strata: presedation (baseline), sedated (ketamine administered and patient deeply sedated), and recovery (ketamine administered with patient minimally sedated), controlling for age and weight.Sixty children were enrolled; 10 were excluded due to missing manipulation time. A total of 394 observations were recorded. Mean sedated SBP, DBP, and HR were 8 mm Hg, 4 mm Hg, and 13 beats/min higher than presedation SBP (P.001), DBP (P.01), and HR (P.001), respectively. Mean sedated SBP and DBP were 3 and 4 mm Hg higher than SBP (P=.006) and DBP (P.01) during recovery. Manipulation increased mean SBP by 5 mm Hg (P.001), mean DBP by 7 mm Hg (P.001), and mean HR by 1 beat/min (P=.35).Ketamine administered during procedural sedation for painful procedures causes a statistically significant but modest increase in SBP, DBP, and HR. Orthopedic manipulation further increases BP.

A proper log-rank test for comparing two waiting (i.e. sojourn, gap) times under right censored data has been absent in the survival literature. The classical log-rank test provides a biased comparison even under independent right censoring since the censoring induced on the time since state entry depends on the entry time unless the hazards are semi-Markov. We develop test statistics for comparing K waiting time distributions from a multi-stage model in which censoring and waiting times may be dependent upon the transition history in the multi-stage model. To account for such dependent censoring, the proposed test statistics utilize an inverse probability of censoring weighted (IPCW) approach previously employed to define estimators for the cumulative hazard and survival function for waiting times in multi-stage models. We develop the test statistics as analogues to K -sample log-rank statistics for failure time data, and weak convergence to a Gaussian limit is demonstrated. A simulation study demonstrates the appropriateness of the test statistics in designs that violate typical independence assumptions for multi-stage models, under which naive test statistics for failure time data perform poorly, and illustrates the superiority of the test under proportional hazards alternatives to a Mann–Whitney type test. We apply the test statistics to an existing data set of burn patients.

Sisto SA, Lorenz DJ, Hutchinson K, Wenzel L, Harkema SJ, Krassioukov A. Cardiovascular status of individuals with incomplete spinal cord injury from 7 NeuroRecovery Network rehabilitation centers. Objective To examine cardiovascular (CV) health in a large cohort of individuals with incomplete spinal cord injury (SCI). The CV health parameters of patients were compared based on American Spinal Injury Association Impairment Scale (AIS), neurologic level, sex, central cord syndrome, age, time since injury, Neuromuscular Recovery Scale, and total AIS motor score. Design Cross-sectional study. Setting Seven outpatient rehabilitation clinics. Participants Individuals (N=350) with incomplete AIS classification C and D were included in this analysis. Interventions Not applicable. Main Outcome Measures Heart rate, systolic and diastolic blood pressure during resting sitting and supine positions and after an orthostatic challenge. Results CV parameters were highly variable and significantly differed based on patient position. Neurologic level (cervical, high and low thoracic) and age were most commonly associated with CV parameters where patients classified at the cervical level had the lowest resting CV parameters. After the orthostatic challenge, blood pressure was highest for the low thoracic group, and heart rate for the high thoracic group was higher. Time since SCI was negatively related to blood pressure at rest but not after orthostatic challenge. Men exhibited higher systolic blood pressure than women and lower heart rate. The prevalence of orthostatic hypotension (OH) was 21% and was related to the total motor score and resting seated blood pressures. Cervical injuries had the highest prevalence. Conclusions Resting CV parameters of blood pressure and heart rate are affected by position, age, and neurologic level. OH is more prevalent in cervical injuries, those with lower resting blood pressures and who are lower functioning. Results from this study provide reference for CV parameters for individuals with incomplete SCI. Future research is needed on the impact of exercise on CV parameters.

Harkema SJ, Schmidt-Read M, Lorenz DJ, Edgerton VR, Behrman AL. Balance and ambulation improvements in individuals with chronic incomplete spinal cord injury using locomotor training–based rehabilitation. Objective To evaluate the effects of intensive locomotor training on balance and ambulatory function at enrollment and discharge during outpatient rehabilitation after incomplete SCI. Design Prospective observational cohort. Setting Seven outpatient rehabilitation centers from the Christopher and Dana Reeve Foundation NeuroRecovery Network (NRN). Participants Patients (N=196) with American Spinal Injury Association Impairment Scale (AIS) grade C or D SCI who received at least 20 locomotor training treatment sessions in the NRN. Interventions Intensive locomotor training, including step training using body-weight support and manual facilitation on a treadmill followed by overground assessment and community integration. Main Outcome Measures Berg Balance Scale; Six-Minute Walk Test; 10-Meter Walk Test. Results Outcome measures at enrollment showed high variability between patients with AIS grades C and D. Significant improvement from enrollment to final evaluation was observed in balance and walking measures for patients with AIS grades C and D. The magnitude of improvement significantly differed between AIS groups for all measures. Time since SCI was not associated significantly with outcome measures at enrollment, but was related inversely to levels of improvement. Conclusions Significant variability in baseline values of functional outcome measures is evident after SCI in individuals with AIS grades C and D and significant functional recovery can continue to occur even years after injury when provided with locomotor training. These results indicate that rehabilitation, which provides intensive activity-based therapy, can result in functional improvements in individuals with chronic incomplete SCI.

Forrest GF, Lorenz DJ, Hutchinson K, VanHiel LR, Basso DM, Datta S, Sisto SA, Harkema SJ. Ambulation and balance outcomes measure different aspects of recovery in individuals with chronic, incomplete spinal cord injury. Objective To evaluate relationships among ambulation and balance outcome measures over time for incomplete spinal cord injury (SCI) after locomotor training, in order to facilitate the selection of effective and sensitive rehabilitation outcomes. Design Prospective observational cohort. Setting Outpatient rehabilitation centers (N=7) from the Christopher and Dana Reeve Foundation NeuroRecovery Network. Participants Patients with incomplete SCI (N=182) American Spinal Injury Association Impairment Scale level C (n=61) and D (n=121). Interventions Intensive locomotor training, including step training using body weight support and manual facilitation on a treadmill followed by overground assessment and community integration. Main Outcome Measures Six-minute and 10-meter walk tests, Berg Balance Scale, Modified Functional Reach, and Neuromuscular Recovery Scale collected at enrollment, approximately every 20 sessions, and on discharge. Results Walking and standing balance measures for all participants were strongly correlated ( r ≥.83 for all pairwise outcome correlations), standing and sitting balance measures were not highly correlated ( r ≤.48 for all pairwise outcome correlations), and walking measures were weakly related to sitting balance. The strength of relationships among outcome measures varied with functional status. Correlations among evaluation-to-evaluation changes were markedly reduced from performance correlations. Walk tests, when conducted with different assistive devices, were strongly correlated but had substantial variability in performance. Conclusions These results cumulatively suggest that changes in walking and balance measures reflect different aspects of recovery and are highly influenced by functional status and the utilization of assistive devices. These factors should be carefully considered when assessing clinical progress and designing clinical trials for rehabilitation.

Behrman AL, Ardolino E, VanHiel LR, Kern M, Atkinson D, Lorenz DJ, Harkema SJ. Assessment of functional improvement without compensation reduces variability of outcome measures after human spinal cord injury. Objective To develop a scale (Neuromuscular Recovery Scale [NRS]) for classification of functional motor recovery after spinal cord injury (SCI) based on preinjury movement patterns that would reduce variability of the populations' level of function within each class, because assessment of functional improvement after SCI is problematic as a result of high variability of the populations' level of function and the insensitivity to change within the available outcome measures. Design Prospective observational cohort with longitudinal follow-up. Setting Seven outpatient rehabilitation centers from the Christopher and Dana Reeve Foundation NeuroRecovery Network (NRN). Participants Individuals (N=95) with American Spinal Injury Association Impairment Scale (AIS) grade C or AIS grade D having received at least 20 locomotor training treatment sessions in the NRN. Interventions Intensive locomotor training including stepping on a treadmill with partial body weight support and manual facilitation and translation of skills into home and community activities. Main Outcome Measures Berg Balance Scale, six-minute walk test, and ten-meter walk test. Results Individuals classified within each of the 4 phases of the NRS were functionally discrete, as shown by significant differences in the mean values of balance, gait speed, and walking endurance, and the variability of these measurements was significantly reduced by NRS classification. The magnitude of improvements in these outcomes was also significantly different among phase groups. Conclusions Assessment with the NRS provides a classification for functional motor recovery without compensation, which reduces variability in performance and improvements for individuals with injuries classified as AIS grades C and D.

Lifetime occurrence of intimate partner violence (IPV) in women has been associated with increased prevalence of aging-related chronic diseases, including those with a pathophysiology involving inflammation. To begin to identify potential biologic mediators of this relationship, this cross-sectional study examined associations between past IPV and circulating levels of C-reactive protein (CRP) and interleukin-6 (IL-6)-measures linked with emergence of aging-related diseases-along with in vitro IL-6 production by peripheral blood mononuclear cells (PBMC) stimulated with either phytohemagglutinin A (PHA) or lipopolysaccharide (LPS).Apparently healthy, midlife women with divorce histories were recruited from the community. Histories of intimate partner psychological aggression, physical assault, sexual coercion, and stalking were assessed, along with current depression, posttraumatic stress symptoms, and health-related characteristics. At two visits, blood was drawn for assessment of biologic measures; measures were averaged across visits.In this sample (n=68), a history of being stalked was significantly positively correlated with CRP levels; in a multiple regression analysis that included body mass index (BMI) and current symptoms, this association was attenuated by adjusting for BMI. Physical assault history was significantly negatively correlated with PHA-stimulated IL-6 production. This was most apparent for severe assault and was not accounted for by BMI or symptoms.IPV histories remitted for an average of 10 years were associated with biologic mediators of inflammation. The profile was not uniformly proinflammatory, suggesting that in situations of traumatic or chronic stress, different aspects of the inflammatory response are differentially regulated and subjected to diverse compensatory mechanisms.

The use of correlation coefficients in measuring the association between two continuous variables is common, but regular methods of calculating correlations have not been extended to the clustered data framework. For clustered data in which observations within a cluster may be correlated, regular inferential procedures for calculating marginal association between two variables can be biased. This is particularly true for data in which the number of observations in a given cluster is informative for the association being measured. In this paper, we apply the principle of inverse cluster size reweighting to develop estimators of marginal correlation that remain valid in the clustered data framework when cluster size is informative for the correlation being measured. These correlations are derived as analogs to regular correlation estimators for continuous, independent data, namely, Pearson's ρ and Kendall's τ. We present the results of a simple simulation study demonstrating the appropriateness of our proposed estimators and the inherent bias of other inferential procedures for clustered data. We illustrate their use through an application to data from patients with incomplete spinal cord injury in the U.S.A.

Objective To assess interrater reliability and accuracy of an expert panel in classifying injuries of patients as abusive or accidental based on comprehensive case information. Study design Data came from a prospective, observational, multicenter study investigating bruising characteristics of children younger than 4 years. We enrolled 2166 patients with broad ranges of illnesses and injuries presenting to one of 5 pediatric emergency departments in whom bruises were identified during examination. We collected comprehensive data regarding current and past injuries and illnesses, and provided deidentified, standardized case information to a 9-member multidisciplinary panel of experts with extensive experience in pediatric injury. Each panelist classified cases using a 5-level ordinal scale ranging from definite abuse to definite accident. Panelists also assessed whether report to child protective services (CPS) was warranted. We calculated reliability coefficients for likelihood of abuse and decision to report to CPS. Results The interrater reliability of the panelists was high. The Kendall coefficient (95% CI) for the likelihood of abuse was 0.89 (0.87, 0.91) and the kappa coefficient for the decision to report to CPS was 0.91 (0.87, 0.94). Reliability of pairs and subgroups of panelists were similarly high. A panel composite classification was nearly perfectly accurate in a subset of cases having definitive, corroborated injury status. Conclusions A panel of experts with different backgrounds but common expertise in pediatric injury is a reliable and accurate criterion standard for classifying pediatric injuries as abusive or accidental in a sample of children presenting to a pediatric emergency department.

OBJECTIVE: To characterize racial and ethnic disparities in the evaluation and reporting of suspected abusive head trauma (AHT) across the 18 participating sites of the Pediatric Brain Injury Research Network (PediBIRN). We hypothesized that such disparities would be confirmed at multiple sites and occur more frequently in patients with a lower risk for AHT. STUDY DESIGN: Aggregate and site-specific analysis of the cross-sectional PediBIRN dataset, comparing AHT evaluation and reporting frequencies in subpopulations of white/non-Hispanic and minority race/ethnicity patients with lower vs higher risk for AHT. RESULTS: In the PediBIRN study sample of 500 young, acutely head-injured patients hospitalized for intensive care, minority race/ethnicity patients (n = 229) were more frequently evaluated (P < .001; aOR, 2.2) and reported (P = .001; aOR, 1.9) for suspected AHT than white/non-Hispanic patients (n = 271). These disparities occurred almost exclusively in lower risk patients, including those ultimately categorized as non-AHT (P = .001 [aOR, 2.4] and P = .003 [aOR, 2.1]) or with an estimated AHT probability of ≤25% (P < .001 [aOR, 4.1] and P < .001 [aOR, 2.8]). Similar site-specific analyses revealed that these results reflected more extreme disparities at only 2 of 18 sites, and were not explained by local confounders. CONCLUSION: Significant race/ethnicity-based disparities in AHT evaluation and reporting were observed at only 2 of 18 sites and occurred almost exclusively in lower risk patients. In the absence of local confounders, these disparities likely represent the impact of local physicians’ implicit bias.

Datta S, Lorenz DJ, Morrison S, Ardolino E, Harkema SJ. A multivariate examination of temporal changes in Berg Balance Scale items for patients with ASIA Impairment Scale C and D spinal cord injuries. Objective To provide a multivariate examination of the Berg Balance Scale (BBS) in patients with spinal cord injury (SCI) as a first step in developing a balance tool for the SCI population. Design Observational cohort. Setting The NeuroRecovery Network (NRN), a specialized network of treatment centers providing standardized, activity-based therapy for patients with SCI. Participants Patients (N=97) with American Spinal Injury Association Impairment Scale C or D SCI who were enrolled in the NRN between March 1, 2005, and June 12, 2007. Interventions All enrolled patients received 3 to 5 locomotor training sessions a week, according to NRN protocol, and were periodically evaluated for progress on functional outcome measurements. Main Outcome Measures Scores on the items of the BBS, six-minute walk test distances, ten-meter walk test speeds, and scores on the SCI Functional Ambulation Index. Temporal rates of change of the BBS items were examined with a principal components and correlation analysis. Results The first principal component accounted for nearly half of the overall variability in the BBS, correlated well with rates of change in functional mobility measures, and had good stability in its composition as verified by a resampling analysis. Further analysis showed that the composition of the first principal component varied with the patient's level of recovery. Conclusions The BBS captures a significant amount of information about balance recovery in persons with SCI and may be a good foundation for a balance tool. However, the utility of BBS items may be dependent on a patient's level of recovery. A dynamic balance instrument for the SCI population may be needed.

The purpose of this article is to evaluate whether social, geographic, and demographic factors have a relationship to trends in volatile substance abuse. Two datasets were obtained. Dataset 1 was all patients reported to U.S. poison centers with inhalation abuse of a non-pharmaceutical substance between 2000 and 2005. Dataset 2 was annual data from the U.S. Dept of Labor and U.S. Census Bureau for each of the 50 states for the years 2000 through 2005 for unemployment rate, population density, poverty rate, high school graduation rate and percentage of population with bachelor degree. The two datasets were compared for geographic (by state) and temporal (by year) relationships using U.S. government demographic categories. The U.S. poison centers state that 12,428 patients with volatile substance abuse have been reported over the 6 year period of 2000-2005, with a mean of 2,071 patients annually. A strong negative trend was found between volatile substance abuse and population density, with volatile substance abuse increasing as population density decreased. This trend remained consistent over the 6 years of evaluation. A negative trend was found with percentage of population with a bachelor's degree and volatile substance abuse. No trend was found when comparing volatile substance abuse and poverty rate, unemployment rate, or high school graduation rate. Volatile substance abuse appears to increase as population density decreases, following a previously suggested relationship with a rural setting. Volatile substance abuse appears to increase as percentage of population with a bachelor's degree decreases.

AIM It is our opinion that the CDC and the WHO have underestimated cross-contamination under examination gloves in dental clinics while wearing jewelry, such as finger rings. These agencies only "recommend" removing jewelry, and only washing hands for 15 seconds with soap and warm water before donning gloves. This study examined several washing procedures and finger rings using simulated microbes. METHODOLOGY A gloved rubber hand manikin was made and fitted with a fresh disposable vinyl glove. Four fingers were fitted with rings or no ring, dusted with simulated microbes, and washed with a scrub brush for 5, 15, and 25 seconds under 20 degrees C and 40 degrees C water alone, or with liquid hand soap. Light levels (in lux) of fluorescent powder before and after washing were measured and delta scores calculated for changes in light levels, equivalent to effectiveness of hand washing procedures. A full-factorial, 3-factor analysis of variance (ANOVA) was used to test for differences among levels of the three study factors-time, temperature, and soap use. Tukey's post hoc honestly significant difference (HSD) test was applied to significant factors to examine pair-wise differences between factor levels. RESULTS It was found that the longer the hands with rings were washed with a scrub brush under flowing water, the more simulated microbes were removed. By 25 seconds, all methods were essentially the same. Simulated microbes were more difficult to remove from the palm compared to the back of the hand. The liquid hand soap used in this study was more effective with warm water than cold. When given a choice of washing with cold water up to 15 seconds, it would be preferable not to use soap to remove simulated microbes. Qualitatively, the outer surface of finger rings were more effectively cleaned than the crevice below the ring, and the ring with a stone setting appeared to accumulate and retain simulated microbes more than other rings. CONCLUSION The most effective treatment was washing with warm water and liquid soap. Longer times were more effective. Rings should not be worn under examination gloves due to difficulty cleaning in the crevice under the ring, and the well-known consequences of cross-contamination between the patient and the health care worker.

The United Network for Organ Sharing (UNOS) recently implemented a 6-month delay before granting exception points to liver transplantation candidates with hepatocellular carcinoma (HCC) to address disparity in transplantation access between HCC and non-HCC patients. An HCC-specific scoring scheme, the Model for End-Stage Liver Disease equivalent (MELDEQ ), has also been developed. We compared projected dropout and transplant probabilities and posttransplant survival for HCC and non-HCC patients under the 6-month delay and the MELDEQ using UNOS data from October 1, 2009, to June 30, 2014, and multistate modeling. Overall (combined HCC and non-HCC) wait-list dropout was similar under both schemes and slightly improved (though not statistically significant) compared to actual data. Projected HCC wait-list dropout was similar between the MELDEQ and 6-month delay at 6 months but thereafter started to differ, with the 6-month delay eventually favoring HCC patients (3-year dropout 10.0% [9.0%-11.0%] for HCC versus 14.1% [13.6%-14.6%]) for non-HCC) and the MELDEQ favoring non-HCC patients (3-year dropout 16.0% [13.2%-18.8%] for HCC versus 12.3% [11.9%-12.7%] for non-HCC). Projected transplant probabilities for HCC patients were substantially lower under the MELDEQ compared to the 6-month delay (26.6% versus 83.8% by 3 years, respectively). Projected HCC posttransplant survival under the 6-month delay was similar to actual, but slightly worse under the MELDEQ (2-year survival 82.9% [81.7%-84.2%] versus actual of 85.5% [84.3%-86.7%]). In conclusion, although the 6-month delay improves equity in transplant and dropout between HCC and non-HCC candidates, disparity between the 2 groups may still exist after 6 months of wait-list time. Projections under the MELDEQ , however, appear to disadvantage HCC patients. Therefore, modification to the exception point progression or refinement of an HCC prioritization score may be warranted. Liver Transplantation 22 1343-1355 2016 AASLD.

MARGINAL NONPARAMETRIC INFERENCE FOR WAITING TIMES IN MULTISTAGE MODELS: HYPOTHESIS TESTING AND REGRESSION

Objective To determine the association between use of physical discipline and parental report of physically aggressive child behaviors in a cohort of young children who were without indicators of current or past physical abuse. Methods The data for this study were analyzed from an initial cohort of patients enrolled in a prospective, observational, multicenter pediatric emergency department-based study investigating bruising and familial psychosocial characteristics of children younger than 4 years of age. Over a 7-month period, structured parental interviews were conducted regarding disciplinary practices, reported child behaviors, and familial psychosocial risk factors. Children with suspected physical abuse were excluded from this study. Trained study staff collected data using standardized questions. Consistent with grounded theory, qualitative coding by 2 independent individuals was performed using domains rooted in the data. Inter-rater reliability of the coding process was evaluated using the kappa statistic. Descriptive statistics were calculated and multiple logistic regression modeling was performed. Results Three hundred seventy-two parental interviews were conducted. Parents who reported using physical discipline were 2.8 (95% confidence interval [CI], 1.7–4.5) times more likely to report aggressive child behaviors of hitting/kicking and throwing. Physical discipline was used on 38% of children overall, and was 2.4 (95% CI, 1.4–4.1) times more likely to be used in families with any of the psychosocial risk factors examined. Conclusions Our findings indicated that the use of physical discipline was associated with higher rates of reported physically aggressive behaviors in early childhood as well as with the presence of familial psychosocial risk factors.

Study objective Bruising can indicate abuse for infants. Bruise prevalence among infants in the pediatric emergency department (ED) setting is unknown. Our objective is to determine prevalence of bruising, associated chief complaints, and frequency of abuse evaluations in previously healthy infants presenting to pediatric EDs. Methods We conducted a prospective, observational, multicenter study of infants aged 12 months or younger presenting to pediatric EDs. Structured sampling was used. Pediatric emergency medicine clinicians performed complete skin examinations to screen for bruising. Study investigators documented skin findings, date of visit, patient's age, chief complaint, and abuse evaluation. The primary outcome was prevalence of bruising. Secondary outcomes were prevalence of bruising based on chief complaint and frequency of abuse evaluation. Point estimates of bruise prevalence and differences in bruise prevalence between patient subgroups were calculated with 95% confidence intervals (CIs). Results Bruising was identified in 88 of 2,488 infants (3.5%; 95% CI 2.9% to 4.4%). Rates of bruising for infants 5 months and younger and older than 5 months were 1.3% and 6.4%, respectively (difference 5.1%; 95% CI 3.6% to 6.8%). For infants 5 months and younger, 83% of bruising was associated with a trauma chief complaint and only 0.2% of infants presenting with a medical chief complaint had bruising. Pediatric emergency medicine clinicians obtained abuse evaluations on 23% of infants with bruising, and that rate increased to 50% for infants 5 months and younger. Conclusion Bruising prevalence in children 12 months and younger who were evaluated in pediatric EDs was low, increased within age strata, and was most often associated with a trauma chief complaint. Most bruised infants did not undergo an abuse evaluation.

Traditional methods for the analysis of failure time data are often employed in the analysis of waiting times of transient states from multistate models. However, such methods can exhibit bias when waiting times among model states are dependent, even when censoring is random. Furthermore, right-censoring can occur prior to entry into the transient state of interest, preventing the observation of transitions from the state and providing another potential source of bias. We introduce a nonparametric linear hazards model for waiting times from multistate models, analogous to Aalen’s linear hazards model for failure time data, where proper estimation can be carried out via reweighting, a method flexible enough to incorporate general forms of induced and other dependent censoring. We illustrate the approximate unbiasedness of the proposed regression coefficient estimators through a simulation study, while also demonstrating the bias arising from traditional Aalen’s linear hazards model estimators obtained from correlated waiting time data. Theoretical results for the parameter estimators are provided. The reweighted estimators are used in the analysis of two data sets, to identify predictors of ambulatory recovery in a data set of spinal cord injury patients receiving activity-based rehabilitation and to identify prognostic indicators for patients receiving bone marrow transplant.

We develop two different adaptations of a U-statistic based on the waiting times in a given transient state in a multistate system when the state entry and/or the exit times are subject to right censoring. In the first version, the inverse probability of censoring weights calculated based on the state exit times are used along with m-tuples of fully observed waiting times, m being the degree of the kernel of the U-statistic. In the second version, an approximate statistic is defined as a multiple integral with respect to a product of Satten–Datta estimators of a state waiting time survival function. We provide a simulation study to investigate the finite sample behavior of the statistics. We demonstrate that the second version is more efficient since it utilizes additional data where the exit times may be censored. The asymptotic normality of our estimators is also studied through simulation. We further extend our approximate U-statistics to that of a K-sample U-statistic of waiting times under right censoring. Another extension considers waiting time data that are clustered. We apply our U-statistics to test whether initial functional status has a significant impact on the waiting time of an intermediate state of functional recovery of a spinal cord injured patient.

Background Previous studies on cardiac function in patients with sickle cell disease (SCD) demonstrated abnormalities of systolic and diastolic function including elevated left ventricular myocardial performance index (LVMPI) on chronic transfusion protocols. LVMPI has been validated as a useful and easy non-invasive measure of overall cardiac function. Up to now, there are no reported studies on cardiac function in patients with SCD maintained on long-term erythrocytapheresis (LTE). Procedures We recorded LVMPI in 22 patients with SCD aged 3–20 years and we compared the results between non-transfused patients (NT-SCD) and patients on LTE (T-SCD). Results Males with SCD had higher mean LVMPI than females (P = 0.04). There were significant differences among T-SCD, severe NT-SCD, and mild NT-SCD patients with respect to hemoglobin (Hb) levels (P = .003) and TR velocity (P = .03). T-SCD patients showed elevated LVMPI compared to NT-SCD patients with severe and mild disease (P = 0.002). Pair-wise comparisons demonstrated that T-SCD patients had LVMPI that was significantly higher than NT-SCD (mild) patients (P = 0.01). Conclusions Our study demonstrates that patients SCD on LTE have cardiac dysfunction based on elevated LVMPI. This may be a reflection of the global severity of disease. Our findings merit further investigation with serial monitoring of LVMPI on a larger number of patients with SCD. © 2005 Wiley-Liss, Inc.