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BackgroundClinical approaches to treating childhood obesity can be expensive and poorly reimbursed, and often produce suboptimal results. It has been theorized that overeating may have addictive qualities, and a sizable number of adolescents with obesity endorse addictive habits. Interestingly, few weight management interventions have tested techniques founded in addiction medicine principles. We therefore performed a pilot study of an addiction model based mHealth weight loss intervention in adolescents.MethodsAdolescents with obesity were recruited from an multidisciplinary weight management clinic (EMPOWER). Adolescents without significant obesity comorbidities, who exhibited signs of addictive eating, based on the Yale Food Addiction Scale, were enrolled in a pilot study of an interactive, addiction-based, weight loss smartphone app with coaching (http://clinicaltrials.gov: NCT02689154). The app was designed to help subjects omit problem foods, avoid snacking and reduce meal size. A contemporary cohort of adolescents who completed the EMPOWER program were evaluated. Feasibility of recruitment, adherence, retention rates, BMI change and cost of intervention were examined.ResultsEighteen participants were recruited to app intervention. App participants had higher retention (100% vs. 37%) and lower total cost per patient ($855.15 vs. $1428.00) than the EMPOWER clinic participants. App participants exhibited a significant decrease in zBMI and %BMIp95 over the 6 months (p

BackgroundThe current consensus guidelines for management of pediatric obesity recommend clinic-based, family-centered, multi-disciplinary interventions. It is well reported that these programs often only lead to modest improvements in BMI status. The individual factors that differentiate which patient's BMI status will improve vs. worsen remains understudied. A retrospective cohort study was conducted to evaluate the outcomes of EMPOWER clinic and identify the participant specific characteristics that predicted BMI status improvement in this population.MethodsYouth who completed at least 6 visits in EMPOWER were included. Paired t-test was utilized to evaluate the mean change in zBMI, modified BMIz and %BMIp95 from baseline to 6th visit, and multivariate mixed effect models were utilized to analyze effect of baseline characteristics on change in BMI status.Results92 participants were included in the analysis, 87% with severe obesity and 66% Hispanic. At the 6th visit, there was a significant reduction in zBMI (-0.09 SD, p

Background: The mechanism of ulnar collateral ligament (UCL) injury during pitching is excessive elbow varus torque (EVT). The EVT-ball velocity (T-V) relationship allows concurrent assessment of player performance and UCL injury risk. Modifiable physical capacities may underlie individual variation seen in the T-V relationship., Purpose: To identify physical performance characteristics that impact the T-V relationship during pitching., Study Design: Descriptive laboratory study., Methods: A total of 87 National Collegiate Athletic Association Division I pitchers participated. Pitching collection involved measurement of EVT and ball velocity during 5 maximal effort fastballs thrown to a catcher. Physical measures collected were the following: shoulder and hip passive range of motion (ROM) and strength, shoulder rate of torque development (RTD), grip strength, and lumbopelvic stability. Physical measures were entered into univariate linear mixed models with ball velocity as a covariate to predict EVT. Variable reduction for multivariate models involved selection of physical measures based on random forest-derived variable importance and univariate relationship significance, rendering a 27-variable pool. Multivariate linear mixed models predicting EVT, adjusting for physical measures and other physical characteristics, were then created using backward elimination., Results: In univariate analysis, for every 1 m/s (2.2 mph) increase in ball velocity, the mean EVT increased by 1.51 Nċm (95% CI, 0.66-2.37 Nċm; P = .001). In univariate analysis, hip abduction strength symmetry and bilateral lumbopelvic stability significantly increased EVT, while dominant-shoulder ROM, scaption RTD symmetry, and hip ROM significantly decreased EVT. Variables that increased EVT while controlling for ball velocity in the final model include grip strength symmetry, lead-leg lumbopelvic stability, and bodyweight. Increased dominant-shoulder internal rotation (IR) strength, dominant-shoulder flexion ROM, and scaption strength asymmetry decreased EVT as ball velocity increased., Conclusion: Several modifiable physical measures affected EVT in the univariate analysis. In our final model, when controlling for ball velocity, EVT increased with increased grip strength symmetry, lead-leg lumbopelvic stability, and bodyweight and decreased with increased dominant-shoulder IR strength, dominant-shoulder flexion ROM, and scaption strength asymmetry., Clinical Relevance: Defining the individual and multivariate effects of these physical capacities on EVT contextualizes their role in the T-V relationship and helps identify access points through which coaches and clinicians can optimize a pitcher's T-V relationship., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: This work was supported by the PAC-12 Student-Athlete Health and Well-Being grant, and grant UL1TR001855 from the National Center for Advancing Translational Science (NCATS) of the US National Institutes of Health. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2024.)

Objectives: Septic shock in critically ill patients can increases morbidity and mortality. We aimed to study the effect on outcomes when integrating point of care (POC) echocardiography in the management of septic shock patients in the Intensive Care Unit (ICU) who are being treated according to the Surviving Sepsis Campaign (SSC) guidelines., Methods: An electronic search of MEDLINE through PubMed, clinical trials.gov and google scholar was conducted for the period from January 1990-January 2024 to identify studies of septic shock adult and pediatric patients in the ICU managed according to SSC guidelines with or without POC echocardiography. Three reviewers extracted data independent of each other. Cochrane collaboration tool was used for bias assessment. Random effect meta-analysis used to pool data., Results: A total of 1701 articles identified. Seven studies included in the final report with a total of 3885 patients. POC echocardiography guided septic shock management was associated with lower in-hospital and 28-day mortality (sOR = 0.82 [95%CI: 0.71-0.95], p = 0.01), more frequent initiation of inotropic support (sOR = 2.42 [95%CI 1.92-3.03], p < 0.0001) and shorter time to achieve lactate clearance (SMD = - 0.87 h [95%CI - 1.23 h to - 0.51 h], p < 0.0001). Summary estimates did not achieve significance for effect of POC echocardiography on 24-h fluid intake (SMD = - 2.11 ml [95%CI - 5.93 ml to 1.72 ml], p = 0.28) on mechanical ventilation-free days (SMD = 0.03 days [95%CI - 0.04 to 0.10], p = 0.94). Shock reversal time analysis was less meaningful due to the small number of studies reporting outcome., Conclusions: POC echocardiography guided management in septic shock patients in the ICU can lead to a decrease in mortality, increase in initiation of inotropic support, and a decrease in lactate clearance time. Larger cohort studies and data collection and analysis are needed for further understanding and optimizing standardization of protocols for POC echocardiography use in septic shock patients in the ICU., (© 2024. Società Italiana di Ultrasonologia in Medicina e Biologia (SIUMB).)

The goal of this study was to determine the potential for right ventricular (RV) and left ventricular (LV) strain to predict cardiopulmonary complications of COVID-19. We identified 276 patients with COVID-19 who underwent transthoracic echocardiography within 30 days of COVID-19 diagnosis at our institution. Patients were excluded if they had a history of any primary outcomes before COVID-19 diagnosis or insufficient imaging. LV global longitudinal strain (GLS) and RV GLS were obtained using 2-dimensional speckle-tracking echocardiography. Primary outcomes were death, pulmonary embolism, congestive heart failure (CHF), cardiomyopathy, pulmonary fibrosis, pulmonary hypertension, acute respiratory distress syndrome (ARDS), and myocardial infarction (MI) occurring after COVID-19 diagnosis. In the final analysis of 163 patients, mean RV GLS and LV GLS were reduced, and 43.6% developed at least one primary outcome. There were significant differences in LV GLS distribution in terms of CHF, cardiomyopathy, and MI in bivariate analysis. However, LV GLS was not significantly associated with CHF after adjusting for LV ejection fraction and RV fractional area change, nor with MI after adjusting for troponin T. RV GLS was significantly associated with ARDS after adjusting for other variables. In the risk stratification of patients with COVID-19, strain imaging can provide incremental prognostic information, as worsened RV GLS is associated with the development of ARDS., (© 2024. The Author(s).)

Introduction: To date, there has been no study investigating how meal-timing impacts glucose and insulin resistance among Latino youth at high risk of type 2 diabetes. A proof-of-concept study was conducted to assess metabolic response to a test-meal consumed in the morning, afternoon, and evening among 15 Latino adolescents with obesity using a within-participant design., Methods: Youth, 13 to 19 years of age, with obesity, consumed the same test-meal after a 16 hour fast at three different times on separate days. Immediately after consumption of the test meal, a mixed meal tolerance test (MMTT) was performed. The co-primary outcomes were the area under the curve (AUC) for glucose, insulin, and c-peptide, and insulinogenic index (IGI)., Results: Twenty-two youth consented to participate for a 24% recruitment rate (78% female, 100% Latino, mean age 16.5±1.3 years, 70% publicly insured). There was a significantly greater rise in glucose and c-peptide levels following at 4 PM compared to 8 AM (glucose: p = 0.006; c-peptide: p &lt; 0.0001) with no significant association found between insulin levels and timing of meal consumption. Pairwise comparisons showed a greater rise in AUC glucose and c-peptide levels at 4 PM compared to 8 AM (glucose p = 0.003; c-peptide p &lt; 0.001) with no significant association found between insulin AUC and timing of meal consumption (p = 0.09). There was a greater reduction in IGI at 4 PM compared to 8 AM (p = 0.027)., Conclusion: Similar to findings in adults at risk for diabetes, Latino youth with obesity show greater insulin resistance in response to a meal consumed in the afternoon and evening compared to early morning food consumption., (S. Karger AG, Basel.)

Background: Sensitization to (meth)acrylates, the most common nail cosmetic allergens, is rising. In recent years, home acrylic nail kits have become easily available. Objective: To investigate the characteristics of individuals reporting skin reactions associated with acrylic nail cosmetics, particularly home kits. Methods: Cross-sectional survey of Facebook nail allergy support groups. Inclusion criteria were self-reported skin reactions associated with acrylic nails and age ≥18 years. Results: There were 199 respondents, nearly all female (99%), mostly white (83%), and 25-54 years old (83%). Seventy-eight percent reported using home acrylic kits, more than half for the first time during COVID-19. They predominantly learned about kits through social media (68%) and received training through websites/online videos (74%). Most home users (83%) first developed skin reactions after starting to use home kits. Compared with nonhome users, significantly more home users reported skin reaction onset within 1 year of use, as well as nail damage ( P  < 0.05). Conclusions: Among online nail allergy support group members, home acrylic nail kit use was common and associated with earlier development of skin reactions and more frequent nail damage than professional acrylic manicures. These findings raise important questions about the need to regulate home acrylic nail kits.

Study Objectives: The relationship between time-limited eating (TLE) and sleep quality is a topic of growing interest in the field of chronobiology. Data in adult cohorts shows that TLE may improve sleep quality, but this has not been evaluated in adolescents. The aim of this secondary analysis was to (1) examine the impact of 8-hour TLE on sleep parameters in youth with obesity and (2) explore if there was any association between sleep patterns and glycemic profiles., Methods: Adolescents with obesity were randomized into one of three groups: 8-hour TLE (participants self-selected their eating window) + real-time continuous glucose monitor, 8-hour TLE + blinded continuous glucose monitor, or a prolonged eating window. In the primary analysis, it was found that participants in the real-time continuous glucose monitor group + 8-hour TLE group did not access their continuous glucose monitor data and thus for this analysis the two TLE groups were combined and only completers who had available Pittsburgh Sleep Quality Index (PSQI) data at all three time points were included. Participants completed the PSQI at baseline, week 4, and week 12. Mixed-effects generalized linear regression models were utilized to examine the change in PSQI score and assess association between glycemic variability and PSQI total score overtime by intervention arm., Results: The median PSQI total score for the TLE groups (n = 27) was 6 at week 0 (interquartile range = 5 to 10) and 5 at week 12 (interquartile range = 2 to 7). There was no significant difference in the change in total PSQI score or sleep latency between TLE and control over the study period ( P > .05). There was no association between PSQI score and change in weight or glycemic profile between groups (all P values > 0.05)., Conclusions: These results suggest that in adolescents with obesity, an 8-hour TLE approach did not negatively impact sleep quality or efficiency when compared to a prolonged eating window. The potential effects of TLE on sleep should be further investigated in larger randomized trials., Citation: Jayakumr A, Gillett ES, Wee CP, Kim A, Vidmar AP. Impact of 8-hour time-limited eating on sleep in adolescents with obesity. J Clin Sleep Med . 2023;19(11):1941-1949., (© 2023 American Academy of Sleep Medicine.)

Objective: Interpersonal psychotherapy (IPT) is an evidence-based treatment for depression, demonstrating efficacy with adolescents and young adults. Social support is proposed to be an important treatment component and may be helpful for adolescents and young adults with chronic illness. The authors sought to assess the feasibility of delivering IPT to this population and to examine changes in depressive symptoms and perceived social support., Methods: An open-label feasibility trial of group-based IPT was conducted for adolescents and young adults with chronic illness (N=17). The 12-session group IPT was concurrent with group members' individual psychotherapy, and group IPT was focused on providing support in navigating interpersonal challenges related to the participants' chronic illness. Participants completed questionnaires assessing depressive symptoms and social support before treatment, midtreatment (6 weeks), and after treatment (12 weeks). Generalized estimating equation models, adjusted for repeated measures, were used to assess changes in depressive symptoms and social support over the course of treatment., Results: Deidentified clinical examples illustrated how IPT was practiced in a community mental health setting. Evidence for the feasibility of group IPT was mixed. Although participants had poor session attendance, there was a significant decrease in depressive symptoms (β=-2.94, 95% CI=-5.30 to -0.59, p=0.014) and a significant increase in perceived social support (β=4.24, 95% CI=0.51 to 7.98, p=0.026) by the end of treatment., Conclusions: IPT may help address depressive symptoms and enhance social support among adolescents and young adults with chronic illness. Further research and adaptation are needed to address feasibility challenges in delivering group IPT to this population., Competing Interests: The authors report no financial relationships with commercial interests.

Introduction: Creatinine has limitations in identifying and predicting acute kidney injury (AKI). Our study examined the utility of neutrophil gelatinase-associated lipocalin (NGAL) in predicting AKI in patients presenting to the emergency department (ED), and in predicting the need for renal replacement therapy (RRT), occurrence of major adverse cardiac events (MACE) and all-cause mortality at three months post visit., Methods: This is a single-centre prospective cohort study conducted at Singapore General Hospital (SGH). Patients presenting to SGH ED from July 2011 to August 2012 were recruited. They were aged ≥21 years, with an estimated glomerular filtration rate <60 mL/min/1.73 m 2 , and had congestive cardiac failure, systemic inflammatory response syndrome or required hospital admission. AKI was diagnosed by researchers blinded to experimental measurements. Serum NGAL was measured as a point-of-care test., Results: A total of 784 patients were enrolled, of whom 107 (13.6%) had AKI. Mean serum NGAL levels were raised (P < 0.001) in patients with AKI (670.0 ± 431.9 ng/dL) compared with patients without AKI (490.3 ± 391.6 ng/dL). The sensitivity and specificity of NGAL levels >490 ng/dL for AKI were 59% (95% confidence interval [CI] 49%-68%) and 65% (95% CI 61%-68%), respectively. Need for RRT increased 21% per 100 ng/dL increase in NGAL (P < 0.001), whereas odds of death in three months increased 10% per 100 ng/dL increase in NGAL (P = 0.028). No clear relationship was observed between NGAL levels and MACE., Conclusion: Serum NGAL identifies AKI and predicts three-month mortality., Competing Interests: None

Introduction: High rates of physician burnout are well documented in the USA. Identifying beneficial leadership behaviors as an organizational approach to mitigating burnout can lead to improved wellness in the physicians that they lead; however, few studies have examined which leadership behaviors are beneficial and which may be detrimental., Materials and Methods: This survey study of academic medical center physicians and their physician leaders assessed the correlation between burnout and leadership behaviors. Data were analyzed for the strength of correlation between scores for leadership behaviors and self-reported physician burnout with analysis of variance by sex, time from training, specialty, and age., Results: Of 1,145 physicians surveyed, 305 returned surveys. Among the respondents, 45% were female, 25% were 56 years or older, and 57% self-identified as practitioners of medicine or medicine subspecialties. Two transformational leadership categories of behaviors (idealized influence behaviors and individualized consideration) and one transactional leadership behavior category (contingent reward) correlated favorably with all domains of burnout (P < .0001). Conversely, two transactional leadership categories of burnout (management by exception passive and laissez-faire) correlated unfavorably with all burnout domains., Conclusions: Organizational interventions are needed to improve burnout in physicians. Adopting favorable leadership behaviors while avoiding unfavorable leadership behaviors can improve burnout in those physicians being led. These findings could inform the conceptual basis of future physician leadership training programs as transactional leadership behaviors also have an impact on physician wellness., (© The Association of Military Surgeons of the United States 2022. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: The purpose was to assess postpartum depression, anxiety, and depression in mothers of children with an inconclusive diagnosis after a positive cystic fibrosis (CF) newborn screening (NBS), known as cystic fibrosis transmembrane conductance regulator (CFTR)-related metabolic syndrome (CRMS) or CF screen positive, inconclusive diagnosis (CFSPID). There is limited information on the prognosis and on the impact of this designation on maternal mental health., Methods: Mothers of children with CRMS/CFSPID and CF identified by NBS were recruited from two centers in California. Maternal mental health was assessed using measures of depression, anxiety, and a scripted interview. Descriptive statistics and multivariate logistic regression were applied for data reporting., Results: A total of 109 mothers were recruited: CF: 51, CRMS/CFSPID: 58. Mothers from both groups showed higher rates of depression and anxiety symptoms than women in the general population. CRMS/CFSPID and CF mothers had no significant difference on their self-reported symptoms of anxiety and depression after adjusting for potential confounders. Mothers equally reported that their child's diagnosis had a negative impact, and that genetic counseling had a positive impact on their emotional health., Conclusions: CF and CRMS/CFSPID diagnoses impact maternal mental health similarly. Uncertain prognosis of CRMS/CFSPID likely contributed to the negative mental health impact. Providers should consider conducting mental health screening for every mother of a child with CRMS/CFSPID, in addition to the recommended mental health screening for mothers of children with CF. Genetic counseling has potential to mitigate emotional stress on these families., Competing Interests: Conflict of Interest Disclosures (includes financial disclosures) Dr. Danieli B. Salinas is currently employed by Vertex pharmaceuticals. The other authors have no example conflicts of interest to disclose., (Copyright © 2022. Published by Elsevier B.V.)

High elbow varus torque during baseball pitching has been identified as a potential cause of ulnar collateral ligament injury in baseball pitchers. In general, elbow varus torque increases as ball velocity increases across pitchers. However, studies incorporating within-subject analyses report that not all professional pitchers have a positive relationship between elbow varus torque and ball velocity (T-V relationship). It remains unknown whether collegiate pitchers show the same trend as professionals in their T-V relationships. The current study investigated the T-V relationship of collegiate pitchers focusing on both across and within pitchers. Division 1 collegiate pitchers (n = 81) were assessed for elbow torque and ball velocity during pitching. Both across- and within-pitcher T-V relationships were significant (p < 0.05) using linear regression. However, more variance in elbow varus torque was explained using the within-pitcher relationship (R 2  = 0.29) than the across-pitcher relationship (R 2  = 0.05). Of the 81 pitchers, nearly half (n = 39) had significant T-V relationships, while the other half (n = 42) did not. Our findings indicate that the T-V relationship should be assessed on an individual basis as T-V is pitcher-specific.

Objectives: Universal implementation of cystic fibrosis (CF) newborn screening (NBS) has led to the diagnostic dilemma of infants with CF screen-positive, inconclusive diagnosis (CFSPID), with limited guidance regarding prognosis and standardized care. Rates of reclassification from CFSPID to CF vary and risk factors for reclassification are not well established. We investigated whether clinical characteristics are associated with the risk of reclassification from CFSPID to a CF diagnosis., Methods: Children with a positive CF NBS were recruited from two sites in California. Retrospective, longitudinal, and cross-sectional data were collected. A subset of subjects had nasal epithelial cells collected for CF transmembrane conductance regulator (CFTR) functional assessment. Multivariate logistic regression was used to assess the risk of reclassification., Results: A total of 112 children completed the study (CF = 53, CFSPID = 59). Phenotypic characteristics between groups showed differences in pancreatic insufficiency prevalence, immunoreactive trypsinogen (IRT) levels, and Pseudomonas aeruginosa (PSA) colonization. Spirometry measures were not different between groups. Nasal epithelial cells from 10 subjects showed 7%-30% of wild-type (WT)-CFTR (wtCFTR) function in those who reclassified and 27%-67% of wtCFTR function in those who retained the CFSPID designation. Modeling revealed that increasing sweat chloride concentration (sw[Cl - ]) and PSA colonization were independent risk factors for reclassification to CF., Conclusion: Increasing sw[Cl - ] and a history of PSA colonization are associated with the risk of reclassification from CFSPID to CF in a population with high IRT and two CFTR variants. A close follow-up to monitor phenotypic changes remains critical in this population. The role of CFTR functional assays in this population requires further exploration., (© 2022 Wiley Periodicals LLC.)

Rationale: Variants within the cystic fibrosis (CF) transmembrane conductance regulator gene, CFTR , that are of unknown significance or are categorized as non-CF causing may be observed in persons with CF. These variants are frequently detected in children with inconclusive newborn screen results and, in some cases, may be associated with a benign presentation in early childhood that progresses to a CF phenotype later in life. Objectives: To analyze data from individuals enrolled in the U.S. Cystic Fibrosis Foundation Patient Registry who have received a diagnosis of CF and who have variants found in a population of children with a CF screen positive, inconclusive diagnosis (CFSPID). Methods: This retrospective review analyzed registry data from individuals with a diagnosis of CF who also harbor one or more variants of interest because of their frequency within a CFSPID population and/or their interpretation as non-CF causing. Three groups were defined by the number of CF-causing variants identified (CF-Cx2, CF-Cx1, and CF-Cx0), which were reported in addition to the variant(s) of interest. Multivariate quantile regression modeling of the outcome for forced expiratory volume in 1 second (FEV 1 ) generated a disease severity score for each person determined by six selected variables. Median scores were calculated for the three groups. Results: Patients carrying one CF-causing variant and at least one variant of interest (CF-Cx1) had higher median disease severity scores compared with those carrying CF-Cx2, suggesting a milder phenotype ( P  < 0.05). However, there was no statistically significant difference in scores between CF-Cx2 and the two other groups combined (CF-Cx1 and CF-Cx0; P  = 0.33). Analysis revealed that the CF-Cx1 and CF-Cx0 groups, when compared with the CF-Cx2 group, had later median diagnoses (8 years vs. newborn; P  < 0.0001), lower median sweat chloride (48 mmol/L vs. 94.5 mmol/L; P  < 0.0001), lower prevalence of pancreatic insufficiency (29% vs. 78%; P  < 0.0001), and higher median FEV 1 % predicted (95% vs. 87%; P  = 0.0002). Conclusions: Individuals with CF who have specific variants frequently identified in children with CFSPID have a similar range of disease severity scores compared with those who have two CF-causing variants, but a milder phenotype overall. Variants that should be given careful scrutiny because of their high prevalence are G576A+R668C, T854T, R75Q, F1052V, R1070W, R31C, and L967S.

Objective: This randomized clinical trial tested the effectiveness of an addiction-based digital weight-loss intervention, focusing on withdrawal/abstinence from self-identified problem foods, snacking and excessive amounts at meals, and discomfort displacement, with and without coaching, compared to an in-person, multi-disciplinary, care model among adolescents with obesity. We hypothesized that the digital intervention with coaching would yield greater weight loss and lower delivery burden than the standard clinical arm, and greater participant engagement than the digital arm without coaching., Methods: Adolescents were randomized to app intervention, with or without coaching, or in-person multidisciplinary obesity intervention for 6 months. The primary outcome was change in %BMI p95 at weeks 12 and 24. A mixed-effects linear regression model was used to assess the association between change in %BMI p95 and intervention arm. We were also interested in assessing delivery burden, participant engagement and evaluating the relationships between weight change and demographic characteristics, mood, executive function and eating behaviours., Results: All adolescents (n = 161; BMI ≥95th%, age 16 ± 2.5 year; 47% Hispanic, 65% female, 59% publicly insured) lost weight over 24-weeks (-1.29%, [-1.82, -0.76], p < 0.0001), with no significant weight loss difference between groups (p = 0.3). Girls lost more weight than boys, whereas binge eating behaviour at baseline was associated with increase in %BMI p95 when controlling for other covariates. There was no association between ethnicity, mood, timing of intervention in relation to the pandemic, or executive function and change in %BMI p95 ., Conclusions: Contrary with our hypothesis, our results showed no difference in the change in BMI status between treatment arms. Since efficacy of this digital intervention was not inferior to in-person, multi-disciplinary care, this could offer a reasonable weight management option for clinicians, based on youth and family specific characteristics, such as accessibility, resources, and communication styles., Clinical Trial Registration: ClinicalTrials.gov identifier: NCT035008353., (© 2022 World Obesity Federation.)

Background: Diabetes technologies, such as insulin pumps and continuous glucose monitors (CGM), have been associated with improved glycemic control and increased quality of life for young people with type 1 diabetes (T1D); however, few young people use these devices, especially those from minority ethnic groups. Current literature predominantly focuses on white patients with private insurance and does not report experiences of diverse pediatric patients with limited resources., Methods: To explore potential differences between Latinx and non-Latinx patients, English- and Spanish-speaking young people with T1D ( n  = 173, ages 11-25 years) were surveyed to assess attitudes about and barriers to diabetes technologies using the Technology Use Attitudes and Barriers to Device Use questionnaires., Results: Both English- and Spanish-speaking participants who identified as Latinx were more likely to have public insurance ( P  = .0001). English-speaking Latinx participants reported higher Hemoglobin A1c values ( P  = .003), less CGM use ( P  = .002), and more negative attitudes about technology (generally, P  = .003; and diabetes-specific, P  < .001) than either non-Latinx or Spanish-speaking Latinx participants. Barriers were encountered with equivalent frequency across groups., Conclusions: Latinx English-speaking participants had less positive attitudes toward general and diabetes technology than Latinx Spanish-speaking and non-Latinx English-speaking peers, and differences in CGM use were associated with socioeconomic status. Additional work is needed to design and deliver diabetes interventions that are of interest to and supportive of patients from diverse ethnic and language backgrounds.

Objective: This study examines changes in the Yale Food Addiction Scale symptom count over a 24-week, weight-loss mobile Health (mHealth) intervention incorporating elements of addiction medicine. Methods: Adolescents ( n  = 117) with obesity (15.5 ± 1.3 years; 66% Hispanic) were randomized to the following: (1) mHealth intervention (AppAlone), (2) mHealth intervention+coaching (AppCoach), or (3) in-person intervention (Control). A multivariate mixed Poisson regression model was used to evaluate changes in symptom counts across intervention arms after adjusting for sex, age, depressive symptomatology, stress, and executive function. Results: After the intervention, 57% of adolescents showed a decrease in symptom count (median change: -0.3 [0 to -1.5]), with a significant change by intervention arm in the intention-to-treat analysis ( p  = 0.045). There was a positive linear relationship between change in symptom count and change in depressive symptomatology ( p  < 0.01) and stress ( p  < 0.01), with no association with change in weight ( p  = 0.3). Discussion: Both mHealth and in-person obesity interventions seemed to confer benefits in food addiction symptomatology associated with change in mood and stress. Clinical Trial Registration number: NCT035008353.

Background: Randomized controlled trials of time restricted eating (TRE) in adults have demonstrated improvements in glucose variability as captured by continuous glucose monitors (CGM). However, little is known about the feasibility of CGM use in TRE interventions in adolescents, or the expected changes in glycemic profiles in response to changes in meal-timing. As part of a pilot trial of TRE in adolescents with obesity, this study aimed to 1) assess the feasibility of CGM use, 2) describe baseline glycemic profiles in adolescents with obesity, without diabetes, and 3) compare the difference between glycemic profiles in groups practicing TRE versus control., Methods: This study leverages data from a 12-week pilot trial (ClinicalTrials.gov Identifier: NCT03954223) of late TRE in adolescents with obesity compared to a prolonged eating window. Feasibility of CGM use was assessed by monitoring 1) the percent wear time of the CGM and 2) responses to satisfaction questionnaires. A computation of summary measures of all glycemic data prior to randomization was done using EasyGV and R. Repeat measures analysis was conducted to assess the change in glycemic variability over time between groups. Review of CGM tracings during periods of 24-hour dietary recall was utilized to describe glycemic excursions., Results: Fifty participants were enrolled in the study and 43 had CGM and dietary recall data available (16.4 + 1.3 years, 64% female, 64% Hispanic, 74% public insurance). There was high adherence to daily CGM wear (96.4%) without negative impacts on daily functioning. There was no significant change in the glycemic variability as measured by standard deviation, mean amplitude glycemic excursion, and glucose area under the curve over the study period between groups., Conclusions: CGM use appears to be a feasible and acceptable tool to monitor glycemic profiles in adolescents with obesity and may be a helpful strategy to confirm TRE dosage by capturing glycemic excursions compared to self-reported meal timing. There was no effect of TRE on glucose profiles in this study. Further research is needed to investigate how TRE impacts glycemic variability in this age group and to explore if timing of eating window effects these findings., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Naguib, Hegedus, Raymond, Goran, Salvy, Wee, Durazo-Arvizu, Moss and Vidmar.)

Objectives: Autologous reconstruction of microtia is advantageous due to its inherent biocompatibility and long-term stability, but postoperative pain associated with costal harvest is a significant issue. A well-planned pain management approach is imperative. Our objective is to introduce the novel application of erector spinae block anesthesia in pediatric microtia reconstruction and evaluate its impact on pain scores, use of opioids, and hospital length of stay., Study Design: Case series with chart review., Setting: Patients undergoing stage 1 microtia reconstruction at a tertiary pediatric hospital., Methods: Data collected included demographics, opioid amounts, Wong-Baker FACES Pain Rating Scale scores, opioid-related side effects, and hospital length of stay. We used generalized estimating equations to examine the effect of erector spinae block use on total opioid use and pain scores and a linear regression model to assess the effect on hospital stay., Results: Forty-seven patients were included: 14 in the erector spinae block group and 33 in the continuous wound pump group. The mean age was 8.3 years (SD, 2; range, 6-13), and 13 (32%) were female. Patients in the erector spinae block group had a 65.44% decrease in adjusted total opioid use (95% CI, -79.72% to -41.10%; P < .0001), a decrease in length of hospital stay (β = -1.69 [95% CI, -2.11 to -1.26], P < .0001), and no difference in reported pain scores when compared with patients in the continuous wound pump group., Conclusions: This study demonstrates that early experience with an erector spinae block resulted in decreased opioid use and shorter hospital stay as compared with continuous wound infiltration with local anesthetic.

Background: Appropriate timing of central venous catheter (CVC) removal, in relation to start of anticoagulation, in children after the diagnosis of a CVC-related thrombosis (CRT) is not well established., Objectives: This retrospective cohort study evaluated the incidence of symptomatic pulmonary embolism (PE) after CVC removal using data from the multi-institutional Children's Hospital-Acquired Thrombosis (CHAT) Consortium Registry., Patients/methods: The CHAT Registry consists of data from children aged 0-21 years with a hospital-acquired venous thromboembolism. Eligible subjects were those with CRT diagnosed <3 days after CVC removal. Subjects were excluded if the CRT was due to a failed CVC insertion. Subjects were divided into three groups: those with CVC removal without anticoagulation, those with CVC removal <48 h after starting anticoagulation, and those with CVC removal ≥48 h after starting anticoagulation., Results: A total of 687 CRT events from 663 subjects were included. A majority of CRT events were in subjects with peripherally inserted central catheters (62.3%, n = 428). For the 611 CRT events in which the CVC was removed, there was only one case of symptomatic PE (0.16%), which occurred <48 h after initiation of anticoagulation., Conclusions: While current guidelines suggest anticoagulation before CVC removal in the setting of a CRT to prevent embolization, CVC removal is not associated with symptomatic PE regardless of duration of anticoagulation before CVC removal., (© 2021 International Society on Thrombosis and Haemostasis.)

There has been a growing number of infants identified as CRMS/CFSPID in countries applying genetic testing as part of cystic fibrosis (CF) newborn screening. Currently there are neither standardized protocols for follow up beyond infancy, nor established predictors to stratify this population as high or low risk of reclassification to CF or CFTR-related disorder. We report a series of 10 children who reclassified, including eight carrying CFTR variants of varying clinical consequence and seven with initial sweat chloride measurements <30 mmol/L. The overall increase in sweat chloride concentration was 5.8 mmol/L/year. Pseudomonas aeruginosa was isolated from respiratory cultures in five subjects, and reclassification was aided by human nasal epithelial cultures in two cases. In this center's experience, 6% of all CRMS/CFSPID referrals reclassified to CF over a 12-year period. The rate of sweat chloride increase, genotype, and CFTR functional assay can potentially be used as prognostic tools in the CRMS/CFSPID population., (Copyright © 2021 European Cystic Fibrosis Society. Published by Elsevier B.V. All rights reserved.)

Due to its simplicity, time-limited eating (TLE) may represent a more feasible approach for treating adolescents with obesity compared to other caloric restriction regimens. This pilot study examines the feasibility and safety of TLE combined with continuous glucose monitoring (CGM) in adolescents. Fifty adolescents with BMI ≥95th percentile were recruited to complete a 12-week study. All received standard nutritional counseling, wore a CGM daily, and were randomized to: (1) Prolonged eating window: 12 h eating/12 h fasting + blinded CGM; (2) TLE (8 h eating/16 h fasting, 5 days per week) + blinded CGM; (3) TLE + real-time CGM feedback. Recruitment, retention, and adherence were recorded as indicators of feasibility. Weight loss, dietary intake, physical activity, eating behaviors, and quality of life over the course of the intervention were explored as secondary outcomes. Forty-five participants completed the study (16.4 ± 1.3 years, 64% female, 49% Hispanic, 75% public insurance). There was high adherence to prescribed eating windows (TLE 5.2 d/wk [SD 1.1]; control 6.1 d/wk [SD 1.4]) and daily CGM wear (5.85 d/wk [SD 4.8]). Most of the adolescents (90%) assigned to TLE reported that limiting their eating window and wearing a CGM was feasible without negative impact on daily functioning or adverse events. There were no between-group difference in terms of weight loss, energy intake, quality of life, physical activity, or eating behaviors. TLE combined with CGM appears feasible and safe among adolescents with obesity. Further investigation in larger samples, with a longer intervention duration and follow-up assessments are needed.

Background: This scoping review provides a timely synthesis of the use of continuous glucose monitoring in obesity research with considerations to adherence to continuous glucose monitor devices and metrics most frequently reported., Methods: This scoping review was conducted adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist. Eligible studies (n = 31) evaluated continuous glucose monitor use in research on participants, of all ages, with overweight or obesity., Results: Reviewed studies varied in duration from one to 84 days (mean: 8.74 d, SD 15.2, range 1-84 d) with 889 participants total (range: 11-118 participants). Across all studies, the mean percent continuous glucose monitor wear time (actual/intended wear time in days) was 92% (numerator - mean: 266.1 d, SD: 452, range: 9-1596 d/denominator - mean: 271.6 d, SD: 451.5, range: 9-1596 d). Continuous glucose monitoring was utilized to provide biofeedback (n = 2, 6%), monitor dietary adherence (n = 2, 6%), and assess glycemic variability (n = 29, 93%). The most common variability metrics reported were standard deviation (n = 19, 62%), area under the curve (n = 12, 39%), and glycemic range (n = 12, 39%)., Conclusions: Available evidence suggests that continuous glucose monitoring is a well-tolerated and versatile tool for obesity research in pediatric and adult patients. Future investigation is needed to substantiate the feasibility and utility of continuous glucose monitors in obesity research and maximize comparability across studies., (Copyright © 2021 Asia Oceania Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.)

Background: Little is known about the normal eating time periods in adolescents with obesity and how these patterns change throughout development. As the obesity epidemic continues to rise in adolescence, it becomes imperative to understand developmentally appropriate eating behaviours and to create weight management strategies that build on those innate patterns and preferences. The purpose of this study was to determine the most common habitual eating windows observed in adolescents with obesity., Methods: Participants were 101 Hispanic adolescents (mean age 14.8 ± 2.1 years; 48 male/53 female) with obesity (BMI ≥95th percentile) who were recruited as part of a larger clinical trial. Dietary intake and meal timing was determined using multiple pass 24-hours recalls. Histograms were utilized to determine the natural distribution of percent consumption of total kilocalories, carbohydrates and added sugar per hour., Results: The majority of total kilocalories (65.4%), carbohydrates (65.3%) and added sugar (59.1%) occurred between 11:00 and 19:00. Adolescents were 2.5 to 2.9 times more likely to consume kilocalories, carbohydrates, and added sugar during the 8-hour window between 11:00 am and 19:00 pm than other time windows examined (all P < .001). The consumption of these calories did not differ between weekdays and weekend (P > .05) or by sex., Conclusions: In this cohort, more than 60% of calories, carbohydrates and added sugar were consumed between 11:00 am and 19:00 pm, which is concordant with an afternoon/evening chronotype that is common in adolescents. Our findings support this 8-hour period as a practical window for weight loss interventions that target pre-specified eating periods in this population., (© 2020 World Obesity Federation.)

Purpose: This study examines how baseline demographics, psychosocial characteristics, and intervention delivery predict engagement among adolescents with overweight and obesity seeking treatment. Methods: Data originates from a multisite randomized control trial evaluating the efficacy of an app-based weight loss intervention, compared with standard in-clinic model in adolescents with overweight and obesity. Participants were randomized to one of the three arms: (1) AppCoach, (2) AppAlone, or (3) Control. Demographic, executive functioning (EF), and depression questionnaires were completed at baseline. Percent engagement was compared within and between groups defined by demographics and depressive symptoms. Quantile regression was used to evaluate the association between age and EF on percent engagement. Results: Baseline demographics were not associated with engagement within or between groups. Neither baseline self-reported depressive symptoms ( p  = 0.244) nor deficits in EF ( p  = 0.34) were predictors of engagement. Univariate analysis found that the control arm had the highest engagement (83%) compared with AppCoach (63.5%) and AppAlone (22.5%, p  = 0.02). Hispanic ethnicity was predictive of higher engagement in the control arm ( p  = 0.02). On multivariate quartile regression no other baseline characteristics were significant predictors of engagement. Conclusion: Baseline demographics and individual psychosocial characteristics were not related to engagement in this cohort. The intervention arm that required parental involvement resulted in the greatest engagement suggesting that family involvement may overshadow individual behavioral phenotype and thus promote better engagement. Further investigation is needed to understand how program delivery can be leveraged to optimize treatment engagement and outcomes in adolescence. Clinical Trial Registration number: NCT03500835.

Objective: Infants with Congenital Heart Disease (CHD) are at risk for developmental delays, though the mechanisms of brain injury that impair development are unknown. Potential causes could include cerebral hypoxia and cerebrovascular instability. We hypothesized that we would detect significantly reduced cerebral oxygen saturation and greater cerebrovascular instability in CHD infants compared to the healthy controls., Methods: We performed a secondary analysis on a sample of 43 term infants (28 CHD, 15 healthy controls) that assessed prospectively in temporal cross-section before or at 12 days of age. CHD infants were assessed prior to open-heart surgery. Cerebral oxygen saturation levels were estimated using Near-Infrared Spectroscopy, and cerebrovascular stability was assessed with the response of cerebral oxygen saturation after a postural change (supine to sitting)., Results: Cerebral oxygen saturation was 9 points lower in CHD than control infants in both postures (β = -9.3; 95%CI = -17.68, -1.00; p = 0.028), even after controlling for differences in peripheral oxygen saturation. Cerebrovascular stability was significantly impaired in CHD compared to healthy infants (β = -2.4; 95%CI = -4.12, -.61; p = 0.008), and in CHD infants with single ventricle compared with biventricular defects (β = -1.5; 95%CI = -2.95, -0.05; p = 0.04)., Conclusion: CHD infants had cerebral hypoxia and decreased cerebral oxygen saturation values following a postural change, suggesting cerebrovascular instability. Future longitudinal studies should assess the associations of cerebral hypoxia and cerebrovascular instability with long-term neurodevelopmental outcomes in CHD infants., Competing Interests: The authors have declared that no competing interests exist.

Background: Venous thromboembolism (VTE) is a known complication among pediatric and adult cancer patients. Adolescent and young adult oncology (AYAO) patients have unique biological and physiological characteristics that make them distinct from other populations. Our objective was to study the VTE incidence, risk factors, and outcomes, which have been understudied in this population., Procedure: A retrospective case-control study was conducted on AYAO participants with new or relapsed cancer and an imaging confirmed VTE from January 2011 to November 2016 at our institution. Eligible AYAO participants without a history of VTE were designated as controls and were randomly selected from our institution's tumor registry. Demographics, medical history, surgeries, central venous catheter (CVC) data, VTE diagnosis and treatment, relapses, and deaths were abstracted., Results: Thirty-five VTE cases and 70 controls were included in this analysis. Eighty percent of cases had leukemia or lymphoma (vs. a solid tumor) compared to 58% of controls. The majority of VTEs (57%) were CVC associated, and more than 70% of cases had more than one CVC placed during their cancer treatment versus 34% of controls. Infection was associated with increased VTE risk (OR = 6.35, 95% CI = 2.30, 17.55, p < .0001). VTE cases had increased cancer relapse (23% vs. 10%) and mortality rates (29% vs. 16%) than controls., Conclusion: AYAO participants with a VTE were more likely to have leukemia or lymphoma, more than one CVC or infection. Further studies are needed to identify patients who would benefit from modifiable prevention measures, such as limiting to one CVC, preventing infections, or considering prophylactic anticoagulation for those with a liquid tumor., (© 2021 Wiley Periodicals LLC.)

Lay Abstract: Children diagnosed with autism are likely to be more overweight than children who do not have autism. There are many group programs that help children to be more physically active and improve their eating habits to achieve healthy weight, but most of these programs do not allow children with autism to participate. We studied a program that was specially adapted so children with autism could participate together with peers who do not have autism. The program lasted 8 weeks and was offered in the evening at a large healthcare center in a big city. The children participated with a parent or another adult who takes care of them. We analyzed data that were part of a previous project where we studied how physical activity trackers called Fitbit help overweight children to change their eating and exercise habits so they can achieve healthier weight. Out of 158 families in the study, 15 families had a child or children with autism. We measured changes in the weight of children with and without autism and compared how many of the children completed the program. Children who had autism had similar results in achieving healthy weight and finishing the program compared to their peers without autism. Our study found that when a group weight management program is slightly changed to meet the needs of children with autism, they can successfully participate and benefit similarly to their peers who do not have autism., Registration: This trial was registered with ClinicalTrials.gov (NCT03215641).

Background: The relationships between food addiction, executive functions and mood in adolescence are not well-understood. This study examines differences in executive functioning, depression symptoms and perceived stress among adolescents with obesity with- and without food addiction., Methods: A total of 110 adolescents with obesity (74 females; age = 15.59 ± 1.3 y; 67% Hispanic; 74% public insurance) completed the Behavior Rating Inventory of Executive Function-2 (BRIEF-2), the Yale Food Addiction Scale for children (YFAS-c), the Perceived Stress Scale (PSS) and the Center for Epidemiologic Studies Depression scale (CES-DC). Chi-squared and Fisher's exact tests were used to evaluate differences in BRIEF-2, CES-DC and PSS scores between participants with and without food addiction. A logistic regression model assessed the associations between executive dysfunction, depression and stress on food addiction individually. Multiple logistic regression was utilized to further examine the association between executive dysfunction and food addiction when accounting for depression and stress., Results: More than a third of participants (34.5%) met the criteria for food addiction. Females were 2.89 times more likely than males to have food addiction (95th%CI = 1.12-7.46, p = 0.03). Participants with FA had significantly higher BRIEF-2 T-scores (all p < 0.05) and higher PSS and CES-DC scores (all p < 0.05). Multiple logistic regression analysis showed depression was strongly correlated with FA when controlling for executive dysfunction and stress (p = 0.010)., Conclusions: Among obesity treatment-seeking adolescents, youths with food addiction displayed greater impairments in executive functioning and higher levels of stress and depressive symptoms than adolescents without food addiction. Prospective studies are needed to determine how this behavioral phenotype helps predict intervention outcomes., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Introduction: Anti-N-methyl-D-aspartate receptor encephalitis is caused by auto-antibodies that target the N-methyl-D-aspartate receptor. Autonomic instability is a hallmark of the disease. The objective of this case series is to examine how anesthesia affects pediatric patients with this disease., Methods: We performed a retrospective chart review of 28 records in 17 patients who underwent anesthesia. Our primary outcomes were hemodynamic changes during the perioperative period. Heart rate, systolic and diastolic blood pressures, respiratory rate, and oxygen saturation comprise our endpoints. A subgroup of patients, who underwent imaging with anesthesia, was then compared to controls., Results: In anti-N-methyl-D-aspartate receptor encephalitis cases, there were significant percent changes from baseline in heart rate; median = -14.3%, 95% CI (-19.3, -9.0), p < .01 at 30 min and -15.7%, (-21.1, -9.8), p < .01 at 60 min; in systolic blood pressure, -19.4%, (-23.7, -14.8) at 30 min, p < .01, and -14.8%, (-19.7, -9.5) at 60 min, p < .01; in diastolic blood pressure, -41.9%, (-46.9, -36.3), p < .01 at 30 min, and -37.5%, (-43.4, -30.9), p < .01 at 60 min. When compared to controls, there were no significant differences between the two groups across time of anesthesia (baseline to 60 min) in heart rate (p = .24), systolic blood pressure (p = .30), and diastolic blood pressure (p = .11). No patients experienced hemodynamic lability under anesthesia. One patient, with severe symptoms, died within 24 h of anesthesia., Conclusion: Although pediatric patients with anti-N-methyl-D-aspartate receptor encephalitis experienced vital sign changes with anesthesia, they were not clinically significant and they behaved similarly to controls. Disease severity may be a risk factor for perioperative complications., (© 2020 John Wiley & Sons Ltd.)

Single- and multiple-breath washout tests (SBW and MBW) measure ventilation inhomogeneity, but the relationship between them is unclear. Forty-three subjects with cystic fibrosis (CF) and healthy controls (HC) 8-21 years of age were recruited (CF = 30 and HC = 13) and performed nitrogen MBW, vital capacity SBW, spirometry, and plethysmography. Mean phase III slope from SBW (SIII) and lung clearance index (LCI) were significantly different between CF and HC (p = 0.017 and p < 0.0001, respectively). Based on Pearson correlation, SIII and LCI showed strong correlation (ρ = 0.81, p < 0.0001). Both SIII and LCI significantly correlated with spirometry (all p < 0.05). Among CF subjects with normal FEV 1 (≥ 80%; n = 17), 76% (n = 13) had normal SIII but abnormal LCI. We conclude that LCI can be abnormal despite normal SIII and FEV 1 in CF children. Although LCI and SIII showed strong correlation, our results suggest that LCI is a better test to detect ventilation inhomogeneity in CF children with normal FEV 1 .

Objectives: Recent technological advances have led to the capability of performing high resolution imaging of the tympanic membrane. Smartphone technologies and applications have provided the opportunity to capture digital images and easily share them. The smartphone otoscope device was developed as a simple system that can convert a smartphone into a digital otoscope. This device has the prospective ability to improve physician-patient communication and assist with the diagnosis and management of ear disease. Our objective was to evaluate the feasibility and physician/parental satisfaction using the Cellscope® smartphone attachment for at home tympanostomy tube monitoring., Methods: Children between 6 months and 15 years of age at an urban tertiary children's hospital that were scheduled for bilateral tympanostomy tube insertion or underwent bilateral tympanostomy tube surgery were prospectively enrolled in the study. Comparisons were made between parental home-recorded videos and findings during in-office otoscopy. Two independent otolaryngologists reviewed the videos and concordance between inter-rater agreements was calculated. Acceptability and use questionnaires were administered to physicians and parents., Results: There was good intra-rater agreement between traditional otoscopy and video-otoscopy for tube extruding, tube blocked and tube extruded with at least 80% agreement ( P  < .05) and excellent inter-rater agreement between physicians for nearly all tube variables ( P  < .0001) There was a high degree of satisfaction with this mode of surveillance. Parents and physicians agreed that the CellScope® smartphone was easy to use, helpful with the occurrence of acute events, and appeared to improve quality of care., Conclusions: The CellScope® smartphone is feasible for use in tympanostomy tube surveillance. Use of the device may allow otolaryngologists to easily follow a child's tympanostomy tube remotely over time and offer greater parental satisfaction.

Background: Children involved with Child Protective Services (CPS) have been shown to have lower academic achievement. It is unclear whether certain qualities of the home environment can optimize academic achievement in this vulnerable population., Objective: This study sought to determine whether home environments with higher levels of emotional support and cognitive stimulation predict later academic achievement and whether this relationship is moderated by placement type (i.e. biological/adoptive parent care, kinship care, or non-kinship foster care)., Participants and Setting: This study included 1,206 children from the second National Survey of Child and Adolescent Well-Being (NSCAW-II) who were involved with CPS between 2-7 years of age., Methods: Multivariate analyses were completed to examine the effect of the Home Observation for Measurement of the Environment (HOME) score on later Woodcock-Johnson III Tests of Achievement (WJ-ACH) scores. Moderation analyses were conducted to determine the effect of placement type on this relationship., Results: Although these relationships between HOME scores and WJ-ACH scores were significant in bivariate analyses, they were not statistically significant in multivariate analyses, primarily due to the variable of household income. Although children placed primarily in non-kinship foster care demonstrated higher WJ-ACH scores for Passage Comprehension and Letter-Word Identification subscales, placement type did not appear to moderate the relationship between HOME scores and academic achievement., Conclusion: Child- and caregiver-level factors, as well as financial resources available in the environment, may account for the relationship between home environment and academic achievement., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Rationale: Little is known about the polysomnogram (PSG) characteristics in infants with bronchopulmonary dysplasia (BPD), especially severe BPD, who do not need home ventilatory support but are at increased risk for chronic hypoxia and are vulnerable to its effects., Objective: This study aims to assess PSG characteristics and change in discharge outcomes in premature infants with BPD who required oxygen therapy at discharge., Methods: This is a retrospective chart review of premature infants with BPD who were admitted to a quaternary newborn and infant intensive care unit from January 1, 2012 to December 31, 2015 and who underwent polysomnography before discharge., Measurements and Main Results: Data from 127 patients were analyzed. The median gestational age of our patients was 26 weeks and 1 day (interquartile range [IQR]: 24.71, 28.86). The majority of the patients had moderate-to-severe BPD. The median obstructive apnea-hypopnea index was 5.3 events/h (IQR: 2.2, 10.1). The median oxygen desaturation index was 15.7 events/h (IQR: 4.7, 35). Nadir oxygen saturation measured by pulse oximeter was 81% (IQR: 76-86) and the arousal/awakening index was 21.9 (IQR: 13.3-30.9). No statistically significant difference was noted between severe and nonsevere BPD groups for PSG characteristics. However, average end-tidal CO 2 was significantly higher in the severe BPD group (p = .0438). Infants in the severe BPD group were intubated longer than infants with nonsevere BPD (p = .0082). The corrected gestational age (CGA) at the time of discharge (CGA-PSG) and PSG (CGA-DC) was higher in severe BPD patients but not statistically different. The majority of premature infants who underwent a PSG were discharged home with oxygen, and 69% required a titration of their level of support based on results from the PSG., Conclusion: Our results highlight the presence of abnormal PSG characteristics in BPD patients, as early as 43 weeks CGA. These findings have not been previously described in this patient population prior to initial discharge from the hospital. A severe BPD phenotype tends to be associated with higher respiratory morbidity compared with a nonsevere BPD phenotype for the comparable CGA. PSG, when available, may be helpful for individualizing and streamlining treatment in preparation for discharge home and mitigating the effects of intermittent hypoxic episodes., (© 2020 Wiley Periodicals LLC.)

Background: Time limited eating (TLE) has been shown to be effective for weight loss and improvement of glycemic control in adults with obesity and type 2 diabetes (T2D), but has not been well studied in adolescents. TLE may be a more feasible, flexible and effective dietary intervention for adolescents because it removes the need for intensive counting of calories or macronutrients, and emphasizes eating during a specified time period., Objectives: The aim of this study is to assess the feasibility of a TLE approach in adolescents with obesity using a continuous glucose monitor (CGM) to promote adherence to the intervention., Methods: We propose a prospective, randomized controlled trial, in 60 adolescents (ages 14-18) with obesity (BMI% ≥ 95th percentile). Youth will be randomized to one of three treatment groups for a 12-week intervention: Group 1) Low sugar and carbohydrate education (LSC, 5% of total daily calories from sugar (<35 g)/day; <90 g carbohydrate (CHO)/day) + blinded CGM (used to monitor adherence and glycemic outcomes without real time feedback), Group 2) LSC + TLE (16-h fast/8-h feed for 5 days per week) + blinded CGM, and Group 3) LSC + TLE+ real time feedback via CGM (to evaluate effect of providing CGM data on intervention efficacy). Outcomes will include change in total body fat (TBF) percentage measured on DEXA scan, BMI status and fasting blood glucose at 12 weeks compared to baseline., Conclusions: TLE is a potentially powerful lifestyle intervention that could be readily integrated into pediatric weight management programs to optimize their impact and accelerate healthy changes., Clinical Trial Registration: ClinicalTrials.gov identifier: NCT03954223., Competing Interests: Declaration of Competing Interest The authors have no financial relationships or conflict of interest relevant to this article to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

In preschool children with cystic fibrosis (CF), lung clearance index (LCI) is a sensitive test to detect early lung disease. Some children with CF screen positive, inconclusive diagnosis (CFSPID) may in time develop clinical features of CF. LCI has not been studied in CFSPID children. LCI and spirometry were performed in preschool age children with CF, CFSPID, and non-CF healthy controls (HCs) during two visits. Fifty-four preschool age children (HC n = 18, CFSPID n = 17, and CF n = 19) were tested. Mean LCI from the CFSPID group was not statistically different from HC (p = 0.49), but significantly different when compared to CF (p = 0.04). LCI was abnormal in 2 CFSPID children who carried potentially deleterious CFTR variants. Mean forced expiratory volume in 1 s (FEV 1 ) was not statistically different between CFSPID and CF (p = 0.26). LCI can potentially detect early lung disease in CFSPID individuals as part of assessing their risk for reclassification to CF diagnosis.

Objective: Management of obstructive sleep apnea in infants with Robin sequence (RS) includes prone positioning during sleep, which conflicts with safe infant sleep data. We examined changes in polysomnography (PSG) parameters for prone versus nonprone body positions in these infants., Design: Pre-post interventional, nonblinded study., Participants: Infants with RS referred for PSG were recruited from craniofacial clinic and inpatient units at Children's Hospital Los Angeles, a tertiary pediatric center. Fourteen infants were recruited, and 12 studies were completed on both body positions; 11 studies were used in the analysis., Interventions: The PSG was divided into nonprone and prone sleep, moving from their usual sleep position to the other position midway in the study., Main Outcome Measures: Data was collected in each position for obstructive apnea-hypopnea index (oAHI), central apnea index (CAI), sleep efficiency (SE), and arousal index (AI). Signed rank test was used to evaluate the change in body position., Results: All infants were term except 1, age 7 to 218 days (mean: 55 days; standard deviation: 58 days), and 8 (57%) of 14 were female. From nonprone to prone sleep position, the median oAHI (16.0-14.0), CAI (2.9-1.0), and AI (28.0-19.9) decreased ( P = .065); SE increased (67.4-85.2; P = .227)., Conclusions: Prone positioning may benefit some infants with RS. However, even those with significant improvement in obstructive sleep apnea did not completely resolve their obstruction. The decision to use prone positioning as a therapy should be objectively evaluated in individual infants.

Background: There is a need to prognosticate the severity of cystic fibrosis (CF) detected by newborn screening (NBS) by early assessment of CF transmembrane conductance regulator (CFTR) protein function. We introduce novel instrumentation and protocol for evaluating CFTR activity as reflected by β-adrenergically stimulated sweat secretion., Methods: A pixilated image sensor detects sweat rates. Compounds necessary for maximum sweat gland stimulation are applied by iontophoresis, replacing ID injections. Results are compared to a validated β-adrenergic assay that measures sweat secretion by evaporation (evaporimetry)., Results: Ten healthy controls (HC), 6 heterozygous (carriers), 5 with CFTR-related metabolic syndrome (CRMS)/CF screen-positive, inconclusive diagnosis (CFSPID), and 12 CF individuals completed testing. All individuals with minimal and residual function CFTR mutations had low ratios of β-adrenergically stimulated sweat rate to cholinergically stimulated sweat rate (β/chol) as measured by either assay., Conclusions: β-Adrenergic assays quantitate CFTR dysfunction in the secretory pathway of sweat glands in CF and CRMS/CFSPID populations. This novel image-sensor and iontophoresis protocol detect CFTR function with minimal and residual function and is a feasible test for young children because it is insensible to movement and it decreases the number of injections. It may also assist to distinguish between CF and CRMS/CFSPID diagnosis.

The Fontan procedure for univentricular heart defects creates a nonphysiologic circulation where systemic venous blood drains directly into the pulmonary arteries, leading to multiorgan dysfunction secondary to chronic low-shear nonpulsatile pulmonary blood flow and central venous hypertension. Although blood viscosity increases exponentially in this low-shear environment, the role of shear-dependent ("non-Newtonian") blood viscosity in this pathophysiology is unclear. We studied three-dimensional (3D)-printed Fontan models in an in vitro flow loop with a Philips 3-T magnetic resonance imaging (MRI) scanner. A 4D flow phase-contrast sequence was used to acquire a time-varying 3D velocity field for each experimental condition. On the basis of blood viscosity of a cohort of patients who had undergone the Fontan procedure, it was decided to use 0.04% xanthan gum as a non-Newtonian blood analog; 45% glycerol was used as a Newtonian control fluid. MRI data were analyzed using GTFlow and MATLAB software. The primary outcome, power loss, was significantly higher with the Newtonian fluid [14.8 (13.3, 16.4) vs. 8.1 (6.4, 9.8)%, medians with 95% confidence interval, P < 0.0001]. The Newtonian fluid also demonstrated marginally higher right pulmonary artery flow, marginally lower shear stress, and a trend toward higher caval flow mixing. Outcomes were modulated by Fontan model complexity, cardiac output, and caval flow ratio. Vortexes, helical flow, and stagnant flow were more prevalent with the non-Newtonian fluid. Our data demonstrate that shear-dependent viscosity significantly alters qualitative flow patterns, power loss, pulmonary flow distribution, shear stress, and caval flow mixing in synthetic models of the Fontan circulation. Potential clinical implications include effects on exercise capacity, ventilation-perfusion matching, risk of pulmonary arteriovenous malformations, and risk of thromboembolism. NEW & NOTEWORTHY Although blood viscosity increases exponentially in low-shear environments, the role of shear-dependent ("non-Newtonian") blood viscosity in the pathophysiology of the low-shear Fontan circulation is unclear. We demonstrate that shear-dependent viscosity significantly alters qualitative flow patterns, power loss, pulmonary flow distribution, shear stress, and caval flow mixing in synthetic models of the Fontan circulation. Potential clinical implications include effects on exercise capacity, ventilation-perfusion matching, risk of pulmonary arteriovenous malformations, and risk of thromboembolism.

Background: The notion of obesity as an addictive process is controversial. However, studies show that between 5.9 and 30.7% of adolescents with obesity report food or eating addiction. Few weight management interventions have tested techniques based on addiction medicine principles., Methods: This multi-center randomized control trial (RCT) is designed to test the effectiveness of a mobile health (mHealth) weight-loss intervention based on addiction principles, such as withdrawal and tolerance, in a sample of 180 adolescents (ages 14-18) recruited from four pediatric weight management clinics in Southern California. Akin to a Multiphase Optimization Strategy (MOST) design evaluating multicomponent behavioral interventions, we will compare the combination of an app + phone coaching (App+Coach) to app alone (App) and in-clinic multi-disciplinary (Clinic) intervention arms. The primary outcome is mean change in zBMI and %BMI p95 over 18 months. We hypothesize that youth who receive App+Coach will have a greater reduction in body weight over the 18-month study period at a lower cost than standard of care models. Secondary outcomes include adherence to treatment regimen, intervention satisfaction, effect of the intervention on metabolic factors and activity level. We will also explore potential moderators of intervention effectiveness such as addictive eating habits, self-regulation and executive functioning., Conclusions: New and creative approaches are needed to address pediatric obesity. If successful, this RCT may provide an innovative and cost-effective mHealth approach, based on addiction methods, for weight loss among adolescents with overweight and obesity., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Rationale: The use of real-time magnetic resonance imaging (MRI) for the evaluation during sleep-related respiratory events can lead to better understanding of airway dynamics., Objectives: To investigate the dynamic anatomy of the upper airway during central apnea., Methods: The study included obese adolescents who snore and were otherwise healthy. Subjects underwent an overnight baseline polysomnogram. Subjects slept during a 24-minute real-time upper airway MRI scan wearing a full face mask attached to a pneumotach. Sleep versus wakefulness during the MRI was inferred from the heart rate and respiratory patterns. Central apneas were scored using tracings of facemask airflow and abdominal bellows. The cross-sectional area of the upper airway before, during, and after each central apnea event was recorded., Results: Eight subjects were studied and 57 central apnea events were observed during real-time MRI scanning during natural sleep. The median age of subjects was 14.0 years (interquartile range [IQR], 13.5 to 15.5). The median average reduction in cross-sectional area during central apnea events was -38% (IQR, -27 to -51) for primary snorers and -45% (IQR, -40 to -54) for subjects with obstructive sleep apnea. The percentage decrease in cross-sectional area of upper airway during a central apnea event was positively correlated to the length of the central apnea (ρ = 0.389; r 2  = 0.152; P = 0.003)., Conclusions: We observed that there is upper airway narrowing during central apneas during natural sleep in obese adolescent subjects, using real-time MRI.

Objectives: Disruption in the care of special healthcare needs children may lead to life-threatening situations or preventable secondary conditions. California averages more than 100 earthquakes per week. Subsequent power outages, damage to utility systems, and road damage after an earthquake can have grave consequences for families with parenteral nutrition (PN)-dependent children. The purpose of the study was to demonstrate that we could improve disaster preparedness of families with PN-dependent children utilizing individualized family education and distribution of personalized disaster survival toolkits., Methods: We administered a baseline survey to assess disaster preparedness of our families with PN-dependent children followed by individualized disaster survival toolkit distribution and education. We followed up with these families with phone call surveys at 2 and 4 months. A generalized estimating equation with both logistic and linear regression was used to analyze data over the follow-up period., Results: We found statistically significant improvements in developing a family emergency plan (P < 0.0001), having a basic emergency supply kit (P < 0.0001), having a completed emergency information form from the child's provider (P < 0.0001), and the confidence level or readiness for a disaster (P < 0.0001). All participants had extra batteries for PN infusion pumps. Having alternative power sources, such as a generator, did not significantly change over time., Conclusions: Individualized disaster education helped families with PN-dependent children not only to prepare for a possible earthquake, but also to feel more confident in their ability to handle a natural disaster.

Objective: To examine clinical characteristics associated with bacteremia in febrile nonneutropenic pediatric oncology patients with central venous catheters (CVCs) in the emergency department (ED)., Background: Fever is the primary reason pediatric oncology patients present to the ED. The literature states that 0.9% to 39% of febrile nonneutropenic oncology patients are bacteremic, yet few studies have investigated infectious risk factors in this population., Methods: This was a retrospective cohort study in a pediatric ED, reviewing medical records from 2002 to 2014. Inclusion criteria were patients with cancer, temperature at least 38°C, presence of a CVC, absolute neutrophil count greater than 500 cells/μL, and age less than 22 years. Exclusion criteria were repeat ED visits within 72 hours, bloodwork results not reported by the laboratory, and patients without oncologic history documented at the study hospital. The primary outcome measure is a positive blood culture (+BC). Other variables include age, sex, CVC type, cancer diagnosis, absolute neutrophil count, vital signs, upper respiratory infection (URI) symptoms, and amount of intravenous (IV) normal saline (NS) administered in the ED. Data were analyzed using descriptive statistics and a multiple logistic regression model., Results: A total of 1322 ED visits were sampled, with 534 enrolled, and 39 visits had +BC (7.3%). Variables associated with an increased risk of +BC included the following: absence of URI symptoms (odds ratio [OR], 2.30; 95% CI, 1.13-4.69), neuroblastoma (OR, 3.65; 95% CI, 1.47-9.09), "other" cancer diagnosis (OR, 4.56; 95% CI, 1.93-10.76), tunneled externalized CVC (OR, 5.04; 95% CI, 2.25-11.28), and receiving at least 20 mL/kg IV NS (OR, 2.34; 95% CI, 1.2-4.55). The results of a multiple logistic regression model also showed these variables to be associated with +BC., Conclusion: The absence of URI symptoms, presence of an externalized CVC, neuroblastoma or other cancer diagnosis, and receiving at least 20 mL/kg IV NS in the ED are associated with increased risk of bacteremia in nonneutropenic pediatric oncology patients with a CVC., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Although retrograde decremental accessory pathways (DAPs) are thought to typically present as permanent junctional reciprocating tachycardia (permanent junctional reciprocating tachycardia), they may also be diagnosed unexpectedly during electrophysiology study. We aimed to compare the clinical and electrophysiological characteristics of patients with DAPs to an age-matched cohort with nondecremental accessory pathways., Methods and Results: We retrospectively studied pediatric patients (<21 years of age) with retrograde DAPs and an age-matched control population with nondecremental accessory pathways who underwent electrophysiology study between 2005 and 2014. Decrement was defined as rate-dependent prolongation of the local ventriculo-atrial time by >30 ms. Twenty-six patients with DAPs were compared with 73 controls (mean age at electrophysiology study 9.8±5.7 and 10.3±5.2 years, respectively [P=nonsignificant]). Compared with controls, patients with DAPs had more frequent syncope (5/26 [19%] versus 3/73 [4%]; P=0.02) and ventricular dysfunction (6/26 [23%] versus 4/73 [6%]; P=0.04). Only 11 (42%) DAP patients manifested clinical permanent junctional reciprocating tachycardia, and these patients had more syncope (5/11 [45%] versus 0/15 [0%]; P<0.01), slower orthodromic reciprocating tachycardia (176±44 beats per minute versus 229±31 beats per minute; P=0.001), and longer ventriculo-atrial times (mean maximum ventriculo-atrial times of 283±116 ms versus 208±42 ms; P=0.02) compared with those with DAPs without clinical permanent junctional reciprocating tachycardia. DAPs and controls had similar rates of acute ablation success (23/26 [89%] versus 67/73 [92%]; P=nonsignificant) and recurrences (1/23 [4%] versus 2/67 [3%]; P=nonsignificant)., Conclusions: The majority of pediatric patients with DAPs do not present with clinical permanent junctional reciprocating tachycardia. DAPs are associated with more severe symptoms, but ablation outcomes are similar to those of age-matched controls., (© 2016 American Heart Association, Inc.)

DNA methyltransferases (MTases), a family of enzymes that catalyse the methylation of DNA, have a profound effect on gene regulation. A large body of evidence has indicated that DNA MTase is potentially a predictive biomarker closely associated with genetic disorders and genetic diseases like cancer. Given the attention bestowed onto DNA MTases in molecular biology and medicine, highly sensitive detection of DNA MTase activity is essential in determining gene regulation, epigenetic modification, clinical diagnosis and therapeutics. Conventional techniques such as isotope labelling are effective, but they often require laborious sample preparation, isotope labelling, sophisticated equipment and large amounts of DNA, rendering them unsuitable for uses at point-of-care. Simple, portable, highly sensitive and low-cost assays are urgently needed for DNA MTase activity screening. In most recent technological advances, many alternative DNA MTase activity assays such as fluorescent, electrochemical, colorimetric and chemiluminescent assays have been proposed. In addition, many of them are coupled with nanomaterials and/or enzymes to significantly enhance their sensitivity. Herein we review the progress in the development of DNA MTase activity assays with an emphasis on assay mechanism and performance with some discussion on challenges and perspectives. It is hoped that this article will provide a broad coverage of DNA MTase activity assays and their latest developments and open new perspectives toward the development of DNA MTase activity assays with much improved performance for uses in molecular biology and clinical practice.

Background: Bleomycin is associated with pulmonary toxic side effects including pneumonitis and pulmonary fibrosis. We evaluated the prevalence of long-term pulmonary function abnormalities in children receiving bleomycin therapy in the context of current chemotherapeutic regimens., Methods: A retrospective review of patients who received bleomycin between January 1999 and December 2011 was conducted. Abnormalities in the most recent pulmonary function test (PFT) at least 1 year after diagnosis were analyzed., Results: Two-hundred and seven patients had received bleomycin. The results of PFT performed at least 1 year from diagnosis were available for 80 patients. Median time of follow up was 3.9 years (range 1.1-11.76 years). Median cumulative dose of bleomycin was 65 IU/m(2) (range 10-120). The most common diagnoses were Hodgkin lymphoma and germ cell tumor. At least one pulmonary function abnormality was present in 42 (52.5%) patients. When classified in groups, 22.5% patients had obstructive lung disease, 7.5% had restrictive lung disease, 28.8% had hyperinflation and 14% of patients had non-uniform distribution of ventilation. Non-Hispanic patients (OR 2.81) and children younger than 8 years (OR 4.14) had higher odds of having an abnormal PFT parameter. Very few patients had pulmonary symptoms., Conclusions: More than half the patients who received bleomycin had subclinical pulmonary dysfunction as evidenced by abnormalities in pulmonary function tests, although the incidence of clinical symptoms was low., (© 2014 Wiley Periodicals, Inc.)