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Objectives: The use of intranasal (IN) analgesics and sedatives has been studied among pediatrics patients in the emergency department and outpatient settings. However, less is known about their usage in inpatient settings. This study aims to evaluate the indications and safety profile for IN fentanyl and midazolam usage in pediatric patients admitted to a large tertiary care children's hospital., Methods: This study is a retrospective chart review of admitted patients receiving IN fentanyl and/or midazolam over a 6-year period. Indications for medication use, medication dosages, patient characteristics, and any serious adverse drug reactions were recorded. Reported serious adverse outcomes include use of reversal agents as well as any documented respiratory depression, hypotension, or need for escalation of care., Results: Of 156 patients included, 119 (76%) received IN midazolam alone, 20 (13%) patients received IN fentanyl alone, and 17 (11%) patients received both medications. The most common applications for IN medication administration were nasogastric tube placements (n = 62), peripheral intravenous line insertions (n = 30), peripherally-inserted central catheter placements (n = 23), and lumbar punctures (n = 16). No serious adverse events were reported., Conclusions: This study suggests that IN fentanyl and midazolam were administered to pediatric inpatients undergoing routine procedures without serious adverse drug reactions being reported. Although these findings are encouraging, more prospective studies are needed before wider implementation of IN fentanyl and midazolam administration in pediatric inpatients., Competing Interests: CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest to disclose. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding organizations. The funding organizations had no role in the design, preparation, review, or approval of this paper., (Copyright © 2024 by the American Academy of Pediatrics.)

Previous studies in adults admitted to pediatric hospitals primarily investigated associations between complex chronic condition characteristics and patient outcomes. Our study explored the association of age with length of stay (LOS) and total cost in these adults, accounting for other patient factors. Using the Pediatric Health Information System, we included 1,215,736 patient encounters from 2021 to 2022. Unadjusted and adjusted analyses were performed using bivariable and multivariable log-linear regression. There was a significant positive association between age and total cost, with adults 18-20 years having 13% higher total cost (95% confidence interval [CI]: 12%-15%), 21-25 years with 25% higher total cost (95% CI: 22%-29%), and 25-99 years having 72% higher total cost (95% CI: 66%-79%) than 1-17 years. Our findings suggest expanding upon the existing status quo to identify the most appropriate environment to care for this unique and growing population, especially given the anticipated reduction in pediatric beds and subspecialty expertise., (© 2024 Society of Hospital Medicine.)

Background and Objectives: Rapid growth in pediatric hospital medicine (PHM) fellowships has occurred, yielding many new program directors (PDs). Characteristics of PDs have potential implications on the field. To describe characteristics (demographic, educational) and scholarly interests of PHM fellowship PDs., Methods: We developed and distributed a 15-question, cross-sectional national survey to the PHM PDs listserv. Questions were pilot tested. The survey was open for 4 weeks with weekly reminders. Responses were summarized using descriptive statistics., Results: Fifty-six current fellowship leaders (40 PDs, 16 associate PDs [APDs]) responded, including at least 1 from 43 of 59 active PHM fellowship programs (73%). Most respondents identified as female (71%) and ≤50 years old (80%). Four (7%, n = 2 PD, 2 APD) leaders identified as underrepresented in medicine. About half (n = 31, 55.4%) completed a fellowship themselves (APDs > PDs; 87.5% vs 42.5%), and 53.5% (n = 30) had advanced nonmedical degrees (eg, Master of Science, Doctor of Philosophy; APDs > PDs; 62% vs 45%). Most leaders (59%, n = 33) chose multiple domains when asked to select a "primary domain of personal scholarship." Education was the most frequently selected (n = 37), followed by quality improvement (n = 29) and then clinical research (n = 19)., Conclusions: This survey confirms a high percentage of women as PHM fellowship leaders and highlights the need to increase diversity. Less than half of senior PDs completed a fellowship in any specialty. Leaders report interest in multiple domains of scholarship; few focus solely on clinical research., (Copyright © 2024 by the American Academy of Pediatrics.)

Background: Children and young adults with sickle cell disease (SCD) develop kidney disease early in childhood, with some patients progressing to require dialysis and kidney transplantation. The prevalence and outcomes of children with kidney failure (chronic kidney disease stage 5) due to SCD are not well described. This study aimed to assess the outcome of children and young adults with SCD with kidney failure compared to matched children and young adults without SCD with kidney failure in a large national database., Methods: Utilizing the United States Renal Data System (USRDS), we retrospectively examined kidney failure outcomes in children and young adults with SCD from 1998 to 2019., Results: We identified 97 patients with SCD who developed kidney failure and identified 96 matched controls with a median age of 19 years (IQR 17, 21) at the time of kidney failure diagnosis. SCD patients had significantly shorter survival (8.4 years vs. 14.0 years, p < 0.001) and had a longer waiting time for their first transplant when compared to matched non-SCD kidney failure patients (12.1 years vs. 7.3 years, p < 0.001)., Conclusions: Children and young adults with SCD kidney failure have significantly higher mortality when matched to non-SCD kidney failure children and experience a longer mean time to kidney transplant., (© 2023. The Author(s), under exclusive licence to International Pediatric Nephrology Association.)

Background and Objectives: High-flow nasal cannula (HFNC) therapy for hospitalized children with bronchiolitis is associated with a longer length of stay (LOS) when used outside of the ICU. We sought to explore the association between HFNC and LOS to identify if demographic and clinical factors may modify the effect of HFNC usage on LOS., Methods: In this multicenter retrospective cohort study, we used a combination of hospital records and the Pediatric Health Information System. We included encounters from September 1, 2018 to March 31, 2020 for patients <2 years old diagnosed with bronchiolitis. Multivariable Poisson regression was performed for the association of LOS with measured covariates, including fixed main effects and interaction terms between HFNC and other factors., Results: Of 8060 included patients, 2179 (27.0%) received HFNC during admission. Age group, weight, complex chronic condition, initial tachypnea, initial desaturation, and ICU services were significantly associated with LOS. The effect of HFNC on LOS differed among hospitals (P < .001), with the estimated increase in LOS ranging from 32% to 139%. The effect of HFNC on LOS was modified by age group, initial desaturation, and ICU services, with 1- to 6-month-old infants, patients without initial desaturation, and patients without ICU services having the highest association between HFNC and LOS, respectively., Conclusions: We identified multiple potential effect modifiers for the relationship between HFNC and LOS. The authors of future prospective studies should investigate the effect of HFNC usage on LOS in non-ICU patients without documented desaturation., (Copyright © 2023 by the American Academy of Pediatrics.)

Objectives: Bronchiolitis is a leading cause of pediatric hospitalization. Treatment focuses on supportive care including supplemental oxygen for hypoxemia. High-flow nasal cannula (HFNC) has emerged as a modality to provide respiratory support with or without supplemental oxygen. At a freestanding children's hospital, inappropriate supplemental oxygen was frequently used. This study aimed to decrease the proportion of patients started on supplemental oxygen without documented hypoxemia from ∼90% to <70% and the proportion of patients weaned from HFNC without supplemental oxygen to nasal cannula with supplemental oxygen from ∼23% to <10%., Methods: A multidisciplinary taskforce was convened to develop an evidence-based protocol for HFNC usage. Data collection was obtained among patients aged <2 years admitted with bronchiolitis from September 2018 to September 2021. Institution-wide protocol changes occurred in November 2019 and October 2020, with ongoing education and evaluation. Data were summarized using statistical process control charts., Results: Following implementation of a revised protocol in October 2020, the percentage of patients without documented hypoxemia (defined as an oxygen saturation <90% on pulse oximetry) who were inappropriately started on supplemental oxygen decreased from a baseline of 90.2% to 57.2%. At the same time, the percentage of patients weaned from HFNC without nasal cannula oxygen decreased from a baseline of 23.1% to 4.7%., Conclusions: Using supplemental oxygen in the absence of hypoxemia in bronchiolitis is an example of low-value care. Implementation of focused, standardized protocols with concurrent education can feasibly decrease inappropriate and unnecessary use of supplemental oxygen in children with bronchiolitis., (Copyright © 2023 by the American Academy of Pediatrics.)

Objective: Many patients hospitalized for croup receive no additional racemic epinephrine (RE) postadmission. We analyzed the association between inpatient racemic epinephrine (RE) use and demographic and emergency department (ED) parameters including timing between RE doses with a goal of identifying patients who may be low risk for ED discharge., Methods: We completed a retrospective cohort study of previously healthy patients ages 2 months to <7 years old who were admitted with a diagnosis of croup from 2016 to 2019 at a freestanding tertiary-care children's hospital. Patients were eligible for this study if they received at least 1 RE treatment before admission., Results: The cohort included 238 patients; 59 (24.7%) patients received additional RE during admission. The number of RE doses in the ED (P = .99) and the median time between RE doses (P = .71) were not different between inpatient RE and no inpatient RE groups. Younger patients (P = .045) and patients with tachypnea for age (odds ratio [OR] 2.33; 95% confidence interval = 1.2-4.4) were more likely to require RE during admission. Median length of hospitalization for patients receiving inpatient RE was significantly longer (38 hours vs 16.7 hours, P < .001), whereas readmit rates were similar between groups (5.1% vs 3.9%, P = .71)., Conclusions: Fewer than 25% of admitted patients received inpatient RE. Age and tachypnea for age were associated with inpatient RE use. Reassessment of admission thresholds for multidose RE use may be warranted to prevent unnecessary hospitalizations., (Copyright © 2023 by the American Academy of Pediatrics.)

Competing Interests: Competing interests: None declared.

Objectives: Bronchiolitis is a viral respiratory infection that can progress to acute respiratory failure. This study evaluated the variability of hospital-wide high-flow nasal cannula (HFNC) usage outside of the ICU and its association with length of stay (LOS) and cost among pediatric patients admitted with bronchiolitis., Methods: This study included patients <2 years old admitted with bronchiolitis between September 1, 2018 and March 31, 2019. Hospitals were divided into groups based on the proportion of patients among those who had never been in the ICU who received HFNC (non-ICU HFNC usage [NIHU]). We performed hierarchical mixed-model linear regression to estimate the association of NIHU with LOS and cost using multiplicative ratios (MR) and 95% confidence intervals (CI), both (1) unadjusted and (2) after adjusting for demographics, clinical characteristics, and individual utilization of HFNC and/or ICU., Results: Unadjusted LOS was longer for patients in moderate (MR 1.14; 95% CI 1.11-1.18) and high (MR 1.26; 95% CI 1.22-1.30) NIHU hospitals. Adjusted LOS was longer in moderate (MR 1.03; 95% CI 1.01-1.06), and high (MR 1.08; 95% CI 1.05-1.11) NIHU hospitals. Unadjusted total cost was higher for patients in moderate (MR 1.20; 95% CI 1.16-1.25) and high (MR 1.26; 95% CI 1.22-1.31) NIHU hospitals. Adjusted total cost was higher for patients in moderate (MR 1.05; 95% CI 1.03-1.08), and high (MR 1.05; 95% CI 1.02-1.08) NIHU hospitals., Conclusions: In this study, increased NIHU is associated with increased LOS and total cost., (Copyright © 2022 by the American Academy of Pediatrics.)

Significant medical advances now enable individuals with pediatric illnesses to survive into adulthood. Finding medical homes for these individuals often remains challenging. We utilized the Pediatric Health Information System to measure the variation in and growth of admissions to children's hospitals, stratified by age and payor from 2004 to 2019. We identified 8,097,081 patient encounters from 30 hospitals. Compared to children, adults discharged at children's hospitals are more likely to have a complex chronic condition, have a higher median cost, and have a longer median length of stay. Hospital-level adult discharges ranged from 1.9% to 10.1% (median 4.1%; interquartile range: 2.8%-5.4%). Significantly higher increases were seen in each adult age subgroup (18-20, 21-25, and >25 years old) compared to the pediatric age group (p < .001). The number of adults discharged from children's hospitals is increasing faster than children, impacting children's hospitals and the populations they serve., (© 2022 Society of Hospital Medicine.)

Background and Objectives: Despite obesity's effect on pediatric patient health, the role of hospitalizations in recognizing and diagnosing pediatric obesity is poorly explored., Methods: We performed a retrospective cohort study of pediatric inpatients aged 2 to 18 years utilizing CERNER Health Facts database to determine the: (1) prevalence of obesity in a large, multicenter inpatient database, (2) appropriate International Classification of Diseases, 10th Revision, obesity diagnosis proportion, and (3) variables associated with appropriate obesity diagnosis. Covariates included patient demographics and hospital descriptors, which were summarized using frequencies, and differences across groups were compared using χ Square testing., Results: Of the hospitalized children with obesity (19.5%), only 13.2% had an appropriate obesity diagnosis. Appropriate obesity diagnosis increased with higher obesity class and was least common in the South census region at only 8.5%., Conclusions: Despite pediatric hospitalizations being a potential area for recognition and intervention of obesity, the majority of hospitalized children do not receive an appropriate obesity diagnosis., (Copyright © 2022 by the American Academy of Pediatrics.)

Background: Previously few means existed to broadly examine variability across conditions/practices within or between hospitals for common pediatric conditions., Objective: Our objective was to develop a novel empiric measure of variation in care and test its association with patient-centered outcomes., Designs: We conducted a retrospective cohort study of children hospitalized from January 2016 to December 2018 using the Pediatric Hospital Information Systems database., Settings and Participants: We included children ages 0-18 years hospitalized with asthma, bronchiolitis, or gastroenteritis., Intervention: We developed a hospital-specific measure of variation in care, the hospital's observed specific standard practice (HOSSP), the most common combination of laboratory studies, imaging, and medications used at each hospital., Main Outcome and Measures: The outcomes were standardized costs, length of stay (LOS), and 7-day all-cause readmissions., Results: Among 133,392 hospitalizations from 41 hospitals (asthma = 50,382, bronchiolitis = 54,745, and gastroenteritis = 28,265), there was significant variation in overall HOSSP adherence across hospitals for these conditions (asthma: 3.5%-47.4% [p < .001], bronchiolitis: 2.5%-19.8% [p < .001], gastroenteritis: 1.6%-11.6% [p < .001]). The majority of HOSSP variation was driven by differences in medication prescribing for asthma and bronchiolitis and laboratory ordering for gastroenteritis. For all three conditions, greater HOSSP adherence was associated with significantly lower hospital costs (asthma: p = .04, bronchiolitis: p < .001, acute gastroenteritis: p = .01), without increases in LOS or 7-day all cause readmissions., Conclusion: We found substantial variation in the components and adherence to HOSSP. Hospitals with greater HOSSP adherence had lower costs for these conditions. This suggests hospitals can use data around laboratory, imaging, and medication prescribing practices to drive standardization of care, reduce unnecessary testing and treatment, determine best practices, and reduce costs., (© 2022 Society of Hospital Medicine.)

Background: Sexually transmitted infections (STIs) are a group of infectious diseases that cause acute illness and lifelong health effects. Half of the diagnosed cases occur in adolescents and young adults, ages 15 to 24. The American Academy of Pediatrics and the Centers for Disease Control and Prevention provide guidelines for STI screening for sexually active adolescents. Despite this, screening rates in adolescents admitted to our hospital are low. The purpose of this study is to use quality improvement methodology to improve the percent of adolescent patients who had documentation of sexual histories from 49% to 69% and STI testing from 29% to 49%., Methods: Eligible patients included adolescents ages 14 to 18 admitted to our hospital's academic general pediatric service. After baseline data collection, we introduced a series of 6 interventions; percentages of sexual history documentation and STI screening were recorded monthly. Interventions included resident education on STI screening, history, and physical form prompts for sexual history documentation, "badge buddy" sexual history templates, faculty development, and an electronic medical record template. Data were interpreted by using statistical process control to show process change., Results: Before the interventions, 48.7% of patients ages 14 to 18 had sexual histories documented; 29.1% of patients were tested for STIs. After interventions, there was a special cause variation resulting in new center lines of 67.1% and 49.1%, respectively., Conclusions: Simple interventions to normalize and standardize adolescent sexual history discussions cumulatively led to a significant increase in sexual history documentation and STI screening in an inpatient adolescent population., (Copyright © 2022 by the American Academy of Pediatrics.)

Objectives: High flow nasal cannula (HFNC) is increasingly used for children hospitalized with bronchiolitis. We aimed to validate identification of HFNC use in a national database, then compare resource utilization among children treated with and without HFNC., Methods: In this cross-sectional, multicenter study, we obtained clinical and resource utilization data from the Pediatric Health Information System (PHIS) database for healthy children aged 1 to 24 months admitted for bronchiolitis. We assessed HFNC use based on a combination of billing codes and reviewed charts at 2 hospitals to determine their accuracy. We compared costs, length of stay, and readmissions between the HFNC and no HFNC groups at hospitals utilizing the HFNC codes., Results: The PHIS codes demonstrated 90.4% sensitivity and 99.3% specificity to detect HFNC use as verified by chart review at 2 hospitals. However, only 24 of 51 PHIS hospitals used these codes for ≥1% of patients with bronchiolitis. Within those hospitals, children treated with HFNC had greater total costs ($7054 vs $4544; P < .001), greater daily costs ($2922 vs $2613; P < .001), and longer length of stay (57.6 vs 41.6 hours; P < .001). Those treated with HFNC were less likely to be readmitted at 3 and 7 days (P < .001), but by 14 days, readmissions were similar in the 2 groups., Conclusions: Billing codes for HFNC are inconsistently applied across PHIS hospitals; however, among those hospitals that routinely apply these codes, HFNC was associated with more intense resource utilization. Standardization of billing practices for HFNC would allow future study to more broadly describe the value of HFNC., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Objectives: Hospital discharge marks an important transition in care from the inpatient team to the family and primary care provider. Parents must know the hospital course and discharge plan to care for their child at home and provide background for future providers. Our study aimed to determine parental knowledge of key aspects of their child's hospital course and discharge plan and to identify markers of increased risk for incomplete or incorrect knowledge among participants., Methods: We conducted a descriptive prospective cohort study of parents within 24 hours of hospital discharge. The primary outcome was concordance of parent responses to verbal interview questions about their child's hospital treatment, laboratory testing, imaging, procedures and discharge plan with the medical record., Results: Of 174 participants, 15% felt less than "completely prepared" to explain the hospital course to their primary care provider or to provide care after discharge. There was >83% overall concordance with interview responses and the medical record, with concordance higher for hospital course events than discharge plan. There were few significant differences in understanding between trainee-based teams and the attending physician-run unit. No patient or family characteristics were consistently associated with poor understanding of hospital course or discharge plan., Conclusions: Although parents were generally knowledgeable about hospital course and discharge plan, areas for improved communication were identified. Individualized counseling about hospital course and discharge plan should be initiated for all parents early during hospitalization. Methods that assess and bolster caregiver comprehension and minimize dependence on written instructions may help with transition to outpatient care., (Copyright © 2016 by the American Academy of Pediatrics.)

Background and Objective: Readmissions have received increasing attention. The goal of this study was to identify demographic and clinical factors associated with hospital utilization and 7-day readmissions., Methods: This retrospective case-control study of inpatient and observation encounters was conducted at a freestanding children's hospital. Over a 1-year period, patients were categorized into 3 groups: patients with a single admission, patients with multiple admissions without any 7-day readmissions, and patients with at least one 7-day readmission. Factors associated with risk of future hospital utilization were determined, and post hoc testing was performed to compare groups., Results: Patients with a single admission had statistically significant lower numbers of medications at admission and discharge, lower rates of home health care at admission and discharge, and fewer diagnosis codes during index admission than patients with multiple admissions. There were no statistically significant differences among patients with multiple admissions between those with and without 7-day readmissions., Conclusions: This study found that patients with multiple admissions were similar regardless of whether they had any 7-day readmissions. Because patients with multiple admissions seemed to represent a single high-risk group, it is possible that many readmissions represent a consequence of medical complexity rather than a failure of care. Further studies are necessary to determine if providing targeted interventions to high-risk patients will lower their future hospital utilization., (Copyright © 2016 by the American Academy of Pediatrics.)

Unlabelled: Family centered rounds (FCR) occur at the bedside and include the patient and their family when creating a daily medical care plan. Despite recommendations that family centered rounds (FCR) with nursing staff be standard practice, nurses were frequently absent from FCR at our institution., Objective: To increase nurse attendance on hospitalist FCR to 80% in three months. Secondary outcomes were to investigate the relationship between nurse-to-patient ratio and nurse attendance, and to assess for change in perception toward FCR., Methods: This resident driven interrupted time series study included a focus group to identify barriers to nurse attendance on FCR, four plan-do-study-act cycles, and surveys to assess for changes in perceptions toward FCR. Control charts, SHEWHART rules, linear regression and chi squared analysis were used for data analysis., Results: Nurse attendance on FCR improved from 30% to 59%. There was no correlation between nurse-to-patient ratio and nurse attendance on FCR. Surveys indicated increase in the perception that it is helpful to have a nurse present at FCR., Conclusions: A resident driven quality improvement project can increase nurse presence on FCR., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background and Objectives: Sickle cell disease (SCD) is a blood disorder affecting many US children that is often associated with hospital readmission. Although previous studies have reported on the clinical factors that influence readmission risk, potential geographic factors have not been fully investigated. The goal of this study was to investigate the importance of geographic risk factors and to confirm previously derived clinical risk factors that influence readmissions for SCD pain crises., Methods: Retrospective analyses were performed on pediatric inpatients with sickle cell crises at a single center. Readmission rates and risk factors were assessed. Geospatial analysis was conducted on point variables that represented health service access, and multivariable logistic regression models were constructed., Results: The study identified 373 patients experiencing sickle cell crises, with 125 (33.5%) having at least one 30-day readmission. Age (mean difference: 2.2 years; P<0.001), length of stay (median difference: 1 day; P<.001), admission pain score>7 of 10 (odds ratio [OR]: 2.21; P<0.01), discharge pain score>4 of 10 (OR: 2.098; P<.01), living within 5 miles of the center's main hospital (OR: 0.573; P=.04), and >3 hospital utilizations in the previous 12 months (OR: 5.103; P<.001) were identified as potential indicators of 30-day readmission risk. Logistic regression models for 30-day readmissions yielded similar results., Conclusions: Increased age, high admission and discharge pain scores, decreased length of stay, and increased hospital utilizations were found to be associated with an increased risk of readmission for sickle cell crisis. Patient's residence was also found to be a significant risk indicator, supporting the utility of geospatial analysis in assessing readmission risk., (Copyright © 2015 by the American Academy of Pediatrics.)

Background: The pediatric hospital medicine (PHM) core competencies were established in 2010 to identify the specific knowledge base and skill set needed to provide the highest quality of care for hospitalized children. The objectives of this study were to examine the perceived core competency achievements of fellowship-trained and non-fellowship-trained early career pediatric hospitalists and identify perceived gaps in our current training models., Methods: An anonymous Web-based survey was distributed in November 2013. Hospitalists within 5 years of their residency graduation reported their perceived competency in select PHM core competencies. χ(2) and multiprobit regression analyses were utilized., Results: One hundred ninety-seven hospitalists completed the survey and were included; 147 were non-fellowship-trained and 50 were PHM fellowship graduates or current PHM fellows. Both groups reported feeling less than competent in sedation and aspects of business practice. Non-fellowship-trained hospitalists also reported mean scores in the less than competent range in intravenous access/phlebotomy, technology-dependent emergencies, performing Plan-Do-Study-Act process and root cause analysis, defining basic statistical terms, and identifying research resources. Non-fellowship-trained hospitalists reported mean competency scores greater than fellowship-trained hospitalists in pain management, newborn care, and transitions in care., Conclusions: Early career pediatric hospitalists report deficits in several of the PHM core competencies, which should be considered when designing PHM-specific training in the future. Fellowship-trained hospitalists report higher levels of perceived competency in many core areas., (© 2015 Society of Hospital Medicine.)

Purpose: To evaluate the efficacy of repeat 360-degree selective laser trabeculoplasty (SLT) in glaucoma patients with prior successful 360-degree SLT., Design: Retrospective chart review., Methods: Forty-four eyes of 35 patients, > or =18 years of age, with open-angle glaucoma (primary open-angle, pseudoexfoliation, or pigmentary glaucoma), uncontrolled on maximum tolerable medical therapy, underwent an initial 360-degree SLT (SLT1), which was successful for > or =6 months, but eventually lost efficacy and was followed by a repeat 360-degree SLT (SLT2). Patients with prior argon laser trabeculoplasty or other glaucoma surgery, before or during the study period, were excluded. Intraocular pressure (IOP) measurements were recorded before each procedure and 1 to 4 weeks, 1 to 3 months, and 5 to 8 months posttreatment and 15 to 21 weeks after the initial SLT., Results: Reduction in IOP after SLT1 and SLT2 was significantly less with repeat treatment at 1 to 3 months, with average decreases of -5.0 and -2.9 mm Hg, respectively (P=0.01), but there were no statistically significant differences between treatments at the other equivalent time points. Using a definition of "success" as > or =20% peak IOP reduction, success rates for SLT1 and SLT2 were not significantly different. There was also no significant difference in eyes that received SLT2 6 to 12 months after SLT1 compared with those that received SLT2 12 months or more after SLT1., Conclusions: Our findings suggest that repeat 360-degree SLT may be safe and effective after an initially successful 360-degree SLT has failed. These results may be achieved as early as 6 months after the first treatment.

Context: Adiponectin levels are lower in obese children and adolescents, whereas markers of inflammation and proinflammatory cytokines are higher. Hypoadiponectinemia may contribute to the low-grade systemic chronic inflammatory state associated with childhood obesity., Objective: We investigated whether C-reactive protein (CRP), the prototype of inflammation, is related to adiponectin levels independently of insulin resistance and adiposity., Design, Setting, Participants, and Main Outcome Measures: In a multiethnic cohort of 589 obese children and adolescents, we administered a standard oral glucose tolerance test and obtained baseline measurements for adiponectin, plasma lipid profile, CRP, IL-6, and leptin., Results: Stratifying the cohort into quartiles of adiponectin levels and adjusting for potential confounding variables, such as age, gender, ethnicity, body mass index z-score, pubertal status, and insulin sensitivity, the present study revealed that low levels of adiponectin are associated not only with higher CRP levels, but also with components of the metabolic syndrome, such as low high-density lipoprotein cholesterol and a high triglyceride-to-high-density-lipoprotein ratio., Conclusions: The link between adiponectin levels and a strong marker of inflammation, CRP, is independent of insulin resistance and adiposity in obese children and adolescents. Adiponectin may be one of the signals linking inflammation and obesity. Thus, adiponectin may function as a biomarker of the metabolic syndrome in childhood obesity.