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Doug Brunk is a San Diego-based award-winning reporter who began covering health care in 1991. Before joining the company, he wrote for the health sciences division of Columbia University and was an associate editor at Contemporary Long Term Care magazine when it won a Jesse H. Neal Award. His work has been syndicated by the Los Angeles Times and he is the author of two books related to the University of Kentucky Wildcats men's basketball program. Doug has a master’s degree in magazine journalism from the S.I. Newhouse School of Public Communications at Syracuse University. Follow him on Twitter @dougbrunk.
Rx for cognitive rest crucial after concussion
SAN DIEGO – With all the media attention drawn to the impact of sports-related concussion in recent years, a significant portion of schools in the United States have adopted “return to play” guidelines, but only a minority have “return to learn” protocols in place, according to Dr. Kelsey Logan.
Literature on the topic is scarce, but one survey of school nurses in Illinois found that 57% of schools in that state had return to play protocols while only 30% had protocols in place for returning to the classroom, Dr. Logan said at the annual meeting of the American Academy of Pediatrics. A separate survey of youth in Nebraska who sustained a concussion in sports found that only 42% of their teachers provided extra assistance in the classroom following their injury.
Limiting cognitive activities “is a big part of their stress in getting over their injury,” said Dr. Logan, who directs the division of sports medicine at Cincinnati Children’s Hospital Medical Center. “I talk to the families about decreasing their child’s emotional stress, and academics are largely a cause of this. They’re stressed from day 1 about the work they’re missing. They’ll say things like, ‘How do I make teachers understand? I don’t want people to think I’m not doing my work.’ If we address those upfront, they tend to be a little less stressed.”
She noted that increasing cognitive activity soon after a concussive injury “worsens symptoms and prolongs recovery. That often takes several conversations with patients and parents before they understand that concept. Many times parents want you to micromanage their kid’s day – tell them exactly what they can and can’t do. That’s not really our role. I cannot predict whether 15 versus 20 minutes of looking on a computer is going to make their symptoms worse. Understanding concepts is important. When you start to experience a big gap in energy and your symptoms get worse, you need to back off. Our goal is to determine the appropriate balance of cognitive activity and cognitive rest.”
Developing a return to learning plan following a concussion starts with an assessment of the patient’s symptoms, which vary from individual to individual. “You can’t predict exactly what a person’s going to go through,” said Dr. Logan, one of the authors of a guideline on return to learning that was published online in Pediatrics (2013 [doi:10.1542/peds.2013-2867]). “Some of it’s trial and error. It’s important to consider physical, cognitive, emotional, and sleep symptoms. All of these can combine. Some patients will have many emotional symptoms after a concussion; others won’t. This is why it’s so important for primary care pediatricians to be treating concussions because they know their patients.”
She recommends that patients and their families use checklists to document symptoms, track their severity and progression, and target symptoms to address with school personnel. The ideal role of family members and friends is to enforce rest and reduce stimulation, while the role of medical team is to evaluate symptoms, prescribe physical and cognitive rest, and get input from family members and school personnel on the patient’s progress. The chief goal is to help the patient get the most out of his or her school day without worsening symptoms. This starts by limiting school time. “For an athlete who has a constant headache, I would recommend that she stay out of school until she feels a little bit better,” Dr. Logan said. “There’s not a specific symptom score that she needs to meet to go back to school. It’s when the family and the patient feel that she can go to school and concentrate. You don’t want to throw that athlete back into a full school day right away. You want to start with a few hours of school, maybe a half-day depending on symptoms.” (The CDC has developed a tip sheet for school personnel on helping students return to school after a concussion.)
Acutely concussed athletes can only concentrate for 30- to 45-minute blocks of time, she added, so “I like to prescribe rest breaks. I try to get them to recognize that if they go to a hard class like calculus and have to work hard for 45 minutes or so they’re probably going to be fried for the next period, so there needs to be something a little less onerous like study hall, or lunch, where they can rest. They need to use common sense during the day.”
During office visits Dr. Logan reviews the school day schedule with patients “and we try to target different areas where they can feel comfortable to rest. I’m asking their opinion on where the best spots in their day are to get some rest. Because if I just say, ‘you’re going to do this, this, and this, what’s their likelihood of following through with those instructions? It’s really low.”
She recommends limiting computer time, reading, math, and note-taking during recovery, as each task tends to cause symptoms to worsen. “Having either the teacher’s notes supplied to them or having another student take notes for them may allow them to tolerate more class time than they would if they were trying to take notes,” said Dr. Logan, who has also served on the National Collegiate Athletic Association Committee on Competitive Safeguards and Medical Aspects of Sports. “Listen to lectures only.” At home, they should perform only activities that don’t exacerbate symptoms. This means limiting instant messaging, texting, watching TV, and playing video games.
A subset of concussive patients will be overstimulated by light and sound, “so it’s important to ask about that and make adjustments in the school day,” she said. “This would involve reducing sound and light when you can, wearing sunglasses and earplugs. You might have to write a note for that. It would involve avoiding classes like band, choir, and shop class, and avoiding crowded hallways, cafeterias, maybe allow that student to leave early or arrive a few minutes late to get them out of that busy hallway and help them extend their school day.”
Dr. Logan recommends delaying tests that may fall in the time line of recovery, such as midterms, finals, or college-readiness tests such as the SAT. “A brain-injured person is not going to do well on any of these tests,” she said. “In notes to school personnel write ‘no testing for now,’ or ‘postpone testing.’ ”
She advises pediatricians to “proactively identify” the point person at school who keeps tabs on how your patient is doing. “It’s going to be different at every school,” she said. “At one school, it might be a nurse. At another, it might be a teacher or an assistant principal. You have to identify that person. If you’re sensing that there’s going to be a problem, or if the parent says ‘nobody’s listening to me,’ call that point person. It really pays to get on the phone and talk about this patient. That goes so far and can help decrease problems with the next concussion patient at that school. Make sure the school feels like they’re on a team with you, that it’s not a doctor telling the school what they have to do.”
Patients can gradually progress to a full school day “when symptoms go away,” Dr. Logan said. “I like them to be able to tolerate nearly a full school day before we start to give them homework, because I know that during the day they’re giving all they have in energy reserve. When they get home they need time for their brain to rest.”
Dr. Logan reported having no financial disclosures.
On Twitter @dougbrunk
SAN DIEGO – With all the media attention drawn to the impact of sports-related concussion in recent years, a significant portion of schools in the United States have adopted “return to play” guidelines, but only a minority have “return to learn” protocols in place, according to Dr. Kelsey Logan.
Literature on the topic is scarce, but one survey of school nurses in Illinois found that 57% of schools in that state had return to play protocols while only 30% had protocols in place for returning to the classroom, Dr. Logan said at the annual meeting of the American Academy of Pediatrics. A separate survey of youth in Nebraska who sustained a concussion in sports found that only 42% of their teachers provided extra assistance in the classroom following their injury.
Limiting cognitive activities “is a big part of their stress in getting over their injury,” said Dr. Logan, who directs the division of sports medicine at Cincinnati Children’s Hospital Medical Center. “I talk to the families about decreasing their child’s emotional stress, and academics are largely a cause of this. They’re stressed from day 1 about the work they’re missing. They’ll say things like, ‘How do I make teachers understand? I don’t want people to think I’m not doing my work.’ If we address those upfront, they tend to be a little less stressed.”
She noted that increasing cognitive activity soon after a concussive injury “worsens symptoms and prolongs recovery. That often takes several conversations with patients and parents before they understand that concept. Many times parents want you to micromanage their kid’s day – tell them exactly what they can and can’t do. That’s not really our role. I cannot predict whether 15 versus 20 minutes of looking on a computer is going to make their symptoms worse. Understanding concepts is important. When you start to experience a big gap in energy and your symptoms get worse, you need to back off. Our goal is to determine the appropriate balance of cognitive activity and cognitive rest.”
Developing a return to learning plan following a concussion starts with an assessment of the patient’s symptoms, which vary from individual to individual. “You can’t predict exactly what a person’s going to go through,” said Dr. Logan, one of the authors of a guideline on return to learning that was published online in Pediatrics (2013 [doi:10.1542/peds.2013-2867]). “Some of it’s trial and error. It’s important to consider physical, cognitive, emotional, and sleep symptoms. All of these can combine. Some patients will have many emotional symptoms after a concussion; others won’t. This is why it’s so important for primary care pediatricians to be treating concussions because they know their patients.”
She recommends that patients and their families use checklists to document symptoms, track their severity and progression, and target symptoms to address with school personnel. The ideal role of family members and friends is to enforce rest and reduce stimulation, while the role of medical team is to evaluate symptoms, prescribe physical and cognitive rest, and get input from family members and school personnel on the patient’s progress. The chief goal is to help the patient get the most out of his or her school day without worsening symptoms. This starts by limiting school time. “For an athlete who has a constant headache, I would recommend that she stay out of school until she feels a little bit better,” Dr. Logan said. “There’s not a specific symptom score that she needs to meet to go back to school. It’s when the family and the patient feel that she can go to school and concentrate. You don’t want to throw that athlete back into a full school day right away. You want to start with a few hours of school, maybe a half-day depending on symptoms.” (The CDC has developed a tip sheet for school personnel on helping students return to school after a concussion.)
Acutely concussed athletes can only concentrate for 30- to 45-minute blocks of time, she added, so “I like to prescribe rest breaks. I try to get them to recognize that if they go to a hard class like calculus and have to work hard for 45 minutes or so they’re probably going to be fried for the next period, so there needs to be something a little less onerous like study hall, or lunch, where they can rest. They need to use common sense during the day.”
During office visits Dr. Logan reviews the school day schedule with patients “and we try to target different areas where they can feel comfortable to rest. I’m asking their opinion on where the best spots in their day are to get some rest. Because if I just say, ‘you’re going to do this, this, and this, what’s their likelihood of following through with those instructions? It’s really low.”
She recommends limiting computer time, reading, math, and note-taking during recovery, as each task tends to cause symptoms to worsen. “Having either the teacher’s notes supplied to them or having another student take notes for them may allow them to tolerate more class time than they would if they were trying to take notes,” said Dr. Logan, who has also served on the National Collegiate Athletic Association Committee on Competitive Safeguards and Medical Aspects of Sports. “Listen to lectures only.” At home, they should perform only activities that don’t exacerbate symptoms. This means limiting instant messaging, texting, watching TV, and playing video games.
A subset of concussive patients will be overstimulated by light and sound, “so it’s important to ask about that and make adjustments in the school day,” she said. “This would involve reducing sound and light when you can, wearing sunglasses and earplugs. You might have to write a note for that. It would involve avoiding classes like band, choir, and shop class, and avoiding crowded hallways, cafeterias, maybe allow that student to leave early or arrive a few minutes late to get them out of that busy hallway and help them extend their school day.”
Dr. Logan recommends delaying tests that may fall in the time line of recovery, such as midterms, finals, or college-readiness tests such as the SAT. “A brain-injured person is not going to do well on any of these tests,” she said. “In notes to school personnel write ‘no testing for now,’ or ‘postpone testing.’ ”
She advises pediatricians to “proactively identify” the point person at school who keeps tabs on how your patient is doing. “It’s going to be different at every school,” she said. “At one school, it might be a nurse. At another, it might be a teacher or an assistant principal. You have to identify that person. If you’re sensing that there’s going to be a problem, or if the parent says ‘nobody’s listening to me,’ call that point person. It really pays to get on the phone and talk about this patient. That goes so far and can help decrease problems with the next concussion patient at that school. Make sure the school feels like they’re on a team with you, that it’s not a doctor telling the school what they have to do.”
Patients can gradually progress to a full school day “when symptoms go away,” Dr. Logan said. “I like them to be able to tolerate nearly a full school day before we start to give them homework, because I know that during the day they’re giving all they have in energy reserve. When they get home they need time for their brain to rest.”
Dr. Logan reported having no financial disclosures.
On Twitter @dougbrunk
SAN DIEGO – With all the media attention drawn to the impact of sports-related concussion in recent years, a significant portion of schools in the United States have adopted “return to play” guidelines, but only a minority have “return to learn” protocols in place, according to Dr. Kelsey Logan.
Literature on the topic is scarce, but one survey of school nurses in Illinois found that 57% of schools in that state had return to play protocols while only 30% had protocols in place for returning to the classroom, Dr. Logan said at the annual meeting of the American Academy of Pediatrics. A separate survey of youth in Nebraska who sustained a concussion in sports found that only 42% of their teachers provided extra assistance in the classroom following their injury.
Limiting cognitive activities “is a big part of their stress in getting over their injury,” said Dr. Logan, who directs the division of sports medicine at Cincinnati Children’s Hospital Medical Center. “I talk to the families about decreasing their child’s emotional stress, and academics are largely a cause of this. They’re stressed from day 1 about the work they’re missing. They’ll say things like, ‘How do I make teachers understand? I don’t want people to think I’m not doing my work.’ If we address those upfront, they tend to be a little less stressed.”
She noted that increasing cognitive activity soon after a concussive injury “worsens symptoms and prolongs recovery. That often takes several conversations with patients and parents before they understand that concept. Many times parents want you to micromanage their kid’s day – tell them exactly what they can and can’t do. That’s not really our role. I cannot predict whether 15 versus 20 minutes of looking on a computer is going to make their symptoms worse. Understanding concepts is important. When you start to experience a big gap in energy and your symptoms get worse, you need to back off. Our goal is to determine the appropriate balance of cognitive activity and cognitive rest.”
Developing a return to learning plan following a concussion starts with an assessment of the patient’s symptoms, which vary from individual to individual. “You can’t predict exactly what a person’s going to go through,” said Dr. Logan, one of the authors of a guideline on return to learning that was published online in Pediatrics (2013 [doi:10.1542/peds.2013-2867]). “Some of it’s trial and error. It’s important to consider physical, cognitive, emotional, and sleep symptoms. All of these can combine. Some patients will have many emotional symptoms after a concussion; others won’t. This is why it’s so important for primary care pediatricians to be treating concussions because they know their patients.”
She recommends that patients and their families use checklists to document symptoms, track their severity and progression, and target symptoms to address with school personnel. The ideal role of family members and friends is to enforce rest and reduce stimulation, while the role of medical team is to evaluate symptoms, prescribe physical and cognitive rest, and get input from family members and school personnel on the patient’s progress. The chief goal is to help the patient get the most out of his or her school day without worsening symptoms. This starts by limiting school time. “For an athlete who has a constant headache, I would recommend that she stay out of school until she feels a little bit better,” Dr. Logan said. “There’s not a specific symptom score that she needs to meet to go back to school. It’s when the family and the patient feel that she can go to school and concentrate. You don’t want to throw that athlete back into a full school day right away. You want to start with a few hours of school, maybe a half-day depending on symptoms.” (The CDC has developed a tip sheet for school personnel on helping students return to school after a concussion.)
Acutely concussed athletes can only concentrate for 30- to 45-minute blocks of time, she added, so “I like to prescribe rest breaks. I try to get them to recognize that if they go to a hard class like calculus and have to work hard for 45 minutes or so they’re probably going to be fried for the next period, so there needs to be something a little less onerous like study hall, or lunch, where they can rest. They need to use common sense during the day.”
During office visits Dr. Logan reviews the school day schedule with patients “and we try to target different areas where they can feel comfortable to rest. I’m asking their opinion on where the best spots in their day are to get some rest. Because if I just say, ‘you’re going to do this, this, and this, what’s their likelihood of following through with those instructions? It’s really low.”
She recommends limiting computer time, reading, math, and note-taking during recovery, as each task tends to cause symptoms to worsen. “Having either the teacher’s notes supplied to them or having another student take notes for them may allow them to tolerate more class time than they would if they were trying to take notes,” said Dr. Logan, who has also served on the National Collegiate Athletic Association Committee on Competitive Safeguards and Medical Aspects of Sports. “Listen to lectures only.” At home, they should perform only activities that don’t exacerbate symptoms. This means limiting instant messaging, texting, watching TV, and playing video games.
A subset of concussive patients will be overstimulated by light and sound, “so it’s important to ask about that and make adjustments in the school day,” she said. “This would involve reducing sound and light when you can, wearing sunglasses and earplugs. You might have to write a note for that. It would involve avoiding classes like band, choir, and shop class, and avoiding crowded hallways, cafeterias, maybe allow that student to leave early or arrive a few minutes late to get them out of that busy hallway and help them extend their school day.”
Dr. Logan recommends delaying tests that may fall in the time line of recovery, such as midterms, finals, or college-readiness tests such as the SAT. “A brain-injured person is not going to do well on any of these tests,” she said. “In notes to school personnel write ‘no testing for now,’ or ‘postpone testing.’ ”
She advises pediatricians to “proactively identify” the point person at school who keeps tabs on how your patient is doing. “It’s going to be different at every school,” she said. “At one school, it might be a nurse. At another, it might be a teacher or an assistant principal. You have to identify that person. If you’re sensing that there’s going to be a problem, or if the parent says ‘nobody’s listening to me,’ call that point person. It really pays to get on the phone and talk about this patient. That goes so far and can help decrease problems with the next concussion patient at that school. Make sure the school feels like they’re on a team with you, that it’s not a doctor telling the school what they have to do.”
Patients can gradually progress to a full school day “when symptoms go away,” Dr. Logan said. “I like them to be able to tolerate nearly a full school day before we start to give them homework, because I know that during the day they’re giving all they have in energy reserve. When they get home they need time for their brain to rest.”
Dr. Logan reported having no financial disclosures.
On Twitter @dougbrunk
EXPERT ANALYSIS FROM THE AAP NATIONAL CONFERENCE
Health care texting is ‘the right format for today’s families’
SAN DIEGO– Dr. Colleen A. Kraft characterizes health care texting as “the right format for today’s families,” because an estimated 91% of young Americans have cell phones and 90% of text messages are read within the first 3 minutes of receiving them.
Text messages “get people’s attention,” she said during a plenary session at the annual meeting of the American Academy of Pediatrics. “They reach a wide audience. Youth text more than their adult counterparts, and low-income Americans text more than higher-income adults.”
One health care–texting program, Text4baby, has become the largest mobile health service in the United States, reaching more than 760,000 moms since it was launched in 2010. Pregnant women and moms with kids under 1 year of age can sign up by texting BABY (or BEBE for the Spanish version) to 511411. Participants receive free health and safety messages three times per week timed to their baby’s due date.
“You also get messages after that until the baby is 1 year old [which] are developmentally appropriate as well,” said Dr. Kraft, who is a member of the content development council for the service. This council creates messages based on the medical literature and comprises representatives from medical organizations including the AAP, the American College of Nurse-Midwives, the American Congress of Obstetricians and Gynecologists, the Centers for Disease Control and Prevention, and the March of Dimes, “a number of people who are very interested in the outcomes of healthy pregnancy,” she said.
Text4baby targets low-income and young women, especially those who identify themselves as Hispanic or African American at higher risk of disproportionately poor birth outcomes. The service addresses critical maternal and child health topics, including safety, development, nutrition, prenatal care, oral health, and preparing for well-baby visits.
“There’s often a very big disconnect with our lower-income families regarding [the notion of] ‘here’s the end of your pregnancy. Now you need to find a pediatrician,’” explained Dr. Kraft, medical director of the Health Network at Cincinnati Children’s Hospital Medical Center. “We find that our upper-income families often will do prenatal visits, but this is not the case with our lower-income families.”
More than half of the messages (58%) contain additional health and resource information and 46% link to mobile Web pages developed in partnership with the AAP and other medical associations. “This is great, because if someone gets a message and they want to find out more about it, they can click a link and be directed to a video or to more information to read,” she said. “There are priority topics, and there’s audience testing so we can see what messages actually resonate with our younger families and with our pregnant moms, because we don’t want to be sending out messages that people aren’t going to read or understand or relate to.”
For example, nine messages prompt mothers to text back LIKE when they find a message helpful, and seven messages encourage mothers to text back MORE to get additional information. Text4baby also features an appointment reminder as a way to improve well-baby and other appointment adherence and immunization rates.
Studies of Text4baby outcomes to date suggest that the service helps participants “become more prepared and more proactive when they go to their obstetric and pediatric appointments, and they’re more likely to keep appointments,” Dr. Kraft said. “It also helps to facilitate interaction with health providers and improves access to health services. We’ve had anecdotal reports of physicians who’ve told us that moms [who use the service] arrive knowing what glucose testing is all about, or what immunizations are all about.”
According to Dr. Kraft, the National Institutes of Health is supporting two research projects related to Text4baby. One involves incorporating the Parents’ Evaluation and Developmental Status (PEDS) as a text message. “If somebody could fill out those questions, would we have access to some developmental information on children prior to when they come in for a physician appointment?” Dr. Kraft asked.
The second research program involves using the service in smoking-cessation efforts, “looking at the feasibility of a text-based interactive tool that counsels pregnant smokers on smoking cessation and ways to develop a sustainability plan.”
Dr. Kraft noted that HIPAA compliance “is one of the big fears about using texting in health care.” HIPAA-compliant texting involves at least four features that are used by current enterprise platforms such as Healthify and Duet Health. First, is there a secure data center at the point of contact of all of these text messages? Is there encryption of the material, so if you lost your cell phone someone could not access the information? Recipient authentication is also important. “You want to make sure that if you’ve sent a text message to somebody, that that particular person is the one who is getting the text message, and that you’re able to verify that the text message is going to the right person,” Dr. Kraft said. The fourth feature of a HIPAA-compliant texting system is having audit controls. In other words, “are you able to monitor what’s happening in terms of the traffic of your text messaging?”
She predicted that the future of health care texting will involve studies of its impact on the way health care is delivered by clinicians at all levels, as well as how it affects patient outcomes such as prematurity, healthy weight, and prevention of diabetes. “We have a lot of process measures for health care texting,” she said. “What we don’t have are the outcomes. These are what we are going to be studying in the future.”
Dr. Kraft reported having no relevant financial disclosures.
On Twitter @dougbrunk
SAN DIEGO– Dr. Colleen A. Kraft characterizes health care texting as “the right format for today’s families,” because an estimated 91% of young Americans have cell phones and 90% of text messages are read within the first 3 minutes of receiving them.
Text messages “get people’s attention,” she said during a plenary session at the annual meeting of the American Academy of Pediatrics. “They reach a wide audience. Youth text more than their adult counterparts, and low-income Americans text more than higher-income adults.”
One health care–texting program, Text4baby, has become the largest mobile health service in the United States, reaching more than 760,000 moms since it was launched in 2010. Pregnant women and moms with kids under 1 year of age can sign up by texting BABY (or BEBE for the Spanish version) to 511411. Participants receive free health and safety messages three times per week timed to their baby’s due date.
“You also get messages after that until the baby is 1 year old [which] are developmentally appropriate as well,” said Dr. Kraft, who is a member of the content development council for the service. This council creates messages based on the medical literature and comprises representatives from medical organizations including the AAP, the American College of Nurse-Midwives, the American Congress of Obstetricians and Gynecologists, the Centers for Disease Control and Prevention, and the March of Dimes, “a number of people who are very interested in the outcomes of healthy pregnancy,” she said.
Text4baby targets low-income and young women, especially those who identify themselves as Hispanic or African American at higher risk of disproportionately poor birth outcomes. The service addresses critical maternal and child health topics, including safety, development, nutrition, prenatal care, oral health, and preparing for well-baby visits.
“There’s often a very big disconnect with our lower-income families regarding [the notion of] ‘here’s the end of your pregnancy. Now you need to find a pediatrician,’” explained Dr. Kraft, medical director of the Health Network at Cincinnati Children’s Hospital Medical Center. “We find that our upper-income families often will do prenatal visits, but this is not the case with our lower-income families.”
More than half of the messages (58%) contain additional health and resource information and 46% link to mobile Web pages developed in partnership with the AAP and other medical associations. “This is great, because if someone gets a message and they want to find out more about it, they can click a link and be directed to a video or to more information to read,” she said. “There are priority topics, and there’s audience testing so we can see what messages actually resonate with our younger families and with our pregnant moms, because we don’t want to be sending out messages that people aren’t going to read or understand or relate to.”
For example, nine messages prompt mothers to text back LIKE when they find a message helpful, and seven messages encourage mothers to text back MORE to get additional information. Text4baby also features an appointment reminder as a way to improve well-baby and other appointment adherence and immunization rates.
Studies of Text4baby outcomes to date suggest that the service helps participants “become more prepared and more proactive when they go to their obstetric and pediatric appointments, and they’re more likely to keep appointments,” Dr. Kraft said. “It also helps to facilitate interaction with health providers and improves access to health services. We’ve had anecdotal reports of physicians who’ve told us that moms [who use the service] arrive knowing what glucose testing is all about, or what immunizations are all about.”
According to Dr. Kraft, the National Institutes of Health is supporting two research projects related to Text4baby. One involves incorporating the Parents’ Evaluation and Developmental Status (PEDS) as a text message. “If somebody could fill out those questions, would we have access to some developmental information on children prior to when they come in for a physician appointment?” Dr. Kraft asked.
The second research program involves using the service in smoking-cessation efforts, “looking at the feasibility of a text-based interactive tool that counsels pregnant smokers on smoking cessation and ways to develop a sustainability plan.”
Dr. Kraft noted that HIPAA compliance “is one of the big fears about using texting in health care.” HIPAA-compliant texting involves at least four features that are used by current enterprise platforms such as Healthify and Duet Health. First, is there a secure data center at the point of contact of all of these text messages? Is there encryption of the material, so if you lost your cell phone someone could not access the information? Recipient authentication is also important. “You want to make sure that if you’ve sent a text message to somebody, that that particular person is the one who is getting the text message, and that you’re able to verify that the text message is going to the right person,” Dr. Kraft said. The fourth feature of a HIPAA-compliant texting system is having audit controls. In other words, “are you able to monitor what’s happening in terms of the traffic of your text messaging?”
She predicted that the future of health care texting will involve studies of its impact on the way health care is delivered by clinicians at all levels, as well as how it affects patient outcomes such as prematurity, healthy weight, and prevention of diabetes. “We have a lot of process measures for health care texting,” she said. “What we don’t have are the outcomes. These are what we are going to be studying in the future.”
Dr. Kraft reported having no relevant financial disclosures.
On Twitter @dougbrunk
SAN DIEGO– Dr. Colleen A. Kraft characterizes health care texting as “the right format for today’s families,” because an estimated 91% of young Americans have cell phones and 90% of text messages are read within the first 3 minutes of receiving them.
Text messages “get people’s attention,” she said during a plenary session at the annual meeting of the American Academy of Pediatrics. “They reach a wide audience. Youth text more than their adult counterparts, and low-income Americans text more than higher-income adults.”
One health care–texting program, Text4baby, has become the largest mobile health service in the United States, reaching more than 760,000 moms since it was launched in 2010. Pregnant women and moms with kids under 1 year of age can sign up by texting BABY (or BEBE for the Spanish version) to 511411. Participants receive free health and safety messages three times per week timed to their baby’s due date.
“You also get messages after that until the baby is 1 year old [which] are developmentally appropriate as well,” said Dr. Kraft, who is a member of the content development council for the service. This council creates messages based on the medical literature and comprises representatives from medical organizations including the AAP, the American College of Nurse-Midwives, the American Congress of Obstetricians and Gynecologists, the Centers for Disease Control and Prevention, and the March of Dimes, “a number of people who are very interested in the outcomes of healthy pregnancy,” she said.
Text4baby targets low-income and young women, especially those who identify themselves as Hispanic or African American at higher risk of disproportionately poor birth outcomes. The service addresses critical maternal and child health topics, including safety, development, nutrition, prenatal care, oral health, and preparing for well-baby visits.
“There’s often a very big disconnect with our lower-income families regarding [the notion of] ‘here’s the end of your pregnancy. Now you need to find a pediatrician,’” explained Dr. Kraft, medical director of the Health Network at Cincinnati Children’s Hospital Medical Center. “We find that our upper-income families often will do prenatal visits, but this is not the case with our lower-income families.”
More than half of the messages (58%) contain additional health and resource information and 46% link to mobile Web pages developed in partnership with the AAP and other medical associations. “This is great, because if someone gets a message and they want to find out more about it, they can click a link and be directed to a video or to more information to read,” she said. “There are priority topics, and there’s audience testing so we can see what messages actually resonate with our younger families and with our pregnant moms, because we don’t want to be sending out messages that people aren’t going to read or understand or relate to.”
For example, nine messages prompt mothers to text back LIKE when they find a message helpful, and seven messages encourage mothers to text back MORE to get additional information. Text4baby also features an appointment reminder as a way to improve well-baby and other appointment adherence and immunization rates.
Studies of Text4baby outcomes to date suggest that the service helps participants “become more prepared and more proactive when they go to their obstetric and pediatric appointments, and they’re more likely to keep appointments,” Dr. Kraft said. “It also helps to facilitate interaction with health providers and improves access to health services. We’ve had anecdotal reports of physicians who’ve told us that moms [who use the service] arrive knowing what glucose testing is all about, or what immunizations are all about.”
According to Dr. Kraft, the National Institutes of Health is supporting two research projects related to Text4baby. One involves incorporating the Parents’ Evaluation and Developmental Status (PEDS) as a text message. “If somebody could fill out those questions, would we have access to some developmental information on children prior to when they come in for a physician appointment?” Dr. Kraft asked.
The second research program involves using the service in smoking-cessation efforts, “looking at the feasibility of a text-based interactive tool that counsels pregnant smokers on smoking cessation and ways to develop a sustainability plan.”
Dr. Kraft noted that HIPAA compliance “is one of the big fears about using texting in health care.” HIPAA-compliant texting involves at least four features that are used by current enterprise platforms such as Healthify and Duet Health. First, is there a secure data center at the point of contact of all of these text messages? Is there encryption of the material, so if you lost your cell phone someone could not access the information? Recipient authentication is also important. “You want to make sure that if you’ve sent a text message to somebody, that that particular person is the one who is getting the text message, and that you’re able to verify that the text message is going to the right person,” Dr. Kraft said. The fourth feature of a HIPAA-compliant texting system is having audit controls. In other words, “are you able to monitor what’s happening in terms of the traffic of your text messaging?”
She predicted that the future of health care texting will involve studies of its impact on the way health care is delivered by clinicians at all levels, as well as how it affects patient outcomes such as prematurity, healthy weight, and prevention of diabetes. “We have a lot of process measures for health care texting,” she said. “What we don’t have are the outcomes. These are what we are going to be studying in the future.”
Dr. Kraft reported having no relevant financial disclosures.
On Twitter @dougbrunk
EXPERT ANALYSIS AT THE AAP NATIONAL CONFERENCE
Incidence of cranial nerve injury after CEA is low
CORONADO, CALIF. – Cranial nerve injury occurred in 4.6% of patients who participated in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), with 34% resolution at 1 month and 80.8% at 1 year, a detailed analysis demonstrated.
While cranial nerve injury (CNI) is the most common neurologic complication of carotid endarterectomy, its reported incidence “is highly variable, ranging from 3% to 30% and depends on the intensity and the methods that are used for evaluation,” Dr. Robert J. Hye said at the annual meeting of the Western Vascular Society. “When using clinical criteria as in CREST, the incidence varies from 5% to 8%, and most injuries resolve in a few weeks. But in rare cases it can result in significant long-term disability.”
Most publications that have evaluated CNI discuss the frequency of nerve injury, not resolution or the time to healing. “Previous publications have identified prolonged operations, urgent operations, and re-exploration as predictors of CNI,” said Dr. Hye of the department of general and vascular surgery at Kaiser Permanente, San Diego. “Advocates of CAS [carotid artery stenting] have equated CNI with minor stroke, mitigating some of the benefit of CEA over CAS.”
He and his associates conducted the present study in an effort to evaluate the incidence, predictive factors, and resolution and also to compare health-related quality of life in patients with and without CNI in CREST, a trial conducted at 117 centers in the United States and Canada in which 2,502 patients were randomized to receive either CAS or CEA. Researchers in that trial observed no difference in outcome in the combined primary endpoint of stroke, MI, and death, but periprocedural stroke was significantly more common in the CAS group and periprocedural MI in the CEA group. Quality of life analyses were performed at 2 weeks, 1 month, and 12 months after the interventions (N. Engl. J. Med. 2010;363:11-23).
For the current analysis, patients with CNI were identified from the CREST database and classified using case report forms, adverse event reports, and clinical follow-up notes. Adjudication of the CNIs was performed by two neurologists and one vascular surgeon. Patients with only cutaneous sensory symptoms were excluded from analysis, and postprocedural outcomes were assessed at 30 days and 12 months. The researchers used the SF-36 and disease-specific Likert scales to measure health-related quality of life.
The mean age of patients at baseline was 68 years. Dr. Hye reported that CNI occurred in 53 of 1,151 (4.6%) randomized to CEA who received their operation within 30 days. CNIs were also noted in five additional patients: three who crossed over from CAS to CEA and two who did not undergo CEA within 30 days of randomization. In contrast to prior studies, CNI was significantly more common when general anesthesia was used, but there were no other demographic or procedural characteristics that were predictive of CNI. About one-third of CNIs (34%) were resolved at 30 days, and 80.8% were resolved at 1 year. CNI had a small effect on quality of life, negatively impacting only swallowing and eating at 2 and 4 weeks but not at 1 year (P less than .001).
Injuries to cranial nerves IX and X were most common, followed by injuries to the marginal mandibular branch of the facial nerve and the hypoglossal nerves. All of the hypoglossal injuries resolved, while injuries involving cranial nerves IX and X were least likely to resolve.
Dr. Hye acknowledged certain limitations of the trial, including the fact that CNI diagnosis was made from a clinical standpoint, and there were no routine otolaryngologic exams. “It’s likely that some of the subtle injuries were missed and that the incidence of cranial nerve injury is underestimated,” he added. “On the other hand, patients did have postoperative exams by experienced neurologists and vascular surgeons, so not many of the injuries should have been missed. Another unique thing about the study is the [quality of life] tools [we used]. They may be insufficiently sensitive to detect the consequences of CNI.”
Dr. Hye went on to note that the persistence of CNI at 1 year in CREST is higher than in most other reports available in the medical literature (19.2% vs. 7%-12%, respectively). “We’re not really sure why this is the case,” he said. “It may be that the postoperative assessment in CREST was more detailed and detected more subtle residual deficits from the CNIs.”
The study was funded by the National Institutes of Health, with supplemental funding from Abbott Vascular Inc. Dr. Hye reported having no financial disclosures.
On Twitter @dougbrunk
CORONADO, CALIF. – Cranial nerve injury occurred in 4.6% of patients who participated in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), with 34% resolution at 1 month and 80.8% at 1 year, a detailed analysis demonstrated.
While cranial nerve injury (CNI) is the most common neurologic complication of carotid endarterectomy, its reported incidence “is highly variable, ranging from 3% to 30% and depends on the intensity and the methods that are used for evaluation,” Dr. Robert J. Hye said at the annual meeting of the Western Vascular Society. “When using clinical criteria as in CREST, the incidence varies from 5% to 8%, and most injuries resolve in a few weeks. But in rare cases it can result in significant long-term disability.”
Most publications that have evaluated CNI discuss the frequency of nerve injury, not resolution or the time to healing. “Previous publications have identified prolonged operations, urgent operations, and re-exploration as predictors of CNI,” said Dr. Hye of the department of general and vascular surgery at Kaiser Permanente, San Diego. “Advocates of CAS [carotid artery stenting] have equated CNI with minor stroke, mitigating some of the benefit of CEA over CAS.”
He and his associates conducted the present study in an effort to evaluate the incidence, predictive factors, and resolution and also to compare health-related quality of life in patients with and without CNI in CREST, a trial conducted at 117 centers in the United States and Canada in which 2,502 patients were randomized to receive either CAS or CEA. Researchers in that trial observed no difference in outcome in the combined primary endpoint of stroke, MI, and death, but periprocedural stroke was significantly more common in the CAS group and periprocedural MI in the CEA group. Quality of life analyses were performed at 2 weeks, 1 month, and 12 months after the interventions (N. Engl. J. Med. 2010;363:11-23).
For the current analysis, patients with CNI were identified from the CREST database and classified using case report forms, adverse event reports, and clinical follow-up notes. Adjudication of the CNIs was performed by two neurologists and one vascular surgeon. Patients with only cutaneous sensory symptoms were excluded from analysis, and postprocedural outcomes were assessed at 30 days and 12 months. The researchers used the SF-36 and disease-specific Likert scales to measure health-related quality of life.
The mean age of patients at baseline was 68 years. Dr. Hye reported that CNI occurred in 53 of 1,151 (4.6%) randomized to CEA who received their operation within 30 days. CNIs were also noted in five additional patients: three who crossed over from CAS to CEA and two who did not undergo CEA within 30 days of randomization. In contrast to prior studies, CNI was significantly more common when general anesthesia was used, but there were no other demographic or procedural characteristics that were predictive of CNI. About one-third of CNIs (34%) were resolved at 30 days, and 80.8% were resolved at 1 year. CNI had a small effect on quality of life, negatively impacting only swallowing and eating at 2 and 4 weeks but not at 1 year (P less than .001).
Injuries to cranial nerves IX and X were most common, followed by injuries to the marginal mandibular branch of the facial nerve and the hypoglossal nerves. All of the hypoglossal injuries resolved, while injuries involving cranial nerves IX and X were least likely to resolve.
Dr. Hye acknowledged certain limitations of the trial, including the fact that CNI diagnosis was made from a clinical standpoint, and there were no routine otolaryngologic exams. “It’s likely that some of the subtle injuries were missed and that the incidence of cranial nerve injury is underestimated,” he added. “On the other hand, patients did have postoperative exams by experienced neurologists and vascular surgeons, so not many of the injuries should have been missed. Another unique thing about the study is the [quality of life] tools [we used]. They may be insufficiently sensitive to detect the consequences of CNI.”
Dr. Hye went on to note that the persistence of CNI at 1 year in CREST is higher than in most other reports available in the medical literature (19.2% vs. 7%-12%, respectively). “We’re not really sure why this is the case,” he said. “It may be that the postoperative assessment in CREST was more detailed and detected more subtle residual deficits from the CNIs.”
The study was funded by the National Institutes of Health, with supplemental funding from Abbott Vascular Inc. Dr. Hye reported having no financial disclosures.
On Twitter @dougbrunk
CORONADO, CALIF. – Cranial nerve injury occurred in 4.6% of patients who participated in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), with 34% resolution at 1 month and 80.8% at 1 year, a detailed analysis demonstrated.
While cranial nerve injury (CNI) is the most common neurologic complication of carotid endarterectomy, its reported incidence “is highly variable, ranging from 3% to 30% and depends on the intensity and the methods that are used for evaluation,” Dr. Robert J. Hye said at the annual meeting of the Western Vascular Society. “When using clinical criteria as in CREST, the incidence varies from 5% to 8%, and most injuries resolve in a few weeks. But in rare cases it can result in significant long-term disability.”
Most publications that have evaluated CNI discuss the frequency of nerve injury, not resolution or the time to healing. “Previous publications have identified prolonged operations, urgent operations, and re-exploration as predictors of CNI,” said Dr. Hye of the department of general and vascular surgery at Kaiser Permanente, San Diego. “Advocates of CAS [carotid artery stenting] have equated CNI with minor stroke, mitigating some of the benefit of CEA over CAS.”
He and his associates conducted the present study in an effort to evaluate the incidence, predictive factors, and resolution and also to compare health-related quality of life in patients with and without CNI in CREST, a trial conducted at 117 centers in the United States and Canada in which 2,502 patients were randomized to receive either CAS or CEA. Researchers in that trial observed no difference in outcome in the combined primary endpoint of stroke, MI, and death, but periprocedural stroke was significantly more common in the CAS group and periprocedural MI in the CEA group. Quality of life analyses were performed at 2 weeks, 1 month, and 12 months after the interventions (N. Engl. J. Med. 2010;363:11-23).
For the current analysis, patients with CNI were identified from the CREST database and classified using case report forms, adverse event reports, and clinical follow-up notes. Adjudication of the CNIs was performed by two neurologists and one vascular surgeon. Patients with only cutaneous sensory symptoms were excluded from analysis, and postprocedural outcomes were assessed at 30 days and 12 months. The researchers used the SF-36 and disease-specific Likert scales to measure health-related quality of life.
The mean age of patients at baseline was 68 years. Dr. Hye reported that CNI occurred in 53 of 1,151 (4.6%) randomized to CEA who received their operation within 30 days. CNIs were also noted in five additional patients: three who crossed over from CAS to CEA and two who did not undergo CEA within 30 days of randomization. In contrast to prior studies, CNI was significantly more common when general anesthesia was used, but there were no other demographic or procedural characteristics that were predictive of CNI. About one-third of CNIs (34%) were resolved at 30 days, and 80.8% were resolved at 1 year. CNI had a small effect on quality of life, negatively impacting only swallowing and eating at 2 and 4 weeks but not at 1 year (P less than .001).
Injuries to cranial nerves IX and X were most common, followed by injuries to the marginal mandibular branch of the facial nerve and the hypoglossal nerves. All of the hypoglossal injuries resolved, while injuries involving cranial nerves IX and X were least likely to resolve.
Dr. Hye acknowledged certain limitations of the trial, including the fact that CNI diagnosis was made from a clinical standpoint, and there were no routine otolaryngologic exams. “It’s likely that some of the subtle injuries were missed and that the incidence of cranial nerve injury is underestimated,” he added. “On the other hand, patients did have postoperative exams by experienced neurologists and vascular surgeons, so not many of the injuries should have been missed. Another unique thing about the study is the [quality of life] tools [we used]. They may be insufficiently sensitive to detect the consequences of CNI.”
Dr. Hye went on to note that the persistence of CNI at 1 year in CREST is higher than in most other reports available in the medical literature (19.2% vs. 7%-12%, respectively). “We’re not really sure why this is the case,” he said. “It may be that the postoperative assessment in CREST was more detailed and detected more subtle residual deficits from the CNIs.”
The study was funded by the National Institutes of Health, with supplemental funding from Abbott Vascular Inc. Dr. Hye reported having no financial disclosures.
On Twitter @dougbrunk
AT THE WESTERN VASCULAR SOCIETY ANNUAL MEETING
Key clinical point: Cranial nerve injury occurred in fewer than 5% of patients undergoing carotid endarterectomy.
Major finding: About one-third of CNIs sustained by patients who underwent CEA resolved within 30 days (34%), and 80.8% resolved at 1 year.
Data source: An analysis of 1,151 patients who were randomized to carotid revascularization endarterectomy in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST).
Disclosures: The study was funded by the National Institutes of Health, with supplemental funding from Abbott Vascular Inc. Dr. Hye reported having no financial disclosures.
Measure associated with LOS in infants with bronchiolitis
SAN DIEGO – Children with a high bronchiolitis risk of admission score are more likely to require longer hospital stays, results from a single-center study showed.
“There’s no tool in the published literature we’re aware of that helps you predict how long a child with bronchiolitis will need to be in the hospital for,” Dr. Matko Marlais said in an interview at the annual meeting of the American Academy of Pediatrics. Such information would be helpful, he continued, because “if the child is quite well, but they still need admission we might decide to put them on the observation ward for 24 hours. But if they’re really unwell, we might decide to put them in the hospital ward as an inpatient. It’s helpful to make that decision at the point of the emergency room triage.”
The 5-point bronchiolitis risk of admission score (BRAS) was developed as a way to help predict the requirement for admission in infants with acute bronchiolitis, and it was validated with this outcome in mind. Points are assigned on the association between the infant and certain factors including duration of symptoms, respiratory rate, heart rate, oxygen saturation, and age at presentation (Arch. Dis. Child. 2011;96:648-52). In an effort to determine whether use of BRAS in the emergency room is able to predict the level of care and length of hospital stay in infants with acute bronchiolitis, Dr. Marlais and his associates evaluated the medical records of all infants who presented to the department of pediatric emergency medicine at Chelsea and Westminster Hospital, London, with the condition during a 12-month period. The analysis was limited to infants up to 1 year of age who required hospitalization.
Clinicians applied the BRAS at the point of emergency room triage and extracted data for each patient from a review of clinical notes, including clinical features at presentation, length of resultant hospital stay, and level of care required (supportive care or noninvasive ventilation via nasal continuous positive airway pressure [CPAP]). The researchers used Spearman Rank correlation coefficient to determine if the BRAS was correlated with the length of hospital stay.
Dr. Marlais reported findings from 163 infants included in the analysis. Of these, 54% were male and their mean age at presentation was 18 weeks. The majority of infants (83%) only required supportive care during their admission, while 17% required noninvasive ventilation via nasal CPAP.
The mean hospital length of stay was 3 days, with a range of 1-30 days. The researchers found that the bronchiolitis risk of admission score was correlated with length of hospital stay (correlation coefficient of 0.47; P< .0001). They also observed that infants who required noninvasive ventilation via CPAP had a significantly higher BRAS, compared with those who required only supportive care (a mean score of 4.14 vs. 3.01, respectively; P< .0001).
“The child with the highest score in this cohort is much more likely to need a hospital stay for 3, 4 or 5 days rather than a child with a lower score,” said Dr. Marlais of the hospital. The association “helps us in managing their flow through the hospital and in giving the parents a bit of an indication as to how long they’ll need to be in the hospital.”
While he characterized the findings as “fairly expected,” he acknowledged certain limitations of the study, including the fact that BRAS “wasn’t developed with [hospital] length of stay as the outcome in mind. It was developed to predict the need for hospital admission. Technically, we would need to develop a new score looking at the predictive factors specifically for length of stay. We haven’t done that.”
Dr. Marlais reported having no relevant financial disclosures.
On Twitter @dougbrunk
SAN DIEGO – Children with a high bronchiolitis risk of admission score are more likely to require longer hospital stays, results from a single-center study showed.
“There’s no tool in the published literature we’re aware of that helps you predict how long a child with bronchiolitis will need to be in the hospital for,” Dr. Matko Marlais said in an interview at the annual meeting of the American Academy of Pediatrics. Such information would be helpful, he continued, because “if the child is quite well, but they still need admission we might decide to put them on the observation ward for 24 hours. But if they’re really unwell, we might decide to put them in the hospital ward as an inpatient. It’s helpful to make that decision at the point of the emergency room triage.”
The 5-point bronchiolitis risk of admission score (BRAS) was developed as a way to help predict the requirement for admission in infants with acute bronchiolitis, and it was validated with this outcome in mind. Points are assigned on the association between the infant and certain factors including duration of symptoms, respiratory rate, heart rate, oxygen saturation, and age at presentation (Arch. Dis. Child. 2011;96:648-52). In an effort to determine whether use of BRAS in the emergency room is able to predict the level of care and length of hospital stay in infants with acute bronchiolitis, Dr. Marlais and his associates evaluated the medical records of all infants who presented to the department of pediatric emergency medicine at Chelsea and Westminster Hospital, London, with the condition during a 12-month period. The analysis was limited to infants up to 1 year of age who required hospitalization.
Clinicians applied the BRAS at the point of emergency room triage and extracted data for each patient from a review of clinical notes, including clinical features at presentation, length of resultant hospital stay, and level of care required (supportive care or noninvasive ventilation via nasal continuous positive airway pressure [CPAP]). The researchers used Spearman Rank correlation coefficient to determine if the BRAS was correlated with the length of hospital stay.
Dr. Marlais reported findings from 163 infants included in the analysis. Of these, 54% were male and their mean age at presentation was 18 weeks. The majority of infants (83%) only required supportive care during their admission, while 17% required noninvasive ventilation via nasal CPAP.
The mean hospital length of stay was 3 days, with a range of 1-30 days. The researchers found that the bronchiolitis risk of admission score was correlated with length of hospital stay (correlation coefficient of 0.47; P< .0001). They also observed that infants who required noninvasive ventilation via CPAP had a significantly higher BRAS, compared with those who required only supportive care (a mean score of 4.14 vs. 3.01, respectively; P< .0001).
“The child with the highest score in this cohort is much more likely to need a hospital stay for 3, 4 or 5 days rather than a child with a lower score,” said Dr. Marlais of the hospital. The association “helps us in managing their flow through the hospital and in giving the parents a bit of an indication as to how long they’ll need to be in the hospital.”
While he characterized the findings as “fairly expected,” he acknowledged certain limitations of the study, including the fact that BRAS “wasn’t developed with [hospital] length of stay as the outcome in mind. It was developed to predict the need for hospital admission. Technically, we would need to develop a new score looking at the predictive factors specifically for length of stay. We haven’t done that.”
Dr. Marlais reported having no relevant financial disclosures.
On Twitter @dougbrunk
SAN DIEGO – Children with a high bronchiolitis risk of admission score are more likely to require longer hospital stays, results from a single-center study showed.
“There’s no tool in the published literature we’re aware of that helps you predict how long a child with bronchiolitis will need to be in the hospital for,” Dr. Matko Marlais said in an interview at the annual meeting of the American Academy of Pediatrics. Such information would be helpful, he continued, because “if the child is quite well, but they still need admission we might decide to put them on the observation ward for 24 hours. But if they’re really unwell, we might decide to put them in the hospital ward as an inpatient. It’s helpful to make that decision at the point of the emergency room triage.”
The 5-point bronchiolitis risk of admission score (BRAS) was developed as a way to help predict the requirement for admission in infants with acute bronchiolitis, and it was validated with this outcome in mind. Points are assigned on the association between the infant and certain factors including duration of symptoms, respiratory rate, heart rate, oxygen saturation, and age at presentation (Arch. Dis. Child. 2011;96:648-52). In an effort to determine whether use of BRAS in the emergency room is able to predict the level of care and length of hospital stay in infants with acute bronchiolitis, Dr. Marlais and his associates evaluated the medical records of all infants who presented to the department of pediatric emergency medicine at Chelsea and Westminster Hospital, London, with the condition during a 12-month period. The analysis was limited to infants up to 1 year of age who required hospitalization.
Clinicians applied the BRAS at the point of emergency room triage and extracted data for each patient from a review of clinical notes, including clinical features at presentation, length of resultant hospital stay, and level of care required (supportive care or noninvasive ventilation via nasal continuous positive airway pressure [CPAP]). The researchers used Spearman Rank correlation coefficient to determine if the BRAS was correlated with the length of hospital stay.
Dr. Marlais reported findings from 163 infants included in the analysis. Of these, 54% were male and their mean age at presentation was 18 weeks. The majority of infants (83%) only required supportive care during their admission, while 17% required noninvasive ventilation via nasal CPAP.
The mean hospital length of stay was 3 days, with a range of 1-30 days. The researchers found that the bronchiolitis risk of admission score was correlated with length of hospital stay (correlation coefficient of 0.47; P< .0001). They also observed that infants who required noninvasive ventilation via CPAP had a significantly higher BRAS, compared with those who required only supportive care (a mean score of 4.14 vs. 3.01, respectively; P< .0001).
“The child with the highest score in this cohort is much more likely to need a hospital stay for 3, 4 or 5 days rather than a child with a lower score,” said Dr. Marlais of the hospital. The association “helps us in managing their flow through the hospital and in giving the parents a bit of an indication as to how long they’ll need to be in the hospital.”
While he characterized the findings as “fairly expected,” he acknowledged certain limitations of the study, including the fact that BRAS “wasn’t developed with [hospital] length of stay as the outcome in mind. It was developed to predict the need for hospital admission. Technically, we would need to develop a new score looking at the predictive factors specifically for length of stay. We haven’t done that.”
Dr. Marlais reported having no relevant financial disclosures.
On Twitter @dougbrunk
AT THE AAP NATIONAL CONFERENCE
Key clinical point: Length of hospital stay is associated with a bronchiolitis risk of admission score (BRAS).
Major finding: In infants with acute bronchiolitis, the BRAS was associated with length of hospital stay (correlation coefficient of .047; P < .0001).
Data source: A review of 163 infants who presented to the department of pediatric emergency medicine at Chelsea and Westminster Hospital, London, with acute bronchiolitis during a 12-month period.
Disclosures: Dr. Marlais reported having no relevant financial disclosures.
Study IDs factors linked to bronchodilator use in bronchiolitis
SAN DIEGO – Key factors associated with the use of bronchodilators in young children hospitalized with bronchiolitis include older age and wheezing and hypoxia upon admission, results from a single-center study showed.
Although the American Academy of Pediatrics does not endorse the routine use of bronchodilators in the treatment of children hospitalized with bronchiolitis (Pediatrics 2006;118:1774-93), “there is substantial variability in the management of bronchiolitis, including the usage of bronchodilators,” researchers led by Dr. Janet Schairer wrote in an abstract presented at the annual meeting of the American Academy of Pediatrics. A recent Cochrane report showed that bronchodilators do not decrease length of hospitalization or reduce the time to illness resolution (Cochrane Database Syst. Rev. 2014; 6:CD001266).
In an effort to determine which demographic and clinical factors are associated with the use of bronchodilators in the treatment of children hospitalized with bronchiolitis, Dr. Schairer and her associates reviewed the medical records of 232 children aged 2 weeks to 24 months who were hospitalized with the condition at Jersey Shore University Medical Center, Neptune, N.J., from October 2009 until September 2012. Data analysis included multivariate regression models to identify variables that were associated with administration of bronchodilators.
Of the 232 children, 120 (51.7%) received bronchodilators and 112 (48.3%) did not. The researchers observed no difference in bronchodilator use among patients with risk factors for asthma, including family history of asthma, personal history of wheezing or eczema, and smoke exposure. “That surprised us,” Dr. Schairer of the division of general pediatrics at the medical center, said in an interview.
Compared with children who did not receive bronchodilators, those who did were older (a mean of 6.5 vs. 4.5 months, respectively; P less than .01); and at hospital admission had a higher prevalence of wheezing (45% vs. 19.6%; P less than .0001); diminished air exchange (10.8% vs. 2.7%; P less than .02), and hypoxia (38.3% vs. 25%; P less than .03). Other treatments administered to those who did and did not receive bronchodilators included nebulized 3% saline (37.9% vs. 36.5%), systemic steroids (10.9% vs. 0%), and antibiotics (45% vs. 33%).
Regression analysis revealed that the use of bronchodilators increased with older age (odds ratio, 0.89), and with oxygen requirement (OR, 1.15) or wheezing (OR, 1.23) at the time of admission. No association between bronchodilator use and length of hospitalization was observed (P > .05).
“Widespread implementation of the AAP guidelines for treatment of children with bronchiolitis is required for reduction of unnecessary use of bronchodilators in hospitalized patients,” Dr. Schairer and her associates concluded in the abstract. “Research to assess which, if any, demographic and clinical factors are associated with response to bronchodilator therapy is needed to further guide physicians in the treatment of bronchiolitis.”
She acknowledged certain limitations of the study, including its single-center design and relatively small cohort size.
Dr. Schairer reported having no financial disclosures.
On Twitter @dougbrunk
SAN DIEGO – Key factors associated with the use of bronchodilators in young children hospitalized with bronchiolitis include older age and wheezing and hypoxia upon admission, results from a single-center study showed.
Although the American Academy of Pediatrics does not endorse the routine use of bronchodilators in the treatment of children hospitalized with bronchiolitis (Pediatrics 2006;118:1774-93), “there is substantial variability in the management of bronchiolitis, including the usage of bronchodilators,” researchers led by Dr. Janet Schairer wrote in an abstract presented at the annual meeting of the American Academy of Pediatrics. A recent Cochrane report showed that bronchodilators do not decrease length of hospitalization or reduce the time to illness resolution (Cochrane Database Syst. Rev. 2014; 6:CD001266).
In an effort to determine which demographic and clinical factors are associated with the use of bronchodilators in the treatment of children hospitalized with bronchiolitis, Dr. Schairer and her associates reviewed the medical records of 232 children aged 2 weeks to 24 months who were hospitalized with the condition at Jersey Shore University Medical Center, Neptune, N.J., from October 2009 until September 2012. Data analysis included multivariate regression models to identify variables that were associated with administration of bronchodilators.
Of the 232 children, 120 (51.7%) received bronchodilators and 112 (48.3%) did not. The researchers observed no difference in bronchodilator use among patients with risk factors for asthma, including family history of asthma, personal history of wheezing or eczema, and smoke exposure. “That surprised us,” Dr. Schairer of the division of general pediatrics at the medical center, said in an interview.
Compared with children who did not receive bronchodilators, those who did were older (a mean of 6.5 vs. 4.5 months, respectively; P less than .01); and at hospital admission had a higher prevalence of wheezing (45% vs. 19.6%; P less than .0001); diminished air exchange (10.8% vs. 2.7%; P less than .02), and hypoxia (38.3% vs. 25%; P less than .03). Other treatments administered to those who did and did not receive bronchodilators included nebulized 3% saline (37.9% vs. 36.5%), systemic steroids (10.9% vs. 0%), and antibiotics (45% vs. 33%).
Regression analysis revealed that the use of bronchodilators increased with older age (odds ratio, 0.89), and with oxygen requirement (OR, 1.15) or wheezing (OR, 1.23) at the time of admission. No association between bronchodilator use and length of hospitalization was observed (P > .05).
“Widespread implementation of the AAP guidelines for treatment of children with bronchiolitis is required for reduction of unnecessary use of bronchodilators in hospitalized patients,” Dr. Schairer and her associates concluded in the abstract. “Research to assess which, if any, demographic and clinical factors are associated with response to bronchodilator therapy is needed to further guide physicians in the treatment of bronchiolitis.”
She acknowledged certain limitations of the study, including its single-center design and relatively small cohort size.
Dr. Schairer reported having no financial disclosures.
On Twitter @dougbrunk
SAN DIEGO – Key factors associated with the use of bronchodilators in young children hospitalized with bronchiolitis include older age and wheezing and hypoxia upon admission, results from a single-center study showed.
Although the American Academy of Pediatrics does not endorse the routine use of bronchodilators in the treatment of children hospitalized with bronchiolitis (Pediatrics 2006;118:1774-93), “there is substantial variability in the management of bronchiolitis, including the usage of bronchodilators,” researchers led by Dr. Janet Schairer wrote in an abstract presented at the annual meeting of the American Academy of Pediatrics. A recent Cochrane report showed that bronchodilators do not decrease length of hospitalization or reduce the time to illness resolution (Cochrane Database Syst. Rev. 2014; 6:CD001266).
In an effort to determine which demographic and clinical factors are associated with the use of bronchodilators in the treatment of children hospitalized with bronchiolitis, Dr. Schairer and her associates reviewed the medical records of 232 children aged 2 weeks to 24 months who were hospitalized with the condition at Jersey Shore University Medical Center, Neptune, N.J., from October 2009 until September 2012. Data analysis included multivariate regression models to identify variables that were associated with administration of bronchodilators.
Of the 232 children, 120 (51.7%) received bronchodilators and 112 (48.3%) did not. The researchers observed no difference in bronchodilator use among patients with risk factors for asthma, including family history of asthma, personal history of wheezing or eczema, and smoke exposure. “That surprised us,” Dr. Schairer of the division of general pediatrics at the medical center, said in an interview.
Compared with children who did not receive bronchodilators, those who did were older (a mean of 6.5 vs. 4.5 months, respectively; P less than .01); and at hospital admission had a higher prevalence of wheezing (45% vs. 19.6%; P less than .0001); diminished air exchange (10.8% vs. 2.7%; P less than .02), and hypoxia (38.3% vs. 25%; P less than .03). Other treatments administered to those who did and did not receive bronchodilators included nebulized 3% saline (37.9% vs. 36.5%), systemic steroids (10.9% vs. 0%), and antibiotics (45% vs. 33%).
Regression analysis revealed that the use of bronchodilators increased with older age (odds ratio, 0.89), and with oxygen requirement (OR, 1.15) or wheezing (OR, 1.23) at the time of admission. No association between bronchodilator use and length of hospitalization was observed (P > .05).
“Widespread implementation of the AAP guidelines for treatment of children with bronchiolitis is required for reduction of unnecessary use of bronchodilators in hospitalized patients,” Dr. Schairer and her associates concluded in the abstract. “Research to assess which, if any, demographic and clinical factors are associated with response to bronchodilator therapy is needed to further guide physicians in the treatment of bronchiolitis.”
She acknowledged certain limitations of the study, including its single-center design and relatively small cohort size.
Dr. Schairer reported having no financial disclosures.
On Twitter @dougbrunk
AT THE AAP NATIONAL CONFERENCE
Key clinical point: Bronchodilator use by young children hospitalized with bronchiolitis had no effect on duration of hospitalization.
Major finding: Compared with children who did not receive bronchodilators, those who did were older (a mean of 6.5 vs. 4.5 months, respectively; P less than .01); and at hospital admission had a higher prevalence of wheezing (45% vs. 19.6%; P less than .0001); diminished air exchange (10.8% vs. 2.7%; P less than .02), and hypoxia (38.3% vs. 25%; P less than .03).
Data source: A review of 232 children aged 2 weeks to 24 months who were hospitalized with bronchiolitis at Jersey Shore University Medical Center, Neptune, N.J., from October 2009 until September 2012.
Disclosures: Dr. Schairer reported having no financial disclosures.
Postcarotid stenting hemodynamic instability doesn’t increase stroke risk
CORONADO, CALIF. – Periprocedural hemodynamic instability, which occurs frequently during carotid artery stenting, may increase the risk of transient ischemic attack, a single-center study showed.
“In carotid artery angioplasty and stenting, manipulation of the carotid sinus baroreceptor can lead to decreased sympathetic vascular tone, increased parasympathetic efferent signals, and a resultant bradycardia and hypotension,” Dr. Tiffany Y. Wu said at the annual meeting of the Western Vascular Society.
According to published reports in the medical literature, the incidence of hemodynamic instability (HI) following carotid artery stenting (CAS) has been observed in 46%-84% of cases. Several studies have also shown that different factors may be associated with the development of HI, according to Dr. Wu of the department of surgery at Huntington Hospital, Pasadena, Calif. “For example, gender, age, tobacco use, and diabetes have all been implicated in being associated with an increased incidence of HI,” she said. “However, the impact of HI on major adverse events is still highly controversial. Thus, it was the purpose of our study to determine the predictors and consequences of hemodynamic instability following CAS.”
She and her associates evaluated consecutive patients who underwent CAS at Huntington Hospital between 2005 and 2013. They examined preoperative risk factors, periprocedural hemodynamic status, and the incidence of major adverse events including stroke, transient ischemic attack, myocardial infarction, and death. The researchers used chi-square analysis to determine the role of periprocedural factors in predicting the risk of HI and to determine if patients experiencing HI were more likely to suffer major adverse events, compared with those who did not.
In all, 199 CAS procedures were performed in 191 patients. More than half (61%) were men, 87% had hypertension, 49% were smokers, 48% had coronary artery disease, 38% had diabetes, 56% were asymptomatic, 24% had experienced a previous TIA, 20% had experienced a previous stroke, 41% were on beta blockers, and 91% received periprocedural atropine.
Hemodynamic instability was classified as hypertension, hypotension, bradycardia, a systolic BP drop of greater than 30 mm Hg, a heart rate drop of more than 20 beats per minute, HI lasting less than 1 hour (transient), or HI lasting more than 1 hour (prolonged).
Dr. Wu reported that 130 cases of HI occurred (65%). Among these, 10% experienced hypotension, 17% experienced bradycardia, and 2.5% experienced a heart rate drop greater than 20 beats per minute. “We also found a low incidence of ICU admission: Only 5.5% of our patients were admitted to the ICU with hemodynamic instability, less than half of whom required the use of vasopressors,” she said. The incidence of major and minor stroke was 1% and 2.5%, respectively, and the incidence of TIA was 2.5%. No MIs or deaths occurred.
The researchers found that age of at least 80 years and female sex were associated with an increased incidence of HI. Previous neck radiation and contralateral occlusion were “somewhat protective against HI,” she noted. “When looking at HI and major adverse events, we found that only prolonged HI was associated with an increased incidence of TIA. However, there was no statistically significant correlation found between HI and stroke.”
Dr. Wu reported having no financial disclosures.
On Twitter @dougbrunk
CORONADO, CALIF. – Periprocedural hemodynamic instability, which occurs frequently during carotid artery stenting, may increase the risk of transient ischemic attack, a single-center study showed.
“In carotid artery angioplasty and stenting, manipulation of the carotid sinus baroreceptor can lead to decreased sympathetic vascular tone, increased parasympathetic efferent signals, and a resultant bradycardia and hypotension,” Dr. Tiffany Y. Wu said at the annual meeting of the Western Vascular Society.
According to published reports in the medical literature, the incidence of hemodynamic instability (HI) following carotid artery stenting (CAS) has been observed in 46%-84% of cases. Several studies have also shown that different factors may be associated with the development of HI, according to Dr. Wu of the department of surgery at Huntington Hospital, Pasadena, Calif. “For example, gender, age, tobacco use, and diabetes have all been implicated in being associated with an increased incidence of HI,” she said. “However, the impact of HI on major adverse events is still highly controversial. Thus, it was the purpose of our study to determine the predictors and consequences of hemodynamic instability following CAS.”
She and her associates evaluated consecutive patients who underwent CAS at Huntington Hospital between 2005 and 2013. They examined preoperative risk factors, periprocedural hemodynamic status, and the incidence of major adverse events including stroke, transient ischemic attack, myocardial infarction, and death. The researchers used chi-square analysis to determine the role of periprocedural factors in predicting the risk of HI and to determine if patients experiencing HI were more likely to suffer major adverse events, compared with those who did not.
In all, 199 CAS procedures were performed in 191 patients. More than half (61%) were men, 87% had hypertension, 49% were smokers, 48% had coronary artery disease, 38% had diabetes, 56% were asymptomatic, 24% had experienced a previous TIA, 20% had experienced a previous stroke, 41% were on beta blockers, and 91% received periprocedural atropine.
Hemodynamic instability was classified as hypertension, hypotension, bradycardia, a systolic BP drop of greater than 30 mm Hg, a heart rate drop of more than 20 beats per minute, HI lasting less than 1 hour (transient), or HI lasting more than 1 hour (prolonged).
Dr. Wu reported that 130 cases of HI occurred (65%). Among these, 10% experienced hypotension, 17% experienced bradycardia, and 2.5% experienced a heart rate drop greater than 20 beats per minute. “We also found a low incidence of ICU admission: Only 5.5% of our patients were admitted to the ICU with hemodynamic instability, less than half of whom required the use of vasopressors,” she said. The incidence of major and minor stroke was 1% and 2.5%, respectively, and the incidence of TIA was 2.5%. No MIs or deaths occurred.
The researchers found that age of at least 80 years and female sex were associated with an increased incidence of HI. Previous neck radiation and contralateral occlusion were “somewhat protective against HI,” she noted. “When looking at HI and major adverse events, we found that only prolonged HI was associated with an increased incidence of TIA. However, there was no statistically significant correlation found between HI and stroke.”
Dr. Wu reported having no financial disclosures.
On Twitter @dougbrunk
CORONADO, CALIF. – Periprocedural hemodynamic instability, which occurs frequently during carotid artery stenting, may increase the risk of transient ischemic attack, a single-center study showed.
“In carotid artery angioplasty and stenting, manipulation of the carotid sinus baroreceptor can lead to decreased sympathetic vascular tone, increased parasympathetic efferent signals, and a resultant bradycardia and hypotension,” Dr. Tiffany Y. Wu said at the annual meeting of the Western Vascular Society.
According to published reports in the medical literature, the incidence of hemodynamic instability (HI) following carotid artery stenting (CAS) has been observed in 46%-84% of cases. Several studies have also shown that different factors may be associated with the development of HI, according to Dr. Wu of the department of surgery at Huntington Hospital, Pasadena, Calif. “For example, gender, age, tobacco use, and diabetes have all been implicated in being associated with an increased incidence of HI,” she said. “However, the impact of HI on major adverse events is still highly controversial. Thus, it was the purpose of our study to determine the predictors and consequences of hemodynamic instability following CAS.”
She and her associates evaluated consecutive patients who underwent CAS at Huntington Hospital between 2005 and 2013. They examined preoperative risk factors, periprocedural hemodynamic status, and the incidence of major adverse events including stroke, transient ischemic attack, myocardial infarction, and death. The researchers used chi-square analysis to determine the role of periprocedural factors in predicting the risk of HI and to determine if patients experiencing HI were more likely to suffer major adverse events, compared with those who did not.
In all, 199 CAS procedures were performed in 191 patients. More than half (61%) were men, 87% had hypertension, 49% were smokers, 48% had coronary artery disease, 38% had diabetes, 56% were asymptomatic, 24% had experienced a previous TIA, 20% had experienced a previous stroke, 41% were on beta blockers, and 91% received periprocedural atropine.
Hemodynamic instability was classified as hypertension, hypotension, bradycardia, a systolic BP drop of greater than 30 mm Hg, a heart rate drop of more than 20 beats per minute, HI lasting less than 1 hour (transient), or HI lasting more than 1 hour (prolonged).
Dr. Wu reported that 130 cases of HI occurred (65%). Among these, 10% experienced hypotension, 17% experienced bradycardia, and 2.5% experienced a heart rate drop greater than 20 beats per minute. “We also found a low incidence of ICU admission: Only 5.5% of our patients were admitted to the ICU with hemodynamic instability, less than half of whom required the use of vasopressors,” she said. The incidence of major and minor stroke was 1% and 2.5%, respectively, and the incidence of TIA was 2.5%. No MIs or deaths occurred.
The researchers found that age of at least 80 years and female sex were associated with an increased incidence of HI. Previous neck radiation and contralateral occlusion were “somewhat protective against HI,” she noted. “When looking at HI and major adverse events, we found that only prolonged HI was associated with an increased incidence of TIA. However, there was no statistically significant correlation found between HI and stroke.”
Dr. Wu reported having no financial disclosures.
On Twitter @dougbrunk
AT THE WESTERN VASCULAR SOCIETY ANNUAL MEETING
Key clinical point: Prolonged hemodynamic instability after carotid artery stenting is associated with increased incidence of TIA, but not MI or death.
Major finding: Age of at least 80 years and female sex were associated with an increased incidence of post-CAS HI. The only significant adverse effect was TIA in patients with prolonged HI.
Data source: A review of 199 CAS procedures performed in 191 consecutive patients at Pasadena, Calif.–based Huntington Hospital between 2005 and 2013.
Disclosures: Dr. Wu reporting having no financial disclosures.
Carotid stenting outcomes similar between surgeons, interventionalists
CORONADO, CALIF. – Major outcomes of stroke, myocardial infarction, and 30-day mortality following carotid stenting are nearly equivalent between surgeons and interventionalists, results from a national cohort study suggest.
In addition, the volume of cases performed by a clinician, rather than the clinician’s specialty, appears to be a stronger predictor of adverse outcomes for performing carotid stenting. Those are key findings from an evaluation of more than 20,000 carotid stenting procedures extracted from the Nationwide Inpatient Sample (NIS) between 2004 and 2011, which was presented at the annual meeting of the Western Vascular Society.
“Stroke is the third most common cause of death in the United States, and 20%-25% of strokes are attributable to carotid stenosis,” said lead author Dr. Michael D. Sgroi, of the division of vascular and endovascular surgery at the University of California, Irvine. “The current standard of care has been carotid endarterectomy. However, in 2010, carotid stenting was recognized as an alternative treatment. Since that time, there’s been an exhaustive debate regarding which is the best treatment.
“In addition, there has been a broad spectrum of physicians practicing the use of carotid stenting, including vascular surgeons, interventional radiologists, neurovascular interventionalists, and interventional cardiologists. This begs the question: Does specialty make a difference in outcomes for carotid stenting?”
Dr. Sgroi and his associates evaluated 20,663 carotid stenting procedures extracted from the NIS dataset. They divided the cohort based on the type of provider performing the procedure: surgeon or interventionalist. All elective, urgent, and emergent cases of carotid stenting were included in the analysis, while patients who underwent balloon angioplasty were excluded, as were those who underwent carotid endarterectomy. The primary endpoints were postoperative stroke or myocardial infarction (MI) and in-hospital mortality. The secondary endpoint was estimated associations with a 10-unit volume difference among centers.
Upon first glance at the data, the researchers detected low numbers of interventionalists. Therefore, they created criteria to identify physicians who were considered surgeons. They defined a surgeon as a physician who performed a carotid endarterectomy and either a femoral-popliteal artery bypass or an arteriovenous fistula within the same calendar year of the carotid stenting procedure.
Of the 20,663 cases, 15,305 (74%) were performed by surgeons, while 5,358 (26%) were performed by interventionalists. The mean patient age was 71 years, 61% were male, and 72% were white. The majority of cases (97%) were performed at teaching hospitals or at designated teaching institutions (61%). Unadjusted outcomes were similar between surgeons and interventionalists in terms of stroke (4.33% vs. 4.41%, respectively), MI (2.10% vs. 2.13%), and mortality (0.84% and 1.03%). When the researchers examined the percentage of stroke in 2008, “we saw an initial increase,” Dr. Sgroi said. “This may have been due to the amount of physicians who were performing carotid stenting.”
The researchers observed a statistically significant difference between the two groups in hospital length of stay as well as total hospital charges, with procedures performed by interventionalists resulting in a stay that was about one-third of a day longer, and about $3,000 more expensive.
Adjusted multivariate analysis demonstrated no statistically significant differences between the two types of clinicians in stroke, MI, or hospital mortality. However, hospital length of stay was significantly lower for procedures performed by surgeons, compared with interventionalists (2.81 vs. 3.08 days, respectively), as were total hospital charges ($48,088 vs. $51,719). “The cause of the difference is unclear and not discernible through the available data,” Dr. Sgroi said.
When he and his associates examined the 10-unit volume difference among centers, they found a statistically significant increase in the rate of stroke among lower-volume centers, but no other significant differences in outcomes were observed. “We believe that the rate of complications secondary to carotid stenting has stayed consistent from 2004 to 2011, despite advances in technology,” Dr. Sgroi concluded.
He acknowledged certain limitations of the study, including its retrospective design and the fact that data from the NIS account for only 20% of the U.S. population.
Dr. Sgroi reported having no financial disclosures.
On Twitter @dougbrunk
CORONADO, CALIF. – Major outcomes of stroke, myocardial infarction, and 30-day mortality following carotid stenting are nearly equivalent between surgeons and interventionalists, results from a national cohort study suggest.
In addition, the volume of cases performed by a clinician, rather than the clinician’s specialty, appears to be a stronger predictor of adverse outcomes for performing carotid stenting. Those are key findings from an evaluation of more than 20,000 carotid stenting procedures extracted from the Nationwide Inpatient Sample (NIS) between 2004 and 2011, which was presented at the annual meeting of the Western Vascular Society.
“Stroke is the third most common cause of death in the United States, and 20%-25% of strokes are attributable to carotid stenosis,” said lead author Dr. Michael D. Sgroi, of the division of vascular and endovascular surgery at the University of California, Irvine. “The current standard of care has been carotid endarterectomy. However, in 2010, carotid stenting was recognized as an alternative treatment. Since that time, there’s been an exhaustive debate regarding which is the best treatment.
“In addition, there has been a broad spectrum of physicians practicing the use of carotid stenting, including vascular surgeons, interventional radiologists, neurovascular interventionalists, and interventional cardiologists. This begs the question: Does specialty make a difference in outcomes for carotid stenting?”
Dr. Sgroi and his associates evaluated 20,663 carotid stenting procedures extracted from the NIS dataset. They divided the cohort based on the type of provider performing the procedure: surgeon or interventionalist. All elective, urgent, and emergent cases of carotid stenting were included in the analysis, while patients who underwent balloon angioplasty were excluded, as were those who underwent carotid endarterectomy. The primary endpoints were postoperative stroke or myocardial infarction (MI) and in-hospital mortality. The secondary endpoint was estimated associations with a 10-unit volume difference among centers.
Upon first glance at the data, the researchers detected low numbers of interventionalists. Therefore, they created criteria to identify physicians who were considered surgeons. They defined a surgeon as a physician who performed a carotid endarterectomy and either a femoral-popliteal artery bypass or an arteriovenous fistula within the same calendar year of the carotid stenting procedure.
Of the 20,663 cases, 15,305 (74%) were performed by surgeons, while 5,358 (26%) were performed by interventionalists. The mean patient age was 71 years, 61% were male, and 72% were white. The majority of cases (97%) were performed at teaching hospitals or at designated teaching institutions (61%). Unadjusted outcomes were similar between surgeons and interventionalists in terms of stroke (4.33% vs. 4.41%, respectively), MI (2.10% vs. 2.13%), and mortality (0.84% and 1.03%). When the researchers examined the percentage of stroke in 2008, “we saw an initial increase,” Dr. Sgroi said. “This may have been due to the amount of physicians who were performing carotid stenting.”
The researchers observed a statistically significant difference between the two groups in hospital length of stay as well as total hospital charges, with procedures performed by interventionalists resulting in a stay that was about one-third of a day longer, and about $3,000 more expensive.
Adjusted multivariate analysis demonstrated no statistically significant differences between the two types of clinicians in stroke, MI, or hospital mortality. However, hospital length of stay was significantly lower for procedures performed by surgeons, compared with interventionalists (2.81 vs. 3.08 days, respectively), as were total hospital charges ($48,088 vs. $51,719). “The cause of the difference is unclear and not discernible through the available data,” Dr. Sgroi said.
When he and his associates examined the 10-unit volume difference among centers, they found a statistically significant increase in the rate of stroke among lower-volume centers, but no other significant differences in outcomes were observed. “We believe that the rate of complications secondary to carotid stenting has stayed consistent from 2004 to 2011, despite advances in technology,” Dr. Sgroi concluded.
He acknowledged certain limitations of the study, including its retrospective design and the fact that data from the NIS account for only 20% of the U.S. population.
Dr. Sgroi reported having no financial disclosures.
On Twitter @dougbrunk
CORONADO, CALIF. – Major outcomes of stroke, myocardial infarction, and 30-day mortality following carotid stenting are nearly equivalent between surgeons and interventionalists, results from a national cohort study suggest.
In addition, the volume of cases performed by a clinician, rather than the clinician’s specialty, appears to be a stronger predictor of adverse outcomes for performing carotid stenting. Those are key findings from an evaluation of more than 20,000 carotid stenting procedures extracted from the Nationwide Inpatient Sample (NIS) between 2004 and 2011, which was presented at the annual meeting of the Western Vascular Society.
“Stroke is the third most common cause of death in the United States, and 20%-25% of strokes are attributable to carotid stenosis,” said lead author Dr. Michael D. Sgroi, of the division of vascular and endovascular surgery at the University of California, Irvine. “The current standard of care has been carotid endarterectomy. However, in 2010, carotid stenting was recognized as an alternative treatment. Since that time, there’s been an exhaustive debate regarding which is the best treatment.
“In addition, there has been a broad spectrum of physicians practicing the use of carotid stenting, including vascular surgeons, interventional radiologists, neurovascular interventionalists, and interventional cardiologists. This begs the question: Does specialty make a difference in outcomes for carotid stenting?”
Dr. Sgroi and his associates evaluated 20,663 carotid stenting procedures extracted from the NIS dataset. They divided the cohort based on the type of provider performing the procedure: surgeon or interventionalist. All elective, urgent, and emergent cases of carotid stenting were included in the analysis, while patients who underwent balloon angioplasty were excluded, as were those who underwent carotid endarterectomy. The primary endpoints were postoperative stroke or myocardial infarction (MI) and in-hospital mortality. The secondary endpoint was estimated associations with a 10-unit volume difference among centers.
Upon first glance at the data, the researchers detected low numbers of interventionalists. Therefore, they created criteria to identify physicians who were considered surgeons. They defined a surgeon as a physician who performed a carotid endarterectomy and either a femoral-popliteal artery bypass or an arteriovenous fistula within the same calendar year of the carotid stenting procedure.
Of the 20,663 cases, 15,305 (74%) were performed by surgeons, while 5,358 (26%) were performed by interventionalists. The mean patient age was 71 years, 61% were male, and 72% were white. The majority of cases (97%) were performed at teaching hospitals or at designated teaching institutions (61%). Unadjusted outcomes were similar between surgeons and interventionalists in terms of stroke (4.33% vs. 4.41%, respectively), MI (2.10% vs. 2.13%), and mortality (0.84% and 1.03%). When the researchers examined the percentage of stroke in 2008, “we saw an initial increase,” Dr. Sgroi said. “This may have been due to the amount of physicians who were performing carotid stenting.”
The researchers observed a statistically significant difference between the two groups in hospital length of stay as well as total hospital charges, with procedures performed by interventionalists resulting in a stay that was about one-third of a day longer, and about $3,000 more expensive.
Adjusted multivariate analysis demonstrated no statistically significant differences between the two types of clinicians in stroke, MI, or hospital mortality. However, hospital length of stay was significantly lower for procedures performed by surgeons, compared with interventionalists (2.81 vs. 3.08 days, respectively), as were total hospital charges ($48,088 vs. $51,719). “The cause of the difference is unclear and not discernible through the available data,” Dr. Sgroi said.
When he and his associates examined the 10-unit volume difference among centers, they found a statistically significant increase in the rate of stroke among lower-volume centers, but no other significant differences in outcomes were observed. “We believe that the rate of complications secondary to carotid stenting has stayed consistent from 2004 to 2011, despite advances in technology,” Dr. Sgroi concluded.
He acknowledged certain limitations of the study, including its retrospective design and the fact that data from the NIS account for only 20% of the U.S. population.
Dr. Sgroi reported having no financial disclosures.
On Twitter @dougbrunk
AT THE WESTERN VASCULAR SOCIETY ANNUAL MEETING
Key clinical point: Outcomes of carotid stenting were similar whether performed by surgeons or interventionalists.
Major finding: Adjusted multivariate analysis demonstrated no significant differences in the rates of stroke, MI, and mortality among cases of carotid stenting performed by surgeons and interventionalists.
Data source: An analysis of 20,663 cases of carotid stenting extracted from the Nationwide Inpatient Sample database between 2004 and 2011.
Disclosures: Dr. Sgroi reported having no financial disclosures.
Intraoperative evaluation may be best for predicting AVF success
CORONADO, CALIF. – Intraoperative vessel assessment, not preoperative vein mapping, was more accurately associated with maturation and cumulative functional patency rates of arteriovenous fistulas, results from a 5-year, single-center retrospective study showed.
“The prevalence of chronic kidney disease has increased over the last 3 decades, and efforts by the Centers for Medicare & Medicaid Services and the National Kidney Foundation have sought to increase the use of fistulas,” Dr. Khanh P. Nguyen said at the annual meeting of the Western Vascular Society.
“Since 2003, the incidence and prevalence of fistulas have increased. More recently, even higher goals have been set. Arteriovenous fistulas are the preferred procedures due to higher patency rates, reduced rates of reintervention, and lower costs, compared with central venous catheters or grafts.”
Dr. Nguyen, formerly of Loma Linda (Calif.) Medical Center who is now a vascular surgery fellow at Oregon Health and Science University, noted that while many studies as well as the Society for Vascular Surgery have advocated the use of routine preoperative ultrasound in predicting the success of arteriovenous fistulas (AVFs), its use varies among vascular surgeons. “Given the additional costs and time of preoperative ultrasound, this study was undertaken to examine the use of this technique and compare it to intraoperative assessment,” she said.
The researchers examined all autologous AVFs created for patients with end-stage-renal disease at the Veterans Affairs Loma Linda Health System between February 2007 and July 2012. Preoperative ultrasound mapping of upper-extremity veins occurred, and patients were divided into two groups: those with veins less than 3 mm in size and those with veins 3 mm or greater in size. Subjective intraoperative evaluation was conducted by the operative surgeon, who rated the vein as either “good” or “poor” because of factors such as inadequate diameter, sclerosis, and calcification. Kaplan-Meier analysis was used to calculate maturation and patency rates.
Over the 5-year period, 387 fistulas were created in 361 patients. Of these, 198 had preoperative vein mapping; 36% were less than 3 mm in size, and 64% were 3 mm or greater in size.
By intraoperative assessment, 14% of patients were determined to have had poor vessels, and 86% were found to have good vessels. About half of the fistulas (51%) were created at the wrist. The average age of patients was 65 years, their mean body mass index was 28 kg/m2, and their mean time on dialysis was 84 years. The majority (97%) were male.
Among patients with preoperative veins less than 3 mm in size or 3 mm in size or greater, the maturation and overall failure rates were similar at 71% vs. 75% (P = .61) and 68% vs. 58% (P = .15). However, among patients with assessments of poor or good veins at the time of operation, the maturation and overall failure rates were 42% vs. 82% (P < .001) and 86% vs. 54% (P < .001).
Subgroup analysis revealed that patients with good intraoperative evaluation, regardless of preoperative ultrasound findings, had higher maturation rates. “Likewise, patients with good intraoperative assessment, regardless of preoperative ultrasound findings, had higher cumulative functional patency rates. Of note, no patient who had both poor preoperative ultrasound and intraoperative assessments had a functional fistula at the time of last follow-up.”
Dr. Nguyen and her associates concluded that intraoperative vessel assessment, and not preoperative ultrasound, was more accurately associated with maturation and cumulative functional patency rates. “Even in patients with inadequate preoperative ultrasound vein mapping, intraoperative assessment may still be warranted,” she said. “If both preoperative and intraoperative assessments conclude that vessels are inadequate, do not create an AVF at that site.”
Dr. Nguyen reported having no relevant financial disclosures.
On Twitter @dougbrunk
CORONADO, CALIF. – Intraoperative vessel assessment, not preoperative vein mapping, was more accurately associated with maturation and cumulative functional patency rates of arteriovenous fistulas, results from a 5-year, single-center retrospective study showed.
“The prevalence of chronic kidney disease has increased over the last 3 decades, and efforts by the Centers for Medicare & Medicaid Services and the National Kidney Foundation have sought to increase the use of fistulas,” Dr. Khanh P. Nguyen said at the annual meeting of the Western Vascular Society.
“Since 2003, the incidence and prevalence of fistulas have increased. More recently, even higher goals have been set. Arteriovenous fistulas are the preferred procedures due to higher patency rates, reduced rates of reintervention, and lower costs, compared with central venous catheters or grafts.”
Dr. Nguyen, formerly of Loma Linda (Calif.) Medical Center who is now a vascular surgery fellow at Oregon Health and Science University, noted that while many studies as well as the Society for Vascular Surgery have advocated the use of routine preoperative ultrasound in predicting the success of arteriovenous fistulas (AVFs), its use varies among vascular surgeons. “Given the additional costs and time of preoperative ultrasound, this study was undertaken to examine the use of this technique and compare it to intraoperative assessment,” she said.
The researchers examined all autologous AVFs created for patients with end-stage-renal disease at the Veterans Affairs Loma Linda Health System between February 2007 and July 2012. Preoperative ultrasound mapping of upper-extremity veins occurred, and patients were divided into two groups: those with veins less than 3 mm in size and those with veins 3 mm or greater in size. Subjective intraoperative evaluation was conducted by the operative surgeon, who rated the vein as either “good” or “poor” because of factors such as inadequate diameter, sclerosis, and calcification. Kaplan-Meier analysis was used to calculate maturation and patency rates.
Over the 5-year period, 387 fistulas were created in 361 patients. Of these, 198 had preoperative vein mapping; 36% were less than 3 mm in size, and 64% were 3 mm or greater in size.
By intraoperative assessment, 14% of patients were determined to have had poor vessels, and 86% were found to have good vessels. About half of the fistulas (51%) were created at the wrist. The average age of patients was 65 years, their mean body mass index was 28 kg/m2, and their mean time on dialysis was 84 years. The majority (97%) were male.
Among patients with preoperative veins less than 3 mm in size or 3 mm in size or greater, the maturation and overall failure rates were similar at 71% vs. 75% (P = .61) and 68% vs. 58% (P = .15). However, among patients with assessments of poor or good veins at the time of operation, the maturation and overall failure rates were 42% vs. 82% (P < .001) and 86% vs. 54% (P < .001).
Subgroup analysis revealed that patients with good intraoperative evaluation, regardless of preoperative ultrasound findings, had higher maturation rates. “Likewise, patients with good intraoperative assessment, regardless of preoperative ultrasound findings, had higher cumulative functional patency rates. Of note, no patient who had both poor preoperative ultrasound and intraoperative assessments had a functional fistula at the time of last follow-up.”
Dr. Nguyen and her associates concluded that intraoperative vessel assessment, and not preoperative ultrasound, was more accurately associated with maturation and cumulative functional patency rates. “Even in patients with inadequate preoperative ultrasound vein mapping, intraoperative assessment may still be warranted,” she said. “If both preoperative and intraoperative assessments conclude that vessels are inadequate, do not create an AVF at that site.”
Dr. Nguyen reported having no relevant financial disclosures.
On Twitter @dougbrunk
CORONADO, CALIF. – Intraoperative vessel assessment, not preoperative vein mapping, was more accurately associated with maturation and cumulative functional patency rates of arteriovenous fistulas, results from a 5-year, single-center retrospective study showed.
“The prevalence of chronic kidney disease has increased over the last 3 decades, and efforts by the Centers for Medicare & Medicaid Services and the National Kidney Foundation have sought to increase the use of fistulas,” Dr. Khanh P. Nguyen said at the annual meeting of the Western Vascular Society.
“Since 2003, the incidence and prevalence of fistulas have increased. More recently, even higher goals have been set. Arteriovenous fistulas are the preferred procedures due to higher patency rates, reduced rates of reintervention, and lower costs, compared with central venous catheters or grafts.”
Dr. Nguyen, formerly of Loma Linda (Calif.) Medical Center who is now a vascular surgery fellow at Oregon Health and Science University, noted that while many studies as well as the Society for Vascular Surgery have advocated the use of routine preoperative ultrasound in predicting the success of arteriovenous fistulas (AVFs), its use varies among vascular surgeons. “Given the additional costs and time of preoperative ultrasound, this study was undertaken to examine the use of this technique and compare it to intraoperative assessment,” she said.
The researchers examined all autologous AVFs created for patients with end-stage-renal disease at the Veterans Affairs Loma Linda Health System between February 2007 and July 2012. Preoperative ultrasound mapping of upper-extremity veins occurred, and patients were divided into two groups: those with veins less than 3 mm in size and those with veins 3 mm or greater in size. Subjective intraoperative evaluation was conducted by the operative surgeon, who rated the vein as either “good” or “poor” because of factors such as inadequate diameter, sclerosis, and calcification. Kaplan-Meier analysis was used to calculate maturation and patency rates.
Over the 5-year period, 387 fistulas were created in 361 patients. Of these, 198 had preoperative vein mapping; 36% were less than 3 mm in size, and 64% were 3 mm or greater in size.
By intraoperative assessment, 14% of patients were determined to have had poor vessels, and 86% were found to have good vessels. About half of the fistulas (51%) were created at the wrist. The average age of patients was 65 years, their mean body mass index was 28 kg/m2, and their mean time on dialysis was 84 years. The majority (97%) were male.
Among patients with preoperative veins less than 3 mm in size or 3 mm in size or greater, the maturation and overall failure rates were similar at 71% vs. 75% (P = .61) and 68% vs. 58% (P = .15). However, among patients with assessments of poor or good veins at the time of operation, the maturation and overall failure rates were 42% vs. 82% (P < .001) and 86% vs. 54% (P < .001).
Subgroup analysis revealed that patients with good intraoperative evaluation, regardless of preoperative ultrasound findings, had higher maturation rates. “Likewise, patients with good intraoperative assessment, regardless of preoperative ultrasound findings, had higher cumulative functional patency rates. Of note, no patient who had both poor preoperative ultrasound and intraoperative assessments had a functional fistula at the time of last follow-up.”
Dr. Nguyen and her associates concluded that intraoperative vessel assessment, and not preoperative ultrasound, was more accurately associated with maturation and cumulative functional patency rates. “Even in patients with inadequate preoperative ultrasound vein mapping, intraoperative assessment may still be warranted,” she said. “If both preoperative and intraoperative assessments conclude that vessels are inadequate, do not create an AVF at that site.”
Dr. Nguyen reported having no relevant financial disclosures.
On Twitter @dougbrunk
AT THE WESTERN VASCULAR SOCIETY ANNUAL MEETING
Key clinical point: Routine preoperative ultrasound is not reliable for predicting the success of arteriovenous fistulas.
Major finding: Among patients with assessments of poor or good veins at the time of operation, the maturation and overall failure rates were 42% vs. 82% (P < .001) and 86% vs. 54% (P < .001).
Data source: A retrospective study of 387 AVFs created in 361 patients at the VA Loma Linda Health System between February 2007 and July 2012.
Disclosures:Dr. Nguyen reported having no relevant financial disclosures.
Sex differences seen in fracture risk among children
SAN DIEGO – Results from a study of children with forearm fractures found that girls had less outdoor play and were more likely to have a previous fracture, compared with boys, while boys were less likely to meet recommended guidelines for calcium intake.
“An increasing amount of research is demonstrating that children who have fractures, in particular forearm fractures, are demonstrating signs of poor bone health,” Dr. Leticia Manning Ryan said in an interview at the annual meeting of the American Academy of Pediatrics. “Prior studies have shown that kids with forearm fractures have lower bone mineral density and vitamin D deficiency, compared to children who don’t have fractures. Other studies have focused on Caucasian kids, and my work to date has focused on African American kids.”
In an effort to identify pertinent gender differences in children with a forearm fracture, help tailor prevention strategies, and promote bone health in childhood, Dr. Ryan and her associates prospectively evaluated 76 African American children with a forearm fracture and 74 age-matched controls without a fracture who were treated at Children’s National Medical Center, Washington. Measures of interest focused on the study population with fractures and included body mass index, dietary intake, outdoor play time, bone mineral density (BMD), and level of serum 25-hydroxyvitamin D. The researchers used descriptive statistics to evaluate gender differences in clinical characteristics that might affect bone health, including socioeconomic status, vitamin D concentration, BMD, mechanism of injury, history of prior fracture, level of physical activity, milk intake, and calcium intake.
Dr. Ryan and her associates found that a significantly higher proportion of girls had a prior fracture, compared with boys (21.9% vs. 4.5%; P = .04). Girls reported significantly less outdoor playing time per week, compared with boys (a mean of 13.6 vs. 18.3 hours; P = .004) and a higher proportion of outdoor playing time that lasted 1 hour or less per day (28.1% vs. 6.9%; P = .02).
“I was surprised that the girls were more likely to have a prior fracture, which is kind of a red flag in terms of a child who is potentially at risk for continuing to have fractures moving forward through life,” said Dr. Ryan, who is a pediatric emergency medicine physician at Johns Hopkins Children’s Center, Baltimore.
She and her associates also found that boys were significantly less likely than girls to meet the 2010 Recommended Dietary Allowance for calcium intake (19% vs. 40.6%; P = .04).
“If your child has a fracture, I think it’s important to take a step back to consider whether or not they are doing everything they can to build strong bones during childhood,” Dr. Ryan said. “That includes getting safe but good weight-bearing exercise, making sure that they’re meeting calcium intake, and checking to make sure that their vitamin D levels are normal, especially in a child who has had more than one fracture.”
Although the study was limited to African American children, she expects that the findings would apply to children from other ethnicities. “There is more that we need to be doing during childhood to build strong bones, as kids reach their peak bone mass around age 18,” she concluded.
The study was supported by the National Center for Research Resources, the D.C.-Baltimore Research Center on Child Health Disparities through the National Institute on Minority Health and Health Disparities, and the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Dr. Ryan reported having no financial disclosures.
On Twitter @dougbrunk
SAN DIEGO – Results from a study of children with forearm fractures found that girls had less outdoor play and were more likely to have a previous fracture, compared with boys, while boys were less likely to meet recommended guidelines for calcium intake.
“An increasing amount of research is demonstrating that children who have fractures, in particular forearm fractures, are demonstrating signs of poor bone health,” Dr. Leticia Manning Ryan said in an interview at the annual meeting of the American Academy of Pediatrics. “Prior studies have shown that kids with forearm fractures have lower bone mineral density and vitamin D deficiency, compared to children who don’t have fractures. Other studies have focused on Caucasian kids, and my work to date has focused on African American kids.”
In an effort to identify pertinent gender differences in children with a forearm fracture, help tailor prevention strategies, and promote bone health in childhood, Dr. Ryan and her associates prospectively evaluated 76 African American children with a forearm fracture and 74 age-matched controls without a fracture who were treated at Children’s National Medical Center, Washington. Measures of interest focused on the study population with fractures and included body mass index, dietary intake, outdoor play time, bone mineral density (BMD), and level of serum 25-hydroxyvitamin D. The researchers used descriptive statistics to evaluate gender differences in clinical characteristics that might affect bone health, including socioeconomic status, vitamin D concentration, BMD, mechanism of injury, history of prior fracture, level of physical activity, milk intake, and calcium intake.
Dr. Ryan and her associates found that a significantly higher proportion of girls had a prior fracture, compared with boys (21.9% vs. 4.5%; P = .04). Girls reported significantly less outdoor playing time per week, compared with boys (a mean of 13.6 vs. 18.3 hours; P = .004) and a higher proportion of outdoor playing time that lasted 1 hour or less per day (28.1% vs. 6.9%; P = .02).
“I was surprised that the girls were more likely to have a prior fracture, which is kind of a red flag in terms of a child who is potentially at risk for continuing to have fractures moving forward through life,” said Dr. Ryan, who is a pediatric emergency medicine physician at Johns Hopkins Children’s Center, Baltimore.
She and her associates also found that boys were significantly less likely than girls to meet the 2010 Recommended Dietary Allowance for calcium intake (19% vs. 40.6%; P = .04).
“If your child has a fracture, I think it’s important to take a step back to consider whether or not they are doing everything they can to build strong bones during childhood,” Dr. Ryan said. “That includes getting safe but good weight-bearing exercise, making sure that they’re meeting calcium intake, and checking to make sure that their vitamin D levels are normal, especially in a child who has had more than one fracture.”
Although the study was limited to African American children, she expects that the findings would apply to children from other ethnicities. “There is more that we need to be doing during childhood to build strong bones, as kids reach their peak bone mass around age 18,” she concluded.
The study was supported by the National Center for Research Resources, the D.C.-Baltimore Research Center on Child Health Disparities through the National Institute on Minority Health and Health Disparities, and the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Dr. Ryan reported having no financial disclosures.
On Twitter @dougbrunk
SAN DIEGO – Results from a study of children with forearm fractures found that girls had less outdoor play and were more likely to have a previous fracture, compared with boys, while boys were less likely to meet recommended guidelines for calcium intake.
“An increasing amount of research is demonstrating that children who have fractures, in particular forearm fractures, are demonstrating signs of poor bone health,” Dr. Leticia Manning Ryan said in an interview at the annual meeting of the American Academy of Pediatrics. “Prior studies have shown that kids with forearm fractures have lower bone mineral density and vitamin D deficiency, compared to children who don’t have fractures. Other studies have focused on Caucasian kids, and my work to date has focused on African American kids.”
In an effort to identify pertinent gender differences in children with a forearm fracture, help tailor prevention strategies, and promote bone health in childhood, Dr. Ryan and her associates prospectively evaluated 76 African American children with a forearm fracture and 74 age-matched controls without a fracture who were treated at Children’s National Medical Center, Washington. Measures of interest focused on the study population with fractures and included body mass index, dietary intake, outdoor play time, bone mineral density (BMD), and level of serum 25-hydroxyvitamin D. The researchers used descriptive statistics to evaluate gender differences in clinical characteristics that might affect bone health, including socioeconomic status, vitamin D concentration, BMD, mechanism of injury, history of prior fracture, level of physical activity, milk intake, and calcium intake.
Dr. Ryan and her associates found that a significantly higher proportion of girls had a prior fracture, compared with boys (21.9% vs. 4.5%; P = .04). Girls reported significantly less outdoor playing time per week, compared with boys (a mean of 13.6 vs. 18.3 hours; P = .004) and a higher proportion of outdoor playing time that lasted 1 hour or less per day (28.1% vs. 6.9%; P = .02).
“I was surprised that the girls were more likely to have a prior fracture, which is kind of a red flag in terms of a child who is potentially at risk for continuing to have fractures moving forward through life,” said Dr. Ryan, who is a pediatric emergency medicine physician at Johns Hopkins Children’s Center, Baltimore.
She and her associates also found that boys were significantly less likely than girls to meet the 2010 Recommended Dietary Allowance for calcium intake (19% vs. 40.6%; P = .04).
“If your child has a fracture, I think it’s important to take a step back to consider whether or not they are doing everything they can to build strong bones during childhood,” Dr. Ryan said. “That includes getting safe but good weight-bearing exercise, making sure that they’re meeting calcium intake, and checking to make sure that their vitamin D levels are normal, especially in a child who has had more than one fracture.”
Although the study was limited to African American children, she expects that the findings would apply to children from other ethnicities. “There is more that we need to be doing during childhood to build strong bones, as kids reach their peak bone mass around age 18,” she concluded.
The study was supported by the National Center for Research Resources, the D.C.-Baltimore Research Center on Child Health Disparities through the National Institute on Minority Health and Health Disparities, and the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Dr. Ryan reported having no financial disclosures.
On Twitter @dougbrunk
AT THE AAP NATIONAL CONFERENCE
Key clinical point: Bone health promotion in children should encourage physical activity in girls and optimization of calcium intake in boys.
Major finding: A significantly higher proportion of girls had a prior fracture, compared with boys (21.9% vs. 4.5%; P = .04), while boys were significantly less likely than girls to meet the 2010 Recommended Dietary Allowance for calcium intake (19% vs. 40.6%; P = .04).
Data source: A prospective evaluation of 76 African American children with a forearm fracture and 74 age-matched controls without a fracture who were treated at Children’s National Medical Center, Washington.
Disclosures: The study was supported by the National Center for Research Resources, the D.C.-Baltimore Research Center on Child Health Disparities through the National Institute on Minority Health and Health Disparities, and the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Dr. Ryan reported having no financial disclosures.
Blood cultures offer little benefit to children with CAP
SAN DIEGO – Obtaining blood cultures in children hospitalized for community-acquired pneumonia led to longer hospital stays and caused physicians to order more broad-spectrum antibiotics, results from a retrospective cohort study showed.
The 2011 Pediatric Infectious Diseases Society/Infectious Diseases Society of America Community Acquired Pneumonia guidelines included a strong recommendation to obtain blood cultures for all children admitted with moderate to severe CAP, “but that was based on low-quality evidence,” Dr. Michael P. Koster said in an interview at the annual meeting of the American Academy of Pediatrics. “Very little is known about how blood cultures influence the management of pneumonia. Our question was getting at whether or not getting a blood culture changes practice management.”
To investigate, Dr. Koster and his associates at four separate medical institutions retrospectively evaluated the charts of 1,142 children aged 3 months to 18 years who were hospitalized for community-acquired pneumonia (CAP) during 2011 and 2012 according to ICD-9 codes for CAP or respiratory distress. Children with severe medical comorbidities were excluded. Dr. Koster, a pediatrician at Hasbro Children’s Hospital, Providence, R.I., and his associates collected data on patient demographics, medical history, laboratory tests, diagnostic radiography, antimicrobials administered, length of stay, ICU transfer, and readmission.
Of the 1,142 initially identified, 763 were used in the final analysis. Of these, 462 had blood cultures and the remaining 301 did not.
Dr. Koster reported that patients in the blood culture group had a significantly longer mean length of stay, compared with the no culture group (3.4 vs. 1.9 days, respectively; P < .0001). This difference persisted when ICU patients were removed from the analysis (2.5 vs. 1.8 days; P < .0001).
The researchers observed no statistically significant differences between those who had blood cultures and those who did not in receipt of antibiotics prior to presentation (41.6% vs. 40.9%, respectively; P = .85), the presence of any pulmonary effusion (57.6% vs. 61.1%; P = .33), or in the 14-day readmission rates (4.1% vs. 3%; P = .42).
However, in the emergency department, the blood culture group was more likely receive a third-generation cephalosporin (68.9% vs. 42.9%; P < .0001) while the no culture group was more likely to receive penicillin/ampicillin alone (38.4% vs. 21.3%; P = .0001).
Among patients in the blood culture group, 2.4% were positive for pathogens and 2.2% were contaminated, for a positive predictive value of 52.4%.
“Blood cultures aren’t free of harm,” Dr. Koster concluded. “They increase how long you stay in the hospital, and they increase the prescription of third-generation cephalosporins. Practice variation among physicians is probably what resulted in these findings. Until we recognize the variance around the interventions that we give to kids, we won’t be able to decrease the variance around their outcomes.”
The study was supported by the Rhode Island Foundation. Dr. Koster reported having no financial disclosures.
On Twitter @dougbrunk
SAN DIEGO – Obtaining blood cultures in children hospitalized for community-acquired pneumonia led to longer hospital stays and caused physicians to order more broad-spectrum antibiotics, results from a retrospective cohort study showed.
The 2011 Pediatric Infectious Diseases Society/Infectious Diseases Society of America Community Acquired Pneumonia guidelines included a strong recommendation to obtain blood cultures for all children admitted with moderate to severe CAP, “but that was based on low-quality evidence,” Dr. Michael P. Koster said in an interview at the annual meeting of the American Academy of Pediatrics. “Very little is known about how blood cultures influence the management of pneumonia. Our question was getting at whether or not getting a blood culture changes practice management.”
To investigate, Dr. Koster and his associates at four separate medical institutions retrospectively evaluated the charts of 1,142 children aged 3 months to 18 years who were hospitalized for community-acquired pneumonia (CAP) during 2011 and 2012 according to ICD-9 codes for CAP or respiratory distress. Children with severe medical comorbidities were excluded. Dr. Koster, a pediatrician at Hasbro Children’s Hospital, Providence, R.I., and his associates collected data on patient demographics, medical history, laboratory tests, diagnostic radiography, antimicrobials administered, length of stay, ICU transfer, and readmission.
Of the 1,142 initially identified, 763 were used in the final analysis. Of these, 462 had blood cultures and the remaining 301 did not.
Dr. Koster reported that patients in the blood culture group had a significantly longer mean length of stay, compared with the no culture group (3.4 vs. 1.9 days, respectively; P < .0001). This difference persisted when ICU patients were removed from the analysis (2.5 vs. 1.8 days; P < .0001).
The researchers observed no statistically significant differences between those who had blood cultures and those who did not in receipt of antibiotics prior to presentation (41.6% vs. 40.9%, respectively; P = .85), the presence of any pulmonary effusion (57.6% vs. 61.1%; P = .33), or in the 14-day readmission rates (4.1% vs. 3%; P = .42).
However, in the emergency department, the blood culture group was more likely receive a third-generation cephalosporin (68.9% vs. 42.9%; P < .0001) while the no culture group was more likely to receive penicillin/ampicillin alone (38.4% vs. 21.3%; P = .0001).
Among patients in the blood culture group, 2.4% were positive for pathogens and 2.2% were contaminated, for a positive predictive value of 52.4%.
“Blood cultures aren’t free of harm,” Dr. Koster concluded. “They increase how long you stay in the hospital, and they increase the prescription of third-generation cephalosporins. Practice variation among physicians is probably what resulted in these findings. Until we recognize the variance around the interventions that we give to kids, we won’t be able to decrease the variance around their outcomes.”
The study was supported by the Rhode Island Foundation. Dr. Koster reported having no financial disclosures.
On Twitter @dougbrunk
SAN DIEGO – Obtaining blood cultures in children hospitalized for community-acquired pneumonia led to longer hospital stays and caused physicians to order more broad-spectrum antibiotics, results from a retrospective cohort study showed.
The 2011 Pediatric Infectious Diseases Society/Infectious Diseases Society of America Community Acquired Pneumonia guidelines included a strong recommendation to obtain blood cultures for all children admitted with moderate to severe CAP, “but that was based on low-quality evidence,” Dr. Michael P. Koster said in an interview at the annual meeting of the American Academy of Pediatrics. “Very little is known about how blood cultures influence the management of pneumonia. Our question was getting at whether or not getting a blood culture changes practice management.”
To investigate, Dr. Koster and his associates at four separate medical institutions retrospectively evaluated the charts of 1,142 children aged 3 months to 18 years who were hospitalized for community-acquired pneumonia (CAP) during 2011 and 2012 according to ICD-9 codes for CAP or respiratory distress. Children with severe medical comorbidities were excluded. Dr. Koster, a pediatrician at Hasbro Children’s Hospital, Providence, R.I., and his associates collected data on patient demographics, medical history, laboratory tests, diagnostic radiography, antimicrobials administered, length of stay, ICU transfer, and readmission.
Of the 1,142 initially identified, 763 were used in the final analysis. Of these, 462 had blood cultures and the remaining 301 did not.
Dr. Koster reported that patients in the blood culture group had a significantly longer mean length of stay, compared with the no culture group (3.4 vs. 1.9 days, respectively; P < .0001). This difference persisted when ICU patients were removed from the analysis (2.5 vs. 1.8 days; P < .0001).
The researchers observed no statistically significant differences between those who had blood cultures and those who did not in receipt of antibiotics prior to presentation (41.6% vs. 40.9%, respectively; P = .85), the presence of any pulmonary effusion (57.6% vs. 61.1%; P = .33), or in the 14-day readmission rates (4.1% vs. 3%; P = .42).
However, in the emergency department, the blood culture group was more likely receive a third-generation cephalosporin (68.9% vs. 42.9%; P < .0001) while the no culture group was more likely to receive penicillin/ampicillin alone (38.4% vs. 21.3%; P = .0001).
Among patients in the blood culture group, 2.4% were positive for pathogens and 2.2% were contaminated, for a positive predictive value of 52.4%.
“Blood cultures aren’t free of harm,” Dr. Koster concluded. “They increase how long you stay in the hospital, and they increase the prescription of third-generation cephalosporins. Practice variation among physicians is probably what resulted in these findings. Until we recognize the variance around the interventions that we give to kids, we won’t be able to decrease the variance around their outcomes.”
The study was supported by the Rhode Island Foundation. Dr. Koster reported having no financial disclosures.
On Twitter @dougbrunk
AT THE AAP NATIONAL CONFERENCE
Key clinical point: Blood cultures in children with community-acquired pneumonia (CAP) are not free of harm.
Major finding: Children in the blood culture group had a significantly longer hospital length of stay, compared with the no culture group (3.4 vs. 1.9 days, respectively; P < .0001).
Data source: A retrospective review of 763 children hospitalized for CAP at four separate sites during 2011 and 2012.
Disclosures: The study was supported by the Rhode Island Foundation. Dr. Koster reported having no financial disclosures.
