How to use noninvasive positive airway pressure device data reports to guide clinical care

There has been a significant increase in the past few decades in the number of children receiving noninvasive positive airway pressure (PAP) therapy at home. At present, PAP therapy can be successfully used in children of all ages, for a variety of indications. Data acquired from PAP devices is clinically useful, providing objective information regarding adherence, leak, and efficacy of PAP therapy. However, guidelines outlining a standardized approach to interpretation of PAP device data in pediatrics is currently lacking. Given the rapidly expanding use of PAP therapy in pediatric practice, we aim to provide an overview of the interpretation of data reports, otherwise called “data downloads,” from PAP devices and illustrate how they can be used to guide clinical care.     

Highly accelerated,real‐time phase‐contrast MRI using radial k‐space sampling and GROG‐GRASP reconstruction: a feasibility study in pediatric patients with congenital heart disease

Retrospective electrocardiogram‐gated, 2D phase‐contrast (PC) flow MRI is routinely used in clinical evaluation of valvular/vascular disease in pediatric patients with congenital heart disease (CHD). In patients not requiring general anesthesia, clinical standard PC is conducted with free breathing for several minutes per slice with averaging. In younger patients under general anesthesia, clinical standard PC is conducted with breath‐holding. One approach to overcome this limitation is using either navigator gating or self‐navigation of respiratory motion, at the expense of lengthening scan times. An alternative approach is using highly accelerated, free‐breathing, real‐time PC (rt‐PC) MRI, which to date has not been evaluated in CHD patients. The purpose of this study was to develop a 38.4‐fold accelerated 2D rt‐PC pulse sequence using radial k‐space sampling and compressed sensing with 1.5 × 1.5 × 6.0 mm³ nominal spatial resolution and 40 ms nominal temporal resolution, and evaluate whether it is capable of accurately measuring flow in 17 pediatric patients (aortic valve, pulmonary valve, right and left pulmonary arteries) compared with clinical standard 2D PC (either breath‐hold or free breathing). For clinical translation, we implemented an integrated reconstruction pipeline capable of producing DICOMs of the order of 2 min per time series (46 frames). In terms of association, forward volume, backward volume, regurgitant fraction, and peak velocity at peak systole measured with standard PC and rt‐PC were strongly correlated (R² > 0.76; P < 0.001). Compared with clinical standard PC, in terms of agreement, forward volume (mean difference = 1.4% (3.0% of mean)) and regurgitant fraction (mean difference = ?2.5%) were in good agreement, whereas backward volume (mean difference = ?1.1 mL (28.2% of mean)) and peak‐velocity at peak systole (mean difference = ?21.3 cm/s (17.2% of mean)) were underestimated by rt‐PC. This study demonstrates that the proposed rt‐PC with the said spatial resolution and temporal resolution produces relatively accurate forward volumes and regurgitant fractions but underestimates backward volumes and peak velocities at peak systole in pediatric patients with CHD.     

Association between first oral examination characteristics and dental treatment needs in privately insured children: A claims data analysis

BackgroundEarly childhood caries (ECC) remains the most common, preventable infectious disease among children in the United States. Screening is recommended after the eruption of the first tooth, but it is unclear how the age at first dental examination is associated with eventual restorative treatment needs. The authors of this study sought to determine how provider type and age at first dental examination are associated longitudinally with caries experience among children in the United States.MethodsDeidentified claims data were included for 706,636 privately insured children aged 0 through 6 years as part of the nationwide IBM Watson Health Market Scan (2012-2017). The authors used Kaplan-Meier survival analysis to describe the association between the age of first visit and restorative treatment needs.ResultsA total of 21% of this population required restorative treatment, and the average age at first dental examination was 3.6 years. A multivariable Cox proportional hazards model showed increased hazard for restorative treatment with age at first dental visit at 3 years (hazard ratio, 2.05; 95% CI, 1.97 to 2.13) and 4 years (hazard ratio, 3.99; 95% CI, 3.84 to 4.16).ConclusionThe high proportion of children requiring restorative treatment and late age at first dental screening show needed investments in educating general dentists, medical students, and pediatricians about oral health guidelines for pediatric patients.Practical ImplicationsCommunicating the importance of children establishing a dental home by age 1 year to parents and health care professionals may help reduce disease burden in children younger than 6 years.     

Pediatric Burkitt's Lymphoma and Diffuse B-Cell Lymphoma: Are Surveillance Scans Required?

Outcomes in pediatric B-Non-Hodgkin Lymphoma (B NHL) have improved with intensive chemotherapy protocols, with long-term survival now over 80%. However, long-term adverse effects of therapy and poor outcomes for patients who relapse remain challenges. In this study, we aimed to evaluate the potential risks and benefits of routine relapse surveillance imaging after the completion of therapy. We reviewed 44 B NHL patients diagnosed and treated at Texas Children's Cancer Center in the period between 2000 to 2011. All cross-sectional diagnostic imaging examinations performed for disease assessment after completion of chemotherapy were reviewed and cumulative radiation dosage from these examinations and the frequency of relapse detection by these examinations were recorded. Only 3 patients of the 44 relapsed (6.8%), though none of the relapses were initially diagnosed by computed tomography (CT) or fludeoxyglucose positron emission tomography (FDG-PET) scans. Median effective dose of ionizing radiation per patient was 40.3 mSv with an average of 49.1 mSv (range 0–276 mSv). This single-institution study highlights the low relapse rate in pediatric B-NHL with complete response at the end of therapy, the low sensitivity of early detection of relapse with surveillance CT or FDG-PET imaging, and the costs and potential increased risk of secondary malignancies from cumulative radiation exposure from surveillance imaging. We propose that routine surveillance CT or FDG-PET scans for these patients may not be necessary.     

Integrative pediatric pain management: Impact & implications of a novel interdisciplinary curriculum

ObjectivesObjectives of this paper are to: 1) Describe a novel interdisciplinary, integrative pain curriculum for pediatric residents. 2) Describe changes in residents’ understanding of pain epidemiology, physiology, and management; application of the biopsychosocial model in pain management; and understanding and application of non-pharmacologic approaches to pain management.Design, settingThis study was done in a pediatric residency program within an urban pediatric teaching hospital. It employed both anonymous, Likert-scale surveys administered via Qualtrics, as well as open-ended, free response questions.InterventionsWe provided a multidisciplinary pain education curriculum to pediatric residents with a focus on pain neuroscience, a history of pain management, the biopsychosocial model of care, and exposure to non-pharmacologic interventions to pain management over six hours of instruction conducted in two blocks of three hours each.Outcome measuresSelf-identified changes via survey measuring resident physician knowledge, comfort, approach, and management of pediatric pain through an interdisciplinary pain curriculum.ResultsPrior to this training, many residents were not confident in their understanding of pain neuroscience, the biopsychosocial model of care, and non-pharmacologic interventions. At completion of training, residents indicated positive changes in knowledge of, and comfort with, all of the domains taught. Ninety percent of residents indicated that the curriculum changed the way they conceptualized, approached, and/or managed pain, and reported thinking more holistically about pain management. Nearly all residents indicated they would like to have more training (98 %, N = 57) in integrative modalities.ConclusionsPediatric resident physicians are receptive to training in an interdisciplinary, integrative, pediatric pain management education intervention, and subsequently show positive changes in knowledge and comfort levels. There is a need and desire for additional pain education in resident training programs.     

硫酸镁注射液治疗婴幼儿喘息性疾病的分析

调查分析我院门诊、急诊患儿硫酸镁注射液的应用情况，为临床合理用药和儿科安全用药提供参考依据。对2017年11月门急诊含硫酸镁电子处方进行回顾性分析，内容包括年龄、用法用量、临床诊断、联合用药，使用天数等。共计204例患儿使用硫酸镁注射液，年龄在6个月至1岁之间的患儿最多，共72例，占比35.29%。67.65%的患儿使用剂量是30~50 mg·kg-1·d-1。临床诊断分别为急性喘息性支气管炎（32.35%）、肺炎（29.41%）、支气管炎（23.53%）等。在治疗方案中，硫酸镁常和糖皮质激素合用，其中有58.82%和醋酸甲泼尼龙合用，55.88%和布地奈德合用。目前硫酸镁在婴幼儿喘息性疾病的应用尚无统一、权威标准，可能存在用药风险。临床用药应加以重视、规范管理，保证用药安全。本研究结果对儿科合理使用硫酸镁注射液有参考价值。