Isabella Zaniletti

Objective: Identify clinical predictors of bloodstream (BSI) and urinary tract infections (UTI) in infants with gastroschisis. Study design: Retrospective analysis of infants with gastroschisis admitted to 47 neonatal intensive care units (NICUs) contributing to the Children’s Hospitals Neonatal Database (CHND) from 2010–23. Outcomes were occurrence of BSI or UTI before discharge. Generalized linear models with generalized estimating equation (GEE) to account for hospitals as clusters utilized to identify factors independently related to the outcomes. Result: Of 3987 eligible infants, rates of early BSI (within 3 days of birth) were 0.4%, any BSI 7.6% and UTI 3.5%. Median age of infection was 32 days for BSI and 39 days for UTI. Bowel atresia, silo/staged closure, patch closure, and additional anomalies were independently associated with these infections. Conclusion: We identified clinical predictors of BSI and UTI, which should facilitate limitation of antibiotic use in low risk patients.

Background/Objectives: Adolescents with chronic medical conditions (A-CMCs) are at increased risk for alcohol and other drug (AOD) use and adverse health outcomes. However, little is known about patterns of AOD-related emergency department (ED) visits and hospitalization among A-CMCs. This study investigates ED patterns and associations between AOD use, chronic medical complexity, and race–ethnicity with hospitalization following ED visits. AOD use was categorized into three groups: mainstream substances (e.g., cannabis), illicit/other psychoactive substances (e.g., opioids), and no documented AOD diagnosis. A-CMCs were divided into two groups: chronic conditions (CC) or complex chronic conditions (CCC). Methods: A retrospective cohort of ED encounters among A-CMCs was analyzed. Data were derived from 45 U.S. children’s hospitals participating in the Pediatric Health Information System from 2021 to 2023. Associations were examined using logistic regression, adjusting for covariates. Results: The cohort included 1,098,496 ED visits among A-CMCs (encounter-level counts, which may include repeat visits by the same A-CMC); 72.9% of encounters involved adolescents with CCs (27.1% with CCCs).4.2% of those visits were AOD-related, with most involving mainstream substances in CCs and CCCs groups (78.0% and 76.3%, respectively; p = 0.002). Compared with encounters with no documented AOD diagnosis, AOD-related ED encounters were associated with significantly higher adjusted odds of hospitalization for both mainstream substances (aOR 2.8, 95% CI 2.68–2.94 for CC; aOR 3.7, 95% CI 3.19–4.28 for CCC) and illicit/other psychoactive substances (aOR 2.2, 95% CI 2.03–2.4 for CC; aOR 3.18, 95% CI 2.47–4.09 for CCC; all p < 0.001)There were significant interactions between AOD use type and race/ethnicity within each A-CMC subgroup (p = 0.002), indicating differing patterns of hospitalization across groups. Discussion/Conclusions: Among A-CMCs, AOD-related ED visits—involving either mainstream or illicit/other psychoactive substances—were associated with increased adjusted odds of hospitalization relative to visits with no documented AOD diagnosis, with mainstream substances accounting for the majority of AOD-related encounters overall. Racial–ethnic differences in hospitalization were observed and may reflect a range of clinical and contextual factors not measured in this study, underscoring the need for standardized AOD screening and evaluation in pediatric settings.

POI and EOI are rare but impactful conditions among adolescents and young adults (AYAs). Little is known about the timing and incidence of mental health (MH) conditions among AYAs diagnosed with POI/EOI. Data were collected using MarketScan Medicaid administrative claims among females aged 12–25 with POI/EOI. Merative™ MarketScan^® Research Databases are large, de-identified U.S. administrative healthcare claims databases that contain individual-level information on enrollment, inpatient and outpatient medical services, and outpatient prescription drug claims. The databases include commercially insured individuals, Medicare beneficiaries with employer-sponsored supplemental coverage, and selected Medicaid populations. Claims are linked longitudinally using unique encrypted patient identifiers, allowing individuals to be followed over time across healthcare settings. In addition to healthcare utilization, the databases include demographic characteristics, diagnosis and procedure codes, dates of service, and payment information, making them well suited for epidemiologic, health services, and outcomes research. We characterized prevalence and timing of MH diagnoses, examined MH subtypes, and estimated new-onset MH among those without prior MH. Comparisons were made to demographically matched controls without POI/EOI (matched on age and calendar time) and to diagnosis-anchored comparator groups. Among 859 AYAs with POI/EOI, 53.9% had any MH diagnosis, including 32.9% with MH diagnoses before and after POI/EOI diagnosis and 11.9% with new-onset MH after POI/EOI diagnosis. Of all anxiety disorders, 60.1% were present pre- and post-diagnosis, while 25.4% were new-onset after diagnosis. Depressive disorders showed a similar pattern, with 58.1% being pre- and post-diagnosis MH group and 22.3% being new-onset. In total, 49.4% of individuals with trauma-related disorders had the diagnosis both before and after POI/EOI diagnosis, while 30.1% had it as a new-onset. In adjusted models, POI/EOI was associated with increased odds of MH diagnoses after diagnosis (aOR ~2.1, 95% CI ~1.4–3.1). Prior MH diagnoses were the strongest predictor of MH after diagnosis (aOR ~12.1). AYAs with POI/EOI experience substantial MH burden, with elevated risk of new-onset MH conditions following diagnosis. Findings highlight the importance of early MH screening and integrated care models for AYAs.

Purpose: Continuous electroencephalography (CEEG) is recommended in critically ill neonates and children at risk for experiencing seizures. Its utilization across time and conditions remains unclear. We evaluated trends in CEEG use and variation based on patient and hospital level factors for six common indications. Methods: This retrospective cohort study queried data from 40 children's hospitals in the Pediatric Health Information Systems database from January 2016 to December 2023. Using ICD-10 diagnosis codes, we defined six CEEG indications: neonatal hypoxic-ischemic encephalopathy (HIE), extracorporeal membrane oxygenation, cardiac arrest, stroke, traumatic brain injury, and neonates postcardiac surgery (post-CS). CEEG utilization was assessed annually. Associations between CEEG utilization and year, age, sex, race, history of seizures or epilepsy, medical complexity, payer, hospital region, and the Child Opportunity Index (COI) were evaluated in unadjusted ORs and an adjusted OR (aOR) in a multivariable generalized linear model. Results: CEEG use varied by condition: neonatal HIE 67%, extracorporeal membrane oxygenation 47%, cardiac arrest 39%, stroke 36%, traumatic brain injury 21%, and post-CS 21%. CEEG use increased over the study period for extracorporeal membrane oxygenation (aOR 4.65; 2.47–8.77; P < 0.001), post-CS (aOR 3.5; 1.36–8.99; P = 0.009), and cardiac arrest (aOR 1.95; 95% CI 1.22–3.12; P = 0.005). CEEG use varied by hospital and condition. Younger age and increased medical complexity were associated with higher odds of CEEG. There was no consistent pattern of CEEG variation by race, ethnicity, insurance type, or COI, although condition specific differences were present. Conclusions: CEEG utilization has increased over time but remains variable across hospitals and indications. Comparative effectiveness approaches that leverage variation could determine optimal CEEG practices.

To characterize relationships between social determinants of health (SDoH) and mortality among infants receiving extracorporeal membrane oxygenation (ECMO). Retrospectively, we identified infants born >34weeks gestation and >1.8 kilograms who received ECMO from 2010-2022. The primary predictor was the child opportunity index (COI). The outcome was in-NICU mortality. Due to interactions between SDoH and diagnoses, the main analyses were performed within the diagnostic cohort using multilevel socioecological factors. Overall, 2254 neonates received ECMO [congenital diaphragmatic hernia (32%, CDH), meconium aspiration syndrome (27%, MAS), cardiac (13%) and other (28%, e.g., sepsis)]. Characteristics differed with MAS more common in lower COI and Black race, while CDH was more common in the White race. COI and maternal race/ethnicity were unrelated to in-NICU mortality. Despite epidemiological differences by SDoH, the primary outcome was consistent across groups, suggesting potential resilience to social risk factors and underscoring the importance of studying distinct cohorts separately.

Objective To evaluate the impact of cardiac lesions on outcomes to discharge in infants with congenital diaphragmatic hernia (CDH). Study design Retrospective analysis of infants with CDH identified in the Children’s Hospitals Neonatal Database (CHND) from 2010 to 22. Patients were stratified into groups based on associated congenital heart disease (CHD): (1) noCHD (2) CDH + atrial, ventricular septal defects (avCHD); (3) CDH + severe CHD (sevCHD). Results Among 2940 neonates with CDH, 570 (19%) had CHD (453 avCDH, 117 sevCHD). CHD of any severity was associated with small for gestational age at birth, a 5 minute Apgar p < 0.05 for all). Mechanical ventilation days, use of extra-corporeal membrane oxygenation, length of stay, and mortality increased with CHD severity (p < 0.005). Home medical needs were more frequent in infants with associated CHD (p < 0.001). Conclusions Comorbid CHD of any severity adds complexity and risk to patients with CDH.

Background: The U.S. Centers for Medicare & Medicaid Services (CMS) has set the substantial clinical benefit (SCB) for the Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) after primary total knee arthroplasty (TKA) at 20 points. We aimed to determine the percentages of patients who achieved the minimal clinically important difference (MCID) and the SCB for KOOS-JR at 1 year following TKA and to evaluate factors associated with benchmark achievement. Methods: We queried the American Joint Replacement Registry (AJRR) and screened 1,284,404 primary TKA cases performed from 2018 to 2023. We determined attainment of the KOOS-JR distribution-based MCID (7.5), anchor-based MCID (14), and SCB (20) at 12 months by each patient. Associations of covariates with the achievement of the MCIDs and the SCB were evaluated using a generalized linear model for binary outcomes that accounted for clustering within institutions. Unadjusted and adjusted odds ratios (ORs) for the outcomes of interest with 95% confidence intervals (CIs) were reported. Covariates included the preoperative KOOS-JR, sex, race or ethnicity, body mass index (BMI), Charlson Comorbidity Index (CCI), fixation type, use of technology, year of the procedure, region, institution type, teaching status, and number of beds. Results: Linked scores were recorded by 64,773 patients. The mean patient age was 68.35 ± 8.60 years, 61.29% of patients were female, and 83.52% of patients were non-Hispanic White. The KOOS-JR threshold achievement rate was 86.8% for the calculated distribution-based MCID, 76.5% for the anchor-based MCID, and 65.7% for the SCB. Patients with higher preoperative scores (adjusted OR, 0.93 [95% CI, 0.93 to 0.93]; p < 0.001), Asian patients (adjusted OR, 0.59 [95% CI, 0.46 to 0.74]; p < 0.001), Black patients (adjusted OR, 0.55 [95% CI, 0.49 to 0.62]; p < 0.001), Hispanic patients (adjusted OR, 0.71 [95% CI, 0.51 to 0.99]; p = 0.042), non-Hispanic patients of other races (adjusted OR, 0.84 [95% CI, 0.74 to 0.95]; p = 0.007), male patients (adjusted OR, 0.89 [95% CI, 0.85 to 0.94]; p < 0.001), and patients with higher BMI (adjusted OR, 0.93 [95% CI, 0.87 to 0.99]; p = 0.025) showed lower odds of achieving the SCB. A CCI of ≥5 was additionally found to be associated with lower odds of achieving the distribution-based MCID (adjusted OR, 0.89 [95% CI, 0.79 to 0.99]; p = 0.032) and anchor-based MCID (adjusted OR, 0.89 [95% CI, 0.81 to 0.97]; p = 0.012). Conclusions: The CMS relatively arbitrarily defined the SCB at a value that is too high for an operation that routinely yields >80% patient satisfaction. Level of Evidence: Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Objective The objective of this study was to characterize the neonatal intensive care unit (NICU) course and outcomes for infants with neonatal-onset urea cycle disorders (UCDs). Study design Using the multicenter Children’s Hospitals Neonatal Database, a descriptive, retrospective cohort study was performed to characterize the presentation, interventions, comorbidities, and hospital outcomes for 176 patients with neonatal-onset UCDs that required level IV NICU care. Results The median age of presentation was 5 [3,7] days, with 167 (95%) infants requiring transfer to a level IV NICU. Renal replacement therapy was undertaken for at least 34 (20%) patients. Neurologic complications occurred most frequently, with 71 (40%) patients affected. Twenty-one (12%) infants experienced in-hospital mortality. Interventions, complications, and mortality were observed most frequently in the ornithine transcarbamylase deficiency group. Conclusion Neonatal-onset UCDs are associated with significant morbidity and mortality, but heterogeneity exists among the specific named UCDs.