Arkansas Children''s Hospital

The evaluation of injured children often involves imaging to assist in diagnosis and management. Many of these imaging tests involve exposure to ionizing radiation, which has been linked to future malignancies. Judicious use of diagnostic tests that expose a child to radiation is an important consideration when identifying children at risk for serious injury. Recognition of children who require a higher level of care and coordination with the receiving center should be a priority prior to obtaining advanced imaging. Detection of injury must be balanced with the risk of ionizing radiation in the pediatric trauma population. This principle has guided a field of pediatric trauma research and resulted in multiple guidelines and algorithms to assist in the diagnosis and management of traumatic injuries. Our review of recent literature shows reference to the Pediatric Emergency Care Applied Research Network (PECARN), Choosing Wisely recommendations, Pediatric Cervical Spine Clearance Working Group guidelines, as well as several recent studies guiding pediatric trauma. There is an emphasis on limiting the use of ionizing radiation imaging, the importance of clinical presentation guiding management, as well as understanding a center’s capabilities and ensuring expedited transfer to referral pediatric trauma centers. The “screen before you scan” approach using evidence-based clinical decision tools can assist in identifying pediatric patients who would benefit most from imaging. With the known risks of radiation in trauma patients, especially in children, more and more evidence-based clinical guidelines to “screen before you scan” are now being utilized to assist in identifying pediatric patients that can be managed with minimal use of ionizing radiation while maintaining safe clinically important injury detection rates while minimizing missed injuries.

INTRODUCTION:Management of missing anterior teeth can pose significant challenges for the orthodontist, as the maxillary incisors are key to esthetic orthodontic treatment planning. Two treatment modalities for patients that are unilaterally missing a maxillary lateral incisor that offer definitive functional and esthetic natural-tooth replacements for patients, regardless of age, are orthodontic canine substitution (OCS) and autotransplantation (AT) of a lower incisor. Using validated indices and an electronic questionnaire, the purpose of the study was to assess, objectively and subjectively, whether AT of a lower incisor or unilateral OCS offers patients who present with a unilateral missing maxillary lateral incisor a better esthetic result. METHODS:An orthodontist, periodontist, restorative dentist, and prosthodontist evaluated intraoral frontal images of 55 patients who were missing a single maxillary lateral incisor and were treated with unilateral OCS (25) or AT of a lower incisor (30) using the Pink and White Esthetic Indices. In addition, the specialists evaluated 30 finished orthodontic cases with no missing teeth as controls. An electronic survey was distributed to orthodontists, general dentists, and laypeople to gauge subjective opinions on the esthetic results of OCS versus AT. RESULTS:Lower incisor autotransplantation and unilateral orthodontic canine substitution had statistically significant lower esthetic scores than cases without missing teeth. The scores of AT and OCS were not significantly different from one another. Electronic survey data showed that dental providers find finished orthodontic cases the most esthetic, followed by lower incisor AT and unilateral OCS. Laypeople find unilateral OCS significantly more esthetic than both control and AT cases. CONCLUSIONS:Compared to unilateral OCS, lower incisor AT offers comparable esthetic outcomes and should be considered in cases of unilateral missing maxillary lateral incisors. CLINICAL SIGNIFICANCE:This study demonstrated that orthodontic space closure and dental autotransplantation can be acceptable treatment solutions for growing patients with a unilateral missing maxillary lateral incisor. Esthetic outcomes in the maxillary anterior region can impact the psychological status of a patient during an important developmental stage.

BACKGROUND:Survival after Fontan palliation for single ventricle heart disease has improved substantially, yet the long-term trajectory remains poorly defined. The Fontan Outcomes Network, a learning health network of 38 congenital heart centers in the United States and Canada, was established to address this gap. We report baseline characteristics and early findings from the first 1121 participants enrolled in this prospective clinical registry. METHODS:We performed a cross-sectional analysis of individuals who had undergone Fontan palliation enrolled in the Fontan Outcomes Network from August 2022 through August 2024. Demographic, clinical, imaging, procedural, and medication data were analyzed descriptively, overall and by age group (<12, 12 to <18, and ≥18 years). RESULTS:A total of 1121 participants were enrolled (mean age, 16.3±10.2 years; 471 [42%] female). Hypoplastic left heart syndrome (n=431 [38.5%]) and right ventricular-dominant anatomy (n=615 [54.9%]) were the most common primary cardiac diagnoses, especially in younger age groups. Extracardiac conduit was the most frequent Fontan type (n=749 [66.8%]). Typical Fontan-related adverse events were noted in 59% of cases (n=662), including chylous pleural effusions (n=108 [9.6%]), Fontan thrombosis (n=79 [7.1%]), and nonperioperative stroke (n=73 [6.5%]). A history of arrhythmia was present in 41.3% of patients (n=463) overall, increasing with age. Acquired comorbidities were present in 57.5% of patients (n=645), including asthma (n=132 [12%]) and sleep apnea (n=103 [9%]), with burden increasing by age. Antithrombotic medication use was nearly universal. Use of other medications varied widely by age, and included β-blockers, angiotensin-converting enzyme inhibitors, and pulmonary vasodilators. A clinical diagnosis of an anxiety disorder was present in 34.1% of patients (n=382), including 48.1% of adults (n=194 of 403), and antidepressants were prescribed in 11.8% of patients (n=132), including 23.6% of adults (n=95 of 403), highlighting the mental health needs of this population. CONCLUSIONS:The Fontan Outcomes Network includes one of the largest prospective, multi-institutional data sets of patients with Fontan circulation. These initial findings demonstrate the potential for a collaborative learning health network to advance research and quality improvement for this rare disease population.

Abstract Corresponding Author Mary Vance, PharmD, Department of Pharmacy, Arkansas Children’s Hospital, 1 Children’s Way, Slot 304, Little Rock, AR 72202, USA, (501) 364-1894, vancemk@archildrens.org Funding No funding to report Conflicts of Interest the authors report no conflicts of interest Background Aspiration pneumonia historically is treated with broad anaerobic coverage, often overtreating cases more consistent with chemical pneumonitis. Adult guidelines support avoiding broad anaerobic coverage given lack of evidence for added benefit. A small, randomized trial in children revealed no improvement in outcomes when comparing use of clindamycin with penicillin (with more limited anaerobic spectrum but excellent coverage of oral flora). We aimed to evaluate the impact of a quality improvement intervention on use of broad anaerobic coverage for uncomplicated aspiration pneumonia in a children’s hospital. Methods The quality improvement intervention consisted of 2 parts: educational sessions held with hospitalist faculty and residents on aspiration pneumonia management followed by implementation of an OurPractice Advisory (OPA) when broader agents were selected for the indication of aspiration pneumonia. A retrospective review of pediatric patients admitted to Arkansas Children’s Hospital January 2023 to February 2026 was conducted. Patients who were admitted to the hospitalist service and received antibiotics with the indication of aspiration pneumonia were included. Oral anaerobic coverage included agents such as ampicillin and ceftriaxone while broad anaerobic coverage included agents such as ampicillin-sulbactam and clindamycin. Variables assessed included proportion of patients treated with oral anaerobic coverage, treatment failure, length of stay, and readmission within 30 days. Results A total of 68 patients were included: 39 in the pre-intervention group, 13 in the post-education group, and 16 in the post-OPA group. A significant decrease was seen in use of agents with broad anaerobic coverage after the 2 interventions (77% vs. 31% vs. 44%, p <0.01) with no significant difference in treatment failure (12% broad vs. 15% oral/none, p = 1) or readmission within 30 days (20% broad vs.15% oral/none, p = 1). Antibiotic duration (8 days broad vs. 7 days oral/none, p=0.06) and length of stay (2 days broad vs. 4 days oral/none, p = 0.09) were also similar. Conclusion Preliminary data review shows similar outcomes for pediatric aspiration pneumonia with agents with oral anaerobic coverage vs broader anaerobic coverage. Analysis may be limited by the small sample size.

BACKGROUND:Anxiety and depression are common yet often underrecognized comorbidities in people with sickle cell disease (PwSCD), contributing to poor quality of life and adverse health outcomes. However, few large-scale studies have examined whether cerebrovascular accident (CVA)-a major complication of SCD-is associated with higher rates of anxiety and depression. Understanding this relationship is essential to inform early screening and comprehensive, multidisciplinary care for PwSCD. METHODS:This retrospective cohort study utilized the Epic Cosmos database, which includes over 200 million patients from 1118 US health systems (January 2003-December 2022). Cases were defined as PwSCD aged 0-110 years with a documented history of CVA; controls were PwSCD without CVA. Depression and anxiety were identified using ICD-10 diagnostic codes. Rates between groups were compared using chi-square tests with Yates' correction and Bonferroni adjustment (p ≤ 0.0083). RESULTS:Among 130,148 PwSCD, 9,306 (7.1%) had a history of CVA. Anxiety and depression were significantly more prevalent in PwSCD with CVA (36.4% and 39.7%) than those without (18.3% and 22.0%; p < 0.0083). Females with CVA had higher rates of both conditions (42.3% and 46.2%) than males (28.5% and 30.9%). The largest proportion of patients with anxiety and depression was in the 50-64-year age group. CONCLUSION:PwSCD with a history of CVA are nearly twice as likely to have anxiety and depression as those without. These findings underscore the need for routine anxiety and depression screening and integration of psychosocial care into comprehensive SCD management to improve long-term outcomes and quality of life.