The development of new point-of-care diagnostic testing tools for the detection of infectious diseases such as COVID-19 are a key aspect of clinical care and research. Accurate predictive classification methods are required to correctly identify and treat patients. Here, the onset of multisystem inflammatory syndrome in children (MIS-C), a more serious form of COVID-19, was predicted in a pediatric population using a set of multivariate immunological biomarker expression values. A first-stage bivariate detection of statistically significant biomarkers was obtained from a chosen set of standard cytokines and chemokine biomarkers considered relevant to COVID-19-related infection and disease. To incorporate the observed correlation structure among the resulting set of significant biomarkers, dimension reduction was then applied in the form of principal components. A second-stage logistic regression model using a small number of the principal component variables provided a highly predictive classification model for MIS-C. The resulting model was shown to compare favorably with an artificial neural network-based predictive model.

OBJECTIVES:While the presence of fatigue and inadequate sleep are well-described in children with inflammatory bowel disease (IBD), little data exist on potential sleep improvement interventions. We aimed to determine if sleep tracking and sleep hygiene counseling can result in sleep behavior change and reduced fatigue in children/adolescents with IBD. METHODS:This was a single-center, prospective, randomized controlled trial. Patients 12-20 years old with IBD, in clinical remission, completed validated Pediatric Quality of Life-Multidimensional Fatigue Scales (PedsQL-MDFS). Those who were found to have impaired sleep/rest fatigue (score <60) were randomized 1:1 into two intervention groups (A and B). Both groups were asked to track their sleep for 2 weeks using a standardized sleep log. Group B also had in-person sleep hygiene counseling. Outcomes were assessed 2 weeks after intervention implementation through repeat PedsQL-MDFS, self-reported behavior change surveys, and analysis of 2-week sleep logs. RESULTS:Sixty-six patients were enrolled. The mean age was 16.5 years, 53% male, 71% Crohn's disease, and 25% ulcerative colitis. Forty-three patients met criteria for randomization into the intervention groups. There was a significant improvement in the PedsQL-MDFS Sleep/Rest Fatigue score in both intervention groups. Sleep hygiene counseling for Group B resulted in a significant increase in patients putting their electronic screens away 30 min before bedtime. CONCLUSION:Sleep tracking and in-person sleep counseling positively impact sleep/rest fatigue scores and sleep behavior change. These simple interventions hold the promise of improving sleep and fatigue in children and adolescents with IBD.

Objective The McGill Thyroid Nodule Score (MTNS) is a preoperative tool used to predict the risk for well-differentiated thyroid cancer in adults. It was developed by a multidisciplinary team using established evidence-based risk factors for thyroid cancer. The modified McGill Thyroid Nodule Score (mMTNS) was developed to predict malignancy risk in children. A pilot study suggested the mMTNS was able to assess malignancy risk in children with indeterminate cytology on fine needle aspiration (FNA). This study seeks to validate these findings. Methods Retrospective chart review identified subjects who underwent FNA biopsy and subsequent resection. Each patient was assigned a score to compare to final pathology. Statistical analysis was performed with SPSS. All tests were 2-tailed and statistical significance defined p< 0.05. Logistic regression used to determine predictive values of scores. Results 46 patients ≤ 21 years of age underwent resection of a thyroid nodule. Female predominance of 85% (n=39). 78% (n=36) of patients had palpable nodule. 65% (n=30) found to have benign pathology and 35% (n=16) found to have malignancy. Malignant nodules associated with greater mean mMTNS compared to benign [13.63 vs 7.23]. An mMTNS greater > 12 had sensitivity of 86.7%, specificity of 90.3%, positive predictive value of 81.3%, and negative predictive value of 93.3%. Conclusion Our data suggests the mMTNS continues to be a useful adjunct in predicting malignancy risk of pediatric thyroid nodules. An mMTNS > 12 has a high risk for malignancy, which can aid in counseling and clinical decision making, particularly when there is indeterminate cytology on FNA. Level of Evidence IV.

Objectives:Payer mandates have resulted in children with inflammatory bowel disease (IBD) switching from originator Remicade® (O-Rem) to an infliximab biosimilar (B-IFX). Patients and families are fearful of switching because disease has been well controlled on O-Rem. Real-world data documenting clinical outcomes after such switches in pediatric patients are limited. The aim of this project was to examine 1 year of follow-up in a large adolescent/young adult IBD cohort who changed from O-Rem to B-IFX. Methods:We identified patients with IBD at Connecticut Children's receiving O-Rem for at least 1 year, who were either in clinical remission or had low disease activity, and who were subsequently switched to B-IFX. An age, gender, IBD-subtype, and duration since diagnosis cohort that continued on O-Rem was then matched to the switch cohort and served as a comparator group (1: switch vs. 2: no-switch). B-IFX was Inflectra® in all cases. Results:Two hundred and seventy-nine patients (mean age 18.7 years, Crohn's disease = 243, ulcerative colitis = 36) were studied (switch, n = 93, no-switch, n = 186). Mean time since diagnosis was >6 years in both groups, and mean duration of anti-tumor necrosis factor use was >5 years. There were no significant changes in hemoglobin, albumin, C-reactive protein, erythrocyte sedimentation rate, or disease activity in either group over 1 year. Dosing modifications as well as the frequency of low-level antibodies to infliximab were similar in both groups over the study period. Conclusion:Switching from O-Rem to B-IFX has no impact on clinical or laboratory parameters over the subsequent year. Clinicians can reliably reassure patients and families that switching is safe.

IntroductionThe national pediatric mental and behavioral health crisis dramatically increased emergency department mental and behavioral health visits and changed emergency nursing practice. Acuity assessment determines patient severity level and supports appropriate resources and interventions. There are no established nursing tools that assess pediatric mental or behavioral health acuity in the emergency department setting. Our goal was to develop and implement the novel pediatric emergency nurse Emergency Behavioral Health Acuity Assessment Tool.MethodsThis quality-improvement project used the plan, do, study, act model to design/refine the Emergency Behavioral Health Acuity Assessment Tool and a non-experimental descriptive design to assess outcomes. The setting was a 47-bed urban level 1 pediatric trauma center with more than 60,000 annual visits. The team designed the tool using published evidence, emergency nurse feedback, and expert opinion. The tool objectively captured patient acuity and suggested acuity-specific nursing interventions. Project outcomes included acuity, length-of-stay, restraint use, and patient/staff injuries. Analyses included descriptive statistics and correlations.ResultsWith over 3000 annual mental/behavioral-related visits, the emergency department had an average daily census of 23 mental and behavioral health patients. Implementation occurred in August 2021. The Emergency Behavioral Health Acuity Assessment Tool dashboard provided the number of patients, patient location, and acuity. Length-of-stay did not change; however, patient restraint use and patient/staff injuries declined. Number of restraints positively correlated with moderate acuity levels (r = 0.472, P = 0.036).DiscussionFor emergency nurses, the Emergency Behavioral Health Acuity Assessment Tool provided an objective measure of patient acuity. Targeted interventions can improve the care of this population.

The Connecticut Newborn Screening (NBS) Network, in partnership with the Connecticut Department of Public Health, strategically utilized the Epic electronic health record (EHR) system to establish registries for tracking long-term follow-up (LTFU) of NBS patients. After launching the LTFU registry in 2019, the Network obtained funding from the Health Resources and Services Administration to address the slow adoption by specialty care teams. An LTFU model was implemented in the three highest-volume specialty care teams at Connecticut Children’s, involving an early childhood cohort diagnosed with an NBS-identified disorder since the formation of the Network in March 2019. This cohort grew from 87 to 115 over the two-year project. Methods included optimizing registries, capturing external data from Health Information Exchanges, incorporating evidence-based guidelines, and conducting qualitative and quantitative evaluations. The early childhood cohort demonstrated significant and sustainable improvements in the percentage of visits up-to-date (%UTD) compared to the non-intervention legacy cohort of patients diagnosed with an NBS disorder before the formation of the Network. Positive trends in the early childhood cohort, including %UTD for visits and condition-specific performance metrics, were observed. The qualitative evaluation highlighted the achievability of practice behavior changes for specialty care teams through responsive support from the nurse analyst. The Network’s model serves as a use case for applying and achieving the adoption of population health tools within an EHR system to track care delivery and quickly fill identified care gaps, with the aim of improving long-term health for NBS patients.

Gourishetti, Sravya1; Kabara, Megan2; Brimacombe, Michael1; Cowl, Allison2 Author Information

Multisystem Inflammatory Syndrome in Children (MIS-C) is a potentially life-threatening complication of COVID-19. The pathophysiological mechanisms leading to severe disease are poorly understood. This study leveraged clinical samples from a well-characterized cohort of children hospitalized with COVID-19 or MIS-C to compare immune-mediated biomarkers. Our objective was to identify selected immune molecules that could explain, in part, why certain SARS-CoV-2-infected children developed MIS-C. We hypothesized that type-2 helper T cell-mediated inflammation can elicit autoantibodies, which may account for some of the differences observed between the moderate–severe COVID-19 (COVID+) and MIS-C cohort. We enumerated blood leukocytes and measured levels of selected serum cytokines, chemokines, antibodies to COVID-19 antigens, and autoantibodies in children presenting to an academic medical center in Connecticut, United States. The neutrophil/lymphocyte and eosinophil/lymphocyte ratios were significantly higher in those in the MIS-C versus COVID+ cohort. IgM and IgA, but not IgG antibodies to SARS-CoV-2 receptor binding domain were significantly higher in the MIS-C cohort than the COVID+ cohort. The serum levels of certain type-2 cytokines (interleukin (IL)-4, IL-5, IL-6, IL-8, IL-10, IL-13, and IL-33) were significantly higher in children with MIS-C compared to the COVID+ and SARS-CoV-2-negative cohorts. IgG autoantibodies to brain antigens and pentraxin were higher in children with MIS-C compared to SARS-CoV-19-negative controls, and children with MIS-C had higher levels of IgG anti-contactin-associated protein-like 2 (caspr2) compared to the COVID+ and SARS-CoV-19-negative controls. We speculate that autoimmune responses in certain COVID-19 patients may induce pathophysiological changes that lead to MIS-C. The triggers of autoimmunity and factors accounting for type-2 inflammation require further investigation.

Kabara, Megan1; Gourishetti, Sravya2; Brimacombe, Michael2; Cowl, Allison1 Author Information

BACKGROUND:With the rising incidence of inflammatory bowel disease (IBD) in pediatric populations, school nurses are increasingly called on to care for and support these students. METHOD:The research team surveyed Connecticut school nurses about their experiences, knowledge, and confidence in addressing IBD in the school setting. The team also developed and implemented an online education intervention to improve knowledge and confidence gaps during the 2022-2023 academic year. RESULTS:Most participants have cared for one to two (46%, n = 66) or several (30%, n = 44) students with IBD. However, 24% (n = 35) have not cared for any students with IBD. School nurses shared their perspectives with three themes identified from the qualitative feedback: (a) limited knowledge and experience with IBD, (b) importance of support at school, and (c) need for interprofessional collaborative practice. CONCLUSION:The online education significantly improved school nurses' knowledge (p < .001) and confidence scores (p < .001). Participants found this intervention beneficial to their work. [J Contin Educ Nurs. 2024;55(12):589-595.].

OBJECTIVES:There was an overall decline in pediatric emergency department visits during the COVID-19 pandemic. Caregivers are educated to bring febrile neonates promptly to the emergency department; however, for infants aged 29 to 60 days, there may not be the same urgency especially during a pandemic. There may have been a resultant change in the clinical and laboratory high-risk markers and infection rates in this patient population during the pandemic. METHODS:This was a single-center retrospective cohort study of infants aged 29 to 60 days presenting to the emergency department of an urban tertiary care children's hospital because of fever (>38°C) between March 11 and December 31, 2020, compared with those presenting in the same period during the 3 prior years (2017 through 2019). Patients were categorized as having high-risk criteria on a predetermined definition of ill appearance, white blood cell count, and urinalysis based on our hospital's evidence-based pathway. Information on infection type was also collected. RESULTS:A total of 251 patients were included in the final analysis. Comparison of the prepandemic and pandemic cohorts showed a significant increase in the proportion of patients with urinary tract infections ( P = 0.017) and bacteremia ( P = 0.02) and those presenting with high-risk white blood cell count ( P = 0.028) and urinalysis ( P = 0.034). There was no significant difference in patient demographics or in high-risk ill appearance ( P = 0.208). CONCLUSIONS:This study demonstrates a significant increase in the rates of urinary tract infection and bacteremia in addition to the objective markers used to risk-stratify febrile infants aged 29 to 60 days. This supports the need for attentiveness in evaluating these febrile infants in the emergency department.

INTRODUCTION:The COVID-19 pandemic has significantly impacted the mental well-being of health care workers (HCWs). This study assessed the feasibility, acceptability, and preliminary efficacy of two psychological interventions, gratitude journaling or cognitive strategies, on pediatric HCWs.METHOD:A pilot randomized parallel repeated measures design was used, with a convenience sample of 59 HCWs. Data were collected before and after the intervention period, 2 weeks after, and again 6 months later. Outcomes included depression, anxiety, meaning and purpose, feasibility, and acceptability.RESULTS:Thirty-seven participants completed the study. The majority were nurses (registered nurses and advanced practice registered nurses) and physicians. In both groups, depression and anxiety scores diminished, but changes were not statistically significant. The study was feasible to conduct, and subjects reported high acceptability.DISCUSSION:Gratitude journaling and cognitive strategies may help mental well-being in HCWs; however, future studies with larger samples are needed.

Objective: There are limited data regarding the impact of gender within congenital heart surgery. Our aim was to assess gender-related experiences by surgeons in this field.Methods: A cross-sectional survey was emailed to practicing congenital heart sur-geons to ascertain the perception of gender in 5 domains: training, professional career, clinical practice, personal life, and career outlook.Results: The survey response rate was 94% (17/18) for women and 44% (112/257) for men. More than half of women (53%) were discouraged from pursuing congenital heart surgery (P < .001) and reported a negative impact of gender in attaining their first congenital heart surgery job (P < .001) compared with men. Despite similar demographics, women reported lower starting annual sal-aries ($150K-$250K vs $250K-$400K), lower current annual salaries ($500K -$750K vs $750K-$1M), lower academic ranks (clinical instructor 6% vs 4% [P = .045], assistant professor 35% vs 19% [P = .19], associate professor 41% vs 25% [P = .24], and professor 6% vs 41% [P = .005]) along with lower annual salaries at the associate professor ($500K-$750K vs $1M-$1.25M) and professor levels ($1M-$1.25M vs>$1.5M) compared with men. Sexual harassment was expe-rienced more frequently by women both in training (65% vs 6%, P <.001) and in practice (65% and 4%, P < .001).Conclusions: This survey highlights many areas of gender-related differences: discouragement due to gender to pursue congenital heart surgery, sexual harass-ment in training and practice, salary and academic rank differentials, negative gender perception at work, and lower career satisfaction for women. Despite various differences between both genders, the majority in each group would choose to enter this profession again as well as encourage others to do so. (J Thorac Cardiovasc Surg 2023;165:1669-77)

Background: The tibial tubercle to trochlear groove (TT-TG) distance is often utilized for determining the surgical treatment for patients with patellar instability (PI). It is thought to directly represent the position of the TT on the tibia. Recent work has shown that the measurement of the TT-TG distance is multifactorial. Purpose: To investigate the relationship between relative tibial external rotation (rTER) and trochlear dysplasia (TD), as well as the location of the TG and TT in patients with and without PI, and to correlate these and other anatomic measurements with the TT-TG distance. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 89 patients with PI who underwent magnetic resonance imaging were identified with 92 matched control patients. A standardized measurement protocol on axial magnetic resonance imaging determined rTER, the proximal and distal TG lateralization (pTGL and dTGL, respectively) ratios, and the TT lateralization (TTL) ratio. Other measures of interest included the lateral trochlear inclination angle, sulcus angle, and lateral patellar inclination angle. Univariate regression was used to determine the associations of TD (lateral trochlear inclination angle, sulcus angle) with rTER and the TG position, and multivariate regression was used to model associations among all the variables with the proximal and distal TT-TG distances. Results: rTER was significantly higher in the study group ( P < .001), and univariate regression showed a significant association between dysplasia measures and rTER ( P < .001). The pTGL ratio was lower in the study group ( P = .025), but there was no difference in the dTGL ratio ( P = .090) or the TTL ratio ( P = .098) between the groups. There were no associations between dysplasia measures and the pTGL and dTGL ratios ( P > .05). Multivariate regression showed that the proximal TT-TG distance is predicted by the sulcus angle, pTGL ratio, rTER, and TTL ratio ( P < .05) and that the distal TT-TG distance is predicted by the lateral patellar inclination angle, dTGL ratio, sulcus angle, rTER, and TTL ratio ( P < .05). Conclusion: rTER had a significant association with TD. The position of the proximal TG was more medial in patients with PI. There was no significant difference in the TTL ratio between patients with and without PI. The TT-TG distance was associated with multiple anatomic measures and was not solely predicated on the position of the TT.

BACKGROUND Develop a clinical and biological predictive model for colectomy risk in children newly diagnosed with ulcerative colitis (UC). METHODS This was a multicenter inception cohort study of children (ages 4-17 years) newly diagnosed with UC treated with standardized initial regimens of mesalamine or corticosteroids (CS) depending upon initial disease severity. Therapy escalation to immunomodulators or infliximab was based on predetermined criteria. Patients were phenotyped by clinical activity per the Pediatric Ulcerative Colitis Activity Index (PUCAI), disease extent, endoscopic/histologic severity, and laboratory markers. In addition, RNA sequencing defined pretreatment rectal gene expression and high density DNA genotyping by the Affymetrix UK Biobank Axiom Array. Coprimary outcomes were colectomy over 3 years and time to colectomy. Generalized linear models, Cox proportional hazards multivariate regression modeling, and Kaplan-Meier plots were used. RESULTS Four hundred twenty-eight patients (mean age 13 years) started initial theapy with mesalamine (n = 136), oral CS (n = 144), or intravenous CS (n = 148). Twenty-five (6%) underwent colectomy at ≤1 year, 33 (9%) at ≤2 years, and 35 (13%) at ≤3 years. Further, 32/35 patients who had colectomy failed infliximab. An initial PUCAI ≥ 65 was highly associated with colectomy (P = 0.0001). A logistic regression model predicting colectomy using the PUCAI, hemoglobin, and erythrocyte sedimentation rate had a receiver operating characteristic area under the curve of 0.78 (95% confidence interval [0.73, 0.84]). Addition of a pretreatment rectal gene expression panel reflecting activation of the innate immune system and response to external stimuli and bacteria to the clinical model improved the receiver operating characteristic area under the curve to 0.87 (95% confidence interval [0.82, 0.91]). CONCLUSIONS A small group of children newly diagnosed with severe UC still require colectomy despite current therapies. Our gene signature observations suggest additional targets for management of those patients not responding to current medical therapies.

Purpose:To evaluate whether there is a correlation between the position of the patella and trochlear morphology in patients with and without patellar instability using exclusively MRI measurements.Methods:MRI scans of knees in patients with patellofemoral instability and knees of patients with an ACL (anterior cruciate ligament) tear as a control group were reviewed. Measurements of patellar position (Canton-Deschamps ratio, Patellar Trochlear Index, and lateral patellar inclination) and trochlear morphology (lateral trochlear inclination and sulcus angle) were obtained from each scan. Bivariate and multivariate analysis was performed to identify correlations between study group, demographics, and patellofemoral joint measurements.Results:There were 70 knees in the patellofemoral instability group and 60 knees in the control group. Bivariate analysis showed a significant difference in all measurements between the patellar instability group and the control group. Multivariate analysis showed modest correlations between patellar position and trochlear morphology. The Caton-Deschamps (CD) ratio correlated with patellar trochlear index (P < .001) and lateral trochlear inclination (P < .001). The respective R-square goodness of fit was 41.1%. Patellar trochlear index correlated with CD ratio (P < .001), lateral trochlear inclination (P < .001), lateral patellar inclination (P < .001), and patellar instability group (P = .011). The R-sq goodness of fit was 37.3%. Lateral patellar inclination correlated with patellar trochlear index (P < .001), Lateral trochlear inclination (P < .001), and age at first dislocation or injury (P = .02). The R-sq goodness of fit was 68.56%.Conclusions:Using MRI-based measurements of the patellofemoral joint, we identified modest, but significant, correlations between measures of patellar height (patellar trochlear index, CD ratio, and lateral patellar inclination) and trochlear dysplasia. This correlation is unclear and is likely multifactorial, but on the basis of this work, a causal relationship between trochlear dysplasia and patella alta cannot be established.Clinical Relevance:Radiographic evaluation of the patella and how it relates to the surrounding boney anatomy provides important information regarding our understanding of patella instability and its treatment.