Objectives: Data on outcomes of children with cystic fibrosis admitted to PICUs are limited and outdated. Prior studies cite PICU mortality rates ranging from 37.5% to 100%. Given the advances made in cystic fibrosis care, we expect outcomes for these patients to have changed significantly since last studied. We provide an updated report on PICU mortality and the factors associated with death among critically ill children with cystic fibrosis. Design:Retrospective multicenter cohort analysis utilizing data from the Virtual Pediatric Systems database.
Objectives: We sought to investigate how race, ethnicity, and socioeconomic status relate to tracheostomy insertion and post-tracheostomy mortality among infants with bronchopulmonary dysplasia (BPD). Methods: The Vizient Clinical Database/Resource Manager was queried to identify infants born ≤32 weeks with BPD admitted to US hospitals from January 2012 to December 2020. Markers of socioeconomic status were linked to patient records from the Agency for Healthcare Research and Quality's Social Determinants of Health Database. Regression models were used to assess trends in annual tracheostomy insertion rate and odds of tracheostomy insertion and posttracheostomy mortality, adjusting for sociodemographic and clinical factors. Results: There were 40,021 ex-premature infants included in the study, 1614 (4.0%) of whom received a tracheostomy. Tracheostomy insertion increased from 2012 to 2017 (3.1%-4.1%), but decreased from 2018 to 2020 (3.3%-1.6%). Non-Hispanic Black infants demonstrated a 25% higher odds (aOR 1.25, 1.09-1.43) and Hispanic infants demonstrated a 20% lower odds (aOR 0.80, 0.65-0.96) of tracheostomy insertion compared with non-Hispanic White infants. Patients receiving public insurance had increased odds of tracheostomy insertion (aOR 1.15, 1.03-1.30), but there was no relation between other metrics of socioeconomic status and tracheostomy insertion within our cohort. In-hospital mortality among the tracheostomy-dependent was 14.1% and was not associated with sociodemographic factors. Conclusions: Disparities in tracheostomy insertion are not accounted for by differences in socioeconomic status or the presence of additional neonatal morbidities. Post-tracheostomy mortality does not demonstrate the same relationships. Further investigation is needed to explore the source and potential mitigators of the identified disparities.
Rationale: Despite lower overall hospitalization rates for asthma in recent years, there has been an increase in the number of pediatric patients receiving intensive care management in the United States.Objectives: To investigate how the use of invasive and noninvasive mechanical ventilation for asthma has changed in the context of an evolving cohort of critically ill pediatric patients with asthma.Methods: We analyzed children admitted to intensive care units for asthma from 2009 through 2019 in the Virtual Pediatric Systems database. Regression analyses were used to evaluate how respiratory support interventions, mortality, and patient characteristics have changed over time. Odds ratios were calculated to determine how patient characteristics were associated with respiratory support needs. Stratified analyses were performed to determine how changing practice patterns may have differed between patient subgroups.Results: There were 67,614 admissions for 56,727 patients analyzed. Intubation occurred in 4.6% of admissions and decreased from 6.9% to 3.4% over time (P , 0.001), whereas noninvasive ventilation as the maximal respiratory support increased from 8.9% to 20.0% (P , 0.001). Over time, the cohort shifted to include more 2-to 6-year-olds and patients of Asian/Pacific Islander or Hispanic race/ethnicity. Although intubation decreased and noninvasive ventilation increased in all subgroups, the changes were most pronounced in the youngest patients and slightly less pronounced for obese patients.Conclusions: In pediatric asthma, use of intubation has halved, whereas use of noninvasive ventilation has more than doubled. This change in practice appears partially related to a younger patient cohort, although other factors merit exploration.
While earlier studies have attempted to resolve the challenges encountered when interpreting gamma-hydroxybutyric acid (GHB) concentrations in hair (primarily due to its endogenous presence), few have had large sample sizes. The first objective of this study was to evaluate the inter-individual variation of endogenous GHB concentrations. The second objective, to be detailed in another report, was to assess intra-individual variation and the impact on exogenous GHB discrimination. Over 2000 hair segments from 141 women and 73 men (all processed hair 3–12 cm long) were analyzed in this study. The raw calculated range of endogenous GHB concentrations was < 0.40–5.47 ng/mg with 97.5% of the segmental results calculated less than 2.00 ng/mg. Imputation, assuming a lognormal distribution, was applied to the data to include non-detect data (<LOQ), which led to an estimated endogenous GHB range of 0.16–5.47 ng/mg. Kruskal-Wallis tests were employed on a segmental basis for group comparisons. This test was applied to the male and female segmental medians and subsequently indicated that these groups were different at the α = 0.05 level of significance. Additionally, female hair samples appeared to have a trend comprising higher endogenous GHB concentrations close to the scalp and a mean net decrease of ~ 0.2–0.3 ng/mg distally. Male hair samples displayed the opposite trend, with a mean net increase of ~ 0.5–0.6 ng/mg from the proximal to the distal end of the hair shaft. It was also concluded that differences exist between the median GHB concentrations of the “treated” and “untreated” hair in the female group at the α = 0.05 level of significance. Age groups and races were analyzed, but none of the observed differences in median concentration were significant at α = 0.05. This is the largest endogenous GHB hair population study to date and provides substantial new data on inter-individual variation and chronological trends of GHB concentrations in hair.
The endogenous presence of gamma-hydroxybutyric acid (GHB) complicates the interpretation of results in cases where an exogenous dosing is suspected. Due to GHB’s rapid metabolism and clearance following exogenous doses, hair has become a preferential matrix for confirmation of GHB exposure in drug-facilitated crimes. However, unlike blood and urine where an agreed upon cut-off concentration for differentiation between endogenous and exogenous GHB has been made, there has been no consensus on a cut-off concentration for hair. This is due in part to the wide inter- and intra-individual variation that has been observed in endogenous GHB hair studies. A large (>50) population study of 214 donors was conducted to better understand these variations and to evaluate whether a cut-off concentration could be established for endogenous GHB in human hair. As seen in our previous study, the inter-individual variation was large, with concentrations ranging from < 0.40 to 5.47 ng/mg. This range made an absolute cut-off concentration recommendation inappropriate, so an alternative approach for GHB discrimination was investigated utilizing the intra-individual variation. Male donors appeared to have greater intra-individual variation than female donors, yet it was noted that segment-to-segment variation along the length of hair had minimal change between individual donor’s adjacent segments. Overall, 97.1% of the adjacent segment differences were within ±0.5 ng/mg. Therefore, instead of a recommended cut-off concentration, it appears that using adjacent segment concentration differences could be a strategy to assist in differentiating endogenous from single exogenous GHB exposure. In the absence of controlled dosing data, previously published segmented results from controlled and suspected dosing donors are examined using the adjacent segmental difference approach and the results compared to currently used ratio-based calculations.
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