Objective: A cross-sectional study was conducted to determine if in-school physical activity (PA) varied by age, gender, weight and asthma status, participation in physical education (PE), outdoor recess, and other in-school PA among urban schoolchildren with asthma. Methods: PA was measured by tri-axial accelerometers. Height and mass were measured and overweight defined as BMI ≥85th percentile. Asthma impairment and risk were assessed as per national guidelines, and asthma status variable with three categories (mild, moderate, and severe) was created. Multivariable generalized linear mixed models adjusting for clustering due to school and student were fitted to identify variables predictive of PA. Results: 108 children with asthma participated. Children spent 374 minutes in school, of which 253 minutes were sedentary, 105 minutes in light PA, and 16 minutes in moderate-to-vigorous PA (MVPA). Only 3 participants reached the recommended ≥30 minutes/day of MVPA. Multivariable analysis revealed age, gender, participation in PE class, outdoor recess, and other in-school PA as independent predictors of PA. BMI and asthma status were not associated with PA. Conclusions: Children with asthma were mostly sedentary at school. Older children and girls were particularly at risk for inactivity. PE, recess, and other in-school PA participation are modifiable factors that should be targeted in school-based interventions aimed at increasing PA in this population.
Comparative effectiveness research (CER), established as a branch of health services research to ascertain which medications or treatments are most effective for patients in specific circumstances, is currently emerging as a highly-promising research field.The most commonly-cited definition of CER was proposed by the Institute of Medicine in 2009, and states that CER is "the generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat, and monitor a clinical condition or to improve the delivery of care."The scope of CER has been further broadened by encompassing not only clinical interventions but also community and other public health interventions which are implemented through a wide range of study designs (experimental, observational, prospective, retrospective, etc.).The overarching goal of CER is to better support the decision-making of patients, caregivers, clinicians, and regulatory officials based on credible information, ultimately leading to improved health outcomes.As can be observed in many biomedical and public health applications, biostatistics plays a core role in CER studies, providing fundamental tools for achieving the goal.
In this article, we discuss the role of formal advocacy education with high-effort advocacy activities among pediatricians. We discuss the historical role of advocacy in the field of pediatrics and the changing role of advocacy education in pediatric training programs. We describe our survey of pediatricians in New York, in which we asked about a history of formal child health advocacy education, current high- and low-effort advocacy activities, perceived barriers to advocacy work, and child health advocacy issues of interest. Our findings demonstrate an association between a history of formal child health advocacy education and recent participation in high-effort advocacy activities on behalf of children’s health. We also found that practicing pediatricians were more likely to participate in high-effort advocacy work than individuals still in pediatric residency training. Our findings imply that education in child health advocacy should be considered an important part of pediatric training. Advocacy education should not only be included in residency and fellowship training programs but also made available as part of continuing medical education for pediatricians. Time for professional advocacy work should be allotted and encouraged.
To characterize the demographic and clinical features of pediatric severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) syndromes and identify admission variables predictive of disease severity.
Posttraumatic stress disorder (PTSD) symptomatology and poorer pulmonary function are highly prevalent psychiatric and medical conditions. In the present study, we tested for the individual, additive, and modifying associations of PTSD symptomatology and pulmonary function with cognitive performance.
Kawasaki disease is the primary cause of acquired pediatric heart disease in developed nations. Timely diagnosis of Kawasaki disease incorporates transthoracic echocardiography for visualization of the coronary arteries. Sedation improves this visualization, but not without risks and resource utilization. To identify potential sedation criteria for suspected Kawasaki disease, we analyzed factors associated with diagnostically inadequate initial transthoracic echocardiography performed without sedation.This retrospective review of patients < 18 years old undergoing initial transthoracic echocardiography for the inpatient evaluation of suspected Kawasaki disease from 2009 to 2015 occurred at a medium-sized urban children's hospital. The primary outcome was diagnostically inadequate transthoracic echocardiography without sedation due to poor visualization of the coronary arteries, determined by review of clinical records. The associations of the primary outcome with demographics, Kawasaki disease type, laboratory data, fever, and antipyretic or intravenous immunoglobulin treatment prior to transthoracic echocardiography were analyzed.In total, 112 patients (44% female, median age 2.1 years, median BSA 0.54 m2 ) underwent initial transthoracic echocardiography for suspected Kawasaki disease, and 99 were not sedated. Transthoracic echocardiography was diagnostically inadequate in 19 out of these 99 patients (19.2%) and was associated with age ≤ 2.0 years, weight ≤ 10.0 kg, and antipyretic use ≤ 6 hours before transthoracic echocardiography (all P < .05). These variables did not reach statistical significance on multivariable analysis.Patients ≤ 2.0 years or ≤ 10.0 kg or those recently receiving antipyretics, potentially a surrogate for irritability, were associated with diagnostically inadequate transthoracic echocardiography during the inpatient workup of Kawasaki disease. These factors should be considered when deciding which patients to sedate for initial Kawasaki disease transthoracic echocardiography.
Prior studies have identified high rates of cannabis use in people with sickle cell disease (SCD).1-3 However, prior studies were underpowered to identify if cannabis use was associated with any SCD-related comorbidities, especially comorbidities such as pulmonary complications or stroke, which have been associated with smoked cannabis use in the general population. To address this gap, we conducted a large cohort study to examine the association between patient demographics and comorbidities of SCD associated with cannabis use. We hypothesised that cannabis users would have more comorbidities related to pain, which may drive use. We had no a priori hypothesis as to whether use would correlate with rates of acute chest syndrome (ACS) or stroke as it has been shown that over half of cannabis users with SCD use infrequently (weekly, monthly, or less than monthly), which may mitigate this association.1 The study was conducted at the Adult Sickle Cell Center at Montefiore Medical Center in Bronx, NY after obtaining approval from the Institutional Review Board of the Albert Einstein College of Medicine. Inclusion criteria were: (i) SCD with any genotype, (ii) age ≥21 years, (iii) presented for routine outpatient SCD care during 8/2018–1/2019 period and (iv) able/willing to complete a survey in English or Spanish. Patients completed a paper survey instrument created by the investigators (see Supplement S1) in English or Spanish. Patients completed surveys independently and then reviewed them with a clinician. Questions asked about demographics, comorbidities of SCD, frequency of Emergency Department (ED) use, hospital admissions, and opioid use. Reported demographics, SCD diagnosis and comorbidities, healthcare utilisation, hydroxycarbamide (hydroxyurea) and opioid use were all confirmed and corrected if necessary via a detailed electronic medical records (EMR) review performed by two clinicians after the survey was completed. Current cannabis users were defined as patients with self-reported use in the previous 30 days, prior users were defined as those with any self-reported use, non-users were defined as those who reported no previous use. No differentiation was made between illicit and medical cannabis. Patients were asked to identify their reason for cannabis use and preferred modality. Multiple answers were allowed in each category. Patients were classified as having frequent pain crisis if they reported experiencing pain crisis monthly or more. They were classified as having high healthcare utilisation if they reported three or more ED visits and/or hospital admissions during the prior 12 months or if three or more were present in the EMR. Clinical characteristics were summarised as means for continuous variables and counts and percentages for categorical variables. Clinical characteristics of prior cannabis users were compared to non-users using the chi-square or Fisher's exact tests for categorical variables and Wilcoxon rank-sum tests for continuous variables. Data were analysed using Statistical Analysis System (SAS) software, version 9.2 (SAS Institute Inc., Cary, NC, USA). Of 224 patients meeting eligibility criteria, the mean age was 37·1 years, 53·6% were female, 66% were born in the United States, genotype was 75% HbSS/HbSB0 and 25% HbSC/HbSB+. Of the 224 patients, 69 (30·8%) were prior cannabis users, 43 (19·2%) were current users and 155 (69%) were non-users. The most common mode of use reported was smoking cannabis cigarettes (i.e. 'joints' or 'blunts') and the most common reason reported for use was pain treatment (Fig 1). Prior cannabis users were more likely to be male (P = 0·04) and to have been born in the United States (P = 0·001) than non-users, there were no differences in age, genotype race, or hydroxycarbamide use. When SCD comorbidities were examined, prior users were more likely to have avascular necrosis (AVN) of the bone that non-users (P = 0·03), there were no differences in rates of ACS, stroke, venous thromboembolism, retinopathy, liver disease, pulmonary hypertension, leg ulcers and priapism, Finally, users were more likely to have frequent pain crisis (P = 0·04), to have high healthcare utilisation (P = 0·02), and to report home opioid use (P = 0·002) (Table I). We found that pain-related outcomes such as AVN, frequent pain crisis, and home opioid use were associated with cannabis use, but cannabis use was not associated with ACS or stroke. While previous studies that examined cannabis use in people with SCD showed that it was common, none were able to detect significant differences in SCD related comorbidities between users and non-users.3 By examining a large cohort we were able to show that the presence of AVN was associated with cannabis use, a novel finding. This suggests that comorbidities related to pain may be associated with cannabis use but cannabis use may not negatively impact respiratory comorbidities such as ACS or central nervous system comorbidities such as stroke. The present study has limitations. Given the cross-sectional nature of this and prior studies it is not possible determine if cannabis use causes pain-related complications, or if patients with pain are using cannabis for pain management. However, prior studies showed illicit cannabis users with SCD had fewer episodes of admission compared to non-users with a similar severity of pain, patients with SCD who obtained medical cannabis had a subsequent reduction in healthcare utilisation, and in a study of 5 days of inhaled cannabis or placebo for chronic pain in SCD, cannabis was associated with an increase in mood and no worsening of pain.4-7 In regards to AVN is it possible that the anti-inflammatory properties of cannabis may help in mitigating inflammatory pain in AVN.8 Therefore, we suggest pain-related outcomes drive cannabis use. Rates of cannabis use in our present cohort were lower than those reported in other studies, which may be because we defined use by self-report and had a large percentage of foreign born individuals in our cohort, the stigma associated with cannabis use in those countries could lead to low rates of use and/or of reporting use.1-3, 9-11 We did not obtain descriptions of pain quality experienced or date of first cannabis use, and reasons for cannabis use was by self-report. Further, all cause ED visits and admissions were examined, although we suspect the majority were due to acute pain exacerbation based on prior studies. Our present study provides reassurance that while patients with SCD who have more pain-related comorbidities are more likely to use cannabis, users do not show increased rates of other SCD comorbidities. Prospective trials are needed to further describe the safety and efficacy of cannabinoids in patients with SCD. Dr Curtis is supported by K23HL151884, Dr Cunningham is supported by K24DA036955, Dr Starrels is supported by K24DA046309, and Drs Starrels, Cunningham, and Arnsten are supported by R01DA044171. Drs Miodownik, Bradford, Cunningham, Arnsten, Choi, and Eisenberg report no conflicts of interest or competing interests. Dr Curtis declares consultancy for Global Blood Therapeutics. Dr Ogu declares Consultancy for Vertex Pharmaceuticals and Novo-Nordisk, Speaker Bureau for Global Blood Therapeutics. Dr Minniti declares Advisory roles to Novartis, Global Blood Therapeutics, Roche, Forma, Bluebird Bio, Emmaus Life Science, CSL- Behring, Chiesi, Novo-Nordisk and Research support from Global Blood Therapeutics and Bayer. Dr Starrels declares research support from the FDA-mandated Opioid Post-Marketing Requirement Consortium. Conceptualisation: Drs Caterina P. Minniti, MD, Ugochi Olivia Ogu, MD, Hope Miodownik, MD, Christopher Bradford, MD; Methodology: Caterina P. Minniti, MD Ugochi Olivia Ogu, MD, Hope Miodownik, MD; Formal analysis and investigation: Hope Miodownik, MD, Christopher Bradford, MD, Jaeun Choi, PhD, Ruth Eisenberg, MS, Susanna Curtis MD PhD; Writing: Hope Miodownik, MD, Susanna Curtis, MD PhD, Christopher Bradford, MD; Writing - review and editing: Susana Curtis, MD PhD, Ugochi Olivia Ogu, MD, Caterina P. Minniti, MD, Joanna L. Starrels, MD, MS, Chinazo O. Cunningham, MD, MS, Julia H. Arnsten, MD, MPH; Supervision: Caterina P. Minniti, MD Ugochi Olivia Ogu, MD Susanna Curtis MD PhD. This study was performed in line principals of the Declaration of Helsinki and approval was granted by the Albert Einstein College of Medicine Institutional Review Board. Informed consented was not obtained as all information was anonymised. Consent for publication was not obtained as all information was anonymised. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
In the US, unaccompanied migrant children and adolescents (hereinafter referred to as children) are predominantly from Central America's Northern Triangle. While unaccompanied migrant children are at high risk for psychiatric sequelae due to complex traumatic exposures, longitudinal investigations of psychiatric distress after resettlement are lacking.To identify factors associated with emotional distress and longitudinal changes in emotional distress among unaccompanied migrant children in the US.For this retrospective cohort study, the 15-item Refugee Health Screener (RHS-15) was administered between January 1, 2015, and December 31, 2019, to unaccompanied migrant children as part of their medical care to detect emotional distress. Follow-up RHS-15 results were included if they were completed before February 29, 2020. Median follow-up interval was 203 days (IQR, 113-375 days). The study was conducted in a federally qualified health center that provides medical, mental health, and legal services. Unaccompanied migrant children who completed the initial RHS-15 were eligible for analysis. Data were analyzed from April 18, 2022, to April 23, 2023.Traumatic events before migration, during migration, during detention, and after resettlement in the US.Emotional distress, including symptoms of posttraumatic stress disorder, anxiety, and depressive symptoms, as indicated by the RHS-15 (ie, score ≥12 on items 1-14 or ≥5 on item 15).In total, 176 unaccompanied migrant children completed an initial RHS-15. They were primarily from Central America's Northern Triangle (153 [86.9%]), were mostly male (126 [71.6%]), and had a mean (SD) age of 16.9 (2.1) years. Of the 176 unaccompanied migrant children, 101 (57.4%) had screen results above the positive cutoff. Girls were more likely to have positive screen results than boys (odds ratio, 2.48 [95% CI, 1.15-5.34]; P = .02). Follow-up scores were available for 68 unaccompanied migrant children (38.6%). On the follow-up RHS-15, most scored above the positive cutoff (44 [64.7%]). Three-quarters of unaccompanied migrant children who scored above the positive cutoff initially continued to have positive scores at follow-up (30 of 40), and half of those with negative screen scores initially had positive scores at follow-up (14 of 28). Female vs male unaccompanied migrant children (unstandardized β = 5.14 [95% CI, 0.23-10.06]; P = .04) and initial total score (unstandardized β = 0.41 [95% CI, 0.18-0.64]; P = .001) were independently associated with increased follow-up RHS-15 total score.The findings suggest that unaccompanied migrant children are at high risk for emotional distress, including symptoms of depression, anxiety, and posttraumatic stress. The persistence of emotional distress suggests that unaccompanied migrant children would benefit from ongoing psychosocial and material support after resettlement.
