Pediatric Tertiary Care Center Research Articles

Surveillance of Health Care-Associated Violence Using Natural Language Processing.

Patient and family violent outbursts toward staff, caregivers, or through self-harm, have increased during the ongoing behavioral health crisis. These health care-associated violence (HAV) episodes are likely under-reported. We sought to assess the feasibility of using nursing notes to identify under-reported HAV episodes. We extracted nursing notes across inpatient units at 2 hospitals for 2019: a pediatric tertiary care center and a community-based hospital. We used a workflow for narrative data processing using a natural language processing (NLP) assisted manual review process performed by domain experts (a nurse and a physician). We trained the NLP models on the tertiary care center data and validated it on the community hospital data. Finally, we applied these surveillance methods to real-time data for 2022 to assess reporting completeness of new cases. We used 70 981 notes from the tertiary care center for model building and internal validation and 19 332 notes from the community hospital for external validation. The final community hospital model sensitivity was 96.8% (95% CI 90.6% to 100%) and a specificity of 47.1% (39.6% to 54.6%) compared with manual review. We identified 31 HAV episodes in July to December 2022, of which 26 were reportable in accordance with the hospital internal criteria. Only 7 of 26 cases were reported by employees using the self-reporting system, all of which were identified by our surveillance process. NLP-assisted review is a feasible method for surveillance of under-reported HAV episodes, with implementation and usability that can be achieved even at a low information technology-resourced hospital setting.

Surveillance of Health Care-Associated Violence Using Natural Language Processing.

Patient and family violent outbursts toward staff, caregivers, or through self-harm, have increased during the ongoing behavioral health crisis. These health care-associated violence (HAV) episodes are likely under-reported. We sought to assess the feasibility of using nursing notes to identify under-reported HAV episodes. We extracted nursing notes across inpatient units at 2 hospitals for 2019: a pediatric tertiary care center and a community-based hospital. We used a workflow for narrative data processing using a natural language processing (NLP) assisted manual review process performed by domain experts (a nurse and a physician). We trained the NLP models on the tertiary care center data and validated it on the community hospital data. Finally, we applied these surveillance methods to real-time data for 2022 to assess reporting completeness of new cases. We used 70 981 notes from the tertiary care center for model building and internal validation and 19 332 notes from the community hospital for external validation. The final community hospital model sensitivity was 96.8% (95% CI 90.6% to 100%) and a specificity of 47.1% (39.6% to 54.6%) compared with manual review. We identified 31 HAV episodes in July to December 2022, of which 26 were reportable in accordance with the hospital internal criteria. Only 7 of 26 cases were reported by employees using the self-reporting system, all of which were identified by our surveillance process. NLP-assisted review is a feasible method for surveillance of under-reported HAV episodes, with implementation and usability that can be achieved even at a low information technology-resourced hospital setting.

Nonoperative Versus Operative Treatment of Z-Type Comminuted Clavicle Fractures in Adolescents: A Prospective Substratified Cohort Analysis.

To compare the clinical, radiographic, and patient-reported outcomes of nonoperative and operative treatment of adolescents with comminuted "Z-type" midshaft clavicle fractures. Prospective observational cohort. Eight tertiary care pediatric centers. Patients aged 10-18 years who were treated either operatively or nonoperatively for a diaphyseal clavicle fracture between 2013 and 2017 were screened/enrolled at the time of injury. The current subcohort analysis was derived from a larger adolescent clavicle study population of 907 patients. Complications and validated patient-reported outcome measures (PROs):(ASES, QuickDASH, Marx Shoulder Activity Score, EQ-5D, EQ-VAS, and patient satisfaction score) were compared between operative and nonoperative cohorts. Eighty-one patients (69 male [85.2%], 12 female; average age 15 years [11.1-18.7]; 78 with sports participation [96.2%]) were followed through bony healing and return to sports, while 59 patients (73%) completed 2-year follow-up with PROs, 26 of whom were treated nonoperatively and 33 treated operatively. All demographic and fracture characteristics were similar (P > 0.05) between the 2-year follow-up cohorts except for fracture shortening, which was greater in the operative cohort (23 vs. 29 mm, P = 0.01). After controlling for this potential confounder through both regression and propensity matched subgroup analysis, nonoperative versus operative cohorts showed no difference in rates of nonunion (0%), delayed union (0% vs. 2.3%, P = 1.0), symptomatic malunion (2.7% vs. 0%, P = 0.4), refracture (2.7% vs. 2.2%, P = 1.0), unexpected subsequent surgery (5.4% vs. 11.4%, P = 0.45), or clinically significant complications (5.4% vs. 16%, P = 0.17). There were no differences in any PROs between cohorts, both before and after controlling for the difference in fracture shortening (all P-values >0.05). In this prospective comparison of complications and 2-year PROs in adolescents with comminuted Z-type clavicle fractures, nonoperative and operative treatment yielded similar outcomes. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Implementation of standardized patient safety and quality improvement rounds in a tertiary care paediatric centre

Abstract Introduction Patient safety is increasingly becoming a major priority for healthcare institutions, and various models of these rounds exist. The Ottawa M&M Model (OM3) is a structured and standardized approach to patient safety and quality improvement rounds that has been implemented at other institutions across Canada with good success. Methods This quality improvement project invited divisions within the Children’s Hospital in London, Ontario to participate in the implementation of the OM3 for M&M rounds. The project aligned with the Institute for Health Improvement’s Model for Improvement. Baseline needs assessments and facilitator training were performed. The main outcome was implementation of a version of the OM3 for PSQI rounds, action items generated from these rounds, and systemic hospital changes. Results The baseline needs assessment showed that 18 (66.7%) respondents were members of divisions with pre-existing M&M rounds. Most found their rounds at least valuable, but only two-thirds found that action items were generated following each meeting. After implementation of the OM3, 58.3% (21 of 36) of action items submitted to the CH-QCC were partially or completed actioned by the end of 2022. A post-implementation survey showed that of the 11 division representatives who responded, 7 (64%) were still participating in PSQI rounds and using the new OM3 format, which they agreed was more organized. Conclusions We were able to successfully implement a new standardized approach to Patient Safety and Quality Improvement Rounds that has led to systemic changes within the paediatrics hospital and continues to be used today.

Statistical analysis plan for the SQUEEZE trial: A trial to determine whether septic shock reversal is quicker in pediatric patients randomized to an early goal-directed fluid-sparing strategy vs. usual care (SQUEEZE)

BackgroundThe SQUEEZE trial is a multicentred randomized controlled trial which seeks to determine the optimal approach to fluid resuscitation in paediatric septic shock. SQUEEZE also includes a nested translational study, SQUEEZE-D, investigating the value of plasma cell-free DNA for prediction of clinical outcomes. ObjectiveTo present a pre-specified statistical analysis plan (SAP) for the SQUEEZE trial prior to finalizing the trial data set and prior to commencing data analysis. DesignSQUEEZE is a pragmatic, two-arm, open-label, prospective multicentre randomized controlled trial. SettingCanadian paediatric tertiary care centres. ParticipantsPaediatric patients with suspected sepsis and persistent signs of shock in need of ongoing resuscitation. Sample size target: 400 participants. InterventionsThe trial is designed to compare a fluid-sparing resuscitation strategy to usual care. Main outcome measuresThe primary outcome for the SQUEEZE trial is the time to shock reversal (in hours). The primary outcome analysis will assess the difference in time to shock reversal between the intervention and control groups, reported as point estimate with 95% confidence intervals. The statistical test for the primary analysis will be a two-sided t-test. Secondary outcome measures include clinical outcomes and adverse events including measures of organ dysfunction and mortality outcomes. ResultsThe SAP presented here is reflective of and where necessary clarifies in detail the analysis plan as presented in the trial protocol. The SAP includes a mock CONSORT diagram, figures and tables. Data collection methods are summarized, primary and secondary outcomes are defined, and outcome analyses are described. ConclusionsWe have developed a statistical analysis plan for the SQUEEZE Trial for transparency and to align with best practices. Analysis of SQUEEZE Trial data will adhere to the SAP to reduce the risk of bias. RegistrationClinicalTrials.gov identifiers: Definitive trial NCT03080038; Registered Feb 28, 2017. Pilot Trial NCT 01973907; Registered Oct 27, 2013.

Cardiovascular manifestations in pediatric multisystem inflammatory syndrome associated with COVID-19 in a tertiary care pediatric center in Mexico City

The objective is to expose the cardiovascular alterations in patients diagnosed with pediatric inflammatory multisystem syndrome (PIMS) associated with COVID-19 during the SARS-CoV-2 pandemic, in order to understand the disease, its evolution, and optimal management upon diagnosis. Retrospective, observational, cross-sectional analytical study of patients diagnosed with PIMS according to the criteria of the World Health Organization at the National Institute of Pediatrics, from March 2020 to December 2021. During the study period, 77 patients with PIMS were diagnosed. The results showed correlation between the shock state and alteration of laboratory markers (platelets 144217.29 ± 139321.6 μL [p < 0.001], procalcitonin 27.37 ± 38.37 ng/ml [p = 0.05] and ferritin 1937.87 ± 2562.63 [p < 0.001]). The ventricular function in patients with shock was significantly lower compared to those without shock (49.6 ± 9.1% vs. 58.1 ± 8.4 %; t-Student p < 0.001), as well as injury to the left coronary artery (p = 0.02). There is a correlation between NT-proBNP and ventricular dysfunction (Kruskal-Wallis p = 0.007). Statistical significance was found in the association between death, elevation of inflammatory markers and ventricular dysfunction (p < 0.001). The cardiovascular alterations observed, in order of frequency, were pericardial effusion (25.7%), myocarditis (15%), mild ventricular dysfunction (13.5%) and small coronary aneurysm with predominance of the left coronary artery and the anterior descending one.

Impact of medication dosage on Helicobacter pylori eradication rates among pediatric patients.

Helicobacter pylori rates of eradication to common first-line regimens continue to decline globally. Prescription of the appropriate medication dosage is an important consideration, particularly in the pediatric population due to medication weight-based dosing. Limited data is available on the impact of guideline-recommended weight-based dosing on the successful eradication of H. pylori in children. Retrospective study of patients with histologic evidence of H. pylori from two pediatric tertiary care centers in New England. We excluded patients who were not treated or those missing eradication data. We compared the eradication rates of patients prescribed recommended weight-based dosages, duration, and frequency of treatment with those who were not. One hundred forty-four patients were included. The overall eradication rate was 73.6% (106/144). All treatment regimens were properly prescribed for 14 days. There was a high rate of improper weight-based dosing: proton pump inhibitor (PPI) 31.2% (45/144), amoxicillin 31.7% (39/123), metronidazole (MET) 19.4% (12/62), clarithromycin (CLA) 23.9% (22/70), tetracycline 50% (6/12), bismuth 26.1% (6/23). When PPIs were properly weight-dosed, there was a 78.8% eradication rate that dropped to 62.2% with suboptimal dosing (p = 0.036, OR: 2.26, CI: 1.04-4.87). When amoxicillin was properly weight-dosed, successful eradication was achieved in 81% versus only 53.8% when improperly dosed (p = 0.002; OR: 3.64, CI: 1.58-8.37). There was no statistically significant impact on eradication rates with improper weight-based dosing of MET, CLA, tetracycline, or bismuth. Proper weight-based dosing of amoxicillin and PPI is important for the successful eradication of H. pylori among children in the New England area.

Preparing Future Pediatric Care Providers with a Clinical Informatics Elective.

Clinical informatics (CI) has reshaped how medical information is shared, evaluated, and utilized in health care delivery. The widespread integration of electronic health records (EHRs) mandates proficiency among physicians and practitioners, yet medical trainees face a scarcity of opportunities for CI education. We developed a CI rotation at a tertiary pediatric care center to teach categorical pediatric, pediatric-neurology, and medicine-pediatric residents foundational CI knowledge and applicable EHR skills. Created in 2017 and redesigned in 2020, a CI rotation aimed to provide foundational CI knowledge, promote longitudinal learning, and encourage real-world application of CI skills/tools. Led by a team of five physician informaticist faculty, the curriculum offers personalized rotation schedules and individual sessions with faculty for each trainee. Trainees were tasked with completing an informatics project, knowledge assessment, and self-efficacy perception survey before and after rotation. Paired t-test analyses were used to compare pre- and postcurriculum perception survey. Thirty-one residents have completed the elective with their projects contributing to diverse areas such as medical education, division-specific initiatives, documentation improvement, regulatory compliance, and operating plan goals. The mean knowledge assessment percentage score increased from 77% (11.6) to 92% (10.6; p ≤ 0.05). Residents' perception surveys demonstrated improved understanding and confidence across various informatics concepts and tools (p ≤ 0.05). Medical trainees are increasingly interested in CI education and find it valuable. Our medical education curriculum was successful at increasing residents' understanding, self-efficacy, and confidence in utilizing CI concepts and EHR tools. Future data are needed to assess the impact such curricula have on graduates' proficiency and efficiency in the use of CI tools in the clinical workplace.

Validity evidence for a team-leading assessment tool in pediatric emergency resuscitations using video review.

Effective leadership of health care action teams has demonstrated positive influence on team performance and patient care, but there is no consensus on how to assess these skills. We developed a novel team leadership assessment tool for leaders of interprofessional pediatric resuscitation teams and collected validity evidence for this tool using video review. This was a prospective cohort study from November 2021 to October 2022. A novel team leadership assessment tool was developed using literature review and local expertise and then piloted and refined using medical simulation. Pediatric emergency medicine (PEM) fellows from a single tertiary care pediatric medical center were enrolled, and videos of one medical resuscitation and one trauma resuscitation were collected per fellow each month. Three reviewers underwent reviewer training and then scored the videos using the assessment tool. Raters provided feedback on feasibility and ease of use using a 5-point Likert scale. Inter-rater reliability for the assessment tool using Gwet's agreement coefficient and the association between performance and clinical level of training using generalized linear mixed model were calculated. Twelve PEM fellows enrolled and 146 videos were reviewed. The inter-rater reliability for each domain ranged from 0.45 (p < 0.0001) to 0.59 (p < 0.0001), with the inter-rater reliability of the total score being 0.49 (p < 0.0001). The reviewers' mean ratings of the elements of the tool were as follows: clarity of the domains (4.6/5), the independence of each domain from each other (3.9/5), the ease of use of the 5-point Likert scale (4.5/5), the usefulness of the provided examples for each domain (4.6/5), and the ability to assess each domain without having to rewatch (4.5/5). The tool differentiated between levels of clinical training for two of the six domains (p < 0.02). We developed a novel team leadership assessment tool for pediatric resuscitation team leaders that demonstrated moderate inter-rater reliability. The tool was easy to use and feasible for educators to assess the performance of PEM trainees in complex high-stakes clinical situations.

AST and ALT Elevation in Suspected Physical Abuse: Can the Threshold to Obtain an Abdominal CT be Raised?

Identification of abdominal injury (AI) in children with concern for physical abuse is important as it can provide important medical and forensic information. Current recommendations are to obtain screening liver function tests (LFTs) in all children with suspected physical abuse and an abdominal computed tomography (CT) when the aspartate aminotransferase (AST) or alanine aminotransferase (ALT) is >80 IU/L. This threshold to obtain an abdominal CT is lower than general trauma guidelines which use a cutoff of AST > 200 or ALT >125 IU/L. This was a retrospective review of children ages 0-60 months at a single pediatric tertiary care center who were evaluated for physical abuse and had AST or ALT >80 IU/L. Subjects were then stratified into two groups: mid-range (AST < 200 and ALT <125 IU/L) and high-range (AST > 200 and/or ALT >125 IU/L) LFTs. Abdominal CTs were performed in 55% (131/237) of subjects, 38% (50/131) with mid-range LFTs and 62% (81/131) with high-range LFTs. AI was identified in 19.8% (26/131) of subjects. Subjects with AI were older than those without AI [mean age (SD) 18.7 (12.5) vs. 11.6 (12.2) months, p = 0.009]. The highest yield of abdominal CTs positive for AI was in the group with high-range LFTs with signs or symptoms of AI at 52.0% (13/25; 95% CI: 31.3-72.2%). The negative predictive value of having mid-range LFTs and no signs or symptoms of AI was 100% (95% CI: 97.0-100%). Our data suggest that abdominal CT may not be necessary in children being evaluated for physical abuse who have AST < 200 and ALT <125 IU/L and do not have signs or symptoms of AI. This could limit the number of abdominal CTs performed. Level IV, Diagnostic Test/Criteria.

Value-based comparison of ambulatory children with respiratory diseases in an emergency department and a walk-in clinic: a retrospective cohort study in Québec, Canada

ObjectiveTo compare health outcomes and costs given in the emergency department (ED) and walk-in clinics for ambulatory children presenting with acute respiratory diseases.DesignA retrospective cohort study.SettingThis study was conducted from...

Granulocytapheresis Donor Deferrals Pattern at a Pediatric Tertiary Care Centre in Northern India

Granulocytapheresis Donor Deferrals Pattern at a Pediatric Tertiary Care Centre in Northern India

Prevalence of burnout and psycho-emotional disorders among non-health workers: a single tertiary care pediatric oncology center experience.

According to scientific literature, burnout can be described as a multidimensional syndrome with three fundamental dimensions: emotional exhaustion, depersonalization and reduced personal accomplishment. Every day, clown-doctors, play therapists, teachers and volunteers, such as ceramic art therapists, work in pediatric cancer wards to improve the quality of life of hospitalized children and activate positive resources during their therapeutic journey. This study investigated burnout levels and the relationship between work-related stress and resilience in a total of 36 operators (clown-doctors, in-hospital teachers, play therapists, and ceramic art therapists), working at the Unit of Pediatric Oncology of IRCCS A. Gemelli University Polyclinic Foundation in Rome, Italy. All participants completed a battery of questionnaires to evaluate burnout (Maslach Burnout Inventory) and resilience (Connor-Davidson Resilience Scale). The results of this study show that these workers are exposed to work-related stress and that the burnout levels are not homogeneous across the various groups considered. The results also show the need to provide non-health hospital workers with a psychological support service or ensure the presence of a mental health professional to help them avoid the risk of burnout. The heavy emotional burden endured by these operators makes them vulnerable and exposes them to burnout.

Improving Adolescent Psychosocial Assessment through Standardized Patient Simulation: An Interdisciplinary Quality Improvement Initiative.

Adolescent suicide and mental illness have increased at alarming rates. Healthcare professionals report a lack of skill and confidence in obtaining adolescent histories and managing confidential care due to limited training in residency. Nursing professional development practitioners face challenges of adequately preparing interdisciplinary healthcare providers to assess, identify, and intervene at all points of contact with adolescents. To increase the confidence in clinical communication skills and clinical competency, and to increase the number of social work referrals related to modifiable risk factors for adolescent patients, a Texas pediatric tertiary care center utilized standardized patient (SP) methodology to supplement traditional clinical experiences with communication-focused education based on the Home, Education, Eating, Activities, Drugs, Sexuality, Suicidality, and Safety (HEEADSSS) interviewing. This quality improvement (QI) pilot demonstrated the benefits of utilizing standardized patient methodology in communication-focused education based on the HEEADSSS interviewing. Following the SP simulations, confidence in clinical communication skills increased by 13%, clinical competency in performing comprehensive psychosocial interviews increased by 11%, use of HEEADSSS increased by 64%, and social work referrals increased by 89%. This interdisciplinary SP interviewing simulation pilot was beneficial in improving the 36 physician and nursing residents' ability to conduct psychosocial assessments for risk factors of suicidality among adolescents.

Laboratory stewardship perceptions and testing patterns at a pediatric tertiary care center.

Despite stewardship efforts, laboratory testing overuse persists across medicine. To understand laboratory stewardship perceptions and testing patterns at a tertiary care pediatric hospital so that we could identify potential improvement opportunities. An electronic survey exploring laboratory stewardship was sent to all pediatric medicine resident and staff physicians. Laboratory testing data were also assessed for patterns of testing and overuse. The survey response rate was 54% (43/80). The results indicated good familiarity with stewardship but poor familiarity with testing specifics (eg, cost). A mobile reference application was the most preferred quality improvement intervention, and online modules were the least desired. Overuse was apparent, with as many as 53% of laboratory tests being repeated within 7 days and only half of repeated tests subsequently yielding abnormal results. Altogether, the data we collated demonstrated poor understanding of laboratory stewardship and substantial repeat testing with few abnormal results. These study findings suggest that laboratory stewardship is lacking at our center, and that multiple improvement opportunities exist.

Decline in case rates of youth onset type 2 diabetes in year three of the COVID-19 pandemic.

To determine changes in case rates of youth onset type 2 diabetes in the three years following the COVID-19 pandemic. A single-center, retrospective medical record review was conducted for patients newly diagnosed with T2D between 3/1/18 and 2/28/23 at a pediatric tertiary care center. The number of patients referred to CHLA with a T2D diagnosis date between 3/1/2020 and 2/28/2023 was compared to historical rates between 3/1/2018 and 2/29/2020. χ2 or Fisher's exact test was used to compare categorical variables between each year and 2019. Compared to prepandemic baseline (3/1/19-2/29/20, 11.8±3.7 cases/month), there was a significant increase in new T2D monthly case rates in pandemic year 1 (3/1/20-2/28/21, 20.1±6.0 cases/month, 171 %, p=0.005) and pandemic year 2 (3/1/21-2/28/22, 25.9±8.9 cases/month, 221 %, p=0.002). Case rates declined in pandemic year 3 to 14.5±4.1 cases/month (3/1/22-2/28/23, p=0.43). Compared to prepandemic year 1, the frequency of DKA at diagnosis was higher in pandemic year 1 (13.3 vs. 5.0 %, p=0.009). The DKA rate in pandemic years 2 (6.8 %) and 3 (3.4 %) were comparable to prepandemic year 1 (p=0.53 and 0.58, respectively). Youth onset type 2 diabetes cases and DKA rates in year 3 of the pandemic have returned to prepandemic level.

Microbiological analysis of skin and soft tissue infections in children presenting to a paediatric tertiary care centre in Sri Lanka

Introduction: Skin and soft tissue infections (SSTIs) are a common cause of hospitalisation in children. They are diverse in spectrum, ranging from impetigo and abscesses to life threatening necrotising infections. The main pathogens associated with SSTIs are Staphylococccus aureus and Streptococcus pyogenes. Emergence of community acquired methicillin resistant S. aureus (CA-MRSA) is of major concern when antibiotics are required, and it is important to know the prevalence of these pathogens in different geographic locations. This study was done with the aim of identifying and characterising the common bacterial pathogens implicated in SSTIs in children presenting to Sirimavo Bandaranaike Children’s Hospital (SBSCH), Peradeniya, Sri Lanka, which is one of the two paediatric referral hospitals in Sri Lanka.Method: A retrospective, descriptive study analysed data gathered from request forms accompanying pus and tissue sent for culture from patients with SSTIs to the SBSCH microbiology laboratory during a period of 13 months from January 2021 to January 2022.Results: Two hundred and ninety samples were received from suspected SSTIs of which 197 (67.9%) were positive for bacterial growth, with S. aureus present in 163 (83%). Methicillin resistant S. aureus (MRSA) was isolated from 113 (57%) and methicillin sensitive S. aureus (MSSA) from 50 (25%). The frequency of coliforms, Pseudomonas spp., and Group A streptococcus were 31 (16%), 3 (1.5%) and 4 (2%) respectively. Sensitivity of MRSA isolates to cotrimoxazole, clindamycin, ciprofloxacin and erythromycin were 97%, 86%,72% and 29% respectively. Among MSSA isolates, 94% were sensitive to cotrimoxazole, while sensitivity to clindamycin, ciprofloxacin and erythromycin were 74%, 67% and 40% respectively.Conclusion: MRSA was the most frequent pathogen associated with purulent SSTIs in children, followed by MSSA. One fourth of MSSA were resistant to ciprofloxacin and clindamycin. Ciprofloxacin and clindamycin resistance in MRSA was 15% and 28% respectively.

Analysis of feeding and eating disorders in 191 children according to psychiatric or gastroenterological recruitment: The PEDIAFED cohort study.

The DSM-5 classification introduced new Feeding and Eating Disorders (FED) diagnostic categories, notably Avoidant and Restrictive Food Intake Disorder (ARFID), which, like other FED, can present psychiatric and gastrointestinal symptoms. However, paediatric clinical research that focuses on children below the age of 12years remains scarce. The aim of this study was first to investigate the clinical features of FED in a cohort of children, second to compare them according to their recruitment (gastroenterology or psychiatry unit). This non-interventional retrospective cohort study analysed 191 patients in a French paediatric tertiary care centre (gastroenterology n=100, psychiatry n=91). The main outcome variables were clinical data (type of FED, BMI, nutritional support, chronic diseases, psychiatric comorbidities, sensory, sleep, language disorders, gastrointestinal complaints, adverse life events, family history). The outcome was defined by a Clinical Global Impression of Change-score. FED diagnoses were ARFID (n=100), Unspecified FED (UFED, n=57), anorexia nervosa (AN, n=33) and one pica/rumination. Mean follow-up was 3.28years (SD 1.91). ARFID was associated with selective and sensory disorders (p<0.001); they had more anxiety disorders than patients with UFED (p<0.001). Patients with UFED had more chewing difficulties, language disorder (p<0.001), and more FED related to chronic disease (p<0.05) than patients with ARFID and AN. Patients with AN were female, underweight, referred exclusively to the psychiatrist, and had more depression than patients with ARFID and UFED (p<0.001). The gastroenterology cohort included more UFED, while the psychiatry cohort included more psychiatric comorbidities (p<0.001). A worse clinical outcome was associated with ARFID, a younger age at onset (p<0.001), selective/sensory disorders and nutritional support (p<0.05). ARFID and UFED children were diagnosed either by gastroenterologists or psychiatrists. Due to frequently associated somatic and psychiatric comorbidities, children with FED should benefit from a multidisciplinary assessment and care.

Use of the Drospirenone-Only Contraceptive Pill in Adolescents with Endometriosis

Study ObjectiveTo evaluate the efficacy and tolerability of a progestin-only pill containing 4 mg drospirenone (DRSP) as a hormonal therapy for the management of endometriosis-associated symptoms in adolescents and young adults. DesignRetrospective cohort study. MethodsA retrospective chart review was performed of all adolescents who were prescribed DRSP continuously (without placebo) for treatment of endometriosis at a single pediatric tertiary care center between 2019 and 2022. Electronic medical records were reviewed to obtain demographics and clinical characteristics of the patients. Measured outcomes included symptom resolution and medication discontinuation. The study was deemed IRB exempt. ResultsA total of 61 patients with endometriosis were prescribed DRSP during the study period, with a median age of 18.9 years (SD 2.3). The majority (97%) were laparoscopically confirmed to have endometriosis, and 85% had stage I disease. Before DRSP use, the most common medications trialed were norethindrone (57%) and norethindrone acetate (68%), and 56% had at least one medical contraindication to receiving estrogen-containing therapy. Of those with follow-up, 52% established an absence of bleeding/spotting, and 67% reported less pain at follow-up. One in 4 patients discontinued DRSP during the study period, most commonly due to breakthrough bleeding. ConclusionDRSP is a well-tolerated and effective option for the treatment of endometriosis-associated symptoms in adolescents and young adults.

Considerations for Gender-Affirming Hormonal and Surgical Care Among Transgender and Gender Diverse Adolescents and Adults With Congenital Heart Disease.

Transgender and gender diverse (TGD) individuals and long-term survivors with adult congenital heart disease (ACHD) are both growing populations with specialized needs. No studies assess temporal trends or evaluate the care of TGD individuals with ACHD. Meetings between congenital cardiology and gender-affirming care specialists identified unique considerations in TGD individuals with ACHD. A retrospective chart review was then performed to describe patient factors and outpatient trends in those with an ACHD diagnosis undergoing gender-affirming hormonal or surgical care (GAHT/S) at 1 adult and 1 pediatric tertiary care center. Thirty-three TGD individuals with ACHD were identified, 21 with a history of GAHT/S. Fourteen (66%) had moderate or complex ACHD, 8 (38%) identified as transgender male, 9 (43%) transgender female, and 4 (19%) other gender identities. Three had undergone gender-affirming surgery. There were zero occurrences of the composite end point of unplanned hospitalization or thrombotic event over 71.1 person-years of gender-affirming care. Median age at first gender-affirming appointment was 16.8 years [interquartile range 14.8-21.5]. The most common treatment modification was changing estradiol administration from oral to transdermal to reduce thrombotic risk (n=3). An increasing trend was observed from zero TGD patients with ACHD attending a gender diversity appointment in 2012 to 14 patients in 2022. There is a growing population of TGD patients with ACHD and unique medical and psychosocial needs. Future studies must fully evaluate the reassuring safety profile observed in this small cohort. We share 10 actionable care considerations for providers with a goal of overseeing a safe and fulfilling gender transition across all TGD patients with ACHD.