Associations of Impulsivity and Risky Decision-Making with E-Cigarette-Related Outcomes Among Adolescents with Congenital Heart Disease: Variable- and Person-Oriented Approaches.

Adolescents with congenital heart disease (CHD) have elevated risk for acquired cardiovascular complications, increasing their vulnerability to e-cigarette-related health harms. Impulsivity and risky decision-making have been associated with adolescent substance use, but the relationships between these factors and e-cigarette-related outcomes among cardiovascular at-risk adolescents with CHD are unknown. This cross-sectional study aimed to (a) determine the associations of impulsivity and risky decision-making with e-cigarette-related outcomes (i.e. susceptibility, ever use, perceptions of harm and addictiveness) via variable-oriented analysis (logistic regression), (b) identify groups of adolescents with similar profiles of impulsivity and risky decision-making via exploratory person-oriented analysis (latent profile analysis; LPA), and (c) examine differences on e-cigarette-related outcomes between profile groups. Adolescents aged 12 to 18 years with CHD (N = 98) completed a survey assessing impulsivity facets (Short UPPS-P) and e-cigarette-related outcomes and were administered a risky decision-making task (Iowa Gambling Task, Version 2; IGT2). In variable-oriented analyses, impulsivity facets (negative urgency, positive urgency, lack of premeditation) but not risky decision-making were associated with e-cigarette susceptibility and ever use. The exploratory LPA identified two groups with similar patterns of responding on the Short UPPS-P and IGT2 labeled "Low Impulsivity" and "High Impulsivity," which were primarily characterized by significant differences in negative and positive urgency. Adolescents in the High Impulsivity group had increased odds of e-cigarette susceptibility but not ever use compared to the Low Impulsivity group. This work indicates that strategies to prevent e-cigarette use among adolescents with CHD may be enhanced by addressing impulsivity, particularly negative and positive urgency.

A Primary Care-Based Quality Improvement Project to Reduce Asthma Emergency Department Visits.

BACKGROUND AND OBJECTIVES: Asthma exacerbation is a common and often preventable cause of Emergency Department (ED) utilization. Children eligible for Medicaid are at increased risk of poor asthma control and subsequent ED visits. In 2010, we implemented a multicomponent longitudinal quality improvement project to improve pediatric asthma care for our primary care population, which was 90% Medicaid-eligible. Our goal was to reduce asthma-related ED visits by patients ages 2 to 18 years by 3% annually. METHODS: The setting was a multisite large urban high-risk primary care network affiliated with a children's hospital. We implemented 5 sequential interventions within our network of pediatric primary care centers to increase: use of asthma action plans by clinicians, primary care-based Asthma Specialty Clinic visits (extended asthma visits in the main primary care site), use of a standard asthma note at all visits, documentation of the Asthma Control Test, and step-up therapy for children with poorly controlled asthma. RESULTS: At baseline in 2010, there were 21.7 asthma-related ED visits per 1000 patients per year. By 2019, asthma-related ED visits decreased to 14.5 per 1000 patients per year, a 33% decrease, with 2 center line shifts over time. We achieved and sustained our goal metrics for 4 of 5 key interventions. CONCLUSIONS: We reduced ED utilization for asthma in a large, high-risk pediatric population. The interventions implemented and used over time in this project demonstrate that sustainable outcomes can be achieved in a large network of primary care clinics.

Patterns and perceptions of nicotine use among U.S. adolescents and young adults receiving medication treatment for opioid use disorder.

Nicotine use among U.S. youth is cause for concern, as previous studies have shown that nicotine use in adolescence increases the risk of developing substance use disorders later in life. This exploratory study aimed to understand patterns of nicotine use and perceptions of various nicotine products among adolescents and young adults (AYA) receiving medication treatment for opioid use disorder (MOUD). We administered an adapted version of the National Youth Tobacco Survey via REDCap to AYA (n = 32) receiving outpatient care in the Medication-Assisted Treatment of Addiction at Nationwide Children's Hospital in Columbus, Ohio, U.S.A. Thirty (97%) participants had tried a combustible cigarette and 27 (90%) had tried an electronic cigarette. By age 13, nineteen (61%) participants had tried combustible cigarettes and eight (25%) had tried opioids. Twenty-two (71%) participants reported smoking combustible cigarettes every day for the past 30 days, and 15 (48%) reported smoking more than 10 cigarettes per day on average. Only ten (32%) participants reported e-cigarette use in the last 30 days. Participants universally agreed that tobacco products are dangerous, and twenty (67%) current tobacco users reported that they planned to quit in the next year. Nicotine use patterns among AYA receiving MOUD differ from that previously shown in the general population, primarily by high prevalence of nicotine use in early adolescence and high current combustible cigarette use. Interventions such as universal screening for nicotine use before age 13 and tailored smoking cessation programs for AYA with OUD may help optimize care for these individuals.

Predicting emergency department visits among children with asthma in two academic medical systems.

Objective: To develop and validate a predictive algorithm that identifies pediatric patients at risk of asthma-related emergencies, and to test whether algorithm performance can be improved in an external site via local retraining.Methods: In a retrospective cohort at the first site, data from 26 008 patients with asthma aged 2-18 years (2012-2017) were used to develop a lasso-regularized logistic regression model predicting emergency department visits for asthma within one year of a primary care encounter, known as the Asthma Emergency Risk (AER) score. Internal validation was conducted on 8634 patient encounters from 2018. External validation of the AER score was conducted using 1313 pediatric patient encounters from a second site during 2018. The AER score components were then reweighted using logistic regression using data from the second site to improve local model performance. Prediction intervals (PI) were constructed via 10 000 bootstrapped samples.Results: At the first site, the AER score had a cross-validated area under the receiver operating characteristic curve (AUROC) of 0.768 (95% PI: 0.745-0.790) during model training and an AUROC of 0.769 in the 2018 internal validation dataset (p = 0.959). When applied without modification to the second site, the AER score had an AUROC of 0.684 (95% PI: 0.624-0.742). After local refitting, the cross-validated AUROC improved to 0.737 (95% PI: 0.676-0.794; p = 0.037 as compared to initial AUROC).Conclusions: The AER score demonstrated strong internal validity, but external validity was dependent on reweighting model components to reflect local data characteristics at the external site.

The Association of Global and Disease-Related Stress With Susceptibility to and Use of E-Cigarettes and Marijuana Among Adolescents With Congenital Heart Disease.

OBJECTIVE: Adolescents with congenital heart disease (CHD) are exposed to disease-related stressors and have elevated risk for cardiovascular and cognitive complications that are exacerbated by e-cigarettes and marijuana. The aims of this cross-sectional study are to: (1) identify the association between perceived global and disease-related stress and susceptibility to e-cigarettes and marijuana, (2) determine if the association between stress and susceptibility differs by gender, and (3) explore the association between stress and ever use of e-cigarettes and marijuana among adolescents with CHD. METHODS: Adolescents with CHD (N = 98; aged 12-18 years) completed self-report measures of susceptibility to/ever use of e-cigarettes and marijuana and global and disease-related stress. RESULTS: Susceptibility to e-cigarettes and marijuana was reported by 31.3% and 40.2% of adolescents, respectively. Ever use of e-cigarettes and marijuana was reported by 15.3% and 14.3% of adolescents, respectively. Global stress was associated with susceptibility to and ever use of e-cigarettes and marijuana. Disease-related stress was associated with susceptibility to marijuana. Females reported more global and disease-related stress than males, but the association of stress with susceptibility to e-cigarettes and marijuana did not differ by gender. CONCLUSIONS: Susceptibility to e-cigarettes and marijuana is common among adolescents with CHD and is associated with stress. Future work to examine the longitudinal associations between susceptibility, stress, and use of e-cigarettes and marijuana is warranted. Global stress may be an important consideration in the development of strategies to prevent these risky health behaviors among adolescents with CHD.

Health effects of electronic cigarettes.

E-cigarettes cause harm to adolescent users. The devices and constituents create multiple substances which are toxic on inhalation, including nicotine, metallic nanoparticles, particulate matter, and carbonyls. In addition, there is a robust relationship between youth vaping and use of combustible cigarettes as adults. This finding is based on longitudinal research and is found among youth who were at low risk for use of combustible cigarettes. Therefore, the most substantially confirmed health hazard of youth vaping is creating a new generation of smokers of combustible cigarettes and the documented health risks of such use. The physiological and psychological harms of nicotine dependence during adolescence also have been well documented. Additionally, population-based research has shown a consistent link between current vaping and respiratory issues during adolescence itself. Significant lung disease (EVALI) has occurred in adolescents and not all cases are linked to vitamin E acetate. Finally, extrapolating research on adults to adolescents raises the possibility that e-cigarette use is linked to pre-symptomatic cardiovascular dysfunction and may have a significant health impact during adulthood. The combination of this evidence, from pre-clinical to population-based longitudinal studies, conclusively demonstrates that e-cigarettes are not safe for youth.

Health Disparities in Tobacco Use and Exposure: A Structural Competency Approach.

Fourteen percent of US adults use tobacco products. Because many of those who use tobacco are parents and/or caregivers, children are disproportionately exposed to tobacco smoke. People who use tobacco products often become addicted to nicotine, resulting in tobacco dependence, a chronic, relapsing disease. Tobacco use and exposure are more likely to occur in vulnerable and marginalized groups, including those living in poverty. Although some view tobacco use as a personal choice, evidence suggests that structural forces play an important role in tobacco uptake, subsequent nicotine addiction, and perpetuation of use. Viewing tobacco use and tobacco dependence through a structural competency lens promotes recognition of the larger systemic forces perpetuating tobacco use, including deliberate targeting of groups by the tobacco industry, lack of enforcement of age-for-sale laws, inferior access to health insurance and health care, poor access to cessation resources, and economic stress. Each of these forces perpetuates tobacco initiation and use; in turn, tobacco use perpetuates the user's adverse health and economic conditions. Pediatricians are urged to view family tobacco use as a social determinant of health. In addition to screening adolescents for tobacco use and providing resources and treatment of tobacco dependence, pediatricians are encouraged to systematically screen children for secondhand smoke exposure and support family members who smoke with tobacco cessation. Additionally, pediatricians can address the structural issues perpetuating tobacco use by becoming involved in policy and advocacy initiatives.

Prenatal and Childhood Tobacco Smoke Exposure Are Associated With Sleep-Disordered Breathing Throughout Early Childhood.

OBJECTIVE: To determine whether prenatal and childhood tobacco smoke exposure (TSE) are each independently associated with mild sleep-disordered breathing (SDB) symptoms throughout early childhood, and whether the association between childhood TSE and SDB differs according to the level of prenatal exposure. METHODS: Longitudinal cohort study, using data from the Avon Longitudinal Study of Parents and Children, a population-based birth cohort from the United Kingdom. Primary exposures were repeated measures of mother-reported prenatal and childhood TSE through age 7 years. Outcomes were mother-reported measures of mild SDB symptoms, including snoring, mouth breathing, and witnessed apnea, repeated annually through age 7 years. RESULTS: A total of 12,030 children were followed for a median duration of 7 years. About 24.2% were exposed to prenatal tobacco smoke, 46.2% were exposed at least once in childhood, and 20.6% were exposed during both periods. Both prenatal and childhood TSE were associated with SDB symptoms throughout early childhood (adjusted OR [aOR] for any prenatal TSE 1.23; 95% confidence interval [CI] 1.08, 1.40; aOR for any childhood TSE 1.17; 95% CI 1.06, 1.29). We observed a dose-response effect between TSE and SBD symptoms, and found evidence of effect modification for those exposed during both time periods (combined high level exposure both prenatally and during childhood: aOR snoring 2.43 [95% CI 1.50, 3.93], aOR apnea 2.65 [95% CI 1.46, 4.82]). CONCLUSIONS: Prenatal and childhood TSE were both independently associated with mild SDB symptoms throughout early childhood in a dose-dependent manner, further supporting the critical importance of maintaining a tobacco-free environment throughout gestation and childhood.

Metabolomics profiling of tobacco exposure in children with cystic fibrosis.

BACKGROUND: Inflammation is integral to early disease progression in children with CF. The effect of modifiable environmental factors on infection and inflammation in persons with CF is poorly understood. Our prior studies determined that secondhand smoke exposure (SHSe) is highly prevalent in young children with CF. SHSe is associated with increased inflammation, heightened bacterial burden, and worsened clinical outcomes. However, the specific metabolite and signaling pathways that regulate responses to SHSe in CF are relatively unknown. METHODS: High-resolution metabolomics was performed on plasma samples from infants (n = 25) and children (n = 40) with CF compared to non-CF controls (n = 15). CF groups were stratified according to infant or child age and SHSe status. RESULTS: Global metabolomic profiles segregated by age and SHSe status. SHSe in CF was associated with changes in pathways related to steroid biosynthesis, fatty acid metabolism, cysteine metabolism, and oxidative stress. CF infants with SHSe demonstrated enrichment for altered metabolite localization to the small intestine, liver, and striatum. CF children with SHSe demonstrated metabolite enrichment for organs/tissues associated with oxidative stress including mitochondria, peroxisomes, and the endoplasmic reticulum. In a confirmatory analysis, SHSe was associated with changes in biomarkers of oxidative stress and cellular adhesion including MMP-9, MPO, and ICAM-1. CONCLUSIONS: SHSe in young children and infants with CF is associated with altered global metabolomics profiles and specific biochemical pathways, including enhanced oxidative stress. SHSe remains an important but understudied modifiable variable in early CF disease.

Age and environmental exposures influence the fecal bacteriome of young children with cystic fibrosis.

BACKGROUND: Mechanisms that facilitate early infection and inflammation in cystic fibrosis (CF) are unclear. We previously showed that young CF children with secondhand smoke exposure (SHSe) have increased susceptibility to respiratory infections. We aimed to define the impact of SHSe and other external factors upon the fecal bacteriome in early CF. METHODS: Twenty CF infants and children were enrolled, clinical data recorded, and hair nicotine measured as an objective surrogate of SHSe. Fecal samples were collected at clinic visits and bacteriome 16S rRNA gene sequencing performed. RESULTS: SHSe was associated with increased alpha diversity and increased relative abundance of Acinetobacter and Akkermansia, along with decreased Bifidobacterium and Lactobacillus. Recent antibiotic exposure predicted bacterial population structure in children less than 2 years of age and was associated with decreased Bacteroides relative abundance. Age was the strongest predictor of overall fecal bacterial composition and positively associated with Blautia and Parabacteroides. Weight for length was negatively associated with Staphylococcus relative abundance. CONCLUSIONS: SHSe and other external factors such as antibiotics appear to alter fecal bacterial composition in young CF children, but the strongest predictor of overall composition was age. These findings have implications for understanding the intestinal microbiome in young CF children.

The Effects of Nicotine on Development.

Recently, there has been a significant increase in the use of noncombustible nicotine-containing products, including electronic cigarettes (e-cigarettes). Of increasing popularity are e-cigarettes that can deliver high doses of nicotine over short periods of time. These devices have led to a rise in nicotine addiction in adolescent users who were nonsmokers. Use of noncombustible nicotine products by pregnant mothers is also increasing and can expose the developing fetus to nicotine, a known teratogen. In addition, young children are frequently exposed to secondhand and thirdhand nicotine aerosols generated by e-cigarettes, with little understanding of the effects these exposures can have on health. With the advent of these new nicotine-delivery systems, many concerns have arisen regarding the short- and long-term health effects of nicotine on childhood health during all stages of development. Although health studies on nicotine exposure alone are limited, educating policy makers and health care providers on the potential health effects of noncombustible nicotine is needed because public acceptance of these products has become so widespread. Most studies evaluating the effects of nicotine on health have been undertaken in the context of smoke exposure. Nevertheless, in vitro and in vivo preclinical studies strongly indicate that nicotine exposure alone can adversely affect the nervous, respiratory, immune, and cardiovascular systems, particularly when exposure occurs during critical developmental periods. In this review, we have included both preclinical and clinical studies to identify age-related health effects of nicotine exposure alone, examining the mechanisms underlying these effects.

A Public Health Crisis: Electronic Cigarettes, Vape, and JUUL.

Electronic cigarettes (e-cigarettes) and vape devices have rapidly become the most common tobacco products used by youth, driven in large part by marketing and advertising by e-cigarette companies. There is substantial evidence that adolescent e-cigarette use leads to use of combustible tobacco products. E-cigarette companies commonly advertise that e-cigarettes contain nicotine, flavoring chemicals, and humectants (propylene glycol and/or vegetable glycerin), but toxicants, ultrafine particles, and carcinogens have also been found in e-cigarette solutions and emissions, many of which are known to cause adverse health effects. Most major e-cigarette brands are owned by big tobacco companies that use similar marketing and advertising strategies to attract youth users as they did with traditional tobacco products. In this review, we provide an overview of e-cigarettes and vape devices with an emphasis on the impact for the pediatric population. We describe the vast array of e-cigarette devices and solutions, concern for nicotine addiction, and the scientific background on the known health harms. There are accompanying visual depictions to assist in identifying these products, including newer e-cigarette products and JUUL. Because current federal regulations are insufficient to protect youth from e-cigarette use, exposure, and nicotine addiction, there are recommendations for pediatricians and pediatric health care providers to counsel and advocate for a tobacco-free lifestyle for patients and families.

Secondhand Smoke Exposure and Sleep-Related Breathing Problems in Toddlers.

BACKGROUND: Adequate sleep during childhood is an important component of overall health and wellbeing for children. Secondhand smoke (SHS) exposure has been linked to a greater risk of sleep-disordered breathing. OBJECTIVE: Our objective was to investigate relationships between SHS exposure and sleep-related breathing problems in healthy toddlers aged 2 to 5 years. We hypothesized that there is an independent relationship between objectively measured SHS exposure and presence of sleep-related breathing problems by parental report. METHODS: A convenience sample of 149 healthy children ages 2 to 5 years was recruited from an academic pediatric primary care center for this cross-sectional study; 138 had complete data that were analyzed. Current SHS exposure was determined by hair nicotine level. Presence of sleep-related breathing problems was assessed by 1 survey item. Inflammation was determined by serum C-reactive protein (CRP) level. Analysis in Stata 15 included a series of multivariate logistic regression models, controlling for individual-level demographics and body mass index z scores according to mediation analysis procedures for dichotomous outcomes. RESULTS: Approximately 24% of parents reported their child snored, gasped, or had difficulty breathing at night sometimes, most of the time, or almost always. Regression models with mediation analysis indicate that SHS exposure significantly increased the odds of reporting the child had sleep-related breathing problems, and 18% of this relationship is explained by log serum CRP levels. CONCLUSIONS: Although the cross-sectional nature of this study limits causality, evidence suggests a relationship exists between SHS exposure, as measured by log hair nicotine and sleep-related breathing problems at night.

A Blended Curriculum to Improve Resident Physical Exam Skills for Patients With Neuromuscular Disability.

Introduction: Children with neuromuscular disabilities (NMD) receive care in a wide variety of clinical settings. Residents lack training to develop physical examination skills for evaluating patients with NMD. We devised a curriculum to teach residents how to examine patients with NMD using a systematic and simplified approach. Methods: Creation of this resource was a response to a survey of final-year residents that revealed the need for education focused on developing physical examination skills. The curriculum has four components-multimedia PowerPoint with embedded video, knowledge assessment, clinical exam (CEX) assessment, and module feedback-and was completed by 37 residents over an 8-month period from January to September 2016. We utilized knowledge assessment, direct clinical skills observation using the CEX, and module-feedback responses as part of the evaluation. Results: All 37 residents completed the curriculum, with an overall knowledge score of greater than 80%. Residents demonstrated most of the desired patient care behaviors on the CEX assessment and provided positive feedback on the quality, usefulness, and applicability of the module, in addition to requesting more curricula to develop their physical examination skills. Discussion: The CEX assessment provided a unique opportunity for faculty feedback on residents' physical exam performance. After completing the module, residents achieved high scores in most areas of the standardized CEX and were able to conduct the NMD physical exam in a sensitive manner. The assessment highlighted the need to improve residents' skills of detecting abnormal clinical findings and communicating with the patient during the physical exam.

Secondhand smoke alters arachidonic acid metabolism and inflammation in infants and children with cystic fibrosis.

BACKGROUND: Mechanisms that facilitate early infection and inflammation in cystic fibrosis (CF) are unclear. We previously demonstrated that children with CF and parental-reported secondhand smoke exposure (SHSe) have increased susceptibility to bacterial infections. SHSe hinders arachidonic acid (AA) metabolites that mediate immune function in patients without CF, and may influence CF immune dysfunction. We aimed to define SHSe's impact on inflammation mediators and infection in children with CF. METHODS: Seventy-seven children with CF <10 years of age (35 infants <1 year; 42 children 1-10 years) were enrolled and hair nicotine concentrations measured as an objective surrogate of SHSe. AA signalling by serum and macrophage lipidomics, inflammation using blood transcriptional profiles and in vitro macrophage responses to bacterial infection after SHSe were assessed. RESULTS: Hair nicotine concentrations were elevated in 63% of patients. Of the AA metabolites measured by plasma lipidomics, prostaglandin D2 (PGD2) concentrations were decreased in children with CF exposed to SHSe, and associated with more frequent hospitalisations (p=0.007) and worsened weight z scores (p=0.008). Children with CF exposed to SHSe demonstrated decreased expression of the prostaglandin genes PTGES3 and PTGR2 and overexpression of inflammatory pathways. These findings were confirmed using an in vitro model, where SHSe was associated with a dose-dependent decrease in PGD2 and increased methicillin-resistant Staphylococcus aureus survival in human CF macrophages. CONCLUSIONS: Infants and young children with CF and SHSe have altered AA metabolism and dysregulated inflammatory gene expression resulting in impaired bacterial clearance. Our findings identified potential therapeutic targets to halt early disease progression associated with SHSe in the young population with CF.

Quality Improvement-Driven Reduction in Countywide Medicaid Acute Asthma Health Care Utilization.

OBJECTIVE: This study evaluates the impact of a coordinated effort by an urban pediatric hospital and its associated accountable care organization to reduce asthma-related emergency department (ED) and inpatient utilization by a large, countywide Medicaid patient population. METHODS: Multiple evidence-based interventions targeting general pediatric asthma care and high health care utilizers were implemented using standardized quality improvement methodologies. Annual asthma ED and inpatient utilization rates by 2- to 18-year-old members of an accountable care organization living in the surrounding county (>140,000 eligible members in 2016), adjusted per 1000 children from 2008 through 2016, were analyzed using Poisson regression. We compared these ED utilization rates to national rates from 2006 to 2014. RESULTS: Asthma ED utilization fell from 18.1 to 12.9 visits/1000 children from 2008 to 2016, representing a 28.7% reduction, with an average annual decrease of 3.9% (P < .001), during a time when national utilization was increasing. Asthma inpatient utilization did not change significantly during the study period. CONCLUSIONS: Asthma-related ED utilization was significantly reduced in a large population of primarily urban, minority, Medicaid-insured children by implementing a multimodal asthma quality improvement program. With adequate support, a similar approach could be successful in other communities.

Assessing pediatric tobacco exposure using parent report: comparison with hair nicotine.

INTRODUCTION: The purpose of this study was to examine the relationships between screening questions for secondhand smoke (SHS) exposure and biomarker results using hair nicotine levels. Our ultimate goal was to develop sensitive and valid screening tools in pediatric clinical settings for SHS exposure. METHODS: Investigators developed a core set of questions regarding exposure. Data from two separate ongoing studies of well children and those with bronchopulmonary dysplasia (BPD) were used to assess the concordance between responses and hair nicotine levels. Sensitivity, a positive predictive value, and accuracy were examined. RESULTS: There was no single question with similar sensitivity in both populations. The question with the highest positive predictive value (90.8% well-cohort and 84.6% BPD cohort) for both the groups was whether the child had been exposed to in-home smoking in the last 7 days. The question with the highest accuracy for both groups was the number of smokers at home (0 vs ≥ 1), with an accuracy of 72.4% for well children and 79.0% for the BPD cohort. CONCLUSIONS: There was a wide variability in the performance of specific questions. These data demonstrate that a "one-size-fits-all" approach to screening for secondhand tobacco smoke exposure may not be appropriate for all pediatric populations.

Learning in a Web-Based World: An Innovative Approach to Teach Physical Examination Skills in Patients with Neurodisability.

Despite increasing numbers of patients with neurodisability, residents lack training to develop physical examination skills. Following a blended educational intervention combining online and bedside teaching, residents demonstrated desired patient-care behaviors on standardized clinical exam assessment.