Abortion Care After the Dobbs Decision: An Academic Health System's Response to a Statewide Ban.

ABSTRACT: Indiana was the first state to pass legislation severely restricting access to abortion care following the Dobbs v. Jackson Women's Health Organization decision. Indiana Senate Enrolled Act 1 (SEA 1) outlaws all abortions with few exceptions. Indiana University Health (IU Health), the largest and only academic health system in the state, has a unique relationship with the Indiana University School of Medicine and a vision to improve the health of Indiana residents. IU Health employed the Hospital Incident Command System model to create a plan to ensure its patients continue to have access to safe, high-quality family planning, maternal, and neonatal care services and that clinicians are protected against criminal penalties and threats to personal safety. This article provides an overview of the Incident Command structure used to rapidly work across many disciplines, tackle complex issues, respond to concerns, and design and implement changes. The article also outlines the key considerations and decisions made by Incident Command leaders, such as where abortions that met the new law's criteria should be performed, changes to clinical workflows and protocols, and the creation of a rapid response team. The article then examines the operational, legal, and clinical challenges encountered by clinicians and health care team members, including a lack of peer support or idea sharing with other health systems in the state; accurate estimation of abortion, live birth, and neonatal intensive care unit volumes; and ambiguity in the law and lack of guidance from the state government. Recommendations regarding communication with clinicians and other health care team members and engaging information technology early are offered for health systems and medical schools that may face legislative barriers to health care delivery in the future. Finally, IU Health's commitment to tracking the impact of SEA 1 on patients, clinicians, employees, and the state is outlined.

Polysomnographic findings in children with 22q deletion & duplication syndrome: relationship to genetic diagnosis, parent-reported symptoms, and calcium levels.

PURPOSE: 22q11.2 deletion syndrome (22q11.2DS) is the most common microdeletion syndrome. In the current study, we assessed the relationship between parent-reported symptoms of obstructive sleep apnea (OSA) and polysomnographic (PSG) results in patients with 22q11.2DS. Additionally, we explored the relationships between genetic diagnosis, serum calcium and ferritin levels, and PSG results. METHODS: Retrospective chart review was completed for patients enrolled in our 22q Center's registry from 2015-2021. Data extracted included: patient characteristics, parent-reported sleep symptoms from the Childhood Sleep Habits Questionnaire (CSHQ), serum calcium and ferritin levels, and results from formal PSG. RESULTS: Overall, n = 89 encounters (60 unique patients) with PSG data demonstrated that there were no differences in OSA between those with deletion vs duplication, but PLMD was more common in those with deletion (35% vs 7%, p = 0.032). In a subset of n = 24 encounters with PSG and survey data in proximity, there were no significant associations between the CSHQ sleep-disordered breathing subscale and OSA presence or severity (p = 0.842). Likewise, we found no significant associations between the individual symptoms of OSA and PSG results (all p > 0.5). In those patients with available calcium (n = 44) and ferritin (n = 17) levels, we found a significant negative correlation between serum calcium and PLMS (r = -0.446, p = 0.002), but not ferritin (r = -0.067, p = 0.797) levels. CONCLUSIONS: Parent-reported symptoms do not predict the presence or severity of OSA in children with 22q11.2DS. There was a negative correlation between serum calcium, but not ferritin, and PLMS on PSG.

Images: Polysomnographic artifact in a patient with Tourette syndrome.

Patients with Tourette syndrome frequently have sleep disturbances that may require polysomnographic testing. The use of deep brain stimulators is increasing with expanding indications including children with medically intractable Tourette syndrome. It is important to understand the effect the stimulator can have on polysomnographic monitoring. Herein we present an interesting case of an adolescent with medically intractable Tourette syndrome with a deep brain stimulator implant who underwent a polysomnogram demonstrating rhythmic, monomorphic artifact. CITATION: Bindra T, Ingram DG. Images: Polysomnographic artifact in a patient with Tourette syndrome. J Clin Sleep Med. 2023;19(12):2149-2151.

Effect of dehydration on the inactivation of Listeria monocytogenes and Salmonella enterica on enoki and wood ear mushrooms.

Foodborne illness outbreaks in the U.S. associated with consumption of both fresh and dried specialty mushrooms have recently occurred. Dried wood ear mushrooms were implicated in a salmonellosis outbreak in 2020, while fresh enoki mushrooms were associated with two listeriosis outbreaks in 2020 and 2023. These specialty mushrooms are commercially available in both their fresh and dried states. Due to the short shelf life of mushrooms, dehydration is a common method used in both industry and by consumers to extend the shelf life and preserve quality. Therefore, the aim of this study was to evaluate the use of dehydration on the inactivation kinetics of both Listeria monocytogenes and Salmonella enterica on enoki and wood ear mushrooms. Fresh mushrooms were inoculated with four strain cocktails of either L. monocytogenes or S. enterica and dried at ambient conditions for 10 min. Following drying of the inoculum, mushrooms were placed into food dehydrators preheated to 70, 80, or 90°C and treated for up to 24 h. At treatment intervals, mushrooms were removed from the dehydrators for pathogen enumeration. Inactivation kinetics for both pathogens were modeled using the Weibull, log-linear with tail, and log-linear with shoulder models. Pathogen reductions of >4 log CFU/g were achieved on both enoki and wood ear mushrooms during dehydration at 90°C after only 2-4 h. At 70 and 80°C, log reductions of >4 log CFU/g were observed on wood ear mushrooms after 4-8 h. On enoki mushrooms, a tailing effect was observed with residual populations (>2 log CFU/g) of L. monocytogenes and S. enterica remaining even after 24 h of treatment at both 70 and 80°C. This study emphasizes the need for an individualized dehydration strategy for each mushroom type to ensure the effectiveness of dehydration as a process to reduce pathogen populations. Results of this study will aid in informing proper time and temperature combinations for dehydration of specialty mushrooms to ensure product safety.

Survival kinetics of Listeria monocytogenes and Salmonella enterica on dehydrated enoki and wood ear mushrooms during long-term storage.

Two specialty mushrooms have recently become novel vectors for foodborne outbreaks in the U.S.: fresh enoki and dried wood ear mushrooms were linked to a listeriosis and salmonellosis outbreak, respectively. The aim of this study was to evaluate the survival kinetics of Listeria monocytogenes and Salmonella enterica on dehydrated enoki and wood ear mushrooms during long-term storage. Following heat dehydration, mushrooms were inoculated with either L. monocytogenes or S. enterica, allowed to dry for 1 h, and then stored for up to 180 d at 25 °C and 33% relative humidity. Both pathogens were enumerated from the mushrooms at intervals during the storage period. Survival kinetics of both pathogens were modeled using both the Weibull and log-linear with tail models. After inoculation and 1 h drying, both pathogen populations decreased 2.26-2.49 log CFU/g on wood ear mushrooms; no decrease was observed on enoki. Both pathogens survived during storage on both mushroom types. On wood ear mushrooms, a 2-log decrease of both pathogens occurred during storage. On enoki mushrooms, 4-log decreases of both pathogens were modeled to occur after 127.50-156.60 d. The results of this study suggest that L. monocytogenes and S. enterica can persist on dehydrated specialty mushrooms during long-term storage.

Anaplasmosis in Pennsylvania: Clinical Features, Diagnosis, and Outcomes of Patients Diagnosed With Anaplasma phagocytophilum Infection at Hershey Medical Center From 2008 to 2021.

Anaplasmosis is an emerging infection in the United States and in particular, Pennsylvania. We highlight the abrupt rise in cases of anaplasmosis in the past decade in the state of Pennsylvania with the hope of increasing clinician awareness. We identified a cohort of 61 patients diagnosed with anaplasmosis at our institution as well as cases reported to the Department of Health. From our review, we identified not only an increase in cases over time but what appears to be an expansion further into central and western Pennsylvania over time.

Paramagnetism in Microwave-Synthesized Metal-Free Nitrogen-Doped Graphene Quantum Dots.

Nitrogen-doped graphene quantum dots (NGQDs) have gained significant attention due to their various physical and chemical properties; however, there is a gap in the study of NGQDs' magnetic properties. This work adds to the efforts of bridging the gap by demonstrating the room temperature paramagnetism in GQDs doped with Nitrogen up to 3.26 at.%. The focus of this experimental work was to confirm the paramagnetic behavior of metal free NGQDs resulting from the pyridinic N configuration in the GQDs host. Metal-free nitrogen-doped NGQDs were synthesized using glucose and liquid ammonia as precursors by microwave-assisted synthesis. This was followed by dialysis filtration. The morphology, optical, and magnetic properties of the synthesized NGQDs were characterized carefully through atomic force microscopy (AFM), transmission electron microscopy (TEM)), UV-VIS spectroscopy, fluorescence, X-ray photon spectroscopy (XPS), and vibrating sample magnetometer (VSM). The high-resolution TEM analysis of NGQDs showed that the NGQDs have a hexagonal crystalline structure with a lattice fringe of ~0.24 nm of (1120) graphene plane. The N1s peak using XPS was assigned to pyridinic, pyrrolic, graphitic, and oxygenated NGQDs. The magnetic study showed the room-temperature paramagnetic behavior of NGQDs with pyridinic N configuration, which was found to have a magnetization of 20.8 emu/g.

Sleep Technology.

Pediatric sleep providers frequently encounter issues related to sleep technology in clinical settings. In this review article, we discuss technical issues related to standard polysomnography, research on putative complementary novel metrics derived from polysomnographic signals as well as research on home sleep apnea testing in children and consumer sleep devices. Although developments across several of these domains are exciting, it remains a rapidly evolving area. When evaluating innovative devices and home sleep testing approaches, clinicians should be mindful of accurately interpreting diagnostic agreement statistics to apply these technologies appropriately.

Modeling the Fate of Listeria monocytogenes and Salmonella enterica on Fresh Whole and Chopped Wood Ear and Enoki Mushrooms.

Two recent foodborne illness outbreaks linked to specialty mushrooms have occurred in the United States, both representing novel pathogen-commodity pairings. Listeria monocytogenes and Salmonella enterica were linked to enoki and wood ear mushrooms, respectively. The aim of this study was therefore to examine the survival of both L. monocytogenes and S. enterica on raw whole and chopped enoki and wood ear mushrooms during storage at different temperatures. Fresh mushrooms were either left whole or chopped and subsequently inoculated with a cocktail of either S. enterica or rifampicin-resistant L. monocytogenes, resulting in an initial inoculation level of 3 log CFU/g. Mushroom samples were stored at 5, 10, or 25°C for up to 7 d. During storage, the population levels of S. enterica or L. monocytogenes on the mushrooms were enumerated. The primary Baranyi model was used to estimate the growth rates of both pathogens and the secondary Ratkowsky square root model was used to model the relationship between growth rates and temperature. Both L. monocytogenes and S. enterica survived on both mushroom types and preparations at all temperatures. No proliferation of either pathogen was observed on mushrooms stored at 5°C. At 10°C, moderate growth was observed for both pathogens on enoki mushrooms and for L. monocytogenes on wood ear mushrooms; no growth was observed for S. enterica on wood ear mushrooms. At 25°C, both pathogens proliferated on both mushroom types with growth rates ranging from 0.43 to 3.27 log CFU/g/d, resulting in 1 log CFU/g increases in only 0.31 d (7.44 h) to 2.32 d. Secondary models were generated for L. monocytogenes on whole wood ear mushrooms and S. enterica on whole enoki mushrooms with goodness-of-fit parameters of r2 = 0.9855/RMSE = 0.0479 and r2 = 0.9882/RMSE = 0.1417, respectively. Results from this study can aid in understanding the dynamics of L. monocytogenes and S. enterica on two types of specialty mushrooms.

Optimal Duration of Systemic Corticosteroids in Coronavirus Disease 2019 Treatment: A Systematic Review and Meta-analysis.

Background: Corticosteroids confer a survival benefit in individuals hospitalized with coronavirus disease 2019 (COVID-19) who require oxygen. This meta-analysis seeks to determine the duration of corticosteroids needed to optimize this mortality benefit. Methods: Electronic databases were searched to 9 March 2022, for studies reporting corticosteroid versus no corticosteroid treatment in hospitalized COVID-19 patients. We estimated the effect of corticosteroids on mortality by random-effects meta-analyses. Subgroup analyses and meta-analyses were conducted to assess the optimal duration of corticosteroid treatment while adjusting for the severity of disease, age, duration of symptoms, and proportion of control group given steroids. Results: We identified 27 eligible studies consisting of 13 404 hospitalized COVID-19 patients. Seven randomized controlled trials and 20 observational studies were included in the meta-analysis of mortality, which suggested a protective association with corticosteroid therapy (risk ratio [RR], 0.71 [95% confidence interval {CI}, .58-.87]). Pooled analysis of 18 studies showed the greatest survival benefit for a treatment duration up to 6 days (RR, 0.54 [95% CI, .39-.74]). Survival benefit was 0.65 (95% CI, .51-.83) up to 7 days, and no additional survival benefit was observed beyond 7 days of treatment (RR, 0.64 [95% CI, .44-.93]). The survival benefit was not confounded by severity of disease, age, duration of symptoms, or proportion of control group given steroids. Conclusions: In this meta-analysis, optimal duration of corticosteroid treatment for hospitalized COVID-19 patients was up to 6 days, with no additional survival benefit with >7 days of treatment.

Moving toward standardization: physician reporting of sleep studies.

Detailed primary data collected from sleep studies should lead to specific and clear reports with evidence-based clinical recommendations that, when introduced by sleep medicine specialists, create a window of opportunity to support our non-sleep medicine referring teams and to engage patients and caregivers in their care as recipients of the reports. This is how sleep study reporting differs from other test reports; currently, there is wide variation in how the data collected are presented and summarized. The goal of this document is to offer recommendations for structured reporting of sleep studies. We offer a practical, complete, and relevant document and a structure that can be implemented across sleep centers nationwide and does not burden the interpreter. We anticipate some readers will opine that some of the content is beyond the scope of what the interpreter physician needs to include, while others will propose missing data that they feel should have been included. We feel that the flexibility of the proposal accommodates for this and allows for a "first step" toward standardization of physician reporting of sleep studies. High-quality structured reporting of sleep studies is becoming ever more important for patient care, benefiting patients, caregivers, clinicians, durable medical equipment companies, and payers. CITATION: Lastra AC, Ingram D, Park J, et al. Moving toward standardization: physician reporting of sleep studies. J Clin Sleep Med. 2023;19(3):595-603.

Sleep profiles in children with 22q deletion syndrome: a study of 100 consecutive children seen in a multidisciplinary clinic.

STUDY OBJECTIVES: While previous studies have suggested a high prevalence of sleep disorders in children with 22q deletion syndrome (22qDS), they were limited by potential selection bias. In the current investigation, we assessed sleep characteristics in 100 consecutive children presenting to a 22qDS multidisciplinary clinic. METHODS: An observational retrospective case series of consecutive children presenting to 22qDS multidisciplinary clinic was performed. Children aged 2 to 17 years of age were included, and data were abstracted including sleep characteristics (sleep history, Childhood Sleep Habits Questionnaire [CSHQ], and free response questions), comorbid medical conditions, and demographics. RESULTS: Overall, 100 children were included in analysis, 85% of whom had scores on the CSHQ consistent with clinically meaningful sleep disorder. Sleep problems were common in all domains of the CSHQ, including daytime sleepiness (66%), sleep-onset delay (54%), parasomnias (52%), night wakings (52%), sleep-disordered breathing (49%), sleep duration (45%), bedtime resistance (38%), and sleep anxiety (33%). Overall CSHQ score was significantly associated with daytime behavioral problems and speech delay [F(2,97) = 10.4, P < .001, adjusted R2 = 0.16]. The most common interventions reported to be helpful for sleep by parents were behavioral (routine, bedtime story), environmental (light avoidance at night, calming music), and pharmacologic (melatonin, clonidine). CONCLUSIONS: These data confirm a high prevalence of sleep disorders in a large, unselected sample of children with 22qDS, and suggest an important relationship between sleep dysfunction and daytime behavioral challenges. Our findings highlight the potential role for multimodal treatment approaches including behavioral, environmental, and pharmacologic interventions. CITATION: Ingram DG, Raje N, Arganbright JM. Sleep profiles in children with 22q deletion syndrome: a study of 100 consecutive children seen in a multidisciplinary clinic. J Clin Sleep Med. 2023;19(1):27-34.

Tonsillectomy in Children with 22q11.2 Deletion Syndrome.

Tonsillectomy is one of the most common procedures performed in children, however there are currently no published studies evaluating tonsillectomy in children with 22q11.2 deletion syndrome (22q11DS). With this study, our goal was to investigate the indications, efficacy, and complications of tonsillectomy in a pediatric cohort of patients with 22q11DS. This is a retrospective chart review of patients in our 22q Center's repository. Inclusion criteria were a diagnosis of 22q11DS and a history of tonsillectomy or adenotonsillectomy. Data collected included: indications for tonsillectomy, preoperative and postoperative polysomnography (PSG) results, and surgical complications. In total, 33 patients were included. Most common indications for tonsillectomy were facilitation with speech surgery (n = 21) and sleep-disordered breathing (SDB)/obstructive sleep apnea (OSA) (n = 16). Average length of stay was 1.15 days. Most patients (69%) had some degree of persistent OSA on postoperative PSG. Complications occurred in 18% of patients and included respiratory distress, hemorrhage, and hypocalcemia. This study demonstrates tonsillectomy was a commonly performed procedure in this cohort of patients with 22q11DS. These data highlight the potential need for close postoperative calcium and respiratory monitoring. The data were limited with respect to PSG outcomes, and future studies are needed to better characterize OSA outcomes and complications in this patient population.

Sleep Disorders in Children with Prader Willi Syndrome: Current Perspectives.

Children with Prader-Willi syndrome (PWS) face a multitude of potential health challenges including life-threatening obesity, endocrinopathies, behavioral and emotional dysregulation, developmental delays, and sleep disorders. In the current perspective piece, we provide a focused review of the condition's etiology and clinical findings, as well as a more in-depth discussion of sleep disorders frequently associated with PWS. In particular, we highlight and discuss difficult clinical scenarios frequently encountered by the pediatric sleep physician caring for this patient population, including diagnosis and treatment of complex sleep-related breathing disorders, considerations for sleep apnea surgery, the interplay between growth hormone and sleep apnea, diagnostic challenges in hypersomnia/narcolepsy, and current and emerging therapies for hypersomnia/narcolepsy. Overall, although there are many areas that need further research, sleep disorders remain a fruitful target for improving quality of life of children with PWS and their families.

Crowdsourced Perceptions of Human Behavior to Improve Computational Forecasts of US National Incident Cases of COVID-19: Survey Study.

BACKGROUND: Past research has shown that various signals associated with human behavior (eg, social media engagement) can benefit computational forecasts of COVID-19. One behavior that has been shown to reduce the spread of infectious agents is compliance with nonpharmaceutical interventions (NPIs). However, the extent to which the public adheres to NPIs is difficult to measure and consequently difficult to incorporate into computational forecasts of infectious diseases. Soliciting judgments from many individuals (ie, crowdsourcing) can lead to surprisingly accurate estimates of both current and future targets of interest. Therefore, asking a crowd to estimate community-level compliance with NPIs may prove to be an accurate and predictive signal of an infectious disease such as COVID-19. OBJECTIVE: We aimed to show that crowdsourced perceptions of compliance with NPIs can be a fast and reliable signal that can predict the spread of an infectious agent. We showed this by measuring the correlation between crowdsourced perceptions of NPIs and US incident cases of COVID-19 1-4 weeks ahead, and evaluating whether incorporating crowdsourced perceptions improves the predictive performance of a computational forecast of incident cases. METHODS: For 36 weeks from September 2020 to April 2021, we asked 2 crowds 21 questions about their perceptions of community adherence to NPIs and public health guidelines, and collected 10,120 responses. Self-reported state residency was compared to estimates from the US census to determine the representativeness of the crowds. Crowdsourced NPI signals were mapped to 21 mean perceived adherence (MEPA) signals and analyzed descriptively to investigate features, such as how MEPA signals changed over time and whether MEPA time series could be clustered into groups based on response patterns. We investigated whether MEPA signals were associated with incident cases of COVID-19 1-4 weeks ahead by (1) estimating correlations between MEPA and incident cases, and (2) including MEPA into computational forecasts. RESULTS: The crowds were mostly geographically representative of the US population with slight overrepresentation in the Northeast. MEPA signals tended to converge toward moderate levels of compliance throughout the survey period, and an unsupervised analysis revealed signals clustered into 4 groups roughly based on the type of question being asked. Several MEPA signals linearly correlated with incident cases of COVID-19 1-4 weeks ahead at the US national level. Including questions related to social distancing, testing, and limiting large gatherings increased out-of-sample predictive performance for probabilistic forecasts of incident cases of COVID-19 1-3 weeks ahead when compared to a model that was trained on only past incident cases. CONCLUSIONS: Crowdsourced perceptions of nonpharmaceutical adherence may be an important signal to improve forecasts of the trajectory of an infectious agent and increase public health situational awareness.

Intravenous iron therapy in the pediatric sleep clinic: a single institution experience.

STUDY OBJECTIVES: Initial reports of intravenous (IV) iron administration have been promising for children with restless legs syndrome, periodic limb movement disorder, and restless sleep disorder. The aim of the current study was to evaluate further the clinical response to IV iron supplementation in children seen in a pediatric sleep clinic. METHODS: We performed a retrospective chart review of children cared for in a single pediatric sleep clinic who also underwent IV iron infusion. Pre and post IV data regarding their sleep symptoms and ferritin levels were abstracted. RESULTS: Overall, 63 pediatric sleep patients underwent IV iron infusion, mostly with ferric carboxymaltose (n = 60), for restless legs syndrome (n = 30), periodic limb movement disorder (n = 22), and restless sleep disorder (n = 17). Of the 59 patients with clinical follow-up, 39 (73%) noted improvement in at least 1 symptom, and 14 (26%) did not notice improvement or noticed worsening symptoms. Of the 59 patients with preinfusion and postinfusion labs, the average ferritin level increased from 21.7 (13.3) to 147.9 (120.9) µg/L, P < .001. Comparing patients who experienced clinical improvement vs those who did not, there were no statistically significant differences in change in ferritin levels (P = .278), sex (P = .452), or age (P = .391). Ferritin change with infusion according to diagnostic subgroups (restless legs syndrome/periodic limb movement disorder/restless sleep disorder) was examined, and no significant differences were noted (F(2,56) = 0.852, P = .432). In terms of immediate adverse reactions to the IV infusion, 7 (11%) experienced at least 1 side effect, with the most common being behavior change (n = 6) or gastrointestinal discomfort (n = 4); no episodes of anaphylaxis or extravasation were noted. CONCLUSIONS: These data provide additional support for the efficacy and safety of IV iron for pediatric restless legs syndrome, periodic limb movement disorder, and restless sleep disorder recalcitrant to oral iron. CITATION: Ingram DG, Al-Shawwa B, DelRosso LM, Sharma M. Intravenous iron therapy in the pediatric sleep clinic: a single institution experience. J Clin Sleep Med. 2022;18(11):2545-2551.

Terrible twos: intravenous iron ameliorates a toddler's iron deficiency and sleep disturbance.

The relation between iron deficiency and restless legs syndrome has been widely described and investigated in both adults and children. However, the diagnosis of restless legs syndrome relies on patients voicing their symptoms, which is very difficult for patients younger than age 5 years. Frequently, we evaluate children between ages 2 and 4 years whom parents describe as "restless sleepers," "difficult to settle down," or having "frequent awakening" or "bedtime resistance." Parents are concerned that their child's poor sleep quality is leading to daytime dysfunction such as increased sleepiness, behavioral outbursts, or hyperactivity. Many of these children are diagnosed with behavioral insomnia of childhood, and behavior modification therapy is recommended with variable degrees of success. Herein, we describe a 2-year-old with similar symptoms of restless sleep, bedtime resistance, and daytime sleepiness who was found to have an underlying iron deficiency without anemia that was treated successfully with iron infusion. We highlight the importance of evaluating for underlying iron deficiency even without anemia in patients with restless sleep and associated poor daytime behavior. We also describe some common challenges associated with iron therapy and clarify iron therapeutic targets. CITATION: Al-Shawwa B, Sharma M, Ingram DG. Terrible twos: intravenous iron ameliorates a toddler's iron deficiency and sleep disturbance. J Clin Sleep Med. 2022;18(2):677-680.