Predicting Serious Bacterial Infections Among Hypothermic Infants in the Emergency Department.

BACKGROUND: There is insufficient evidence to guide the initial evaluation of hypothermic infants. We aimed to evaluate risk factors for serious bacterial infections (SBI) among hypothermic infants presenting to the emergency department (ED). METHODS: We conducted a multicenter case-control study among hypothermic (rectal temperature <36.5°C) infants ≤90 days presenting to the ED who had a blood culture collected. Our outcome was SBI (bacteremia, bacterial meningitis, and/or urinary tract infection). We performed 1:2 matching. Historical, physical examination and laboratory covariables were determined based on the literature review from febrile and hypothermic infants and used logistic regression to identify candidate risk factors. RESULTS: Among 934 included infants, 57 (6.1%) had an SBI. In univariable analyses, the following were associated with SBI: age > 21 days, fever at home or in the ED, leukocytosis, elevated absolute neutrophil count, thrombocytosis, and abnormal urinalysis. Prematurity, respiratory distress, and hypothermia at home were negatively associated with SBI. The full multivariable model exhibited a c-index of 0.91 (95% confidence interval: 0.88-0.94). One variable (abnormal urinalysis) was selected for a reduced model, which had a c-index of 0.82 (95% confidence interval: 0.75-0.89). In a sensitivity analysis among hypothermic infants without fever (n = 22 with SBI among 116 infants), leukocytosis, absolute neutrophil count, and abnormal urinalysis were associated with SBI. CONCLUSIONS: Historical, examination, and laboratory data show potential as variables for risk stratification of hypothermic infants with concern for SBI. Larger studies are needed to definitively risk stratify this cohort, particularly for invasive bacterial infections.

Racial and Ethnic Disparities in Emergency Department Wait Times for Children: Analysis of a Nationally Representative Sample.

OBJECTIVE: To evaluate the association of race and ethnicity with wait times for children in US emergency departments (ED). METHODS: We performed a cross-sectional study of ED encounters of children (<18 years) from 2014 to 2019 using a multistage survey of nonfederal US ED encounters. Our primary variable of interest was composite race and ethnicity: non-Hispanic White (NHW), non-Hispanic Black, Hispanic, and all others. Our outcome was ED wait time in minutes. We evaluated the association between race and ethnicity and wait time in Weibull regression models that sequentially added variables of acuity, demographics, hospital factors, and region/urbanicity. RESULTS: We included 163,768,956 survey-weighted encounters. In univariable analysis, Hispanic children had a lower hazard ratio (HR) of progressing to evaluation (HR 0.84, 95% confidence interval [CI] 0.76-0.93) relative to NHW children, indicating longer ED wait times. This association persisted in serial multivariable models incorporating acuity, demographics, and hospital factors. This association was not observed when incorporating variables of hospital region and urbanicity (HR 0.91, 95% CI 0.83-1.00). In subgroup analysis, Hispanic ethnicity was associated with longer wait times in pediatric EDs (HR 0.76, 95% CI 0.63-0.92), non-metropolitan EDs (HR 0.75, 95% CI 0.64-0.89), and the Midwest region (HR 0.77, 95% CI 0.69-0.87). No differences in wait times were observed for children of Black race or other races. CONCLUSIONS: Hispanic children experienced longer ED wait times across serial multivariable models, with significant differences limited to pediatric, metropolitan, and Midwest EDs. These results highlight the presence of disparities in access to prompt emergency care for children.

Impact of Screening for Sexual Trauma in a Gynecologic Oncology Setting.

OBJECTIVES: Sexual trauma poses a significant concern and is associated with heightened stress, negative health repercussions, and adverse economic effects. A history of abuse may increase a woman's risk of developing cancer, in particular cervical cancer. We analyzed the impact of screening for sexual abuse in a gynecologic oncology population. METHODS: Patients were screened for sexual trauma in a gynecologic oncology clinic over 5 and a half years (April 1, 2011, to September 30, 2016) in this cohort study. The screening questions were selected by behavioral oncology physicians and integrated into the gynecologic history component of the new patient assessment. Patients who screened positive for a history of sexual abuse or intimate partner violence were offered a behavioral oncology referral. Providers were also questioned about the effect of screening on their practice. RESULTS: Of the 1,423 consecutive patients screened for sexual trauma, a total of 164 patients (12%) disclosed a history of sexual abuse. Of the 133 patients who specified their age at the sexual trauma, the majority (107 [80%]) responded that they were a young child or early teen. Most patients (92%) declined counseling. Among individuals presenting with cancer, the distribution of cancer type was statistically different between those patients with and without a sexual trauma history (p = 0.0001). CONCLUSION: Screening for sexual trauma in a gynecologic oncologic population serves as a valuable opportunity to uncover a history of abuse that may increase a woman's susceptibility to cancer. This study demonstrates that screening for sexual abuse in a gynecologic oncology setting may be integrated into new patient interviews with minimal disruption. Identification of an undisclosed sexual trauma history allows for an opportunity to offer counseling and minimize the emotional distress that may be precipitated by treatment and exams.

Validation of a Clinical Decision Rule to Predict Abuse in Young Children Based on Bruising Characteristics.

Importance: Bruising caused by physical abuse is the most common antecedent injury to be overlooked or misdiagnosed as nonabusive before an abuse-related fatality or near-fatality in a young child. Bruising occurs from both nonabuse and abuse, but differences identified by a clinical decision rule may allow improved and earlier recognition of the abused child. Objective: To refine and validate a previously derived bruising clinical decision rule (BCDR), the TEN-4 (bruising to torso, ear, or neck or any bruising on an infant <4.99 months of age), for identifying children at risk of having been physically abused. Design, Setting, and Participants: This prospective cross-sectional study was conducted from December 1, 2011, to March 31, 2016, at emergency departments of 5 urban children's hospitals. Children younger than 4 years with bruising were identified through deliberate examination. Statistical analysis was completed in June 2020. Exposures: Bruising characteristics in 34 discrete body regions, patterned bruising, cumulative bruise counts, and patient's age. The BCDR was refined and validated based on these variables using binary recursive partitioning analysis. Main Outcomes and Measures: Injury from abusive vs nonabusive trauma was determined by the consensus judgment of a multidisciplinary expert panel. Results: A total of 21 123 children were consecutively screened for bruising, and 2161 patients (mean [SD] age, 2.1 [1.1] years; 1296 [60%] male; 1785 [83%] White; 1484 [69%] non-Hispanic/Latino) were enrolled. The expert panel achieved consensus on 2123 patients (98%), classifying 410 (19%) as abuse and 1713 (79%) as nonabuse. A classification tree was fit to refine the rule and validated via bootstrap resampling. The resulting BCDR was 95.6% (95% CI, 93.0%-97.3%) sensitive and 87.1% (95% CI, 85.4%-88.6%) specific for distinguishing abuse from nonabusive trauma based on body region bruised (torso, ear, neck, frenulum, angle of jaw, cheeks [fleshy], eyelids, and subconjunctivae), bruising anywhere on an infant 4.99 months and younger, or patterned bruising (TEN-4-FACESp). Conclusions and Relevance: In this study, an affirmative finding for any of the 3 BCDR TEN-4-FACESp components in children younger than 4 years indicated a potential risk for abuse; these results warrant further evaluation. Clinical application of this tool has the potential to improve recognition of abuse in young children with bruising.

Feasibility of Risk Reducing Salpingo-Oophorectomy at the Time of Abdominal Surgery for Correction of Pelvic Organ Prolapse and Urinary Incontinence.

OBJECTIVE: The objective of this study is to assess the perioperative outcomes when prophylactic bilateral salpingo-oophorectomy (BSO) is performed concomitantly with surgery to repair pelvic organ prolapse (POP) or stress urinary incontinence (SUI). MATERIALS AND METHODS: This is a retrospective case-control study of patients who underwent abdominal surgery for the correction of POP and/or SUI with or without concomitant BSO at a tertiary care center. The primary outcome measures were postsurgery length of hospitalization, estimated blood loss, and 30-day readmission rate. The secondary outcome measure was detection of ovarian cancer precursor lesions. RESULTS: We identified 734 patients who had surgery for POP and/or SUI. The control group contained 385 patients, and the BSO group contained 349 patients. There was no difference between the control and BSO groups in the postsurgery length of stay (LOS) (35.2 h vs. 34.1 h; P = 0.49), and all-cause 30-day readmission rate (14.2% vs. 11.6%; P = 0.3085). However, there was decreased blood loss (40.8 ml vs. 67.2 ml, P < 0.0001) in the BSO group compared to the control group. Sub-analysis of primary outcomes in postmenopausal women (age > 55) showed decreased postsurgery LOS (33.4 h vs. 37.4 h; P = 0.0208) and decreased blood loss (35.9 ml vs. 82.7 ml; P < 0.0001) in the BSO group compared to control. CONCLUSION: Secondary to the lack of additional complications, we recommend surgeons give more consideration to finding appropriate candidates for a risk reducing BSO at time of abdominal surgery to repair POP or SUI.

Standardized warfarin monitoring decreases adverse drug reactions.

BACKGROUND: While warfarin is the most commonly prescribed medication to prevent thromboembolic disorders, the risk of adverse drug reactions (ADR) poses a serious concern. This prospective study evaluated how primary care providers (PCP) and cardiologists at our Institution managed patients treated with warfarin with the goal of decreasing the number of warfarin ADRs. METHODS: A multidisciplinary anticoagulation task force was established at our Institution in 2014 to standardize warfarin monitoring and management. Between 2013 and 2017, we analyzed patients who were prescribed warfarin by their PCP or cardiologist upon hospital discharge and in the ambulatory setting to determine the international normalized ratio (INR) within 5, 10, and 30 days after discharge, time in therapeutic range (TTR), number of severe warfarin ADRs, and total and average cost reduction of all severe warfarin ADRs to determine whether there was an organizational cost savings following the implementation of standardized warfarin care. RESULTS: The warfarin ADR rate significantly decreased over the 5-year period, from 3.8 to 0.98% (p < 0.0001). The proportion of warfarin prescriptions out of all anticoagulants significantly decreased, from 72.2 to 42.1% (p < 0.001). The proportion of individuals who received an INR at 5, 10, and 30 days after hospital discharge compared to the total number of patients prescribed warfarin significantly increased (p < 0.001). The total cost of severe warfarin ADRs decreased by 57.6% between 2013 and 2017. CONCLUSIONS: This study serves as a model to reduce the number of severe warfarin ADRs by the following tactics: (1) educating PCPs and cardiologists about evidence-based guidelines for warfarin management, (2) increasing the use of our Institution's electronic warfarin module, and (3) enhancing patient compliance with obtaining INR.

Decline in primary care providers' prescribing of Schedule II opioids following the implementation of federal and state guidelines.

OBJECTIVE: Prescription opioid misuse represents a social and economic dilemma in the United States. The authors evaluated primary care providers' (PCPs) prescribing of Schedule II opioids at our institution in Kentucky. DESIGN: Prospective evaluation of PCPs' prescribing practices over a 3-year period (October 1, 2014 to September 30, 2017) in an outpatient setting. METHODS: An analysis of Schedule II opioid prescribing following the implementation of federal and state guidelines and evidence-based standards. Special attention focused on Schedule II opioid prescriptions with a quantity > 90, Opana/Oxycontin, and morphine equivalent daily dosage. RESULTS: A statistically significant increase in the total number of PCPs and PCPs who prescribed Schedule II opioids was observed, while there was a concurrent significant decrease in the average number of Schedule II opioid pills prescribed per PCP, Schedule II opioid prescriptions per PCP, Schedule II opioid pills prescribed per patient by PCPs, Schedule II opioid prescriptions with a quantity > 90 per PCP, and Opana/Oxycontin prescriptions per PCP. A statistically significant decline in the average morphine equivalent daily dosage of Schedule II opioids per PCP was noted. CONCLUSIONS: This study reports the benefit of incorporating federal and state regulations and institutional evidence-based guidelines into primary care practice to decrease the number of Schedule II opioids prescribed. Further preventive measures include selecting alternative treatments to opioids and reducing the rates of opioid nonmedical use and overdose while maintaining access to prescription opioids when indicated.

Who's Watching the Children? Caregiver Features Associated with Physical Child Abuse versus Accidental Injury.

OBJECTIVE: To compare caregiver features and caregiving arrangements of children with physical abuse vs accidental injuries. STUDY DESIGN: Data came from a prospective, observational, multicenter study investigating bruising and psychosocial characteristics of children younger than 4 years of age. Using logistic regression, we examined how abuse vs accidental injury and severity of injury were associated with caregiver sex, relation to the child, whether caregiving arrangements were different than usual at the time of injury, and length of the main caregiver's relationship with his/her partner. RESULTS: Of 1615 patients, 24% were determined to have been physically abused. Abuse was more likely when a male caregiver was present (OR 3.31, 95% CI 2.38-4.62). When the male was the boyfriend of the mother (or another female caregiver), the odds of abuse were very high (OR 169.2, 95% CI 61.3-614.0). Severe or fatal injuries also were more likely when a male caregiver was present. In contrast, abuse was substantially less likely when a female caregiver was present (OR 0.25, 95% CI 0.17-0.37) with the exception of a female babysitter (OR 3.87, 95% CI 2.15-7.01). Caregiving arrangements that were different than usual and caregiver relationships <1 year were also associated with an increased risk of abuse. CONCLUSIONS: We identified caregiver features associated with physical abuse. In clinical practice, questions regarding caregiver features may improve recognition of the abused child. This information may also inform future abuse prevention strategies.

Classifying Injuries in Young Children as Abusive or Accidental: Reliability and Accuracy of an Expert Panel Approach.

OBJECTIVE: To assess interrater reliability and accuracy of an expert panel in classifying injuries of patients as abusive or accidental based on comprehensive case information. STUDY DESIGN: Data came from a prospective, observational, multicenter study investigating bruising characteristics of children younger than 4 years. We enrolled 2166 patients with broad ranges of illnesses and injuries presenting to one of 5 pediatric emergency departments in whom bruises were identified during examination. We collected comprehensive data regarding current and past injuries and illnesses, and provided deidentified, standardized case information to a 9-member multidisciplinary panel of experts with extensive experience in pediatric injury. Each panelist classified cases using a 5-level ordinal scale ranging from definite abuse to definite accident. Panelists also assessed whether report to child protective services (CPS) was warranted. We calculated reliability coefficients for likelihood of abuse and decision to report to CPS. RESULTS: The interrater reliability of the panelists was high. The Kendall coefficient (95% CI) for the likelihood of abuse was 0.89 (0.87, 0.91) and the kappa coefficient for the decision to report to CPS was 0.91 (0.87, 0.94). Reliability of pairs and subgroups of panelists were similarly high. A panel composite classification was nearly perfectly accurate in a subset of cases having definitive, corroborated injury status. CONCLUSIONS: A panel of experts with different backgrounds but common expertise in pediatric injury is a reliable and accurate criterion standard for classifying pediatric injuries as abusive or accidental in a sample of children presenting to a pediatric emergency department.

Are negative/unrealistic parent descriptors of infant attributes associated with physical abuse?

Parents' perceptions of child behavior influence their responses to the child and may be important predictors of physical abuse. We examined whether infants 12 months of age or younger who were described with negative or developmentally unrealistic words were more likely than other infants to have been physically abused. As part of a prospective observational multicenter study investigating bruising and familial psychosocial characteristics, parents were asked to (1) describe their child's personality, and (2) list three words to describe their child. Four independent raters coded parent responses using a qualitative content analysis, identifying descriptors of infants and classifying each as positive, neutral, or negative/unrealistic. A medical expert panel, blinded to the psychosocial data, separately categorized each case as abuse or accident. We then analyzed the potential association between negative/unrealistic descriptors and abusive injury. Of 185 children enrolled, 147 cases (79%) were categorized as accident and 38 (21%) as abuse. Parents used at least one negative/unrealistic descriptor in 35/185 cases (19%), while the remaining 150 cases (81%) included only positive or neutral descriptors. Of the infants described with negative/unrealistic words, 60% were abused, compared to 11% of those described with positive or neutral words (p < .0001; age group-adjusted OR = 9.95; 95% confidence interval [3.98, 24.90]). Though limited by sample-size, this pilot study informs future work to create a screening tool utilizing negative/unrealistic descriptors in combination with other predictive factors to identify infants at high risk for physical child abuse.

Inferring marginal association with paired and unpaired clustered data.

In the marginal analysis of clustered data, where the marginal distribution of interest is that of a typical observation within a typical cluster, analysis by reweighting has been introduced as a useful tool for estimating parameters of these marginal distributions. Such reweighting methods have foundation in within-cluster resampling schemes that marginalize potential informativeness due to cluster size or within-cluster covariate distribution, to which reweighting methods are asymptotically equivalent. In this paper, we introduce a reweighting scheme for the marginal analysis of clustered data that generalizes prior reweighting methods, with a particular application to measuring bivariate correlation in unpaired clustered data, in which observations of two random variables are not naturally paired at the within-cluster level. We develop unpaired clustered data analogs of well-known product moment correlation coefficients (Pearson, Spearman, phi), as well as the polyserial coefficient for measuring correlation between one discrete and one continuous variable. We evaluate the performance of these coefficients via a simulation study and demonstrate their use by finding no statistically significant association between dental caries at an early age and dental fluorosis at age 13 using a large dental dataset.

Dataset on psychosocial risk factors in cases of fatal and near-fatal physical child abuse.

This article presents the psychosocial risk factors identified in the cases of 20 children less than four years of age who were victims of fatal or near-fatal physical abuse during a 12 month period in the Commonwealth of Kentucky. These data are related to the article "History, injury, and psychosocial risk factor commonalities among cases of fatal and near-fatal physical child abuse" (Pierce et al., 2017) [1].

History, injury, and psychosocial risk factor commonalities among cases of fatal and near-fatal physical child abuse.

Failure to recognize child maltreatment results in chronic exposure to high-risk environments where re-injury or death may occur. We analyzed a series (n=20) of fatal (n=10) and near-fatal (n=10) physical child abuse cases from the Commonwealth of Kentucky to identify commonalities and determine whether indicators of maltreatment were present prior to the child's fatal or near-fatal event. We conducted retrospective state record reviews involving children <4years of age classified as physical child abuse by the Cabinet for Health and Family Services during a 12 month period. Cases were distributed across 17 counties. IRB approvals were obtained. Three reviewers concurrently abstracted case data from medical, social, and legal documents, and descriptive statistics were analyzed. Median age of subjects was 7.5 months (range 1-32 months); 55% were male. Psychosocial risk factors (PRFs) were present in 100% of cases. Traumatic brain injury (95%) and bruising (90%) were the most common injuries. Of the 14 children with available prior medical records, 9 (64%) had sentinel injuries in the form of prior unexplained bruising; all nine suffered subsequent traumatic brain injury resulting in four deaths. A male was caring for the child at the time of the final event in 70% of cases. Our study identified key commonalities across cases of fatal and near-fatal abuse, highlighting the prevalence of psychosocial risk factors and the significance of prior unexplained bruising as a herald of escalating abuse. Further study is warranted to ascertain the predictive value of our findings in the larger population.

Comparison of two equivalent model for end-stage liver disease scores for hepatocellular carcinoma patients using data from the United Network for Organ Sharing liver transplant waiting list registry.

Patients with hepatocellular carcinoma (HCC) have been advantaged on the liver transplant waiting list within the United States, and a 6-month delay and exception point cap have recently been implemented to address this disparity. An alternative approach to prioritization is an HCC-specific scoring model such as the MELD Equivalent (MELDEQ ) and the mixed new deMELD. Using data on adult patients added to the UNOS waitlist between 30 September 2009 and 30 June 2014, we compared projected dropout and transplant probabilities for patients with HCC under these two models. Both scores matched actual non-HCC dropout in groups with scores <22 and improved equity with non-HCC transplant probabilities overall. However, neither score matched non-HCC dropout accurately for scores of 25-40 and projected dropout increased beyond non-HCC probabilities for scores <16. The main differences between the two scores were as follows: (i) the MELDEQ assigns 6.85 more points after 6 months on the waitlist and (ii) the deMELD gives greater weight to tumor size and laboratory MELD. Post-transplant survival was lower for patients with scores in the 22-30 range compared with those with scores <16 (P = 0.007, MELDEQ ; P = 0.015, deMELD). While both scores result in better equity of waitlist outcomes compared with scheduled progression, continued development and calibration is recommended.

Is the Use of Physical Discipline Associated with Aggressive Behaviors in Young Children?

OBJECTIVE: To determine the association between use of physical discipline and parental report of physically aggressive child behaviors in a cohort of young children who were without indicators of current or past physical abuse. METHODS: The data for this study were analyzed from an initial cohort of patients enrolled in a prospective, observational, multicenter pediatric emergency department-based study investigating bruising and familial psychosocial characteristics of children younger than 4 years of age. Over a 7-month period, structured parental interviews were conducted regarding disciplinary practices, reported child behaviors, and familial psychosocial risk factors. Children with suspected physical abuse were excluded from this study. Trained study staff collected data using standardized questions. Consistent with grounded theory, qualitative coding by 2 independent individuals was performed using domains rooted in the data. Inter-rater reliability of the coding process was evaluated using the kappa statistic. Descriptive statistics were calculated and multiple logistic regression modeling was performed. RESULTS: Three hundred seventy-two parental interviews were conducted. Parents who reported using physical discipline were 2.8 (95% confidence interval [CI], 1.7-4.5) times more likely to report aggressive child behaviors of hitting/kicking and throwing. Physical discipline was used on 38% of children overall, and was 2.4 (95% CI, 1.4-4.1) times more likely to be used in families with any of the psychosocial risk factors examined. CONCLUSIONS: Our findings indicated that the use of physical discipline was associated with higher rates of reported physically aggressive behaviors in early childhood as well as with the presence of familial psychosocial risk factors.

Changes in blood pressure and heart rate during sedation with ketamine in the pediatric ED.

BACKGROUND: Ketamine is commonly used in the emergency department for short, painful procedures. We describe changes in blood pressure (BP) and heart rate (HR) during procedural sedation with ketamine, as these changes have not been well described in children. METHODS: We performed a secondary analysis of a prospective, observational study involving children aged 8 to 18 years who received procedural sedation with ketamine in a pediatric emergency department. Serial vital signs and sedation scores were recorded from baseline until recovery from ketamine procedural sedation. Time of orthopedic manipulation was also recorded. Linear mixed-effect models were used to evaluate changes in systolic BP (SBP), diastolic BP (DBP), and HR using 3 sedation strata: presedation (baseline), sedated (ketamine administered and patient deeply sedated), and recovery (ketamine administered with patient minimally sedated), controlling for age and weight. RESULTS: Sixty children were enrolled; 10 were excluded due to missing manipulation time. A total of 394 observations were recorded. Mean sedated SBP, DBP, and HR were 8 mm Hg, 4 mm Hg, and 13 beats/min higher than presedation SBP (P<.001), DBP (P<.01), and HR (P<.001), respectively. Mean sedated SBP and DBP were 3 and 4 mm Hg higher than SBP (P=.006) and DBP (P<.01) during recovery. Manipulation increased mean SBP by 5 mm Hg (P<.001), mean DBP by 7 mm Hg (P<.001), and mean HR by 1 beat/min (P=.35). CONCLUSIONS: Ketamine administered during procedural sedation for painful procedures causes a statistically significant but modest increase in SBP, DBP, and HR. Orthopedic manipulation further increases BP.

Projected outcomes of 6-month delay in exception points versus an equivalent Model for End-Stage Liver Disease score for hepatocellular carcinoma liver transplant candidates.

The United Network for Organ Sharing (UNOS) recently implemented a 6-month delay before granting exception points to liver transplantation candidates with hepatocellular carcinoma (HCC) to address disparity in transplantation access between HCC and non-HCC patients. An HCC-specific scoring scheme, the Model for End-Stage Liver Disease equivalent (MELDEQ ), has also been developed. We compared projected dropout and transplant probabilities and posttransplant survival for HCC and non-HCC patients under the 6-month delay and the MELDEQ using UNOS data from October 1, 2009, to June 30, 2014, and multistate modeling. Overall (combined HCC and non-HCC) wait-list dropout was similar under both schemes and slightly improved (though not statistically significant) compared to actual data. Projected HCC wait-list dropout was similar between the MELDEQ and 6-month delay at 6 months but thereafter started to differ, with the 6-month delay eventually favoring HCC patients (3-year dropout 10.0% [9.0%-11.0%] for HCC versus 14.1% [13.6%-14.6%]) for non-HCC) and the MELDEQ favoring non-HCC patients (3-year dropout 16.0% [13.2%-18.8%] for HCC versus 12.3% [11.9%-12.7%] for non-HCC). Projected transplant probabilities for HCC patients were substantially lower under the MELDEQ compared to the 6-month delay (26.6% versus 83.8% by 3 years, respectively). Projected HCC posttransplant survival under the 6-month delay was similar to actual, but slightly worse under the MELDEQ (2-year survival 82.9% [81.7%-84.2%] versus actual of 85.5% [84.3%-86.7%]). In conclusion, although the 6-month delay improves equity in transplant and dropout between HCC and non-HCC candidates, disparity between the 2 groups may still exist after 6 months of wait-list time. Projections under the MELDEQ , however, appear to disadvantage HCC patients. Therefore, modification to the exception point progression or refinement of an HCC prioritization score may be warranted. Liver Transplantation 22 1343-1355 2016 AASLD.

Assessment of Functional Improvement without Compensation for Human Spinal Cord Injury: Extending the Neuromuscular Recovery Scale to the Upper Extremities.

The Neuromuscular Recovery Scale (NRS) is a tool for measuring functional recovery in spinal cord injured (SCI) persons based on tasks that test pre-injury functional capability. The NRS has been shown to be a valid, reliable, and responsive instrument for measuring functional recovery. The NRS has been updated to include three items measuring upper extremity function, and a new scoring mechanism has been defined. The purpose of this prospective, observational study was to explore the properties of the expanded NRS, introduce and evaluate the new scoring method, and to examine the score's relationship with other SCI outcome measures. The NRS and seven other SCI outcome measures were assessed at enrollment and after every 20 locomotor training sessions in 64 participants of the NeuroRecovery Network (NRN) of the Christopher and Dana Reeve Foundation (CDRF). The NRS exhibited a dominant first principal component that correlated strongly with the new NRS score, as well as a potential secondary component discriminating upper extremity function. The new NRS score and its empirical subscales were generally well-correlated with International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI) motor scores and other established SCI functional measures, but exhibited substantial variability at their boundary values. The NRS score was more strongly correlated with other SCI functional measures than ISNCSCI motor scores were. The new NRS score was most responsive to change brought on by locomotor training. The expanded NRS appears to be a valuable tool in measuring functional recovery from SCI; further evaluation of its psychometric properties is warranted.

Responsiveness of the Neuromuscular Recovery Scale During Outpatient Activity-Dependent Rehabilitation for Spinal Cord Injury.

BACKGROUND: The Neuromuscular Recovery Scale (NRS) was developed by researchers and clinicians to functionally classify people with spinal cord injury (SCI) by measuring functionally relevant motor tasks without compensation. Previous studies established strong interrater and test-retest reliability and validity of the scale. OBJECTIVE: To determine responsiveness of the NRS, a version including newly added upper-extremity items, in an outpatient rehabilitation setting. METHODS: Assessments using the NRS and 6 other instruments were conducted at enrollment and discharge from a locomotor training program for 72 outpatients with SCI classified as American Spinal Injury Association Impairment Scale grades A to D (International Standards for Neurological Classification of Spinal Cord Injury). Mixed-model t statistics for instruments were calculated and adjusted for confounding factors (eg, sample size, demographic variables) for all patients and subgroups stratified by injury level and/or severity. The resulting adjusted response means (ARMs) and 95% confidence intervals (CIs) were used to determine responsiveness, and significant differences between instruments were identified with pairwise comparisons. RESULTS: The NRS was significantly responsive for SCI outpatients (ARM = 1.05; CI = 0.75-1.35). Changes in motor function were detected across heterogeneous groups. Regardless of injury level or severity, the responsiveness of the NRS was equal to, and often significantly exceeded, the responsiveness of other instruments. CONCLUSIONS: The NRS is a responsive measure that detects change in motor function during outpatient neurorehabilitation for SCI. There is potential utility for its application in randomized controlled trials and as a measure of clinical recovery across diverse SCI populations.

The Prevalence of Bruising Among Infants in Pediatric Emergency Departments.

STUDY OBJECTIVE: Bruising can indicate abuse for infants. Bruise prevalence among infants in the pediatric emergency department (ED) setting is unknown. Our objective is to determine prevalence of bruising, associated chief complaints, and frequency of abuse evaluations in previously healthy infants presenting to pediatric EDs. METHODS: We conducted a prospective, observational, multicenter study of infants aged 12 months or younger presenting to pediatric EDs. Structured sampling was used. Pediatric emergency medicine clinicians performed complete skin examinations to screen for bruising. Study investigators documented skin findings, date of visit, patient's age, chief complaint, and abuse evaluation. The primary outcome was prevalence of bruising. Secondary outcomes were prevalence of bruising based on chief complaint and frequency of abuse evaluation. Point estimates of bruise prevalence and differences in bruise prevalence between patient subgroups were calculated with 95% confidence intervals (CIs). RESULTS: Bruising was identified in 88 of 2,488 infants (3.5%; 95% CI 2.9% to 4.4%). Rates of bruising for infants 5 months and younger and older than 5 months were 1.3% and 6.4%, respectively (difference 5.1%; 95% CI 3.6% to 6.8%). For infants 5 months and younger, 83% of bruising was associated with a trauma chief complaint and only 0.2% of infants presenting with a medical chief complaint had bruising. Pediatric emergency medicine clinicians obtained abuse evaluations on 23% of infants with bruising, and that rate increased to 50% for infants 5 months and younger. CONCLUSION: Bruising prevalence in children 12 months and younger who were evaluated in pediatric EDs was low, increased within age strata, and was most often associated with a trauma chief complaint. Most bruised infants did not undergo an abuse evaluation.