Progressive, Long-Term Hearing Loss in Congenital CMV Disease After Ganciclovir Therapy.

BACKGROUND: Long-term hearing outcomes among children with symptomatic congenital cytomegalovirus (CMV) disease who received 6-week ganciclovir therapy early in life are unknown. METHODS: Longitudinal study of 76 children with symptomatic congenital CMV disease, born 1983-2005, who were categorized into three groups: group A treated with ganciclovir; group B untreated who had microcephaly, chorioretinitis, or sensorineural hearing loss (SNHL; ≥25 dB) diagnosed in the first month of life (congenital); and group C untreated who did not meet criteria for group B. RESULTS: Patients in groups A (n = 17), B (n = 27), and C (n = 32) were followed to median age of 13, 11, and 13 years, respectively. In group A, patients received ganciclovir for median of 40 (range, 11-63) days; 7 (41%) had grade 3 or 4 neutropenia. Congenital SNHL was diagnosed in 11 (65%) patients in group A, 15 (56%) in group B, and none in group C. Early-onset SNHL was diagnosed between ages ≥1-12 months in an additional 4 (24%), 6 (22%), and 8 (25%) patients in groups A, B, and C, respectively. By the end of follow-up, 12 (71%), 16 (59%), and 7 (22%) of patients in groups A, B, and C, respectively, had severe (>70 dB) SNHL in the better-hearing ear. CONCLUSIONS: In this study, most patients with symptomatic congenital CMV disease and congenital or early-onset SNHL eventually developed hearing loss severe enough to have been potential candidates for cochlear implantation, with or without 6-week ganciclovir therapy. Understanding long-term hearing outcomes of patients treated with 6-month oral valganciclovir (current standard of care) is needed.

Multimonth Prescription of Antiretroviral Therapy Among Children and Adolescents: Experiences From the Baylor International Pediatric AIDS Initiative in 6 African Countries.

BACKGROUND: To reach 90-90-90 targets, differentiated approaches to care are necessary. We describe the experience of delivering multimonth prescription (MMP) schedules of antiretroviral therapy (ART) to youth at centers of excellence in 6 African countries. METHODS: We analyzed data from electronic medical records of patients aged 0-19 years started on ART. Patients were eligible to transition from monthly prescribing to MMP when clinically stable [improving CD4, viral load (VL) suppression, or minimal HIV-associated morbidity] and ART adherent (pill count 95%-105%). Patients were classified as transitioned to MMP after 3 consecutive visits at intervals of >56 days. We used survival analysis to describe death and lost to follow-up. We described adherence and acceptable immunologic response by CD4 using 6-month and VL suppression (<400 copies per milliliter) using 12-month intervals. RESULTS: Twenty-two thousand six hundred fifty-eight patients aged 0-19 years received ART and 14,932 (66%) transitioned to MMP between 2003 and 2015. Of these 2.6% were lost to follow-up and 2.0% died. Median duration of MMP was 3.9 (interquartile range: 2.2-5.9) years. There were significant differences in survival (P < 0.0001) between age groups, worst among those younger than 1 year and 15-19 years. The frequency of favorable clinical endpoints was high throughout the first 5 years of MMP, by year ranging from 87% to 94% acceptable immunologic response, 75% to 80% adherent, and 79% to 85% VL suppression. CONCLUSIONS: These analyses from 6 African countries demonstrate that youth on ART who transitioned to MMP overall maintained favorable outcomes in terms of death, retention, adherence, immunosuppression, and viral suppression. These results reassure that children and adolescents, who are clinically stable and ART adherent, can do well with reduced visit frequencies and extended ART refills.

Efficacy of a near-infrared light device in pediatric intravenous cannulation: a randomized controlled trial.

OBJECTIVES: To determine whether the use of a near-infrared light venipuncture aid (VeinViewer; Luminetx Corporation, Memphis, Tenn) would improve the rate of successful first-attempt placement of intravenous (IV) catheters in a high-volume pediatric emergency department (ED). METHODS: Patients younger than 20 years with standard clinical indications for IV access were randomized to have IV placement by ED nurses (in 3 groups stratified by 5-year blocks of nursing experience) using traditional methods (standard group) or with the aid of the near-infrared light source (device group). If a vein could not be cannulated after 3 attempts, patients crossed over from one study arm to the other, and study nurses attempted placement with the alternative technique. The primary end point was first-attempt success rate for IV catheter placement. After completion of patient enrollment, a questionnaire was completed by study nurses as a qualitative assessment of the device. RESULTS: A total of 123 patients (median age, 3 years) were included in the study: 62 in the standard group and 61 in the device group. There was no significant difference in first-attempt success rate between the standard (79.0%, 95% confidence interval [CI], 66.8%-88.3%) and device (72.1%, 95% CI, 59.2%-82.9%) groups. Of the 19 study nurses, 14 completed the questionnaire of whom 70% expressed neutral or unfavorable assessments of the device in nondehydrated patients without chronic underlying medical conditions and 90% found the device a helpful tool for patients in whom IV access was difficult. CONCLUSIONS: First-attempt success rate for IV placement was nonsignificantly higher without than with the assistance of a near-infrared light device in a high-volume pediatric ED. Nurses placing IVs did report several benefits to use of the device with specific patient groups, and future research should be conducted to demonstrate the role of the device in these patients.

Managing well-appearing neonates with hyperbilirubinemia in the emergency department observation unit.

BACKGROUND: In September 2005, Texas Children's Hospital initiated a protocol for all neonates presenting to the emergency department (ED) with hyperbilirubinemia based on the American Academy of Pediatrics guidelines. As part of the protocol, low-risk neonates with hyperbilirubinemia requiring phototherapy are treated in the ED observation unit (EDOU). OBJECTIVE: The aim of the study was to compare time to phototherapy and duration of hospital stay in low-risk neonates with hyperbilirubinemia presenting to the Texas Children's Hospital ED before and after the initiation of a triage-based protocol. DESIGN/METHODS: We performed a retrospective historical control study comparing neonates with hyperbilirubinemia treated in the EDOU between January 1 and December 31, 2006 (EDOU group), with neonates with hyperbilirubinemia admitted to the inpatient unit between January 1 and December 31, 2004 (inpatient group). RESULTS: There were 167 neonates included in the study: 62 neonates were treated in the EDOU and 105 in the inpatient unit. Median time to phototherapy (inpatient: 6.7 hours, EDOU: 1.6 hours) and duration of hospital stay (inpatient: 41.8 hours, EDOU: 17.8 hours) were shorter for neonates treated in the EDOU compared with neonates treated in the inpatient unit. Of the neonates treated in the EDOU initially, 11 were admitted to the inpatient unit after 24 hours because their bilirubin level did not decline adequately. CONCLUSIONS: Low-risk neonates with hyperbilirubinemia can be managed more efficiently in an EDOU than in an inpatient unit. Phototherapy is initiated more rapidly, and patients are discharged sooner in the EDOU than in the inpatient setting.

Use of a discharge facilitator improves recall of emergency department discharge instructions for acute gastroenteritis.

OBJECTIVE: To determine whether the use of a bilingual discharge facilitator (DF) improves parental recall of discharge instructions in acute gastroenteritis in a pediatric emergency department (ED). METHODS: A nonrandomized educational intervention study with a historical control was conducted in a tertiary children's hospital between January 2004 and November 2004. English- or Spanish-speaking parents of patients aged 3 months to 18 years with conditions diagnosed as acute gastroenteritis were eligible. The standard discharge group received written discharge instructions and standard ED discharge protocols. The intervention group received the written discharge instructions reinforced verbally by the DF in the parent's language of choice. Recall of 7 warning signs and symptoms was assessed 24 to 48 hours after the ED visit for both groups. RESULTS: For the English-speaking subgroup, a mean of 3.5 (95% confidence interval [CI], 3.26-3.78) signs or symptoms was identified correctly by 71 subjects in the standard discharge group, and a mean of 4.1 (95% CI, 3.83-4.43) signs or symptoms was identified correctly by 94 subjects in the DF group. For the Spanish-speaking subgroup, a mean of 3.0 (95% CI, 2.67-3.36) signs or symptoms was identified correctly by 62 subjects in the standard discharge group, and a mean of 4.5 (95% CI 4.18-4.88) signs or symptoms was identified correctly by 64 subjects in the DF group. The differences remained significant after adjusting for patient age and the highest level of education attained by the parent. CONCLUSIONS: Verbal reinforcement of written discharge instructions by a bilingual DF improves parental recall of discharge instructions for gastroenteritis.