Association of Circulating Markers of Microbial Translocation and Hepatic Inflammation with Liver Injury in Patients with Type 2 Diabetes.

BACKGROUND: Virtually the entire spectrum of liver disease is observed in association with type 2 diabetes mellitus (T2DM); indeed, T2DM is now the most common cause of liver disease in the U.S. We conducted a pilot study to investigate the relevance of increased microbial translocation and systemic inflammation in the development of liver injury in patients with T2DM. METHODS: Patients with T2DM (n = 17) and non-diabetic controls (NDC; n = 11) aged 25-80 yrs. participated in this study. Serum levels of endotoxin, calprotectin, soluble CD14 and CD163, and several inflammatory cytokines were measured. In addition to standard liver injury markers, ALT and AST, novel serum markers of liver injury, keratin 18 (K-18) M30 (apoptosis-associated caspase-cleaved keratin 18), and M65 (soluble keratin 18) were evaluated. Statistical analyses were performed using the Mann-Whitney test to assess differences between study groups. Pearson's correlation analysis was performed to determine the strength of association between two variables using GraphPad Prism 9.5.0 software. RESULTS: Patients with T2DM had significantly higher levels of sCD14 in comparison to NDC, suggesting an increase in gut permeability, microbial translocation, and monocyte/macrophage activation. Importantly, relevant to the ensuing inflammatory responses, the increase in sCD14 in patients with T2DM was accompanied by a significant increase in sCD163, a marker of hepatic Kupffer cell activation and inflammation. Further, a positive correlation was observed between sCD163 and endotoxin and sCD14 in T2DM patients but not in NDC. In association with these changes, keratin 18 (K-18)-based serum markers (M65 and M30) that reflect hepatocyte death were significantly higher in the T2DM group indicating ongoing liver injury. Notably, both M65 and M30 levels correlated with sCD14 and sCD163, suggesting that immune cell activation and hepatic inflammation may be linked to the development of liver injury in T2DM. CONCLUSIONS: These findings suggest that the pathogenic changes in the gut-liver axis, marked by increased microbial translocation, may be a major component in the etiology of hepatocyte inflammation and injury in patients with T2DM. However, larger longitudinal studies, including histological evidence, are needed to confirm these observations.

Changes in Psychiatric Medication Use During the COVID-19 Pandemic in a Pediatric Long-Term Care Facility.

Background: Coronavirus disease 2019 (COVID-19) caused a global pandemic that dramatically altered infection control procedures in long-term care facilities. Mental health decline among residents of geriatric facilities during the pandemic has been described (Ferro Uriguen et al., 2022). Our study aims to evaluate psychological effects of the pandemic on residents of a pediatric long-term care facility, a population comprised of medically complex children. To characterize this, we compared patterns of psychotropic medication use during the COVID-19 pandemic to those of the prepandemic period among residents of a 76-bed pediatric long-term care facility. Methods: We conducted a retrospective study of psychotropic medication use from January 2019 to August 2022 using de-identified monthly facility medication refill data. Linear multivariable regression models were used to estimate the level and trends in the monthly rates of medication refills per 10,000 bed days among resident children before and after the pandemic onset. Six classes of psychotropic medications were analyzed including antipsychotics, antidepressants and anxiety medications, trazodone, clonidine, mood stabilizers, and gabapentin. Results: The pandemic onset was associated with a significant increase in the monthly prescribing rates of antidepressant and anxiety medications (20.83; 95% CI, 3.96-37.71; p = 0.017), mood stabilizers (10.44; 95% CI, 5.79-15.09; p < 0.001), and trazodone (-27.66; 95% CI, -40.44 to 14.88; p < 0.001) above those expected by prepandemic trends. The trend in trazodone use changed significantly during the pandemic from decreasing prepandemic to increasing (2.21; 95% CI, 1.28-3.14; p < 0.001). Antidepressant, anxiety medication, and gabapentin use increased throughout the study. Antidepressant and anxiety medication use surged early in the pandemic, but then continued growth at their prior rates of use. Discussion: Increased use of antidepressant and anxiety medications and trazodone suggests a possible impact of the COVID-19 pandemic on rates of anxiety, depression, sleep disturbance, and agitation among children with severe intellectual and developmental disabilities living in long-term care.

A case study on variations in network structure and cross-sector alignment in two local systems serving pregnant and parenting women in recovery.

OBJECTIVE: To describe network structure and alignment across organizations in healthcare, public health, and social services sectors that serve pregnant and parenting women with substance use disorder (SUD) in an urban and a rural community. DATA SOURCES AND STUDY SETTINGS: Two community networks, one urban and one rural with each including a residential substance use treatment program, in Kentucky during 2021. STUDY DESIGN: Social network analysis measured system collaboration and cross-sector alignment between healthcare, public health, and social services organizations, applying the Framework for Aligning Sectors. To understand the alignment and structure of each network, we measured network density overall and between sectors, network centralization, and each organization's degree centrality and effective size. DATA COLLECTION/EXTRACTION METHODS: Computer-assisted telephone interviews were conducted to document alignment around shared purpose, data, financing, and governance. PRINCIPAL FINDINGS: On average, overall and cross-sector network densities in both communities were similar. However, alignment was highest for data sharing and financing in the urban community and for shared purpose and governance in the rural community. Cross-sector partnerships involving healthcare organizations were more prevalent in the rural county (44% vs. 38% for healthcare/public health, 44% vs. 29% for healthcare/social services), but more prevalent for those involving public health/social services organizations in the urban county (42% vs. 24%). A single healthcare organization had the highest degree centrality (Mdn [IQR] = 26 [26-9.5]) and effective size (Mdn [IQR] = 15.9 [20.6-8.7]) within the rural county. Social services organizations held more central positions in the urban county (degree centrality Mdn [IQR] = 13 [14.8-9.5]; effective size Mdn [IQR] = 10.4 [11.4-7.9]). CONCLUSIONS: Cross-sector alignment may strengthen local capacity for comprehensive SUD care for pregnant and parenting women. Healthcare organizations are key players in cross-sector partnerships in the rural community, where one healthcare facility holds the central brokerage role. In contrast, public health agencies are key to cross-sector collaboration with social services in the urban community.

Polysomnographic outcomes of revision adenoidectomy in children with obstructive sleep apnea and recurrent/residual adenoidal hypertrophy.

INTRODUCTION: Recurrent/residual adenoidal hypertrophy after adenotonsillectomy in children can result in obstructive sleep apnea (OSA). We aimed to assess the polysomnographic (PSG) outcomes of revision adenoidectomy in children with recurrent/residual adenoidal hypertrophy and OSA. METHODS: This was a single-center retrospective study that included children with sleep studies that confirmed OSA and known history of adenotonsillectomy who were diagnosed with adenoidal hypertrophy and subsequently underwent revision adenoidectomy. Pre- and postoperative PSG variables of revision adenoidectomy were included in the analysis. RESULTS: A total of 20 children were included in the study. The cohort included 13 males and 7 females with a mean age of 7.8 years (± 3.6 years). The mean BMI z score was 1.96 [1.31, 2.43]. The median duration from adenotonsillectomy performance was 2.3 years [1.4, 4.0]. Overall, revision adenoidectomy resulted in significant improvements in multiple respiratory parameters, including AHI 6.6 [1.4, 13. 7] vs 14.8 [7.4, 20.7], p = 0.02; oxygen desaturations nadir 88.0 [84.0, 93.0] vs 80.0 [72.2, 88.9], p = 0.01; supine AHI 8.6 [1.5, 14.3] vs 17.6 [8.3, 30.2], p = 0.02; and arousal index 12.2 [9.6, 15.7] vs 18.9 [13.4, 24.9], p = 0.04. CONCLUSIONS: Children with recurrent/residual adenoidal hypertrophy after adenotonsillectomy who undergo revision adenoidectomy experience improvements in respiratory event, gas exchange, and arousal index.

Associations With Severe Desaturation Events Among Children Receiving Noninvasive Respiratory Support at Time of Intubation.

BACKGROUND: Endotracheal intubation is a common procedure associated with adverse events, including severe desaturation. Many patients receive noninvasive respiratory support to reduce the need for intubation. There are minimal data about the association between noninvasive respiratory support and the risk of a severe desaturation event during intubation. We aim to differentiate patients based on the level of noninvasive respiratory support, analyze the severe desaturation event by groups, and identify modifiable risk factors. METHODS: Oral intubations, excluding tube exchanges or re-intubation after unplanned extubation, from October 2018 through July 2020, at the study site were reviewed. A severe desaturation event was defined as [Formula: see text] < 70% or a >15% decrease from baseline in cyanotic heart disease. We analyzed outcomes by 4 groups: room air/nasal cannula (≤0.5 L/kg/min), high-flow nasal cannula (HFNC) (0.5-2 L/kg/min), high HFNC (≥2 L/kg/min), and noninvasive ventilation (NIV). RESULTS: Of 243 subjects who were intubated, 31% were receiving room air/nasal cannula, 25% were receiving HFNC, 18% were receiving high HFNC, and 26% were receiving NIV. Twelve percent of all the subjects had a severe desaturation event. In a univariate analysis, the incidence of a severe desaturation event was similar among all levels of respiratory support (P = .14). A severe desaturation event was more likely in those subjects who were receiving [Formula: see text] ≥ 0.6 at the time of the decision to intubate (19.6%) versus [Formula: see text] < 0.6 (8.1%) (P = .02). The duration of noninvasive respiratory support was longer (5 vs 1 h; P = .02) among those with a severe desaturation event. In a regression analysis, when adjusting for ≥2 intubation attempts pre-intubation, NIV use was independently associated with increased odds of severe desaturation events (odds ratio 3.14, CI 1.08-10.5). CONCLUSIONS: Results of our study suggest that [Formula: see text] > 0.60, the duration of noninvasive respiratory support, and exposure to NIV before an intubation are risk factors of severe desaturation events during intubation.

Role of neck radiography in assessing recurrent/residual adenoid hypertrophy in children with OSA and history of adenotonsillectomy: a sleep physician perspective.

STUDY OBJECTIVES: Recurrent/residual adenoid hypertrophy after adenotonsillectomy in children can result in obstructive sleep apnea (OSA). We aimed to assess the role of soft tissue neck X-ray (STN-XR) in evaluating recurrent/residual adenoid tissue hypertrophy. METHODS: This was a single-center retrospective study that included children with sleep study-confirmed OSA and a known history of adenotonsillectomy who underwent STN-XR to evaluate for recurrent/residual adenoid tissue hypertrophy. STN-XR nasopharyngeal obliteration and baseline polysomnographic data were analyzed. Multiple linear regression was used to assess the independent relationship between the results of STN-XR and the total apnea-hypopnea index, while controlling for relevant characteristics. RESULTS: The study included 160 participants with a median age of 10 years (quartile [Q] 1 = 7, Q3 = 12.25). More than half of the children were male (59.4%) and the median body mass index z-score was 2.11 (Q1 = 1.23, Q3 = 2.54). STN-XR was normal in 39.4%, and it showed mild, moderate, and complete nasopharyngeal obliteration in 20.6%, 32.5%, and 7.5% of the participants, respectively. Multiple regression analysis showed that moderate and complete nasopharyngeal obliteration was associated with an increase in the mean total apnea-hypopnea index by 109% (P = .0002) and 185% (P = .001), respectively, when compared with children without nasopharyngeal obliteration. However, mild nasopharyngeal obliteration, body mass index z-score, age, sex, and race were not significantly associated with an increase in the total apnea-hypopnea index. CONCLUSIONS: STN-XR was useful in assessing recurrent/residual adenoid tissue hypertrophy in children with OSA and a history of adenotonsillectomy. Moderate and complete nasopharyngeal obliteration were associated with significantly increased apnea-hypopnea index. Pediatric sleep physicians may consider STN-XR in the evaluation of children with OSA and previous history of adenotonsillectomy. CITATION: Senthilvel E, Nguyen QL, Gunaratnam B, Feygin YB, Palani R, El-Kersh K. Role of neck radiography in assessing recurrent/residual adenoid hypertrophy in children with OSA and history of adenotonsillectomy: a sleep physician perspective. J Clin Sleep Med. 2023;19(6):1027-1033.

Attention-Deficit/Hyperactivity Disorder Practice Patterns: A Survey of Kentucky Pediatric Providers.

OBJECTIVE: Kentucky ranks among the highest in the nation for attention-deficit/hyperactivity disorder (ADHD) prevalence in children aged 4 to 17 years. In 2011, the American Academy of Pediatrics (AAP) released a clinical practice guideline based on the DSM-IV. A guideline revision based on the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5) was released in October 2019. In this study, we assess and describe pediatric providers' ADHD practices using the 2011 guideline and DSM-5 diagnostic criteria. METHODS: This was a cross-sectional, survey-based descriptive study. Kentucky Chapter of the AAP (KY AAP) members were anonymously surveyed. The results were examined for trends in routine practice. RESULTS: Fifty-eight general pediatricians and pediatric residents responded to the survey, yielding a 38% (58/154) response rate. Among respondents performing routine diagnosis of ADHD (N = 51), 73% (37/51) used DSM-5 criteria. Most providers usually or always initially assessed for coexisting behavioral conditions (96%; 49/51), developmental conditions (78%; 39/51), and adverse childhood experiences (73%; 37/51). Among respondents performing routine management of ADHD (N = 55), only 11% (6/55) of respondents indicated that they titrated stimulant medications every 3 to 7 days. After initiation of medication, 78% of providers scheduled a follow-up visit within 2 to 4 weeks. During subsequent visits, only half indicated discussing behavioral interventions, screening for coexisting conditions, and reviewing follow-up teacher-rated ADHD scales. CONCLUSION: Pediatricians in the KY AAP adhere to the DSM-5 criteria for diagnosing ADHD. Pediatric providers' practices would benefit from education in improvements in pharmacotherapy titration, surveillance of coexisting conditions associated with ADHD, discussion of psychosocial interventions, and school support strategies.

Parents' attitudes toward consent and data sharing in biobanks: A multisite experimental survey.

BACKGROUND: The factors influencing parents' willingness to enroll their children in biobanks are poorly understood. This study sought to assess parents' willingness to enroll their children, and their perceived benefits, concerns, and information needs under different consent and data-sharing scenarios, and to identify factors associated with willingness. METHODS: This large, experimental survey of patients at the 11 eMERGE Network sites used a disproportionate stratified sampling scheme to enrich the sample with historically underrepresented groups. Participants were randomized to receive one of three consent and data-sharing scenarios. RESULTS: In total, 90,000 surveys were mailed and 13,000 individuals responded (15.8% response rate). 5737 respondents were parents of minor children. Overall, 55% (95% confidence interval 50-59%) of parents were willing to enroll their youngest minor child in a hypothetical biobank; willingness did not differ between consent and data-sharing scenarios. Lower educational attainment, higher religiosity, lower trust, worries about privacy, and attitudes about benefits, concerns, and information needs were independently associated with less willingness to allow their child to participate. Of parents who were willing to participate themselves, 25% were not willing to allow their child to participate. Being willing to participate but not willing to allow one's child to participate was independently associated with multiple factors, including race, lower educational attainment, lower annual household income, public health care insurance, and higher religiosity. CONCLUSIONS: Fifty-five percent of parents were willing to allow their youngest minor child to participate in a hypothetical biobank. Building trust, protecting privacy, and addressing attitudes may increase enrollment and diversity in pediatric biobanks.