Association of Neighborhood Opportunity, Race and Ethnicity with Pediatric Day-of-Surgery Cancellations: a Cohort Study.

BACKGROUND: Day-of-surgery cancellations impede healthcare access and contribute to inequities in pediatric healthcare. Socially disadvantaged families have many risk factors for surgical cancellation, including low health literacy, transportation barriers, and childcare constraints. These social determinants of health are captured by the Childhood Opportunity Index (COI) 2.0, a national quantification of neighborhood-level characteristics that contribute to a child's vulnerability to adversity. We studied the association of neighborhood opportunity with pediatric day-of-surgery cancellations. METHODS: We conducted a retrospective cohort study of children younger than 18 years of age scheduled for ambulatory surgery at a tertiary pediatric hospital between 2017 and 2022. We geocoded the primary address to determine COI 2.0 neighborhood opportunity. We used log-binomial regression to estimate the relative risk of day-of-surgery cancellation comparing different levels of neighborhood opportunity. We also estimated the relative risk of cancellations associated with race and ethnicity, by neighborhood opportunity. RESULTS: Overall, the incidence of day-of-surgery cancellation was 3.8%. The incidence of cancellation was lowest in children residing in very high opportunity neighborhoods and highest in children residing in very low opportunity neighborhoods (2.4% vs 5.7%, p<0.001). The adjusted relative risk of day-of-surgery cancellation in very low opportunity neighborhoods compared to very high opportunity neighborhoods was 2.24 (95%CI: 2.05-2.44, p<0.001). We found statistical evidence of an interaction of COI with race and ethnicity. In very low opportunity neighborhoods, Black children had 1.48 times greater risk of day-of-surgery cancellation than White children (95%CI: 1.35-1.63, p<0.001). Likewise, in very high opportunity neighborhoods, Black children had 2.17 times greater risk of cancellation (95%CI: 1.75-2.69, p<0.001). CONCLUSION: We found a strong relationship between pediatric day-of-surgery cancellation and neighborhood opportunity. Black children at every level of opportunity had the highest risk of cancellation, suggesting that there are additional factors that render them more vulnerable to neighborhood disadvantage.

Difficult intubation in syndromic versus nonsyndromic forms of micrognathia in children.

BACKGROUND: We investigated how syndromic versus nonsyndromic forms of micrognathia impacted difficult intubation outcomes in children. Primary outcome was the first-attempt success rate of tracheal intubation, secondary outcomes were number of intubation attempts and complications. We hypothesized that syndromic micrognathia would be associated with lower first-attempt success rate. METHODS: In micrognathic patients enrolled in the Pediatric Difficult Intubation Registry (08/2012-03/2019) we retrospectively compared demographic and clinical characteristics between children with nonsyndromic and syndromic micrognathia using standardized mean differences (SMD) and assessed the association of the presence of syndrome with the primary and secondary outcomes using propensity score matching analysis with and without matching for airway assessment findings. RESULTS: Nonsyndromic patients (628) were less likely to have additional airway abnormalities. Syndromic patients (216) were less likely to have unanticipated difficult intubation (2% vs. 20%, SMD 0.59). First-attempt success rates of intubation were: 38% in the syndromic versus 34% in the nonsyndromic group (odds ratio [OR] 1.18; 95% confidence intervals [95% CI] 0.74, 1.89; p = .478), and 37% versus 37% (OR 0.99; 95% CI 0.66, 1.48; p = .959). Median number of intubation attempts were 2 (interquartile range [IQR]: 1, 3; range: 1, 8) versus 2 (IQR: 1, 3; range 1, 12) (median regression coefficient = 0; 95% CI: -0.7, 0.7; p = .999) and 2 (IQR: 1, 3; range: 1, 12) versus 2 (IQR: 1, 3; range 1, 8) (median regression coefficient = 0; 95% CI: -0.5, 0.5; p = .999). Complication rates were 14% versus 22% (OR 0.6; 95% CI 0.34, 1.04; p = .07) and 16% versus 21% (OR 0.71; 95% CI 0.43, 1.17; p = .185). CONCLUSIONS: Presence of syndrome was not associated with lower first-attempt success rate on intubation, number of intubation attempts, or complication rate among micrognathic patients difficult to intubate, despite more associated craniofacial abnormalities. Nonsyndromic patients were more likely to have unanticipated difficult intubations, first attempt with direct laryngoscopy.

Pro-Con Debate: Perioperative Research Should Be Color-Blind.

Profound racial and ethnic disparities have been documented in health and health care outcomes in recent decades. Some researchers have erroneously ascribed these inequities to biological variations, prompting debate as to how, or even if, race and ethnicity should be included as an outcome variable. Color blindness is a racial ideology with roots in constitutional law that posits that equality is best achieved by disregarding the racial and ethnic characteristics of the individual. Color consciousness, in contrast, approaches disparities with the knowledge that experiences related to one's race and ethnicity influence an individual's health and well-being. In this Pro-Con commentary article, we discuss the concept of color blindness and debate its use as an approach in medicine and research.

Bilingual randomized controlled trial design, of a telephone-based intervention to promote rehabilitation adherence; A study focus on recruitment of Hispanic children with traumatic brain injury.

BACKGROUND: While Hispanic children experience large long-term disparities in disability after traumatic Brain Injury (TBI), there is a gap in evidenced-based interventions to improve outcomes among this rapidly growing and at high-risk population. We developed and pilot tested a bilingual/bicultural intervention informed by Hispanic families consisting of Brain Injury Education and outpatient Navigation (1st BIEN). It integrates bilingual in-person education enriched by video content delivered through mobile phone devices, with outpatient navigation by bilingual and bicultural navigators during transitions of care and school return. METHODS: Randomized controlled trial to test the efficacy of 1st BIEN to maintain long-term adherence to rehabilitation and determine its effect on children's functional outcomes. The primary outcome is treatment adherence at 6 months post-discharge at centralized acute facilities and community providers. Secondary outcomes are functional status of the child using PROMIS parental report measures and parental health literacy, self-efficacy, and mental health; measured at baseline (pre-injury and discharge) 3-,6- and 12- months post discharge. Children's academic performance is assessed using school records the year before and the year after injury. DISCUSSION: Our study evaluates a novel, flexible and scalable approach using mobile phone devices to aid transitions of care, increase treatment adherence and improve TBI outcomes. It addresses the needs of an understudied population and builds upon their strengths. It is implemented by a bilingual and bicultural team with a deep understanding of the study population. It can serve as a model for TBI family centered interventions for at risk groups. TRIAL REGISTRATION: ClinicalTrials.govNCT05261477. Registered on March 2, 2022.

The role of social determinants of health in the receipt of school services after traumatic brain injury: A focus review on underserved pediatric populations.

BACKGROUND: Return to school is key for community re-integration after a traumatic brain injury (TBI). School support facilitates and ensure a successful transition back to school. However, access to school services is not uniform among U.S. children. OBJECTIVE: To describe school services for children with TBI from minoritized backgrounds and highlight population-specific risk factors and facilitators for accessing services. METHODS: Narrative review of the literature including studies on return to school after a mild-complicated, moderate, or severe TBI, among children enrolled in the U.S. school system. We describe receipt of services, enabling and risk factors, and outcomes, for minority children. RESULTS: There is a gap in knowledge regarding return to school among minoritized children with TBIs. Studies have few participants from racial and ethnic minority backgrounds, or low income or rural communities. Transgender and non-binary youth are not represented in present research efforts. Studies highlight larger barriers to receipt of school services among minority children and additional barriers associated with their minority status. CONCLUSION: Diversity in the U.S pediatric population is increasing. Minoritized populations are at increased risk for TBI and poor outcomes. Research focused on the needs of these populations is required to optimize school return after TBI hospitalization and overall post-discharge care.

Community Health Worker-led Implementation of the Stanford Youth Diabetes Coaching Program in Underserved Latinx Communities.

BACKGROUND: The Stanford Youth Diabetes Coaching Program (SYDCP) is an evidence-based program led by health care professionals to teach healthy youth who then coach family members with diabetes or other chronic conditions. This purpose of this study is to evaluate a Community Health Worker (CHW)-led implementation of the SYDCP for low-income Latinx students from underserved agricultural communities. METHOD: CHWs were trained and virtually led 10 training sessions virtually during the COVID-19 for Latinx students who were recruited from high schools in agricultural regions of Washington state. Feasibility measures include recruitment, retention, class attendance, and successful coaching of a family member or friend. Acceptability was measured by responses on the post-training survey. Effectiveness was evaluated by pre-post changes in measures used in prior studies of the SYDCP such as level of activation and diabetes knowledge. RESULTS: Thirty-four students were recruited, 28 completed the training and 23 returned both pre- and post-surveys. Over 80% of students attended 7 or more classes. All met with a family or friend and 74% met with them weekly. Approximately 80% of the students rated the program's usefulness as "very good" or "excellent." Pre-post increases in diabetes knowledge, nutrition-related behaviors, resilience, and activation were significant and similar to those observed in prior published studies of the SYDCP. CONCLUSIONS: Findings support the feasibility, acceptability, and effectiveness of a CHW-led implementation of the SYDCP in underserved Latinx communities using a virtual remote model.

Diversity, equity, and inclusion within the Society for Pediatric Anesthesia: A mixed methods assessment.

BACKGROUND: Leadership of the Society for Pediatric Anesthesia created the Diversity, Equity, and Inclusion committee in 2018 to prioritize diversity work. The Society for Pediatric Anesthesia-Diversity, Equity, and Inclusion committee implemented a baseline survey of the Society for Pediatric Anesthesia membership in 2020 to assess demographics, equity in leadership, inclusivity, and attitudes toward diversity work. The Society for Pediatric Anesthesia plays a significant role in shaping the future of pediatric anesthesiology and in supporting our diverse pediatric patients. METHODS: This study is an IRB-exempt, cross-sectional survey of the Society for Pediatric Anesthesia membership. Quantitative analysis provided descriptive statistics of demographics, practice characteristics, and involvement within the Society for Pediatric Anesthesia. Qualitative thematic analysis provided an in-depth assessment of perceptions of diversity, challenges faced, and prioritization of Diversity, Equity, and Inclusion efforts within the Society for Pediatric Anesthesia. RESULTS: Out of 3 242 Society for Pediatric Anesthesia members, 1 232 completed the survey representing 38% of overall membership. Respondents were 89.2% United States members, 52.7% female, 55.7% non-Hispanic White, 88.6% heterosexual, 95.7% non-military, 59.2% religious, and 2.1% have an Americans with Disabilities Act recognized disability. All major United States geographical areas were represented equally with 71% practicing in urban areas and 67% in academic settings. Ethnic/racial minorities were more likely to be international medical graduates (p < .001). Among United States members, 41.5% report being fluent in a language other than English, and 23.5% of those fluent in another language are certified to interpret. Compared to men, women are less likely to be in leadership roles (p < .003), but we found no difference in participation and leadership when stratified by race/ethnicity, geography, international medical graduate status, or sexuality. Racial/ethnic minorities (p < .028), women (p < .001), and lesbian, gay, bisexual, transgender, and queer members (p < .044) more frequently hold lower academic rank positions when compared to white, heterosexual, and male members. Half of respondents were unsure whether diversity, equity, and inclusion challenges existed within the Society for Pediatric Anesthesia while the other half demonstrated opposing views. Among those who reported diversity, equity, and inclusion challenges, the themes centered around persistent marginalization, the need for more inclusive policies and increased psychological safety, and lack of leadership diversity. CONCLUSIONS: Compared to the diversity of the pediatric population we serve, there are still significant gaps in demographic representation within the Society for Pediatric Anesthesia. As well, there is no consensus among Society for Pediatric Anesthesia membership regarding perceptions of diversity, equity, and inclusion in pediatric anesthesia in the United States. Among those who reported diversity challenges, opportunities for the Society for Pediatric Anesthesia and Anesthesiology Departments to better support minoritized members included bolstering workforce diversity efforts and awareness via more inclusive policies, improved psychological safety, and increasing diversity in leadership. If pediatric anesthesiology is like other specialties, gaining consensus and improving diversity in the workforce might advance pediatric anesthesia innovation, quality, and safety for children of all backgrounds in the United States.

Racial and Ethnic Disparities in U.S Children Undergoing Surgery for Congenital Heart Disease: A Narrative Literature Review.

Congenital Heart Disease (CHD) is a significant source of pediatric morbidity and mortality. As in other fields of medicine, studies have demonstrated racial and ethnic disparities in congenital heart disease outcomes. The cause of these outcome disparities is multifactorial, involving biological, behavioral, environmental, sociocultural, and systemic medical factors. Potential contributors include differences in preoperative illness severity secondary to coexisting medical conditions, differences in the rate of prenatal and early postnatal detection of CHD, and delayed access to care, as well as discrepancies in socioeconomic and insurance status, and systemic disparities in hospital care. Understanding the factors that contribute to these disparities is an essential step towards developing strategies to address them. As stewards of the perioperative surgical home, anesthesiologists have an important role in developing institutional policies that mitigate racial disparities. Here, we provide a thorough narrative review of recent research concerning perioperative factors contributing to surgical outcomes disparities for children of all ages with CHD, examine potentially modifiable contributing factors, discuss avenues for future research, and suggest strategies to address disparities both locally and nationally.

Racial and ethnic differences in pediatric surgery utilization in the United States: A nationally representative cross-sectional analysis.

OBJECTIVES: Children of minority background have reduced access to surgery. This study assessed for racial/ethnic differences in surgical utilization by location. MATERIALS AND METHODS: We conducted a cross-sectional analysis of U.S. children (0-17 years of age) participating in the nationally representative Medical Expenditure Panel Survey (MEPS, 2015-2018). Race/ethnicity was the variable of interest. The primary outcome variables were prevalence rates of surgery defined by location of surgical procedure (inpatient, emergency department, hospital outpatient, and office). Covariates included contextual factors that may influence access to and need for healthcare services, including age, sex, insurance status, residential geographic status, usual source of care, and parental reports of child's physical and mental health. We employed multivariate logistic regression models to assess the relationship between outcomes and race/ethnicity. RESULTS: The study population included 31,024 children with an overall surgical rate of 4.8%. Adjusted odds of surgery in an ambulatory location were lower for all racial/ethnic minority groups compared to non-Hispanic White counterparts (non-Hispanic Black aOR = 0.3, 95% CI: 0.2-0.5; Hispanic aOR = 0.4, 95% CI: 0.3-0.6; non-Hispanic Asian aOR = 0.2, 95% CI 0.0-0.5 for hospital outpatient surgery; for office-based setting, non-Hispanic Black aOR = 0.4, 95% CI 0.3-0.6; Hispanic aOR = 0.5, 95% CI: 0.4-0.7; non-Hispanic Asian aOR = 0.4; 95% CI 0.3-0.7). No racial/ethnic differences were observed for surgical procedures in inpatient or emergency department locations. CONCLUSIONS: Staggering differences exist in pediatric surgery utilization patterns by racial/ethnic background, even after adjusting for important contextual factors (income, insurance, health status). Our findings in a nationally representative dataset may suggest systemic barriers related to racial/ethnic background for the pediatric surgical population.

Effects of D-serine treatment on outer retinal function.

The role of the N-Methyl-D-Aspartate Receptor (NMDAR) in the outer retina is unclear despite expression of the NMDAR-complex and its subunits in the outer retina. The flash-electroretinogram (fERG) offers a non-invasive measurement of the retinal field potentials of the outer retina that can serve to clarify NMDAR contribution to early retinal processing. The role of the NMDAR in retinal function was assessed using a genetic mouse model for NMDAR hypofunction (SR-/-), where the absence of the enzyme serine racemase (SR) results in an 85% reduction of retinal D-serine. NMDAR hypo- and hyperfunction in the retina results in alterations in the components of the fERG. The fERG was examined after application of exogenous D-serine to the eye in order to determine whether pre- and post-topical delivery of D-serine would alter the fERG in SR-/- mice and their littermate WT controls. Amplitude and implicit time of the low-frequency components, the a- and b-wave, were conducted. Reduced NMDAR function resulted in a statistically significantly delayed a-wave and reduced b-wave in SR-/- animals. The effect of NMDAR deprivation was more prominent in male SR-/- mice. A hyperfunction of the NMDAR, through exogenous topical delivery of 5 mM D-serine, in WT mice caused a significantly delayed a-wave implicit time and reduced b-wave amplitude. These changes were not observed in female WT mice. There were temporal delays in the a-wave and amplitude and a decrease in the b-wave amplitude and implicit time in both hypo- and NMDAR hyperfunctional male mice. These results suggest that NMDAR and D-serine are involved in the retinal field potentials of the outer retina that interact based on the animal's sex. This implicates the involvement of gonadal hormones and D-serine in retinal functional integrity.

Feasibility and Acceptability of a Telephone-Based Intervention for Hispanic Children to Promote Treatment Adherence After Traumatic Brain Injury: A Pilot Study.

OBJECTIVE: To assess the feasibility and acceptability of a telephone-based education and navigation program for Hispanic parents of children hospitalized with traumatic brain injury (TBI). SETTING: Level I trauma hospital and pediatric inpatient rehabilitation unit in the Northwestern United States. PARTICIPANTS: Fourteen Hispanic parent-child dyads. Parents were 85% female, with a mean age of 35 years. Children were 58% male, with a mean age of 9.7 years, and had been hospitalized for complicated mild/moderate (n = 5) or severe (n = 9) TBI. DESIGN: Pilot prospective cohort design. MAIN MEASURES: Feasibility measures include recruitment, retention, and intervention adherence rates. Acceptability of intervention was measured by parents' use of educational materials and satisfaction with navigation program. We also evaluated study processes, including completion of baseline, 3, 6, and 12 months functional assessments of the child; assessment of parental health literacy and self-efficacy; and adherence to follow-up rehabilitation appointments. RESULTS: Eighty-two percent of approached potential participants were recruited into the study. One hundred percent of participants completed the intervention, and 85% had 1-year follow-up. Intervention acceptability was high: 90% reported satisfaction with navigator, and 92% used the educational manual. Assessments demonstrated significant improvement in parents' TBI caregiving and community self-efficacy; 92% attendance to follow-up rehabilitation appointments; and improvement in the child's functional measures, except communication skills. CONCLUSIONS: Findings support feasibility and acceptability of a culturally relevant program to facilitate transitions of care for Hispanic children with TBI. A future randomized trial is warranted to determine the efficacy of the intervention on long-term treatment adherence and the child's post-TBI function.

Racial and ethnic disparities among children with primary central nervous system tumors in the US.

INTRODUCTION: Primary central nervous system (CNS) tumors are among the most common and lethal types of cancer in children. However, the existence of health disparities in CNS tumors by race or ethnicity remains poorly understood. This systematic review sought to determine whether racial and ethnic disparities in incidence, healthcare access, and survival exist among pediatric patients diagnosed with CNS tumors. METHODS: A search of MEDLINE, Embase, CINAHL, Web of Science, and Scopus was conducted. Inclusion criteria selected for studies published between January 1, 2005 and July 15, 2020 that focused on pediatric populations in the US, evaluated for potential differences based on racial or ethnic backgrounds, and focused on CNS tumors. A standardized study form was used to collect study information, population of interest, research design, and quality of analysis, sample size, participant demographics, pathology evaluated, and incidence or outcomes observed. RESULTS: A total of 30 studies were inlcuded. Studies suggest White children may be more likely to be diagnosed with a CNS tumor and Hispanic children to present with advanced-stage disease and have worse outcomes. The degree of influence derived from socioeconomic factors is unclear. This review was limited by few available studies that included race and ethnicity as a variable, the overlap in databases used, and unclear categorization of race and ethnicity. CONCLUSIONS: This review identified notable and at times contradicting variations in racial/ethnic disparities among children with CNS tumors, suggesting that the extent of these disparities remains largely unknown and prompts further research to improve health equity.

Trends in Race/Ethnicity Among Applicants and Matriculants to US Surgical Specialties, 2010-2018.

Importance: Surgical programs across the US continue to promote and invest in initiatives aimed at improving racial/ethnic diversity, but whether this translates to changes in the percentage of applicants or matriculants from racial/ethnic minority groups remains unclear. Objective: To examine trends in the percentage of applicants and matriculants to US surgical specialties who identified as part of a racial/ethnic group underrepresented in medicine from the 2010-2011 to 2018-2019 academic years. Design, Setting, and Participants: This cross-sectional study examined trends in self-reported racial/ethnic identity among applicants and matriculants to US residency programs to evaluate demographic changes among surgical programs from 2010 to 2018. Data were obtained from the Association of American Medical Colleges. Results: The study population consisted of a total of 737 034 applicants and 265 365 matriculants to US residency programs, including 134 158 applicants and 41 347 matriculants to surgical programs. A total of 21 369 applicants (15.9%) and 5704 matriculants (13.8%) to surgical specialties identified as underrepresented in medicine. There was no statistically significant difference in the percentage of applicants underrepresented in medicine based on race/ethnicity for all surgical specialties combined in 2010 vs 2018 (15.3% [95% CI, 14.7%-15.9%] vs 17.5% [95% CI, 16.9%-18.1%]; P = .63). Thoracic surgery was the only surgical specialty in which there was a statistically significant change in the percentage of applicants (8.1% [95% CI, 4.9%-13.2%] vs 14.6% [95% CI, 10.2%-20.4%]; P = .02) or matriculants (0% [95% CI, 0%-19.4%] vs 10.0% [95% CI, 4.0%-23.1%]; P = .01) underrepresented in medicine based on race/ethnicity. Obstetrics and gynecology had the highest mean percentage of applicants (20.2%; 95% CI, 19.4%-20.8%) and matriculants (19.0%; 95% CI, 18.2%-19.8%) underrepresented in medicine among surgical specialties. Thoracic surgery had the lowest mean percentage of applicants (12.5%; 95% CI, 9.46%-15.4%) and otolaryngology the lowest mean percentage of matriculants (8.5%; 95% CI, 7.2%-9.9%) underrepresented in medicine. Conclusions and Relevance: In this cross-sectional study, overall US surgical programs had no change in the percentage of applicants or matriculants who self-identified as underrepresented in medicine based on race/ethnicity, but the proportion remained higher than in nonsurgical specialties. Reevaluation of current strategies aimed at increasing racial/ethnic representation appear to be necessary to help close the existing gap in medicine and recruit a more racially/ethnically diverse surgical workforce.

Transitions to Outpatient Care After Traumatic Brain Injury for Hispanic Children.

BACKGROUND AND OBJECTIVES: Rehabilitation after a child's traumatic brain injury (TBI) occurs in hospital, community, and school settings, requiring coordination of care and advocacy by parents. Our objective was to explore Hispanic parents' experiences during child's transitions of care after TBI. METHODS: We conducted this qualitative study using semistructured interviews. We used a convenient sample of Hispanic parents of children hospitalized for a TBI in a single level I trauma center. Thematic content analysis using iterative deductive coding and triangulation with clinical data was conducted to identify barriers and facilitators for transitions of care. RESULTS: Fifteen mothers, mostly from rural areas and with limited English proficiency, participated in the study. Obtaining outpatient rehabilitation was difficult. Barriers included lack of therapists and clinical providers close to home, worsened by insufficient transportation and other support resources; poor understanding of child's illness and treatments; and suboptimal communication with clinicians and school administrators. Facilitators included interpreter use, availability of Spanish written information, and receipt of inpatient rehabilitation. Parents of patients discharged to inpatient rehabilitation reported that observing therapies, receiving school discharge plans by hospital-teachers, and coordination of care were facilitators to access outpatient treatments and to support school return. Parents of children discharged from the hospital from acute care reported need of legal services to obtain school services. CONCLUSIONS: Hispanic parents, especially those with limited English proficiency, can face significant challenges accessing TBI outpatient rehabilitation and school resources for their children. Although barriers are multifactorial, efforts to improve communication, parent's TBI education, and care coordination during transitions of care may facilitate a child's reintegration to the community and school.

Electroretinographic Abnormalities and Sex Differences Detected with Mesopic Adaptation in a Mouse Model of Schizophrenia: A and B Wave Analysis.

Purpose: Mesopic flash electroretinography (fERG) as a tool to identify N-methyl-d-aspartate receptor (NMDAR) hypofunction in subjects with schizophrenia shows great potential. We report the first fERG study in a genetic mouse model of schizophrenia characterized by NMDAR hypofunction from gene silencing of serine racemase (SR) expression (SR-/-), an established risk gene for schizophrenia. We analyzed fERG parameters under various background light adaptations to determine the most significant variables to allow for early identification of people at risk for schizophrenia, prior to onset of psychosis. SR is a risk gene for schizophrenia, and negative and cognitive symptoms antedate the onset of psychosis that is required for diagnosis. Methods: The scotopic, photopic, and mesopic fERGs were analyzed in male and female mice in both SR-/- and wild-type (WT) mice and also analyzed for sex differences. Amplitude and implicit time of the a- and b-wave components, b-/a-wave ratio, and Fourier transform analysis were analyzed. Results: Mesopic a- and b-wave implicit times were significantly delayed, and b-wave amplitudes, b/a ratios, and Fourier transform were significantly decreased in the male SR-/- mice compared to WT, but not in female SR-/- mice. No significant differences were observed in photopic or scotopic fERGs between genotype. Conclusions: The fERG prognostic capability may be improved by examination of background light adaptation, a larger array of light intensities, considering sex as a variable, and performing Fourier transform analyses of all waveforms. This should improve the ability to differentiate between controls and subjects with schizophrenia characterized by NMDAR hypofunction.

Electoretinographic evidence of retinal ganglion cell-dependent function in schizophrenia.

Schizophrenia is a complex disorder that is diagnosed mainly with clinical observation and evaluation. Recent studies suggest that many people with schizophrenia have abnormalities in the function of the N-methyl-d-aspartate receptor (NMDAR). The retina is part of the central nervous system and expresses the NMDAR, raising the possibility of the early detection of NMDAR-related schizophrenia by detecting differences in retinal function. As a first-step, we used two non-invasive outpatient tests of retinal function, the photopic negative response (PhNR) of the light-adapted flash-electroretinogram (PhNR-fERG) and the pattern ERG (PERG), to test individuals with schizophrenia and controls to determine if there were measurable differences between the two populations. The PhNR-fERG showed that males with schizophrenia had a significant increase in the variability of the overall response, which was not seen in the females with schizophrenia. Additionally at the brightest flash strength, there were significant increases in the PhNR amplitude in people with schizophrenia that were maximal in controls. Our results show measurable dysfunction of retinal ganglion cells (RGCs) in schizophrenia using the PhNR-fERG, with a good deal of variability in the retinal responses of people with schizophrenia. The PhNR-fERG holds promise as a method to identify individuals more at risk for developing schizophrenia, and may help understand heterogeneity in etiology and response to treatment.

Comparison between epidural and opioid analgesia for infants undergoing major abdominal surgery.

BACKGROUND: Epidural analgesia is considered optimal for postoperative pain management after major abdominal surgery. The potential to decrease anesthetic and opioid exposure is particularly desirable for infants, given their vulnerability to respiratory depression and concern for anesthetic neurotoxicity. We reviewed our experience with infants undergoing major abdominal surgery to determine if epidural catheter use decreased anesthetic and opioid exposure and improved postoperative analgesia. METHODS: This retrospective cohort study included infants (<12 months) who underwent exploratory laparotomy, ureteral reimplantation, or bladder exstrophy repair between November 2011 and November 2014. Primary outcomes of anesthetic exposure (mean endtidal sevoflurane) and intraoperative opioid administration were compared between infants who received epidural catheters and those who did not. Secondary outcomes included postoperative pain and sedation scores and morphine equivalents administered 0-24 and 24-48 hours after surgery. RESULTS: Of 158 eligible infants, 82 were included and 47 received epidurals. Patients with epidurals underwent bladder exstrophy repair (N = 9), ureteral reimplantation (N = 8), and exploratory laparotomy (N = 30). Infants with epidurals received less intraoperative fentanyl (2.6 mcg/kg (0,4.5) vs 3.3 mcg/kg (2.4,5.8), P = 0.019) and morphine (6% (3/47) vs 26% (9/35), P = 0.014) in univariate analysis. After controlling for age and emergency surgery, differences in long-acting opioid administration persisted, with significantly less morphine given in the epidural group (OR 0.181; 95% CI 0.035-0.925; P = 0.040). Mean endtidal sevoflurane concentrations were similar between groups. There was no significant difference in postoperative median morphine equivalents. CONCLUSION: Placement of epidural catheters in infants undergoing major abdominal surgery is associated with decreased long-acting opioid requirements intraoperatively. Epidural placement does not preclude opioid exposure however, as opioids may be administered for indications other than nociceptive pain in the difficult-to-assess postoperative infant. Further prospective studies are warranted to better quantify the effect of epidural analgesia on intraoperative anesthetic exposure in infants.