ECMO utilization in infants with congenital diaphragmatic hernia in the USA.

Background: Congenital diaphragmatic hernia (CDH) is a cause of significant morbidity. CDH is the most common neonatal diagnosis requiring extracorporeal membrane oxygenation (ECMO). Methods: We compared the different characteristics of ECMO and non-ECMO patients with CDH in a case-control study. Data were extracted from the Kids' Inpatient Database. Records from 2006 to 2016 were used. Patients <28 days of age were selected. CDH infants (n=9217) were stratified based on whether they were treated with ECMO (n=348) or not (n=8869). Demographic data and hospital characteristics were collected. Categorical variables were analyzed using χ2 tests to determine associations between the ECMO-treated and non-ECMO-treated infants on demographic and clinical characteristics. Differences in hospitalization costs were analyzed using t-test. Multivariable logistic regression analyses were stratified by clinical and demographic characteristics to identify factors associated with ECMO. Significant variables were included in the model to determine predictors for ECMO. Results: The proportion of infants treated with ECMO was higher in White infants, and lower in Hispanics. The cost of hospitalization was higher with ECMO (p<0.0001). ECMO patients were more likely to be treated in their birth hospital (p<0.001), at an urban location (p<0.001) and more likely to have private insurance (p=0.011). After adjusting for confounders, odds of ECMO treatment remained lower in Hispanics (p=0.001) and self-payers (p=0.004). Conclusion: There was a decrease in the proportion of CDH infants needing ECMO use in the USA from 2006 to 2016. Disparities exist in ECMO use and mortality between different ethnic groups and regions of the USA.

Picoscale structural insight into superconductivity of monolayer FeSe/SrTiO3.

Remarkable enhancement of the superconducting transition temperature (T c) has been observed for monolayer (ML) FeSe films grown on SrTiO3 substrates. The atomic-scale structure of the FeSe/SrTiO3 interface is an important determinant of both the magnetic and interfacial electron-phonon interactions and is a key ingredient to understanding its high-T c superconductivity. We resolve the atomic-scale structure of the FeSe/SrTiO3 interface through a complementary analysis of scanning transmission electron microscopy and in situ surface x-ray diffraction. We find that the interface is more strongly bonded for a particular registration, which leads to a coherently strained ML. We also determine structural parameters, such as the distance between ML FeSe and the oxide, Se─Fe─Se bond angles, layer-resolved distances between Fe─Se, and registry of the FeSe lattice relative to the oxide. This picoscale structure determination provides an explicit structural framework and constraint for theoretical approaches addressing the high-T c mechanism in FeSe/SrTiO3.

Stabilization of Competing Ferroelectric Phases of HfO_{2} under Epitaxial Strain.

Hafnia (HfO_{2})-based thin films have promising applications in nanoscale electronic devices due to their robust ferroelectricity and integration with silicon. Identifying and stabilizing the ferroelectric phases of HfO_{2} have attracted intensive research interest in recent years. In this work, first-principles calculations on (111)-oriented HfO_{2} are used to discover that imposing an in-plane shear strain on the metastable tetragonal phase drives it to a polar phase. This in-plane-shear-induced polar phase is shown to be an epitaxial-strain-induced distortion of a previously proposed metastable ferroelectric Pnm2_{1} phase of HfO_{2}. This ferroelectric Pnm2_{1} phase can account for the recently observed ferroelectricity in (111)-oriented HfO_{2}-based thin films on a SrTiO_{3} (STO) (001) substrate [Nat. Mater. 17, 1095 (2018)NMAACR1476-112210.1038/s41563-018-0196-0]. Further investigation of this alternative ferroelectric phase of HfO_{2} could potentially improve the performances of HfO_{2}-based films in logic and memory devices.

School Disciplinary Style and Adolescent Health.

PURPOSE: Parenting style is strongly associated with adolescent health. However, little is known about how school disciplinary style relates to health. We categorized adolescents' perceptions of their schools as authoritative, authoritarian, permissive, or neglectful, and test whether perceived school disciplinary style is associated with health. METHODS: We analyze data from the RISE Up study (Reducing Health Inequities Through Social and Educational Change Follow-up), comprised of baseline (eighth grade) and 2-year follow-up surveys (10th grade) from 1,159 low-income minority adolescents in Los Angeles attending 157 schools. At 10th grade, students' ratings of school support and structure were used to categorize perceived school disciplinary style as authoritative (highest tertile for support and structure), authoritarian (low support, high structure), permissive (high support, low structure), neglectful (low on both dimensions), and average (middle tertile on either dimension). Mixed effects logistic regressions controlling for sociodemographic factors, parenting style, grades, and baseline health tested whether school disciplinary style was associated with substance use, violence, bullying, and depression symptoms. RESULTS: Risky behaviors varied by school disciplinary style. After adjusting for covariates, compared with an average school disciplinary style, a neglectful school was associated with higher odds of substance use (adjusted odds ratio [AOR] 2.3, p < .001) and bullying (AOR 1.5, p = .02), a permissive school was associated with higher odds of depression symptoms (AOR 2.1, p = .04), and an authoritative school was associated with lower odds of substance use (AOR .6, p = .049), violence (AOR .6, p = .03), and bullying (AOR .5, p = .001). CONCLUSIONS: Structured and supportive school environments may impact the health of vulnerable adolescents.

Food Allergy Sensitization and Presentation in Siblings of Food Allergic Children.

BACKGROUND: Many parents of food allergic children have concerns about the development of food allergies in their other children. OBJECTIVE: We sought to determine prevalence of food sensitization and clinical food allergy among siblings of food allergic children. METHODS: Two thousand eight hundred and thirty-four children were enrolled in the Chicago Family Cohort Food Allergy study. One thousand one hundred and twenty children (ages 0-21 years) with a food allergy (defined by a reported reaction history and evidence of food-specific IgE or skin prick test) and at least 1 biological sibling were included in this study. RESULTS: Among siblings of children with food allergy, 33.4% had no sensitization and no clinical symptoms to food. Fifty-three percent had a positive food serum-specific IgE or skin prick test, but no reported symptoms of food allergy. Only 13.6% of siblings were both sensitized and clinically reactive to the same food. Milk allergy was the most common allergy among siblings (5.9%), followed by egg allergy (4.4%) and peanut allergy (3.7%). CONCLUSIONS: In a large cohort of food allergic families, only a small proportion of siblings were both sensitized and clinically reactive to a food. Sensitization without reactivity was common among siblings. Testing for food allergy in siblings without a history of clinical reactivity appears to be unjustified. Screening may lead to negative consequences related to potential misdiagnosis and unnecessary avoidance of a food. More data are needed to determine the absolute risk of food allergy development in siblings of food allergic children.

Pediatric emergency department visits and hospitalizations due to food-induced anaphylaxis in Illinois.

BACKGROUND: Rates of food-induced anaphylaxis among children remain uncertain. In addition, little is known about the demographics of children who have experienced food-induced anaphylaxis resulting in emergency department (ED) visits and/or subsequent hospitalizations. OBJECTIVES: To evaluate trends in ED visits and hospital admissions due to food-induced anaphylaxis among Illinois children and to identify socioeconomic variation in trend distribution. METHODS: Illinois hospital discharge data compiled by the Illinois Hospital Association were used to identify ED visits or hospitalizations for food-induced anaphylaxis in Illinois hospitals from 2008-2012. Data for children aged 0 to 19 years who were Illinois residents and received a diagnosis of food-induced anaphylaxis based on International Classification of Diseases, Ninth Revision, Clinical Modification codes (995.60 through 995.69) were included for analysis. RESULTS: There was a significant increase in the rate of ED visits and hospital admissions due to food-induced anaphylaxis among children in Illinois during the 5-year period, with an annual percent increase of 29.1% from 6.3 ED visits and hospital admissions per 100,000 children in 2008 to 17.2 in 2012 (P < .001). Increases in visit frequency were observed for all study variables, including age, sex, race/ethnicity, insurance type, metropolitan status, hospital type, and allergenic food. Visits were most frequent each year for Asian children and children with private insurance. However, the annual percent increase in visits was most pronounced among Hispanic children (44.3%, P < .001) and children with public insurance (30.2%, P < .001). CONCLUSION: ED visits and hospital admissions for food-induced anaphylaxis have increased during a 5-year period among children in Illinois, regardless of race/ethnicity and socioeconomic status.

Predicting outcomes of oral food challenges by using the allergen-specific IgE-total IgE ratio.

BACKGROUND: Although allergists typically use allergen-specific IgE (sIgE) levels or skin prick test wheal sizes to identify food allergens that may provoke IgE-mediated food-induced allergic reactions, both tests have high rates of false positivity and mislabel patients who are tolerant as allergic to the food allergen. OBJECTIVE: To examine the accuracy of the ratio of sIgE to total IgE ("Ratio") in predicting the outcome of challenges performed to confirm the development of tolerance. METHODS: Medical records of children diagnosed with food allergy who participated in oral food challenge at an allergy outpatient clinic (2009-2013) were reviewed for IgE antifood serology and concomitant oral food challenge outcomes, which were analyzed for associations by using logistic regression models and receiver operator characteristics curves. RESULTS: The Ratio for participants who failed their challenge was higher than the Ratio of those who passed their challenge (failed 1.48% vs passed 0.49%; n = 195). Receiver operator characteristic curves showed that the Ratio was significantly more accurate than sIgE alone in predicting challenge outcome (Ratio 0.69 vs sIgE alone 0.55; P = .03). These trends were mostly associated with more persistent food allergens, such as peanut, tree nuts, shellfish, and seeds (failed 2.18% vs passed 0.41%; n = 93) (Ratio 0.81 vs sIgE alone 0.54; P < .01). CONCLUSION: Our findings suggest that the Ratio is more accurate than sIgE alone in predicting outcomes of challenges performed to confirm the development of tolerance to select food allergens, especially to peanut and tree nuts. The Ratio may be useful in identifying patients most likely to pass oral food challenge.

Food allergy diagnosis and management practices among pediatricians.

Our goals were to (1) estimate the rates of parent-reported versus physician-diagnosed food allergy, (2) determine pediatrician adherence to national guidelines, and (3) obtain pediatricians' perspectives on guideline nonadherence. A mixed method approach was used, including survey, chart review, and qualitative methods. Overall, 10.9% of parents reported having a child with food allergy and two thirds of these cases were detected by the pediatrician. Chart reviews revealed high rates of guideline adherence with respect to allergist referral (67.3%), but less consistent adherence regarding documentation of reaction history (38.8%), appropriate use of diagnostic tests (34.7%), prescription of epinephrine autoinjectors (44.9%), and counseling families in food allergy management (24.5%). Pediatricians suggested that poor adherence was due to lack of documentation, familiarity with guidelines, and clarity regarding the pediatrician's role in managing food allergy. Findings emphasize the need to better establish the role of the pediatrician and to improve awareness and adherence to guidelines.

Factors associated with reported food allergy tolerance among US children.

BACKGROUND: Limited studies exist on predictors of food allergy tolerance. OBJECTIVE: To describe factors associated with tolerance to 9 common food allergens based on caregiver report in a nationally representative survey. METHODS: Data from children with current and outgrown food allergies were identified for analysis from a randomized, cross-sectional survey administered in US households with children from June 2009 through February 2010. Allergies were analyzed based on type of allergy, age at which allergies were outgrown, and reaction history. Adjusted models were formulated to examine the association of child and food allergy characteristics with odds of reporting an allergy as being outgrown. RESULTS: Of 40,104 children surveyed, 1,245 cases of outgrown food allergy were identified. The frequency of tolerance in children with food allergy was 26.6% at a mean age of 5.4 years. Children with milk (41.1%), egg (40.2%), or soy (35.7%) allergy had significantly higher frequencies of tolerance, whereas children with shellfish (13.0%), tree nut (14.3%), and peanut (15.6%) allergies had significantly lower frequencies (P < .05). Factors significantly associated with a report of outgrowing an allergy included a mild to moderate reaction history, being allergic to only 1 food, eczema as the sole allergy symptom, and white compared with black race (P < .05). Probability of tolerance also was significantly higher at younger ages of first reaction and decreased for first reactions occurring later in life, irrespective of allergen, severity, or presentation (P < .05). CONCLUSION: Multiple factors were associated with a report of outgrowing an allergy. Understanding factors associated with outgrowing an allergy can improve disease management and counseling.

The pediatrician's role in the diagnosis and management of food allergy.

CME EDUCATIONAL OBJECTIVES 1. Recognize the signs and symptoms of food allergy versus food intolerance. 2. Review currently available diagnostic testing modalities for food allergy and their applicability in the pediatric outpatient setting. 3. Review appropriate management practices for pediatricians, including prescription of medications, counseling of families, and referrals to keep children safe. Food allergy is a rapidly increasing and potentially life-threatening health concern in the United States. Given the ubiquity of food in our society and the absence of a cure, it is crucial that families receive proper guidance and medication to keep children safe. The pediatrician plays a key role to this end as he or she is often the first, and sometimes the only physician, these children can access. Accordingly, pediatricians must be equipped to recognize, manage, and evaluate food allergies over time while preventing unnecessary avoidance. This review provides practical translation of guidelines into recommended practices that are most pertinent to pediatricians.

Readability, suitability, and characteristics of asthma action plans: examination of factors that may impair understanding.

OBJECTIVE: Recognition of the complexity of asthma management has led to the development of asthma treatment guidelines that include the recommendation that all pediatric asthma patients receive a written asthma action plan. We assessed the readability, suitability, and characteristics of asthma action plans, elements that contribute to the effectiveness of action plan use, particularly for those with limited literacy. METHODS: This was a descriptive study of 30 asthma action plans (27 state Department of Health (DOH)-endorsed, 3 national action plans endorsed by 6 states). OUTCOME MEASURES: (1) readability (as assessed by Flesch Reading Ease, Flesch-Kincaid, Gunning Fog, Simple Measure of Gobbledygook, Forcast), (2) suitability (Suitability Assessment of Materials [SAM], adequate: ≥ 0.4; unsuitable: <0.4), (3) action plan characteristics (peak flow vs symptom-based, symptoms, recommended actions). RESULTS: Mean (SD) overall readability grade level was 7.2 (1.1) (range = 5.7-9.8); 70.0% were above a sixth-grade level. Mean (SD) suitability score was 0.74 (0.14). Overall, all action plans were found to be adequate, although 40.0% had an unsuitable score in at least 1 factor. The highest percent of unsuitable scores were found in the categories of layout/typography (30.0%), learning stimulation/motivation (26.7%), and graphics (13.3%). There were no statistically significant differences between the average grade level or SAM score of state DOH developed action plans and those from or adapted from national organizations. Plans varied with respect to terms used, symptoms included, and recommended actions. CONCLUSIONS: Specific improvements in asthma action plans could maximize patient and parent understanding of appropriate asthma management and could particularly benefit individuals with limited literacy skills.

The impact of student-directed videos on community asthma knowledge.

The Student Asthma Research Team (START) program was designed to enable students to explore socio-ecological factors contributing to asthma through the use of Photovoice, a technique that gathers both photographs and personal experiences from participants. The photographs taken by and commentary from student participants were integrated into public service announcements (PSAs) intended to increase community asthma awareness and catalyze behavior change. This article evaluates the effectiveness of these student-directed PSAs at improving asthma awareness among peers and community members. Pre-PSA, immediate post-PSA, and 4 month post-PSA follow-up assessments were conducted to evaluate changes in community members' asthma knowledge and behavior. The student-directed PSAs were found to significantly increase asthma knowledge among community members, irrespective of age, gender, or race. Increased knowledge persisted through the 4-month post-PSA follow-up. Of the thirty-six participants who were successfully contacted for the follow-up survey, nearly 40 % reported meaningful behavior-change in response to the PSAs. Photovoice and media production techniques were effective in engaging adolescent students--an under-served and often disenfranchised population--in asthma health education through the development and dissemination of PSAs. The extension of participatory techniques such as Photovoice to include the creation of student-directed PSAs holds promise for engaging adolescents in public health initiatives within their communities.

A brief intervention to improve food allergy knowledge among US pediatricians: lessons learned.

OBJECTIVE: To evaluate a brief educational tool for pediatricians developed to address known gaps in food allergy knowledge. STUDY DESIGN: Pre- and post-assessments were administered to a convenience sample of 61 US pediatricians completing the Food Allergy Comprehension Tool between February and March of 2010. McNemar's and Wilcoxon signed rank tests were used to determine whether clinical knowledge of food allergy and level of comfort in caring for food-allergic children increased significantly after reviewing the tool. Logistic regression models were used to measure the association of participant characteristics with increased knowledge and comfort. RESULTS: Sixty-one percent of surveyed physicians answered more knowledge questions correctly after reviewing the tool. Significantly more participants correctly indicated that anaphylaxis poses the greatest threat to teenagers rather than young children, and correctly rejected chronic nasal problems as a symptom of food allergy (p < 0.05). Comfort in caring for food-allergic children increased significantly on all items post-intervention (p < 0.05). Odds of increased knowledge and comfort were significantly higher among pediatricians without previous training in food allergy. CONCLUSION: The Food Allergy Comprehension Tool is a rapid way to address known knowledge gaps among pediatricians and to identify areas in need of further intervention. We recommend integration of the tool with current food allergy guidelines.

Hand hygiene instruction decreases illness-related absenteeism in elementary schools: a prospective cohort study.

BACKGROUND: Illness-related absences have been shown to lead to negative educational and economic outcomes. Both hand washing and hand sanitizer interventions have been shown to be effective in reducing illness-related absences. However, while the importance of hand hygiene in schools is clear, the role of instruction in use is less obvious. The purpose of this study was to compare absenteeism rates among elementary students given access to hand hygiene facilities versus students given both access and short repetitive instruction in use, particularly during influenza season when illness-related absences are at a peak. METHODS: A hand hygiene intervention was implemented from October to May during the 2009/2010 academic year, including peak flu season, in two Chicago Public Elementary Schools among students grades pre-kindergarten to eighth grade (ages 4-14). Classrooms were systematically assigned to an intervention or control group by grade (cluster design). Hand hygiene facilities (sanitizer and soap) were made available to all students. Students in the intervention group also received short repetitive instruction in hand hygiene every 2 months. Only absences as a result of respiratory or gastrointestinal illness were used to establish illness-related absenteeism rates. Percent absent days were calculated and bivariate analyses were performed to compare percent absent days among students given access to hand hygiene facilities versus students given both access and instruction. Prior to the intervention, teachers' perceptions of students' hand hygiene were also evaluated. Teacher perceptions were analysed to describe attitudes and beliefs. RESULTS: Data were collected and analysed for 773 students reporting 1,886 absences during the study period (1.73% of total school days). Both the percent total absent days and percent illness-related absent days were significantly lower in the group receiving short instruction during flu season (P = 0.002, P < 0.001, respectively). This difference peaked during the influenza season (when intervention began) and declined in the following months. Teachers (n = 23) agreed that hand hygiene is not performed properly among students and reported time constraints as a barrier to frequent hand washing. CONCLUSIONS: Adding hand hygiene instruction to existing hand hygiene practices improved attendance at public elementary schools during the flu season. Standardized and brief repetitive instruction in hand hygiene holds potential to significantly reduce absenteeism.

Parent report of childhood shellfish allergy in the United States.

Although shellfish allergy frequently results in emergency department visits, national prevalence studies focusing on shellfish allergy in children are scarce. This study describes parent reports of shellfish allergy among children in the United States. Data from shellfish-allergic children were identified for analysis from a randomized, cross-sectional survey administered in US households with children from June 2009 to February 2010. Child characteristics, parent-reported prevalence, severity, symptoms, diagnostic methods, and reaction history were analyzed as weighted proportions. Adjusted models were estimated to examine the association of child characteristics, reaction history, and diagnosis methods with odds of shellfish allergy and severe shellfish allergy. Among the 38,480 children included in this study, 499 were reported to have a shellfish allergy, corresponding to a prevalence of 1.3%. The mean age for first reaction to shellfish allergy was 5.8 years. Nearly one-half of all children with shellfish allergy had a history of severe life-threatening reactions (47.1%). Shellfish allergy was diagnosed by a physician at a rate of 58.5% (35.0% confirmed with testing), significantly lower than the rate of diagnosis for other common childhood food allergies (72.7%). Children with a shellfish allergy had lower odds (odds ratio, 0.39; 95% CI, 0.28-0.54) of developing tolerance compared with children with other common food allergies. Childhood shellfish allergy is a serious and underdiagnosed problem in the United States. Findings suggest that the impact of disease may be greater than previously reported. Accordingly, efforts are needed to improve awareness and management of shellfish allergy among children in the United States.