PROBLEM/CONDITION
Priority health risk behaviors that contribute to the leading causes of mortality, morbidity, and social problems among youth and adults often are established during youth, extend into adulthood, and are interrelated.


REPORTING PERIOD
February through May 1993.


DESCRIPTION OF SYSTEM
The Youth Risk Behavior Surveillance System (YRBSS) monitors six categories of priority health risk behaviors among youth and young adults: behaviors that contribute to unintentional and intentional injuries, tobacco use, alcohol and other drug use, sexual behaviors, dietary behaviors, and physical activity. The YRBSS includes a national, school-based survey conducted by CDC and state and local school-based surveys conducted by state and local education agencies. This report summarizes results from the national survey, 24 state surveys, and nine local surveys conducted among high school students during February through May 1993.


RESULTS AND INTERPRETATION
In the United States, 72% of all deaths among school-age youth and young adults are from four causes: motor vehicle crashes, other unintentional injuries, homicide, and suicide. Results from the 1993 YRBSS suggest that many high school students practice behaviors that may increase their likelihood of death from these four causes: 19.1% rarely or never used a safety belt, 35.3% had ridden with a driver who had been drinking alcohol during the 30 days preceding the survey, 22.1% had carried a weapon during the 30 days preceding the survey, 80.9% ever drank alcohol, 32.8% ever used marijuana, and 8.6% had attempted suicide during the 12 months preceding the survey. Substantial morbidity and social problems among adolescents also result from unintended pregnancies and sexually transmitted diseases, including human immunodeficiency virus (HIV) infection. YRBSS results indicate that in 1993, 53.0% of high school students had had sexual intercourse, 52.8% of sexually active students had used a condom during last sexual intercourse, and 1.4% ever injected an illegal drug. Among adults, 67% of all deaths are from three causes: heart disease, cancer, and stroke. In 1993, many high school students practiced behaviors that may increase the risk for these health problems: 30.5% of high school students had smoked cigarettes during the 30 days preceding the survey, only 15.4% had eaten five or more servings of fruits and vegetables during the day preceding the survey, and only 34.3% had attended physical education class daily.


ACTIONS TAKEN
YRBSS data are being used nationwide by health and education officials to improve school health policies and programs designed to reduce risks associated with the leading causes of mortality and morbidity. At the national level, YRBSS data are being used to measure progress toward achieving 26 national health objectives and one of eight National Education Goals.

Youth Risk Behavior Surveillance - United States, 1993

Key Points Question What is the frequency and severity of ocular symptoms reported by young users of electronic cigarettes (e-cigarettes) and cigarettes in the US? Findings This cross-sectional study of 4351 individuals aged 13 to 24 years noted that users of both e-cigarettes and cigarettes have a higher likelihood of experiencing more severe and frequent ocular symptoms than users of a single tobacco product. Cigarette users experienced more ocular symptoms than e-cigarette users, and those who used these products more recently reported more symptoms than others. Meaning The findings of this study provide additional possible reasons for users of e-cigarettes and cigarettes to reduce their tobacco use to prevent or minimize ocular symptoms.

Ocular Symptoms in Adolescents and Young Adults With Electronic Cigarette, Cigarette, and Dual Use

In New York State (NYS), motor vehicle (MV) injury to child passengers is a leading cause of hospitalization and emergency department (ED) visits in children aged 0–12 years. NYS laws require appropriate child restraints for ages 0–7 years and safety belts for ages 8 and up while traveling in a private passenger vehicle, but do not specify a seating position. Factors associated with injury in front-seated (n = 11,212) compared to rear-seated (n = 93,092) passengers aged 0–12 years were examined by age groups 0–3, 4–7 and 8–12 years using the 2012–2014 NYS Crash Outcome Data Evaluation System (CODES). CODES consists of Department of Motor Vehicle (DMV) crash reports linked to ED visits and hospitalizations. The front seat was row 1 and the rear rows 2–3. Vehicle towed from scene and air bag deployed were proxies for crash severity. Injury was dichotomized based on Maximum Abbreviated Injury Severity (MAIS) scores greater than zero. Multivariable logistic regression (odds ratios (OR) with 95% CI) was used to examine factors predictive of injury for the total population and for each age group. Front-seated children had more frequent injury than those rear-seated (8.46% vs. 4.92%, p < 0.0001). Children in child restraints experienced fewer medically-treated injuries compared to seat belted or unrestrained children (3.80, 6.50 and 13.62%, p < 0.0001 respectively). A higher proportion of children traveling with an unrestrained vs. restrained driver experienced injury (14.50% vs 5.26%, p < 0.0001). After controlling for crash severity, multivariable adjusted predictors of injury for children aged 0–12 years included riding in the front seat (1.20, 1.10–1.31), being unrestrained vs. child restraint (2.13, 1.73–2.62), being restrained in a seat belt vs. child restraint (1.20, 1.11–1.31), and traveling in a car vs. other vehicle type (1.21, 1.14–1.28). Similarly, protective factors included traveling with a restrained driver (0.61, 0.50–0.75), a driver aged < 25 years (0.91, 0.82–0.99), being an occupant of a later vehicle model year 2005–2008 (0.68, 0.53–0.89) or 2009–2015 (0.55, 0.42–0.71) compared to older model years (1970–1993). Compared to front-seated children, rear-seated children and children in age-appropriate restraints had lower adjusted odds of medically-treated injury.

/pdf/using-crash-outcome-data-evaluation-system-codes-to-examine-3qg5hl64qw.pdf

Using Crash Outcome Data Evaluation System (CODES) to examine injury in front vs. rear-seated infants and children involved in a motor vehicle crash in New York State.

OBJECTIVES: To determine practices and beliefs of pediatric hospitalists regarding smoking cessation counseling for caregivers of hospitalized children. METHODS: An electronic survey was distributed to 249 members of the Pediatric Research in Inpatient Settings Network over 6 weeks in 2017 (83 responses [33%]). Questions explored beliefs regarding the impact of tobacco smoke exposure (TSE) and practices in TSE screening, provision of counseling, resources, and pharmacotherapy. Nonparametric tests were used to compare groups on numeric variables, χ2 tests were used to compare groups on nominal variables, and McNemar’s test was used to compare dichotomous responses within subjects. RESULTS: All respondents were familiar with the term “secondhand smoke,” and >75% were familiar with “thirdhand smoke” (THS). Familiarity with THS was associated with more recent completion of training (P = .04). Former smokers (7%) were less likely to agree that THS has a significant impact on a child’s health (P = .04). Hospitalists ask about TSE more often than they provide counseling, resources, or pharmacotherapy to caregivers who want to quit smoking. Hospitalists are more likely to ask about TSE and provide cessation counseling when patients have asthma as opposed to other diseases. Time was identified by 41% of respondents as a barrier for providing counseling and by 26% of respondents as a barrier for providing resources. Most respondents never prescribe pharmacotherapy (72%), nor do they follow-up with caregivers after hospitalization regarding cessation (87%). CONCLUSIONS: Although most respondents ask about TSE, opportunities are missed for counseling and providing support to caregivers who want to quit smoking. Providers should be educated about THS, and systems should be streamlined to facilitate brief counseling sessions.

Smoking Cessation Counseling in the Inpatient Unit: A Survey of Pediatric Hospitalists.

To identify and review key research advances from the literature published between 2019 and 2023 on the diagnosis and microbiology of otitis media (OM) including acute otitis media (AOM), recurrent AOM (rAOM), otitis media with effusion (OME), chronic suppurative otitis media (CSOM) and AOM complications (mastoiditis). PubMed database of the National Library of Medicine. All relevant original articles published in Medline in English between July 2019 and February 2023 were identified. Studies that were reviews, case studies, relating to OM complications (other than mastoiditis), and studies focusing on guideline adherence, and consensus statements were excluded. Members of the panel drafted the report based on these search results. For the diagnosis section, 2294 unique records screened, 55 were eligible for inclusion. For the microbiology section 705 unique records were screened and 137 articles were eligible for inclusion. The main themes that arose in OM diagnosis were the need to incorporate multiple modalities including video-otoscopy, tympanometry, telemedicine and artificial intelligence for accurate diagnoses in all diagnostic settings. Further to this, was the use of new, cheap, readily available tools which may improve access in rural and lowmiddle income (LMIC) settings. For OM aetiology, PCR remains the most sensitive method for detecting middle ear pathogens with microbiome analysis still largely restricted to research use. The global pandemic response reduced rates of OM in children, but post-pandemic shifts should be monitored. Cheap, easy to use multi-technique assessments combined with artificial intelligence and/or telemedicine should be integrated into future practice to improve diagnosis and treatment pathways in OM diagnosis. Longitudinal studies investigating the in-vivo process of OM development, timings and in-depth interactions between the triad of bacteria, viruses and the host immune response are still required. Standardized methods of collection and analysis for microbiome studies to enable inter-study comparisons are required. There is a need to target underlying biofilms if going to effectively prevent rAOM and OME and possibly enhance ventilation tube retention. 

ISOM 2023 research Panel 4 - Diagnostics and microbiology of otitis media.

OBJECTIVES
The purpose of this study is to describe an advocacy effort to implement a food insecurity (FI) screening during hospital admission and describe characteristics of hospitalized patients with household FI.


METHODS
This is a descriptive study after the implementation of FI screening at a quaternary-care children's hospital in the Southeastern United States between August 2020 and April 2021. The Hunger Vital Sign, a 2-question screening tool for FI, was added to the intake questionnaire performed on inpatient admissions. A positive screen triggered a social work consult to connect patients with resources. Chart review and statistical analyses were performed on patients with household FI.


RESULTS
There were 7751 hospital admissions during the study period, of which 4777 (61.6%) had an FI screen completed. Among those with a completed screen, 233 patients (4.9%) were positive for household FI. Patients with household FI were more likely to be Black (P <.001) and have Medicaid (P <.001). Social work documented care specific to FI in 125 of the 233 (56%) FI patients, of which 39 (31%) were not enrolled in the Women, Infants, and Children Program/Supplemental Nutrition Assistance Program.


CONCLUSIONS
This initiative highlights hospitalization as an opportunity to screen for FI using a multidisciplinary approach. Our findings underscore the importance of identifying FI with the goal of reducing FI and mitigating the adverse effects of FI on child health outcomes.

Food Insecurity Screening of Hospitalized Patients: A Descriptive Analysis.

Tobacco use begins in adolescence for the majority of smokers. The purpose of this study was to increase screening and reporting of tobacco use in hospitalized adolescents at a tertiary care children’s hospital. We completed a nursing focus group to understand challenges and completed four iterative Plan-Do-Study-Act cycles, which included: (1) in-person nursing education regarding tobacco use screening, (2) addition of an e-cigarette-specific screening question, (3) the creation and dissemination of an educational video for nursing, and (4) adding the video as a mandatory component of nursing orientation. Run charts of the percentage of patients screened who reported tobacco use were created. Absolute counts of tobacco products used were also captured. From January 2016 to September 2018, 12,999 patients ≥13 years of age were admitted to the hospital. At baseline, 90.1% of patients were screened and 4.8% reported tobacco use. While the absolute number of adolescents reporting e-cigarette use increased from zero patients per month at baseline to five, the percentage of patients screened and reporting tobacco use was unchanged; the majority of e-cigarette users reported use of other tobacco products. This study demonstrates that adding e-cigarettes to screening increases reporting and suggests systems level changes are needed to improve tobacco use reporting.

Quality Improvement Project to Improve Screening for Tobacco Use in Adolescent Inpatients at a Children's Hospital.

This is a case of an 8-year-old, Caucasian boy with a complex prior medical history who presented with worsening, acute, left-sided abdominal pain and fever after empiric treatment for a urinary tract infection. Repeat urinalysis was negative for infection. A renal ultrasound assessing for occult perinephric abscess or nephronia revealed normal kidneys but found a tubular structure adjacent to the left kidney. A CT scan further revealed a splenic infarction secondary to torsion. He had a surgical evaluation but was treated empirically with piperacillin/tazobactam for 10 days due to concern for infectious complications following splenic infarction. He had complete resolution of his pain and symptoms. He received routine vaccines for asplenia prior to being discharged home without any further sequelae.

https://casereports.bmj.com/content/bmjcr/12/5/e228425.full.pdf

Splenic infarction from vascular torsion in a child with normal splenic anatomy.

Despite advances in technology and research, cardiac arrest remains a leading cause of death around the world. It is estimated that 292,000 adults, 15,200 children, and 1% of newborns admitted to U.S. hospitals suffer an in-hospital cardiac arrest (IHCA), and hospitalists are often at the forefront of management. The most basic principles of cardiac arrest management are still the prevailing determinants of survival: high-quality chest compressions and rapid defibrillation.1 The American Heart Association (AHA) and the International Liaison Committee on Resuscitation have moved from updating basic life support (BLS), advanced cardiac life support (ACLS), pediatric advanced life support (PALS), and neonatal resuscitation program (NRP) guidelines from every five years to a continuously updated review, with the most recent updates released in October of 2020. Given the unpredictable nature of cardiac arrests, there is a paucity of clinical trials and strong evidence to support current recommendations. Specifically noted within the 2020 guidelines is that 51% of recommendations are based on limited data and 17% are based on expert opinion.1 In addition, the AHA released a Scientific Statement in April 2020 providing initial guidance on BLS and ACLS for patients with suspected or confirmed COVID-19, updated in October 2021 to account for the increased understanding of viral transmissibility and to mitigate some of the early pandemic data that showed decreased cardiac arrest survival for both IHCA and out-of-hospital cardiac arrest (OHCA) since the onset of the pandemic. But with the emergence of more transmissible strains, further interim guidance was provided in January 2022 to focus on the protection of healthcare workers.2-4 The highlights of these updated guidelines and COVID-19 recommendations that are most relevant to hospitalist practice are summarized below. In the AHA ACLS 2020 updates, there were minor changes to the Cardiac Arrest algorithms. In the Adult Bradycardia algorithm, the Atropine dose was increased from 0.5 to 1 mg, maintaining the same frequency of every 3–5 min with a maximum dose of 3 mg. Other notable mentions in the 2020 updates include the reaffirmation of early epinephrine in nonshockable rhythms, the lack of evidence for double sequential defibrillation (using two defibrillators at once), preference of intravenous (IV) before intraosseous route for delivery of medications, utilization of end-tidal CO2 (ETCO2) for monitoring CPR quality, and guidance for timing of neuroprognostication after cardiac arrest. Two new algorithms addressing opioid overdose and pregnancy were also included (Table 1), as well as a new postcardiac arrest care algorithm. In addition, postcardiac arrest care has been added to the AHA chain of survival for both IHCA and OHCA. Atropine dose increased to 1 mg (from 0.5 to 1 mg) every 3–5 min with a max dose of 3 mg on the algorithm Nonshockable rhythms: Give 1 mg epi as soon as feasible (Class 2a, C-LD) Shockable rhythms: Give 1 mg epi after initial defibrillation attempts have failed (Class 2b, C-LD). Per the published ACLS algorithm, epi is given after the second defibrillation attempt Intravenous (IV) delivery of medications is preferable to intraosseous (IO) due to efficacy concerns. IO may be used if IV is not readily available (Class 2a, LOE B-NR) Perform multimodal neuroprognostication at a minimum of 72 h after return to normothermia (Class 2a, LOE B-NR) Recommends against the routine use (Class 2b, LOE C-LD) Reasonable to use physiologic parameters such as arterial blood pressure or ETCO2 (targets of at least 10mmHg, ideally >20mmHg) to optimize quality (2b, C-LD) Do not delay activating emergency response systems while awaiting a response to naloxone In cardiac arrest, resuscitative measures take priority over naloxone administration Priorities include the provision of high-quality CPR and relief of aortocaval compression through left lateral uterine displacement (the uterus is cupped or pushed upward and leftward off maternal vessels while the patient is supine)4 (Class 1, LOE C-LD) If no ROSC within 5 min, consider immediate perimortem cesarean delivery The most important update to PALS is an increase in the delivery rate of breaths during cardiac arrest with an advanced airway from 1 breath every 6 s (10/min), as in the adult algorithms, to 1 breath every 2–3 s (20–30/min) for all scenarios.1, 5 Another new recommendation is the use of electroencephalography monitoring after cardiac arrest to detect and monitor nonconvulsive seizures for patients that remain encephalopathic. Early delivery of epinephrine (within 5 min of starting chest compressions) is still encouraged and may be shown to increase survival to discharge rates. Cuffed ET tubes are recommended. Routine use of cricoid pressure during intubation is discouraged. The relative risks and benefits of fluid resuscitation remain uncertain, although avoiding fluid overload is recommended (Table 2). With an advanced airway, it may be reasonable to target a RR of 1 breath every 2–3 s (20–30 breaths per minute) (Class 2b, LOE C-LD) Use of epinephrine within 5 min from the start of chest compressions is reasonable (Class 2a, LOE C-LD) When resources are available, continuous EEG monitoring is recommended for the detection of seizures in patients that remain encephalopathic after cardiac arrest (Class 1, LOE C-LD) Umbilical vein is the recommended route at the time of delivery for babies requiring vascular access. Intraosseous access is an alternative if umbilical vein or other IV access is not feasible (Class 1, LOE C-EO) For nonvigourous newborns delivered through meconium-stained amniotic fluid, routine laryngoscopy with or without tracheal suctioning is not recommended. Endotracheal suctioning is only indicated if airway obstruction is suspected after positive pressure ventilation (Class 3: No benefit, LOE C-LD) Every birth should be attended by at least 1 person who can perform the initial steps of newborn resuscitation and whose only responsibility is to the newborn For newborns who have not responded to resuscitation efforts after 20 min, termination of resuscitation can be considered. (Class 1: LOE C-LD) There were four updates for NRP.1, 6 There is no longer a need to intubate and suction nonvigorous newborns delivered through meconium unless there is a concern for airway obstruction after positive pressure ventilation. The umbilical vein is the preferred vascular access for the delivery of IV medications. Every birth should be attended by at least one person who can perform newborn resuscitation and is only responsible for the neonate. Finally, for newborns who have not responded to resuscitation efforts after 20 min, termination of resuscitation can be considered (Table 2). Knowing when to terminate a resuscitation attempt remains a challenge. Several clinical decision rules have been developed to assist in this decision, most notably the UN10 rule which uses three intra-arrest variables (unwitnessed arrest, nonshockable rhythm, and 10 min of CPR without ROSC) to predict survival. The 2020 guidelines made a strong recommendation against the use of the UN10 rule as the sole strategy for stopping resuscitation. They recommend using the clinicians' experience, the clinical exam, and the patient's prearrest condition and wishes to inform their decision to terminate resuscitative attempts.1 In intubated patients, failure to achieve an ETCO2 of >10 mmHg after 20 min of CPR may be used to inform a multimodal decision to terminate resuscitation efforts.7 In January 2022, the AHA released updated interim guidance for BLS and ACLS in adults, children, and neonates with suspected or confirmed COVID-19.4 The initial guidance released early in the pandemic in April 2020 recommended donning appropriate personal protective equipment (PPE) prior to any resuscitative attempt in suspected or confirmed cases.2 However, the October 2021 guidance recommended not delaying chest compressions or defibrillation to don provider PPE, but did recommend appropriate PPE as soon as feasible, and especially prior to any ventilation strategies. Given the emergence of new, more transmissible strains, the AHA returned to the initial guidance of ensuring adequate PPE is worn prior to any resuscitative attempts. In addition, the AHA aligns with the World Health Organization and the Center for Disease Control and Prevention in that it now considers all components of resuscitation (chest compressions, ventilation, and defibrillation) to be aerosol-generating (Table 3). Don appropriate PPE prior to performing any resuscitative attempts, including chest compressions, defibrillation, bag-mask ventilation, intubation and positive pressure ventilation Consider using mechanical compression devices if available and personnel are already trained Relieve initial resuscitation personnel with providers Attach a HEPA filter to any manual or mechanical ventilation device Intubate early and connect to a ventilator with HEPA filter Use the most skilled and experienced provider to intubate Consider the use of video laryngoscopy if available and if the operator is experienced Avoid endotracheal administration of meds Leave on mechanical ventilation with appropriate adjusted settings with a HEPA filter Without an advanced airway: attempt to place in supine position first With an advanced airway: if unable to be safely turned, place pads in AP position and perform compressions over T7/T10 vertebral bodies The goals of these updates were to incorporate recently published studies and provide graded recommendations based on the strength of the evidence. Addressing the COVID-19 pandemic, the AHA recommends strategies to keep healthcare workers safe, including donning appropriate PPE prior to any resuscitation attempt and encouraging vaccination with a booster. Significant gaps in knowledge surrounding cardiac resuscitation remain. Ongoing research and innovation are vital to achieve the goals of improved survival and quality of life. The authors have reported no conflicts of interest. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article. 

https://onlinelibrary.wiley.com/doi/pdfdirect/10.1002/jhm.2778

Clinical progress note: AHA ACLS/PALS/NRP updates and cardiac arrest management in the time of COVID‐19

Injuries are the leading cause of death and a major source of disability in children. Injuries are the number one cause of death for children after the first year of life. This article discusses a number of common pediatric injuries with prevention strategies. Abstract In children, injuries are the leading cause of death, a major source of disability, and the number one cause of death for children after the first year of life. The principles of injury prevention include surveillance, coalitions, communication, interventions, and evaluation. This article discusses a number of common pediatric injuries and their prevention strategies. This review article addresses key components of injury prevention and specifically addresses the following injuries: motor vehicle crashes (with a section on teen driver crashes, sleep-related injury, and death), poisoning, all-terrain vehicle crashes, drowning, and firearm injuries. Injuries are preventable occurrences that can result in devastating sequelae or death. We present an overview of the more common pediatric injuries along with injury-prevention strategies.

Important Advances in Pediatric Injury Prevention

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