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Mokhaberi N, Vasileiadis V, Ambs JM, Reinshagen K. Pneumothorax After VATS for Pleural Empyema in Pediatric Patients. CHILDREN (BASEL, SWITZERLAND) 2025; 12:154. [PMID: 40003256 PMCID: PMC11854581 DOI: 10.3390/children12020154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2025] [Revised: 01/20/2025] [Accepted: 01/25/2025] [Indexed: 02/27/2025]
Abstract
(1) Background: In children, bacterial pneumonia is the most common cause of parapneumonic pleural effusions which can eventually lead to pleural empyema. Treatment is varied and is a combination of antibiotic therapy, chest tube drainage, fibrinolytics and video-assisted thoracoscopic surgery (VATS). Postoperative complications of the latter include pneumothoraces and bronchopleural fistula (BPF). The aim of this study is to investigate the incidence and duration of pneumothoraces during the perioperative period and follow-up (FU) to elucidate their progression following video-assisted thoracoscopic surgery (VATS) to start to create an evidence-based standardized FU protocol. (2) Methods: This retrospective study included all patients who underwent VATS for pleural empyema between January 2013-May 2023 at the University Medical Center Hamburg-Eppendorf (UKE) and the Hamburg Children's Hospital Altona (AKK). (3) Results: We identified 47 patients with pleural empyema who underwent VATS. A proportion of 43% of patients were found to have a pneumothorax with 55% of those being unresolved at discharge. At the end of FU, 27% of those had a "pneumothorax ex vacuo". No surgical interventions were needed. (4) Conclusions: The majority of pneumothoraces after VATS in pediatric patients can be managed conservatively. In the context of follow-up care, it is recommended that X-ray examinations should be used sparingly, while sonographic follow-up examinations should be conducted more frequently. If the pneumothorax persists, further thoracoscopy for resection of the visceral pleura and treatment of bronchopleural fistula may be the next step in treatment.
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Affiliation(s)
- Nariman Mokhaberi
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
- Department of Pediatric Surgery, Hamburg Children’s Hospital Altona, 22763 Hamburg, Germany
| | - Vasileios Vasileiadis
- Department of Pediatric Surgery, Hamburg Children’s Hospital Altona, 22763 Hamburg, Germany
- Paediatric Urology, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3BH, UK
| | - Jan-Malte Ambs
- Department of Pediatric Radiology, Hamburg Children’s Hospital Altona, 22763 Hamburg, Germany
| | - Konrad Reinshagen
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
- Department of Pediatric Surgery, Hamburg Children’s Hospital Altona, 22763 Hamburg, Germany
- German Center for Child and Adolescent Health (DZKJ), Partner Site Hamburg, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
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2
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Teresinha Mocelin H, Bueno Fischer G, Danezi Piccini J, de Oliveira Espinel J, Feijó Andrade C, Bush A. Necrotizing Pneumonia In Children: A Review. Paediatr Respir Rev 2024; 52:51-57. [PMID: 38749797 DOI: 10.1016/j.prrv.2024.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 02/16/2024] [Indexed: 12/16/2024]
Abstract
The objective of the review was to determine the long-term outcomes of necrotising pneumonia (NP). Studies published since 1990 in English, Portuguese, or Spanish, published on PubMed and Scielo were evaluated. Our findings showed ultrasound scanning is the diagnostic modality of choice. Despite prolonged hospitalisation (median 13-27 days) and fever (median 9-16 days), most patients recover completely. Empyema and bronchopleural fistulae are frequent in bacterial NP. Streptococcus pneumoniae is the most prevalent cause. Seventeen studies with 497 patients followed for 30 days to 8.75 years showed that most patients were clinically asymptomatic and had normal lung function. X-ray or CT chest imaging demonstrated that almost all lung lesions recovered within 4-6 months. We suggest that it is not necessary to request frequent chest X-rays during the treatment and recovery process. Chest CT scans should be reserved for specific cases not following the expected clinical course.
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Affiliation(s)
- Helena Teresinha Mocelin
- Department of Paediatrics, Federal University of Health Sciences of Porto Alegre (UFCSPA), Brazil; Pediatric Pulmonology Section, Hospital da Criança Santo Antônio, Porto Alegre, Brazil.
| | - Gilberto Bueno Fischer
- Department of Paediatrics, Federal University of Health Sciences of Porto Alegre (UFCSPA), Brazil; Pediatric Pulmonology Section, Hospital da Criança Santo Antônio, Porto Alegre, Brazil.
| | - Júlia Danezi Piccini
- Pediatric Pulmonology Section, Hospital da Criança Santo Antônio, Porto Alegre, Brazil; Paediatric Section, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.
| | - Júlio de Oliveira Espinel
- Paediatric Thoracic Surgeon - Paediatric Pulmonology Section, Hospital da Criança Santo Antônio, Porto Alegre, Brazil
| | - Cristiano Feijó Andrade
- Paediatric Thoracic Surgeon - Paediatric Pulmonology Section, Hospital da Criança Santo Antônio, Porto Alegre, Brazil
| | - Andrew Bush
- National Heart and Lung Institute, Imperial College, and Imperial Centre for Paediatrics and Child Health; Consultant Paediatric Chest Physician, Royal Brompton Hospital, UK
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Buonsenso D, Cusenza F, Passadore L, Bonanno F, Calanca C, Mariani F, Di Martino C, Rasmi S, Esposito S. Parapneumonic empyema in children: a scoping review of the literature. Ital J Pediatr 2024; 50:136. [PMID: 39080794 PMCID: PMC11290072 DOI: 10.1186/s13052-024-01701-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 07/16/2024] [Indexed: 08/02/2024] Open
Abstract
Community-acquired pneumonia can lead to a serious complication called empyema, which refers to pus within the pleural space. While it poses a significant threat to morbidity, particularly in children, it is fortunately not associated with high mortality rates. However, determining the best course of management for children, including decisions regarding antibiotic selection, administration methods, and treatment duration, remains a topic of ongoing debate. This scoping review aims to map the existing literature on empyema in children, including types of studies, microbiology, therapies (both antimicrobial and surgical) and patient outcomes. We systematically searched PubMed and SCOPUS using the terms "pediatric" (encompassing children aged 0 to 18 years) and "pleural empyema" to identify all relevant studies published since 2000. This search adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA ScR) checklist.A total of 127 studies was included. Overall, 15 attempted to compare medical treatments (alone or in combination with pleural drainage or fibrinolysis) with more invasive surgical approaches, and six studies compared diverse surgical interventions. However, the diversity of study designs makes it difficult to derive firm conclusions on the optimal approach to pediatric empyema. The heterogeneity in inclusion criteria, pharmacological/surgical approaches and settings limit the ability to draw definitive conclusions. Overall, 78 out of 10,896 children (0.7%) included in the review died, with mortality being higher in Asia and Africa. Our scoping review highlights important gaps regarding several aspects of empyema in children, including specific serotypes of the most common bacteria involved in the etiology, the optimal pharmacological and surgical approach, and the potential benefits of newer antibiotics with optimal lung penetration. New trials, designed on a multi-country level a higher number of patients and more rigorous inclusion criteria and designs, should be urgently funded.
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Affiliation(s)
- Danilo Buonsenso
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Francesca Cusenza
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Lucrezia Passadore
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Francesca Bonanno
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Carolina Calanca
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Francesco Mariani
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - Sonia Rasmi
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Susanna Esposito
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, Parma, Italy
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Buonsenso D, Cusenza F, Passadore L, Bonanno F, Calanca C, Rasmi S, Mariani F, Esposito SMR. Therapy of parapneumonic empyema in children: a protocol for a scoping review of the literature. F1000Res 2024; 12:1527. [PMID: 39099674 PMCID: PMC11294806 DOI: 10.12688/f1000research.135295.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/30/2024] [Indexed: 08/06/2024] Open
Abstract
Background Empyema (the presence of pus in the pleural space) is a severe complication of community-acquired pneumonia and significant cause of morbidity, but, fortunately, not mortality in children. Between 0.6 and 2% of pneumonias are complicated by empyema and the three main pathogens involved are Streptococcus pneumoniae, Staphylococcus aureus and group A Streptococcus 1,2,3,4. Optimal management in children, especially the choice of antibiotics, method of administration and duration of therapy, pleural dranage or surgery, are still a matter of debate and currently, lack of strong specific recommendations. This paper displays the study protocol for a scoping review that aims to summarize the available literature on the microbiological epidemiology, the medical and surgical treatment options, and the outcomes of pleural empyema in pediatric population. Methods Comprehensive research combining the terms pediatric (children aged 0 to 18 years) and pleural empyema will be performed on PubMed and SCOPUS to identify all eligible studies. At first, two reviewers will screen the abstract and then their full text to determine the articles that meet the inclusion criteria. This work will be carried out independently, everyone on a different Excel spreadsheet and each researcher will be blinded to the decision of the other researcher. When the process is completed, in case of discordance, any disagreement will be identified and resolved through discussion or with help of a third author. Dissemination The findings of this review will be published in a peer-reviewed journal.
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Affiliation(s)
- Danilo Buonsenso
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy, Rome, Italy
| | - Francesca Cusenza
- ] Pediatric Clinic, Department of Medicine and Surgery, University of Parma, Parma, Italy, parma, Italy
| | - Lucrezia Passadore
- ] Pediatric Clinic, Department of Medicine and Surgery, University of Parma, Parma, Italy, parma, Italy
| | - Francesca Bonanno
- ] Pediatric Clinic, Department of Medicine and Surgery, University of Parma, Parma, Italy, parma, Italy
| | - Carolina Calanca
- ] Pediatric Clinic, Department of Medicine and Surgery, University of Parma, Parma, Italy, parma, Italy
| | - Sonia Rasmi
- ] Pediatric Clinic, Department of Medicine and Surgery, University of Parma, Parma, Italy, parma, Italy
| | - Francesco Mariani
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy, Rome, Italy
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Morris MF, Henry TS, Raptis CA, Amin AN, Auffermann WF, Hatten BW, Kelly AM, Lai AR, Martin MD, Sandler KL, Sirajuddin A, Surasi DS, Chung JH. ACR Appropriateness Criteria® Workup of Pleural Effusion or Pleural Disease. J Am Coll Radiol 2024; 21:S343-S352. [PMID: 38823955 DOI: 10.1016/j.jacr.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/28/2024] [Indexed: 06/03/2024]
Abstract
Pleural effusions are categorized as transudative or exudative, with transudative effusions usually reflecting the sequala of a systemic etiology and exudative effusions usually resulting from a process localized to the pleura. Common causes of transudative pleural effusions include congestive heart failure, cirrhosis, and renal failure, whereas exudative effusions are typically due to infection, malignancy, or autoimmune disorders. This document summarizes appropriateness guidelines for imaging in four common clinical scenarios in patients with known or suspected pleural effusion or pleural disease. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Michael F Morris
- University of Arizona College of Medicine, Phoenix, Tucson, Arizona.
| | | | | | - Alpesh N Amin
- University of California, Irvine, Irvine, California; American College of Physicians
| | | | - Benjamin W Hatten
- University of Colorado School of Medicine Anschutz Medical Campus, Aurora, Colorado; American College of Emergency Physicians
| | | | - Andrew R Lai
- University of California San Francisco, San Francisco, California, Hospitalist
| | - Maria D Martin
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Kim L Sandler
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Devaki Shilpa Surasi
- The University of Texas MD Anderson Cancer Center, Houston, Texas; Commission on Nuclear Medicine and Molecular Imaging
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Jalunis MM, Hng SY, Eg KP, Gowdh NFM, Sanmugam A, Nah SA, Nathan AM, de Bruyne JA. Long-Term Respiratory Outcome of Children with Empyema. Indian J Pediatr 2024; 91:632. [PMID: 38224429 DOI: 10.1007/s12098-024-05021-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/01/2024] [Indexed: 01/16/2024]
Affiliation(s)
- Mohamed Mustakim Jalunis
- Department of Pediatrics, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Shih Ying Hng
- Pediatric Respiratory Unit, Department of Pediatrics, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Kah Peng Eg
- Pediatric Respiratory Unit, Department of Pediatrics, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | | | - Anand Sanmugam
- Division of Pediatric & Neonatal Surgery, Department of Surgery, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Shireen Anne Nah
- Division of Pediatric & Neonatal Surgery, Department of Surgery, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Anna Marie Nathan
- Pediatric Respiratory Unit, Department of Pediatrics, University of Malaya, 50603, Kuala Lumpur, Malaysia.
| | - Jessie Anne de Bruyne
- Pediatric Respiratory Unit, Department of Pediatrics, University of Malaya, 50603, Kuala Lumpur, Malaysia
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Fernandez Elviro C, Longcroft-Harris B, Allin E, Leache L, Woo K, Bone JN, Pawliuk C, Tarabishi J, Carwana M, Wright M, Nama N. Conservative and Surgical Modalities in the Management of Pediatric Parapneumonic Effusion and Empyema: A Living Systematic Review and Network Meta-Analysis. Chest 2023; 164:1125-1138. [PMID: 37463660 DOI: 10.1016/j.chest.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 04/08/2023] [Accepted: 06/08/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND The optimal treatment for community-acquired childhood pneumonia complicated by empyema remains unclear. RESEARCH QUESTION In children with parapneumonic effusion or empyema, do hospital length of stay and other key clinical outcomes differ according to the treatment modality used? STUDY DESIGN AND METHODS A living systematic review of randomized controlled trials (RCTs) was conducted by searching the Cochrane Central Register of Controlled Trials, Embase, Latin American and Caribbean Health Sciences Literature, Ovid MEDLINE, and Web of Science Core Collection databases. Eligible RCTs included patients aged < 18 years and compared two of the following treatment modalities: antibiotics alone, chest tube insertion with or without fibrinolytics, video-assisted thoracoscopic surgery (VATS), and decortication via thoracotomy. A network meta-analysis was performed to evaluate treatment effects on hospital length of stay (LOS), the primary outcome. RESULTS Eleven trials including a total of 590 patients were selected for the network meta-analysis. Compared with a chest tube alone, a chest tube with fibrinolytics, thoracotomy, and VATS were all associated with shorter LOS, with a mean difference of 5.05 days (95% CI, 2.46-7.64), 6.33 days (95% CI, 3.17-9.50), and 5.86 days (95% CI, 3.38-8.35), respectively. No substantial differences in LOS were observed between the latter three interventions. None of the 11 RCTs compared antibiotics alone vs other types of treatment. Most trials reported peri-procedural complications and the need for reintervention, but the descriptions differed significantly between trials, preventing meta-analysis. In trials reporting health care-associated costs, fibrinolytics had cost advantages compared with VATS. Short- and long-term morbidity and mortality were very low, regardless of the treatment modality. INTERPRETATION The results of this network meta-analysis showed that a chest tube alone was associated with a longer LOS compared with other treatment modalities. The lower cost associated with a chest tube plus fibrinolytics warrants consideration when choosing between treatment options, given similar LOS and clinical outcomes compared with the other modalities.
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Affiliation(s)
- Clara Fernandez Elviro
- Division of Respiratory Medicine, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, BC, Canada; Department Woman-Mother-Child, Service of Paediatrics, Paediatric Pulmonology and Cystic Fibrosis Unit, University Hospital of Lausanne and Faculty of Biology and Medicine, University of Lausanne, Switzerland
| | | | - Emily Allin
- Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Leire Leache
- Unit of Innovation and Organization, Navarre Institute for Health Research (IdiSNA), Pamplona, Spain
| | - Kellan Woo
- Vancouver-Fraser Medical Program, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jeffrey N Bone
- British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Colleen Pawliuk
- British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Jalal Tarabishi
- Department of Biological Sciences, Faculty of Science, University of Alberta, Edmonton, AB, Canada
| | - Matthew Carwana
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada; British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada; Division of General Pediatrics, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Marie Wright
- Division of Respiratory Medicine, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, BC, Canada; Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Nassr Nama
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, WA.
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Differential Pneumococcal Growth Features in Severe Invasive Disease Manifestations. Microbiol Spectr 2022; 10:e0005022. [PMID: 35678554 PMCID: PMC9241771 DOI: 10.1128/spectrum.00050-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The nasopharyngeal commensal Streptococcus pneumoniae can become invasive and cause metastatic infection. This requires the pneumococcus to have the ability to adapt, grow, and reside in diverse host environments. Therefore, we studied whether the likelihood of severe disease manifestations was related to pneumococcal growth kinetics. For 383 S. pneumoniae blood isolates and 25 experimental mutants, we observed highly reproducible growth curves in nutrient-rich medium. The derived growth features were lag time, maximum growth rate, maximum density, and stationary-phase time before lysis. First, the pathogenicity of each growth feature was probed by comparing isolates from patients with and without marked preexisting comorbidity. Then, growth features were related to the propensity of causing severe manifestations of invasive pneumococcal disease (IPD). A high maximum bacterial density was the most pronounced pathogenic growth feature, which was also an independent predictor of 30-day mortality (P = 0.03). Serotypes with an epidemiologically higher propensity for causing meningitis displayed a relatively high maximum density (P < 0.005) and a short stationary phase (P < 0.005). Correspondingly, isolates from patients diagnosed with meningitis showed an especially high maximum density and short stationary phase compared to isolates from the same serotype that had caused uncomplicated bacteremic pneumonia. In contrast, empyema-associated strains were characterized by a relatively long lag phase (P < 0.0005), and slower growth (P < 0.005). The course and dissemination of IPD may partly be attributable to the pneumococcal growth features involved. If confirmed, we should tailor the prevention and treatment strategies for the different infection sites that can complicate IPD. IMPORTANCEStreptococcus pneumoniae is a leading infectious cause of deaths worldwide. To understand the course and outcome of pneumococcal infection, most research has focused on the host and its response to contain bacterial growth. However, bacterial epidemiology suggest that certain pneumococcal serotypes are particularly prone to causing complicated infections. Therefore, we took the bacterial point of view, simply examining in vitro growth features for hundreds of pneumococcal blood isolates. Their growth curves were very reproducible. Certain poles of pneumococcal growth features were indeed associated with specific clinical manifestations like meningitis or pleural empyema. This indicates that bacterial growth style potentially affects the progression of infection. Further research on bacterial growth and adaptation to different host environments may therefore provide key insight into pathogenesis of complicated invasive disease. Such knowledge could lead to more tailored vaccine targets or therapeutic approaches to reduce the million deaths that are caused by pneumococcal disease every year.
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Baldes N, Bölükbas S. [Not Available]. Zentralbl Chir 2022; 147:287-298. [PMID: 35104898 DOI: 10.1055/a-1720-2292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Inflammatory diseases of the lung and pleura in children and adolescents cover a broad spectrum, including complicated pneumonia, tuberculosis, mycoses, and hydatid disease. Their frequency strongly depends on the geographical origin. The following article gives an overview - from diagnosis to surgical treatment of these diseases in the paediatric population.
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Affiliation(s)
- Natalie Baldes
- Klinik für Thoraxchirurgie, KEM Kliniken Essen-Mitte, Essen, Deutschland
| | - Servet Bölükbas
- Klinik für Thoraxchirurgie, KEM Kliniken Essen-Mitte, Essen, Deutschland
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Thimmesch M, Mulder A, Lebrun F, Piérart F, Genin C, Loeckx I, Demaret P. Management of parapneumonic pleural effusion in children: Is there a role for corticosteroids when conventional nonsurgical management fails? A single-center 15-year experience. Pediatr Pulmonol 2022; 57:245-252. [PMID: 34559458 DOI: 10.1002/ppul.25699] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 09/15/2021] [Accepted: 09/21/2021] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Description of the use of corticosteroids for the management of parapneumonic pleural effusion in children. METHODS Retrospective single-center observational study of all children hospitalized with a diagnosis of parapneumonic pleural effusion during a 15-year period. RESULTS We documented 97 cases of parapneumonic effusion during the study period, with a median age (interquartile range [IQR]) of 43 (33-61) months. Most of the children benefited from an evacuation of the pleural effusion (89/97, 91.8%): 21 patients (21.6%) were treated with needle thoracocentesis only, while a chest tube was inserted in 68 children (70.1%). Thirty-two patients (33%) were treated with intrapleural fibrinolysis. Fifty-five children (56.7%) received corticosteroids for persistent fever. The median time (IQR) between hospital admission and initiation of corticosteroids was 5.5 (4-7) days. When corticosteroids were initiated, children had been febrile for 9 (IQR: 8-11) days. The fever ceased in a median (IQR) of 0 (0-1) day after corticosteroids initiation. Only one patient required a video-assisted thoracoscopy that was necessary for morphological reasons (morbid obesity). No children treated with corticosteroids required surgery. All children were discharged from hospital. The median (IQR) hospital length of stay was 11 (8-14) days, with no difference between children with and those without corticosteroids. CONCLUSION Our findings indicate that corticosteroids may be a part of the therapeutic armamentarium for children with parapneumonic effusion when conventional nonsurgical management fails.
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Affiliation(s)
- Matthieu Thimmesch
- Division of Pediatric Pulmonology, Department of Pediatrics, CHC MontLégia, Liège, Belgium
| | - André Mulder
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHC MontLégia, Liège, Belgium
| | - Frédéric Lebrun
- Division of Pediatric Pulmonology, Department of Pediatrics, CHC MontLégia, Liège, Belgium.,Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHC MontLégia, Liège, Belgium
| | - Frédéric Piérart
- Division of Pediatric Pulmonology, Department of Pediatrics, CHC MontLégia, Liège, Belgium
| | - Caroline Genin
- Division of Pediatric Infectiology, Department of Pediatrics, CHC MontLégia, Liège, Belgium
| | - Isabelle Loeckx
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHC MontLégia, Liège, Belgium
| | - Pierre Demaret
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHC MontLégia, Liège, Belgium
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11
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Serbée MJV, Dulfer EA, Dirkx KKT, Bosboom R, Robberts B, Wertheim HFL, Mulder B, de Jonge MI, Schaars CF, Swanink CMA, Cremers AJH. C-Reactive Protein to rule out complicated pneumococcal disease manifestations; a retrospective cohort study in adults with pneumococcal bacteraemia. Int J Infect Dis 2021; 111:172-178. [PMID: 34384896 DOI: 10.1016/j.ijid.2021.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 08/04/2021] [Accepted: 08/05/2021] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES To explore the negative predictive value (NPV) of CRP at admission to exclude complicated disease manifestations. METHODS A Dutch multicentre retrospective cohort study was conducted between 01-01-2012 and 30-06-2020. Adults with positive blood cultures for S. pneumoniae, whose CRP was measured at admission, and whose infection focus was known, were included. Electronic medical and microbiological records were reviewed. RESULTS Of the 832 bacteremic patients enrolled, 30% had complicated manifestations of pneumococcal disease. Most frequent were pleural effusion (8.9%), pleural empyema (5.4%), and meningitis (7.5%). Compared to solitary pneumonia, patients with pleural effusion and empyema presented with higher CRP levels. Although low CRP did not exclude complicated disease in general, a CRP level < 114 mg/L at admission could reliably exclude empyema among adult pneumonia patients with an NPV of 93% and a specificity of 26%. However, in cases where pleural fluid was present, CRP levels were mostly above 114 mg/L, such that suspicion of empyema could only be ruled out in a minority of cases (10%). CONCLUSIONS Complicated manifestations are prevalent in adult pneumococcal bacteraemia. Low blood CRP levels can reliably exclude the development of pulmonary empyema. Practical value may be largest in settings without thoracic imaging at hand.
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Affiliation(s)
- Milou J V Serbée
- Department of Clinical Microbiology and Immunology, Rijnstate, Wagnerlaan 55, 6815 AD Arnhem, the Netherlands; Department of Clinical Microbiology, Radboud Centre for Infectious Diseases, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands.
| | - Elisabeth A Dulfer
- Department of Clinical Microbiology, Radboud Centre for Infectious Diseases, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands; Deparment of Internal Medicine, Pantein, Dokter Kopstraat 1, 5835 DV, Beugen, the Netherlands
| | - Kirsten K T Dirkx
- Department of Clinical Microbiology, Canisius-Wilhelmina Ziekenhuis, Weg door Jonkerbos 100, 6532 SZ, Nijmegen, the Netherlands
| | - Ron Bosboom
- Department of Clinical Microbiology and Immunology, Rijnstate, Wagnerlaan 55, 6815 AD Arnhem, the Netherlands
| | - Bas Robberts
- Deparment of Pulmonary Diseases, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands
| | - Heiman F L Wertheim
- Department of Clinical Microbiology, Radboud Centre for Infectious Diseases, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands
| | - Bert Mulder
- Department of Clinical Microbiology, Canisius-Wilhelmina Ziekenhuis, Weg door Jonkerbos 100, 6532 SZ, Nijmegen, the Netherlands
| | - Marien I de Jonge
- Department of Clinical Microbiology, Radboud Centre for Infectious Diseases, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands
| | - Carel F Schaars
- Deparment of Internal Medicine, Pantein, Dokter Kopstraat 1, 5835 DV, Beugen, the Netherlands
| | - Caroline M A Swanink
- Department of Clinical Microbiology and Immunology, Rijnstate, Wagnerlaan 55, 6815 AD Arnhem, the Netherlands
| | - Amelieke J H Cremers
- Department of Clinical Microbiology and Immunology, Rijnstate, Wagnerlaan 55, 6815 AD Arnhem, the Netherlands; Department of Clinical Microbiology, Radboud Centre for Infectious Diseases, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands
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12
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Moral L, Toral T, Clavijo A, Caballero M, Canals F, Forniés MJ, Moral J, Revert R, Lucas R, Huertas AM, González MC, García-Avilés B, Belda M, Marco N. Population-Based Cohort of Children With Parapneumonic Effusion and Empyema Managed With Low Rates of Pleural Drainage. Front Pediatr 2021; 9:621943. [PMID: 34368022 PMCID: PMC8335639 DOI: 10.3389/fped.2021.621943] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 06/24/2021] [Indexed: 12/03/2022] Open
Abstract
Introduction: The most appropriate treatment for parapneumonic effusion (PPE), including empyema, is controversial. We analyzed the experience of our center and the hospitals in its reference area after adopting a more conservative approach that reduced the use of chest tube pleural drainage (CTPD). Methods: Review of the clinical documentation of all PPE patients in nine hospitals from 2010 to 2018. Results: A total of 318 episodes of PPE were reviewed; 157 had a thickness of <10 mm. The remaining 161 were 10 mm or thicker and were subdivided into three increasing sizes: PE+1, PE+2, and PE+3. There was a strong relationship between the size of the effusion and complicated effusion/empyema, defined by its appearance on imaging studies or by the physical or bacteriological characteristics of the pleural fluid. The size of effusion was also strongly related to the duration of fever and intravenous treatment and was the best independent predictor of the length of hospital stay (LHS) (p < 0.001). CTPD was placed in 2.9% of PE+1 patients, 19.3% of PE+2, and 63.9% of PE+3 (p < 0.001). The referral of patients with PE+1 decreased over time (p = 0.033), as did the use of CTPD in the combined PE+1/PE+2 group (p = 0.018), without affecting LHS (p = 0.814). There were no changes in the use of CTPD in the PE+3 group (p = 0.721). Conclusions: The size of the PPE is strongly correlated with its severity and with LHS. Most patients can be treated with antibiotics alone.
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Affiliation(s)
- Luis Moral
- Pediatric Respiratory and Allergy Unit, Alicante University General Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Teresa Toral
- Pediatric Respiratory and Allergy Unit, Alicante University General Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Agustín Clavijo
- Department of Pediatrics, Marina Baixa Hospital, Villajoyosa, Spain
| | - María Caballero
- Department of Pediatrics, Vinalopó University Hospital, Elche, Spain
| | - Francisco Canals
- Department of Pediatrics, Elche University General Hospital, Elche, Spain
| | - María José Forniés
- Department of Pediatrics, Virgen de la Salud University General Hospital, Elda, Spain
| | - Jorge Moral
- Faculty of Medicine, Miguel Hernández University, Sant Joan d'Alacant, Spain
| | - Raquel Revert
- Department of Pediatrics, Alicante University General Hospital, Alicante, Spain
| | - Raquel Lucas
- Department of Pediatrics, Marina Salud Hospital, Denia, Spain
| | - Ana María Huertas
- Department of Pediatrics, Vinalopó University Hospital, Elche, Spain
| | | | - Belén García-Avilés
- Department of Pediatrics, Sant Joan d'Alacant University Clinical Hospital, Sant Joan d'Alacant, Spain
| | - Mónica Belda
- Department of Pediatrics, Virgen de los Lirios Hospital, Alcoy, Spain
| | - Nuria Marco
- Department of Pediatrics, Vega Baja Hospital, Orihuela, Spain
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13
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Buonsenso D, Tomà P, Scateni S, Curatola A, Morello R, Valentini P, Ferro V, D'Andrea ML, Pirozzi N, Musolino AM. Lung ultrasound findings in pediatric community-acquired pneumonia requiring surgical procedures: a two-center prospective study. Pediatr Radiol 2020; 50:1560-1569. [PMID: 32821992 DOI: 10.1007/s00247-020-04750-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 04/14/2020] [Accepted: 06/02/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Lung ultrasound (US) in the evaluation of suspected pediatric pneumonia is increasingly used and has a recognized role in evaluating pleural effusions, although there are no detailed studies specifically addressing its use in the pediatric population. OBJECTIVES To define lung US findings of severe pediatric community-acquired pneumonia that required surgical procedures during admission. MATERIALS AND METHODS Our prospective case-control study compared lung US findings in patients ages 1 month to 17 years admitted with community-acquired pneumonia that required surgical procedures from findings those who did not. Lung US was performed at admission and always before surgical procedures. Medical treatment, laboratory and microbiological findings, chest X-ray, computed tomography scan and surgical procedures are described. RESULTS One hundred twenty-one children with community-acquired pneumonia were included; of these, 23 underwent surgical intervention. Compared with the control group, children requiring a surgical procedure had a significantly higher rate of large consolidations (52.2%; 95% confidence interval [CI]: 30.6% to 73.2%), larger and complicated pleural effusions (100%; 95% CI: 85.2% to 100%), and both liquid and air bronchograms (73.9%; 95% CI: 51.6% to 89.8%). CONCLUSION Larger consolidations, larger and more complicated pleural effusions, and liquid and air bronchograms were associated with surgical treatment.
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Affiliation(s)
- Danilo Buonsenso
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
- Istituto di Microbiologia, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Paolo Tomà
- Department of Radiology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Simona Scateni
- Emergency Department, Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Antonietta Curatola
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Rosa Morello
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Piero Valentini
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Pediatrics, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Valentina Ferro
- Emergency Department, Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | | | - Nicola Pirozzi
- Emergency Department, Ospedale Pediatrico Bambino Gesù, Rome, Italy
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14
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de Benedictis FM, Kerem E, Chang AB, Colin AA, Zar HJ, Bush A. Complicated pneumonia in children. Lancet 2020; 396:786-798. [PMID: 32919518 DOI: 10.1016/s0140-6736(20)31550-6] [Citation(s) in RCA: 117] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 05/20/2020] [Accepted: 06/10/2020] [Indexed: 12/13/2022]
Abstract
Complicated community-acquired pneumonia in a previously well child is a severe illness characterised by combinations of local complications (eg, parapneumonic effusion, empyema, necrotising pneumonia, and lung abscess) and systemic complications (eg, bacteraemia, metastatic infection, multiorgan failure, acute respiratory distress syndrome, disseminated intravascular coagulation, and, rarely, death). Complicated community-acquired pneumonia should be suspected in any child with pneumonia not responding to appropriate antibiotic treatment within 48-72 h. Common causative organisms are Streptococcus pneumoniae and Staphylococcus aureus. Patients have initial imaging with chest radiography and ultrasound, which can also be used to assess the lung parenchyma, to identify pleural fluid; CT scanning is not usually indicated. Complicated pneumonia is treated with a prolonged course of intravenous antibiotics, and then oral antibiotics. The initial choice of antibiotic is guided by local microbiological knowledge and by subsequent positive cultures and molecular testing, including on pleural fluid if a drainage procedure is done. Information from pleural space imaging and drainage should guide the decision on whether to administer intrapleural fibrinolytics. Most patients are treated by drainage and more extensive surgery is rarely needed; in any event, in low-income and middle-income countries, resources for extensive surgeries are scarce. The clinical course of complicated community-acquired pneumonia can be prolonged, especially when patients have necrotising pneumonia, but complete recovery is the usual outcome.
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Affiliation(s)
| | - Eitan Kerem
- Department of Pediatrics, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Anne B Chang
- Child Health Division, Menzies School of Health Research, Darwin, NT, Australia; Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, South Brisbane, QLD, Australia; Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Andrew A Colin
- Division of Pediatric Pulmonology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Heather J Zar
- Department of Paediatrics and Child Health, Red Cross Children's Hospital, Cape Town, South Africa; MRC Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Andrew Bush
- Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial School of Medicine, Imperial College London, London, UK.
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15
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Livingston MH, Mahant S, Connolly B, MacLusky I, Laberge S, Giglia L, Yang C, Roberts A, Shawyer A, Brindle M, Parsons S, Stoian C, Walton JM, Thorpe KE, Chen Y, Zuo F, Mamdani M, Chan C, Loong D, Isaranuwatchai W, Ratjen F, Cohen E. Effectiveness of Intrapleural Tissue Plasminogen Activator and Dornase Alfa vs Tissue Plasminogen Activator Alone in Children with Pleural Empyema: A Randomized Clinical Trial. JAMA Pediatr 2020; 174:332-340. [PMID: 32011642 PMCID: PMC7042898 DOI: 10.1001/jamapediatrics.2019.5863] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Clinical guidelines recommend that children with pleural empyema be treated with chest tube insertion and intrapleural fibrinolytics. The addition of dornase alfa (DNase) has been reported to improve outcomes in adults but remains unproven in children. OBJECTIVE To determine if intrapleural tissue plasminogen activator (tPA) and DNase is more effective than tPA and placebo at reducing hospital length of stay in children with pleural empyema. DESIGN, SETTING, AND PARTICIPANTS This multicenter, parallel-group, placebo-controlled, superiority randomized clinical trial included children diagnosed as having pleural empyema requiring drainage aged 6 months to 18 years treated at 6 tertiary Canadian children's hospitals. A total of 379 children were assessed for eligibility; 281 were excluded and 98 were randomized. One child was excluded after randomization for not meeting the inclusion criteria. Data were collected from March 4, 2013, to December 13, 2017. INTERVENTIONS Participants underwent chest tube insertion and 3 daily administrations of intrapleural tPA, 4 mg, followed by DNase, 5 mg (intervention group), or 5 mL of normal saline (placebo; control group). Participants, families, clinical staff, and members of the study team were blinded to allocation. MAIN OUTCOMES AND MEASURES The primary outcome was hospital length of stay from chest tube insertion to discharge. Secondary outcomes included time to meeting discharge criteria, time to chest tube removal, mean fever duration, additional pleural drainage procedures, hospital readmissions, and total health care cost. RESULTS Of the 97 analyzed children with pleural empyema, 52 (54%) were male, and the mean (SD) age was 5.1 (3.6) years. A total of 49 children were randomized to tPA and DNase and 48 were randomized to tPA and placebo. Treatment with tPA and DNase was not associated with decreased hospital length of stay compared with tPA and placebo (mean [SD] length of stay, 9.0 [4.9] vs 9.1 [5.3] days; mean difference, -0.1 days; 95% CI, -2.0 to 2.1; P = .96). Similarly, no significant differences were observed for any of the secondary outcomes. Of the 14 adverse events in the tPA and DNase group, 6 (43%) were serious; of the 21 adverse events in the tPA and placebo group, 8 (38%) were serious. There were no deaths. CONCLUSIONS AND RELEVANCE The addition of DNase to intrapleural tPA for children with pleural empyema had no effect on hospital length of stay or other outcomes compared with tPA with placebo. Clinical practice guidelines should continue to support the use of chest tube insertion and intrapleural fibrinolytics alone as first-line treatment for pediatric empyema. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01717742.
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Affiliation(s)
- Michael H. Livingston
- McMaster Children’s Hospital, McMaster University, Hamilton, Ontario, Canada,Golisano Children’s Hospital, University of Rochester Medical Center, Rochester, New York
| | - Sanjay Mahant
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Bairbre Connolly
- Image-Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Ian MacLusky
- Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Sophie Laberge
- Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
| | - Lucia Giglia
- McMaster Children’s Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Connie Yang
- British Columbia’s Children’s Hospital, Division of Respiratory Medicine, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ashley Roberts
- British Columbia’s Children’s Hospital, Division of Respiratory Medicine, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Anna Shawyer
- Health Sciences Centre, Winnipeg, Manitoba, Canada
| | - Mary Brindle
- Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Simon Parsons
- Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Cristina Stoian
- Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada
| | - J. Mark Walton
- McMaster Children’s Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Kevin E. Thorpe
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada,Applied Health Research Centre, Li Ka Shing Knowledge Institute, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Yang Chen
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Fei Zuo
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Muhammad Mamdani
- Li Ka Shing Centre for Healthcare Analytics Research and Training, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Carol Chan
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Desmond Loong
- Centre for Excellence in Economic Analysis Research (CLEAR), The HUB Health Research Solutions, St Michael’s Hospital, Toronto, Ontario, Canada,Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Wanrudee Isaranuwatchai
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada,Centre for Excellence in Economic Analysis Research (CLEAR), The HUB Health Research Solutions, St Michael’s Hospital, Toronto, Ontario, Canada,Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Felix Ratjen
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Eyal Cohen
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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